CMS-P-0015A Health Insurance

Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

2024_Health_Insurance_HIQ

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

OMB: 0938-0568

Document [pdf]
Download: pdf | pdf
2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

HEALTH INSURANCE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If (INTTYPE in(C001, C002, C004, C005, C006) and SEASON=FALL) or (INTTYPE=C003), administer after HAQ.
If (INTTYPE in(C001, C002, C004, C005, C006) and SEASON=WINTER or SUMMER) or (INTTYPE in (C007,
C010)), administer after ENS.

BOX HIBEG

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE), GO TO HIMCINTR - HIINTR1.
ELSE GO TO BOX MC1AA.

SHOW CARD HI1
The next questions are about [your/(SP's)] health insurance benefits. This card outlines the types of health
insurance that I’ll be asking you about. [INTERVIEWER SHOULD POINT TO HEALTH INSURANCE OPTIONS ON
FRONT OF SHOWCARD HI1.] Please refer to this card as we talk about [your/(SP’s)] health insurance coverage.
HIINTR1

HIMCINTR

no entry

BOX MC1AA

It would also be helpful if I could look at a health plan card, insurance statement, or something with the plan name
on it. These materials will ensure that I record the information accurately.
(EXPAIN IF NECESSARY: We ask about health insurance coverage because it is important to understand how
beneficiaries cover the costs of their medical care, such as doctor visits, prescribed medicines, and hospital
stays.)

BOX MC1AA

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A LOADED CMS MEDICARE MANAGED CARE
PLAN), GO TO MC1 - LOADCORR.
ELSE IF (SP IS NOT IN THE SUPPLEMENTAL SAMPLE) AND (SP HAS A MEDICARE MANAGED CARE PLAN
THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW), GO TO HIMC1A MHMOSAME.
ELSE GO TO HIMC1 - MHMOCOV.

As you (may) know, Medicare beneficiaries can enroll in either Original Medicare or a Medicare Advantage plan,
such as an HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).
LOADCORR

MC1

yes/no

According to Medicare records, [you are/(SP) is] currently enrolled in a Medicare Advantage Plan called (CMS
MEDICARE MANAGED CARE PLAN NAME). Is this information correct?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) BOX HIMC1
(02) MC2 - WHATWRNG
(-8) MC11 - REFERMED
(-9) BOX HIMC4

Page 1 of 26

2024 MCBS Community Questionnaire

Variable Name

WHATWRNG

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

MC2

code 1

Question Text/Description

Code List

Routing

How is this information incorrect?
SELECT ONLY ONE. IF MORE THAN ONE RESPONSE IS APPLICABLE, SELECT THE RESPONSE THAT IS
CLOSEST TO THE TOP OF THE LIST.

(01) SP DISENROLLED FROM (CMS MHMO PLAN
NAME), ENROLLED IN NEW MEDICARE ADVANTAGE
PLAN
(02) SP HAS PLAN CALLED (CMS MHMO PLAN
NAME), R DOESN'T THINK IT'S A MEDICARE
ADVANTAGE PLAN
(03) SP NOW DISENROLLED FROM (CMS MHMO
PLAN NAME), NO LONGER IN ANY MEDICARE
ADVANTAGE PLAN
(04) SP ENROLLED IN MEDICARE ADVANTAGE
PLAN, BUT NEVER (CMS MHMO PLAN NAME)
(05) SP NEVER COVERED BY OR ENROLLED IN (CMS
MHMO PLAN NAME)

(01) MC2B - YDISNROL
(02) MC3 - PRIMPHYS
(03) MC2B - YDISNROL
(04) MC4 - SAMEPLAN
(05) MC11 - REFERMED

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX MC1A
(02) BOX MC1A
(03) BOX MC1A
(04) BOX MC1A
(05) BOX MC1A
(06) BOX MC1A
(07) BOX MC1A
(08) BOX MC1A
(09) BOX MC1A
(10) BOX MC1A
(11) BOX MC1A
(91) MC2B - YDISNROS
(-8) BOX MC1A
(-9) BOX MC1A

YDISNROL

MC2B

code 1

What is the most important reason [you/(SP)] stopped the (CMS MEDICARE MANAGED CARE PLAN NAME)
coverage?

YDISNROS

MC2B

verbatim text

OTHER (SPECIFY)

BOX MC1A

routing

IF MC2 - WHATWRNG = 1/EnrolledNewPlan, GO TO MC5 - PLAN_MHMOMCA.
ELSE GO TO HIMC16 - MHMOMORE.

PRIMPHYS

MC3

yes/no

(01) YES
In many Medicare Advantage Plans, such as HMOs or PPOs, the health plan gives the patient a list of doctors
(02) NO
from which he chooses a primary care physician. This primary care physician provides the patient’s usual medical
(-8) Don't Know
care and can refer the patient to specialists, if necessary. [Do you/Does (SP)] have a primary care physician?
(-9) Refused

SAMEPLAN

MC4

code 1

Is it possible that [your/(SP’s)] current insurance plan is just another name for (CMS MEDICARE MANAGED
CARE PLAN NAME), or are they not the same plans?

PLAN_MHMOMCA

MC5

roster

What is the name of the Medicare Advantage Plan that provides [your/(SP’s)] health care benefits?
[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

BOX MC1A

(01) SAME PLANS
(02) NOT THE SAME PLANS
(-8) Don't Know
(-9) Refused

BOX HIMC1

(01) BOX HIMC1
(02) MC5 - PLAN_MHMOMCA
(-8) MC5 - PLAN_MHMOMCA
(-9) MC5 - PLAN_MHMOMCA

BOX HIMC1

Page 2 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

REFERMED

MC11

code 1

(01) MEDICARE ONLY
(02) OTHER NAME
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-8) Don't Know
on it?]
(-9) Refused

(01) BOX HIMC4
(02) MC12 - PLAN_MHMOMCB
(-8) BOX HIMC4
(-9) BOX HIMC4

PLAN_MHMOMCB

MC12

roster

What do you call [your/(SP’s)] coverage?
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.

BOX HIMC1

Do you refer to [your/(SP’s)] Medicare coverage by any name besides Medicare?

At the time of the last interview [you were/(SP) was] covered by the Medicare Advantage Plan named (MEDICARE
MANAGED CARE PLAN NAME).
[[Are you/Is (SP)] now covered by (MEDICARE MANAGED CARE PLAN NAME)?] [Was (SP) covered by
(MEDICARE MANAGED CARE PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW DATE,
BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Routing

(01) BOX HIMC1
(02) HIMC1B - COVENDMM
(-8) HIMC1C - MHMOOTHR
(-9) BOX HIMC4

MHMOSAME

HIMC1A

yes/no

COVENDMM

HIMC1B

date

(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused

COVENDYY

COVENDYY

HIMC1B

date

(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused

HIMC1B1 - YDISNROL

YDISNROL

HIMC1B1

code 1

What is the most important reason [you/(SP)] stopped the (MEDICARE MANAGED CARE PLAN NAME)
coverage?

YDISNROS

HIMC1B1

verbatim text

OTHER (SPECIFY)

MHMOOTHR

HIMC1C

yes/no

SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)],
[have you/has (SP) been/was (SP)] covered by any other Medicare Advantage Plans besides (MEDICARE
MANAGED CARE PLAN)?

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) HIMC1C - MHMOOTHR
(02) HIMC1C - MHMOOTHR
(03) HIMC1C - MHMOOTHR
(04) HIMC1C - MHMOOTHR
(05) HIMC1C - MHMOOTHR
(06) HIMC1C - MHMOOTHR
(07) HIMC1C - MHMOOTHR
(08) HIMC1C - MHMOOTHR
(09) HIMC1C - MHMOOTHR
(10) HIMC1C - MHMOOTHR
(11) HIMC1C - MHMOOTHR
(91) HIMC1B1 - YDISNROS
(-8) HIMC1C - MHMOOTHR
(-9) HIMC1C - MHMOOTHR

HIMC1C - MHMOOTHR

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HIMC5-PLAN_MHMO
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

Page 3 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

SHOW CARD HI2
As you (may) know, Medicare beneficiaries can enroll in either Original Medicare or a Medicare Advantage plan,
such as an HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization).
MHMOCOV

HIMC1

yes/no

(01) YES
(Please look at this card.) At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF (02) NO
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been enrolled in or covered by [(one (-8) Don't Know
of these/any)] Medicare Advantage plans?
(-9) Refused

Routing

(01) HIMC5-PLAN_MHMO
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

PLAN_MHMO

HIMC5

roster

What is the name of the Medicare Advantage Plan that [currently covers/covered] [you/(SP)] [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE ADVANTAGE PLAN AT THIS ROSTER.

COVTIME

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

(01) BOX HIMC1
(02) BOX HID
(-8) BOX HID
(-9) BOX HID

HIMC3

code 1

Were you covered by (MEDICARE ADVANTAGE PLAN NAME) the whole time between [(REFERENCE DATE)
and (today], or only part of the time?

BOX HID

routing

IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI3.
ELSE GO TO HI2-CURRCOV.

HI2

yes/no

(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE ADVANTAGE PLAN NAME)? [Was (SP) covered by (MEDICARE (02) NO
ADVANTAGE PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]
(-8) Don't Know
(-9) Refused

BOX HI3

routing

IF THIS MEDICARE ADVANTAGE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO BOX HIMC1.
ELSE GO TO HI3 - COVBEGMM.

COVBEGMM

HI3

date

When did [your/(SP’s)] (MEDICARE ADVANTAGE PLAN NAME) start between (REFERENCE DATE) and
[today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HI3-COVBEGYY

COVBEGYY

HI3

date

When did [your/(SP’s)] (MEDICARE ADVANTAGE PLAN NAME) start between (REFERENCE DATE) and
[today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

BOX HIMC1

COVENDMM

HI3A

date

(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused

COVENDYY

COVTIME

CURRCOV

(01) BOX HI3
(02) HI3A - COVENDMM
(-8) BOX HIMC1
(-9) BOX HIMC1

Page 4 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

COVENDYY

HI3A

date

(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Advantage Plan's coverage [most recently/last] stop?
(-9) Refused

BOX HIMC1

routing

IF (THIS MEDICARE MANAGED CARE PLAN IS NEW) OR THIS IS A FALL ROUND GO TO MHMOCVR.
ELSE GO TO BOX HIMC2

SHOWCARD HI6
I'd like to know what [your/SP's] [CURRENT MEDICARE MANAGED CARE PLAN] coverage [includes/included].
(Please look at this card). Which services [are/were] covered through [CURRENT MEDICARE MANAGED CARE
PLAN)]?
MHMOCVR

MHMOCVR

mark all

[PROBE: I am asking about the type of insurance coverage that [you personally have/(SP) personally has/(SP)
personally had], not what the plan offers everyone.]
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]
CHECK ALL THAT APPLY

MHMOCVOS

MHMOCVOS

verbatim text

[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]

Code List

Routing

BOX HIMC1

(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
(04) Inpatient hospital care
(05) Nursing home or long term care
(06) Dental care
(07) Optical or vision care
(08) Hearing care
(09) Behavioral health care (e.g., counseling,
psychotherapy, mental health and substance use
disorder services)
(91) Other services
(-8) Don't Know
(-9) Refused

(01)-(08) HIMC11 - MHMOPAY
(91) MHMOCVOS
(-8) HIMC11 - MHMOPAY
(-9) HIMC11 - MHMOPAY

(01) [Continuous Answer]

HIMC11 - MHMOPAY

OTHER (SPECIFY)

Besides the cost of [your/(SP’s)] Medicare Part B premium, [is/was] there an additional cost for [your/(SP’s)]
(CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage? Please do not include any amount that
[you/(SP)] may (pay/have paid) as a co-payment for an office visit or a prescribed medicine.
MHMOPAY

MHMOAMT

HIMC11

HIMC12

yes/no

(01) YES
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: Some managed care plans may charge a monthly premium to cover the cost of the
deductibles and coinsurance for Medicare-covered services or because they provide services that are not covered (-9) Refused
by Original Medicare such as prescribed medicines, and dental, vision, or hearing care. Plans that have premiums
typically charge from $50 to $75 per month.]

Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that [you
pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(Please do not include any copayments or any amount that may [be/have been] paid for anyone other than
quantity unit hybrid
[you/(SP)].)

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) HIMC12 - MHMOAMT
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2

(01) HIMC12 - MHMOUNIT
(-8) HIMC12 - MHMOUNIT
(-9) HIMC12 - MHMOUNIT

[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]

Page 5 of 26

2024 MCBS Community Questionnaire

Variable Name

MHMOUNIT

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

HIMC12

Question Text/Description

Not including the cost of [your/(SP’s)] Medicare Part B premium, what [is/was] the additional amount that [you
pay/(SP) pays/(SP) paid] for [your/his/her] (CURRENT MEDICARE MANAGED CARE PLAN NAME) coverage?
(Please do not include any copayments or any amount that may [be/have been] paid for anyone other than
quantity unit hybrid
[you/(SP)].)
[PROBE IF NECESSARY: Is that per year, per month, per week, or what?]

MHMOUNOS

MHMOUNOS

BOX MHMOCAT

verbatim text

OTHER (SPECIFY)

routing

IF MHMOAMT=DK AND MHMOUNIT=1/PER YEAR, GO TO MHMOPYR.
ELSE IF MHMOAMT=DK AND MHMOUNIT=2/QUARTERLY, GO TO MHMOQR.
ELSE IF MHMOAMT=DK AND MHMOUNIT=3/BIMONTHLY, GO TO MHMOBI.
ELSE IF MHMOAMT=DK AND MHMOUNIT=4/PER MONTH, GO TO MHMOMO.
ELSE IF MHMOAMT=DK AND MHMOUNIT=5/PER WEEK, GO TO MHMOWE.
ELSE IF MHMOAMT=DK AND MHMOUNIT=6/SEMI-ANNUALLY/2 TIMES PER YEAR, GO TO MHMOSA.
ELSE IF MHMOAMT=DK AND MHMOUNIT=7/SEMI-MONTHLY/2 TIMES PER MONTH, GO TO MHMOSM.
ELSE GO TO HI33A-MHMOCOST.

Code List

Routing

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(07) BOX MHMOCAT
(91) MHMOUNOS-MHMOUNOS
(-8) BOX MHMOCAT
(-9) BOX MHMOCAT

BOX MHMOCAT

MHMOPYR

MHMOPYR

code 1

PER YEAR: Please tell me which is the closest…

(01) <250
(02) 250-749
(03) 750-1499
(04) 1500-3999
(05) 4000+

MHMOQR

MHMOQR

code 1

PER QUARTER: Please tell me which is the closest…

(01) <200
(02) 200-399
(03) 400-599
(04) 600-899
(05) 900+

HI33A-MHMOCOST

BIMONTHLY: Please tell me which is the closest…

(01) <150
(02) 150-299
(03) 300-449
(04) 450-599
(05) 600+

HI33A-MHMOCOST

HI33A-MHMOCOST

HI33A-MHMOCOST

MHMOBI

MHMOBI

code 1

MHMOMO

MHMOMO

code 1

PER MONTH: Please tell me which is the closest…

(01) <50
(02) 50-99
(03) 100-199
(04) 200-399
(05) 400+

MHMOWE

MHMOWE

code 1

PER WEEK: Please tell me which is the closest…

(01) <10
(02) 10-24
(03) 25-74
(04) 75-149
(05) 150+

HI33A-MHMOCOST

Page 6 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

HI33A-MHMOCOST

MHMOSA

MHMOSA

code 1

2 TIMES/YEAR: Please tell me which is the closest…

(01) <100
(02) 100-299
(03) 300-999
(04) 1000-1999
(05) 2000+

MHMOSM

MHMOSM

code 1

2 TIMES/MONTH: Please tell me which is the closest…

(01) <10
(02) 10-34
(03) 35-99
(04) 100-199
(05) 200+

HI33A-MHMOCOST

MHMOCOST

HI33A

yes/no

[Does/Did] anyone else, such as an employer, a union or professional organization pay all or some portion of the
premium or cost for [your/(MIP’s)] (PLAN NAME) coverage?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HIMC12B - MHMOWHO
(02) BOX HIMC2
(-8) BOX HIMC2
(-9) BOX HIMC2

(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX HIMC2
(02) BOX HIMC2
(03) BOX HIMC2
(04) BOX HIMC2
(05) BOX HIMC2
(06) BOX HIMC2
(07) BOX HIMC2
(91) HIMC12B - MHMOWHOS
(-8) BOX HIMC2
(-9) BOX HIMC2

MHMOWHO

HI33B

code 1

Who else [pays/paid] all or some portion of the cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

MHMOWHOS

HIMC12B

verbatim text

OTHER (SPECIFY)

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE IF HIMC1A - MHMOSAME = 1/Yes, GO TO BOX HIMC4.
ELSE IF HI2-CURRCOV = 2/No, DK OR RF, GO TO HIMC17 - PLAN_MHMOOTHER.
ELSE GO TO HIMC16 - MHMOMORE.

BOX HIMC2

MHMOMORE

HIMC16

yes/no

SHOW CARD HI2
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)] been covered by any other Medicare Advantage Plans
besides (MEDICARE MANAGED CARE PLAN and MEDICARE MANAGED CARE PLAN)?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

BOX HIMC2

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HIMC17 - PLAN_MHMOOTHER
(02) BOX HIMC4
(-8) BOX HIMC4
(-9) BOX HIMC4

Page 7 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

PLAN_MHMOOTHER

HIMC17

Besides (MEDICARE MANAGED CARE PLAN [and MEDICARE MANAGED CARE PLAN]), what other/What]
Medicare Advantage Plans provided [your/(SP’s)] health care since (REFERENCE DATE)?
SELECT OR ADD MEDICARE ADVANTAGE PLAN NAMES AT THIS ROSTER.

roster

Code List

Routing

BOX HIMC4

[MEDICARE ADVANTAGE PLAN LOOKUP CALLED AT THIS SCREEN]

BOX HIMC4

routing

IF FALL ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED) AND (SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS "CURRENT"), GO TO HIMC19 - RECMHMO.
ELSE GO TO BOX HI1.

HIMC19

yes/no

Would you recommend (CURRENT MEDICARE MANAGED CARE PLAN NAME) to your family or friends?

BOX HIMC5

routing

IF (SP HAS A MEDICARE MANAGED CARE PLAN THAT IS "CURRENT") AND (THE NUMBER OF YEARS THE
SP WAS COVERED BY A MANAGED CARE PLAN HAS NEVER BEEN COLLECTED), GO TO HIMC24 HMONUMYR.
ELSE GO TO BOX HI1.

HMONUMYR

HIMC24

numeric

HMONUM96

HIMC24

RECMHMO

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

BOX HIMC5

How many years [have you/has (SP)] been enrolled in a Medicare Advantage plan?
[IF THE RESPONDENT HAS BEEN ENROLLED IN MORE THAN ONE MEDICARE ADVANTAGE PLAN, THEN
ENTER THE TOTAL NUMBER OF YEARS THAT HE/SHE HAS BEEN ENROLLED IN ALL MEDICARE
ADVANTAGE PLANS.]

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

HIMC24 - HMONUM96

numeric

How many years [have you/has (SP)] been enrolled in a managed care plan?

(01) LESS THAN ONE YEAR
(-7) Empty

BOX HI1

BOX HI1

routing

IF A MEDICAID PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO HI6 COVTIME.
ELSE GO TO HI5INTRO - MCAIDINT.

HI5INTRO

no entry

BOX HI1B

routing

SHOW CARD HI3
MCAIDINT

PLEASE READ THIS INTRODUCTION SLOWLY AND CLEARLY:
Medicaid[, also known as (MEDICAID STATE PLAN NAME),] is a state program for low income persons or for
persons on public assistance. Sometimes persons with very large medical bills are also covered by Medicaid.

BOX HI1B

IF STATE IN WHICH SP LIVES DOES NOT OFFER A MEDICAID MANAGED CARE PLAN, GO TO HI5 AIDCOVER.
ELSE GO TO HI5INTRB - MCAIDINTB.

Page 8 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

MCAIDINTB

HI5INTRB

no entry

SHOW CARD HI4
Some people receive their Medicaid benefits from plans that have names like those listed on this card.

AIDCOVER

HI5

yes/no

COVTIME

HI6

Code List

Routing

HI5 - AIDCOVER

At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] covered by Medicaid?

(01) YES
(02) NO
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
(-9) Refused
on it?]

(01) HI6 - COVTIME
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1

code 1

(01) THE WHOLE TIME
(At the time of the last interview [you were/(SP) was] covered by Medicaid[, also known as (READ FROM ABOVE).]
(02) PART OF THE TIME
[Were you/Was (SP)] covered by Medicaid the whole time between (REFERENCE DATE) and [(today/DATE OF
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the time?
(-9) Refused

(01) BOX HI1C
(02) BOX HI1C
(-8) BOX HI1C
(-9) BOX HI1C

BOX HI1C

routing

IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI4.
ELSE IF COVTIME = THE WHOLE TIME, GO TO HI10A-MCAIDHMO,
ELSE GO TO HI7-CURRCOV.

HI7

yes/no

[[Are you/Is (SP)] now covered by Medicaid?] [Was (SP) covered by Medicaid on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]

BOX HI4

routing

IF COVTIME=PART OF THE TIME, GO TO COVENDMM,
ELSE IF COVTIME=THE WHOLE TIME AND [(IT'S A NEW PLAN) OR (IT'S A FALL ROUND)], GO TO HI10A MCAIDHMO,
ELSE GO TO BOX HIT1.

COVBEGMM

HI8

date

COVBEGYY

HI8

COVENDMM

COVENDYY

CURRCOV

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI8-COVBEGMM
(02) HI9 - COVENDMM
(-8) HI10A - MCAIDHMO
(-9) HI10A - MCAIDHMO

Between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)], when did
[your (SP's) Medicaid coverage start?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HI8-COVBEGYY

date

Between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)], when did
[your (SP's) Medicaid coverage start?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HI10A - MCAIDHMO

HI9

date

[since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicaid coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HI9 - COVENDYY

HI9

date

[since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicaid coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

BOX HI4A

Page 9 of 26

2024 MCBS Community Questionnaire

Variable Name

MCAIDHMO

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

BOX HI4A

IF THIS MEDICAID PLAN IS NEW, GO TO HI10A-MCAIDHMO,
ELSE GO TO BOX HIT1.

HI10A

routing

yes/no

Code List

(Some states now use managed care plans, such as HMOs (Health Maintenance Organizations), to provide some
or all health care for Medicaid beneficiaries.) [At the time of the last interview [you were/(SP) was] enrolled in a
Medicaid Managed Care Plan.] [Are you now/Is (SP) now/Were you/Was (SP)] enrolled in a Medicaid Managed
Care Plan [as of (DATE OF DEATH)/(DATE OF INSTITUTIONALIZATION)/(MEDICAID COVERAGE STOP
(01) YES
DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?
(02) NO
(-8) Don't Know
[ONLY SELECT “YES” IF THE RESPONDENT IS ACTUALLY ENROLLED IN THE PLAN; SOME STATES MAY
(-9) Refused
OFFER MANAGED CARE, BUT NOT REQUIRE ENROLLMENT.]

Routing

BOX HI5D

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

BOX HI5D

routing

IF ((ADMINISTERING ST, NS OR CPS) AND SP WAS COVERED BY A MEDICARE PRESCRIPTION DRUG
PLAN ANYTIME DURING THE CURRENT ROUND) OR (ADMINSTERING HI AND THERE WAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW), GO TO BOX HIT1.
ELSE IF (ADMINISTERING ST, NS OR CPS) AND SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION
DRUG PLAN ANYTIME DURING THE CURRENT ROUND, GO TO HI10D - MCDRXCOV.
ELSE GO TO HI10C1 - MPDCOVER.

(Some people who receive Medicaid benefits are also enrolled in a Medicare Prescription Drug plan, or Medicare
Part D plan, that pays for some or all of their prescribed medicines. The Medicare program automatically enrolls
such beneficiaries into a Medicare Prescription Drug plan, although the beneficiary may choose to switch to a
different prescription plan.)
MPDCOVER

HI10C1

yes/no

At any time [since (REFERENCE DATE)/between (REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you been/has (SP) been/was (SP)] enrolled in a Medicare Prescription Drug
plan that [covers/covered] medicines prescribed by a doctor or other health professional?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI10C2 - PDPCURR
(02) HI10D - MCDRXCOV
(-8) HI10D - MCDRXCOV
(-9) HI10D - MCDRXCOV

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI10C3 - PLAN_CAIDMPDP
(02) HI10D-MCDRXCOV 
(-8) HI10D-MCDRXCOV 
(-9) HI10D-MCDRXCOV

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

PDPCURR

PLAN_CAIDMPDP

HI10C2

HI10C3

yes/no

roster

[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in a Medicare Prescription Drug plan [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

[What is the name of the Medicare Prescription Drug plan that (currently covers/covered) [you/(SP)] [on (DATE OF
DEATH)/(DATE OF INSTITUTIONALIZATION)]?]
SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.

HI10C4 - PDPMORE

[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

Page 10 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)],
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)?
PDPMORE

HI10C4

Yes/No

(PROBE IF NECESSARY: Please include Medicare Prescription Drug plans [you were/(SP) was] automatically
enrolled in through Medicaid as well as any [you/he/she] enrolled in on [your/his/her] own.)

Code List

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI10C5 - PLAN_CAIDMPDPOTHR
(02) BOX HIT1
(-8) BOX HIT1
(-9) BOX HIT1

[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

Please tell me the names of [the other/all] Medicare Prescription Drug plans that [you have/he has/she has] been
enrolled in since (REFERENCE DATE) [besides (CURRENT MEDICARE PRESCRIPTION DRUG PLAN)].
PLAN_CAIDMPDPOTHR HI10C5

roster

[PROBE IF NECESSARY: Please include Medicare Prescription Drug plans [you were/(SP) was] automatically
enrolled in through Medicaid as well as any [you/he/she] enrolled in on [your/his/her) own.]
SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN NAMES AT THIS ROSTER.

BOX HIT1

[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

MCDRXCOV

HI10D

BOX HIT1

yes/no

(Does/Did) [your/(SP’s)] Medicaid plan cover medicines prescribed by a doctor or other health professional?

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF A TRICARE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO
HIT2 - COVTIME.
ELSE GO TO HIT1 - TRICOVER.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

SHOW CARD HIT1
As you (may) know, the Department of Defense sponsors a regionally managed health care program called
TRICARE for active duty and retired members of the uniformed Armed Forces, their families, and survivors.
TRICOVER

HIT1

yes/no

(01) YES
Please look at this card. At any time [since (REFERENCE DATE)/ between (PREVIOUS ROUND INTERVIEW
(02) NO
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] enrolled (-8) Don't Know
in or covered by any of these TRICARE plans?
(-9) Refused

BOX HIT1

(01) HIT2 - COVTIME
(02) BOX HIT3
(-8) BOX HIT3
(-9) BOX HIT3

(EXPLAIN IF NECESSARY: You may have received a reference card that looks like this (BACK OF SHOWCARD
HIT1).)

COVTIME

HIT2

code1

[At the time of the last interview [you were/(SP) was] covered by TRICARE.] [Were you/Was (SP)] covered by
TRICARE the whole time between [(REFERENCE DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], or only part of the time?

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

(01) BOX HIT2A
(02) BOX HIT2
(-8) BOX HIT2
(-9) BOX HIT2

Page 11 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

BOX HIT2

routing

IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HIT2A,
ELSE GO TO HIT3-CURRCOV.

HIT3

yes/no

[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered by TRICARE on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION?]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HIT5-COVBEGMM
(02) HIT4-COVENDMM
(-8) TRICOV
(-9) TRICOV

BOX HIT2A

routing

IF COVTIME=PART OF THE TIME, GO TO HIT4-COVENDMM,
ELSE IF COVTIME=THE WHOLE TIME AND [(IT'S A NEW PLAN) OR (IT'S A FALL ROUND)], GO TO TRICOV.
ELSE GO TO BOX HIT3.

COVENDMM

HIT4

date

[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] TRICARE coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HIT4 - COVENDYY

COVENDYY

HIT4

date

[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], when did [your/(SP’s)] TRICARE coverage [most recently/last] stop?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

BOX HIT2AA

BOX HI2AA

routing

IF THIS TRICARE PLAN IS NEW, GO TO HI10A-TRICOV,
ELSE GO TO BOX HIT3.

COVBEGMM

HIT5

date

When did [your/(SP’s)] TRICARE plan start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HIT5-COVBEGYY

COVBEGYY

HIT5

date

When did [your/(SP’s)] TRICARE plan start between (REFERENCE DATE) and [today/(DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

TRICOV

CURRCOV

Page 12 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

SHOWCARD HI6

(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
(04) Inpatient hospital care
(05) Nursing home or long term care
(06) Dental care
(Please look at this card). Which services are covered through TRICARE?
(07) Optical or vision care
(08) Hearing care
[PROBE: I am asking about the type of insurance coverage that you personally [have/have had], not what the plan
(09) Behavioral health care (e.g., counseling,
offers everyone.]
psychotherapy, mental health and substance use
disorder services)
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
(91) Other services
education, or gym membership.]
(-8) Don't Know
(-9) Refused
CHECK ALL THAT APPLY
TRICARE insurance plans may cover a variety of services or may be specific to only certain services, such as
prescribed medicines or dental coverage. I'd like to know what [your/(SP's)] TRICARE coverage
[includes/included].

TRICOV

TRICOV

mark all

TRICOVOS

TRICOVOS

verbatim text

[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]

BOX HIT2B
(91) TRICOVOS

(01) [Continuous Answer]

BOX HIT2B

OTHER (SPECIFY)

BOX HIT2B

routing

If TRICOV includes 01/Prescribed medicines, GO TO TRIMEDS;
ELSE GO TO BOX HIT3

(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
(02) A TRICARE RETAIL PHARMACY NETWORK
PHARMACY (TRRX)
(03) A MILITARY TREATMENT FACILITY PHARMACY
(MTF)
(04) A NON-NETWORK RETAIL PHARMACY
(91) SOMEWHERE ELSE
(-8) Don't Know
(-9) Refused

(01) BOX HIT3
(02) BOX HIT3
(03) BOX HIT3
(04) BOX HIT3
(91) TRIMEDOS-TRIMEDOS
(-8) BOX HIT3
(-9) BOX HIT3

(01) [Continuous Answer]

BOX HIT3

TRIMEDS

HIT4A1

code 1

SHOW CARD HIT2
Where [do you/does (SP)/did you/did (SP)] usually obtain [your/his/her] medicines? [Do you/Does (SP)/Did you/Did
(SP)] usually obtain them at a TRICARE mail order pharmacy (TMOP), a TRICARE retail pharmacy network
pharmacy (TRRx), a military treatment facility pharmacy (MTF), a non-network retail pharmacy, or somewhere
else?

TRIMEDOS

TRIMEDOS

verbatim text

SOMEWHERE ELSE (SPECIFY)

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO BOX CPS29A.
ELSE IF [(SP DID NOT REPORT RECEIVING HEALTH CARE SERVICES FROM M.T.F IN THE PREVIOUS
ROUND) AND ((SP WAS COVERED BY TRICARE IN THE CURRENT OR PREVIOUS ROUND)] OR (SP
SERVED IN THE ARMED FORCES)), GO TO HIT11- MILTHOSP.
ELSE GO TO BOX HI20.

BOX HIT3

MILTHOSP

HIT11

yes/no

[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE),
[have you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines at a
TRICARE Military Treatment Facility or MTF?

(01) YES
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY: A TRICARE Military Treatment Facility is any military hospital, or clinic, or NAVCARE (-9) Refused
clinic located on a military base or post around the world. MTFs are different from VA facilities.]

BOX HI20

Page 13 of 26

2024 MCBS Community Questionnaire

Variable Name

VACOVER

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

BOX HI20

routing

IF (SP DID NOT REPORT RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE PREVIOUS ROUND)
FALL ROUND AND (SP SERVED IN THE ARMED FORCES, P_SPAFEVER =1), GO TO HI36 - VACOVER
VACARCOV-VACARCOV.
ELSE GO TO BOX HI7.

HI36

yes/no

[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since (REFERENCE DATE),
[have you/has (SP) received/did (SP) receive] health care or health services or prescribed medicines through the
Department of Veterans Affairs or V.A.?

Since (TODAY'S DATE - 12 MONTHS, MONTH AND YEAR), did [you/(SP)] receive any care at a Veteran's Health
Administration facility or receive any other health care paid for by the VA?
VACARCOV

VACARCOV

yes/no

[IF NEEDED: Veteran's Health Administration facilities include VA hospitals, VA medical centers, VA outpatient
clinics, and VA nursing homes.]

Code List

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

BOX HI7

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) BOX HI17
(02) VAENROLL- VAENROLL
(-8) VAENROLL- VAENROLL
(-9) VAENROLL- VAENROLL

INCLUDE PRESCRIBED MEDICINES THROUCH THE DEPARTMENT OF VETERANS AFFAIRS OR VA.

VAENROLL

yes/no

(01) YES
Since (TODAY'S DATE - 12 MONTHS, MONTH AND YEAR), [have you been/has (SP) been/was (SP)] enrolled in (02) NO
VA health care?
(-8) Don't Know
(-9) Refused

BOX HI7

routing

IF AT LEAST ONE PUBLIC PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW,
GO TO HI11PREV - PUBINTRO.
ELSE GO TO HI11 - PUBCOVER.

PUBINTRO

HI11PREV

no entry

The next questions are about public plans [you were/(SP) was] covered by as of (REFERENCE DATE).

(01) CONTINUE
(-7) Empty

HI13 - COVTIME

PUBCOVER

HI11

yes/no

SHOW CARD HI6
At any time [since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] covered by any public program
other than Medicaid that pays for medical care for example, a public program that pays for prescribed medicines?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI12 - PLAN_PUBLIC
(02) BOX HI12AA
(-8) BOX HI12AA
(-9) BOX HI12AA

PLAN_PUBLIC

HI12

roster

What is the name of each of the public programs other than Medicaid that covered [you/(SP)]?
SELECT OR ADD ALL PUBLIC PROGRAM NAMES AT THIS ROSTER.
[WHEN YOU ENTER A PLAN, VERIFY WITH THE RESPONDENT THAT IT IS A PUBLIC PLAN.]

(01) ADD NEW PLAN

(01) HI13 - COVTIME

COVTIME

HI13

code 1

[At the time of the last interview [you were/(SP) was] covered by (PUBLIC PLAN NAME).] [Were you/Was (SP)]
covered by (PUBLIC PLAN NAME) the whole time between [(REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)], or only part of the time?

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

(01) BOX HI10
(02) BOX HI8
(-8) BOX HI8
(-9) BOX HI8

VAENROLL

BOX HI17

Page 14 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

BOX HI8

routing

IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO BOX HI10,
ELSE GO TO HI14-CURRCOV.

HI14

yes/no

[[Are you/Is (SP)] now covered by (PUBLIC PLAN NAME)?] [Was (SP) covered by (PUBLIC PLAN NAME) on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]

BOX HI10

routing

IF COVTIME=PART OF THE TIME, GO TO HI16-COVENDMM,
ELSE IF COVTIME=THE WHOLE TIME AND [(IT'S A NEW PLAN) OR (IT'S A FALL ROUND)], GO TO PUBCOV.
ELSE GO TO BOX HI12.

COVBEGMM

HI15

date

COVBEGYY

HI15

COVENDMM

COVENDYY

CURRCOV

Code List

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI15 - COVBEGMM
(02) HI16 - COVENDMM
(-8) PUBCOV
(-9) PUBCOV

When did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start [between (REFERENCE DATE) and (today/DATE
OF DEATH/DATE OF INSTITUTIONALIZATION)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HI15 - COVBEGYY

date

When did [your/(SP’s)] (PUBLIC PLAN NAME) coverage start [between (REFERENCE DATE) and (today/DATE
OF DEATH/DATE OF INSTITUTIONALIZATION)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

PUBCOV

HI16

date

(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] stop?
(-9) Refused

HI16 - COVENDYY

HI16

date

(01) [Continuous answer.]
[Since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] (PUBLIC PLAN NAME) coverage [most recently/last] stop?
(-9) Refused

BOX HI11

BOX HI11

routing

IF THIS PUBLIC PLAN IS NEW, GO TO PUBCOV.
ELSE GO TO BOX HI12.

(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
I'd like to know what your PUBLIC PLAN coverage [includes/included].
(04) Inpatient hospital care
(05) Nursing home or long term care
(Please look at this card). Which services [are/were] covered through [your/(SP's)] PUBLIC PLAN?
(06) Dental care
(07) Optical or vision care
[PROBE: I am asking about the type of insurance coverage that you personally [have/had], not what the plan offers
(08) Hearing care
everyone.]
(09) Behavioral health care (e.g., counseling,
psychotherapy, mental health and substance use
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
disorder services)
education, or gym membership.]
(91) Other services
(-8) Don't Know
CHECK ALL THAT APPLY
(-9) Refused
SHOWCARD HI6

PUBCOV

PUBCOV

mark all

(01)-(08), (-8), (-9) BOX HI12
(91) PUBCOVOS

Page 15 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

PUBCOVOS

PUBCOVOS

verbatim text

Question Text/Description

[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]

Code List

Routing

(01) [Continuous Answer]

BOX HI12

OTHER (SPECIFY)

BOX HI12

PUBMORE

PUBMORE

BOX HI12AA

routing

code one

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERIGN CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING ADDITIONAL PUBLIC PLANS THAT WERE "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI13-COVTIME.
ELSE GO TO PUBMORE.

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION)], [have you/has (SP)/had (SP)] been covered by any other public program other than
Medicaid that pays for medical care [for example, a public program that pays for prescribed medicines?

(01) YES
(02) NO
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-9) Refused
on it?]

IF (SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW), GO TO HI16AB - PDPSAME.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT" MEDICARE
MANAGED CARE PLAN WITH RX COVERAGE) AND (HI10C1 - MPDCOVER = empty)), GO TO HI16B PDPCOVER.
ELSE IF ((SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG PLAN THAT WAS "CURRENT" AT THE
TIME OF THE PREVIOUS ROUND INTERVIEW) AND (SP DOES NOT HAVE A "CURRENT" MEDICARE
MANAGED CARE PLAN WITH RX COVERAGE) AND (HI10C1 - MPDCOVER = 2/No)), GO TO HI16B1 PDPCOVER.
ELSE GO TO BOX HI12A.

At the time of the last interview [you were/(SP) was] covered by a Medicare Prescription Drug Plan named
(MEDICARE PRESCRIPTION DRUG PLAN NAME).
PDPSAME

HI16AB

yes/no

COVENDMM

HI16ABB

date

(01) HI12-PLAN_PUBLIC
(02) BOX HI12AA
(-8) BOX HI12AA
(-9) BOX HI12AA

(01) YES
[[Are you/Is (SP)] now covered by (MEDICARE PRESCRIPTION DRUG PLAN NAME)?] [Was (SP) covered by
(02) NO
(MEDICARE PRESCRIPTION DRUG PLAN NAME) on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?] (-8) Don't Know
[IF THE RESPONDENT DROPPED THE INDICATED COVERAGE SINCE THE PREVIOUS INTERVIEW DATE, (-9) Refused
BUT PICKED UP THE COVERAGE AGAIN AND CURRENTLY IS COVERED BY THE NAMED PLAN, SELECT
“YES” FOR THIS QUESTION.]

[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused

(01) BOX HI12A
(02) HI16ABB - COVENDMM
(-8) BOX HI12A
(-9) HI16AD - PDPOTHER

COVENDYY

Page 16 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

COVENDYY

HI16ABB

[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused

date

PDPYSTOP

HI16AC

code 1

What is the most important reason [you/(SP)] stopped the (MEDICARE PRESCRIPTION DRUG PLAN NAME)
coverage?

PDPYSTOS

HI16AC

verbatim text

OTHER (SPECIFY)

Code List

(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH PLAN'S COVERAGE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET DIFFERENT HEALTH CARE COVERAGE
(05) PLAN NO LONGER CONTRACTS FOR MEDICARE
RX COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS BOUGHT
BY/MERGED WITH ANOTHER PLAN
(07) SP MOVED OUT OF PLAN AREA
(91) OTHER
(-8) Don't Know
(-9) Refused

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/INSTITUTIONALIZATION)],
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (MEDICARE
PRESCRIPTION DRUG PLAN CURRENT LAST ROUND)?
PDPOTHER

HI16AD

yes/no

(01) YES
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (02) NO
on it?]
(-8) Don't Know
(-9) Refused
ONLY ENTER STAND-ALONE PRESCRIPTION DRUG PLANS AT THIS QUESTION. IF THE R HAS RX
COVERAGE THROUGH ANOTHER INSURANCE PLAN, SUCH AS A MEDICARE ADVANTAGE PLAN, DO NOT
ENTER A SEPARATE PRESCRIPTION DRUG PLAN.

Routing

HI16AC - PDPYSTOP

(01) HI16AD - PDPOTHER
(02) HI16AD - PDPOTHER
(03) HI16AD - PDPOTHER
(04) HI16AD - PDPOTHER
(05) HI16AD - PDPOTHER
(06) HI16AD - PDPOTHER
(07) HI16AD - PDPOTHER
(91) HI16AC - PDPYSTOS
(-8) HI16AD - PDPOTHER
(-9) HI16AD - PDPOTHER

HI16AD - PDPOTHER

(01) HI16E-PLAN_MPDP
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

(Medicare beneficiaries can receive insurance coverage for prescription drugs through Medicare Prescription Drug
plans. These plans are also called "Medicare Part D" plans.)
At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled in a Medicare Prescription
Drug plan that [covers/covered] medicines prescribed by a doctor or other health professional?
PDPCOVER

HI16B

yes/no

(01) YES
(02) NO
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-8) Don't Know
on it?]
(-9) Refused

(01) HI16E-PLAN_MPDP
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

ONLY ENTER STAND-ALONE PRESCRIPTION DRUG PLANS AT THIS QUESTION. IF THE R HAS RX
COVERAGE THROUGH ANOTHER INSURANCE PLAN, SUCH AS A MEDICARE ADVANTAGE PLAN, DO NOT
ENTER A SEPARATE PRESCRIPTION DRUG PLAN.

Page 17 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

You mentioned that [you are not currently/(SP) is not currently/(SP) had not been] enrolled in a Medicare
Prescription Drug plan that is associated with [your/his/her] Medicaid coverage.
PDPCOVER

HI16B1

yes/no

At any time since (REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled in a Medicare Prescription
Drug plan in any way other than through Medicaid?
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

Code List

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI16E-PLAN_MPDP
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

What is the name of the Medicare Prescription Drug plan that [currently covers/covered] [you/(SP)] [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?]
PLAN_MPDP

HI16E

roster

COVTIME

SELECT OR ADD ONLY ONE MEDICARE PRESCRIPTION DRUG PLAN AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

(01) BOX HIEA
(02) BOX HIE
(-8) BOX HIE
(-9) BOX HIE

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI16D-COVBEGMM
(02) HI16H-COVENDMM
(-8) BOX HI12A
(-9) BOX HI12A

HIMPDP

code 1

Were you covered by (Medicare Prescription Drug PLAN NAME) the whole time between [(REFERENCE DATE)
and (today], or only part of the time?

BOX HIE

routing

GO TO HI16C-CURRCOV.

CURRCOV

HI16C

yes/no

[Are you/Is (SP)/Was (SP)] [currently] covered by or enrolled in (Medicare Prescription Drug PLAN NAME) [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

COVBEGMM

HI16D

date

(01) [Continuous answer.]
When did [your/(SP’s)] Medicare Prescription Drug Plan start between (REFERENCE DATE) and [today/(DATE OF
(-8) Don't Know
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-9) Refused

COVBEGYY

HI16D

date

(01) [Continuous answer.]
When did [your/(SP’s)] Medicare Prescription Drug Plan start between (REFERENCE DATE) and [today/(DATE OF
(-8) Don't Know
DEATH)/(DATE OF INSTITUTIONALIZATION)]?
(-9) Refused

BOX HIEA

COVENDMM

HI6H

date

[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused

COVENDYY

COVENDYY

HI16H

date

[Since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) [Continuous answer.]
INSTITUTIONALIZATION)], when did [your/(SP’s)] Medicare Prescription Drug Plan's coverage [most recently/last] (-8) Don't Know
stop?
(-9) Refused

BOX HIEA

COVTIME

HI8-COVBEGYY

Page 18 of 26

2024 MCBS Community Questionnaire

Variable Name

PDPMORE

PLAN_MPDPOTHR

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

BOX HIEA

routing

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE GO TO HI16F - PDPMORE.

yes/no

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and (DATE OF DEATH/ INSTITUTIONALIZATION)],
(01) YES
[have you/has (SP)/had (SP)] been covered by any other Medicare Prescription Drug plans besides (CURRENT
(02) NO
MEDICARE PRESCRIPTION DRUG PLAN)?
(-8) Don't Know
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name (-9) Refused
on it?]

HI16F

HI16G

roster

Code List

[Besides (CURRENT PRESCRIPTION DRUG PLAN), what other/Besides (PREVIOUS ROUND PRESCRIPTION
DRUG PLAN), what other/What] Medicare Prescription Drug plans covered [your/(SP’s)] medicines since
(REFERENCE DATE)?

Routing

(01) HI16G - PLAN_MPDPOTHR
(02) BOX HI12A
(-8) BOX HI12A
(-9) BOX HI12A

BOX HI12A

SELECT OR ADD MEDICARE PRESCRIPTION DRUG PLAN NAMES AT THIS ROSTER.
[PRESCRIPTION DRUG PLAN LOOKUP CALLED AT THIS SCREEN]

PRIVINTRO

BOX HI12A

routing

IF AT LEAST ONE PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW,
GO TO HI17PREV - PRIVINTRO.
ELSE GO TO HI17 - PRIVCOV

HI17PREV

no entry

The next questions are about private plans [you were/(SP) was] covered by as of (REFERENCE DATE).

(01) CONTINUE
(-7) Empty

HI21 - COVTIME

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI18A - EXCHGCOV
(02) BOX HI13A
(-8) BOX HI13A
(-9) BOX HI13A

You reported that [you are/(SP) is/(SP) was] covered by [READ PLAN NAME(S) AND PLAN TYPE(S) LISTED
ABOVE].

PRIVCOV

HI17

yes/no

(Now, I would like to ask about another type of health insurance.) At any time [since (REFERENCE
DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)] covered by [any other] private health insurance
plans?
Private plans include supplemental or Medigap plans, plans that are provided by a former or current employer, and
plans that you have directly purchased. Such plans cover the cost of hospital or doctor visits, prescribed
medicines, dental care, vision care, or hearing care.

Page 19 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

HI20 - PLAN_PRIVATE

As you may know, every state now offers a health insurance marketplace, also referred to as an exchange.
The marketplace[, known as (STATE MARKETPLACE NAME),] allows residents to compare and purchase
available health insurance options that meet their needs. While most Medicare beneficiaries are not eligible for
insurance from a health insurance marketplace, there are some special circumstances that allow enrollment.
EXCHGCOV

HI18A

yes/no

At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been enrolled in or covered by one of these exchange
plans?
[MEDICARE BENEFICIARIES ARE NOT ELIGIBLE TO OBTAIN INSURANCE THROUGH THESE PLANS. THE
RESPONSE TO THIS QUESTION SHOULD ALMOST ALWAYS BE “NO”. HOWEVER, SOME RESPONDENTS
MAY SIGN UP FOR THESE PLANS DUE TO CONFUSION ABOUT THE PROGRAM.]

BOX HI13A

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO HI19 - GAPCOVER.
ELSE GO TO BOX HI19B.

(01) HI20 - PLAN_PRIVATE
(02) HI35 - PRVOCOV
(-8) HI35 - PRVOCOV
(-9) HI35 - PRVOCOV

GAPCOVER

HI19

yes/no

Some people who are eligible for Medicare have additional coverage through a private insurance carrier referred to
as Medigap or Medicare Supplement -insurance. These plans help pay some of the health care costs that Original
Medicare doesn't cover, like copayments, coinsurance and deductibles.
(01) YES
(02) NO
At any time since (REFERENCE DATE) did [you/(SP)] have this type of health insurance coverage?
(-8) Don't Know
(-9) Refused
[PROBE IF NECESSARY: Do you have a health plan card, insurance statement, or something with the plan name
on it?]

PLAN_PRIVATE

HI20

roster

What is the name of each of the [other] private plans that [provide/provided] [your/(SP’s)] medical insurance
coverage?
SELECT OR ADD ALL PRIVATE PLAN NAMES AT THIS ROSTER.

(01) continuous answer
(996) PLAN ENTERED IN ERROR

HI21-COVTIME

COVTIME

HI21

code 1

[At the time of the last interview [you were/(SP) was] covered by a private plan named (PRIVATE PLAN NAME).]
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the whole time between (REFERENCE DATE) and
[today/ DATE OF DEATH/DATE OF INSTITUTIONALIZATION], or only part of the time?

(01) THE WHOLE TIME
(02) PART OF THE TIME
(-8) Don't Know
(-9) Refused

(01) BOX HI17
(02) BOX HI14
(-8) BOX HI14
(-9) BOX HI14

BOX HI14

routing

IF THIS PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW AND COVTIME=PART
OF THE TIME, GO TO COVENDMM,
ELSE GO TO HI22-CURRCOV.

HI22

yes/no

[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was (SP) covered by (PRIVATE PLAN NAME) on
(DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)?]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI23-COVBEGMM
(02) HI24 - COVENDMM
(-8) BOX HI17
(-9) BOX HI17

CURRCOV

Page 20 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

COVBEGMM

HI23

date

When did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (REFERENCE DATE) and
[today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HI23 - COVBEGYY

COVBEGYY

HI23

date

When did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) start between (REFERENCE DATE) and
[today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

BOX HI17

COVENDMM

HI24

date

(01) [Continuous answer.]
[since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-9) Refused

HI24 - COVENDYY

COVENDYY

HI24

date

(01) [Continuous answer.]
[since (REFERENCE DATE)/between (PREVIOUS ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
(-8) Don't Know
INSTITUTIONALIZATION)], when did [your/(SP’s)] coverage under (PRIVATE PLAN NAME) stop?
(-9) Refused

BOX HI17

BOX HI17

routing

IF THIS PRIVATE PLAN IS NEW, GO TO HI25 - PPRVHMO
ELSE IF THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE PREVIOUS ROUND INTERVIEW AND
IS STILL "CURRENT", AND IT IS A FALL ROUND, GO TO HI26 - PERS_MIPNUM.
ELSE GO TO BOX HI19.

PPRVHMO

PERS_MIPNUM

HI25

HI26

yes/no

roster

CODE WITHOUT ASKING IF VOLUNTEERED.
[Is/Was] this a managed care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred
Provider Organization)?
[EXPLAIN IF NECESSARY: Managed care plans generally provide a full range of health care services for a
prepaid fee. Health care is generally provided by primary care doctors, specialists, or hospitals on the plan’s list
(network) except in an emergency.]

Who [is/was] listed as the main insured person on the (PRIVATE PLAN NAME) policy or contract?
SELECT OR ADD ONLY ONE PERSON.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

DISPLAY PERSON ROSTER AS RESPONSE
OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/OtherRelative or 92/OtherNonRelative, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

HI26 - PERS_MIPNUM

(01-N) BOX HI15
(N+1) HI26_NEW-ROSTFNAM
IF EXISTING PERSON SELECTED, GO TO BOX HI15
ELSE IF "ADD ANOTHER" SELECTED, GO TO
HI26_NEW-ROSTFNAM

ROSTFNAM

HI26_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

HI26_NEW - ROSTLNAM

ROSTLNAM

HI26_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) continuous answer

HI26_NEW - ROSTREL

Page 21 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HI15
(56) BOX HI15
(58) BOX HI15
(59) BOX HI15
(60) BOX HI15
(61) BOX HI15
(91) HI26_NEW - ROSTREOS
(-8) BOX HI15
(-9) BOX HI15

ROSTREL

HI26_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HI26_NEW

verbatim text

[What is the name of the person and relationship to (SP)?]

BOX HI15

routing

IF PRIVOBTN HAS NEVER BEEN ASKED FOR THIS PLAN (PLAN.PRIVOBTN=.), GO TO PRIVOBTN,
ELSE GO TO PRVNMCOV.

(01) HI29 - PRVNMCOV
(02) HI29 - PRVNMCOV
(03) HI29 - PRVNMCOV
(04) HI29 - PRVNMCOV
(05) HI29 - PRVNMCOV
(06) HI29 - PRVNMCOV
(07) HI29 - PRVNMCOV
(08) HI29 - PRVNMCOV
(09) HI29 - PRVNMCOV
(91) HI27 - PRIVOBOS
(-8) HI29 - PRVNMCOV
(-9) HI29 - PRVNMCOV

HI29 - PRVNMCOV

(01) continuous reponse
(-8) Don't Know
(-9) Refused

PRIVOBTN

HI27

code 1

(01) DIRECTLY
(02) (MIP'S) CURRENT EMPLOYER
(03) (MIP'S) FORMER EMPLOYER
(04) (MIP'S) UNION
(05) (MIP'S) FAMILY BUSINESS
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up directly, or did [you/(MIP)] get this insurance through (06) AARP
a current employer, a former employer, a union, a family business, AARP, or some other way?
(07) DECEASED SPOUSE'S EMPLOYER
(08) DECEASED SPOUSE'S UNION
(09) PROFESSIONAL/FRATERNAL ORGANIZATION
(91) SOME OTHER WAY
(-8) Don't Know
(-9) Refused

PRIVOBOS

HI27

verbatim text

OTHER (SPECIFY)

PRVNMCOV

HI29

numeric

BOX HI17AB

routing

How many family members, including [yourself/(SP)], [are/were] covered by [your/(MIP’s)] (PRIVATE PLAN
NAME)?
[INCLUDE ALL FAMILY MEMBERS COVERED BY THE PLAN REGARDLESS OF WHETHER OR NOT THEY
LIVE WITH THE RESPONDENT. MAKE SURE THE RESPONDENT INCLUDES HIM/HERSELF IN THE COUNT.]

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

BOX HI15

BOX HI17AB

IF (THIS PRIVATE PLAN IS NEW) OR (THIS PRIVATE PLAN WAS "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW AND IS STILL "CURRENT", AND IT IS A FALL ROUND), GO TO HI31A PRIVSERV.
ELSE GO TO BOX HI19.

Page 22 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

SHOWCARD HI6

(01) Prescribed medicines
(02) Visits to a doctor or other health professional
(03) Lab work
(04) Inpatient hospital care
(05) Nursing home or long term care
(06) Dental care
(Please look at this card). Which services [are/were] covered through [PLAN NAME]?
(07) Optical or vision care
(08) Hearing care
[PROBE: I am asking about the type of insurance coverage that [you/(SP) personally [have/has/had], not what the
(09) Behavioral health care (e.g., counseling,
plan offers everyone.]
psychotherapy, mental health and substance use
disorder services)
[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
(91) Other services
education, or gym membership.]
(-8) Don't Know
(-9) Refused
CHECK ALL THAT APPLY
Private insurance plans may cover a variety of services or may be specific to only certain services, such as
prescribed medicines or dental coverage. I'd like to know what [your/(SP)'s] [PLAN NAME] coverage
[includes/included].

PRIVSERV

HI31A

mark all

PRIVSVOS

PRIVSVOS

text

[IF NEEDED: Other services may include physical therapy, occupational therapy, speech therapy, health
education, or gym membership.]

HI32 - MIPPINS
(91) PRIVSVOS

(01) [Continuous answer]

HI32 - MIPPINS

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI33 - MIPPAMT
(02) HI33A - MHMOCOST
(-8) HI33A - MHMOCOST
(-9) HI33A - MHMOCOST

OTHER (SPECIFY)

MIPPINS

HI32

yes/no

[Do/Does/Did] [you/(MIP)] pay any or all of the premium or cost for the (PRIVATE PLAN NAME) coverage?
[Do not include the cost of any deductibles [you/(SP)] or [your/(SP’s)] family may [have/have had] to pay.]

How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN NAME) coverage?

MIPPAMT

HI33

quantity unit hybrid

[Please include the full amount paid for the coverage, including any amount that may be paid for anyone other
than [you/(SP)].]
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per week, or what?]

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) HI33 - MIPPUNIT
(-8) HI33-MIPPUNIT
(-9) HI33-MIPPUNIT

IF MORE THAN ONE PERSON (EX: SPOUSE, FAMILY MEMBER) IS COVERED BY THIS PLAN, THEN ENTER
THE TOTAL AMOUNT PAID, INCLUDING THE COST FOR THESE OTHER MEMBERS.

MIPPUNIT

HI33

quantity unit hybrid

How much [do/does/did] [you/(MIP)] pay for the (PRIVATE PLAN NAME) coverage?
[Please do not include any amount that may be paid for anyone other than [you/(SP)].]
[PROBE IF NECESSARY: [Is/Was] that per year, per month, per week, or what?]

MIPPUNOS

HI33

verbatim text

OTHER (SPECIFY)

(01) PER YEAR
(02) QUARTERLY/EVERY 3 MONTHS
(03) BIMONTHLY/EVERY 2 MONTHS
(04) PER MONTH
(05) PER WEEK
(06) SEMI-ANNUALLY/2 TIMES PER YEAR
(07) SEMI-MONTHLY/2 TIMES PER MONTH
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(07) BOX PRIVCAT
(91) HI33 - MIPPUNOS
(-8) BOX PRIVCAT
(-9) BOX PRIVCAT

BOX PRIVCAT

Page 23 of 26

2024 MCBS Community Questionnaire

Variable Name

HIQ-HEALTH INSURANCE

MR Screen Name Question Type

Question Text/Description

Code List

Routing

BOX PRIVCAT

routing

IF MIPPAMT=DK AND MIPPUNIT=1/PER YEAR, GO TO MIPPYR.
ELSE IF MIPPAMT=DK AND MIPPUNIT=2/QUARTERLY, GO TO MIPPQR.
ELSE IF MIPPAMT=DK AND MIPPUNIT=3/BIMONTHLY, GO TO MIPPBI.
ELSE IF MIPPAMT=DK AND MIPPUNIT=4/PER MONTH, GO TO MIPPMO.
ELSE IF MIPPAMT=DK AND MIPPUNIT=5/PER WEEK, GO TO MIPPWE.
ELSE IF MIPPAMT=DK AND MIPPUNIT=6/SEMI-ANNUALLY/2 TIMES PER YEAR, GO TO MIPPSA.
ELSE IF MIPPAMT=DK AND MIPPUNIT=7/SEMI-MONTHLY/2 TIMES PER MONTH, GO TO MIPPSM.
ELSE GO TO HI33A-MHMOCOST.

MIPPYR

MIPPYR

code 1

PER YEAR: Please tell me which is the closest…

(01) <250
(02) 250-749
(03) 750-1499
(04) 1500-3999
(05) 4000+

HI33A-MHMOCOST

MIPPQR

MIPPQR

code 1

PER QUARTER: Please tell me which is the closest…

(01) <200
(02) 200-399
(03) 400-599
(04) 600-899
(05) 900+

HI33A-MHMOCOST

MIPPBI

MIPPBI

code 1

BIMONTHLY: Please tell me which is the closest…

(01) <150
(02) 150-299
(03) 300-449
(04) 450-599
(05) 600+

HI33A-MHMOCOST

HI33A-MHMOCOST

MIPPMO

MIPPMO

code 1

PER MONTH: Please tell me which is the closest…

(01) <50
(02) 50-99
(03) 100-199
(04) 200-399
(05) 400+

MIPPWE

MIPPWE

code 1

PER WEEK: Please tell me which is the closest…

(01) <10
(02) 10-24
(03) 25-74
(04) 75-149
(05) 150+

HI33A-MHMOCOST

MIPPSA

MIPPSA

code 1

2 TIMES/YEAR: Please tell me which is the closest…

(01) <100
(02) 100-299
(03) 300-999
(04) 1000-1999
(05) 2000+

HI33A-MHMOCOST

Page 24 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

MIPPSM

MIPPSM

code 1

2 TIMES/MONTH: Please tell me which is the closest…

(01) <10
(02) 10-34
(03) 35-99
(04) 100-199
(05) 200+

HI33A-MHMOCOST

MHMOCOST

HI33A

yes/no

[Does/Did] anyone else, such as an employer, a union or professional organization pay all or some portion of the
premium or cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) HI33B - MHMOWHO
(02) BOX HI17B
(-8) BOX HI17B
(-9) BOX HI17B

(01) [(SP's)/(MIP's)] CURRENT EMPLOYER
(02) (SP's/MIP's) FORMER EMPLOYER
(03) (SP's/MIP's) UNION
(04) SPOUSE'S CURRENT EMPLOYER
(05) SPOUSE'S FORMER EMPLOYER
(06) PROFESSIONAL/FRATERNAL ORGANIZATION
(07) MEDICAID/MEDICAL ASSISTANCE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX HI17B
(02) BOX HI17B
(03) BOX HI17B
(04) BOX HI17B
(05) BOX HI17B
(06) BOX HI17B
(07) BOX HI17B
(91) HI33B - MHMOWHOS
(-8) BOX HI17B
(-9) BOX HI17B

MHMOWHO

HI33B

code 1

Who else [pays/paid] all or some portion of the cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

MHMOWHOS

HI33B

verbatim text

OTHER (SPECIFY)

BOX HI17B

routing

IF THIS PRIVATE PLAN IS A MANAGED CARE PLAN, GO TO HI33C - MHMOPOS.
ELSE GO TO BOX HI19.

BOX HI17B

Some managed care plans offer a point-of-service option which allows members to receive services from out-ofplan providers even in non-emergency situations. [Are/Were/Is/Was] [you/(SP)] enrolled in a point-of-service
option offered by (PRIVATE PLAN NAME)?
MHMOPOS

HI33C

BOX HI19

yes/no

routing

(01) YES
(02) NO
[EXPLAIN IF NECESSARY: In a point-of-service option, the member typically pays a higher copayment when
(-8) Don't Know
seeing an out-of-plan provider. For example, if a member sees an in-plan provider, there may only be a $10
(-9) Refused
copayment. However, the member may have to pay 20 percent of the cost and the managed care plan will pay 80
percent of the cost to receive the same service from an out-of-plan provider.]

BOX HI19

IF ADMINISTERING ST, GO TO BOX ST69A.
ELSE IF ADMINISTERING NS, GO TO BOX NS69A.
ELSE IF ADMINISTERING CPS, GO TO BOX CPS29A.
ELSE IF REVIEWING ADDITIONAL PRIVATE PLANS THAT WERE "CURRENT" AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO HI21-COVTIME.
ELSE GO TO HI35-PRVOCOV.

Page 25 of 26

2024 MCBS Community Questionnaire

HIQ-HEALTH INSURANCE

Variable Name

MR Screen Name Question Type

Question Text/Description

PRVOCOV

HI35

yes/no

(01) YES
We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do you/Does (SP)/Did (SP)] have medical coverage under (02) NO
any (other) private insurance plans we haven’t talked about?
(-8) Don't Know
(-9) Refused

BOX HI19B

routing

IF (SP IS IN THE SUPPLEMENTAL SAMPLE) OR (SP IS NEW FROM FACILITY), GO TO HI34 - OTHNHCOV.
ELSE GO TO BOX HI21A.

HI34

yes/no

[Other than the plans you have already told me about, [do you/does (SP)/did (SP)]/[Do you/Does (SP)/Did (SP)]]
have any insurance that [pays/paid] just for nursing home care or other long term care?

BOX HI21A

routing

IF SEASON=FALL, GO TO MBQ.
IF SEASON= WINTER OR SUMMER, GO TO PVQ.

OTHNHCOV

Code List

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Routing

(01) HI20 - PLAN_PRIVATE
(02) BOX HI19B
(-8) BOX HI19B
(-9) BOX HI19B

BOX HI21A

Page 26 of 26


File Typeapplication/pdf
AuthorTheresa Juliano
File Modified2023-05-17
File Created2023-05-17

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