STASE
Covered by non-comprehensive state-specific program in September
Description
Extracts include the STAJA-STADE variables if users choose STAMM during the extract process.
Codes and Frequencies
An 'X' indicates the category is available for that sample
| Code | Label |
16
|
15
|
14
|
13
|
12
|
11
|
10
|
09
|
08
|
07
|
06
|
05
|
04
|
03
|
02
|
01
|
00
|
99
|
98
|
97
|
96
|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 0 | NIU | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X |
| 1 | No | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X |
| 2 | Yes | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X |
Can't find the category you are looking for? Try the Detailed codes
Comparability
No information available.Universe
- 1996-2016: All persons in a reference period that includes September of the current year.
Availability
- 1996-2016
Survey Text
| 2016 | 2010 | 2004 | 1998 |
| 2015 | 2009 | 2003 | 1997 |
| 2014 | 2008 | 2002 | 1996 |
| 2013 | 2007 | 2001 | |
| 2012 | 2006 | 2000 | |
| 2011 | 2005 | 1999 |
2016
Survey form
view entire document:
text
image
HX16
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[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2015
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2014
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2013
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2012
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2011
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2010
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2009
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2008
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2007
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2006
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2005
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2004
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2003
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2002
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2001
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
2000
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
1999
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
1998
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
1997
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
1996
Survey form
view entire document:
text
image
HX16
====
====
====
====
====
====
====
====
====
[STR-DT]
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
[During the last interview, we recorded that no one in the family/Some people] receive[d] health benefits from other state programs [such as (READ PROGRAM NAMES BELOW) or other public programs] that provide coverage for health care services.
[STATE NAME FOR PROGRAM #1..................]
[STATE NAME FOR PROGRAM #2..................]
[STATE NAME FOR PROGRAM #3..................]
At any time since (START DATE), has anyone in the family been covered by any program like this?
YES .................................... 1
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
HX17
NO ..................................... 2 [HX21]
REF ................................... -7 [HX21]
DK .................................... -8 [HX21]
PRESS F1 FOR A LIST OF OTHER STATE PROGRAMS.
----------------------------------------------------
DISPLAY 'During the last interview, we recorded that no one in the family' AND THE 'd' ON 'receive' IF NOT ROUND 1. OTHERWISE, DISPLAY 'Some people'.
DISPLAY 'such as...programs' IF INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN NEXT BOX) FOR 'STATE NAME FOR PROGRAM #N' IF STATE HAS OTHER STATE PROGRAMS. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
ALABAMA Hypertension Program
ARIZONA Teen Prenatal Express Program (TPE)
ARKANSAS Arkansas Kidney Disease Commission
CALIFORNIA AIDS Drug Assistance Program (ADAP) HIV Children Program
COLORADO Colorado Child Health Plan Assistance for AIDS Specific Drugs (AASD)
CONNECTICUT ConnPACE Connecticut AIDS Drug Assistance Progam (CADAP)
DISTRICT OF COLUMBIA Medical Charities Plan
FLORIDA Florida Statewide Kidney Disease Progam
GEORGIA AIDS Drug Assistance Program
HAWAII Hawaii Chronic Renal Disease Program HIV Drug Assistance Program
IDAHO Catastrophic Fund
ILLINOIS Circuit Breaker Pharmaceutical Assistance Program
INDIANA Indiana State Department of Health- Renal Program
IOWA Caring Program for Children Chronic Renal Disease Program
KENTUCKY Kentucky AIDS Drug Assistance Progam (KADAP)
LOUISIANA HIV Formulary
MAINE Elderly Low Cost Drug Program Maine AIDS Drug Assistance Program (ADAP)
MARYLAND Kidney Disease Program Maryland Pharmacy Asssistance Program (MPAP) Maryland State Family Planning Program
MASSACHUSETTS CenterCare Program Children's Medical Security Plan Healthy Start
MICHIGAN Caring Program for Children Non-Medicaid MICH-Care Program
MISSOURI Missouri Kidney Program (MoKP)
MONTANA End-Stage Renal Disease Program
NEBRASKA Chronic Renal Disease Program
NEW HAMPSHIRE Catastophic Illness Program
----------------------------------------------------
----------------------------------------------------
STATE OTHER PUBLIC PROGRAM(S)
NEW JERSEY Pharmaceutical Assistance for the Aged and Disabled (PAAD) Chronic Renal Disease Services
NEW MEXICO Home Delivery Drug Program
NEW YORK Child Health Plus (CHP) Elderly Pharmacuetical Insurance Program (EPIC)
NORTH CAROLINA State Kidney Program HIV Medications Program Caring Program for Children
OHIO Ohio Disability Assistance Medical Program Ohio AIDS Drug Assistance Program (ADAP)
OKLAHOMA HIV Drug Assistance Programs
PENNSYLVANIA Special Pharmaceutical Benefits Program (SPBP) Pharmaceutical Assistance Contract for the Elderly (PACE)
RHODE ISLAND Other Public Assistance (GPA) Medical Program Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
TENNESSEE Tennessee Renal Disease Program
TEXAS Division of Kidney Health Care Program AIDS/STD Medication Program
UTAH HIV/AIDS Drug Therapy Program
VERMONT General Assistance Medical Program Vscript Pharmaceutical Program
WASHINGTON Washington State Kidney Disease Program
WEST VIRGINIA Special Pharmacy Program
WYOMING Minimum Medical Program (MMP)
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
What is the name of the program?
PROBE: Any other state program?
NOTE: IF ONLY AFDC, SSI, WIC, IHS, PUBLIC HEALTH CLINIC, OR VA IS MENTIONED, CODE 95.
[STATE SPECIFIC PLAN 1] ................ 1
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
HX18
[STATE SPECIFIC PLAN 2] ................ 2
[STATE SPECIFIC PLAN 3] ................ 3
[STATE SPECIFIC PLAN 4] ................ 4
[STATE SPECIFIC PLAN 5] ................ 5
[STATE SPECIFIC PLAN 6] ................ 6
OTHER ................................. 91
NONE OF THESE ......................... 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
FOR 'STATE SPECIFIC PLAN N', DISPLAY AN ACTUAL NAME OF A STATE PLAN WHEN INTERVIEW IS BEING CONDUCTED IN A STATE THAT HAS OTHER STATE PROGRAMS THAT IS, A STATE OTHER THAN ONE OF THE FOLLOWING:
ALASKA MISSISSIPPI SOUTH CAROLINA DELAWARE NEVADA SOUTH DAKOTA KANSAS NORTH DAKOTA VIRGINIA MINNESOTA OREGON WISCONSIN
FOR THE SPECIFIC NAMES OF PROGRAMS BY STATE, SEE BOX ON HX16.
USE A NULL DISPLAY WHEN INTERVIEW IS BEING CONDUCTED IN ONE OF THE STATES LISTED ABOVE.
----------------------------------------------------
----------------------------------------------------
ANY PROGRAM SELECTED IN HX17 IS CONSIDERED A GROUP
1 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19.
----------------------------------------------------
----------------------------------------------------
CODES '1', '2', '3', '4', '5', AND '6' ARE RESERVED FOR STATE SPECIFIC PLANS. IF THE STATE HAS LESS THAN 6 PLANS, DO NOT ADJUST THE OTHER CODES. (I.E., FOR A STATE WITH NO STATE-SPECIFIC PLANS, CODES WOULD START WITH '91' AT HX17 OR '7' AT HX18.)
----------------------------------------------------
----------------------------------------------------
EDIT: CODE '95' (NONE OF THESE) CANNOT BE ENTERED WITH ANY OTHER CODES. IF CODED '95' (NONE OF THESE) WITH ANY OTHER CODES, DISPLAY THE FOLLOWING MESSAGE: '95 CANNOT BE CODED WITH ANY OTHER RESPONSES. VERIFY AND RE-ENTER. PRESS ENTER TO CONTINUE.'
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX17OV
----------------------------------------------------
----------------------------------------------------
IF CODED '95' (NONE OF THESE), GO TO HX18
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_21
----------------------------------------------------
====
[STR-DT]
What is the name of the program?
PROBE: Any other state program?
What is the name of the program?
PROBE: Any other state program?
AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN) .............................. 7
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
HX19
SSI (SUPPLEMENTAL SECURITY INCOME) ..... 8
WIC (WOMEN, INFANTS AND CHILDREN) ...... 9
IHS (INDIAN HEALTH SERVICE) ........... 10
PUBLIC HEALTH CLINIC .................. 11
VA (VETERANS ADMINISTRATION) .......... 12
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ANY PROGRAM SELECTED IN HX18 IS CONSIDERED A GROUP 2 PROGRAM AND WILL BE GROUPED TOGETHER WHEN ASKED ABOUT IN HX19
----------------------------------------------------
----------------------------------------------------
IF:
NO CURRENT RU MEMBER COVERED BY MEDICAID OR GOVT- HOSPITAL/PHYSICIAN DURING CURRENT ROUND
AND
HX18 IS CODED '7' (AFDC), '8' (SSI), OR '9' (WIC), ALONE OR WITH ANY OTHER COMBINATION OF CODES, CONTINUE WITH BOX_21
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO END_LP08
----------------------------------------------------
====
[STR-DT]
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
PROGRAM:
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
[STATE PROGRAM PROVIDING COVERAGE]
Who is covered by (READ PROGRAMS ABOVE)?
PROBE: Who else is covered by (READ PROGRAMS ABOVE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
PR35
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]
----------------------------------------------------
IF COMING FROM HX17, DISPLAY ALL PROGRAMS SELECTED AT HX17. IF COMING FROM HX18, DISPLAY ALL PROGRAMS SELECTED AT HX18.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- MEMBERS-ROSTER.
----------------------------------------------------
====
[STR-DT]
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
During the last interview, we recorded that (READ NAMES BELOW) were covered by one or more of the following programs:
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Have all of these people been covered by any of these programs at any time since (START DATE)?
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
PR36
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
YES, ALL .............................. 1
NO, ONLY SOME ......................... 2
NO, NONE .............................. 3
REF ................................... -7 [BOX_15]
DK .................................... -8 [BOX_15]
PRESS F1 FOR DEFINITION STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
-----------------------------------------------------
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '1' (YES, ALL), MARK ALL RU MEMBERS LISTED HERE AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND. THEN GO TO BOX_13
----------------------------------------------------
----------------------------------------------------
IF PR35 IS CODED '3' (NO, NONE), FLAG ALL RU MEMBERS LISTED HERE AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE)
AND
IF ANY CURRENT RU MEMBERS NOT LISTED AT PR35, GO TO PR37
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (NO, NONE),
AND
IF ALL CURRENT RU MEMBERS ARE LISTED AT PR35, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO, ONLY SOME), CONTINUE WITH PR36
----------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
PR37
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-ESTABLISHMENT-PERSON-PAIRS-ROSTER WHO WERE COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
----------------------------------------------------
====
[STR-DT]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
Besides the family members we've just talked about, have any additional family members been covered by any of the following programs since (START DATE)? (READ PROGRAM NAMES BELOW.)
[STATE NAME FOR PROGRAM #1....]
[STATE NAME FOR PROGRAM #2....]
[STATE NAME FOR PROGRAM #3....]
YES ................................... 1
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
PR38
NO .................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF STATE SPECIFIC PROGRAMS LISTED.
-----------------------------------------------------
DISPLAY THE LIST OF UP TO THREE ACTUAL NAMES OF STATE PROGRAMS (AS LISTED IN HX16) FOR 'STATE NAME FOR PROGRAM #N'.
-----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND AT LEAST ONE RU MEMBER FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED) OR '-8' (DON'T KNOW) AND NO RU MEMBERS FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND, GO TO BOX_15
----------------------------------------------------
----------------------------------------------------
OTHERWISE (I.E., IF CODED '1' (YES)), CONTINUE WITH PR38
---------------------------------------------------
====
[STR-DT]
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
Who has been covered by any of these programs since (START DATE)?
PROBE: Who else has been covered by any of these programs since (START DATE)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO MEET EITHER ONE OF THE FOLLOWING CONDITIONS:
- PERSON WAS ADDED TO RU THIS ROUND
OR
- PERSON WAS NOT FLAGGED AS COVERED BY GROUP 1 OTHER PUBLIC INSURANCE AT ANY TIME DURING THE PREVIOUS ROUND
----------------------------------------------------
----------------------------------------------------
FLAG ALL PERSONS SELECTED AS 'COVERED BY GROUP 1 OTHER PUBLIC INSURANCE' DURING CURRENT ROUND.
FLAG ALL PERSONS NOT SELECTED AS 'NOT COVERED BY GROUP 1 OTHER PUBLIC INSURANCE DURING CURRENT ROUND.'
----------------------------------------------------
Weights
- 1996-2016 : PERWEIGHT