Survey Text

2021 2014 2007 2000
2020 2013 2006 1999
2019 2012 2005 1998
2018 2011 2004 1997
2017 2010 2003 1996
2016 2009 2002
2015 2008 2001
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2021

No questionnaire text is available for this sample.


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2020

No questionnaire text is available for this sample.


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2019

No questionnaire text is available for this sample.


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2018
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2017
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2016
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2015
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2014
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2013
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2012
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2006
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2005
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2004
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2003
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2002
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2001
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
2000
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
1999
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
1998
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
1997
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
-----------------------------------------------------
-----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
-----------------------------------------------------
HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
----------------------------------------------------
----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
----------------------------------------------------
----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
----------------------------------------------------
NOTE: PERSON REFERS TO JOBHOLDER.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------

top
1996
Survey form view entire document:  text  image
HX05
====

[STR-DT]
My records indicate that (READ NAMES BELOW) [(are/is)] [either] [65 years old or older] [or] [joined the household since our last interview].
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]
(Has (READ NAME ABOVE)/Have any of these people) been covered by Medicare since (START DATE)?
YES .................................... 1
NO ..................................... 2 [LOOP_04]
REF ................................... -7 [LOOP_04]
DK .................................... -8 [LOOP_04]
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY '(are/is)' AND '65 years old' IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.

DISPLAY 'joined the household since our last interview' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND.

DISPLAY 'either' AND 'or' IF ANY NEW RU MEMBERS ADDED TO THE RU THIS ROUND AND IF ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE TURNED 65 SINCE START DATE OR ANY RU MEMBERS NOT ALREADY FLAGGED AS RECEIVING MEDICARE WERE = OR ) 65 PREVIOUS ROUND.
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ANY ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE AND HAS TURNED 65 SINCE START DATE
OR
- PERSON IS AN RU MEMBER WHO IS NOT ALREADY FLAGGED AS RECEIVING MEDICARE (NOT SELECTED AT HX07 DURING PREVIOUS ROUND) AND WHO WAS = OR ) 65 (OR IN AGE CATEGORY 9) DURING THE PREVIOUS ROUND
OR
- PERSON IS A NEW RU MEMBER
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND ONLY ONE RU MEMBER ELIGIBLE FOR HX05, SELECT THAT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF HX05 IS CODED '1' (YES) AND MORE THAN ONE RU MEMBER ELIGIBLE FOR HX05, GO TO HX07
----------------------------------------------------
HX06
====

[STR-DT]
There are two large public health insurance programs [with similar names] that are easily confused.
Medicare is a health insurance program for persons 65 years or over and for disabled persons. The other program, [Medicaid/[STATE NAME FOR MEDICAID]], is a state program for low income persons or for persons on public assistance.
SHOW CARD HX-2.
Let me first ask about Medicare. People covered by Medicare usually have a card that looks like this.
At any time since (START DATE), has anyone in the family been covered by Medicare?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MEDICARE.
----------------------------------------------------
DISPLAY 'with similar names' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES 'MEDICAID' OR A NAME SIMILAR TO MEDICARE (SUCH AS MEDI-CAL).
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS
BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALABAMA MINNESOTA NORTH DAKOTA ARKANSAS MISSISSIPPI OHIO COLORADO MISSIOURI OKLAHOMA CONNECTICUT MONTANA OREGON DELAWARE NEBRASKA PENNSYLVANIA FLORIDA NEVADA SOUTH CAROLINA ILLINOIS NEW HAMPSHIRE SOUTH DAKOTA INDIANA NEW JERSEY TEXAS KANSAS NEW MEXICO UTAH LOUISIANA NEW YORK VERMONT MAINE NORTH CAROLINA WEST VIRGINIA WYOMING

DISPLAY 'Medical Assistance' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ONE OF THE FOLLOWING:
ALASKA IDAHO MICHIGAN DISTRICT OF COLUMBIA IOWA RHODE ISLAND GEORGIA KENTUCKY VIRGINIA HAWAII MARYLAND WASHINGTON WISCONSIN

DISPLAY 'Arizona Health Care Cost Containment System' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS ARIZONA.

DISPLAY 'Medi-Cal' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS CALIFORNIA.

DISPLAY 'MassHealth' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS MASSACHUSETTS.

DISPLAY 'TennCare' FOR 'STATE NAME FOR MEDICAID' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED IS TENNESSEE.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX07 AND GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX07
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND ONE OR MORE RU MEMBER = ) 65 YEARS OLD, GO TO LOOP_04
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T KNOW) AND NO RU MEMBER = ) 65 YEARS OLD, GO TO BOX_12
----------------------------------------------------
----------------------------------------------------
NOTE: HX06 IS ASKED ONLY IN ROUND 1.
----------------------------------------------------
HX07
====

[STR-DT]
Who is covered by Medicare?
PROBE: Who else is covered by Medicare?

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:
IF ROUND 1, THIS ITEM DISPLAYS THE COMPLETE RU-MEMBERS-ROSTER.
IF ROUND 2, THIS ITEM DISPLAYS PERSONS ON THE RU-MEMBERS-ROSTER THAT MEET ONE OF THE FOLLOWING CONDITIONS:
- PERSON IS A NEW RU MEMBER THIS ROUND
OR
- PERSON TURNED 65 YEARS OLD THIS ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND
OR
- PERSON =) 65 YEARS OLD (OR IN AGE CATEGORY 9) LAST ROUND AND NOT FLAGGED AS COVERED BY MEDICARE DURING ANY ROUND.
----------------------------------------------------
HX10
====

[STR-DT]
[Some people are covered by a program called [Medicaid/[STATE NAME FOR MEDICAID]]. This is a state program for persons with low incomes and persons on public assistance. It sometimes covers persons with very large medical bills or those in nursing homes.]
[SHOW CARD HX-3.]
[People covered by [Medicaid/[STATE NAME FOR MEDICAID]] usually have a (piece of paper/card) that looks like this.]
[During the last interview, we recorded that no one in the family was covered by [Medicaid/[STATE NAME FOR MEDICAID]].]
Has anyone in the family been covered by [Medicaid/[STATE NAME FOR MEDICAID]] at any time since (START DATE)?
YES .................................... 1
NO ..................................... 2 [BOX_14]
REF ................................... -7 [BOX_14]
DK .................................... -8 [BOX-14]
PRESS F1 FOR DEFINITION OF MEDICAID.
----------------------------------------------------
DISPLAY FIRST PARAGRAPH ('Some .... homes.') ONLY IF ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY SECOND PARAGRAPH (INCLUDING REFERENCE TO SHOW CARD) ONLY IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED ISSUES A CARD OR PIECE OF PAPER TO MEDICAID RECIPIENTS. THIS INCLUDES ALL STATES EXCEPT TENNESSEE. IF THE INTERVIEW IS BEING CONDUCTED IN TENNESSEE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY THIRD PARAGRAPH ('During... MEDICAID]].') ONLY IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AUTOMATICALLY BY CAPI AT HX11 AND GO TO
LOOP_05
----------------------------------------------------
----------------------------------------------------
IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX11
----------------------------------------------------
HX11
====

[STR-DT]
Who is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?
PROBE: Who else is covered by [Medicaid/[STATE NAME FOR MEDICAID]]?

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]
-----------------------------------------------------
DISPLAY 'Medicaid' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED USES THE NAME 'MEDICAID'. DISPLAY 'STATE NAME FOR MEDICAID' (SUBSTITUTING THE REAL STATE NAME FOR PROGRAM) IF THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED DOES NOT USE THE NAME 'MEDICAID.' FOR THE SPECIFIC NAME TO USE BY STATE, SEE BOX ON HX06.
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ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
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HX12
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by CHAMPUS, TRICARE or CHAMPVA.]
At any time since (START DATE), has anyone in the family been covered by CHAMPUS, TRICARE or CHAMPVA?
YES .................................... 1
NO ..................................... 2 [BOX_16]
REF ................................... -7 [BOX_16]
DK .................................... -8 [BOX_16]
PRESS F1 FOR DEFINITION OF CHAMPUS/CHAMPVA.
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DISPLAY FIRST PARAGRAPH ('During .... CHAMPVA.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
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IF CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX13 AUTOMATICALLY BY CAPI AND GO TO LOOP_06
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IF CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX13
----------------------------------------------------
HX13
====

[STR-DT]
Who is covered by CHAMPUS, TRICARE or CHAMPVA?
PROBE: Who else is covered by CHAMPUS, TRICARE or CHAMPVA?

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]
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ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU-MEMBERS-ROSTER.
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HX14
====

[STR-DT]
[During the last interview, we recorded that no one in the family was covered by any other state sponsored program which provided hospital and physician benefits.]
At any time since (START DATE), has anyone in the family had any type of health insurance obtained through any state or local government agency which provided hospital and physician benefits?
YES .................................... 1
NO ..................................... 2 [BOX_19]
REF ................................... -7 [BOX_19]
DK .................................... -8 [BOX_19]
PRESS F1 FOR DESCRIPTION OF INSURANCE TYPES TO INCLUDE.
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DISPLAY FIRST PARAGRAPH ('During .... benefits.') IF NOT ROUND 1. OTHERWISE, USE A NULL DISPLAY.
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IF HX14 IS CODED '1' (YES) AND SINGLE-PERSON RU, SELECT PERSON AT HX15 AUTOMATICALLY BY CAPI AND GO TO LOOP_07
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----------------------------------------------------
IF HX14 IS CODED '1' (YES) AND MULTI-PERSON RU, CONTINUE WITH HX15
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----------------------------------------------------
NOTE: 'GOVT-HOSPITAL/PHYSICIAN' SHOULD BE USED FOR THE ESTABLISHMENT NAME IN THE CONTEXT HEADER (WHERE APPROPRIATE).
----------------------------------------------------
HX15
====

[STR-DT]
Who is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?
PROBE: Who else is covered by a program sponsored by a state or local government agency which provided hospital and physician benefits?

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 THE RU-MEMBERS-ROSTER.
----------------------------------------------------
HP09
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF ESTABLISHMENT.........] [STR-DT]
(Are/Is) (PERSON) the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
YES .................................... 1 [LOOP_02]
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
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NOTE: PERSON REFERS TO JOBHOLDER.
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----------------------------------------------------
IF CODED '1' (YES), FLAG JOBHOLDER AS 'POLICYHOLDER'.
----------------------------------------------------
HP11
====

[NAME OF ESTABLISHMENT.........] [STR-DT]
Who is the primary insured person or policyholder of this health coverage through (ESTABLISHMENT)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
REF .............................. .... -7
DK ............................... ..... -8
PRESS F1 FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
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ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS ON THE DU-MEMBERS-ROSTER.
----------------------------------------------------
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DISPLAY 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' AS LAST TWO ENTRIES ON THIS ROSTER.
----------------------------------------------------
----------------------------------------------------
IF BOTH 'POLICYHOLDER NOT LISTED IN DU' AND 'POLICYHOLDER DECEASED' ARE NOT SELECTED, GO TO LOOP_02
----------------------------------------------------
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IF 'POLICYHOLDER DECEASED' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES, EXCEPT 'POLICYHOLDER NOT LISTED IN DU', GO TO HP11B
----------------------------------------------------
----------------------------------------------------
IF 'POLICYHOLDER NOT LISTED IN DU' SELECTED, ALONE OR IN COMBINATION WITH OTHER NAMES AND/OR 'POLICYHOLDER DECEASED', CONTINUE WITH HP11A
----------------------------------------------------