Survey Text

2021
2020
2019
2018
2017
2016
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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
HX21
====

[STR-DT] [END-DT]
Next, I have some questions about other sources of health insurance anyone in the family may have had [since [START DATE]/between [START DATE] and [END DATE]] to help pay hospital and doctor bills and other health expenses such as nursing home care or prescribed medicines. [This includes Medigap or Medicare Supplements, plans through a private insurance carrier, which some people who are eligible for Medicare have as additional coverage.]
[Since [START DATE]/Between [START DATE] and [END DATE]] we show the family has had the following health insurance:
HX21_01. ESTABLISHMENT NAME (INSURER) HX21_02. COVERED RU MEMBERS
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY 'This includes...coverage.' IF ANYONE IN RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING THE CURRENT ROUND.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.

DISPLAY 'So far, ... and [END DATE]]:' AND THE REPORT OF CURRENT ROUND HEALTH INSURANCE IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.
----------------------------------------------------
HX22
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
Please look at this card. It lists various ways people can obtain health insurance.
[Not counting insurance you already told me about, at/At] any time [since [START DATE]/between [START DATE] and [END DATE]], was anyone in the family covered by health insurance from any [other] source, such as those listed on the card?
YES .................................... 1 [LOOP_10]
NO ..................................... 2 [BOX_25]
REF ................................... -7 [BOX_25]
DK .................................... -8 [BOX_25]
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY 'Not counting insurance you already told me about, at' AND 'other' IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.

IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS RU, DISPLAY 'At'.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.
----------------------------------------------------
HX23
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
From which of the sources on this card did anyone in the family purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 [BOX_24]
DIRECTLY THROUGH A SCHOOL ................ 3 [BOX_24]
DIRECTLY FROM AN INSURANCE AGENT ......... 4 [BOX_24]
DIRECTLY FROM INSURANCE COMPANY .......... 5 [BOX_24]
DIRECTLY FROM AN HMO ..................... 6 [BOX_24]
FROM A UNION ............................. 7 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (COBRA) .. 8 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (NOT COBRA) ............................ 9 [BOX_24]
FROM SPOUSE'S/DECEASED SPOUSE'S PREVIOUS EMPLOYER .............................. 10 [BOX_24]
FROM SOME OTHER EMPLOYER ................ 11 [BOX_24]
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 [BOX_24]
DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]] ............. 13 [BOX_24]
DIRECTLY FROM [STATE EXCHANGE NAME-A] ... 14 [BOX_24]
OTHER SOURCE ............................ 91 [HX23OV]
REF ..................................... -7 [BOX_24]
DK ...................................... -8 [BOX_24]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY '2' (FROM A HEALTH INSURANCE PURCHASING ALLIANCE) WAS OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND PANEL 16 ROUND 1, CATEGORY '13' (DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]]) WAS ADDED AS A CATEGORY AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 17 ROUND 5, PANEL 18 ROUND 3 AND PANEL 19 ROUND 1, CATEGORY '14' (DIRECTLY FROM [STATE EXCHANGE NAME] WAS ADDED AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY '/[STATE NAME FOR HIGH RISK POOL]' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI, ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL DISPLAY.

FOR 'STATE NAME FOR HIGH RISK POOL' DISPLAY THE HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.

FOR 'STATE EXCHANGE NAME' DISPLAY THE EXCHANGE NAME 'A' ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.
----------------------------------------------------
----------------------------------------------------
DISPLAY AN 'ADD OTHER SOURCE' BUTTON ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF 'ADD OTHER SOURCE' IS SELECTED, PRESENT 'ADD OTHER SOURCE' POP-UP (HX23OV) AND THEN GO TO BOX_24.
----------------------------------------------------
HX48
====

[POLICYHOLDER FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
SHOW CARD HX-9.
Now think again about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. Looking at this card, what health insurance coverage [[do/does]/did] [you/he/she] have [as of [END DATE]]?
PROBE: Any other health coverage through this plan?
CHECK ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER'S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91 [HX48OV]
REF ................................... -7 [BOX_33]
DK .................................... -8 [BOX_33]
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[NOTE: 'DISABILITY,' 'WORKER'S COMPENSATION,' AND 'ACCIDENT' WILL NOT APPEAR ON THE SHOW CARD.]
----------------------------------------------------
DISPLAY '[do/does]' IF INSURANCE BEING ASKED ABOUT IS CURRENT (I.E., HQ02 IS CODED '1' (YES, COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY 'did'.

DISPLAY 'as of [END DATE]' IF ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE SHOW CARD.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT ALLOW '-7' (REFUSED) OR '-8' (DON'T KNOW) IN COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX48OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_33
----------------------------------------------------
OE01
====

[POLICYHOLDER'S FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
Now think about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. [[Are/Is]/[Were/Was]] [you/he/she] or anyone in the family covered by this insurance as of [today,] [END DATE]?
YES ................................... 1 [BOX_02]
NO .................................... 2 [OE02]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
----------------------------------------------------
DISPLAY '[Are/Is]' IF NOT ROUND 5. DISPLAY '[Were/Was]' IF ROUND 5.

DISPLAY 'today,' IF NOT ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
HP01
====
Does the insurance from the school cover only injuries caused by accidents, or does it have general health coverage?
GENERAL HEALTH COVERAGE ................ 1 [HP02]
ONLY INJURIES CAUSED BY ACCIDENTS ...... 2 [BOX_11]
REF ................................... -7 [HP02]
DK .................................... -8 [HP02]
HELP AVAILABLE FOR DEFINITION OF GENERAL HEALTH COVERAGE.
[Code One]
HP11
====

[NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
[Please tell me the names of everyone who is a primary insured person or policyholder of the/Who [is/was] the primary insured person or policyholder of this] health coverage through [ESTABLISHMENT] [on [END DATE]]?
[CODE ALL THAT APPLY.]
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
HELP AVAILABLE FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
DISPLAY 'Please tell me the names of everyone who is a primary insured person or policyholder of the' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, DISPLAY 'Who [is/was] the primary insured person or policyholder of the'. DISPLAY 'CODE ALL THAT APPLY' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'is' IF NOT ROUND 5. DISPLAY 'was' IF ROUND 5. DISPLAY 'on [END DATE]' IF ROUND 5. OTHERWISE, USE NULL DISPLAY. DISPLAY A "POLICYHOLDER NOT LISTED IN DU" AND "POLICYHOLDER DECEASED" OPTION ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
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
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: DU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY DU MEMBER'S FIRST, MIDDLE, AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS DU-MEMBERS- ROSTER FOR SELECTION.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NO FILTER; DISPLAY ALL DU MEMBERS.
----------------------------------------------------

top
2017
Survey form view entire document:  text  image
HX21
====

[STR-DT] [END-DT]
Next, I have some questions about other sources of health insurance anyone in the family may have had [since [START DATE]/between [START DATE] and [END DATE]] to help pay hospital and doctor bills and other health expenses such as nursing home care or prescribed medicines. [This includes Medigap or Medicare Supplements, plans through a private insurance carrier, which some people who are eligible for Medicare have as additional coverage.]
[Since [START DATE]/Between [START DATE] and [END DATE]] we show the family has had the following health insurance:
HX21_01. ESTABLISHMENT NAME (INSURER) HX21_02. COVERED RU MEMBERS
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY 'This includes...coverage.' IF ANYONE IN RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING THE CURRENT ROUND.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.

DISPLAY 'So far, ... and [END DATE]]:' AND THE REPORT OF CURRENT ROUND HEALTH INSURANCE IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.
----------------------------------------------------
HX22
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
Please look at this card. It lists various ways people can obtain health insurance.
[Not counting insurance you already told me about, at/At] any time [since [START DATE]/between [START DATE] and [END DATE]], was anyone in the family covered by health insurance from any [other] source, such as those listed on the card?
YES .................................... 1 [LOOP_10]
NO ..................................... 2 [BOX_25]
REF ................................... -7 [BOX_25]
DK .................................... -8 [BOX_25]
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY 'Not counting insurance you already told me about, at' AND 'other' IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.

IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS RU, DISPLAY 'At'.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.
----------------------------------------------------
HX23
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
From which of the sources on this card did anyone in the family purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 [BOX_24]
DIRECTLY THROUGH A SCHOOL ................ 3 [BOX_24]
DIRECTLY FROM AN INSURANCE AGENT ......... 4 [BOX_24]
DIRECTLY FROM INSURANCE COMPANY .......... 5 [BOX_24]
DIRECTLY FROM AN HMO ..................... 6 [BOX_24]
FROM A UNION ............................. 7 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (COBRA) .. 8 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (NOT COBRA) ............................ 9 [BOX_24]
FROM SPOUSE'S/DECEASED SPOUSE'S PREVIOUS EMPLOYER .............................. 10 [BOX_24]
FROM SOME OTHER EMPLOYER ................ 11 [BOX_24]
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 [BOX_24]
DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]] ............. 13 [BOX_24]
DIRECTLY FROM [STATE EXCHANGE NAME-A] ... 14 [BOX_24]
OTHER SOURCE ............................ 91 [HX23OV]
REF ..................................... -7 [BOX_24]
DK ...................................... -8 [BOX_24]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY '2' (FROM A HEALTH INSURANCE PURCHASING ALLIANCE) WAS OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND PANEL 16 ROUND 1, CATEGORY '13' (DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]]) WAS ADDED AS A CATEGORY AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 17 ROUND 5, PANEL 18 ROUND 3 AND PANEL 19 ROUND 1, CATEGORY '14' (DIRECTLY FROM [STATE EXCHANGE NAME] WAS ADDED AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY '/[STATE NAME FOR HIGH RISK POOL]' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI, ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL DISPLAY.

FOR 'STATE NAME FOR HIGH RISK POOL' DISPLAY THE HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.

FOR 'STATE EXCHANGE NAME' DISPLAY THE EXCHANGE NAME 'A' ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.
----------------------------------------------------
----------------------------------------------------
DISPLAY AN 'ADD OTHER SOURCE' BUTTON ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF 'ADD OTHER SOURCE' IS SELECTED, PRESENT 'ADD OTHER SOURCE' POP-UP (HX23OV) AND THEN GO TO BOX_24.
----------------------------------------------------
HX48
====

[POLICYHOLDER FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
SHOW CARD HX-9.
Now think again about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. Looking at this card, what health insurance coverage [[do/does]/did] [you/he/she] have [as of [END DATE]]?
PROBE: Any other health coverage through this plan?
CHECK ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER'S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91 [HX48OV]
REF ................................... -7 [BOX_33]
DK .................................... -8 [BOX_33]
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[NOTE: 'DISABILITY,' 'WORKER'S COMPENSATION,' AND 'ACCIDENT' WILL NOT APPEAR ON THE SHOW CARD.]
----------------------------------------------------
DISPLAY '[do/does]' IF INSURANCE BEING ASKED ABOUT IS CURRENT (I.E., HQ02 IS CODED '1' (YES, COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY 'did'.

DISPLAY 'as of [END DATE]' IF ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE SHOW CARD.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT ALLOW '-7' (REFUSED) OR '-8' (DON'T KNOW) IN COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX48OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_33
----------------------------------------------------
OE01
====

[POLICYHOLDER'S FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
Now think about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. [[Are/Is]/[Were/Was]] [you/he/she] or anyone in the family covered by this insurance as of [today,] [END DATE]?
YES ................................... 1 [BOX_02]
NO .................................... 2 [OE02]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
----------------------------------------------------
DISPLAY '[Are/Is]' IF NOT ROUND 5. DISPLAY '[Were/Was]' IF ROUND 5.

DISPLAY 'today,' IF NOT ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
HP01
====
Does the insurance from the school cover only injuries caused by accidents, or does it have general health coverage?
GENERAL HEALTH COVERAGE ................ 1 [HP02]
ONLY INJURIES CAUSED BY ACCIDENTS ...... 2 [BOX_11]
REF ................................... -7 [HP02]
DK .................................... -8 [HP02]
HELP AVAILABLE FOR DEFINITION OF GENERAL HEALTH COVERAGE.
[Code One]
HP11
====

[NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
[Please tell me the names of everyone who is a primary insured person or policyholder of the/Who [is/was] the primary insured person or policyholder of this] health coverage through [ESTABLISHMENT] [on [END DATE]]?
[CODE ALL THAT APPLY.]
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
HELP AVAILABLE FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
DISPLAY 'Please tell me the names of everyone who is a primary insured person or policyholder of the' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, DISPLAY 'Who [is/was] the primary insured person or policyholder of the'. DISPLAY 'CODE ALL THAT APPLY' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'is' IF NOT ROUND 5. DISPLAY 'was' IF ROUND 5. DISPLAY 'on [END DATE]' IF ROUND 5. OTHERWISE, USE NULL DISPLAY. DISPLAY A "POLICYHOLDER NOT LISTED IN DU" AND "POLICYHOLDER DECEASED" OPTION ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
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
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: DU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY DU MEMBER'S FIRST, MIDDLE, AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS DU-MEMBERS- ROSTER FOR SELECTION.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NO FILTER; DISPLAY ALL DU MEMBERS.
----------------------------------------------------

top
2016
Survey form view entire document:  text  image
HX21
====

[STR-DT] [END-DT]
Next, I have some questions about other sources of health insurance anyone in the family may have had [since [START DATE]/between [START DATE] and [END DATE]] to help pay hospital and doctor bills and other health expenses such as nursing home care or prescribed medicines. [This includes Medigap or Medicare Supplements, plans through a private insurance carrier, which some people who are eligible for Medicare have as additional coverage.]
[Since [START DATE]/Between [START DATE] and [END DATE]] we show the family has had the following health insurance:
HX21_01. ESTABLISHMENT NAME (INSURER) HX21_02. COVERED RU MEMBERS
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY 'This includes...coverage.' IF ANYONE IN RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING THE CURRENT ROUND.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.

DISPLAY 'So far, ... and [END DATE]]:' AND THE REPORT OF CURRENT ROUND HEALTH INSURANCE IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.
----------------------------------------------------
HX22
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
Please look at this card. It lists various ways people can obtain health insurance.
[Not counting insurance you already told me about, at/At] any time [since [START DATE]/between [START DATE] and [END DATE]], was anyone in the family covered by health insurance from any [other] source, such as those listed on the card?
YES .................................... 1 [LOOP_10]
NO ..................................... 2 [BOX_25]
REF ................................... -7 [BOX_25]
DK .................................... -8 [BOX_25]
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY 'Not counting insurance you already told me about, at' AND 'other' IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.

IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS RU, DISPLAY 'At'.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.
----------------------------------------------------
HX23
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
From which of the sources on this card did anyone in the family purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 [BOX_24]
DIRECTLY THROUGH A SCHOOL ................ 3 [BOX_24]
DIRECTLY FROM AN INSURANCE AGENT ......... 4 [BOX_24]
DIRECTLY FROM INSURANCE COMPANY .......... 5 [BOX_24]
DIRECTLY FROM AN HMO ..................... 6 [BOX_24]
FROM A UNION ............................. 7 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (COBRA) .. 8 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (NOT COBRA) ............................ 9 [BOX_24]
FROM SPOUSE'S/DECEASED SPOUSE'S PREVIOUS EMPLOYER .............................. 10 [BOX_24]
FROM SOME OTHER EMPLOYER ................ 11 [BOX_24]
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 [BOX_24]
DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]] ............. 13 [BOX_24]
DIRECTLY FROM [STATE EXCHANGE NAME-A] ... 14 [BOX_24]
OTHER SOURCE ............................ 91 [HX23OV]
REF ..................................... -7 [BOX_24]
DK ...................................... -8 [BOX_24]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY '2' (FROM A HEALTH INSURANCE PURCHASING ALLIANCE) WAS OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND PANEL 16 ROUND 1, CATEGORY '13' (DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]]) WAS ADDED AS A CATEGORY AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 17 ROUND 5, PANEL 18 ROUND 3 AND PANEL 19 ROUND 1, CATEGORY '14' (DIRECTLY FROM [STATE EXCHANGE NAME] WAS ADDED AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY '/[STATE NAME FOR HIGH RISK POOL]' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI, ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL DISPLAY.

FOR 'STATE NAME FOR HIGH RISK POOL' DISPLAY THE HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.

FOR 'STATE EXCHANGE NAME' DISPLAY THE EXCHANGE NAME 'A' ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.
----------------------------------------------------
----------------------------------------------------
DISPLAY AN 'ADD OTHER SOURCE' BUTTON ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF 'ADD OTHER SOURCE' IS SELECTED, PRESENT 'ADD OTHER SOURCE' POP-UP (HX23OV) AND THEN GO TO BOX_24.
----------------------------------------------------
HX48
====

[POLICYHOLDER FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
SHOW CARD HX-9.
Now think again about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. Looking at this card, what health insurance coverage [[do/does]/did] [you/he/she] have [as of [END DATE]]?
PROBE: Any other health coverage through this plan?
CHECK ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER'S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91 [HX48OV]
REF ................................... -7 [BOX_33]
DK .................................... -8 [BOX_33]
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[NOTE: 'DISABILITY,' 'WORKER'S COMPENSATION,' AND 'ACCIDENT' WILL NOT APPEAR ON THE SHOW CARD.]
----------------------------------------------------
DISPLAY '[do/does]' IF INSURANCE BEING ASKED ABOUT IS CURRENT (I.E., HQ02 IS CODED '1' (YES, COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY 'did'.

DISPLAY 'as of [END DATE]' IF ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE SHOW CARD.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT ALLOW '-7' (REFUSED) OR '-8' (DON'T KNOW) IN COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX48OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_33
----------------------------------------------------
OE01
====

[POLICYHOLDER'S FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
Now think about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. [[Are/Is]/[Were/Was]] [you/he/she] or anyone in the family covered by this insurance as of [today,] [END DATE]?
YES ................................... 1 [BOX_02]
NO .................................... 2 [OE02]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
----------------------------------------------------
DISPLAY '[Are/Is]' IF NOT ROUND 5. DISPLAY '[Were/Was]' IF ROUND 5.

DISPLAY 'today,' IF NOT ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
HP01
====
Does the insurance from the school cover only injuries caused by accidents, or does it have general health coverage?
GENERAL HEALTH COVERAGE ................ 1 [HP02]
ONLY INJURIES CAUSED BY ACCIDENTS ...... 2 [BOX_11]
REF ................................... -7 [HP02]
DK .................................... -8 [HP02]
HELP AVAILABLE FOR DEFINITION OF GENERAL HEALTH COVERAGE.
[Code One]
HP11
====

[NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
[Please tell me the names of everyone who is a primary insured person or policyholder of the/Who [is/was] the primary insured person or policyholder of this] health coverage through [ESTABLISHMENT] [on [END DATE]]?
[CODE ALL THAT APPLY.]
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
HELP AVAILABLE FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
DISPLAY 'Please tell me the names of everyone who is a primary insured person or policyholder of the' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, DISPLAY 'Who [is/was] the primary insured person or policyholder of the'. DISPLAY 'CODE ALL THAT APPLY' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'is' IF NOT ROUND 5. DISPLAY 'was' IF ROUND 5. DISPLAY 'on [END DATE]' IF ROUND 5. OTHERWISE, USE NULL DISPLAY. DISPLAY A "POLICYHOLDER NOT LISTED IN DU" AND "POLICYHOLDER DECEASED" OPTION ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
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
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: DU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY DU MEMBER'S FIRST, MIDDLE, AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS DU-MEMBERS- ROSTER FOR SELECTION.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NO FILTER; DISPLAY ALL DU MEMBERS.
----------------------------------------------------

top
2015
Survey form view entire document:  text  image
HX21
====

[STR-DT] [END-DT]
Next, I have some questions about other sources of health insurance anyone in the family may have had [since [START DATE]/between [START DATE] and [END DATE]] to help pay hospital and doctor bills and other health expenses such as nursing home care or prescribed medicines. [This includes Medigap or Medicare Supplements, plans through a private insurance carrier, which some people who are eligible for Medicare have as additional coverage.]
[Since [START DATE]/Between [START DATE] and [END DATE]] we show the family has had the following health insurance:
HX21_01. ESTABLISHMENT NAME (INSURER) HX21_02. COVERED RU MEMBERS
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY 'This includes...coverage.' IF ANYONE IN RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING THE CURRENT ROUND.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.

DISPLAY 'So far, ... and [END DATE]]:' AND THE REPORT OF CURRENT ROUND HEALTH INSURANCE IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.
----------------------------------------------------
HX22
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
Please look at this card. It lists various ways people can obtain health insurance.
[Not counting insurance you already told me about, at/At] any time [since [START DATE]/between [START DATE] and [END DATE]], was anyone in the family covered by health insurance from any [other] source, such as those listed on the card?
YES .................................... 1 [LOOP_10]
NO ..................................... 2 [BOX_25]
REF ................................... -7 [BOX_25]
DK .................................... -8 [BOX_25]
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY 'Not counting insurance you already told me about, at' AND 'other' IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.

IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS RU, DISPLAY 'At'.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.
----------------------------------------------------
HX23
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
From which of the sources on this card did anyone in the family purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 [BOX_24]
DIRECTLY THROUGH A SCHOOL ................ 3 [BOX_24]
DIRECTLY FROM AN INSURANCE AGENT ......... 4 [BOX_24]
DIRECTLY FROM INSURANCE COMPANY .......... 5 [BOX_24]
DIRECTLY FROM AN HMO ..................... 6 [BOX_24]
FROM A UNION ............................. 7 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (COBRA) .. 8 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (NOT COBRA) ............................ 9 [BOX_24]
FROM SPOUSE'S/DECEASED SPOUSE'S PREVIOUS EMPLOYER .............................. 10 [BOX_24]
FROM SOME OTHER EMPLOYER ................ 11 [BOX_24]
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 [BOX_24]
DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]] ............. 13 [BOX_24]
DIRECTLY FROM [STATE EXCHANGE NAME-A] ... 14 [BOX_24]
OTHER SOURCE ............................ 91 [HX23OV]
REF ..................................... -7 [BOX_24]
DK ...................................... -8 [BOX_24]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY '2' (FROM A HEALTH INSURANCE PURCHASING ALLIANCE) WAS OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND PANEL 16 ROUND 1, CATEGORY '13' (DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]]) WAS ADDED AS A CATEGORY AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 17 ROUND 5, PANEL 18 ROUND 3 AND PANEL 19 ROUND 1, CATEGORY '14' (DIRECTLY FROM [STATE EXCHANGE NAME] WAS ADDED AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY '/[STATE NAME FOR HIGH RISK POOL]' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI, ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL DISPLAY.

FOR 'STATE NAME FOR HIGH RISK POOL' DISPLAY THE HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.

FOR 'STATE EXCHANGE NAME' DISPLAY THE EXCHANGE NAME 'A' ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.
----------------------------------------------------
----------------------------------------------------
DISPLAY AN 'ADD OTHER SOURCE' BUTTON ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF 'ADD OTHER SOURCE' IS SELECTED, PRESENT 'ADD OTHER SOURCE' POP-UP (HX23OV) AND THEN GO TO BOX_24.
----------------------------------------------------
HX48
====

[POLICYHOLDER FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
SHOW CARD HX-9.
Now think again about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. Looking at this card, what health insurance coverage [[do/does]/did] [you/he/she] have [as of [END DATE]]?
PROBE: Any other health coverage through this plan?
CHECK ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER'S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91 [HX48OV]
REF ................................... -7 [BOX_33]
DK .................................... -8 [BOX_33]
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[NOTE: 'DISABILITY,' 'WORKER'S COMPENSATION,' AND 'ACCIDENT' WILL NOT APPEAR ON THE SHOW CARD.]
----------------------------------------------------
DISPLAY '[do/does]' IF INSURANCE BEING ASKED ABOUT IS CURRENT (I.E., HQ02 IS CODED '1' (YES, COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY 'did'.

DISPLAY 'as of [END DATE]' IF ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE SHOW CARD.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT ALLOW '-7' (REFUSED) OR '-8' (DON'T KNOW) IN COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX48OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_33
----------------------------------------------------
OE01
====

[POLICYHOLDER'S FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
Now think about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. [[Are/Is]/[Were/Was]] [you/he/she] or anyone in the family covered by this insurance as of [today,] [END DATE]?
YES ................................... 1 [BOX_02]
NO .................................... 2 [OE02]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
----------------------------------------------------
DISPLAY '[Are/Is]' IF NOT ROUND 5. DISPLAY '[Were/Was]' IF ROUND 5.

DISPLAY 'today,' IF NOT ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
HP01
====
Does the insurance from the school cover only injuries caused by accidents, or does it have general health coverage?
GENERAL HEALTH COVERAGE ................ 1 [HP02]
ONLY INJURIES CAUSED BY ACCIDENTS ...... 2 [BOX_11]
REF ................................... -7 [HP02]
DK .................................... -8 [HP02]
HELP AVAILABLE FOR DEFINITION OF GENERAL HEALTH COVERAGE.
[Code One]
HP11
====

[NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
[Please tell me the names of everyone who is a primary insured person or policyholder of the/Who [is/was] the primary insured person or policyholder of this] health coverage through [ESTABLISHMENT] [on [END DATE]]?
[CODE ALL THAT APPLY.]
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
HELP AVAILABLE FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
DISPLAY 'Please tell me the names of everyone who is a primary insured person or policyholder of the' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, DISPLAY 'Who [is/was] the primary insured person or policyholder of the'. DISPLAY 'CODE ALL THAT APPLY' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'is' IF NOT ROUND 5. DISPLAY 'was' IF ROUND 5. DISPLAY 'on [END DATE]' IF ROUND 5. OTHERWISE, USE NULL DISPLAY. DISPLAY A "POLICYHOLDER NOT LISTED IN DU" AND "POLICYHOLDER DECEASED" OPTION ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
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
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: DU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY DU MEMBER'S FIRST, MIDDLE, AND LAST NAMES (PERS.FULLNAME)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM DISPLAYS DU-MEMBERS- ROSTER FOR SELECTION.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
NO FILTER; DISPLAY ALL DU MEMBERS.
----------------------------------------------------

top
2014
Survey form view entire document:  text  image
HX21
====

[STR-DT] [END-DT]
Next, I have some questions about other sources of health insurance anyone in the family may have had [since [START DATE]/between [START DATE] and [END DATE]] to help pay hospital and doctor bills and other health expenses such as nursing home care or prescribed medicines. [This includes Medigap or Medicare Supplements, plans through a private insurance carrier, which some people who are eligible for Medicare have as additional coverage.]
[Since [START DATE]/Between [START DATE] and [END DATE]] we show the family has had the following health insurance:
HX21_01. ESTABLISHMENT NAME (INSURER) HX21_02. COVERED RU MEMBERS
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
[Display Establishment Name (Display Insurer Name)]
[Display First and Last Names of All Covered RU Members]
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
----------------------------------------------------
DISPLAY 'This includes...coverage.' IF ANYONE IN RU HAS MEDICARE AS A SOURCE OF INSURANCE DURING THE CURRENT ROUND.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.

DISPLAY 'So far, ... and [END DATE]]:' AND THE REPORT OF CURRENT ROUND HEALTH INSURANCE IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.
----------------------------------------------------
HX22
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
Please look at this card. It lists various ways people can obtain health insurance.
[Not counting insurance you already told me about, at/At] any time [since [START DATE]/between [START DATE] and [END DATE]], was anyone in the family covered by health insurance from any [other] source, such as those listed on the card?
YES .................................... 1 [LOOP_10]
NO ..................................... 2 [BOX_25]
REF ................................... -7 [BOX_25]
DK .................................... -8 [BOX_25]
HELP AVAILABLE FOR DEFINITIONS OF ITEMS ON SHOW CARD.
----------------------------------------------------
DISPLAY 'Not counting insurance you already told me about, at' AND 'other' IF ANY SOURCES OF INSURANCE ARE RECORDED FOR THIS RU.

IF NO SOURCES OF INSURANCE ARE RECORDED FOR THIS RU, DISPLAY 'At'.

DISPLAY 'since [START DATE]' IF NOT ROUND 5.
DISPLAY 'between [START DATE] and [END DATE]' IF ROUND 5.
----------------------------------------------------
HX23
====

[STR-DT] [END-DT]
SHOW CARD HX-4.
From which of the sources on this card did anyone in the family purchase health insurance?
FROM A GROUP OR ASSOCIATION .............. 1 [BOX_24]
DIRECTLY THROUGH A SCHOOL ................ 3 [BOX_24]
DIRECTLY FROM AN INSURANCE AGENT ......... 4 [BOX_24]
DIRECTLY FROM INSURANCE COMPANY .......... 5 [BOX_24]
DIRECTLY FROM AN HMO ..................... 6 [BOX_24]
FROM A UNION ............................. 7 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (COBRA) .. 8 [BOX_24]
FROM ANYONE'S PREVIOUS EMPLOYER (NOT COBRA) ............................ 9 [BOX_24]
FROM SPOUSE'S/DECEASED SPOUSE'S PREVIOUS EMPLOYER .............................. 10 [BOX_24]
FROM SOME OTHER EMPLOYER ................ 11 [BOX_24]
UNDER PLAN OF SOMEONE NOT LIVING HERE ... 12 [BOX_24]
DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]] ............. 13 [BOX_24]
DIRECTLY FROM [STATE EXCHANGE NAME-A] ... 14 [BOX_24]
OTHER SOURCE ............................ 91 [HX23OV]
REF ..................................... -7 [BOX_24]
DK ...................................... -8 [BOX_24]
[Code One]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
STARTING IN PANEL 12 ROUND 2, CATEGORY '2' (FROM A HEALTH INSURANCE PURCHASING ALLIANCE) WAS OMITTED AND WILL BE OMITTED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 14 ROUND 5, PANEL 15 ROUND 3 AND PANEL 16 ROUND 1, CATEGORY '13' (DIRECTLY FROM A HIGH RISK POOL [/[STATE NAME FOR HIGH RISK POOL]]) WAS ADDED AS A CATEGORY AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
STARTING IN PANEL 17 ROUND 5, PANEL 18 ROUND 3 AND PANEL 19 ROUND 1, CATEGORY '14' (DIRECTLY FROM [STATE EXCHANGE NAME] WAS ADDED AND WILL BE ADDED IN ALL FUTURE ROUNDS.
----------------------------------------------------
----------------------------------------------------
DISPLAY '/[STATE NAME FOR HIGH RISK POOL]' IF STATE IN WHICH INTERVIEW IS BEING CONDUCTED OFFERS A HIGH RISK POOL HEALTH INSURANCE PLAN. THIS INCLUDES ALL STATES EXCEPT: AZ, DE, DC, GA, HI, ME, MA, MI, NV, NJ, NY, OH, PA, RI, VT, VA. IF INTERVIEW STATE IS ONE OF THESE STATES, USE A NULL DISPLAY.

FOR 'STATE NAME FOR HIGH RISK POOL' DISPLAY THE HIGH RISK POOL PLAN NAME ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.

FOR 'STATE EXCHANGE NAME' DISPLAY THE EXCHANGE NAME 'A' ASSOCIATED WITH THE STATE IN WHICH INTERVIEW IS BEING CONDUCTED.
----------------------------------------------------
----------------------------------------------------
DISPLAY AN 'ADD OTHER SOURCE' BUTTON ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF 'ADD OTHER SOURCE' IS SELECTED, PRESENT 'ADD OTHER SOURCE' POP-UP (HX23OV) AND THEN GO TO BOX_24.
----------------------------------------------------
HX48
====

[POLICYHOLDER FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
SHOW CARD HX-9.
Now think again about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. Looking at this card, what health insurance coverage [[do/does]/did] [you/he/she] have [as of [END DATE]]?
PROBE: Any other health coverage through this plan?
CHECK ALL THAT APPLY.
HOSPITAL AND PHYSICIAN BENEFITS, INCLUDING COVERAGE THROUGH AN HMO ...... 1
DENTAL ................................. 2
PRESCRIPTION DRUGS ..................... 3
VISION ................................. 4
MEDICARE SUPPLEMENT/MEDIGAP ............ 5
LONG TERM CARE IN A NURSING HOME ....... 6
EXTRA CASH FOR HOSPITAL STAYS .......... 7
SERIOUS DISEASE OR DREAD DISEASE ....... 8
DISABILITY ............................. 9
WORKER'S COMPENSATION ................. 10
ACCIDENT .............................. 11
OTHER ................................. 91 [HX48OV]
REF ................................... -7 [BOX_33]
DK .................................... -8 [BOX_33]
[Code All That Apply]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[NOTE: 'DISABILITY,' 'WORKER'S COMPENSATION,' AND 'ACCIDENT' WILL NOT APPEAR ON THE SHOW CARD.]
----------------------------------------------------
DISPLAY '[do/does]' IF INSURANCE BEING ASKED ABOUT IS CURRENT (I.E., HQ02 IS CODED '1' (YES, COVERED NOW) FOR THE POLICYHOLDER, AND THE CURRENT ROUND IS NOT ROUND 5. OTHERWISE, DISPLAY 'did'.

DISPLAY 'as of [END DATE]' IF ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
NOTE: CODES 9, 10 AND 11 WILL NOT APPEAR ON THE SHOW CARD.
----------------------------------------------------
----------------------------------------------------
FOR SPECIFICATIONS PURPOSES ONLY: CAPI DOES NOT ALLOW '-7' (REFUSED) OR '-8' (DON'T KNOW) IN COMBINATION WITH ANY OTHER CODE.
----------------------------------------------------
----------------------------------------------------
IF CODED '91' (OTHER), ALONE OR IN COMBINATION WITH ANY OTHER CODE, CONTINUE WITH HX48OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_33
----------------------------------------------------
OE01
====

[POLICYHOLDER'S FIRST MIDDLE LAST NAME] [NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
Now think about [your/[POLICYHOLDER]'s] health insurance through [ESTABLISHMENT]. [[Are/Is]/[Were/Was]] [you/he/she] or anyone in the family covered by this insurance as of [today,] [END DATE]?
YES ................................... 1 [BOX_02]
NO .................................... 2 [OE02]
REF ................................... -7 [END_LP01]
DK .................................... -8 [END_LP01]
----------------------------------------------------
DISPLAY '[Are/Is]' IF NOT ROUND 5. DISPLAY '[Were/Was]' IF ROUND 5.

DISPLAY 'today,' IF NOT ROUND 5. OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
HP01
====
Does the insurance from the school cover only injuries caused by accidents, or does it have general health coverage?
GENERAL HEALTH COVERAGE ................ 1 [HP02]
ONLY INJURIES CAUSED BY ACCIDENTS ...... 2 [BOX_11]
REF ................................... -7 [HP02]
DK .................................... -8 [HP02]
HELP AVAILABLE FOR DEFINITION OF GENERAL HEALTH COVERAGE.
[Code One]
HP11
====

[NAME OF ESTABLISHMENT] [STR-DT] [END-DT]
[Please tell me the names of everyone who is a primary insured person or policyholder of the/Who [is/was] the primary insured person or policyholder of this] health coverage through [ESTABLISHMENT] [on [END DATE]]?
[CODE ALL THAT APPLY.]
[1. First Name,[Middle Name],Last Name-35] ..
[2. First Name,[Middle Name],Last Name-35] ..
[3. First Name,[Middle Name],Last Name-35] ..
HELP AVAILABLE FOR DEFINITION OF POLICYHOLDER.
[Code All that Apply]
----------------------------------------------------
DISPLAY 'Please tell me the names of everyone who is a primary insured person or policyholder of the' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, DISPLAY 'Who [is/was] the primary insured person or policyholder of the'. DISPLAY 'CODE ALL THAT APPLY' IF HX23 IS CODED '14' (DIRECTLY FROM [STATE EXCHANGE NAME]). OTHERWISE, USE A NULL DISPLAY.
----------------------------------------------------
----------------------------------------------------
DISPLAY 'is' IF NOT ROUND 5. DISPLAY 'was' IF ROUND 5. DISPLAY 'on [END DATE]' IF ROUND 5. OTHERWISE, USE NULL DISPLAY. DISPLAY A "POLICYHOLDER NOT LISTED IN DU" AND "POLICYHOLDER DECEASED" OPTION ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
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
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
TITLE: DU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY DU MEMBER'S FIRST, MIDDLE, AND LAST NAMES (PERS.FULLNAME)
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ROSTER DEFINITION: THIS ITEM DISPLAYS DU-MEMBERS- ROSTER FOR SELECTION.
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ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.
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ROSTER FILTER:
NO FILTER; DISPLAY ALL DU MEMBERS.
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