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hmo

[p.68]


4a. Does anyone in the family belong to a Health Maintenance Organization or a prepaid group practice plan?

1 [] Y
2 [] N (7)
9 [] DK (7)

b. What is the name? Record in Table P below. ____

c. Does anyone in the family belong to any other Health Maintenance Organization or prepaid group practice plan?

[] Y (Reask 4b and c)
[] N
[] DK

TABLE P


[MK Note: There are two separate response areas for Plan 1 and Plan 2. Only one response area is represented here, as the information in each area is identical.]


5a. Name of plan ____


b. Who is the policyholder or subscriber of this (name) plan? ____


c. How long has (name of subscriber) belonged to this (name) plane?

1 [] Mos.
2 [] Yrs.


ASK FOR EACH PLAN LISTED IN TABLE P

6a. Does -- belong to this (name) plan?

1 [] Belongs
2 [] Does not belong (NP)


b. Does he ever see a doctor who is not part of this plan?

1 [] Y
2 [] N (NP)
9 [] DK (NP)


c. Why does -- sometimes see other doctors? ________

d. Is there any other reason -- sometimes sees doctors who are not part of this plan?

[] Y (Reask 5c and d)
[] N (NP)

[p. 69]


7a. (Besides ____ plan) Is anyone in the family covered by a health insurance plan which pays any part of a hospital, doctor's, or surgeon's bill?

1 [] Y
2 [] N (10)
9 [] DK (10)

b. What is the name of the plan? Record in Table H.I. below ____

c. Is anyone in the family covered by any other health insurance plan?

[] Y (Reask 7b and c)
[] N


TABLE H.I.


[MK Note: There are three separate response areas for Plan 1, Plan 2, and Plan 3. Only one response area is represented here, as the information in each area is identical.]


8a. Name of plan ____

b. Who is the policyholder or subscriber of this (name) plan?

ASK FOR EACH PLAN LISTED IN TABLE H.I.

9. Is -- covered under this (name) plan?

1 [] Covered (NP)
2 [] Not covered (NP)


10. Is there ONE particular doctor or place -- usually goes to when he is sick or when you need advice about his health?

1 [] Y
2 [] N (NP)


11. Where do you go for this care or advice for --, to a clinic, hospital, doctor's office, or some other place?

If Hospital: Is this an outpatient clinic or the emergency room?
If Clinic: Is this a hospital outpatient clinic, a company clinic, or some other kind of clinic?

1 [] Private dr's office
2 [] Home
3 [] Doctor's clinic
4 [] Group practice
5 [] Hosp. Outpatient Clinic
6 [] Hosp. Emerg. Room
7 [] Company or Industry Clinic
[] Other -- Specify ____