[p. 80]
HEALTH INSURANCE PAGE
Medicare is a Social Security health insurance program for disabled persons and for persons 65 years old and over. People covered by Medicare have a card that looks like this. Show Card.
1a. Is anyone in this family covered by Medicare?
[] N (4)
[] DK
b. Is -- covered? Mark box in person's column.
2 [] Not cov.
9 [] DK
Ask for each person with "Covered" in 1b.
2a. Is -- covered by that part of Social Security Medicare which pays for hospital bills? Mark box in person's column.
2 [] No
9 [] DK
b. Is -- covered by that part of Medicare which pays for doctor's bills, that is, the Medicare plan for which he or some agency must pay a certain amount each month? Mark box in person's column.
2 [] No
9 [] DK
Ask for each person with "DK" in 2 and for each person under 65 with "Covered" in 1b.
3. May I please see the Social Security Medicare card(s) for -- (and [other covered individual]) to determine the (type/dates) of coverage?
Transcribe the information from the card or mark the "Card N.A." box.
2 [] Cov. Med
3 [] Card N.A.
We are interested in all kinds of health insurance plans except those which pay only for accidents.
4a. (Not counting Medicare) Is anyone in the family covered by hospital insurance, that is, a health insurance plan which pays any part of a hospital bill?
[] N
b. What is the name of the plan? (Record in Table H.I.) ____
c. Is anyone in the family covered by any other hospital insurance plan?
[] N
d. Is anyone in the family covered by any (other) health insurance plan which pays any part of a DOCTOR'S or SURGEON'S bill?
[] N (5)
e. What is the name of the plan? (Record in Table H.I., reask 4d) ____
TABLE H.I.
[Table H.I. contains lines for 3 different lines. Each asks the same questions, so Plans 2 and 3 have been omitted here.]
Plan 1
5a. Was this (name) plan obtained through an employer or union?
2 [] N
9 [] DK
b. Was it obtained through some other group?
2 [] N
9 [] DK
c. Does this plan pay any part of hospital expenses?
2 [] N
9 [] DK
d. Does this plan pay any part of doctor's or surgeon's bills for operations?
2 [] N
9 [] DK
6a. Is -- covered under this (name) plan?
2 [] Not cov. (NP)
b. During the past 12 months did -- receive medical care which has been or will be paid for by this plan?
2 [] N
9 [] DK
[End Table H.I.]
I
For each person review 1, 2, 3, and 5 for each plan and determine if "Covered" by either Medicare or insurance, or "Not covered."
2 [] Not cov. (NP)
Ask for each person "Not covered,"
Many people do not carry health insurance for various reasons. Hand Card N.
CARD N
2. Unemployed, or reasons related to employment.
3. Can't obtain insurance because of poor health, illness, or age.
4. Too expensive, can't afford health insurance.
5. Dissatisfied with previous insurance.
6. Don't believe in insurance.
7. Have been healthy, not much sickness in the family, haven't needed health insurance.
8. Military dependent, (CHAMPUS), veteran's benefits.
9. Some other reason -- Specify
7a. Which of those statements describes why -- is not covered by any health insurance plan? Any other reason?
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9 -- Specify ____
b. What is the MAIN reason -- is not covered by any health insurance plan?
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9 -- Specify ____
[p. 81]
[AL Note: Page 82 is a response sheet to questions in the Health Insurance section. Question 1a as well as several other questions do not appear on this sheet.]
2 [] Not cov.
9 [] DK
2 [] No
9 [] DK
b.
2 [] No
9 [] DK
2 [] Cov. Med
3 [] Card N.A.
2 [] Not cov. (NP)
b.
2 [] N
9 [] DK
I.
2 [] Not cov. (NP)
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9 -- Specify ____
b.
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9 -- Specify ____
[p. 90]
4a. Does anyone in this family receive assistance through the "Aid to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?
[] N (5)
b. Which (other) family members are included in the AFDC assistance payment? Mark "AFDC" box in each person's column. ____
c. Are any other family members included in this program?
[] N
5a. Does anyone in this family receive the "Supplemental Security Income" or "SSI" gold-colored check?
[] N (6)
b. Who receives this check? ____
Mark "SSI" box in person's column.
c. Anyone else?
[] N
6a. There is a national program called Medicaid which pays for health care for persons in need. (In this State it is also called ____.) During the past 12 months, has anyone in this family received health care which has been or will be paid by Medicaid (or ____)?
[] N (7)
b. Who was this? Mark "Medicaid" box in person's column. ____
c. Anyone else?
[] N
7a. Does anyone in the family now have a Medicaid (or ____ ) card which looks like this? Show Medicaid card.
[] N (8)
b. Who is this? Mark "Card" box in person's column. ____
c. Anyone else?
[] N
If "Card," ask:
d. May I please see --'s (and [other covered individual's]) card(s)? Mark appropriate box(es) in person's column.
2 [] Expired
8 [] Other card seen (Specify) ____
8a. During the past 12 months, has anyone in the family received health care provided or paid for by the Veterans Administration?
[] N (9)
b. Who was this? ____
Mark "VA" box in person's column.
c. Anyone else?
[] N
[p. 91]
[MK Note: Page 91 contains a response sheet for questions asked on page 90. The response sheet has five columns to enter information in; only one is represented here since each column contains the same information.]
d.
2 [] Expired
8 [] Other card seen (Specify) ____