[p.158]
M. HEALTH INSURANCE PAGE
Read to respondent(s):
Medicare is a Social Security health insurance program for disabled persons and for persons 65 years
old and older. People covered by Medicare have a card that looks like this. Show card.
1a. Is anyone in this family, that is (read names), now covered by Medicare?
[] N(4)
[] DK
b. Is -- now covered? Mark box in person's column.
2[] Noc cov
9[] DK
Ask for each person with "Covered" in 1b.
2a. Is -- covered by the part of Social Security Medicare which pays for hospital bills? Mark box in person's column.
2[] No
9[] DK
b. Is -- now covered by that part of Medicare which pays for doctor's bills? This is the Medicare plan for which -- 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 2a and/or b:
3. May I please see the Social Security Medicare card(s) for -- (and --) to determine the (type/dates) of coverage?
Transcribe the information from the card or mark the "Card N.A." box.
2[] Medical
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 a health insurance plan which pays any part of a hospital, doctor's or surgeon's bill?
[] No (M1)
b. What is the name of the plan? (Record in Table H.I.)
c. Is anyone in the family now covered by any other health insurance plan which pays any part of a hospital, doctor's or surgeon's bill?
[] No (5)
TABLE H.I.
Plan 1-4
[option for up to 3 plans in original documention. Not presented here]
5a. Was this (name) plan obtained through an employer or union?
2[] No (6)
9[] DK (6)
b. Is it now carried through an employer or union?
2[] No
9[] DK
6a. Does this plan pay any part of hospital expenses?
2[] No
9[] DK
b. Does this plan pay any part of doctor's or surgeon's bills for operations?
2[] No
9[] DK
7. Is -- covered under this (name) plan?
Mark box in person's column.
2[] Not covered (NP)
M1
Review 1 and 7 for each person and determine if "Covered" by either Medicare and/ or insurance, or "Not covered."
2[] Not covered under 65 (NP)
3[] Not covered 65 and over (NP)
Ask for each person "Not covered" in M1. If "not covered 65 and over," include "or Medicare".
Many people do not carry health insurance for various reasons. Hand card N.
Card N
2. Can't obtain insurance because of poor health, illness or age
3. Too expensive, can't afford health insurance
4. Dissatisfied with previous insurance
5. Don't believe in insurance
6. Have been healthy, not much sickness in the family, haven't needed health insurance
7. Covered by some other health plan
8. Some other reason- Specify
8a. Which of those statements describes why -- is not covered by any health insurance (or Medicare)? Any other reason? Circle all reasons given.
2
3
4
5
6
7
8 ________ (specify)
Mark box if only one reason. If "Not covered 65 and over," in M1, include "or Medicare."
b. What is the main reason -- is not covered by any health insurance (or Medicare)?
1
2
3
4
5
6
7
8 ________ (specify)
[p. 159]
M. HEALTH INSURANCE PAGE, Continued
9a. Does anyone in this family now receive assistance through the "Aid to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?
[] No (10)
[] DK (10)
b. Which (other) family members are included in the AFDC assistance payment?
Mark "AFDC" box in person's column.
c. Are any other family members included in this program?
[] No
10a. Does anyone in this family now receive the "Supplemental Security Income" of "SSI" gold-colored check?
[] No (11)
[] DK (11)
b. Who (else) received this check? Mark "SSI" box in person's column.
c. Anyone else?
[] No
11a. There is a national program called Medicaid which pays for health care for persons in need. (In this State it is also called (name).) During the past 12 months, has anyone in this family received health care which has been or will be paid for by Medicaid (or (name))?
[] N (12)
[] DK (12)
b. Who was this? Mark "Medicaid" box in person's column.
c. Anyone else?
[] No
12a. Does anyone in the family now have a Medicaid (or (name)) card which looks like this? Show Medicaid card.
[] No (13)
[] DK (13)
b. Who is this? Mark "Card" box in person's column.
c. Anyone else?
[] No
Ask for each person with "Card" in 12b:
d. May I please see --'s (and --) card(s)?
Mark appropriate box(es) in person's column.
2[] expired
3[] No card seen
8[] Other card seen
Specify ____
13a. Is anyone in the family now covered by any other public assistance program that pays for health care?
[] No (Next page)
[] DK (Next page)
b. Who is this? Mark "Other PA" box in person's column.
c. Anyone else?
[] No
[p.160]
M. HEALTH INSURANCE PAGE, Continued
14a. Does anyone in the family now receive military retirement payments from any branch of the Armed Forces or a pension from the Veterans Administration? Do not include VA disability compensation.
[] No (15)
[] DK (15)
b. Who is this?
Mark "Mil. ret./VA pen." box in person's column.
c. Anyone else?
[] No
Ask for each person with "Mil. ret./VA pen." in 14b:
d. Which does -- receive - the Armed Forces retirement, the VA pension or both?
2[] VA
3[] Both
15a. Is anyone in the family now covered by CHAMP-VA, which is medical insurance for dependents of survivors of disabled veterans?
[] No (16)
[] DK (16)
b. Who is this?
Mark "CHAMP-VA" box in person's column.
c. Anyone else?
[] No
16a. Is anyone in the family now covered by any other program that provides health care for military dependents or survivors of military persons?
[] No (M2)
[] DK (M2)
b. Who is this?
Mark "Health Care" box in person's column.
c. Anyone else?
[] No
M2
Refer to "AF" box above person's column.
2 [] Other (NP)
17a. Does -- have a disability related to --'s service in the Armed Forces of the United States?
2[] No (NP)
b. Does -- now receive compensation for this disability from the Veteran's Administration?
2[] No