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[p.166]

Section M -- Health Insurance

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 Medicare Card.

1a. Is anyone in this family, that is (read names), now covered by Medicare?

b. Is -- now covered?

Ask for each person with "Covered" or "DK" in 1b
2. May I please see the Social Security Medicare card(s) for -- (and --) to determine the type of coverage and to record the Health Insurance Claim Number. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. There will be no effect on -- benefits and no information will be given to any other government or non-government agency.
Read if necessary The Public Health Service Act is Title 42, United States Code, Section 242k.
Transcribe the number, then mark the appropriate box(es).

Ask for each person with "Card NA" in 2
3a. Is -- now covered by the part of Social Security Medicare which pays for hospital bills?

b. Is -- now covered by that part of Medicare which pays for doctor's bills? This is the Medicare plan for which [he/she] or some agency must pay a certain amount each month.

4a. (Not counting Medicare) is anyone in the family now covered by a health insurance plan which pays any part of hospital, doctor, or dental bills? Do not include plans that pay for only one type of service, such as nursing home care or accidents.

b. It's important that we have the complete and accurate name of your health insurance plan. What is the complete name of the plan?
Record in Table H.I. If "DK", probe: Do you have something with the plan name on it?

c. Is anyone in the family now covered by any other health insurance plan? Again, do not include plans that pay for only one service.

Table H.I.

(Now I am going to ask some questions about the plan(s) you just told me about.)
Read if necessary: Health Maintenance Organizations, or HMO's, sometimes called Individual Practice Associations, or IPA's, are plans whose members are required to use only those health care providers who work for the HMO or IPA. Also, members do not have to submit claims for costs of medical care services.

[option for providing 5 different plan entries in the original document not presented here. That is "Plan1 - Plan 5" with the same questions asked for Plan 1]

Plan 1-5 name ____

5a. Is this (name) plan a Health Maintenance Organization or HMO?

b. Was this plan obtained through an employer or union?

c. Is it now carried through an employer or union?

6a. Does this (name) plan pay any part of hospital expenses?

b. Does this plan pay any part of doctor's or surgeon's bills for operations?

c. Does it pay for any dental services other than oral surgery?

d. Does it pay for any prescription drugs other than those administered during a hospital stay?

e. Does it pay for any mental health, alcoholism, or drug abuse services?

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

[p. 167]

Section M - Health Insurance- continued

8a. (In addition to the plan(s) you just mentioned) Is anyone in the family now covered by an insurance plan that pays for only one type of health care service, such as nursing home care, eye care, or prescriptions?

b. Is -- covered by this type of plan?

Ask for each person "Covered" in 8b:
c. What type of service does --'s plan pay for?

d. Is -- now covered by any other insurance plan that pays for only one service?

[p.168]

1. Book ____ of ____ books

2. R.O. Number ____

3. Sample ____

4. Control number

Table H.I. (Continued)

Transcribe each plan name from Table H.I.

[option for providing 5 different plan entries in the original document not presented here. That is "Plan1 - Plan 5" with the same questions asked for Plan 1]

Plan 1-5 Name ____

Check Item 1

5d. Does the employer or union pay for any part of the cost for this (name) plan?

1[] Yes (5e)
2[] No (5f)
9[] DK (5f)

5e. Does the employer or union pay for all or just part of the cost?

5f. In whose name is the (name) plan?
Enter person number.

[p.169]

Section M -- Health Insurance -- Continued

Check Item 2
Review 1b and 7 for each person and determine if "Covered" by either Medicare and/or insurance, or "Not covered."

Ask for each person "Not covered" in Check item 2.
If "Not covered 65 and over." in Check item 2, include "or Medicare."

9a. (Many people do not carry health insurance for various reasons.) Hand Card M. Which of those statements directly describes why -- is not covered by any health insurance (or Medicare)?
Any other reason?
Circle all reasons given.

Mark box if only one reason.

If "not covered 65 and over," in Check item 2, include "or Medicare."
b. What is the main reason -- is not covered by any health insurance (or Medicare)?

Ask only if persons under age 20 in family; otherwise skip to 11.
10a. Does anyone in the family now receive assistance through the "Aid to Families with Dependent Children" program, sometimes called "AFDC" or "ADC"?

b. Does -- now receive AFDC or ADC?

11a. Does anyone in the family now receive the "Supplemental Security Income" or "SSI" check?

b. Does -- now receive this check?

12a. There is a program called Medicaid that 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))?

b. Has -- received this care in the past 12 months?

13a. Does anyone in the family now have a Medicaid (or (name)) card?

b. Does -- now have this card?

Ask for each person with "Yes" in 13b.
c. May I please see --'s (and --) card(s)?
Mark appropriate box(es) in person's column.

14a. Is anyone in the family now covered by any other public assistance program that pays for health care?

b. Is -- now covered?

15. Is anyone in this family now covered by health care benefits from the Armed Forces or Veterans' Administration?

16a. 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.

b. Does -- now receive military retirement or a VA pension?

Ask for each person with "Yes" in 16b.
c. Which does -- receive - the Armed Forces retirement, the VA pension, or both?

[p. 170]

Section M -- Health Insurance -- Continued

17a. Is anyone in the family now covered by champus, which is a program of medical care for dependents of military personnel?

b. Is -- now covered by CHAMPUS?

c. Is anyone in the family now covered by CHAMP-VA, which is medical insurance for dependents or survivors of disabled veterans?

d. Is -- now covered by CHAMP-VA?

18a. Is anyone in the family now covered by any other program that provides health care for military dependents or survivors of military persons?

b. Is -- now covered?

Check Item 3
Refer to "AF" box above person's column in HIS-1.

19a. Does -- have a disability related to [his/her] service in the Armed Forces of the United States?

b. Does -- now receive compensation for this disability from the Veterans' Administration?

c. Has -- ever applied for a service-connected disability rating from the Veterans' Administration?

d. Was it approved or denied?

20a. During the past 12 months, that is since (12-month date) a year ago, have (read names of related HH members 18 or over) been laid off from a job or lost a job?

b. Who was this?
Mark "Laid off/lost job" box in person's column.

c. Anyone else?

Ask 20d, e, and f for each person with "Laid off/lost job" in 20b.
d. How many times has -- been laid off or lost a job during the past 12 months?

e. In what month and year was -- laid off or did [he/she] lose a job ((the last time/the time before that))?

f. For anytime during (that/those) job layoff(s) or job loss(es), did -- receive unemployment insurance benefits?

21a. Because of (names of persons in 20b) job layoff(s) or job loss(es), did anyone in the family lose any health insurance coverage that had been carried through (that/those) job(s)?

b. Who was this?
Mark "Lost coverage" box in person's column.

c. Anyone else?

Check Item 4
Refer to 21b and mark appropriate box.

22a. Was -- covered by some other health insurance plan at any time during (that/those) job layoffs(s) or job loss(es)? Do not count military insurance or health programs such as Medicaid or AFDC.

b. Was -- covered by another plan for the entire time (names of persons in 20b) (was/were) off work?

c. For how long was -- not covered by any kind of health insurance plan?

23a. At anytime during (that/those) job layoff(s) or job loss(es), was -- covered by a military program or by a health program such as Medicaid or AFDC?

b. For how long was -- covered by this kind of program?