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[p. 175]


SECTION FA- HEALTH CARE COVERAGE

ITEM FA1

Refer to household composition. Mark (X) for each person including those deleted in the HIS-1.

1 [] Civilian
2 [] AF living at home
3 [] Deleted

The next questions are about health insurance coverage and the kinds and amounts of income that people receive. For this family, that includes (read names, including Armed Forces members living at home).
The answers to these questions will add greatly to our knowledge about the health problems of the American people, the types of health care they receive, and whether they can afford the care that they need. The information will help in planning health care services and finding ways to lower costs of care.


There are several government programs that provide medical care or help pay medical bills.
People covered by Medicare have a card that looks like this. SHOW MEDICARE CARD.

1a. In (month), was anyone in the family, that is (read names), covered by Medicare?

1 [] Yes (1b)
2 [] No (2 on page 22)
9 [] DK (2 on page 22)

b. Who was covered?
Mark (X) "Medicare" box in person's column.

1 [] Medicare
(enter 'Cov' on HIS-1)

c. Anyone else?

[] Yes (Reask 1b and c)
[] No


Ask 1d-g as appropriate for each person with "Medicare" in 1b.
d. May I please see the Medicare card(s) for -- (and --) to determine the type of coverage and to record the Health Insurance Claim Number. This number is needed to allow Medicare records to be easily and accurately located and identified for statistical research purposes. Providing the Health Insurance Claim Number is voluntary and collected under the authority of the Public Health Service Act. Whether the number is given or not, there will be no effect on benefits and no identifying 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 (X) the appropriate box.

H.I.C. Number
___-____-_______( )_( )_
1 [] Part A- Hospital only
2 [] Part B- Medical only
3 [] Both Part A and Part B
4 [] Card N.A

Ask 1e-g for each person with "Card N.A" in 1d.
e. Was -- covered by Part A, that part of Medicare that pays for hospital bills?

1 [] Yes
2 [] No
9 [] DK

f. Was -- covered by Part B, that part of Medicare that pays for doctor's bills?
Read if necessary: This is the Part B Medicare plan for which -- or some agency or program must pay a certain amount each month.

1 [] Yes
2 [] No
9 [] DK


ITEM FA2
Refer to age

1 [] Under age 67 (1g)
2 [] Age 67 or older (NP)

g. How long has -- been covered by Medicare?

1 [] Less than 6 months
2 [] 6 months, but less than 1 year
3 [] 1 year, but less than 2 years
4 [] 2 years or more
9 [] DK

[p. 176]


Section FA -- HEALTH CARE COVERAGE -- Continued


There is a program called Medicaid that pays for health care for persons in need. In this State it is also called (State name).
2a. Does anyone in the family NOW have a Medicaid or (state name) card?

1 [] Yes (2b)
2 [] No (3)
9 [] DK (3)

b. Who is this? Mark (x) "Has Card" box in person's column.

1 [] Has card

c. Anyone else?

[] Yes (Reask 2b and c)
[] No


Ask 2d for each person with "Has Card" box marked in 2b.
d. May I please see -- (and --) card(s)? Mark (x) appropriate box in person's column. Record expiration date for each Medicaid card seen.

1 [] Medicaid card seen
Expiration date
____ (Month)
____ (Day)
2 [] No card seen
8 [] Other card seen - Specify ____


3a. In (month), was anyone in the family covered by Medicaid?

1 [] Yes (3b)
2 [] No (4)
9 [] DK (4)

b. Who was covered?
Mark (X) "Medicaid" box in person's column.

1 [] Medicaid (Enter "Cov" on HIS-1.)

c. Anyone else?

[] Yes (Reask 3b and c)
[] No


Ask 3d for each person with "Medicaid" box marked in 3b.
d. How long has -- had Medicaid coverage?

1 [] Less than 6 months
2 [] 6 months, but less than a year
3 [] 1 year, but less than 2 years
4 [] 2 years, but less than 5 years
5 [] 5 years or more
6 [] On and off for 2 years, but less than 5 years
8 [] On and off for 5 years or more
9 [] DK

ITEM FA3

Refer to household composition and question 3a.

1 [] Single person family and "Yes" in 3a (5)
2 [] Other (4)

4a. During the past 12 months, has anyone in the family received health care that has been or will be paid for by Medicaid or (state name)?

1 [] Yes (4b)
2 [] No (5)
9 [] DK (5)

b. Who received this care in the past 12 months?
Mark (X) "Received Medicaid Care" box in person's column.

1 [] Received Medicaid Care

c. Anyone else?

[] Yes (Reask 4b and c)
[] No


5a. In (month), was anyone in the family covered by any OTHER public assistance program (other than Medicaid) that pays for health care? Do NOT include use of public or free clinics if that is the only source of care.

1 [] Yes (5b)
2 [] No (6)
9 [] DK (6)

b. Who was covered?
Mark (X) "Public assistance" box in person's column.

1 [] Public assistance
(Enter "Cov" on HIS-1)

c. Anyone else?

[] Yes (Reask 5b and c)
[] No

[p. 177]


Section FA -- HEALTH CARE COVERAGE -- Continued

PERSON 1


6a. In (month), was anyone in the family covered by military health care, including armed forces retirement benefits, the VA (Department of Veterans' Affairs), CHAMPUS, or CHAMP-VA?

1 [] Yes (6b)
2 [] No (7)
9 [] DK (7)

b. Was this CHAMPUS or CHAMP-VA?
Read if necessary: CHAMPUS is a program of medical care for dependents of active or retired military personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans?

1 [] Yes (6c)
2 [] No (6f)
9 [] DK (6e)

c. Who was covered by CHAMPUS or CHAMP-VA?
Mark (X) "CHAMPUS/CHAMP-VA" box in person's column.

1 [] CHAMPUS/CHAMP-VA (Enter "Cov" on HIS-1)

d. Anyone else?

[] Yes (Reask 6c and d)
[] No


e. In (month), was anyone in the family covered by any other military health care, including armed forces retirement benefits or the VA (Department of Veterans' Affairs)?

1 [] Yes (6f)
2 [] No (7)
9 [] DK (7)

f. Who was covered by other military health care?
Mark (X) "Military" box in person's column.

1 [] Military (Enter "Cov" on HIS-1)

g. Anyone else?

[] Yes (Reask 6f and g)
[] No


7a. In (month), was anyone in the family covered by the Indian Health Service?

1 [] Yes (7b)
2 [] No (8)
9 [] DK (8)

b. Who was covered?
Mark (X) "IHS" box in person's column.

1 [] IHS (Enter "Cov" on HIS-1)

c. Anyone else?

[] Yes (Reask 7b and c)
[] No


8a. (Not counting the government health programs we just mentioned), In (month) was anyone in the family covered by a private health insurance plan?
Read if necessary: Besides government programs, people also get health insurance through their job or union, through other private groups, or directly from an insurance company. A variety of types of plans are available, including health maintenance organizations (HMOs).

1 [] Yes (8b)
2 [] No (8 on page 34)
9 [] DK (8 on page 34)

b. It's important that we have the complete and accurate name of each health insurance plan. What is the COMPLETE name of the plan? If "DK", probe: Do you have something with the plan name on it?
Record up to 4 plan names in Sec. FB, Table H.I. Then ask 8c.

c. In (month), was anyone in the family covered by any OTHER private health insurance plan?

1 [] Yes (Reask 8b and c)
2 [] No (Section FB)

[p. 178]


Section FB -- PRIVATE PLAN AND COVERAGE DETAIL

PERSON 1

PLAN 1 NAME

____

Now, I am going to ask some questions about the plan(s) you just told me about, (Starting with (plan name)).

1a. Who was covered under this plan?
Mark (X) "Private insurance" box in person's column.

1 [] Private insurance (enter "Cov" on HIS-1)

b. Anyone else?

[] Yes (Reask 1a and b)
[] No


2. In whose name is this plan?
Mark (X) "In name" box in person's column.

1 [] In name
2 [] Person not in household


3a. Was this plan originally obtained through the workplace, that is through a present or former employer or union?
If "Yes", probe for employer or union.

1 [] Employer ... (3b)
2 [] Union ... (3b)
3 [] Through workplace, but DK whether employer or union (3b)
4 [] No (4)
9 [] DK (4)


b. Does the employer or union currently pay for all, some, or none of the cost of premiums for this health insurance plan?
Read if necessary: The cost of the plan refers to the premiums, which are regular payments for health insurance coverage only, not for health care services. Frequently, these payments are made by payroll deduction.

1 [] All (5)
2 [] Some (4)
3 [] None (4)
9 [] DK (4)


HAND CARD FR3. Read each category if telephone interview.
CARD FR3

1. Zero
2. $1-$9
3. $10-$19
4. $20-$49
5. $50-$99
6. $100-$199
7. $200-$499
8. $500 or more

4. In (month), how much did [you/your family] spend for health insurance premiums for (plan name)? Please include payroll deductions for premiums.

1 [] Zero
2 [] $1-$9
3 [] $10-$19
4 [] $20-$49
5 [] $50-$99
6 [] $100-$199
7 [] $200-$499
8 [] $500 or more
9 [] DK


5a. Does this plan pay for a variety of health care services or does it pay for ONLY ONE type of services or care?

1 [] Variety of services (6)
2 [] Only one type of service/care (5b)
9 [] DK (6)

b. What type of service or care does the plan pay for?
Mark (X) only one type of service

01 [] Accidents
02 [] AIDS care
03 [] Cancer treatment
04 [] Catastrophic care
05 [] Dental care
06 [] Disability insurance (cash payments when unable to work for health reasons)
07 [] Hospice care
08 [] Hospitalization-only
09 [] Long term care (nursing home care)
10 [] Prescriptions
11 [] Vision care
98 [] Other-Specify ____
99 [] DK

GO TO 1a FOR NEXT HI PLAN; IF NO OTHER HI PLAN, GO TO 8a.

[p. 179]

PERSON 2

1a.

1 [] Private insurance (Enter "Cov" on HIS-1)
____

2.

1 [] In name

PERSON 3

1a.

1 [] Private insurance (Enter "Cov" on HIS-1)
____

2.

1 [] In name

PERSON 4

1a.

1 [] Private insurance (Enter "Cov" on HIS-1)
____

2.

1 [] In name

PERSON 5

1a.

1 [] Private insurance (Enter "Cov" on HIS-1)
____

2.

1 [] In name


6a. Is (plan name) an HMO (Health Maintenance Organization) or IPA (Individual Practice Association), or is it some other kind of plan?
Read if necessary: Health Maintenance Organizations, or HMO's and Individual Practice Associations, or IPA's, are plans whose members are required to use only those health care providers who work for or in association with the HMO or IPA. Sometimes there is an option to permit use of providers not associated with the Plan, but usually at greater cost to the enrollee. Generally, members do not have to submit claims for costs of medical care services.

1 [] HMO/IPA
2 [] Other
9 [] DK


b. Under this plan can you choose ANY doctor or MUST you choose one from a specific group or list of doctors?

1 [] Any doctor (6c)
2 [] Select from group/list (6d)
9 [] DK (7)


c. Do you have the option of choosing a doctor from a preferred or select list at lower cost to you?

1 [] Yes (7)
2 [] No (7)
9 [] DK (7)


d. If you select a doctor who is not in the plan, will (plan name) pay for any part of the cost?

1 [] Yes
2 [] No
9 [] DK


Ask if family has at least one person under the age of 18.
7a. Does (plan name) pay for any of the costs of well child care, that is visits when a child is NOT sick, but needs a check-up or immunization?

1 [] Yes
2 [] No
9 [] DK


Ask if family has at least one female over the age of 39.
b. Does this plan pay for any part of the cost for mammograms?
Read if necessary: A mammogram is an X-ray taken only of the breasts by a machine that presses the breast against a plate.

1 [] Yes
2 [] No
9 [] DK

GO TO 1a FOR NEXT PLAN; IF NO OTHER PLAN GO TO 8a.

[p. 180]


Section FB -- PRIVATE PLAN AND COVERAGE DETAIL -- Continued


8a. In the past 2 years, has anyone in the family been denied coverage, or had restricted or limited coverage, (under [this plan/any of the plans you just told me about]) because he or she already had a particular health condition, sometimes called a pre-existing condition?

1 [] Yes (8b)
2 [] No (9)
9 [] DK (9)

b. Who is this?
Mark (x) "Pre-existing condition" box in person's column

1 [] Pre-existing condition

c. Anyone else?

[] Yes (Reask 8b and c)
[] No
[] DK


9a. In the past 2 years, has anyone in the family applied for health insurance and not been able to get it?

1 [] Yes (9b)
2 [] No (10)
9 [] DK (10)

b. Who is this?
Mark (X) "Turned down" box in person's column

1 [] Turned down

c. Anyone else?

[] Yes (Reask 9b and c)
[] No
[] DK


Ask for each person with "Turned down" box marked in 9b.
d. Why was -- unable to get that health insurance? Anything else?
Mark (X) all that apply

1 [] Because of pre-existing condition, as cancer or diabetes
2 [] Because of health risk(s), such as smoking or overweight
3 [] Because of work, such as construction worker, beautician, farm worker
4 [] Because premiums were too high
8 [] Other- Specify ____
9 [] DK


10a. In the past two years or so, has anyone in the family decided to stay in one job rather than take another job mainly because of reasons related to health insurance?

1 [] Yes (10b)
2 [] No (FB1)
9 [] DK (FB1)

b. Who is this?
Mark (X) "Stayed in job" box in person's column

1 [] Stayed in job

c. Anyone else?

[] Yes (Reask 10b and c)
[] No
[] DK

ITEM FB1
Refer to age and Wa/Wb in HIS-1
Mark (X) first appropriate box

1 [] 70+ (NP)
2 [] Wa/Wb marked (Check Item FB2)
8 [] Other (NP)


ITEM FB2
Refer to 2 for ALL plans in HI.

1 [] Any "In name" (NP)
8 [] Other (11)

11. Was health insurance offered by -- employer?

1 [] Yes (NP)
2 [] No (NP)
9 [] DK (NP)

ITEM FB3
Refer to Age and "Cov." on HIS-1
Mark (X) first appropriate box

1 [] Covered (13)
2 [] Not covered, under 65 (12)
3 [] Not covered, 65+ (12)

If no other persons in the family, Skip to 14 on page 40

[p. 181]


Section FB -- PRIVATE PLAN AND COVERAGE DETAIL -- Continued

HAND CARD FR4. Read each category if telephone interview. If "Not covered 65 and over," include "or Medicare".
CARD FR4

01. Job layoff/loss/unemployment
02. Wasn't offered by employer
03. Not eligible because part time worker
04. Family coverage not offered by employer
05. Benefits from former employer ran out
06. Can't obtain because of poor health, illness, or age
07. Too expensive/Can't afford
08. Dissatisfied with previous insurance
09. Don't believe in insurance
10. Have usually been healthy, haven't needed insurance
11. Covered by some other plan
12. Too old for coverage under family plans
13. Free/inexpensive source of care readily available
98. Other reason (Specify)

12a. Many people do not have health insurance for various reasons. Which of these statements describes why -- is not covered by any health insurance (or Medicare)?
Anything else?
Mark (X) all that apply.

01 [] Job layoff/loss/unemployment
02 [] Wasn't offered by employer
03 [] Not eligible because part time worker
04 [] Family coverage not offered by employer
05 [] Benefits from former employer ran out
06 [] Can't obtain because of poor health, illness, or age
07 [] Too expensive/Can't afford
08 [] Dissatisfied with previous insurance
09 [] Don't believe in insurance
10 [] Have usually been healthy, haven't needed insurance
11 [] Covered by some other plan
12 [] Too old for coverage under family plans
13 [] Free/inexpensive source of care readily available
98 [] Other reason- Specify ____
99 [] DK (12c)


Ask if more than one box is marked in 12a, otherwise transcribe number of box marked without asking.
b. What is the MAIN reason -- was not covered in (month) by any health insurance (or Medicare)?
Record number from CARD FR4

Main reason ____


c. When was the LAST time -- had health insurance?

1 [] Less than 6 months ago (12d)
2 [] 6 months ago, but less than 1 year ago (12d)
3 [] 1 year ago, but less than 3 years ago (12d)
4 [] 3 or more years ago (FB3 for NP)
5 [] Never had health insurance (FB3 for NP)
9 [] DK (12e)

HAND CARD FR5. Read categories if telephone interview.
CARD FR5

01. Lost job or changed employers
02. Spouse/parent lost job or changed employers
03. Death of spouse or parent
04. Became divorced or separated
05. Became ineligible because of age
06. Employer stopped offering coverage
07. Cut back to part time
08. Benefits from employer/former employer ran out
98. Other (Specify)


d. What was the MAIN reason -- stopped being covered by health insurance?
Mark (X) only one.

01 [] Lost job or changed employers
02 [] Spouse/parent lost job or changed employers
03 [] Death of spouse or parent
04 [] Became divorced or separated
05 [] Became ineligible because of age
06 [] Employer stopped offering coverage
07 [] Cut back to part time
08 [] Benefits from employer/former employer ran out
98 [] Other- Specify ____
99 [] DK


e. At the time that -- stopped being covered by health insurance, did -- try to find some other type of health insurance?

1 [] Yes (12f)
2 [] No (FB3 for NP)
9 [] DK (FB3 for NP)


f. What was the MAIN reason -- was unable to find some other type of health insurance?

1 [] Could not afford (FB3 for NP)
2 [] Was rejected (FB3 for NP)
8 [] Other reason - Specify ____ (FB3 for NP)
9 [] DK (FB3 for NP)

[p. 181]


Section FB -- PRIVATE PLAN AND COVERAGE DETAIL -- Continued


13a. In the past 12 months, was there any time that -- did NOT have ANY health insurance or coverage?

1 [] Yes (13b)
2 [] No (FB3 for NP)
9 [] DK (FB3 for NP)


b. In how many of the past 12 months was -- without coverage?

1 [] 1 month or less
2 [] 2-3 months
3 [] 4-6 months
4 [] More than 6 months
9 [] DK

HAND CARD FR5. Read each category if telephone interview
CARD FR5

01. Lost job or changed employers
02. Spouse/parent lost job or changed employers
03. Death of spouse or parent
04. Became divorced or separated
05. Became ineligible because of age
06. Employer stopped offering coverage
07. Cut back to part time
08. Benefits from employer/former employer ran out
98. Other (Specify)

c. What was the MAIN reason -- was without coverage?

01 [] Lost job or changed employers (FB3 for NP)
02 [] Spouse/parent lost job or changed employers (FB3 for NP)
03 [] Death of spouse or parent (FB3 for NP)
04 [] Became divorced or separated (FB3 for NP)
05 [] Became ineligible because of age (FB3 for NP)
06 [] Employer stopped offering coverage (FB3 for NP)
07 [] Cut back to part time (FB3 for NP)
08 [] Benefits from employer/former employer ran out (FB3 for NP)
98 [] Other- Specify ____ (FB3 for NP)
99 [] DK (FB3 for NP)

HAND CARD FR6. Read each category if telephone interview
CARD FR6

1. Zero
2. Less than $500
3. $500-$1,999
4. $2,000-$2,999
5. $3,000-$4,999
6. $5,000 or more

14. During the past 12 months, about how much did [you/your family] spend for medical care? Do NOT include the cost of over-the-counter remedies, the cost of health insurance premiums, or any costs for which you expect to be reimbursed.

1 [] Zero
2 [] Less than $500
3 [] $500-$1999
4 [] $2000-$2999
5 [] $3000-$4999
6 [] $5000 or more
9 [] DK

ITEM FB4
About how often did the Respondent appear to answer the questions in Sections FA and FB accurately?

1 [] All the time
2 [] Most of the time
3 [] Some of the time
4 [] Rarely or never
9 [] DK

ITEM FB5
About how often did the Respondent appear to answer the questions in Sections FA and FB honestly?

1 [] All the time
2 [] Most of the time
3 [] Some of the time
4 [] Rarely or never
9 [] DK


ITEM FB6
Enter the person number of the Respondent. If more than one, enter the person number of the one who answered the most questions in Sections FA and FB.

Person number ____