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 covered by Medicare?

b. Who was covered?
Mark (x) "Medicare" box in person's column and "Cov" on HIS-1

c. Anyone else?

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. In (month), was anyone in the family covered by Medicare?

b. Who was covered?
Mark (x) "Medicaid" in person's column and "Cov" on the HIS-1

c. Anyone else?

4a. 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.

b. Who was covered?
Mark (x) "Public assistance" in person's column and "Cov" on HIS-1.

c. Anyone else?

5a. 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 TRICARE, or CHAMP-VA?

b. Was this CHAMPUS or TRICARE, or CHAMP-VA?
Read if necessary: CHAMPUS or TRICARE 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?

c. Who was covered by CHAMPUS or TRICARE, or CHAMP-VA? Mark (x) "CHAMPUS/TRICARE/CHAMP-VA" in person's column and "Cov" on the HIS-1.

d. Anyone else?

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)?

f. Who was covered by other military health care?
Mark (x) "Military" in person's column and "Cov" box on the HIS-1.

g. Anyone else?

6a. In (month), was anyone in the family covered by the Indian Health Service?

b. Who was covered?
Mark (x) "IHS" in person's column and "Cov" on the HIS-1.

c. Anyone else?

7a. (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).

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?
Ask 7c after recording each plan. Record up to 4 plan names in Part C, Table H.I

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

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" in person's column and "Cov" on the HIS-1

b. Anyone else?

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 covered by Medicare?

b. Who was covered?
Mark (x) "Medicare" box in person's column and "Cov" on HIS-1

c. Anyone else?

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

b. Who was covered?
Mark (x) "Medicaid" in person's column and "Cov" on the HIS-1

c. Anyone else?

4a. 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.

b. Who was covered?
Mark (x) "Public assistance" in person's column and "Cov" on HIS-1.

c. Anyone else?

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)?

f. Who was covered by other military health care?
Mark (x) "Military" in person's column and "Cov" box on the HIS-1.

g. Anyone else?

6a. In (month), was anyone in the family covered by the Indian Health Service?

b. Who was covered?
Mark (x) "IHS" in person's column and "Cov" on the HIS-1.

c. Anyone else?

7a. (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).

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?
Ask 7c after recording each plan. Record up to 4 plan names in Part C, Table H.I

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

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

c. Anyone else?

Ask 1d-g as appropriate for each person with "Medicare" in 1b.
d. May I please see the Medicare card(s) for -- (and [other sample persons]) 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.

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?

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.

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?

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

c. Anyone else?

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.

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

c. Anyone else?

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?

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?

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

d. Anyone else?

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)?

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

g. Anyone else?

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

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

c. Anyone else?

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?

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

c. Anyone else?

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?

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

c. Anyone else?

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

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

c. Anyone else?

Refer to household composition and question 3a.

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)?

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

c. Anyone else?

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?

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?

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

d. Anyone else?

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)?

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

g. Anyone else?

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

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

c. Anyone else?