Items Booklet - He Items Booklet - Health Insurance

CTRLNUM
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LINENO
***Non-Displayed Item***

HINTRO
^HINTRO1
Press 1 to Continue

1. Enter 1 to continue

MCARE1
Medicare is the health insurance for people 65 years and older, or people under 65 with
disabilities.
(Are / Is) (name/you) NOW covered by Medicare?
Medicare read-if-necessary
Code Medigap and Medicare Parts A, B, and C as "Yes"
1. Yes
2. No

ANYCOV
(Do/Does) (name/you) NOW have any type of health plan or health coverage?

1. Yes
2. No

MCAID
(Are / Is) (name/you) NOW covered by Medicaid, Medical Assistance, CHIP, or any other kind of
government assistance program that helps pay for health care?
Page 1 of 31

Medicare read-if-necessary
Code State Medicaid Name 1 State Medicaid Name 2 State Medicaid Name 3 State CHIP Name 1
State CHIP Name 2 State Name 6 State-specific Medicaid Program Name 7 Program Name 8 State
Health Program Name 9 as "YES"

1. Yes
2. No

MCARE2
Medicare is the health insurance for people 65 years and older, or people under 65 with
disabilities.
(Are / Is) (name/you) NOW covered by Medicare?
Medicare read-if-necessary
Code Medigap and Medicare Parts A, B, and C as "YES"

1. Yes
2. No

OTHGOVT
(Are / Is) (name/you) NOW covered by any kind of health plan such as State Medicaid Name 1,
State Medicaid Name 2, State Medicaid Name 3, State CHIP Name 1, State CHIP Name 2, State
Name 6, State-specific Medicaid Program Name 7, Program Name 8, State Health Program Name
9?
Code Medicaid and CHIP as "YES"
1. Yes
2. No

EXCHNG
(Are / Is) (name/you) NOW covered by any kind of health plan through State Exchange Portal
Name such as ^STEXCH1comma and 'or' State Exchange Program Name 2comma and or State
Exchange Program Name 3?

Page 2 of 31

1. Yes
2. No

VERIFY
OK, I have recorded that (name/you) (are / is) not covered by any kind of health plan or health
coverage. Is that correct?

1. Yes, not covered
2. No, ^NAME is covered

CTRLNUM
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LINENO
*NON-SCREEN ITEM

SRCEGEN_LC1
ASK OR VERIFY
^SRCE_INTRO. (Do/Does) (name/you) get covit through a job, the government or state, or some
other way?
"Job" includes coverage from someone's own job as well as coverage from a spouse's or parent's job.
Include coverage through former employers and unions, and COBRA plans.
If this coverage is provided through a job with the government, state or military, consider that coverage
through a job.
IF R CHOOSES MORE THAN ONE:
OK let's talk about one plan at a time. Which would you like to tell me about first?

1. Job (current or former)
2. Government or State
3. Some other way

Page 3 of 31

SRCEDEPDIR_LC1
ASK OR VERIFY
How (do/does) (name/you) get that coverage? Is it through a parent or spouse, (do/does)
(name/you) buy it (yourself/himself/herself), or (do/does) (name/you) get it some other way?
IF A PARENT/SPOUSE BUYS THE COVERAGE (BOTH 1 AND 2) THEN CODE <2> FOR "BUY IT"

1. Parent or spouse
2. Buy it
3. Some other way

SRCEBIZ_LC1
ASK OR VERIFY
(Do/Does) (name/you) get it through a former employer, a union or business association, or some
other way?
1. Former employer
2. Union
3. Business Association
4. Some other way

SRCEMISC_LC1
(Do/Does) (name/you) get it through the Indian Health Service, a school, or some other way?

1. Indian Health Service
2. School
3. Some other way

JOBCOV_LC1
Is that coverage related to a JOB with the government or state?
Include coverage through FORMER employers and unions, and COBRA plans.

1. Yes
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2. No

MILPLAN_LC1
ASK OR VERIFY
Is that plan related to military service in any way?

1. Yes
2. No

GOVTYPE_LC1
ASK OR VERIFY
What type of coverage is it - Medicaid, CHIP, Medicare, military or VA care, or some other type of
coverage?
Medicare read-if-necessary
IF R CHOOSES MORE THAN ONE: OK let's talk about one plan at a time. Which would you like to tell
me about first?
Code State Medicaid Name 1 State Medicaid Name 2 State Medicaid Name 3 State CHIP Name 1
State CHIP Name 2 State Name 6 State-specific Medicaid Program Name 7 Program Name 8 State
Health Program Name 9 as "Medicaid"
Code Medigap and Medicare Parts A, B, and C as "Medicare"
Code State Exchange Portal Name ^STEXCH1 State Exchange Program Name 2 State Exchange
Program Name 3 as "Other"

1. Medicaid, Medical Assistance, or CHIP
2. Medicare
3. Military or VA care
4. Other

MILTYPE_LC1
ASK OR VERIFY
Page 5 of 31

Which plan (are / is) (name/you) covered by? Is it TRICARE, TRICARE for Life, CHAMPVA,
Veterans Administration care, military health care, or something else?

1. TRICARE
2. TRICARE for Life
3. CHAMPVA
4. Veterans Administration care
5. Military health care
6. Other

POLHOLDER_LC1
ASK OR VERIFY
Whose name is the policy in?

1. ^NAME
2. ^NAME
3. ^NAME
4. ^NAME
5. ^NAME
6. ^NAME
7. ^NAME
8. ^NAME
9. ^NAME
10. ^NAME
11. ^NAME
12. ^NAME
13. ^NAME
14. ^NAME
15. ^NAME
16. ^NAME
17. Someone living outside the household

SRCEPTSP_LC1
ASK OR VERIFY
Do they get that coverage through their job, do they buy it themselves, or do they get it some
Page 6 of 31

other way?
1. Job (current or former)
2. Buy it
3. Some other way

GOVPLAN_LC1
ASK OR VERIFY
What do you call the program?
IF R ANSWERS WITH INSURANCE COMPANY NAME:
OK, so that would be the plan name. What do you call the program? Some examples of programs in
(state) are read full list below.

1. Medicaid
2. Medical Assistance
3. CHIP (the State Children's Health Insurance Program)
4. ^STMCAID1
5. ^STMCAID2
6. ^STMCAID3
7. ^STMCAID4
8. ^STMCAID5
9. ^STMCAID6
10. ^STMCAID7
11. ^STMCAID8
12. ^STMCAID9
13. ^STEXCH1
14. ^STEXCH2
15. ^STEXCH3
16. plan through ^STPORTAL
17. other government plan
18. other (please specify)

MISCSPEC_LC1
Please Specify

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PORTAL_LC1
ASK OR VERIFY
Is that coverage through State Exchange Portal Name such as ^STEXCH1comma and 'or' State
Exchange Program Name 2comma and or State Exchange Program Name 3?
1. Yes
2. No

EXCHTYPE_LC1
ASK OR VERIFY
Which plan is it - ^STEXCH1comma and 'or' State Exchange Program Name 2comma and or State
Exchange Program Name 3?
1. ^STEXCH1
2. ^STEXCH2
3. ^STEXCH3

HIPAID_LC1
Does (name's/your) employer or union pay for all, part, or none of the health insurance premium?
Report here employer's contribution to employee's health insurance premiums, not the employee's
medical bills.
1. All
2. Part
3. None

SHOP_LC1
Small businesses can offer health coverage to their employees through State Exchange Portal
Name. Is the coverage at all related to State Exchange Portal Name, which offers ^STEXCH1,
State Exchange Program Name 2, State Exchange Program Name 3?
1. Yes
2. No

POLHOLDER2_LC1
ASK OR VERIFY
Page 8 of 31

Whose name is the policy in?

1. ^NAME
2. ^NAME
3. ^NAME
4. ^NAME
5. ^NAME
6. ^NAME
7. ^NAME
8. ^NAME
9. ^NAME
10. ^NAME
11. ^NAME
12. ^NAME
13. ^NAME
14. ^NAME
15. ^NAME
16. ^NAME
17. Someone living outside the household

PREMYN_LC1
Is there a monthly premium for this plan?
Premium read-if-necessary

1. Yes
2. No

PREMSUBS_LC1
Is the cost of the premium subsidized based on (your/family) income?
Premium read-if-necessary
1. Yes
2. No

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CTRLNUM
**Non-Displayed Item**

LINENO
*NON-SCREEN ITEM

BEFORAFT_LC1
Did (name's/your) coverage from plantype start before or after January 1, CY-1?
Your best estimate is fine.
job probe
direct probe

1. Before January 1, 2012
2. On or after January 1, 2012

MNTHBEG1_LC1
In what month did that coverage start?
This question refers to plantype
Your best estimate is fine.
job probe
direct probe

1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
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YEARBEG1_LC1
ASK OR VERIFY
And what year was that?
This question refers to plantype
^JOBPROBE
direct probe

1. 2012
2. 2013

CNTCOV_LC1
And has it been continuous since COVBEG?
This question refers to plantype
If the gap in coverage was less than 3 weeks, consider the coverage "continuous."
job probe
direct probe

1. Yes
2. No

MNTHBEG2_LC1
In what month did this most recent period of coverage start?
This question refers to plantype
Your best estimate is fine.
job probe
direct probe

1. January
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2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December

YEARBEG2_LC1
ASK OR VERIFY
And what year was that?
This question refers to plantype

1. 2012
2. 2013

SPELLADD_LC1
So far I have recorded that you were covered by plantype in months of coverage. Were there any
OTHER months between January CY-1 and now that you were also covered by plantype?
1. Yes
2. No

ANYTHIS_LC1
What months (was/were) (name/you) covered by plantype THIS year -- in CY?

1. January CY
2. February CY
3. March CY
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4. April CY
20. All months of CY
21. No months of CY

ANYLAST_LC1
What months (was/were) (name/you) covered by plantype LAST year -- in CY-1?

1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
20. All months during CY-1
21. No months during CY-1

CTRLNUM
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LINENO
*NON-SCREEN ITEM

OTHMEMB_LC1
And other than (name/you) is anyone else who is living or staying in this household ALSO
covered by plantype?
Please include the policyholder.

Page 13 of 31

1. Yes
2. No

COVWHO_LC1
Who? (Who else in this household is covered by plantype)?
Anyone else?
Please include the policyholder.

0. No one listed
1. Person 1's name
2. Person 2's name
3. Person 3's name
4. Person 4's name
5. Person 5's name
6. Person 6's name
7. Person 7's name
8. Person 8's name
9. Person 9's name
10. Person 10's name
11. Person 11's name
12. Person 12's name
13. Person 13's name
14. Person 14's name
15. Person 15's name
16. Person 16's name
96. All persons listed

SAMEMNTHS_LC1
And ^WEREWASA Secondary members covered also covered from birth until now?
This question refers to plantype
1. ^All also covered from ^BIRTH until now
2. ^None not covered from ^BIRTH until now
Page 14 of 31

MNTHS_LC1
(What months between Jan CY-1 and now was NAME covered?/How about NAME?)
This question refers to plantype
1. January CY-1
2. February CY-1
3. March CY-1
4. April CY-1
5. May CY-1
6. June CY-1
7. July CY-1
8. August CY-1
9. September CY-1
10. October CY-1
11. November CY-1
12. December CY-1
13. January CY
14. February CY
15. March CY
16. April CY
20. All months from January 2012 until now
21. No months from January 2012 until now

MNTHS_LC1
(What months between Jan CY-1 and now was NAME covered?/How about NAME?)
This question refers to plantype
1. January CY-1
2. February CY-1
3. March CY-1
4. April CY-1
5. May CY-1
6. June CY-1
7. July CY-1
8. August CY-1
9. September CY-1
10. October CY-1
11. November CY-1
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12. December CY-1
13. January CY
14. February CY
15. March CY
16. April CY
20. All months from January 2012 until now
21. No months from January 2012 until now

OTHOUT_LC1
Does that plan cover anyone living outside this household?

OTHWHO_LC1
How old are they -- under 19, 19-25 or older than 25?
Mark all that apply

AddGap1_L
Ok so far I have recorded that (name/you) (was/were) covered by plantype
in months of coverage. What about months of no coverage? (were/was) (name/you) covered
by any type of health plan or health coverage in those months?

1. Yes
2. No

CTRLNUM
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LINENO
*NON-SCREEN ITEM

SRCEGEN_LP1
^SRCE_INTRO. Was that coverage provided through a job, the government or state, or some
other way?
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"Job" includes coverage from someone's own job as well as coverage from a spouse's or parent's job.
Include coverage through former employers and unions, and COBRA plans.
If this coverage is provided through a job with the government or the military, consider that coverage
through a job.
PROBE IF R CHOOSES MORE THAN ONE: OK let's talk about one plan at a time. Which would you
like to tell me about first?

1. Job (current or former)
2. Government or State
3. Some other way

SRCEDEPDIR_LP1
ASK OR VERIFY
How did (name/you) get that coverage? Was it through a parent or spouse, did ( you/he/she) buy
it (yourself/himself/herself), or did ( you/he/she) get it some other way?
IF A PARENT/SPOUSE BUYS THE COVERAGE (BOTH 1 AND 2) THEN CODE <2> FOR "BUY IT".

1. Parent or spouse
2. Buy it
3. Some other way

SRCEBIZ_LP1
ASK OR VERIFY
Did (name/you) get it through a former employer, a union or business association, or some other
way?
1. Former employer
2. Union
3. Business Association
4. Some other way

Page 17 of 31

SRCEMISC_LP1
Did (name/you) get it through the Indian Health Service, a school or some other way?
1. Indian Health Service
2. School
3. Some other way

JOBCOV_LP1
Was that coverage related to a JOB with the government or state?
Include coverage through FORMER employers and unions, and COBRA plans.

1. Yes
2. No

MILPLAN_LP1
READ IF NECESSARY
Was that plan related to military service in any way?

1. Yes
2. No

GOVTYPE_LP1
ASK OR VERIFY
What type of coverage was it - Medicaid, CHIP, Medicare, military or VA care, or some other type
of coverage?
Medicare read-if-necessary
IF R CHOOSES MORE THAN ONE: OK let's talk about one plan at a time. Which would you like to tell
me about first?
Code State Medicaid Name 1 State Medicaid Name 2 State Medicaid Name 3 State CHIP Name 1 State
CHIP Name 2 State Name 6 State-specific Medicaid Program Name 7 Program Name 8 State Health
Program Name 9 as "Medicaid"
Code Medigap and Medicare Parts A, B, and C as "Medicare"
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Code State Exchange Portal Name ^STEXCH1 State Exchange Program Name 2 State Exchange
Program Name 3 as "Other"
1. Medicaid, Medical Assistance, or CHIP
2. Medicare
3. Military or VA care
4. Other

MILTYPE_LP1
ASK OR VERIFY
Which plan (was/were) (name/you) covered by? Was it TRICARE, TRICARE for Life, CHAMPVA,
Veterans Administration care, military health care, or something else?

1. TRICARE
2. TRICARE for Life
3. CHAMPVA
4. Veterans Administration care
5. Military health care
6. Other

POLHOLDER_LP1
ASK OR VERIFY
Whose name was the policy in?

1. ^NAME
2. ^NAME
3. ^NAME
4. ^NAME
5. ^NAME
6. ^NAME
7. ^NAME
8. ^NAME
9. ^NAME
Page 19 of 31

10. ^NAME
11. ^NAME
12. ^NAME
13. ^NAME
14. ^NAME
15. ^NAME
16. ^NAME
17. Someone living outside the household

SRCEPTSP_LP1
ASK OR VERIFY
And did they get that coverage through their job, did they buy it themselves, or did they get it
some other way?

1. Job (current or former)
2. Buy it
3. Some other way

GOVPLAN_LP1
ASK IF NECESSARY
What did you call the program?
IF R ANSWERS WITH INSURANCE COMPANY NAME: OK, so that would be the plan name. What do
you call the program? Some examples of programs in (state) are read full list below.

1. Medicaid
2. Medical Assistance
3. CHIP (the State Children's Health Insurance Program)
4. ^STMCAID1
5. ^STMCAID2
6. ^STMCAID3
7. ^STMCAID4
8. ^STMCAID5
9. ^STMCAID6
10. ^STMCAID7
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11. ^STMCAID8
12. ^STMCAID9
13. ^STEXCH1
14. ^STEXCH2
15. ^STEXCH3
16. plan through ^STPORTAL
17. other government plan
18. other (please specify)

MISCSPEC_LP1
Please Specify

PORTAL_LP1
ASK OR VERIFY
Was that coverage through State Exchange Portal Name, such as ^STEXCH1comma and 'or'
State Exchange Program Name 2comma and or State Exchange Program Name 3?

1. Yes
2. No

EXCHTYPE_LP1
ASK IF NECESSARY
Which plan was it - ^STEXCH1comma and 'or' State Exchange Program Name 2comma and or
State Exchange Program Name 3?

1. ^STEXCH1
2. ^STEXCH2
3. ^STEXCH3

HIPAID_LP1
Did (name's/your) employer or union pay for all, part, or none of the health insurance premium?
Report here employee's health insurance premiums, not the employee's medical bills
Page 21 of 31

1. All
2. Part
3. None

SHOP_LP1
Small businesses can offer health coverage to their employees through State Exchange Portal
Name. Was the coverage at all related to State Exchange Portal Name, which offers ^STEXCH1,
State Exchange Program Name 2, State Exchange Program Name 3?

1. Yes
2. No

POLHOLDER2_LP1
ASK OR VERIFY
Whose name was the policy in?

1. ^NAME
2. ^NAME
3. ^NAME
4. ^NAME
5. ^NAME
6. ^NAME
7. ^NAME
8. ^NAME
9. ^NAME
10. ^NAME
11. ^NAME
12. ^NAME
13. ^NAME
14. ^NAME
15. ^NAME
16. ^NAME
17. Someone living outside the household

PREMYN_LP1
Page 22 of 31

Was there a monthly premium for this plan?
Premium read-if-necessary
1. Yes
2. No

PREMSUBS_LP1
Was the cost of the premium subsidized based on (your/family) income?
Premium read-if-necessary
1. Yes
2. No

CTRLNUM
**Non-Displayed Item**

LINENO
*NON-SCREEN ITEM

WMNTHS_LP1
What months between January CY-1 and now (was/were) (name/you) covered plantype?

1. January CY-1
2. February CY-1
3. March CY-1
4. April CY-1
5. May CY-1
6. June CY-1
7. July CY-1
8. August CY-1
9. September CY-1
10. October CY-1
11. November CY-1
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12. December CY-1
13. January CY
14. February CY
15. March CY
16. April CY
20. All months from January 2012 until now
21. No months from January 2012 until now

CTRLNUM
**Non-Displayed Item**

LINENO
*NON-SCREEN ITEM

OTHMEMB_LP1
And other than (name/you) was anyone who was living or staying in this household ALSO
covered by plantype?

1. Yes
2. No

COVWHO_LP1
Who? (Who else was covered by plantype)?
Anyone else?

0. No one listed
1. Person 1's name
2. Person 2's name
3. Person 3's name
4. Person 4's name
5. Person 5's name
Page 24 of 31

6. Person 6's name
7. Person 7's name
8. Person 8's name
9. Person 9's name
10. Person 10's name
11. Person 11's name
12. Person 12's name
13. Person 13's name
14. Person 14's name
15. Person 15's name
16. Person 16's name
96. All persons listed

SAMEMNTHS_LP1
And ^WEREWASA Secondary members covered all also covered in months of coverage?

1. ^All also covered in ^MNTHCOV
2. ^None not covered in ^MNTHCOV

MNTHS_LP1
(What months between Jan CY-1 and now was NAME covered?/How about NAME?)
This question refers to coverage plantype

OTHOUT_LP1
Did that plan cover anyone living outside this household?

OTHWHO_LP1
How old were they -- under 19, 19-25, or older than 25?
MARK ALL THAT APPLY

CTRLNUM
Page 25 of 31

**Non-Displayed Item**

LINENO
*NON-SCREEN ITEM

ADDGAP2_L
Ok so far I have recorded that (name/you) (was/were) covered by ^MULTPLAN in months of
coverage. What about months of no coverage? (were/was) (name/you) covered by any type of
health plan or health coverage in those months?
1. Yes
2. No

GAPMNTHS_LPR
What months between January CY-1 and now (was/were) (name/you) covered?

1. January CY-1
2. February CY-1
3. March CY-1
4. April CY-1
5. May CY-1
6. June CY-1
7. July CY-1
8. August CY-1
9. September CY-1
10. October CY-1
11. November CY-1
12. December CY-1
13. January CY
14. February CY
15. March CY
16. April CY
20. All months from January 2012 until now
21. No months from January 2012 until now

AddNow_L
Page 26 of 31

OK other than ^MULTPLAN (do/does) (name/you) NOW have any other type of health plan or
health coverage?
Do not include plans that cover only one type of care, such as dental or vision plans.

1. Yes
2. No

AddPast_L
And how about any other plans plans in the past? other plansMULT (were/was) (name/you)
covered by any other plans type of health plan or health coverage AT ANY TIME between January
CY-1 and now?
Do not include plans that cover only one type of care, such as dental or vision plans.

1. Yes
2. No

ASSIST
Did (name/you) visit a hospital or health clinic to get care at any time from Janaury CY-1 and
now?
1. Yes
2. No

FHINTRO
Now I'd like to ask you about (name/you)'s health coverage.
Press 1 to Continue

1. Enter 1 to continue

AddNow_F
Other than ^MULTPLAN, (Is NAME now covered by Medicaid/Medicare/any other plan)

Page 27 of 31

Do not include plans that cover only one type of care, such as dental or vision plans.
1. Yes
2. No

AddGap1_F
So far I have recorded that (name/you) (was/were) covered by ^MULTPLAN in months of
coverage. What about months of no coverage? (were/was) (name/you) covered by any type of
health plan or health coverage in those months?

1. Yes
2. No

CTRLNUM
**NON-DISPLAYED ITEM**

LINENO
*NON-SCREEN ITEM

ADDGAP2_F
So far I have recorded that (name/you) (was/were) covered by ^MULTPLAN in months of
coverage. What about months of no coverage? (were/was) (name/you) covered by any type of
health plan or health coverage in those months?

1. Yes
2. No

GAPMNTHS_FPR
What months between January CY-1 and now (was/were) (name/you) covered?

1. January CY-1
2. February CY-1
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3. March CY-1
4. April CY-1
5. May CY-1
6. June CY-1
7. July CY-1
8. August CY-1
9. September CY-1
10. October CY-1
11. November CY-1
12. December CY-1
13. January CY
14. February CY
15. March CY
16. April CY
20. All months from January 2012 until now
21. No months from January 2012 until now

AddNow2_F
^FRST_NXT Other than ^MULTPLAN (do/does) (name/you) NOW have any other type of health
plan or health coverage?
Do not include plans that cover only one type of care, such as dental or vision plans.

1. Yes
2. No

AddPast_F
And how about plans in the past? Other than ^MULTPLAN, (was/were) (name/you) covered by
any other type of health plan or health coverage AT ANY TIME between January CY-1 and now?
Do not include plans that cover only one type of care, such as dental or vision plans.

1. Yes
2. No

Page 29 of 31

CTRLNUM
**Non-Displayed Item**

LINENO
*NON-SCREEN ITEM

OFFER
^FTOFFER Earlier I recorded that (name/you) (are / is) employed but (do/does) not have health
coverage through (your/his/her) job. Does ^EMPNAME offer health insurance to any of its
employees?

COULD
Could (name/you) be in this plan if ( you/he/she) wanted to?

1. Yes
2. No

WNTAKE
Why (aren't/isn't) ( you/he/she) in this plan?
Choose all that apply

1. Covered by another plan
2. Traded health insurance for higher pay
3. Too expensive
4. Don't need health insurance
5. Have a pre-existing condition
6. Haven't yet worked for this employer long enough to be covered
7. Contract or temporary employees not allowed in plan
8. Other/specify

WNTAKESPEC
Please specify other reason why not in the plan

WNELIG
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Why not? Why can't (name/you) be in this plan if ( you/he/she) wanted to?
Choose all that apply

1. Don't work enough hours per week or weeks per year
2. Contract or temporary employees not allowed in plan
3. Haven't yet worked for this employer long enough to be covered
4. Have a pre-existing condition
5. Too expensive
6. Other/specify

WNELIGSPEC
Please specify other resason why not eligible

Page 31 of 31