VA Form 10-21034j Cover Sheet for Health Insurance Module 1

SURVEY OF VETERAN ENROLLEES' HEALTH AND RELIANCE UPON VA - HEALTH INSURANCE MODULE
I	ENROLLMENT SCREENER
	(For Enrollment Section of Key Drivers Module)
PREQ 1	Are you enrolled in VA health care?	1		Yes
		2		No
		3		I don't remember enrolling
		98		Don't Know
		99		Refused
II	HEALTH INSURANCE QUESTIONS
1	Are you covered by Medicare?	1		Yes
		2		No (SKIP to Q7)
		98		Don't Know (SKIP to Q7)
		99		Refused (SKIP to Q7)
2	Did you choose to receive your Medicare coverage through a Medicare Advantage Plan and not through the Original Medicare Plan? Medicare Advantage Plans include Medicare HMOs (Health Maintenance Organizations), Medicare PPOs (Preferred Provider Organizations), Medicare Special Needs Plans, and Medicare Private Fee-for-Service Plans.	1		Yes (SKIP to Q6)
		2		No
		98		Don't Know
		99		Refused
3	Does your Medicare coverage pay for care if you are hospitalized?	1		Yes
	Interviewer Note: This type of Medicare is also sometimes called "Part A"; if they have it , there is generally no premium because they or a spouse paid for it through payroll taxes while they were working.	2		No
		98		Don't Know
		99		Refused
4	Does your Medicare coverage pay for doctor's office visits?	1		Yes
	Interviewer Note: This type of Medicare is also sometimes called "Part B"; if they have it , they generally pay a monthly fee or premium which may be directly deducted from their Social Security check.	2		No
		98		Don't Know
		99		Refused
5	Do you purchase any private health care coverage to supplement Medicare; that is to pay for services Medicare does not pay for?
		1		Yes
	Interviewer Note: "Yes" - Types of private insurance a person can purchase to supplement Medicare include Medigap or Medicare Supplement. Does not include Medicare Advantage or Medicare + Choice.	2		No
		98		Don't Know
		99		Refused
	Interviewer Note: "No" - A type of insurance that does not count is the Departament of Defense's TRICARE for Life plan for Medicare eligible military retirees.
6	Do you have Medicare prescription drug coverage ("Part D")?
		1		Yes
		2		No
		98		Don't Know
		99		Refused
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7	Are you currently covered by Medicaid for any of your health care?
	Interviewer, if necessary: Medicaid is a program that pays for Medical Assistance for certain individuals with low incomes and resources and is provided by your State governments's social services department.	1		Yes
		2		No
		98		Don't Know
	Interviewer Note: "Medical Assistance" = "Medicaid" in some States.	99		Refused
8	Are you currently covered by the Department of Defense's TRICARE or TRICARE for Life health care programs?		1		Yes
			2		No
			98		Don't Know
			99		Refused
9	Are you currently covered by any other individual or group health plan that either you, or an employer, or someone else, such as a family member obtains for you?
		1		Yes
	Interviewer Note: "Yes" - Do count any private retiree health insurance plan.	2		No (SKIP to Q13)
		98		Don't Know (SKIP to Q13)
	Interviewer Note: "No" - Do not count private Medigap, Medicare Supplement, Medicare Advantage, or Medicare + Choice plans.	99		Refused (SKIP to Q13)
10	Who provides this coverage? If more than one source applies, please indicate the primary source.	1		Current employer (including COBRA coverage)
		2		Former employer
	(Interviewer read list)	3		Individually purchased coverage
		4		Federal, State, County, or local community health
				services program
		5		Family member (spouse, parent, etc.)
		6		Other (allow text input here)…………………………….
		98		Don't Know
		99		Refused
11	Does this coverage include prescription drug coverage?	1		Yes
		2		No
		98		Don't Know
		99		Refused
12	Is this coverage provided through an HMO or other managed care organization?
		1		Yes
	Interviewer Note: An HMO or Health Maintenance Organization or other managed care coverage requires you to use certain doctors, hospitals, and other providers. If you use health care services or providers who are not in the plan, you pay more, or all of the cost for that health care.	2		No
		98		Don't Know
		99		Refused
13	Do you currently have prescription drug coverage from VA?	1		Yes
		2		No
		98		Don't Know
		99		Refused
14a.	How many different over the counter medications did you use in the last 30 days?	##		Enter Number (Range=0-97; If "0" SKIP to Q15a,
				Else Continue).
		98		Don't Know (SKIP to Q15a)
		99		Refused (SKIP to Q15a)
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14b	Of these over the counter medications, how many did you obtain from VA?	##		Enter Number (Range=0-97)
		98		Don't Know
		99		Refused
15a	How many different prescription medications did you use in the last 30 days?	##		Enter Number (Range=0-97, If "0" SKIP to Q16, Else Continue)
		98		Don't Know (SKIP to Q16)
		99		Refused (SKIP to Q16)
15b	Of these prescription medications, how many did you obtain from VA?	##		Enter Number (Range=0-97)
		98		Don't Know
		99		Refused
16	On average, how much do you spend out-of-pocket for all your over the counter and prescription medications on a monthly basis, not including any health insurance premiums you may pay?	####		Enter Number (Range=0-9997)
		9998		Don't Know
		9999		Refused
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