Not Assigned Family Health Insurance

Page 1 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.050_00.000 Instrument Variable Name: FHICOV QuestionnaireFileName: Family

QuestionText: (book) F12 and (book) F13

The next questions are about health insurance. Include health insurance obtained through employment or purchased directly

as well as government programs like Medicare and Medicaid that provide Medical care or help pay medical bills.

[fill:Are you/Is anyone in the family] covered by any kind of health insurance or some other kind of health care plan?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families

SkipInstructions: <1,R,D> [goto HIKIND]

<2> [if QUARTER=1 or 2, goto SINCOV; else, if QUARTER=3 or 4 and AGE ge 65, goto MCAREPRB; else,

goto MCAIDPRB]

Question ID: FHI.070_00.000 Instrument Variable Name: HIKIND QuestionnaireFileName: Family

QuestionText: (book) F12 and (book) F13 ? [F1]

What kind of health insurance or health care coverage [fill: do you/does ALIAS] have? INCLUDE those that pay for only

one type of service (nursing home care, accidents, or dental care). EXCLUDE private plans that only provide extra cash

while hospitalized.

* Enter all that apply, separate with commas.

01 Private health insurance

02 Medicare

03 Medi-Gap

04 Medicaid

05 SCHIP (CHIP/Children's Health Insurance Program)

06 Military health care (TRICARE/VA/CHAMP-VA)

07 Indian Health Service

08 State-sponsored health plan

09 Other government program

10 Single service plan (e.g., dental, vision, prescriptions)

11 No coverage of any type

97 Refused

99 Don't know

UniverseText: All persons in families where FHICOV= yes, don't know, or refused

SkipInstructions: <R,D> [goto HCSPFYR]

<1-10> [if QUARTER=1 or 2 and HIKIND ne 10, goto SINCOV; else, goto HICHANGE]

<1-10> [if QUARTER=3 or 4 and AGE ge 65 and HIKIND ne 2, goto MCAREPRB; else, if HIKIND ne 10 goto

SINCOV; else, goto HICHANGE]

<11> [if QUARTER=1 or 2 and HIKIND=1-10, goto ERR_HIKIND; else, goto HICHANGE]

<11> [if QUARTER=3 or 4 and HIKIND = 1-10, goto ERR_HIKIND; else, if AGE ge 65 goto MCAREPRB; else,

goto MCAIDPRB]

Page 2 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.072_00.000 Instrument Variable Name: MCAREPRB QuestionnaireFileName: Family

QuestionText: (book) F12a

People covered by Medicare have a card that looks like this.

[fill: Are you/Is ALIAS] covered by Medicare?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons 65 years of age or older in families not covered by health insurance or Medicare was not selected for those

persons at HIKIND

SkipInstructions: if HIKIND ne 10, goto SINCOV; else, goto HICHANGE

NOTE: MCAREPRB was only asked in Quarters 3 and 4.

Question ID: FHI.073_00.000 Instrument Variable Name: MCAIDPRB QuestionnaireFileName: Family

QuestionText: (book F13)

* Refer to flashcard F13 for state Medicaid names.

There is a program called Medicaid that pays for health care for persons in need. In this State it is also called (* fill State

name). [fill: Are you/Is ALIAS] covered by Medicaid?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons less than 65 years of age with no insurance coverage of any type

SkipInstructions: goto SINCOV

NOTE: MCAIDPRB was only asked in Quarters 3 and 4.

Question ID: FHI.074_00.000 Instrument Variable Name: SINCOV QuestionnaireFileName: Family

QuestionText: [fill: Do you/Does ALIAS] have any type of insurance that pays for only one type of service such as dental, vision, or

prescriptions?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons in families not covered by health insurance or single service plan was not selected for those persons at

HIKIND

SkipInstructions: goto HICHANGE

Page 3 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.075_00.000 Instrument Variable Name: HICHANGE QuestionnaireFileName: Family

QuestionText: I have recorded [fill1: you are/ALIAS is] [fill 2: covered by:

fill3: ^HIKIND] / not covered by health insurance.]

Is this correct?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons

SkipInstructions: <1,R,D> [repeat for all eligible persons, then goto MCNO]

<2> [goto ERR_HICHANGE]

Question ID: FHI.080_01.000 Instrument Variable Name: MCNO QuestionnaireFileName: Family

QuestionText: 1 of 2 ? [F1]

I recorded that you are covered by Medicare. May I please see your Medicare card to determine the type of coverage and to

record the Health Insurance Claim Number?

*Enter the claim number from the card.

This number is needed to allow Medicare records of the Centers for Medicare and Medicaid Services to be easily and

accurately located and identified for statistical or research purposes. We may also need to link it with other records in order

to re-contact you. Except for these purposes, NCHS will not release your Health Insurance Claim Number to anyone,

including any other government agency. 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 your benefits.

This number will be held in strict confidence.

* Read if necessary: The Public Health Service Act is Title 42, United States Code, Section 242K.

0-999999996 0-999999996

999999997 Refused

999999999 Don't know

UniverseText: Family respondents with Medicare

SkipInstructions: <0-99999996> [goto MCLET]

<R,D> [goto MCPART]

Question ID: FHI.080_02.000 Instrument Variable Name: MCLET QuestionnaireFileName: Family

QuestionText: 2 of 2

*Enter the letters that appear after the claim number.

2 letters

97 Refused

99 Don't know

UniverseText: Family respondents with Medicare who reported a Medicare claim number

SkipInstructions: goto MCPART

Page 4 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.090_00.000 Instrument Variable Name: MCPART QuestionnaireFileName: Family

QuestionText: {if subject ne respondent}:

Earlier I recorded that ALIAS is covered by Medicare. May I please see ALIAS’s Medicare card to determine the type of

coverage?

{if subject eq respondent}:

* Read if necessary.

What type of Medicare coverage do you have? Is it Part A - hospital insurance, Part B - medical insurance, or both?

* Fill in appropriate coverage type below.

1 Part A - Hospital only

2 Part B - Medical only

3 Both Part A and Part B

7 Refused

9 Don't know

UniverseText: All persons with Medicare

SkipInstructions: <1-3> [goto MCCARD]

<R,D> [prefill MCCARD with a "2" and goto MCCHOICE]

Question ID: FHI.092_00.000 Instrument Variable Name: MCCARD QuestionnaireFileName: Family

QuestionText: * Do not read. Was the type of coverage obtained from a Medicare card or some other form of documentation?

1 Yes

2 No

UniverseText: All persons with Part A Medicare coverage, Part B Medicare coverage, or both

SkipInstructions: if MCPART = 1, goto MCPARTD; else, goto MCCHOICE

Question ID: FHI.095_00.000 Instrument Variable Name: MCCHOICE QuestionnaireFileName: Family

QuestionText: ? [F1]

Medicare Advantage is the new name for Medicare Plus Choice plans. [fill: Are you/Is ALIAS] enrolled in a Medicare

Advantage plan?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part B

coverage

SkipInstructions: goto MCHMO

Page 5 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.100_00.000 Instrument Variable Name: MCHMO QuestionnaireFileName: Family

QuestionText: ? [F1]

[fill: Are you/Is ALIAS] under a Medicare managed care arrangement, such as an HMO, that is, a Health Maintenance

Organization? (With an HMO, you must generally receive care from HMO doctors, otherwise the expense is not covered

unless you were referred by the HMO or there was a medical emergency).

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part B

coverage

SkipInstructions: <1> [goto MCNAME]

<2,R,D> [goto MCREF]

Question ID: FHI.110_00.000 Instrument Variable Name: MCNAME QuestionnaireFileName: Family

QuestionText: ? [F1]

What is the name of the HMO?

* Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim response

UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for part B

coverage, and are enrolled under a Medicare managed care arrangement

SkipInstructions: goto MCREF

Question ID: FHI.114_00.000 Instrument Variable Name: MCREF QuestionnaireFileName: Family

QuestionText: ? [F1]

Under [fill1: your/ALIAS's] Medicare plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place for

special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part B

coverage

SkipInstructions: goto MCPAYPRE

Page 6 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.116_00.000 Instrument Variable Name: MCPAYPRE QuestionnaireFileName: Family

QuestionText: Besides [fill1: your/ALIAS's] Medicare insurance, [fill2: are you/is ALIAS] paying an additional monthly or yearly premium

to receive a more comprehensive health benefit plan?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicare who signed up for part B coverage or for whom it is unknown if they signed up for Part B

coverage

SkipInstructions: goto MCPARTD

Question ID: FHI.118_00.000 Instrument Variable Name: MCPARTD QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] enrolled in Medicare Part D, also known as the Medicare Prescription Drug Plan?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicare

SkipInstructions: goto MCPART for next person with Medicare; else, goto MACHMD

Question ID: FHI.120_00.000 Instrument Variable Name: MACHMD QuestionnaireFileName: Family

QuestionText: (book F13) ? [F1]

* Refer to flashcard F13 for state Medicaid names.

The next questions are about Medicaid coverage. In this State it is also called (* fill State Name). [fill1: You are/ALIAS is]

listed as having Medicaid coverage. Can [fill2: you/ALIAS] go to ANY doctor who will accept Medicaid or MUST [fill3:

you/he/she] choose from a book or list of doctors or is a doctor assigned?

1 Any doctor

2 Select from book/list

3 Doctor is assigned

7 Refused

9 Don't know

UniverseText: All persons with Medicaid

SkipInstructions: <1,R,D> [goto MAPCMD]

<2> [goto MACHMD1]

<3> [goto MACHMD2]

Page 7 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.130_00.000 Instrument Variable Name: MACHMD1 QuestionnaireFileName: Family

QuestionText: * Ask or verify.

What is the name of the health plan that provided the book or list?

*Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons with Medicaid who must select a doctor from a book or list of doctors

SkipInstructions: goto MANAM

Question ID: FHI.131_00.000 Instrument Variable Name: MACHMD2 QuestionnaireFileName: Family

QuestionText: * Ask or verify.

What is the name of the health plan that assigned the doctor?

*Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons with Medicaid for whom a doctor is assigned

SkipInstructions: goto MANAM

Question ID: FHI.132_00.000 Instrument Variable Name: MANAM QuestionnaireFileName: Family

QuestionText: ? [F1]

* Do not read. Was the Health Plan name obtained from a Health Plan Card or something with the Health Plan name on it?

1 Yes

2 No

UniverseText: All persons with Medicaid who must select a doctor from a book or list or for whom a doctor is assigned

SkipInstructions: goto MAPCMD

Page 8 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.140_00.000 Instrument Variable Name: MAPCMD QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which

[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a

specialist [fill4: you were/he was/she was] referred to.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicaid

SkipInstructions: goto MAREF

Question ID: FHI.150_00.000 Instrument Variable Name: MAREF QuestionnaireFileName: Family

QuestionText: ? [F1]

Under [fill1: your/ALIAS's] Medicaid plan, if [fill2: you need/he needs/she needs] to go to a different doctor or place for

special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with Medicaid

SkipInstructions: goto MACHMD for the next person with Medicaid; else, goto SSTYPE2

Page 9 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.156_00.000 Instrument Variable Name: SSTYPE2 QuestionnaireFileName: Family

QuestionText: (book) F14

* Enter all that apply, separate with commas.

You mentioned that [fill1: you have/ALIAS has] a single-service plan - that is, an insurance plan that provides one specific

type of coverage. What type of service or care does [fill2: your/ALIAS's] single service plan or plans pay for?

01 Accidents

02 AIDS care

03 Cancer treatment

04 Catastrophic care

05 Dental care

06 Disability insurance

07 Hospice care

08 Hospitalization only

09 Long-term care

10 Prescriptions

11 Vision care

12 Other (specify)

97 Refused

99 Don't know

UniverseText: All persons with single service plans

SkipInstructions: <1-11,R,D> [repeat for all eligible persons, then goto FHICCI6]

<12> [goto SSOTHER]

Question ID: FHI.157_00.000 Instrument Variable Name: SSOTHER QuestionnaireFileName: Family

QuestionText: * Other type of single-service plan

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons with an "other" single service plan

SkipInstructions: goto SSTYPE2 for the next person with a single service plan; else, goto FHICCI6

Page 10 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.158_00.000 Instrument Variable Name: FHICCI6 QuestionnaireFileName: Family

QuestionText: The next questions are about private health insurance plans [fill1: /including Medi-Gap]. These plans can be obtained

through work, purchased directly, or through a state or local government program or community program.

[fill2: We have the following persons listed as being covered by such plans:

* Read names.

(display roster of eligible persons)]

* Enter 1 to continue

1 Continue

UniverseText: All families with at least one person covered by private health insurance

SkipInstructions: goto HIPNAM1

Question ID: FHI.160_00.000 Instrument Variable Name: HIPNAM1 QuestionnaireFileName: Family

QuestionText: It is important that we record the complete and accurate name of each health insurance plan. What is the COMPLETE name

of the first plan?

Do NOT include plans that only provide extra cash while in the hospital or plans that pay for only one type of service, such

as nursing home care, accidents, or dental care.

* Read if necessary: Do you have your health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All families with at least one person covered by private health insurance

SkipInstructions: <verbatim> [goto PCARD1]

<R,D> [prefill PCARD1 with a "2" and goto HIPNAM1B]

Question ID: FHI.160_01.000 Instrument Variable Name: PCARD1 QuestionnaireFileName: Family

QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

1 Yes

2 No

UniverseText: All private health insurance plans where the plan name was entered at HIPNAM1

SkipInstructions: goto HIPNAM1B

Page 11 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.170_00.000 Instrument Variable Name: HIPNAM1B QuestionnaireFileName: Family

QuestionText:

* Ask or verify. Enter all that apply, separate with commas.

Which family members are covered by this plan?

* Indicate each family member covered by this plan.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families with a private health insurance plan and the plan name, refused, or don't know was entered at HIPNAM1

SkipInstructions: <R,D> [if HIPNAM1= R or D, goto STNAME]

goto MORPLAN

NOTE: In the instrument, interviewers enter the line numbers associated with the persons reported by the respondent.

As shown above, each eligible person receives an edited response code in subsequent data processing.

Question ID: FHI.171_00.000 Instrument Variable Name: MORPLAN QuestionnaireFileName: Family

QuestionText: * Ask if necessary

Are there any more private health insurance plans?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families where a private health insurance plan name was entered at HIPNAM1 or a person number was entered at

HIPNAM1B

SkipInstructions: <1> [goto HIPNAM2]

<2,R,D> [if no persons selected at HIPNAM1B, goto FHICCI8; else, if persons selected at HIPNAM1B, but not all

persons with HIKIND = 1 or 3 selected at HIPNAM1B, goto HIVER1]

Question ID: FHI.172_00.000 Instrument Variable Name: HIPNAM2 QuestionnaireFileName: Family

QuestionText: What is the name of the next plan?

*Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All families with a second private health insurance plan

SkipInstructions: <verbatim> [goto PCARD2]

<R,D> [prefill PCARD2 with a "2" and goto HIPNAM2B]

Page 12 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.172_01.000 Instrument Variable Name: PCARD2 QuestionnaireFileName: Family

QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

1 Yes

2 No

UniverseText: All private health insurance plans where the plan name was entered at HIPNAM2

SkipInstructions: goto HIPNAM2B

Question ID: FHI.173_00.000 Instrument Variable Name: HIPNAM2B QuestionnaireFileName: Family

QuestionText: * Ask or verify. Enter all that apply, separate with commas.

Which family members are covered by that plan?

* Indicate each family member covered by this plan.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families with a second private health insurance plan and the plan name, refused, or don't know was entered at

HIPNAM2

SkipInstructions: <R,D> [if HIPNAM2 eq R or D and persons selected at HIPNAM1B, but not all persons with HIKIND eq 1 or 3

selected at HIPNAM1B, goto HIVER1; else, if HIPNAM2 eq R or D and persons selected at HIPNAM1B, and all

persons with HIKIND eq 1 or 3 selected at HIPNAM1B, goto FHICCI8; else, if HIPNAM2 eq R or D and persons

not selected at HIPNAM1B, goto FHICCI8; else, if a health plan name recorded in HIPNAM2, goto MORPLAN2]

goto MORPLAN2

Question ID: FHI.174_00.000 Instrument Variable Name: MORPLAN2 QuestionnaireFileName: Family

QuestionText: * Ask if necessary

Are there any more private health insurance plans?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families where a private health insurance plan name was entered at HIPNAM2 or a person number was entered at

HIPNAM2B

SkipInstructions: <1> [goto HIPNAM3]

<2,R,D> [if persons selected at HIPNAM2B or HIPNAM1B, but not all persons with HIKIND eq 1 or 3 selected at

HIPNAM2B or HIPNAM1B, goto HIVER1; else, goto FHICCI8]

Page 13 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.175_00.000 Instrument Variable Name: HIPNAM3 QuestionnaireFileName: Family

QuestionText: What is the name of the next plan?

*Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All families with a third private health insurance plan

SkipInstructions: <verbatim> [goto PCARD3]

<R,D> [prefill PCARD3 with a "2" and goto HIPNAM3B]

Question ID: FHI.175_01.000 Instrument Variable Name: PCARD3 QuestionnaireFileName: Family

QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

1 Yes

2 No

UniverseText: All private health insurance plans where the plan name was entered at HIPNAM3

SkipInstructions: goto HIPNAM3B

Question ID: FHI.176_00.000 Instrument Variable Name: HIPNAM3B QuestionnaireFileName: Family

QuestionText:

* Ask or verify. Enter all that apply, separate with commas.

Which family members are covered by that plan?

* Indicate each family member covered by this plan.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families with a third private health insurance plan and the plan name, refused, or don't know was entered at

HIPNAM3

SkipInstructions: <R,D> [if HIPNAM3 eq R or D and persons selected at HIPNAM1B or HIPNAM2B, but not all persons with

HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B, goto HIVER1; else, if HIPNAM3 eq R or D and persons

selected at HIPNAM1B or HIPNAM2B, and all persons with HIKIND eq 1 or 3 selected at HIPNAM1B or

HIPNAM2B, goto FHICCI8; else, if HIPNAM3 eq R or D and persons not selected at HIPNAM1B and

HIPNAM2B, goto FHICCI8; else, if the health plan name was entered at HIPNAM3, goto MORPLAN3]

goto MORPLAN3

Page 14 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.177_00.000 Instrument Variable Name: MORPLAN3 QuestionnaireFileName: Family

QuestionText: * Ask if necessary

Are there any more private health insurance plans?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families where a private health insurance plan name was entered at HIPNAM3 or a person number was entered at

HIPNAM3B

SkipInstructions: <1> [goto HIPNAM4]

<2,R,D> [if persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all persons with HIKIND eq 1

or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto FHICCI8]

Question ID: FHI.178_00.000 Instrument Variable Name: HIPNAM4 QuestionnaireFileName: Family

QuestionText: What is the name of the next plan?

*Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All families with a fourth private health insurance plan

SkipInstructions: <verbatim> [goto PCARD4]

<R,D> [prefill PCARD4 with a "2" and goto HIPNAM4B]

Question ID: FHI.178_01.000 Instrument Variable Name: PCARD4 QuestionnaireFileName: Family

QuestionText: * Do not read. Was the health plan name obtained from a health plan card or something with the health plan name on it?

1 Yes

2 No

UniverseText: All private health insurance plans where the plan name was entered at HIPNAM4

SkipInstructions: goto HIPNAM4B

Page 15 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.179_00.000 Instrument Variable Name: HIPNAM4B QuestionnaireFileName: Family

QuestionText:

* Ask or verify. Enter all that apply, separate with commas.

Which family members are covered by that plan?

* Indicate each family member covered by this plan.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families with a fourth private health insurance plan and the plan name, refused, or don't know was entered at

HIPNAM4

SkipInstructions: <R,D> [if HIPNAM4 eq R or D and persons selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, but not all

persons with HIKIND eq 1 or 3 selected at HIPNAM1B or HIPNAM2B or HIPNAM3B, goto HIVER1; else, goto

FHICCI8]

goto FHICCI8

Question ID: FHI.180_00.000 Instrument Variable Name: HIVER1 QuestionnaireFileName: Family

QuestionText: ? [F1]

[fill1: You are/ALIAS is] listed as having private insurance but [fill2: were/was] not mentioned as being covered by any of

the plans we just discussed. [fill3: Are you/Is ALIAS] covered by private insurance?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons who have private health insurance coverage, but were not mentioned as being covered by any of the

reported plans

SkipInstructions: <1> [ goto HIVER2]

<2,R,D> [goto ERR_HIVER1]

Page 16 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.190_00.000 Instrument Variable Name: HIVER2 QuestionnaireFileName: Family

QuestionText: ? [F1]

* Enter all that apply, separate with commas.

Is [fill: your/ALIAS's] health insurance plan the same as one of those already mentioned?

1 1st plan mentioned (^HIPNAM1)

2 2nd plan mentioned (^HIPNAM2)

3 3rd plan mentioned (^HIPNAM3)

4 4th plan mentioned (^HIPNAM4)

5 Some other plan not already mentioned

7 Refused

9 Don't know

UniverseText: All persons for whom it was verified they have private health insurance coverage, but were not mentioned as being

covered by any of the reported plans

SkipInstructions: <1-4> [update responses for HIPNAM1B/HIPNAM2B/HIPNAM3B/HIPNAM4B and goto FHICCI8]

<5> [if 4 plans were reported, ignore this 5th plan and goto FHICCI8; else, goto HIPNAM2, or HIPNAM3, or

HIPNAM4 accordingly to enter information on this plan]

<R,D> [goto FHICCI8]

Question ID: FHI.195_01.000 Instrument Variable Name: FHICCI8 QuestionnaireFileName: Family

QuestionText: [fill1: Now I am going to ask some questions about the [fill2: plan/plans] you just told me about [fill3: /,starting with [fill4:

^HIPNAM1/Plan1]]./Next I would like to ask you about [fill5: ^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 2/Plan 3/Plan

4]].

* Enter 1 to continue.

1 Continue

UniverseText: All families where a private health insurance plan was reported

SkipInstructions: goto FHI200

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Page 17 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.200_01.000 Instrument Variable Name: FHI200 QuestionnaireFileName: Family

QuestionText: ? [F1]

Health insurance plans are usually obtained in one person's name even if other family members are covered. That person is

called the policyholder. In whose name is this plan?

* Enter line number of family member (from list below) in whose name this plan is held.

* Enter 0 if the policyholder is not on the family roster."

00 Policyholder not on family roster

01-25 Two-digit person number

97 Refused

99 Don't know

UniverseText: All private health insurance plans

SkipInstructions: goto PLNWRK

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.210_01.000 Instrument Variable Name: PLNWRK QuestionnaireFileName: Family

QuestionText: (book) F15 ? [F1]

Which one of these categories best describes how this plan was obtained?

01 Through employer

02 Through union

03 Through workplace, but don't know if employer or union

04 Through workplace, self-employed or professional association

05 Purchased directly

06 Through a state/local government or community program

07 Other, specify

97 Refused

99 Don't know

UniverseText: All private health insurance plans

SkipInstructions: <1-6,R,D> [goto PLNPAY]

<7> [goto PLNWKSP]

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Page 18 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.211_01.000 Instrument Variable Name: PLNWKSP QuestionnaireFileName: Family

QuestionText: *Read if necessary.

How was this plan obtained?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All private health insurance plans where the plan was obtained through an "other" source

SkipInstructions: goto PLNPAY

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.220_10.000 Instrument Variable Name: PLNPAY QuestionnaireFileName: Family

QuestionText: ? [F1]

* Enter all that apply, separate with commas.

Who pays for this health insurance plan?

* If government program is reported, probe for Medicare or Medicaid or SCHIP before entering code 7. If government is the

employer, enter code 2.

01 Self or family (living in the household)

02 Employer or union

03 Someone outside the household

04 Medicare

05 Medicaid

06 Children's Health Insurance Program (CHIP/SCHIP)

07 State or local government or community program

97 Refused

99 Don't know

UniverseText: All private health insurance plans

SkipInstructions: <1> [goto HICOSTN]

<2-7,R,D> [if PLNPAY=1, goto HICOSTN; else, goto PLNMGD]

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Page 19 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.230_11.000 Instrument Variable Name: HICOSTN QuestionnaireFileName: Family

QuestionText: 1 of 2 ? [F1]

How much [fill1: do you/does your family] currently spend for health insurance premiums for [fill2:

^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4]? Please include payroll deductions for

premiums.

*Enter dollar amount for premium payments.

00001-99995 $1-$99,995

99997 Refused

99999 Don't know

UniverseText: All private health insurance plans payed for by self or family

SkipInstructions: <1-99995> [goto HICOSTT]

<R> [store "R" in HICOSTT and goto PLNMGD]

<D> [store "D" in HICOSTT and goto PLNMGD]

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.230_12.000 Instrument Variable Name: HICOSTT QuestionnaireFileName: Family

QuestionText: 2 of 2 ? [F1]

* Enter time period for premium payments.

01 Once a week

02 Once every 2 weeks

03 Once a month

04 Twice a month

05 Every 2 months

06 Quarterly (every 3 months)

07 Once a year

08 Twice a year

97 Refused

99 Don't know

UniverseText: All private health insurance plans with a valid response to HICOSTN

SkipInstructions: goto PLNMGD

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Page 20 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.240_01.000 Instrument Variable Name: PLNMGD QuestionnaireFileName: Family

QuestionText: ? [F1]

Is [fill: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] an HMO (Health Maintenance

Organization), an IPA (Individual Practice Association), a PPO (Preferred Provider Organization), a POS (Point-Of-Service),

fee-for-service, or indemnity or is it some other kind of plan?

1 HMO/IPA

2 PPO

3 POS

4 Fee-for-service/indemnity

5 Other

7 Refused

9 Don't know

UniverseText: All private health insurance plans

SkipInstructions: goto HDHP

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.241_00.000 Instrument Variable Name: HDHP QuestionnaireFileName: Family

QuestionText: ?[F1]

[If only one person covered by this plan:]

Is the deductible for medical care for this plan less than $1,100 or $1,100 or more? If there is a separate deductible for

prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.

[If two or more persons in the family are covered by this plan:]

Is the family deductible for medical care for this plan less than $2,200 or $2,200 or more? If there is a separate deductible for

prescription drugs, hospitalization, or out-of-network care, do not include those deductible amounts here.

1 Less than [fill 1: $1,100/$2,200]

2 [fill 1: $1,100/$2,200] or more

7 Refused

9 Don't know

UniverseText: All private health insurance plans

SkipInstructions: <1,R,D> [goto MGCHMD] <2> [goto HSAHRA]

Page 21 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.242_00.000 Instrument Variable Name: HSAHRA QuestionnaireFileName: Family

QuestionText: ?[F1]

With this plan, is there a special account or fund that can be used to pay for medical expenses? The accounts are sometimes

referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), Personal Care accounts, Personal

Medical funds, or Choice funds, and are different from Flexible Spending Accounts.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: Asked of all high deductible private health insurance plans

SkipInstructions: <1,2,R,D> [goto MGCHMD]

Question ID: FHI.243_01.000 Instrument Variable Name: MGCHMD QuestionnaireFileName: Family

QuestionText: Under this plan, can [fill1:you/ALIAS/the family members with this plan] choose ANY doctor or MUST

[fill2:you/he/she/they] choose one from a specific group or list of doctors?

1 Any doctor

2 Select from group/list

7 Refused

9 Don't know

UniverseText: All private health insurance plans

SkipInstructions: <1> [goto MGPRMD]

<2> [goto MGPYMD]

<R,D> [goto MGPREF]

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.244_01.000 Instrument Variable Name: MGPRMD QuestionnaireFileName: Family

QuestionText: [fill: Do you/Does ALIAS/Do the family members with this plan] have the option of choosing a doctor from a preferred or

select list at a lower cost?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All private health insurance plans where covered persons can choose any doctor

SkipInstructions: goto MGPREF

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Page 22 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.246_01.000 Instrument Variable Name: MGPYMD QuestionnaireFileName: Family

QuestionText: If [fill1: you select/ALIAS selects/the family members with this plan select] a doctor who is not in the plan, will [fill2:

^HIPNAM1/^HIPNAM2/^HIPNAM3/^ HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any or part of the cost?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All private health insurance plans where covered persons must select from a group or list of doctors

SkipInstructions: goto MGPREF

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.248_01.000 Instrument Variable Name: MGPREF QuestionnaireFileName: Family

QuestionText: ? [F1]

When [fill1: you need/ALIAS needs/the family members with this plan need] to go to a different doctor or place for special

care, [fill2: do you/does ALIAS/do they] need approval or a referral? Do not include emergency care.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All private health insurance plans

SkipInstructions: goto PRRXCOV

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Question ID: FHI.249_01.000 Instrument Variable Name: PRRXCOV QuestionnaireFileName: Family

QuestionText: Does [fill1: ^HIPNAM1/^HIPNAM2/^HIPNAM3/^HIPNAM4/Plan 1/Plan 2/Plan 3/Plan 4] pay for any of the costs for

medicines prescribed by a doctor?

* Read if necessary: Does this plan have a drug benefit?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All private health insurance plans

SkipInstructions: goto FHICCI8 for the next private health insurance plan; else, goto STNAME1

NOTE: Detailed questions about private health insurance plans are looped through for each plan mentioned in a

family. Information on up to 4 plans per family is collected.

Page 23 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.250_00.000 Instrument Variable Name: STNAME1 QuestionnaireFileName: Family

QuestionText: Earlier I recorded that [fill: you are/ALIAS is] covered by the Children’s Health Insurance Program (CHIP/SCHIP). What is

the name of the plan?

* Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons with SCHIP

SkipInstructions: goto STDOC1

Question ID: FHI.251_00.000 Instrument Variable Name: STDOC1 QuestionnaireFileName: Family

QuestionText: Under the [fill1:^STNAME1/SCHIP plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or MUST

[fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?

1 Any doctor

2 Select from book/list

3 Doctor is assigned

7 Refused

9 Don't know

UniverseText: All persons with SCHIP

SkipInstructions: goto STPCMD1

Question ID: FHI.252_00.000 Instrument Variable Name: STPCMD1 QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which

[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a

specialist [fill4: you were/he was/she was] referred to.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with SCHIP

SkipInstructions: goto STREF1

Page 24 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.253_00.000 Instrument Variable Name: STREF1 QuestionnaireFileName: Family

QuestionText: ? [F1]

Under [fill1: ^STNAME1/this SCHIP plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place for special

care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with SCHIP

SkipInstructions: goto STNAME1 for the next person with SCHIP; else, goto STNAME2

Question ID: FHI.257_00.000 Instrument Variable Name: STNAME2 QuestionnaireFileName: Family

QuestionText: Earlier I recorded that [fill: you are/ALIAS is] covered by a state sponsored health plan. What is the name of the plan?

* Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons covered by a state sponsored health plan

SkipInstructions: goto STDOC2

Question ID: FHI.258_00.000 Instrument Variable Name: STDOC2 QuestionnaireFileName: Family

QuestionText: Under the [fill1:^STNAME2/state sponsored plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or

MUST [fill3: you/he/she] choose from a book or list of doctors or is the doctor assigned?

1 Any doctor

2 Select from book/list

3 Doctor is assigned

7 Refused

9 Don't know

UniverseText: All persons covered by a state sponsored health plan

SkipInstructions: goto STPCMD2

Page 25 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.259_00.000 Instrument Variable Name: STPCMD2 QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which

[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a

specialist [fill4: you were/he was/she was] referred to.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons covered by a state sponsored health plan

SkipInstructions: goto STREF2

Question ID: FHI.260_00.000 Instrument Variable Name: STREF2 QuestionnaireFileName: Family

QuestionText: ? [F1]

Under [fill1:^STNAME2/this state sponsored plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place for

special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons covered by a state sponsored health plan

SkipInstructions: goto STNAME2 for the next person with a state sponsored health plan; else, goto STNAME3

Question ID: FHI.264_00.000 Instrument Variable Name: STNAME3 QuestionnaireFileName: Family

QuestionText: Earlier I recorded that [fill: you are/ALIAS is] covered by an other government program. What is the name of the plan?

* Read if necessary: Do you have a health plan card or something with the plan name on it?

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons covered by an "other" government plan

SkipInstructions: goto STDOC3

Page 26 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.265_00.000 Instrument Variable Name: STDOC3 QuestionnaireFileName: Family

QuestionText: Under the [fill1:^STNAME3/other government plan] can [fill2: you/ALIAS] go to ANY doctor who will accept this plan or

MUST [fill3:you/he/she] choose from a book or list of doctors or is the doctor assigned?

1 Any doctor

2 Select from book/list

3 Doctor is assigned

7 Refused

9 Don't know

UniverseText: All persons covered by an "other" government plan

SkipInstructions: goto STPCMD3

Question ID: FHI.266_00.000 Instrument Variable Name: STPCMD3 QuestionnaireFileName: Family

QuestionText: [fill1: Are you/Is ALIAS] required to sign up with a certain primary care doctor, group of doctors, or certain clinic which

[fill2: you/he/she] must go to for all of [fill3: your/his/her] routine care? Do not include emergency care or care from a

specialist [fill4: you were/he was/she was] referred to.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons covered by an "other" government plan

SkipInstructions: goto STREF3

Question ID: FHI.267_00.000 Instrument Variable Name: STREF3 QuestionnaireFileName: Family

QuestionText: ? [F1]

Under [fill1:^ STNAME3/this other government plan], if [fill2: you need/ALIAS needs] to go to a different doctor or place

for special care, [fill3: do you/does he/does she] need approval or a referral? Do not include emergency care.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons covered by an "other" government plan

SkipInstructions: goto STNAME3 for the next person with an "other" government plan; else, goto MILSPC

Page 27 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.270_00.000 Instrument Variable Name: MILSPC QuestionnaireFileName: Family

QuestionText: ? [F1]

* Enter all that apply, separate with commas.

Earlier I recorded that [fill1: you are/ALIAS is] covered by military health care. What types of military health care [fill2: are

you/is ALIAS] covered by?

1 TRICARE

2 VA

3 CHAMP-VA

4 Other military coverage (specify)

7 Refused

9 Don't know

UniverseText: All persons with military health care

SkipInstructions: <1> [goto MILMAN]

<2,3,R,D> [repeat question for next person with military health care; else, goto HILAST]

<4> [goto MILSPCOT]

Question ID: FHI.271_00.000 Instrument Variable Name: MILSPCOT QuestionnaireFileName: Family

QuestionText: * Other military coverage

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons with "other" military coverage

SkipInstructions: if MILSPC eq 1, goto MILMAN; else, goto MILSPC for the next person with military health care; else, goto

HILAST

Question ID: FHI.275_00.000 Instrument Variable Name: MILMAN QuestionnaireFileName: Family

QuestionText: ? [F1]

Is [fill: your/ALIAS's] TRICARE plan, TRICARE prime, TRICARE Extra, TRICARE Standard or TRICARE for Life?

1 TRICARE Prime

2 TRICARE Extra

3 TRICARE Standard

4 TRICARE for life

5 TRICARE other (specify)

7 Refused

9 Don't know

UniverseText: All persons with TRICARE coverage

SkipInstructions: <1-4,R,D> [goto MILSPC for the next person with military health care; else, goto HILAST]

<5> [goto MILMANOT]

Page 28 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.276_00.000 Instrument Variable Name: MILMANOT QuestionnaireFileName: Family

QuestionText: * Other type of TRICARE coverage

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons with "other" type of TRICARE coverage

SkipInstructions: goto MILSPC for the next person with military health care; else, goto HILAST

Question ID: FHI.280_00.000 Instrument Variable Name: HILAST QuestionnaireFileName: Family

QuestionText: (book) F16 ? [F1]

Not including Single Service Plans, about how long has it been since [fill: you/ALIAS] last had health care coverage?

1 6 months or less

2 More than 6 months, but not more than 1 year ago

3 More than 1 year, but not more than 3 years ago

4 More than 3 years

5 Never

7 Refused

9 Don't know

UniverseText: All persons without known health insurance or with only single service plans

SkipInstructions: goto HISTOP

Question ID: FHI.290_00.000 Instrument Variable Name: HISTOP QuestionnaireFileName: Family

QuestionText: (book) F17

[fill1: Which of these are reasons [fill2: you/ALIAS] stopped being covered?/Which of these are reasons [fill3:you do/ALIAS

does] not have health insurance?]

* Enter up to 5 reasons, separate with commas.

01 Person in family with health insurance lost job or changed employers

02 Got divorced or separated/death of spouse or parent

03 Became ineligible because of age/left school

04 Employer does not offer coverage/or not eligible for coverage

05 Cost is too high

06 Insurance company refused coverage

07 Medicaid/Medical plan stopped after pregnancy

08 Lost Medicaid/Medical plan because of new job or increase in income

09 Lost Medicaid (other)

10 Other (specify)

97 Refused

99 Don't know

UniverseText: All persons without known health insurance or with only single service plans

SkipInstructions: <1-9,R,D> [goto HCSPFYR]

<10> [goto HISTOPOT]

Page 29 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.291_00.000 Instrument Variable Name: HISTOPOT QuestionnaireFileName: Family

QuestionText: ? [F1]

* Other reason for not having coverage

7 Refused

9 Don't know

Verbatim Verbatim Response

UniverseText: All persons without known health insurance and an "other" reason for stopping or not having coverage

SkipInstructions: goto HISTOP for the next person without known health insurance coverage or only single service plans; else, goto

HCSPFYR

Question ID: FHI.300_00.000 Instrument Variable Name: HINOTYR QuestionnaireFileName: Family

QuestionText: In the PAST 12 MONTHS, was there any time when [fill: you/ALIAS] did NOT have ANY health insurance or coverage?

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All persons with known health insurance coverage except single service plans

SkipInstructions: <1> [goto HINOTMYR]

<2,R,D> [goto HCSPFYR]

Question ID: FHI.310_00.000 Instrument Variable Name: HINOTMYR QuestionnaireFileName: Family

QuestionText: In the PAST 12 MONTHS, about how many months [fill: were you/was ALIAS] without coverage?

* If less than 1 month, enter '1'.

01-12 1-12 months

97 Refused

99 Don't know

UniverseText: All persons with known health insurance coverage, but did not have health insurance for some period of time in the

past 12 months

SkipInstructions: goto HINOTYR for the next person with known health insurance coverage, except single service plans; else, goto

HCSPFYR

Page 30 of 30

2007 NHIS Questionnaire - Family

Family Health Insurance

Document Version Date: 12-Jul-06

Question ID: FHI.320_00.000 Instrument Variable Name: HCSPFYR QuestionnaireFileName: Family

QuestionText: (book) F18

The next question is about money that [fill1: you have/your family has] spent out of pocket on medical care. We do NOT

want you to count health insurance premiums, over the counter drugs, or costs that you will be reimbursed for. In the

PAST 12 MONTHS, about how much did [fill2: you/your family] spend for medical care and dental care?

0 Zero

1 Less than $500

2 $500 - $1,999

3 $2,000 - $2,999

4 $3,000 - $4,999

5 $5,000 or more

7 Refused

9 Don't know

UniverseText: All families

SkipInstructions: goto FSA

Question ID: FHI.330_00.000 Instrument Variable Name: FSA QuestionnaireFileName: Family

QuestionText: [fill 1: Do you/Does anyone in your family] have a Flexible Spending Account for health expenses? These accounts are

offered by some employers to allow employees to set aside pre-tax dollars of their own money for their use throughout the

year to reimburse themselves for their out-of-pocket expenses for health care. With this type of account, any money

remaining in the account at the end of the year, following a short grace period, is lost to the employee.

1 Yes

2 No

7 Refused

9 Don't know

UniverseText: All families

SkipInstructions: <1,2,R,D> [goto PLBORN]