Comparing Health Insurance Measurement Error (CHIME)

Comparing Health Insurance Measurement Error (CHIME)

chime questionnaire FINAL

Comparing Health Insurance Measurement Error (CHIME)

OMB: 0607-0983

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CHIME March 2015 DRAFT Questionnaire

April 2, 2015



Overview: Content and Sequence


  1. Introduction (“Front/Back”): Contact and callback screens


  1. Demographics

A. Household roster (first, middle, last name)

B. Sex

C. Relationship to household respondent

D. Date of birth and age

E. Hispanic origin

F. Race

G. Education (only asked about age 15+)

H. Armed forces service (only asked about age 15+)

I. Marital status (only asked about age 15+)

J. State of residence

K. Family size and income (ranges mimic program eligibility bands)


  1. Labor force (only asked about age 15+)

  1. Any work in 2014 (full or part time)

  2. If not, main reason

  3. If worked, number of weeks worked

  4. Usual hours worked per week

  5. Employer size


  1. Unearned Income (only asked about age 15+)

A. Unemployment compensation

B. Social Security

C. SSI

D. TANF

E. Food Stamps

F. WIC

G. Pension income


  1. Health Insurance: asked about all ages

  1. CPS redesign, plus follow-up questions on:

    1. premium amount and unit

    2. metal level

  2. ACS, plus follow-up questions on:

    1. Marketplace (yes/no)

    2. Premium (yes/no)

    3. Subsidy (yes/no)

    4. Premium amount and unit

    5. metal level

    6. pathway to enrollment


  1. Wrap Up

  1. Health status

  2. Address

  3. Thank you


  1. FRONT/BACK (display and check items only)


INITIAL CONTACT SCREENS


LANDCELL

Hello. This is .... from the U.S. Census Bureau. I’m calling to conduct a survey about health insurance. Have I reached you on a cell phone?

  1. Yes (this IS a cell phone) CELLSAFE

  2. No (this is NOT a cell phone) HELLO_NEW

  3. Other outcome PROBCALL

  • DK/REF TY_CLBK


CELLSAFE

Since we have reached you on your cell phone, we want to ensure your safety. Are you currently driving?

  1. Yes TY_CLBK

  2. No HELLO_NEW

  3. DK/REF TY_CLBK


HELLO_NEW

I’d like to speak with someone who lives in your household who is 18 years old or older. [If appropriate]: Would that be you?

  1. Respondent is resident 18+ INTRO_1st

  2. Resident 18+ called to phone INTRO_1st

  3. Eligible person not home now or not available now ID_OTHER

  4. No one living in household is 18+ THANKRES set OUTCOME=020 (ineligible hh unit)

  5. Other outcome PROBCALL


INTRO_1ST

(If necessary: Hello. This is ... from the U.S. Census Bureau.) We’re conducting an important survey on health insurance coverage and we’d like your participation to make the survey as accurate as possible. The survey will take 13 minutes and is voluntary. You can skip any questions you don’t want to answer and you can end the interview at any time. We are conducting this survey under the authority of Title 13, United States Code, Sections 141, 182 and 193. Title 13, United States Code, Section 9, requires us to keep your information confidential and use it for statistical purposes only. Response to this collection of information is not required unless it displays a valid approval number from the Office of Management and Budget (OMB). The following is the eight-digit OMB number: 0607-XXXX.


  • ID_SPVR


CALLBACK-ONLY SCREENS: these screens are only used for callbacks -- that is, where an initial contact was made but the interview was not completed. The break-off point may have occurred before even reaching the demographics section, or it may have occurred at some later point in the interview. The fills in these four screens account for these various conditions.


HELLOTWO

May I please speak to <fill RESNAME> ?

  1. This is correct person CB_LANDCELL

  2. Correct person called to phone CB_LANDCELL

  3. Person not home or not available now HELLO_RS

  4. Other outcome PROBCALL

RESNAME FILL instructions:

  • If the end of the household roster was reached, use FIRSTNAME LASTNAME of respondent from previous interview

  • else if CBNAME is not blank, use CBNAME

  • else use “a resident who is 18 years old or older. Would that be you?”


HELLO_RS

Perhaps you can help me. I’d like to speak with a member of this household who is 18 years old or older.

  1. Respondent is resident 18+ CK-NEWRESP

  2. Resident 18+ called to phone CK-NEWRESP

  3. Eligible person not home now or not available now TY_CLBCK

  4. No one living in household is 18+ THANKRES

  5. Other outcome PROBCALL


CK-NEWRESP

  • if a new household member (different from the person originally listed as Person 1) is now completing the survey NEWRESP

  • else CB_LANDCELL


NEWRESP

(FILL instructions: display ROSTER)

To whom am I speaking?

Select appropriate person from displayed household roster CB_LANDCELL

NOTE: the original HHR is always listed as Person 1. If there is a change in HHR part-way thru the interview, the HHR and all household members remain listed in the same line numbers where they were originally listed, but questions for the new HHR should fill “you” (versus NAME) and questions for the original Person 1 should fill NAME.


CB_LANDCELL

(If necessary: Hello. This is .... from the U.S. Census Bureau). I’m calling to conduct a survey about health insurance. Have I reached you on a cell phone?

  1. Yes (this IS a cell phone) CB_CELLSAFE

  2. No (this is NOT a cell phone) ID_SPVR

  3. Other outcome PROBCALL

DK/REF TY_CLBK


CB_CELLSAFE

Since we have reached you on your cell phone, we want to ensure your safety. Are you currently driving?

  1. Yes TY_CLBK

  2. No ID_SPVR

DK/REF TY_CLBK


ID_SPVR

[If HELLOTWO=1 or 2 (correct person is on phone) or HELLO_RS=1 or 2 (resident 18+ is on phone) fill: We recently contacted your household as part of a survey on health insurance coverage that the Census Bureau is conducting.]


[If fill in HELLOTWO was ”a resident who is...” then fill: We’re conducting an important survey on health insurance coverage and we’d like your participation to make the survey as accurate as possible. The survey will take 13 minutes and is voluntary. You can skip any questions you don’t want to answer and you can end the interview at any time. We are conducting this survey under the authority of Title 13, United States Code, Sections 141, 182 and 193. Title 13, United States Code, Section 9, requires us to keep your information confidential and use it for statistical purposes only. Response to this collection of information is not required unless it displays a valid approval number from the Office of Management and Budget (OMB). The following is the eight-digit OMB number: 0607-XXXX.


This interview may be recorded for quality assurance purposes. Do I have your permission to record this interview?

PERSUADE RESPONDENT TO COMPLETE INTERVIEW NOW IF POSSIBLE.

If the respondent indicates they do not wish to be recorded, please click on the NICE stop recording button located in your CTI Toolkit Agent Desktop.

  1. Continue with interview FIND_QUEST set MARK ge 11 (eligible hh unit)

  2. Inconvenient time, callback needed ID_OTHER

  3. Refused to participate EXITTHNK

  4. Language problem EXITTHNK

  5. Refer to supervisor EXITTHNK


FIND_QUEST

  • Press the <END> key for the next unanswered question.


PROBCALL

Person Not Available

  1. Respondent wants to be called back at a different number ID_OTHER

  2. No one uses this place as usual residence (for example: vacation home, vacant, business, teen phone line) THANKRES

  3. No one living in household is 18 or older THANKRES

  4. Away, ill, physically or mentally unable, language or hearing problem, bad connection; Nobody available through closeout EXITTHNK

  5. Answering machine/service reached TY_LAST set OUTCOME=130

  6. Refer to Supervisor TY_LAST

  7. Refused interview EXITTHNK

  8. Immediate hangup TY_LAST

ID_OTHER

Ok that’s fine. I’ll call back later. Whom should I ask for when I call back? (If appropriate: What number should I call?)

PROBE: If respondent prefers NOT to give their name, use YOUR best judgment and key LADY OF HOUSE or MAN of HOUSE.

[open-text] store in CBNAME TY_CLBCK

[Do not allow DK or Refused]


THANKRES

Thank you for your time. Your phone number is not eligible for this survey. set OUTCOME=020 (ineligible hh unit) TY_LAST


EXITTHNK

Thank you for your time and cooperation. If you’d like to send us any comments about this survey I’d be glad to give you an address. The expiration date for this survey is XXXX TY_LAST

READ IF NECESSARY

Paperwork Project 0607-XXXX

U.S. Census Bureau

4600 Silver Hill Road, Room 3K138

Washington, DC 20233.

e-mail: Paperwork@census.gov (use "Paperwork Project 0607-XXXX" as the subject).

If ID_SPVR=3 or PROBCALL=7,8 then set OUTCOME=035 (refusal)

If ID_SPVR=5 or PROBCALL=6 then set OUTCOME=059 (refer to supervisor)


TY_CLBCK

We will try again at another time. What are the best days and times to call? [record days/times] Thank you for your help.

  • TY_LAST


F10_TY_CLBCK

Thank you for your time. I would like to set an appointment to call back at a better time to complete the interview. What are the best days and times to call? [record days/times] Thank you for your help.

  • TY_LAST


TY_LAST

End Call

2. DEMOGRAPHICS


FNAME/MNAME/LNAME

What are the names of all persons living or staying here? Let’s start with you. (What is your name?)

PROBE: And what is [your/NAME’s] middle name?

Fill 1: Is anyone else living or staying here now?

Fill 2: What is the name of the next person living or staying here?

  • HHCHECK


HHCHECK

So I have listed [one person/# people] living or staying here now: [READ NAMES]. Is there anyone else living or staying here now -- any babies, small children, non-relatives or anyone else?

  • Yes

  • No

INTERVIEWER: Please verify that the information on this screen is correct. You will not be able to alter the list of household members after this screen.

  • SEX


SEX

ASK ONLY IF NECESSARY:

Person 1: What is your sex?

Persons 2+: And how about NAME? (What is NAME’s sex?)

  1. Male

  2. Female

  • CK-RELATE


CK-RELATE

  • if single-person household DOB

  • else RELATE


RELATE

Person 1: How is NAME related to you/Person 1?

Persons 2+: How about NAME? (How is NAME related to you/Person 1?)

  1. Self

  2. Spouse

  3. Unmarried partner

  4. Child

  5. Grandchild

  6. Parent (mother/father)

  7. Brother/Sister

  8. Other relative (Aunt, Cousin, Nephew, Mother-in-Law, etc.)

  9. Foster child

  10. Housemate/Roommate

  11. Other non-relative

DK/Ref

  • DOB

NOTE: Once the roster is collected, household members maintain their original line number throughout the entire survey. “Person 1” will always start off as the HHR, but if there’s a break-off/callback and the interviewer cannot reach the original household respondent, a different household member may serve as the new household respondent. In these cases the wording above would fill the name of the original household respondent as “Person 1” rather than “you.”

DOB

Person 1: What is your date of birth?

Persons 2+: And how about NAME? (What is NAME’s date of birth?)

  • MONTH

  • DAY

  • YEAR

  • DK/REF

Skips:

  • if day/month combination is are not possible (e.g.: February 30) MONTH_CHECK

  • else if MONTH=DK or Ref AGEGSS

  • else if DAY=DK or Ref AGEGSS

  • else VERIFY_AGE

Note: complete series from DOB thru to AGE2 about each person before moving on to the next person on the roster


VERIFY_AGE

As of last week, that would make [you/NAME] [if YEAR=DK fill: approximately] [agefill] years old. Is that correct?

  1. Yes HSPNON

  2. No AGEGSS

  • DK AGEGSS

  • Ref AGE2


AGEGSS

Even though you don’t know [NAME’s] exact birth date, what is your best guess as to how old [he/she] was on [his/her] last birthday?

<number> HSPNON

  • DK/REF AGE2


AGE2

ASK IF NECESSARY

Is he/she under 15, 15 to 64, or 65 or older?

  1. under 15 years old

  2. 15-64 years old

  3. 65 years old or older

  • DK

  • Ref

  • HSPNON


THSPNON

Person 1: Are you Spanish, Hispanic, or Latino?

Persons 2+: And how about NAME? (Is NAME Spanish, Hispanic, or Latino?)

  1. Yes

  2. No

  • DK

  • Ref

  • RACE


RACE

Person 1: I am going to read you a list of five race categories. Please choose one or more races that you consider yourself to be: White; Black or African American; American Indian or Alaska Native; Asian; OR Native Hawaiian or Other Pacific Islander.

Persons 2+: And how about NAME? (Please choose one or more races that NAME considers himself/herself to be: White; Black or African American; American Indian or Alaska Native; Asian; OR Native Hawaiian or Other Pacific Islander).

Do not probe unless response is Hispanic or a Hispanic origin.

Enter all that apply.

  1. White

  2. Black or African American

  3. American Indian or Alaska Native

  4. Asian

  5. Native Hawaiian or Other Pacific Islander

  6. Other [DO NOT READ] => RACEOT: What is his/her/your race? [open text]

  • DK/Ref

  • EDUCA


EDUCA

ASK ONLY FOR PEOPLE AGE 15+

Person 1: What is the highest level of school you have completed or the highest degree you have received?

Persons 2+: And how about NAME? (What is the highest level of school NAME has completed or the highest degree NAME has received?)

  1. Less than 1st grade

  2. 1st,, 2nd, 3rd or 4th grade

  3. 5th or 6th grade

  4. 7th or 8th grade

  5. 9th grade

  6. 10th grade

  7. 11th grade

  8. 12th grade, NO DIPLOMA

  9. HIGH SCHOOL GRADUATE, High school DIPLOMA or the equivalent (For example: GED)

  10. Some college but no degree

  11. Associate degree in college B Occupational/vocational program

  12. Associate degree in college B Academic program

  13. Bachelor’s degree (For example: BA, AB, BS)

  14. Master’s degree (For example: MA, MS, MEng, Med, MSW, MBA)

  15. Professional School Degree (For example: MD, DDS, DVM, LLB, JD)

  16. Doctorate degree (For example: PhD, EdD)

  • DK/Ref

  • AFEVER


AFEVER

ASK ONLY FOR PEOPLE AGE 15+

Person 1: Did you ever serve on active duty in the U.S. Armed Forces?

Persons 2+: And how about NAME? (Did NAME ever serve on active duty in the U.S. Armed Forces?)

  1. Yes

  2. No

  • DK/REF

  • MARITL



MARITL

READ IF NECESSARY; ASK ONLY FOR PEOPLE AGE 15+

[NOTE: If reference person reports being married to any other household member in RELATE, store “married” in MARITL for both the reference person and his/her spouse and do not ask this question for either of them.]

Person 1: Are you now married, widowed, divorced, separated, or never married?

Persons 2+: And how about NAME? (Is NAME now married, widowed, divorced, separated, or never married?)

  1. Married

  2. Widowed

  3. Divorced

  4. Separated

  5. Never married

  • DK/Ref

  • STATE


STATE

What state do you live in?

[menu with hard-coded state codes for all 50 states plus District of Columbia]

  • HHINC


FAMSIZE

To better understand the affordability of health care, we’re interested in your family’s income, which would include your income plus the income of your spouse and any children or stepchildren under 19 who are living with you. [If household respondent’s unmarried partner lives in the household AND the household respondent has at least one child who lives in the household then fill: If [UNMARRIED PARTNER NAME] is the parent of any of the children in this household, please count [UNMARRIED PARTNER NAME] as family]. Your family size, including you, is…

  1. One person

  2. Two people

  3. Three people

  4. Four people

  5. Five people

  6. Six people

  7. Seven people

  8. Eight people

  9. Nine people

  10. Ten or more people

  • DK/Ref


FAMINC

Please tell me the category that best describes your family’s total income during 2014 before taxes and other deductions. Your best estimate is fine.

[AUTHOR NOTE: use answer to FAMSIZE along with table below to determine how to fill response categories 1-4]

  1. Response category 1

  2. Response category 2

  3. Response category 3

  4. Response category 4

  • DK/Ref

  • JOBS

FAMSIZE answer

Response item 1

(at or below 138%)

Response item 2 (above 138% and less than 200%)

Response item 3

(at or above 200% and less than 400%)

Response item 4

(above 400%)

One person

At or below $16,200

Above $16,200 and less than $23,400

At or above $23,400 and less than $46,700

At or above $46,700

Two people

At or below $21,800

Above $21,800 and less than $31,500

At or above $31,500 and less than $63,000

At or above $63,000

Three people

At or below $27,400

Above $27,400 and less than $39,600

At or above $39,600 and less than $79,200

At or above $79,200

Four people

At or below $33,000

Above $33,000 and less than $47,700

At or above $47,700 and less than $95,400

At or above $95,400

Five people

At or below $38,600

Above $38,600 and less than $55,900

At or above $55,900 and less than $111,700

At or above $111,700

Six people

At or below $44,200

Above $44,200 and less than $64,000

At or above $64,000 and less than $127,900

At or above $127,900

Seven people

At or below $50,000

Above $50,000 and less than $72,100

At or above $72,100 and less than $144,200

At or above $144,200

Eight people

At or below $55,400

Above $55,400 and less than $80,200

At or above $80,200 and less than $160,400

At or above $160,400

Nine people

At or below $61,000

Above $61,000 and less than $88,300

At or above $88,300 and less than $176,600

At or above $176,600

Ten or more people

At or below $66,600

Above $66,600 and less than $96,500

At or above $96,500 and less than $192,900

At or above $192,900




LABOR FORCE


NOTE: Questions only asked of household members 15+


JOBS

(Next I have some questions about work experience.) (First/Next I’d like to ask you about yourself/NAME). Did [you/NAME] work at a job or business at any time during 2014?

  1. Yes WKSWORK

  2. No PART

  • DK/Ref PART


PART

Did [you/NAME] do any temporary, part-time, or seasonal work even for a few days during 2014?

  1. Yes WKSWORK

  2. No NOWRK

  • DK/Ref CK_MORE_JOBS


NOWRK

What was the main reason [you/NAME] did not work in 2014?

  1. Ill, or disabled and unable to work

  2. Taking care of home or family

  3. Going to school

  4. Retired

  5. No work available

  6. Other (please specify) NOWRKSP (open-text specify)

  • DK/Ref

  • CK_MORE_JOBS


WKSWORK

During 2014 in how many weeks did [you/NAME] work even for a few hours? Include paid vacation and sick leave as work.

PROBE: If respondent can only answer in months, multiply the number of months by four to derive number of weeks and ask if that number sounds about right.

  • [number of weeks (1-52)] HRSWEEK

  • DK EMP_SIZE

  • Ref EMP_SIZE


HRSWEEK (Q41)

In the weeks that [you/NAME] worked, how many hours did [you/NAME] usually work per week?

  • [number of hours, 1-168]

  • DK/Ref

  • EMP_SIZE


EMP_SIZE

Counting all locations where your/NAME’s employer operates, what is the total number of persons who work for that employer?

READ IF NECESSARY: If you/NAME works for more than one employer, answer for the largest employer.

  1. Less than 10

  2. 10-50

  3. 51-99

  4. 100-499

  5. 500-999

  6. 1000+

  • DK/REF

  • CK_MORE_JOBS


CK_MORE_JOBS

  • if there are more people age 15+ back to JOBS

  • else CK-UNEMP


  1. UNEARNED INCOME


CK-UNEMP:

  • if SUBJECT did not work all year (PART=no) or worked less than 35 weeks (WKSWORK<35) or is retired (NOWRK=4) UNEMP

  • else SSYN


UNEMP

(Now I have some questions about benefits.) (First/Next I’d like to ask you about yourself/NAME). At any time during 2014 did [you/NAME] receive any State or Federal unemployment compensation?

  1. Yes

  2. No

  • DK/Ref

  • CK-SSYN


CK-SSYN

  • if there are more people age 15+ back to CK-UNEMP for next person on the roster

  • else SSYN


SSYN (56a)

(Now I have some questions about benefits.) During 2014 did (you/anyone in this household) receive any Social Security payments from the U.S. Government?

  1. Yes if single-person household SSWHO

  2. No SSIYN

  • DK/Ref SSIYN


SSWHO (56b)

Who received Social Security payments either for themselves or as combined payments with other family members?

PROBE: Anyone else?

  • [display hh roster]

  • DK/Ref

SSIYN


SSIYN (57a)

During 2014 did (you/anyone in this household) receive any SSI payments, that is, Supplemental Security Income?

Note: SSI are assistance payments to low-income aged, blind and disabled persons, and come from state or local welfare offices, the Federal government, or both.

  1. Yes SSIWHO

  2. No TANFYN

  • DK/Ref TANFYN


SSIWHO (57b)

Who received SSI?

PROBE: Anyone else?

  • TANFYN


TANFYN (59a88)

At any time during 2014, even for one month, did (you/anyone in this household) receive any CASH assistance from a state or county welfare program [fill state-specific name]?

PROBE: Include cash payments from:

welfare or welfare‑to‑work programs,

Temporary Assistance for Needy Families program (TANF),

Aid to Families with Dependent Children (AFDC),

General Assistance/Emergency Assistance program,

Diversion Payments,

Refugee Cash and Medical Assistance program,

General Assistance from Bureau of Indian Affairs, or

Tribal Administered General Assistance.

PROBE: Do not include food stamps, Supplemental Nutrition Assistance Program (SNAP) benefits, SSI, energy assistance, WIC, school meals or transportation, childcare, rental, or educational assistance.

  1. Yes TANFWHO

  2. No FSYN

  • DK/Ref FSYN


TANFWHO (59b_88)

Who received this cash assistance?

PROBE: Anyone else?

  • display hh roster]

  • [no one selected]

  • DK/Ref

FSYN


FSYN (Q87ar)

At any time during 2014, even for one month, did (you/anyone in this household) receive any food assistance from [fill state-specific name]?

PROBE: Do not include WIC benefits.

PROBE: Include SNAP (Supplemental Nutrition Assistance Program).

  1. Yes FSWHO

  2. No CK-WIC

  • DK/Ref CK-WIC

FSWHO (Q88)

Which of the people now living here were covered by food stamps during 2014?

PROBE: Anyone else?

  1. [display hh roster]

  2. [no one selected]

  • DK/Ref

CK-WIC


CK-WIC

  • if there is at least one female age 15-64 in the household WICYN

  • else PENSYN


WICYN

At any time during 2014, (was/were) (you/ anyone in this household) on WIC, the Women, Infants, and Children Nutrition Program?

  1. Yes WICWHO

  2. No PENSYN

  • DK/Ref PENSYN


WICWHO

Who received WIC for themselves or on behalf of a child?

PROBE: Anyone else?

  • PENSYN


PENSYN (Q62A)

During 2014 did (you/anyone in this household) receive any pension or retirement income from a previous employer or union, or any other type of retirement income (other than Social Security)?

  1. Yes PENSWHO

  2. No HEALTH_TREAT

  • DK/Ref HEALTH_TREAT


PENSWHO (Q62b)

Who received pension or retirement income?

PROBE: Anyone else?

  • [display hh roster]

  • [DK/REF/no one selected]

HEALTH_TREAT


HEALTH_TREAT

  • If 1st digit in case ID=1 then CPS health insurance module (HINTRO)

  • Else if 1st digit in case ID=y then ACS health insurance module (ACSJOB)

5A. HEALTH INSURANCE: CPS Health Insurance Module

Section A: Coverage Status (Leader)


HINTRO

These next questions are about health coverage between January 1, [CY-1] and now.

  • Press 1 to continue PINTRO

PINTRO

[First/Next] I’m going to ask about [your/NAME’s] health coverage.

  • Press 1 to continue CK-MCARE1


CK-MCARE1

Is NAME either 65+?

  • Yes MCARE1

  • No ANYCOV

MCARE1

Medicare is health insurance for people 65 years and older and people under 65 with disabilities. [Are you/Is NAME] NOW covered by Medicare?

Code Medicare Parts A, B and C and Medicare Advantage as “Yes”.

  1. Yes BEFORAFT_LC1

  2. No/DK/REF ANYCOV


ANYCOV

[Do you/Does NAME] NOW have any type of health plan or health coverage?

  1. Yes SRCEGEN_LC1

  2. No/DK/REF MEDI


MEDI

[Are you/Is NAME] NOW covered by Medicaid, Medical Assistance [or] CHIP [if MCARE1 not yet asked: or Medicare]?

  1. Yes GOVTYPE_LC1

  2. No/DK/REF OTHGOVT


OTHGOVT

[Are you/Is NAME] NOW covered by a state or government assistance program that helps pay for healthcare, such as [STMCAID1-9, STPORTAL, STEXCH1-3]?

Stop reading the list if respondent says “YES.”

  1. Yes GOVPLAN_LC1

  2. No/DK/REF If ever served in Armed Forces (AFEVER=1) VET; else VERIFY


VET

[Are you/Is NAME] NOW covered by Veteran’s Administration (VA) care?

  1. Yes BEFORAFT_LC1

  2. No/DK/REF VERIFY


VERIFY

I have recorded that [you are/NAME is] not currently covered by a health plan. Is that correct?

  1. Yes, is NOT covered ADDOTH1_L

  2. No, is covered SRCEGEN_LC1

  3. DK/REF ADDOTH1_L



Section B: Plan Type (Leader, Current Loop)


SRCEGEN_LC1

ASK OR VERIFY

For the coverage you/NAME has/have NOW, [do you/does NAME] get it through a job, the government or state, or some other way?

JOB: Former job/Retiree, Union, Spouse/parent's job, Job with the government, COBRA, TRICARE/TRICARE for Life

GOVERNMENT OR STATE: Medical Assistance, Medicaid, Medicare (Parts A+B; Part C), Medicare Advantage, State-provided health coverage, VA Care/CHAMPVA/other military

OTHER: Privately purchased, Parent or spouse, Medicare Supplements, Exchange plan/Marketplace, Group or association, School,

IF RESPONDENT CHOOSES MORE THAN ONE: Ok let’s talk about one plan at a time. Which would you like to tell me about first?

If VERIFY=2 then fill: If respondent is not covered, go back to VERIFY and select "Yes"

  1. Job (current or former) MILPLAN_LC1

  2. Government or State JOBCOV_LC1

  3. Other way SRCEDEPDIR_LC1

  • DK/REF SRCEDEPDIR_LC1


SRCEDEPDIR_LC1

ASK OR VERIFY

[Do you/Does NAME] get that coverage through a parent or spouse, [do you/does he/she] buy it [yourself/himself/herself], or [do you/does he/she] get it some other way?

PARENT/SPOUSE: Parent, Spouse

BUY IT DIRECTLY: Buy it, Parent or spouse buys it, Medicare Supplement

SOME OTHER WAY: Former employer, Group or association, Indian Health Service, School

  1. Parent or spouse POLHOLDER_LC1

  2. Buy it POLHOLDER_LC1

  3. Other way SRCEOTH_LC1

  • DK/REF SRCEOTH_LC1


SRCEOTH_LC1

ASK OR VERIFY

[Do you/Does NAME] get it through a former employer, a union, a group or association, the Indian Health Service, a school, or some other way?

  1. Former employer POLHOLDER_LC1

  2. Union POLHOLDER_LC1

  3. Group or association POLHOLDER_LC1

  4. Indian Health Service BEFORAFT_LC1

  5. School POLHOLDER_LC1

  6. Some other way GOVPLAN_LC1

  • DK/REF GOVPLAN_LC1


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 MILPLAN_LC1

  2. No GOVTYPE_LC1

  • DK/REF GOVTYPE_LC1

Soft edit: If “yes” and no one in the household was reported to have a job (more than part time, seasonal or temp work), nor is anyone in the household a retiree, then ask soft edit: “Can I just check -- I recorded that this coverage is related to a JOB. Is that correct?”
If this is correct, continue to MILPLAN_LC1
If this is not correct, go back to JOBCOV_LC1 and correct


MILPLAN_LC1

ASK OR VERIFY

Is that plan related to military service in any way?

Examples of military plans include:
- VA Care
- TRICARE
- TRICARE for Life
- CHAMPVA
- Other military care

  1. Yes MILTYPE_LC1

  2. No POLHOLDER_LC1

  • DK/REF POLHOLDER_LC1


GOVTYPE_LC1

ASK OR VERIFY

Is that coverage Medicaid, CHIP, Medicare, a plan through the military, or some other program?

Code Medicare Parts A, B and C and Medicare Advantage as “Medicare”.

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. Medicaid or Medical Assistance GOVPLAN_LC1

  2. CHIP PORTAL_LC1

  3. Medicare soft edit then BEFORAFT_LC1

  4. Military MILTYPE_LC1

  5. Other GOVPLAN_LC1

  • DK/REF GOVPLAN_LC1

Soft edit: if Medicare is selected and NAME is under 65 ask: “There are two programs that sound a lot alike. MediCARE is for people 65 years and older, or people under 65 with disabilities. MediCAID is a government-assistance plan for those with low-incomes or a disability. Just to be sure, which program are you/is NAME covered by?”

If Medicare is correct, suppress and continue.
If Medicare is not correct, go back to GOVTYPE_LC1 and correct.


MILTYPE_LC1

ASK OR VERIFY

Is that plan through TRICARE, TRICARE for Life, CHAMPVA, VA care, military health care, or something else?

  1. TRICARE

  2. TRICARE for Life

  3. CHAMPVA

  4. Veterans Administration (VA) care

  5. Military health care

  6. Other

  • DK/REF

[all] POLHOLDER_LC1


POLHOLDER_LC1

ASK OR VERIFY

Whose name is the policy in? (Who is the policyholder)?

  1. household member 1

  2. household member 2

………

  1. household member 16

  2. Someone living outside the household

  • DK/REF

[all] CK-SRCEPTSP_LC1


CK-SRCEPTSP_LC1

  • If SRCEDEPDIR_LC1 = “parent or spouse” then SRCEPTSP_LC1

  • Else if SRCEDEPDIR_LC1=2 = “buy it” then PORTAL_LC1

  • Else CK-HIPAID_LC1


SRCEPTSP_LC1

ASK OR VERIFY

Do they get that coverage through their job, do they buy it themselves, or do they get it some other way?

  1. Job (current or former) HIPAID_LC1

  2. Buy it PORTAL_LC1

  3. Other way GOVPLAN_LC1

  • DK/REF GOVPLAN_LC1


GOVPLAN_LC1

ASK OR VERIFY

What do you call the program?

IF RESPONDENT 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. Indian Health Service

  4. STMCAID1

  5. STMCAID2

………

  1. STMCAID9

  2. Healthcare.gov

  3. STEXCH1

  4. STEXCH2

  5. Plan through [STPORTAL]

  6. Other government plan

  7. Other (please specify)

  • DK/REF

Skip Instructions

  • if 3 (IHS) BEFORAFT_LC1

  • else if 17, 18 (non-specific other government plan or other/specify) then MISCSPEC_LC1

  • else if 13-16 (marketplace plan) then POLHOLDER2_LC1

  • all others (Medicaid, CHIP, state-specific government plan, DK, REF) PORTAL_LC1


MISCSPEC_LC1

[open text; 65 characters] PORTAL_LC1


PORTAL_LC1

ASK OR VERIFY

Is that coverage through [STPORTAL], [such as STEXCH1-3]?

  1. Yes EXCHTYPE_LC1

  2. No CK-POLHOLDER2_LC1

  • DK/REF CK-POLHOLDER2_LC1


EXCHTYPE_LC1

ASK OR VERIFY

What do you call it – [STPORTAL, STEXCH1-3]?

  1. STPORTAL

  2. STEXCH1

  3. STEXCH2

  4. STEXCH3

  • DK/REF

[all] CK-POLHOLDER2_LC1


CK-HIPAID_LC1

Is coverage related to employment?

  • Yes HIPAID_LC1

  • No BEFOREAFT_LC1


HIPAID_LC1

Does (name’s/policyholder names’s) 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

  • DK/REF

[all] BEFOREAFT_LC1


CK-POLHOLDER2_LC1

Was POLHOLDER_LC1 already asked?

  • Yes PREMYN_LC1

  • No POLHOLDER2_LC1


POLHOLDER2_LC1

ASK OR VERIFY

Whose name is the policy in (Who is the policyholder)?

  1. household member 1

  2. household member 2

………

  1. household member 16

  2. Someone living outside the household

  • DK/REF

[all] PREMYN_LC1


PREMYN_LC1

Is there a monthly premium for this plan?

READ IF NECESSARY: A monthly premium is a fixed amount of money people pay each month to have health coverage. It does not include copays or other expenses such as prescription costs.

  1. Yes PREMSUBS_LC1

  2. No METAL_LC1

  • DK/REF METAL_LC1


PREMSUBS_LC1

Is the cost of the premium subsidized based on [if single-person hh and NAME is policyholder fill: your/else fill: family] income?

READ IF NECESSARY: A monthly premium is a fixed amount of money people pay each month to have health coverage. It does not include copays or other expenses such as prescription costs.

READ IF NECESSARY: Subsidized health coverage is insurance with a reduced premium. Low and middle income families are eligible to receive tax credits that allow them to pay lower premiums for insurance bought through healthcare exchanges or marketplaces.

  1. Yes

  2. No

  • DK/REF

[all] PREMCOST_LC1


PREMCOST_LC1

How much do you or your family pay for the premium?

READ IF NECESSARY: A monthly premium is a fixed amount of money people pay each month to have health coverage. It does not include copays, deductibles, or other expenses such as prescription costs.

[open text] PREMUNIT_LC1

  • DK/REF METAL_LC1


PREMUNIT_LC1

ASK OR VERIFY

Is that per month, quarter, year, or some other time period?

  1. Month

  2. Quarter

  3. Year

  4. Other (please specify) UNITSP_LC1 (open-text specify)

  • DK/Ref

  • METAL_LC1


METAL_LC1

Some health plans are sold at different levels of coverage: bronze, silver, gold and platinum. And some people, including young people under 30, can purchase a catastrophic plan. Is this plan a…

[READ LIST; ENTER ONLY ONE].

NOTE: Catastrophic plans are only available for those under 30 years old or those with a "hardship exemption"

  1. Bronze

  2. Silver

  3. Gold

  4. Platinum or a

  5. Catastrophic plan?

  6. No, none of the above

  • DK/Ref

  • BEFORAFT_LC1

Section C: Months of Coverage (Leader, Current Loop)


BEFORAFT_LC1

Did [your/NAME’s] coverage from [PLANTYPE] start before January 1, [CY-1]?

READ IF NECESSARY: Your best estimate is fine.

If PLANTYPE is job-related fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched employers or plans through [your/their] employer, consider it the same plan.

If PLANTYPE is directly-purchased fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched plans that you/he/she buys, consider it the same plan.

  1. Yes CNTCOV_LC1

  2. No MNTHBEG1_LC1

  • DK/REF ANYTHIS_LC1


MNTHBEG1_LC1

In which month did that coverage start?

READ IF NECESSARY: Your best estimate is fine.

If PLANTYPE is job-related fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched employers or plans through [your/their] employer, consider it the same plan.

If PLANTYPE is directly-purchased fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched plans that you/he/she buys, consider it the same plan.

This question refers to [PLANTYPE].

  1. January

  2. February

……..

  1. December

  • DK/REF

If MNTHBEG1_LC1=current month or earlier YEARBEG1_LC1

If MNTHBEG1_LC1= later than current month CNTCOV_LC1

If MNTHBEG1_LC1= (D/R) ANYTHIS_LC1


YEARBEG1_LC1

ASK OR VERIFY

Which year was that?

If PLANTYPE is job-related fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched employers or plans through [your/their] employer, consider it the same plan.

If PLANTYPE is directly-purchased fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched plans that you/he/she buys, consider it the same plan.

This question refers to [PLANTYPE].

  1. CY-1 CNTCOV_LC1

  2. CY CNTCOV_LC1

  • DK/REF ANYTHIS_LC1


CNTCOV_LC1

Has it been continuous since [January, CY-1/month and year from MNTH/YRBEG1]?

If PLANTYPE is job-related fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched employers or plans through [your/their] employer, consider it the same plan.

If PLANTYPE is directly-purchased fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched plans that you/he/she buys, consider it the same plan.

  • READ IF NECESSARY: If the gap in coverage was less than three weeks, consider the coverage “continuous.”

  • This question refers to [PLANTYPE].

  1. Yes CK-OTHMEMB_LC1

  2. No MNTHBEG2_LC1

  • DK MNTHBEG2_LC1

  • REF ANYTHIS_LC1


MNTHBEG2_LC1

In which month did this most recent period of coverage start?

READ IF NECESSARY: Your best estimate is fine.

If PLANTYPE is job-related fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched employers or plans through [your/their] employer, consider it the same plan.

If PLANTYPE is directly-purchased fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched plans that you/he/she buys, consider it the same plan.

This question refers to [PLANTYPE].

  1. January

  2. February

……..

  1. December

  • DK/REF

If MNTHBEG2_LC1=current month or earlier YEARBEG2_LC1

If MNTHBEG2_LC1= later than current month SPELLADD_LC1

Else If MNTHBEG2_LC1= (D/R) if covered all months of CY => ANYLAST_LC1; else ANYTHIS_LC1


YEARBEG2_LC1

ASK OR VERIFY

Which year was that?

If PLANTYPE is job-related fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched employers or plans through [your/their] employer, consider it the same plan.

If PLANTYPE is directly-purchased fill:

READ IF NECESSARY: If [you/POLICYHOLDER NAME] switched plans that you/he/she buys, consider it the same plan.

This question refers to [PLANTYPE].

  1. [CY-1] SPELLADD_LC1

  2. [CY] SPELLADD_LC1

  • DK if covered all months of CY ANYLAST_LC1; else ANYTHIS_LC1

  • REF if covered all months of CY ANYLAST_LC1; else ANYTHIS_LC1


SPELLADD_LC1

I have recorded that [you were/NAME was] covered by [PLANTYPE] in [read months covered]. Were there any OTHER months between January [CY-1] and now that [you were/NAME was] also covered by [PLANTYPE]?

  1. Yes if covered all months of CY ANYLAST_LC1; else ANYTHIS_LC1

  2. No CK-OTHMEMB_LC1

  • DK/REF CK-OTHMEMB_LC1

ANYTHIS_LC1

Which months [were you/was NAME] covered by [PLANTYPE] THIS year – in [CY]?

Choose all months that apply

  1. January

  2. February

  3. March

  4. April

  1. All months of CY

  2. No months of CY

  • DK/REF

[all] ANYLAST_LC1


ANYLAST_LC1

Which months [were you/was NAME] covered by [PLANTYPE] LAST year – in [CY-1]?

Choose all months that apply

  1. January

  2. February

……..

  1. December

  1. All months of CY-1

  2. No months of CY-1

  • DK/REF

[all] CK-OTHMEMB_LC1


CK-OTHMEMB_LC1

Does this household have 2 or more members?

  • Yes OTHMEMB_LC1

  • No CK-OTHOUT_LC1


Section D: Other Household Members Covered by Leader’s Plan, and Months Covered (Current Loop)


OTHMEMB_LC1

Between January 1, [CY-1] and now, was anyone in the household other than [you/NAME] ALSO covered by [PLANTYPE]?

  1. Yes COVWHO_LC1

  2. No CK-OTHOUT_LC1

  • DK/REF CK-OTHOUT_LC1

Hard edit: If NAME is a dependent on a job or direct-purchase plan and OTHMEMB_LC1 ne “yes” (that is, the respondent fails to report that the policyholder is also on the plan) store a “Yes”


COVWHO_LC1

Who else was covered? (Who else was covered by [PLANTYPE]?)

PROBE: Anyone else?

  1. household member 1

  2. household member 2

………

  1. household member 16

  1. all persons listed

  2. DK/REF

  • Any household member CK-SAMEMNTHS_LC1

  • DK/REF => CK-OTHOUT_LC1

Hard edit: If NAME is a dependent on a job or direct-purchase plan and the policyholder is not selected, store policyholder’s name in COVWHO_LC1

CK-SAMEMNTHS_LC1

  • If leader was covered all months SAMEMNTHS_LC1

  • If leader was NOT covered all months MNTHS_LC1


SAMEMNTHS_LC1

[Was/Were] [NAME/NAMEs] also covered from January 1, CY-1 until now?

This question refers to [PLANTYPE].

  1. Yes (all also covered from January CY-1 until now) CK-OTHOUT_LC1

  2. No (at least one person not covered from January, CY-1 until now)

  • DK/REF MNTHS_LC1


MNTHS_LC1

[First person] Which months between January [CY-1] and now was [NAME from COVWHO_LC1] covered?

[Second+ person] How about NAME? (Which months between January [CY-1] and now was [NAME] covered?)

Choose all months that apply

This question refers to [PLANTYPE].

  1. January CY-1

  2. February CY-1

……..

  1. December CY-1

  2. January CY

  3. February CY

  4. March CY

  5. April CY

  6. DK/REF

  1. All months from January 2013 until now

  2. No months from January 2013 until now

[all] Loop through all persons reported in COVWHO_LC1; then =>CK-OTHOUT_LC1


CK-OTHOUT_LC1

  • If PLANTYPE is private OTHOUT_LC1

  • Else CK-ADDGAP1_L


OTHOUT_LC1

Does that plan cover anyone living outside this household?

  1. Yes OTHWHO_LC1

  2. No CK- ADDGAP1_L

  • DK/REF CK- ADDGAP1_L


OTHWHO_LC1

How old are they – under 19, 19-25 or older than 25? [MARK ALL THAT APPLY]?

  1. Under 19

  2. 19-25 years old

  3. Older than 25

  • DK/REF

[all] CK-ADDGAP1_L

Additional Plans for Leader


CK-ADDGAP1_L

Are there any gaps in coverage for NAME?

  • Yes (gaps in coverage) ADDGAP1_L

  • No (no gaps in coverage) ADDOTH1_L

ADDGAP1_L

So far, I have recorded that [you were/NAME was] NOT covered in [months not covered]. [Were you/Was NAME] covered by any type of health plan or health coverage in [that/those] month(s)?

READ IF NECESSARY: Do not include plans that cover only one type of care, such as dental or vision plans.

  1. Yes SRCEGEN_LP1

  2. No ADDOTH1_L

  • DK/REF ADDOTH1_L

Past Loop

The Past Loop is designed to capture plan type, months of coverage, other household members covered by the same plan, and the months they were covered. As such, the Past Loop consists of all items in Sections B through D above, but with the following exceptions. First, all items in the Past Loop are worded in the past tense. Second, for Section C of the past loop, there is only a single item asking about months of coverage. This is because for current coverage the questionnaire anchors the respondent in their day-of coverage and then establishes the start month of the spell. For coverage that is not held on the day of the interview it is not possible to employ this same technique so we simply ask what months throughout the 16-month reference period the coverage was held, as follows:


WMNTHS_LP1

Which months between January [CY-1] and now [were you/was NAME] covered by [PLANTYPE]?

Choose all months that apply

  1. January CY-1

  2. February CY-1

……..

  1. December CY-1

  2. January CY

  3. February CY

  4. March CY

  5. April CY

  6. DK/REF

  1. All months from January 2013 until now

  2. No months from January 2013 until now

[all] CK-OTHMEMB_LP1

Once months of coverage are established for the leader, the respondent skips to Section D to determine whether other household members were also covered by the same plan.


SRCEGEN_LP1 thru OTHWHO_LP1

  • Copy all items in Sections B through D in the Current Loop (with the exception above for Section C) and replace “_LC1” with “__LP1.”

  • All answer choices at end of Section D => ADDOTH1_L


ADDOTH1_L

[Other than [PLANTYPEs],] [W/were you/W/was NAME] covered by any [other] health plan or health coverage AT ANY TIME between January 1, CY-1 and now?

READ IF NECESSARY: Do not include plans that cover only one type of care, such as dental or vision plans.

  1. Yes SRCEGEN_LP2

  2. No CK-NEXTMEMB

  • DK/REF CK-NEXTMEMB

If ADDOTH1_L is answered for Person 1 then set MARKTWO=2 (sufficient partial)


SRCEGEN_LP2 thru OTHWHO_LP2

  • Copy all items in Past Loop and replace “_LP1” with “__LP2.”

  • All answer choices at end of Section D => ADDOTH2_L


ADDOTH2_L

[Other than [PLANTYPEs],] [W/were you/W/was NAME] covered by any [other] health plan or health coverage AT ANY TIME between January 1, CY-1 and now?

READ IF NECESSARY: Do not include plans that cover only one type of care, such as dental or vision plans.

  1. Yes SRCEGEN_LP3

  2. No CK-NEXTMEMB

  • DK/REF CK-NEXTMEMB


SRCEGEN_LP3 thru OTHWHO_LP3

  • copy all items in Past Loop and replace “_LP1” with “__LP3.”

  • All answer choices at end of Section D => CK-NEXTMEMB


CK-NEXTMEMB

Have all household members been asked about explicitly?

  • Yes HEALTHSTATUS_INTRO

  • No FINTRO

Additional Plans for Follower


FHINTRO

Next I'm going to ask you about NAME’s health coverage.

Press 1 to Continue


CK-ADDGAP1_F

Are there any gaps in coverage for NAME?

  • Yes (gaps in coverage) ADDGAP1_F

  • No (no gaps in coverage) ADDOTH1_F

ADDGAP1_F

So far, I have recorded that [you were/NAME was] NOT covered in [months not covered]. [Were you/Was NAME] covered by any type of health plan or health coverage in [that/those] month(s)?

READ IF NECESSARY: Do not include plans that cover only one type of care, such as dental or vision plans.

  1. Yes SRCEGEN_FP1

  2. No ADDOTH1_F

  • DK/REF ADDOTH1_F


SRCEGEN_FP1 thru OTHWHO_FP1

  • copy all items in Past Loop and replace “_LP1” with “__FP1.”

  • All answer choices at end of Section D => ADDOTH1_F


ADDOTH1_F

[Other than [PLANTYPEs],] [W/were you/W/was NAME] covered by any [other] health plan or health coverage AT ANY TIME between January 1, CY-1 and now?

READ IF NECESSARY: Do not include plans that cover only one type of care, such as dental or vision plans.

  1. Yes SRCEGEN_FP2

  2. No CK-NEXTMEMB2

  • DK/REF CK-NEXTMEMB2


SRCEGEN_FP2 thru OTHWHO_FP2

  • copy all items in Past Loop and replace “_LP1” with “__FP2.”

  • All answer choices at end of Section D => ADDOTH2_F


ADDOTH2_F

[Other than [PLANTYPEs],] [W/were you/W/was NAME] covered by any [other] health plan or health coverage AT ANY TIME between January 1, CY-1 and now?

READ IF NECESSARY: Do not include plans that cover only one type of care, such as dental or vision plans.

  1. Yes SRCEGEN_FP3

  2. No CK-NEXTMEMB2

  • DK/REF CK-NEXTMEMB2


SRCEGEN_FP3 thru OTHWHO_FP3

  • copy all items in Past Loop and replace “_LP1” with “__FP3.”

  • All answer choices at end of Section D => HEALTHSTATUS_INTRO


CK-NEXTMEMB2

Have all household members been asked about explicitly?

  • Yes HEALTHSTATUS_INTRO

  • No FINTRO for next person

5B. HEALTH INSURANCE: ACS Health Insurance Module


ACSJOB

I am now going to ask you some questions about [your/NAME’s] health insurance and health coverage. [Are you/Is NAME] currently covered by health insurance through a current or former employer or union of [yours/yours or another family member/<him/her> or another family member]?

NOTE: If the respondent says this person has health coverage through the military, mark “2” and tell them that military health insurance/coverage will be discussed later.

  1. Yes

  2. No

  • DK/Ref

  • ACSDIR


ACSDIR

[Are you/Is NAME] currently covered by health insurance purchased directly from an insurance company by [you/you or another family member/<him/her> or another family member]?

  1. Yes

  2. No

  • DK/Ref

  • ACSMCARE


Soft Edit: if ACSJOB=1 and ACSDIR=1 ask: “I recorded that (Fill 1: you/<NAME>) (have/has) both insurance through an employer or union AND insurance directly purchased through an insurance company. These are two different plans, is that correct?”

If correct, suppress and continue.
If not, determine which is the primary plan and go back to and change the “yes” to a “no” for the other plan


ACSMCARE

[Are you/Is NAME] currently covered by Medicare, for people age 65 or older or people with certain disabilities?

  1. Yes

  2. No

  • DK/Ref

  • ACSMCAID


ACSMCAID

[Are you/Is NAME] currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?

  1. Yes

  2. No

  • DK/Ref

  • ACSMIL


ACSMIL

[Are you/Is NAME] currently covered by TRICARE or other military health care?

  1. Yes

  2. No

  • DK/Ref

  • ACSVA


ACSVA

[Are you/Is NAME] currently covered through the Veteran’s Administration or [have you/has NAME] ever used or enrolled for VA health care)?

  1. Yes

  2. No

  • DK/Ref

  • ACSIHS


ACSIHS

[Are you/Is NAME] currently covered through the Indian Health Service?

  1. Yes

  2. No

  • DK/Ref

  • ACSOTHER


ACSOTHER

[Are you/Is NAME] currently covered by any other health insurance or health coverage plan?

  1. Yes ACSOTHERS

  2. No CK-ACSLAST

  • DK/Ref CK-ACSLAST

If ACSOTHER is answered for Person 1 then set MARKTWO=2 (sufficient partial)


ACSOTHERS

What is the name of the health care plan?

[open text; allow 30 characters]

  • CK-ACSLAST


CK-ACSLAST

  • If there is another person on the roster (regardless of age) ACSJOB

  • Else if at least one plan was reported ACS_MKT

  • Else HEALTHSTAT


ACS_MKT

Was this plan obtained through a State or Federal Marketplace, Healthcare.gov, or a similar state website?

  1. Yes

  2. No

  • DK/REF

  • ACS_PREM


ACS_PREM

Do you or another family member pay a premium for this health insurance plan? A premium is a fixed amount of money paid on a regular basis for health coverage. It does not include copays, deductibles, or other expenses such as prescription costs.

  1. Yes ACS_SUBS

  2. No ACS_METAL

  • DK/REF ACS_METAL


ACS_SUBS

Based on family income, do you or another family member receive financial assistance through a subsidy or tax credit to help pay part or all of the cost of the premium for this plan?

  1. Yes

  2. No

  • DK/REF

  • ACS_PREMCOST


ACS_PREMCOST

How much do you or your family pay for the premium?

READ IF NECESSARY: A premium is a fixed amount of money paid on a regular basis for health coverage. It does not include copays, deductibles, or other expenses such as prescription costs.

[open text] ACS_PREMUNIT

  • DK/REF ACS_METAL


ACS_PREMUNIT

ASK OR VERIFY

Is that per month, quarter, year, or some other time period?

  1. Month

  2. Quarter

  3. Year

  4. Other (please specify) ACS_UNITSP (open text specify)

  • DK/Ref

  • ACS_METAL


ACS_METAL

Some health plans are sold at different levels of coverage: bronze, silver, gold and platinum. And some people, including young people under 30, can purchase a catastrophic plan. Is this plan a…

[READ LIST; ENTER ONLY ONE].

NOTE: Catastrophic plans are only available for those under 30 years old or those with a "hardship exemption"

  1. Bronze

  2. Silver

  3. Gold

  4. Platinum or a

  5. Catastrophic plan?

  6. No, none of the above

  • DK/Ref

  • ACS_PATHWAY


ACS_PATHWAY

There are many different ways to obtain information on the health insurance plans in the marketplace. Which of the following sources of information did you use or try to use to obtain information?

MARK ALL THAT APPLY

  1. Website, including online chat option

  2. Newspaper, radio, or television

  3. Call center

  4. Assistance from navigators, application assisters, certified application counselors, or community health workers

  5. Assistance from an insurance agent or broker

  6. Assistance from family or friends

  7. Assistance from an employer

  8. Assistance from a tax preparer

  9. Assistance from Medicaid or another program agency such as TANF, SNAP, or WIC

  10. Assistance from a hospital, doctor’s office, or clinic

  11. Other (please specify) ACS_PATHSP (open text specify)

  • DK/Ref

  • HEALTHSTAT


HELP SCREENS


For ACSMCAID:

Medicaid, medical assistance, or government assistance plans for those with low incomes or a disability may be known by different names in different states. Below is a list of program names by state. This list is not comprehensive, but provides guidance for those not familiar with the term Medicaid and may only know their specific state program name. [fill state-specific program name(s) based on the attachment]


For all items except ACSMCAID:

DATA USES

  • Used to allocate funds to states and local areas for government‑provided health care.

  • Used by federal agencies, such as the Department of Health and Human Services, to evaluate the effectiveness of government health care programs.

  • Used by federal and local agencies to examine the adequacy of existing health care facilities in meeting current and future health care needs.

WHY WE ASK IT THIS WAY

  • These questions ask about each type of insurance a respondent may have.

  • Insurance can include both private coverage (provided by an employer or purchased) as well as public coverage (from government programs such as Medicare, Medicaid, and VA).

  • The reason the question specifies Ahealth insurance or health coverage plans@ is because many types of public (government) coverage are not technically health insurance plans. The goal of the item is to obtain information on whether an individual has health insurance coverage and if so, what kind of coverage he/she has.

  1. WRAP-UP


HEALTHSTATUS_INTRO

An important factor in evaluating a person's or family's health insurance situation is their current health status and/or the current health status of other family members.

  • Press 1 to continue HEALTHSTAT


HEALTHSTATUS

Person 1: Would you say your health in general is excellent, very good, good, fair, or poor?

Person 2: How about NAME? (Would you say your health in general is excellent, very good, good, fair, or poor?)

  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor

  • DK/REF

  • REPEAT FOR NEXT PERSON ON ROSTER then ZIP


ZIP

What is your zip code?

  • [5 digit boxes] ADDR1

  • DK ADDR1

  • REF TY_LAST outcome=001


ADDR1

And your address? (STREET NUMBER AND NAME)

  • Non-blank ADDR2

  • DK CITY

  • REF TY_LAST outcome=001


ADDR2

Is there an apartment number?

  • CITY


CITY

What city?

  • TY_LAST outcome=001



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File Typeapplication/msword
File TitleSHIPP 2010 Flow Document
AuthorBureau Of The Census
Last Modified ByJeannette D Greene-Bess
File Modified2015-05-04
File Created2015-05-04

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