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Section 14, Part B collects detailed information about each health insurance policy that was reported in Part A.
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Now I am going to ask some details about your health insurance.
What is/was the name of the insurance company for "your (1st, 2nd, 3rd)" health insurance policy? [enter text] ____________________
* Enter name of insurance company, not the insurance agent.
* Do not read to respondent.
* Is the insurance company Blue Cross/Blue Shield?
How many CU members are/were covered by this policy? [enter value] ______________
What type of insurance plan is it?
Is this fee for service plan a -
Is this special purpose insurance plan -
* Specify: [enter text] ___________
Was the policy obtained on an individual or group basis?
Are the policy premiums paid -
Are any premiums paid through payroll deductions?
What is your part of the regular health insurance payment including all payroll deductions? [enter value] ______________
What period of time is covered by the regular payment?
* Specify: [enter text] ___________
Since the first of the reference month, were any payments made on this policy?
How many payments were made? [enter value] ______________
What was the total expense paid for this policy since start of the reference month? [enter value] ______________
How much was paid this month? [enter value] ______________
Go to Section 15 Part A - Medical and Health Expenditures - Screening Questions for Payments »
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Last Modified Date: October 11, 2005