Section 14, Part C - Hospitalization and Health Insurance - Medicare, Medicaid, and Other Health Insurance Plans Not Directly Paid For By The Consumer Unit

Section 14, Part C covers participation in health insurance plans for which the consumer unit does not pay directly, such as Medicare, Medicaid, and military health care plans.

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Last time you said that a CU member was/CU members were enrolled in Medicare. Has the number of CU members enrolled in Medicare changed?

  1. Yes
  2. No

Are you or any members of your CU presently enrolled in Medicare or have you or any members of your CU been enrolled since the first of the reference month? Medicare is the Federal Health Insurance Plan.

  1. Yes
  2. No

Are you/How many members of your CU are covered by Medicare? [enter value] ______________

Last time you said that a CU member was/CU members were enrolled in Medicaid. Has the number of members enrolled in Medicaid changed?

  1. Yes
  2. No

Are you or any members of your CU enrolled in Medicaid or have you or any members of your CU been enrolled since the first of the reference month?

  1. Yes
  2. No

Are you/How many members of your CU are covered by Medicaid? [enter value] ______________

Are any members of your CU still covered by a plan other than Medicare or Medicaid TRICARE, CHAMPUS, or military health care?

  1. Yes
  2. No

Are you or any member of your CU covered by any plan other than Medicare or Medicaid which provides free health care such as TRICARE, CHAMPUS or military health care?

  1. 1. Yes
  2. 2. No

End of Section 14C

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Last Modified Date: October 11, 2005