Section 14, Part B - Hospitalization and Health Insurance - Detailed Questions
Section 14, Part B collects detailed information about each health insurance policy that was reported in Part A.
What is the name of the insurance company for this health insurance policy?
* 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?
What type of insurance plan is it?
For definitions Information Booklet »
Under normal circumstances, if you go to a doctor who is not part of your plan without a referral, will your insurance company pay for the cost?
Is this fee for service plan a -
Is this special purpose insurance plan -
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?
What period of time is covered by the regular payment?
Since the first of the reference month, were any payments made on this policy?
Was each payment in the amount of "your part of the regular health insurance payment including all payroll deductions?"
How many payments were made?
What was the total expense paid for this policy since start of the reference month?
How much was paid this month?
Did you have any other hospitalization or health insurance plans?
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Last Modified Date: April 16, 2009