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 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?

1. Yes
2. No

How many household members are/were covered by this policy?

[enter value]

What type of insurance plan is it?

* Do not include Medicare prescription drug plans in Commercial Medicare Supplements. Medicare prescription drug plans are collected in Part C.

1. Health Maintenance Organization
2. Fee for Service Plan
3. Commercial Medicare Supplement
4. Other special purpose plan

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?

1. Yes
2. No

Is this special purpose insurance plan -

1. Dental insurance?
2. Vision insurance?
3. Prescription drug insurance?
4. Other type of special purpose health insurance? - Specify

* Specify: [enter text]

Was the policy obtained on an individual or group basis?

1. Individually obtained
2. Group through place of employment
3. Group through other organization

Do you or any member of your household pay ANY portion of the premiums for this policy?

1. Yes
2. No

Are any premiums paid through payroll deductions?

1. Yes
2. No

How much [do you/does your household] currently spend for this plan [including payroll deductions]?
* Enter dollar amount for premium payments. Select time period in next question.

[enter value]

   

* Enter time period for premium payments.

1. Once a week
2. Once every 2 weeks
3. Twice a month
4. Once a month
5. Every 2 months
6. Quarterly (every 3 months)
7. Once every 4 months
8. Twice a year (every 6 months)
9. Once a year
10. Other

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]

Who pays the policy premiums?

1. An employer or union?
2. Another group or persons outside your household?

Did you have any other hospitalization or health insurance plans?

1. Yes
2. No

End of Section 14B

Go to Section 14 Part C - Medicare, Medicaid, and Other Health Insurance Plans Not Directly Paid For By The Household »

Go to Section 15 Part A - Medical and Health Expenditures - Screening Questions for Payments »

Go to CAPI Home Page »

 

Last Modified Date: April 12, 2013