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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 name of insurance company, not the insurance agent.

[enter text]

* Do not read to respondent.

Is the insurance company Blue Cross/Blue Shield?
* Do not read to respondent.
Is the insurance company Tricare?
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.

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 special purpose insurance plan -

* Specify: [enter text]

Was the policy obtained on an individual or group basis?
Was the policy obtained through Healthcare.gov?
Is this policy a platinum, gold, silver, bronze, or catastrophic plan?
Do you or any member of your household pay ANY portion of the premiums for this policy?
Who pays the policy premiums?
Are any premiums paid through payroll deductions?
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]


* FR Instruction: 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.
Is the cost of the premium subsidized based on income?
Is the subsidy paid directly to the health insurance company?
Did you have any other hospitalization or health insurance plans?

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 7,2016