CP, YP, YA, YX

CSHCN

D1. The next questions are about all types of health insurance and
health care coverage that (FILL "NAME" IF RTYPE=01, 03; "YOU" IF
RTYPE=02) may have. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF
RTYPE=02) covered by Medicaid, a health insurance program for persons
with certain income levels and persons with disabilities? In this state,
the program is sometimes called (FILL STATE MEDICAID NAME).

> Las próximas preguntas son acerca de todos los tipos de seguro de
> salud y cobertura de servicios de salud que (FILL "NAME" IF
> RTYPE=01,03; "UD." IF RTYPE=02) pueda tener. ¿Está (FILL "NAME" IF
> RTYPE=01,03; "UD." IF RTYPE=02) cubierto(a) por Medicaid, un programa
> de seguro de salud para personas con ciertos niveles de ingresos y
> para personas con incapacidades? En este estado el programa a veces se
> llama (FILL STATE MEDICAID NAME).

PROBE: Medicaid is a medical assistance program. It serves low-income
people of every age. Medical bills are paid from federal, state and
local tax funds. Patients usually pay no part of the costs for covered
medical expenses. It is run by state and local governments within
federal guidelines.

PROBE: Medicaid es un programa de asistencia médica. Sirve a gente de
ingresos bajos de todas las edades. Las cuentas médicas se pagan de
fondos de impuestos federales, estatales, y municipales. Generalmente
los pacientes no pagan ninguna parte de los costos por gastos médicos
que estan cubiertos. Los gobiernos estatales y municipales lo dirigen
bajo directrices (pautas) federales.

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

D2. Deleted

D3. CHECK AGE: Is NAME's age...

\<21 01 *Continue*

21+ 00 *Go to D5*

CP, YP, YA, YX (If living in S--CHIP state and under 21 years old)

CSHCN

D4. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) covered by
the State Children's Health Insurance Program, or S-CHIP? (FILL IF
S-CHIP NAME IS DIFFERENT THAN STATE MEDICAID NAME) In this state, the
program is sometimes called (FILL S-CHIP NAME).

¿Está (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) cubierto(a) por el
Programa Estatal de Seguro de Salud de Niños, o S-CHIP? (FILL IF S-CHIP
NAME IS DIFFERENT THAN STATE MEDICAID NAME) En este estado el programa a
veces se llama (FILL S-CHIP NAME).

PROBE: The State Children's Health Insurance Program (S-CHIP) expands
health coverage to uninsured children whose families earn too much for
Medicaid but too little to afford private health insurance.

PROBE: El programa estatal de seguro de salud de nintos, S-CHIP extiende
cobertura de seguro de salud a los niños sin seguro cuyas familias ganan
demasiado para que reciban Medicaid, pero demasiado poco para poder
pagar seguro de salud privado.

YES 01

> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

CSHCN

D5. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) covered by
health insurance that is provided by an employer or union or obtained
directly from an insurance company?

> ¿Está (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) cubierto(a) por
> un seguro de salud privado, o sea seguro de salud que se obtenido por
> medio de un empleo o de un sindicato o comprado directamente de una
> compañía de aseguranza?
>
> YES 01
>
> NO 00  *Go to D8*
>
> DON'T KNOW d  *Go to D8*
>
> REFUSED r  *Go to D8*

D6. CHECK AGE: Is NAME'S age...

> \<17 01 *Go to D8*
>
> 17+ 00  *Continue*

YP, YA, YX (with private health insurance)

Created

D7. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) get that
insurance through a job of (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR" IF
RTYPE=02) own, (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02)
purchase it directly from an insurer, or (FILL "IS NAME" IF RTYPE=01,
03; "ARE YOU" IF RTYPE=02) insured through someone else's policy, for
example, (FILL "HIS/HER" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) parents?

¿Recibe (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) ese seguro por
medio de un empleo que (FILL "él/ella" IF RTYPE=01,03; "UD." IF
RTYPE=02) mismo(a) tiene, lo compra (FILL "NAME" IF RTYPE=01,03; "UD."
IF RTYPE=02) directamente de una compañía de seguros, o está (FILL
"NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) asegurado(a) por de la póliza
de otra persona, por ejemplo, de sus padres ?

> INSURED THROUGH OWN JOB/UNION 01
>
> PURCHASE FROM INSURER 02
>
> ![](media/image1.wmf)SOMEONE ELSE'S POLICY/PARENTS 03
>
> OTHER (SPECIFY) 04
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

CSHCN

D8. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) covered by
military health care, TRICARE, CHAMPUS, OR CHAMP-V.A.?

> ¿Está (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) cubierto(a) por
> servicios de salud militar (military health care), por CHAMPUS, por
> CHAMP-VA, o por TRICARE?
>
> PROBE: **TRICARE** is a managed care program for active duty and
> retired members of the uniformed services, their families and
> survivors. **CHAMPUS** is a program of medical care for dependents of
> active or retired military personnel. **CHAMP-V.A.** is medical
> insurance for dependents or survivors of disabled veterans.
>
> PROBE: **TRICARE** es un programa de cuidado de salud para miembros de
> los servicios uniformados, en servicio activos y retirados, sus
> familias y sobrevivientes. **CHAMPUS** es un programa de cuidado de
> salud para dependientes de personal militar de servicio o retirado.
> **CHAMP-V.A.** es seguro de salud para dependientes o sobrevivientes
> de veteranos discapacitados.
>
> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

D9. Deleted

CP, YP, YA, YX

CSHCN

D10. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) enrolled in
a Title 5 program? Title 5 programs are state level programs that
usually provide maternal and child health services.

> ¿Está (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) registrado en un
> programa TITLE V. Programas Title V son programas de nivel estatal que
> generalmente proporcionan servicios de salud de maternidad y de niños.

PROBE: Title 5 is a State-Level type of health coverage that a child may
have. Children may get health care services, care coordination,
medications, equipment, or supplies through the Title 5 program.

PROBE: Title 5 es un tipo de cobertura de salud a nivel estatal que un
niño puede tener. Los niños pueden conseguir servicios de salud,
coordinación de servicios, medicamentos, equipo, o provisiones/víveres a
traves el programa Title V.

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

CSHCN

D11. (FILL "IS NAME" IF RTYPE=01, 03; "ARE YOU" IF RTYPE=02) covered by
any other kind of health insurance or health care plan that pays for
services obtained from hospitals, doctors, and other health
professionals?

¿Está (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) cubierto(a) por
cualquier otro tipo de seguro de salud o por un plan de servicios de
salud que paga por servicios obtenidos de hospitales, de doctores, y de
otros profesionales médicos?

> YES 01
>
> NO 00  *Go to D13*
>
> DON'T KNOW d  *Go to D13*
>
> REFUSED r  *Go to D13*

CP, YP, YA,YX

CSHCN

D12. What kind of health plan is it?

¿Qué tipo de plan de salud es?

*Do not read, code all that apply*

MEDICAID/(FILL STATE NAME) 01

MEDICARE 02

S-CHIP/(FILL STATE NAME FOR S-CHIP) 03

TITLE V 04

MEDIGAP 05

CHAMPUS/CHAMP-VA, TRICARE,

VA, OTHER MILITARY 06

INDIAN HEALTH SERVICE 07

PRIVATE INSURANCE 08

SINGLE SERVICE PLAN (DENTAL, VISION,

![](media/image2.wmf) PRESCRIPTIONS, ETC.) 09

OTHER PLAN (SPECIFY) 10

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

D13. CHECK: Is D1=01, D4=01, D5=01, D8=01, D10=01, or D11=01, that is,
does NAME have **any** health insurance coverage?

YES 01  *Go to D17*

NO 00

CP, YP, YA,YX

CSHCN

D14. It appears that (FILL "NAME DOES" IF RTYPE=01,03; "YOU DO" IF
RTYPE=02) not have any health insurance coverage to help pay for
services from both hospitals and doctors, and other health
professionals. Is that correct?

Pareciera que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) no tiene
ningun tipo de cobertura de seguro de salud para ayudar a pagar por
servicios obtenidos de hospitales, de doctores, y de otros profesionales
médicos. ¿Es correcto?

> YES 01 *Go to D19*
>
> NO 00 *Continue*
>
> DON'T KNOW .d *Go to D19*

REFUSED .r *Go to D19*

CP, YP, YA,YX

CSHCN

D15. What kind of health coverage (FILL "DOES NAME" IF RTYPE=01,03; "DO
YOU" IF RTYPE=02) have? Any other kind?

¿Qué tipo de cobertura de salud tiene (FILL "NAME" IF RTYPE=01,03; "UD."
IF RTYPE=02)? ¿Algún otro tipo?

*Do not read, code all that apply*

MEDICAID/(FILL STATE NAME) 01

MEDICARE 02

S-CHIP/(FILL STATE NAME FOR S-CHIP) 03

TITLE 5 04

MEDIGAP 05

CHAMPUS/CHAMP-VA, TRICARE,

VA, OTHER MILITARY 06

INDIAN HEALTH SERVICE 07

PRIVATE INSURANCE 08

SINGLE SERVICE PLAN (DENTAL, VISION,

![](media/image3.wmf) PRESCRIPTIONS, ETC.) 09

OTHER PLAN (SPECIFY) 10

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

D16. Is this coverage paid for **mainly** by the government, an employer
or union, (FILL "NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) family, or
someone else?

¿Es esta cobertura pagada **principalmente** por el gobierno, un
empleador o sindicato (FILL "LA" IF RTYPE=01,03; "SU" IF RTYPE=02)
familia (FILL "DE NAME" IF RTYPE=01, 03; ELSE BLANK), o por otra
persona?

GOVERNMENT 01

EMPLOYER/UNION 02

![](media/image4.wmf)
FAMILY.....................................................03

OTHER (SPECIFY) 04

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

CSHCN

D17. In the past 12 months, that is since (FILL THIS MONTH, LAST YEAR),
was there any time when (FILL "NAME WAS" IF RTYPE=01, 03; "YOU WERE" IF
RTYPE=02) not covered by **any** health insurance?

En los últimos 12 meses, o sea que desde (FILL THIS MONTH, LAST YEAR),
¿hubo algún tiempo cuando (FILL "NAME" IF RTYPE=01,03; "UD." IF
RTYPE=02) no estaba cubierto(a) por cualquier seguro de salud?

> YES 01 *Continue*
>
> ![](media/image5.wmf)NO 00
>
> DON'T KNOW .d

REFUSED .r

CP, YP, YA, YX

CSHCN

D18. In the past 12 months, about how many months (FILL "WAS NAME" IF
RTYPE=01, 03; "WERE YOU" IF RTYPE=02) without coverage?

> En los últimos 12 meses, ¿más o menos cuántos meses estuvo (FILL
> "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) sin cobertura?

\|\_\_\|\_\_\| MONTHS

DON'T KNOW d

REFUSED r

[]{.mark}

CP, YP, YA,YX

CSHCN

D19. About how long has it been since (FILL "NAME" IF RTYPE=01, 03;
"YOU" IF RTYPE=02) last had health coverage, if ever?

¿Más o menos cuánto tiempo ha pasado desde la ultima vez que (FILL
"NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) tuvo cobertura de salud, si es
que la tuvo?

> 6 months or less 01 *Continue*

More than 6 months, but not more than

> 1 year ago 02 *Continue*

More than 1 year, but not more than 3

years ago 03 *Go to D21*

> More than 3 years 04 *Go to D21*
>
> Never 05 *Go to D23*
>
> 6 meses o menos 01 *Continue*

Más de 6 meses, pero no más de

> un (1) año 02 *Continue*

Más de un (1) año, pero no más de

tres (3) años 03 *Go to D21*

> Más de tres (3) años 04 *Go to D21*
>
> Nunca 05 *Go to D23*

DON'T KNOW. d *Go to D21*

REFUSED..................................................r *Go to D21*

CP, YP, YA,YX

CSHCN

D20. In the past 12 months, about how many months (FILL "WAS NAME" IF
RTYPE=01, 03; "WERE YOU" IF RTYPE=02) without any health insurance or
coverage?

En los últimos 12 meses, ¿más o menos cuántos meses estaba (FILL "NAME"
IF RTYPE=01,03; "UD." IF RTYPE=02) sin cobertura de seguro de salud?

\|\_\_\|\_\_\| MONTHS

DON'T KNOW d

REFUSED r

CP, YP, YA,YX

NEILS

D21. (FILL "HAVE YOU" IF RTYPE=01, 02; "HAS NAME" IF RTYPE=03) ever
tried to get (FILL "YOUR" IF RTYPE=01, 02; "HIS/HER" IF RTYPE=03)
insurance or health plan to pay for something for (FILL "NAME" IF
RTYPE=01, 03; "YOU" IF RTYPE=02; "HIMSELF/HERSELF" IF RTYPE=03) but they
wouldn't pay?

¿Alguna vez ha tratado (FILL "UD." IF RTYPE=01, 02; "NAME" IF RTYPE=03)
de conseguir que su seguro o su plan de salud pague por algo para (FILL
"NAME" IF RTYPE=01, 03; "UD." IF RTYPE=02), pero ellos no querían pagar?

> YES 01  *Continue*
>
> ![](media/image6.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA,YX

NEILS

D22. What wouldn't (FILL "YOUR" IF RTYPE=01, 02; "NAME'S" IF RTYPE=03)
insurance pay for?

> ¿Por que cosas no quería pagar (FILL "SU" IF RTYPE=01,02; "EL" IF
> RTYPE=03) seguro (FILL "DE NAME" IF RTYPE=01, 03; ELSE BLANK)?

*Code all that apply*

> DIAGNOSTIC PROCEDURES OR TESTS 01
>
> REFERRAL TO/CARE FROM A SPECIALIST 02
>
> SURGERY 03
>
> MEDICATIONS 04
>
> EYE EXAM/GLASSES/CONTACT LENSES 05
>
> SPECIAL EQUIPMENT 06
>
> ![](media/image7.wmf)THERAPY SERVICES 07
>
> OTHER (SPECIFY) 08

DON\'T KNOW d

> REFUSED r

CP, YP, YA,YX

NHIS-D Child Core (modified)

D23. (FILL "HAVE YOU" IF RTYPE=01, 02; "HAS NAME" IF RTYPE=03) ever
wanted private health insurance for (FILL "NAME" IF RTYPE=01; "YOURSELF"
IF RTYPE=02; "HIMSELF/HERSELF" IF RTYPE=03) and not been able to get it?

> ¿Alguna vez ha querido (FILL "NAME" IF RTYPE=03; "UD." IF RTYPE=01,02)
> seguro de salud privado para (FILL "NAME" IF RTYPE=01; "UD. MISMO(A)"
> IF RTYPE=02; "él/ella MISMO(A)" IF RTYPE=03), y no lo ha podido
> conseguir?
>
> YES 01
>
> ![](media/image8.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA,YX

NHIS-D Child Core (modified)

D24. Why (FILL "WERE YOU" IF RYTPE=01, 02; "WAS NAME" IF RTYPE=03)
unable to get private health insurance for (FILL "NAME" IF RTYPE=01;
"YOURSELF" IF RTYPE=02; "HIMSELF/HERSELF" IF RTYPE=03)?

¿Por qué no pudo (FILL "UD." IF RTYPE=01,02; "NAME" IF RTYPE=03)
conseguir seguro de salud privado para (FILL "NAME" IF RTYPE=01; "UD.
MISMO(A)" IF RTYPE=02; "él/ella MISMO(A)" IF RTYPE=03)?

*Do not read list, code all that apply*

> BECAUSE OF PRE-EXISTING CONDITION 01
>
> BECAUSE OF HEALTH RISKS 02
>
> ![](media/image9.wmf)COULDN'T AFFORD IT 03
>
> OTHER (SPECIFY) 04
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> DON'T KNOW d
>
> REFUSED r