What is the name of the insurance company for this health insurance 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?
How many CU members are/were covered by this policy? [enter value] ______________
What type of insurance plan is it?
For definitions Information Booklet »
If, except in the case of an emergency, you go to a doctor other than one in the group center or your primary care doctor, without a referral, will the plan pay any of your expenses?
Is this fee for service plan a -
Is this special purpose insurance plan -
* Specify: [enter text] ___________
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? [enter value] ______________
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? [enter value] ______________
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] ______________
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 Consumer Unit »
Go to Section 15 Part A - Medical and Health Expenditures - Screening Questions for Payments »
Go to CAPI Home Page »
Last Modified Date: November 8, 2007
U.S. Bureau of Labor Statistics U.S. Bureau of Labor Statistics
