NIDCR/CDC
Dental, Oral and Craniofacial
Data Resource Center
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Dental Expense and Payment Source
Q.B1b, SIPP TM Wave 7 Section 4, 1992
During (Read last month), did…pay any of the following:Dentist bills?
1 Yes
2 No
x1 DK
Q.P1, NHIS, 1991; 1993
a. During (Read last month) did ….pay any dentist bills? 1 Yes
2 No
9 DK
Q.FF.R5.6, NMCES, 1977
Did (person) have any visits to the [doctor/dentist/medical provider] covered by this charge before January 1, 1977? 1 Yes
2 No
Q.RS.R5.1, a, b, NMCES, 1977
Did (person) have to take off from work to go to the dentist for (any of) the visit(s) we just talked about? 1 Yes
2 No
a. Was (person) paid in full, in part, or not at all for the time missed from work to go to the dentist?
In full
In part
Not at all
Self-employed
DK
b. What percentage of [his/her] salary or wage did [he/she] get? ____ %
Q.DV.R5.7, a, b, NMCES, 1977
How much was the total charge for this visit on (date), including any amount that may be paid by health insurance or other sources? $_________
1 No charge
2 Included in charges for other visits
94 DK
a. Do you expect to receive a bill for this visit?
1 Yes
2 No
b. Why don't you expect to receive a bill?
1 Free from provider
2 Included in charges for other visits
3 Other source will pay
4 Already paid
Q.DV.R5.8, NMCES, 1977
Why was there no charge for this visit? 1 Free from provider
2 Included in charges for other visits
3 Other source will pay
Q.DV.R5.9, NMCES, 1977
How much of the (charge) did you or your family already pay? Partial $______%
1 All
2 None
Q.DV.R5.10, NMCES, 1977
How much (more) of this will you or your family pay? Partial $______%
1 All
2 None
Q.DV.R5.11, a, b, NMCES, 1977
Do you expect any source to reimburse you or pay you back? 1 Yes
2 No
a. Who will reimburse or pay you back? Anyone else?
__________________
b. How much will (each source) reimburse or pay you back?
_______%
Q.DV.R5.12, a, NMCES, 1977
Who else paid or will pay any part of the charge? Anyone else?
__________________a. How much did or will (each source) pay?
_______%
Q.RV.R5.2, NMCES, 1977
Of these [number of orthodontia] visits, how many cost the identical amount as the visit we just talked about? _____ Visits
0 None
_____ Visits included in same Flat Fee___
Q.D8, NMES, 1987
Now I'd like to ask you about the charges for this visit to the dentist. Have you received any bill or statement for this visit on (date)? 1 Yes
2 No
Q.D9, NMES, 1987
Do you expect to receive a bill or statement for this visit? 1 Yes
2 No
Q.D10, NMES, 1987
Why is that? 1 Paid at time of visit
2 Bill sent directly to other source, haven't received statement yet- specify source_______
3 No bill will be sent - Charges paid or to be paid by HMO plan
4 No bill will be sent - Charges paid or to be paid by VA
5 No bill will be sent - Charges paid or to be paid by Military facility
6 No bill will be sent - Charges paid or to be paid by Welfare/Medicaid
7 No bill will be sent - Charges paid or to be paid by Indian Health Service
8 No bill will be sent - Charges paid or to be paid by Indian Tribe/Inter-tribal council/Alaska Native Corporation
9 Free from provider
10 Included with other charges
Q.D11, NMES, 1987
Including any amounts that may be paid by health insurance, Medicare, Medicaid, or other sources, how much was the total charge for this visit on (date)? (If the bill separately listed charges for procedures such as x-rays, include those charges in the total.) Total charge $________
95 Included with other charges
-8 DK
Q.D12, NMES, 1987
Since (date of visit), how much of the total charge have you (or any member of your family) paid? Amount $______ or
Percentage %______
0 Nothing
1 Total charge was paid
2 Less than total charge paid
-8 DK
Q.D13, NMES, 1987
Has any source reimbursed or paid you (or your family) back anything for the amount you paid? 1 Yes
2 No
-8 DK
Q.D14, NMES, 1987
Who reimbursed or paid you back? Anyone else?
Q.D15, NMES, 1987
How much did (source) reimburse or pay you back? $ _________ or %______%
Q.D16, NMES, 1987
Do you expect any (other) source to reimburse you for what you paid? 1 Yes
2 No
Q.BOX D2, NMES, 1987
Has total charge been paid? 1 Yes
2 No
Q.D17, NMES, 1987
Do you (or anyone in the family) expect to pay any (additional) amount for this visit? 1 Yes
2 No
Q.D18, NMES, 1987
Have any (other) sources already paid any of the charges for this visit? 1 Yes
2 No
-8 DK
Q.D19, NMES, 1987
Who (else) paid? Anyone else?
Q.D20, NMES, 1987
How much did (source) pay? $ _________ or %______%
Q.D21, NMES, 1987
Do you expect anyone else to pay any of the charges for this visit? 1 Yes
2 No
Q.D22, NMES, 1987
Do you know what the total charge was for this visit? 1 Yes
2 No
Q.D23, NMES, 1987
Including any amounts that may be paid by health insurance, Medicare, Medicaid, or other sources, how much was the total charge for this visit on (date)? Total Charge $_________
95 Included with other charges
Q.D24, NMES, 1987
Did you (or anyone in the family) pay anything for this visit? 1 Yes
2 No
Q.D25, NMES, 1987
How much did you (or anyone in the family) pay? Amount $______
Q.Box D4, NMES, 1987
Was the charge for this visit part of a flat fee ("included with other charges")? 1 Yes
2 No
Q.D28, NMES, 1987
How many of these (answer to D27) visits were included in the same flat fee as the visit on (date)? Number of visits: _____
Q.D29, NMES, 1987
Of those (answer to D27) visits, how many cost the identical amount as the visit you just told me about? Number of visits: _____
Q.CP05, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
Has (person or anyone in the family) received anything in writing such as a bill, receipt, or statement for (person's) visit to (provider) on (visit date)/ the services for (flat fee group) for (person)? 1 Yes, and documentation is available
2 Yes, but documentation is not available
3 No
4 No, free sample
-7 Ref
-8 DK
Q.CP06, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
Why has (person or anyone in the family) not received anything in writing? 1 Paid at time of visit
2 Made a co-payment
3 Bill sent directly to other source
4 Bill has not arrived
5 No bill sent: HMO plan
6 VA
7 Military facility
8 Welfare/Medicaid
9 Worker's compensation
10 Private health center/clinic
11 Public clinic/health center or private charity
12 No charge: telephone call
13 Free from provider
14 Government-financed research and clinical trials
95 Included with other charges
-7 Ref
-8 DK
Q.CP07, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
To whom was the bill sent? 1 HMO
2 VA
3 CHAMPUS/CHAMPVA
4 Other military
5 Welfare/Medicaid
6 Worker's compensation
7 Private insurance company
91 Other
-7 Ref
-8 DK
Q.CP09, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
How much was the total charge for [(person's) visit to (provider) on (visit date)/the services for (flat fee group) for (person)/(provider's) services as part of the visit made on (visit date)? Please include any amounts that may be paid by insurance or other sources. 1 Amount
95 Included with other charges
Enter $ amount ___________
-7 Ref
-8 DK
Q.CP11, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
How much of the total charge did anyone in the family pay…? 1 Dollars
2 Percent
Enter Dollars _____________
Enter Percent _____________
Q.CP12, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
Has any other source already paid (provider) …? 1 Yes
2 No
-7 Ref
-8 DK
Q.CP13, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
How much did (source) pay?
Q.CP14, a, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002;
2003; 2004; 2005
Has any source reimbursed or paid back (person or anyone in the family) for the amount paid out-of-pocket? That is, has any source reimbursed any of the ($/% family paid) paid? 1 Yes
2 No
-7 REF
-8 DK
a. Who reimbursed or paid anyone in the family back? Anyone else?
Q.CP15, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
How much did anyone reimburse or pay anyone in the family back?
Q.CP16, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001
Did (PROVIDER) discount any portion of the total charges? 1 Yes
2 No
-7 Ref
-8 DK
Q.CP17, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001
How much was the discount? _____________
Q.CP29, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001
Do you know if any portion of the total charge is disallowed or disapproved by (person's) insurance, Medicare, or Medicaid? 1 Yes
2 No
-7 Ref
-8 DK
Q.CP30, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001
How much was disallowed or disapproved?
Q.CP31, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
Do you expect anyone in the family to pay any amount/more? 1 Yes
2 No
-7 Ref
-8 DK
Q.CP32, MEPS HC, 1996; 1997; 1998; 1999; 2000; 2001; 2002; 2003;
2004; 2005
How much do you expect anyone in the family to pay?
Q.15A.1, CES, 1999; 2000; 2001; 2002; 2003; 2004; 2005
Since the 1st of (month, 3 months ago), have you (or any members of your CU) made any payments for the following….dental care? 1 Yes
2 No
Q.15B.b, c, d, CES, 1999; 2000; 2001; 2002; 2003; 2004;
2005
b. What was the (care/service or item)? Who received the (care/service or item)? Was the person a CU member?c. In what month was (were) the payment(s) made?
d. What was the amount of payment?
Q.15C.1, CES, 1999; 2000; 2001; 2002; 2003; 2004; 2005
Since the 1st of (month, 3 months ago), have you (or any members of your CU) received any reimbursements for the following…dental care?
Q.15D.b, c, d, CES, 1999; 2000; 2001; 2002; 2003; 2004; 2005
b. What was the (care/service or item)? Who received the (care/service item)? Was the person a CU member?c. In what month was (were) the reimbursement(s) received?
d. What was the amount of reimbursement?
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