MEPS-HC Survey Instrument

OMB#: 0935-0108

PATIENT LABEL

FORM ___ OF ___

MEDICAL EXPENDITURE SURVEY
MEDICAL PROVIDER COMPONENT
HOME CARE EVENT BOOKLET
FOR NON-HEALTH CARE PROVIDERS

FOR
REFERENCE YEAR 2005

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D1. During calendar year 2005, what was the (first/next)
month during which your records show that
services were provided in (PATIENT NAME)'s
home?

D2. I need to know which type or types of persons
provided services at (PATIENT NAME)'s home
during (MONTH) and either the number of hours or
the number of visits for each type.
EXPLAIN IF NECESSARY: By type of person I
mean a housekeeper, therapist, nurse aide, yard
worker, and so forth.

D3. I need a description of the services provided during
(MONTH).

MONTH: _____________ YEAR: 2005

OFFICE
USE
ONLY

TYPE OF PERSON

|__|

______________

______ / ______ OR ____

|___|___|

|__|

______________

______ / ______ OR ____

OFFICE

|__|

______________

______ / ______ OR ____

USE

|__|

______________

______ / ______ OR ____

ONLY

|__|

______________

______ / ______ OR ____

|__|

______________

______ / ______ OR ____

|__|

______________

______ / ______ OR ____

|__|

______________

______ / ______ OR ____

HOURS/MINUTES:

CLEANING OR YARD WORK ..............................
TRANSPORTATION .............................................
SHOPPING............................................................
EMOTIONAL SUPPORT PERSON OR
ONE-ON-ONE BUDDY .......................................
SUPPORT GROUPS.............................................
CHILD CARE.........................................................
OTHER (SPECIFY):
__________________________________ ........

VISITS:

YES

NO

1
1
1

2
2
2

1
1
1

2
2
2

1

2

C2. What were the charges for the services provided to
(PATIENT NAME) during (MONTH)?

TOTAL CHARGES:

$________.__

C3. NOT ASKED THIS VERSION

| 1 |
OFFICE USE
ONLY

C4a. Who paid your organization for the charges during
(MONTH)?

C4b. ASK FOR EACH SOURCE OF PAYMENT
MENTIONED: How much did (SOURCE OF
PAYMENT) pay?
IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?

C5. IF NOT VOLUNTEERED, ASK: And what was the total
of all payments received for (MONTH)?
[IF NOT AVAILABLE, COMPUTE.]

a. Patient or patient’s family

$________.__

b. Medicare

$________.__

c. Medicaid

$________.__

d. Private Insurance

$________.__

e. VA

$________.__

f. TRICARE/CHAMPVA/
CHAMPUS

$________.__

g. Worker's Comp

$________.__

h. OTHER (SPECIFY):
_____________________

$________.__

TOTAL PAYMENTS:

$________.__

BOX 1
DO TOTAL PAYMENTS (C5) EQUAL TOTAL CHARGES (C2)?
YES ............................... 1 (D4)
NO ................................. 2 (C6)

C6. It appears that the total payments were (less than/
more than) the total charges. What is the reason for
that difference? [CODE 1 (YES) FOR ALL REASONS
MENTIONED.]

PAYMENTS LESS THAN CHARGES:
YES NO
Adjustment or discount
a. Medicare limit or adjustment..................... 1
2
b. Medicaid limit or adjustment ..................... 1
2
c. Contractual arrangement with insurer
or managed care organization................ 1
2
d. Courtesy discount ..................................... 1
2
e. Insurance write-off .................................... 1
2
f. Worker's Comp limit or adjustment........... 1
2
g Eligible veteran ......................................... 1
2
h. Other (Specify:) ____________________ 1
2
Expecting additional payment
i. Patient or Patient’s Family ...........................
j. Medicare ........................................................
k. Medicaid .........................................................
l. Private Insurance ..........................................
m. VA....................................................................
n. TRICARE/CHAMPVA/CHAMPUS..............
o. WORKER'S COMP ..................................
p. Other (Specify:) ____________________

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

q. Charity care or sliding scale .................... 1
r. Bad debt ........................................................ 1

2
2

PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment ....................................
t. Medicaid adjustment ....................................
u. Private insurance adjustment......................
v. Other (Specify:).........................................
________________________________

2
2
2
2

1
1
1
1

D4. Have we covered all of the months your organization
provided services to (PATIENT NAME) during the
calendar year 2005?

YES, ALL MONTHS COVERED....... 1 (D5)
NO, NEED TO COVER
ADDITIONAL MONTH(S) ............... 2 (D1-NEXT
EVENT FORM)

D5. REVIEW NUMBER OF MONTHS OF HOME CARE
SERVICE REPORTED BY HOUSEHOLD. IF FEWER
MONTHS OF SERVICE ARE REPORTED BY THE
HOME CARE ORGANIZATION, PROBE TO EXPLAIN
THE DIFFERENCE.

NO DIFFERENCE OR PROVIDER
REPORTED MORE MONTHS OF
HOME CARE SERVICE THAN
HOUSEHOLD ................................. 1 (D6)
PROVIDER RECORDED FEWER
VISITS:............................................ 2
PROBE: (PATIENT NAME) reported
(NUMBER) months of home care
service. Do you have any information
in your records that would explain this
discrepancy?
_____________________________
_____________________________
_____________________________

D6. GO TO NEXT PATIENT FOR THIS PROVIDER.
IF NO MORE PATIENTS, THANK THE RESPONDENT AND END THE CALL.

4