CMS-P-0015A MCBS Facility Round 46 Expenditure Questionnaire

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX. EXPENDITURES QUESTIONNAIRE
(CORE ONLY)

BOX
FEX1

If this is the first round that EX is administered for this SP in this facility, go to EX1PRE;
Else, if this is a subsequent round that EX is administered for this SP in this facility:
If FEX2 or EX19 has not been asked in this facility in this round for this
respondent, go to FEX1PRE;
Else, go to BOX FEX2.

FEX1PRE
The next series of questions ask about expenditures for room and board and ancillary charges for residents. We will
need complete billing records for services provided to residents.
PRESS ENTER TO CONTINUE.

BOX
FEX2

If this is the first SP in this round and this is the first respondent for this SP, go to
FEX2;
this is the first respondent for this SP, and
this is the first time this round the respondent has been asked EX, for any SP,
go to FEX2;
Else, go to EX1PRE.

FEX2
DO YOU WANT TO...
( )
1.

COLLECT BILLING INFORMATION FOR ALL BILLING PERIODS, BEFORE COLLECTING ANY PAYMENT
INFORMATION?
OR

2.

COLLECT BILLING AND THEN PAYMENT INFORMATION FOR A BILLING PERIOD, THEN BILLING AND
PAYMENT INFORMATION IN SEQUENCE FOR ALL REMAINING BILLING PERIODS?
PRESS ENTER TO CONTINUE.

1

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

A. CHARGES AND SOURCE OF PAYMENT MODULE

BOX
EX0

If SP is a SSM2 from the last round, go to KEX1; else
Go to BOX EX1.

If FEX2 = 1, (COLLECT ALL BILLING FIRST):
If in retrieval mode for CRRD-1 ancillary charges and there are additional periods
to collect ancillary charges for, go to EX15PRE; else
If SP was living in an eligible part of the facility for any billing period for which
expenditures data has not already been collected and this is the first billing period
for which expenditures data has not already been collected, go to EX2; else
BOX
EX1

If SP was living in an eligible part of the facility for any billing period for which
expenditures data has not already been collected and this is the second or
subsequent billing periods for which expenditures data has not already been
collected, loop through EX8 through EX18 until all billing periods have been
collected; then go to BOX EX7B; else
Go to BOX EX7B.
Else, if FEX2 = 2 (COLLECT BILLING, THEN PAYMENT FOR EACH BP), go to EX2.

KEX1
When {SP} was first admitted to {FACILITY/[READ FACILITY UNITS ABOVE]} on {FAD}, what were all of the
sources of payment for {her/his} room and board and basic care? SELECT ALL THAT APPLY.
NO CHARGES
MEDICAID
PRIVATE PAY
SOCIAL SECURITY
SP OR SPOUSE'S OWN INCOME/ASSETS
OTHER FAMILY INCOME/ASSETS
PRIVATE INSURANCE, INCLUDING LTC INSURANCE, BC/BS
PENSION
OTHER PRIVATE PAY (SPECIFY:
)
MEDICARE
VA CONTRACT
HMO CONTRACT
OTHER (SPECIFY:
)
DON'T KNOW
USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

BOX
KEX1

If "NO CHARGES" was selected in KEX1, go to KEX2; else
If more than one source of payment was selected in KEX1, go to KEX3; else go to
EX2.

2

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

KEX2
Why were there no charges?
IF ANSWER IS "MEDICAID PAID," BACK UP TO KEX1 AND SELECT "MEDICAID."
RECORD VERBATIM.

KEX3
Which of these sources was the primary source?
SELECT ONE.
USE ARROW KEYS. TO SELECT OR DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

EX2
(The following questions are about {SP's} basic care between {REFERENCE START DATE} and {REFERENCE
END DATE}.) Was there a charge for {her/his} room and board and basic care between {REFERENCE START
DATE} and {REFERENCE END DATE}? Please include any charges to {SP}, {her/his} family, or a third party, such
as Medicaid, Medicare, or a legal guardian.
YES .............................................................................................
NO...............................................................................................
DK ..............................................................................................
RF ...............................................................................................

1
0
-8
-7

(EX4)
(EX3)
(EX2a)
(EXEND)

EX2A
Please tell me the name and title of someone in {FACILITY [READ FACILITY UNITS ABOVE]} who could give me
that information. RECORD RESPONDENT INFORMATION ON PAPER FROG.
Thank you for your time, I will need to continue with [NAME FROM FROG] to complete these questions.
PRESS ENTER TO CONTINUE.

EX3
Why were there no charges?
IF ANSWER IS "MEDICAID PAID," BACK UP TO EX2 AND ENTER "1."
RECORD VERBATIM.

BOX
EX1A

If there are any CRIN-1 billing periods missing payment data, go to BOX EX7B;
Else, go to EXEND.

3

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX4
Between {REFERENCE START DATE} and {REFERENCE END DATE}, was SP billed separately for health-related
ancillary services? (That is, were there charges for ancillary services that were not included in the basic rate?)
IF FACILITY NEVER BILLS SEPARATELY FOR ANCILLARIES, ENTER SHIFT/5.
YES..............................................................................................
NO................................................................................................

1
0

PRESS F1 FOR DEFINITION OF ANCILLARY SERVICES.

BOX
EX2

If EX5 has not been asked in this facility in this round, go to EX5; else
go to BOX EX2A.

EX5
Through what date do you have complete billing records for the services provided to residents?
MONTH (

BOX
EX2AA

) DAY (

) YEAR (

)

If EX6 has not been asked in this facility, go to EX6; else go to BOX EX2A.

EX6
What is the length of the facility's billing period? Is it...
monthly,........................................................................................ 1
every two weeks,.......................................................................... 2
every week, or ............................................................................. 3
quarterly? ..................................................................................... 4
OTHER (SPECIFY:)
91

4

EX. EXPENDITURES QUESTIONNAIRE

BOX
EX2A

2006 Facility Interview
(Core Only)

If the SP's {REF DATE} > {DATE FROM EX5}, go to EXEND; else
Go to EX7PRE.

EX7PRE
BILLING INFORMATION
FACILITY HAS UP-TO-DATE RECORDS THROUGH {DATE FROM EX5}
LENGTH OF BILLING PERIOD: {RESPONSE CODE FROM EX6.}
START WITH EARLIEST BILLING PERIOD.
COLLECT BILLING INFORMATION FROM {REFERENCE START DATE} THROUGH {REFERENCE END
DATE}.
EX8
VERIFY THE START AND END
DATES FOR EACH BILLING PERIOD

BP START DATE:
BP END DATE:

(
(

NUMBER OF DAYS IN BILLING PERIOD ....................................................(

)/(
)/(

)/(
)/(

)
)

)

EX9
Between {BP START DATE} and {BP END DATE}, how many days was {SP} billed for care?
NUMBER OF BILLED DAYS: (

5

)

EX. EXPENDITURES QUESTIONNAIRE

BOX
EX3

2006 Facility Interview
(Core Only)

If there are any DKs or RFs in the Billing Period Start and End Date, the number of
billed days (EX9) is missing or days in eligible LTC from {BP START DATE} to
{BP END DATE} cannot be calculated from Residence History, go to EX11; else
If the number of billed days (EX9) is not missing and the days in the billing period
(EX8) = number of billed days (EX9) and number of billed days = days in eligible
LTC from {BP START DATE} to {BP END DATE}, as reported in Residence
History, go to BOX EX3B; else
If the number of billed days (EX9) = days in eligible LTC from {BP START DATE} to
{BP END DATE}, as reported in Residence History, and the days in eligible LTC <
the number of days in the billing period (EX8), go to BOX EX3B; else
If the number of days in the billing period (EX8) = days in eligible LTC from {BP START
DATE} to {BP END DATE}, as reported in Residence History and the days in
eligible LTC > number of billed days (EX9), go to EX10; else
If the number of days in the billing period (EX8) > number of billed days (EX9) and
number of billed days > days in eligible LTC from {BP START DATE} to {BP END
DATE}, as reported in Residence History, go to EX10A; else
If the number of days in the billing period (EX8) > days in eligible LTC from {BP START
DATE} to {BP END DATE}, as reported in Residence History and the days in
eligible LTC > number of billed days (EX9), go to EX10A; else
If the number of days in the billing period (EX8) = number of billed days (EX9) and
number of billed days > days in eligible LTC from {BP START DATE} to {BP END
DATE}, as reported in Residence History, go to EX10A; else
Go to EX10.

EX10
Can you tell me why I have a discrepancy between the number of days in this billing period, that is, {EX8} and
the number of days for which {SP} was billed, that is, {EX9}?
SELECT ALL THAT APPLY.
SP DISCHARGED TO COMMUNITY
SP SENT TO HOSPITAL
SP DECEASED
SP ADMITTED AFTER BP START DATE
SP DISCHARGED TO ANOTHER NH
OTHER (SPECIFY:
DK
RF

)

USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC. (BOX EX3B)

6

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX10A
Earlier, I collected information that {SP} was a resident of this {nursing home/facility} for {NUMBER OF DAYS
DURING BILLING PERIOD IN WHICH RH INDICATES SP WAS A RESIDENT IN ELIGIBLE LTC PLACE IN SF
OR NF} days during this billing period. Yet, {s/he} was billed for {EX9} days. Can you tell me why I have this
discrepancy?
SELECT ALL THAT APPLY.
SP SENT TO HOSPITAL, BED HELD
SP NOT BILLED ON ADMISSION DAY
SP NOT BILLED ON DISCHARGE DAY
SP NOT BILLED ON DATE OF DEATH
OTHER (SPECIFY:
DK
RF

)

USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

7

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

If EX9 ("Number of days billed for care") = 0, go to BOX EX5; else
Go to EX11.

BOX
EX3B

EX11
Between {BP START DATE} and {BP END DATE}, what rate was billed for {SP's} care? {(I'll ask about billing for
ancillary services later.)}
PROBE: If more than one rate was billed, please give me the first rate within the billing period.
{BP START DATE} - {BP END DATE}
# OF BILLED DAYS {EX9}
{ } DAYS YET TO BE ACCOUNTED FOR
[(EX9) - (EX12+ EX14)]
TOTAL AMOUNT BILLED ${_.__}
RATE
[EX11 & EX13]
$
.
$
.
$
.
$
.

UNIT DAYS
[EX12 & EX14]

PER

1. DAY
2. MONTH
3. QUARTER
91. OTHER

USE ARROW KEYS. {F6=DITTO.} {CTRL/A=ADD} CTRL/D=DELETE. TO EXIT, PRESS ESC.

EX12
How many days were billed at that rate?

BOX
EX4

(
)
NUMBER OF BILLED DAYS

If all billed days in the billing period have been accounted for (EX9 - EX12 = 0), go to
BOX EX5; else go to EX13.

EX13
Between {BP START DATE} and {BP END DATE}, what other rate was billed for {SP's} care?

EX14
How many days were billed at that rate?

PROGRAMMER SPECS: Repeat EX13 and EX14 until all billed days in the billing period have been accounted for.

BOX
EX5

If EX4 = 1 (SP billed separately for ancillaries) and billed days (EX9) > 0, go to EX15PRE;
else
Go to BOX EX6.

8

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX15PRE
The next questions are about health-related services received by {SP} for which there was a separate charge
{, that is, your facility's ancillary services. Please do not include non-health-related services such as hairdressing,
television, or telephone}.
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS ENTER TO CONTINUE.
EX16
Have all charges for ancillaries been posted for the period from {BP START DATE} to {BP END DATE}?
YES..............................................................................................
NO................................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

(EX17)
(BOX EX6)
(BOX EX6)
(BOX EX6)

EX17
Does {SP} have any ancillary charges between {BP START DATE} and {BP END DATE}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(EX18)
(BOX EX6)
(BOX EX6)
(BOX EX6)

EX18
Altogether, what was the total charge for those health-related ancillary services?
RECORD AMOUNT BELOW.
$________________________

BOX
EX6

If this is the first round that EX is administered for this SP in this facility:
If this is the first SP in this round and this is the first respondent for this SP, go to
EX19; else
If this is not the first SP in this round and
this is the first time this round the respondent has been asked EX, for any SP, go
to Ex19; else
Go to BOX EX7.
Else, if EX was administered in this facility in CRRD-1, go to BOX EX7A.

9

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX19
DO YOU WANT TO ...
(

)

1.

COLLECT BILLING INFORMATION FOR ALL BILLING PERIODS, BEFORE COLLECTING ANY PAYMENT
INFORMATION?
OR

2.

COLLECT BILLING AND PAYMENT INFORMATION FOR THIS BILLING PERIOD, THEN BILLING AND
PAYMENT INFORMATION IN SEQUENCE FOR ALL REMAINING BILLING PERIODS?

BOX
EX7

If EX19 = 1, "COLLECT ALL BILLING FIRST", loop EX8 through EX18 until all billing
periods have been collected; then go to EX20; else
If EX19 = 2, "COLLECT BILLING, THEN PAYMENT FOR EACH BP", go to EX20, then
loop EX8 through BOX EX14 until all billing periods for which billed days > 0 have
been accounted for.

If FEX2 = 1, (COLLECT ALL BILLING FIRST):
If in retrieval mode for CRRD-1 ancillary charges and there are additional periods
to collect ancillary charges for, go to EX17; else
If SP was living in an eligible part of the facility for any billing period for which
expenditures data has not already been collected and this is the first billing period
for which expenditures data has not already been collected, go to EX2; else
If SP was living in an eligible part of the facility for any billing period for which
expenditures data has not already been collected and this is the second or
subsequent billing periods for which expenditures data has not already been
collected, loop through EX8 through EX18 until all billing periods have been
collected; then go to BOX EX7B; else

BOX
EX7A

Go to BOX EX7B.
Else, if FEX2 = 2 (COLLECT BILLING, THEN PAYMENT FOR EACH BP), go to BOX
EX7B.

1.

If EX20 for this billing period (receipt of expected payments for basic care) = NO
(0) in CRIN-1, go to EX20; else go to step 2.

2.

If EX28 for this billing period (receipt of expected payments for ancillaries) = NO
(0) in CRIN-1 or EX17 = YES (1) and ancillary payments have not been
collected for this billing period, go to EX28; else

3.

For any additional billing periods for which billed days > 0 and for which payment
data has not already been collected; go to EX20; else

4.

Go to BOX EX21.

BOX
EX7B

10

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX20
{(When I was last here on {DATE OF CRRD-1 INTERVIEW}, you had not yet received expected payments for {SP}'s
care for some of the billing periods. I'd like to review that information with you now.)}
Have you received all of the payments for basic care you expect to receive for {SP} during the [READ BILLING
PERIOD ABOVE] billing period?
YES..............................................................................................
NO................................................................................................

1
0

(EX21)
(BOX EX14)

EX21
Please tell me the sources of payment for {SP}'s basic care for this billing period and the total amount each source
paid.
{BP START DATE} - {BP END DATE}
# OF BILLED DAYS {EX9}
TOTAL BILLED:
${
. }
AMOUNT REMAINING:
${
. }
MEDICAID ...................................................................................
PRIVATE PAY .............................................................................
SOCIAL SECURITY.....................................................................
SP/FAMILY INCOME ..................................................................
PRIVATE INSURANCE................................................................
PENSION.....................................................................................
MEDICARE ..................................................................................
VA CONTRACT ...........................................................................
HMO CONTRACT TEXT..............................................................
SUPPLEMENTAL SECURITY INCOME (SSI) .............................
OTHER SPECIFY TEXT ..............................................................
USE ARROW KEYS. CTRL/A=ADD, CTRL/D=DELETE. TO EXIT, PRESS ESC.

11

$
$
$
$
$
$
$
$
$
$
$

.
.
.
.
.
.
.
.
.
.
.

EX. EXPENDITURES QUESTIONNAIRE

BOX
EX7C

2006 Facility Interview
(Core Only)

If Residence History is completed for the SP and this is the first time this round that
Medicare is identified as a payment source for this SP, review the Residence
History timeline for a stay, of at least one day, in which place type is HOSPITAL.
Review from REF DATE through the billing period in which Medicare was
selected/added.
If there is no HOSPITAL day reported, go to EX21B; else, do not display.

12

EX. EXPENDITURES QUESTIONNAIRE

EX21B

2006 Facility Interview
(Core Only)

{BP START DATE} - {BP END DATE}
Medicare has been reported as a payment source for basic care for {SP} for [READ BILLING PERIOD ABOVE], but I
have not recorded any preceding hospital stays for {him/her}.
Please tell me why Medicare paid for {SP} during this billing period.
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.
IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.

After collecting all payment information for the billing period,
If this is the first time this round coming to BOX EX8 for this SP, and if the
difference between the "total amount paid" and the "total amount billed" is greater
than 10%,
If Medicaid is one of the sources of payment and the "total payments
received" is 70% or more of the "total amount billed" and less than or equal
to 110% of the "total amount billed", go to BOX EX9;
Else, if the difference between the "total amount billed" and the "total
amount paid" is greater than 10%, go to EX22;
Else, go to BOX EX9;

BOX
EX8

Else, if this is the second time (or greater) this round coming to BOX EX8 for this
SP, and if the difference between the "total amount paid" and the "total amount
billed" is greater than 10%,
If EX22 = 1 (MEDICAID WRITE-OFF) or 2 (OTHER WRITE-OFF) for any
previous billing period and if the "total amount paid" is 70% or more of the
"total amount billed" and less than or equal to 110% of the "total amount
billed", go to BOX EX9;
Else, if Medicaid is one of the sources of payment and the "total payments
received" is 70% or more of the "total amount billed" and less than or equal
to 110% of the "total amount billed", go to BOX EX9.
Else, if the difference between the "total amount billed" and the "total
amount paid" is greater than 10%, go to EX22;
Else, go to BOX EX9.
Else, go to BOX EX9.

13

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX22
There seems to be a difference between what {FACILITY/[READ FACILITY/UNITS ABOVE]} billed between {BP
START DATE} and {BP END DATE} and the payments received. The total amount billed I have entered for this
billing period is {EX11} and the total payments for the period are {SUM OF EX21 PAYMENTS}. Why is that?
MEDICAID WRITE-OFF/ADJUSTMENT...................................... 1
OTHER WRITE-OFF/ADJUSTMENT .......................................... 2
OTHER (SPECIFY:______________________________) ......... 91
DK ................................................................................................ -8
RF ................................................................................................ -7
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BOX
EX9

The first time Medicaid is identified as a payment source for this SP, check REF DATE
and determine from Residence History where the SP was residing at that time
(i.e., in which eligible LTC place) and whether that place was certified for
Medicaid in that round.
If the place is not certified for Medicaid, go to EX23; and
The first time Medicare is identified as a payment source for this SP, check REF DATE
and determine from Residence History where the SP was residing at that time
and whether that place was certified for Medicare (Facility Questionnaire) in that
round.
If the place is not certified for Medicare, go to EX23; else
Go to BOX EX9A.

EX23
I seem to have recorded some discrepant information. Earlier, I recorded that {FACILITY/UNITS NOT CERTIFIED
BY MEDICAID/MEDICARE} is not certified by {Medicaid/Medicare} but I have identified {Medicaid/Medicare} as a
payment source. Why would {Medicaid/Medicare} be paying for {SP's} care?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT.

BOX
EX9A

For an SP whose Medicaid status in this round is "PENDING", or whose Medicaid
number is unknown (IN3 = -1, -8 or -7 and HA47 = -8, -7, or -5) the first time
Medicaid is identified as a payment source, go to EX23A; else
Go to BOX EX10, STEP 2.

14

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX23A
Please tell me {SP}'s {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} ID
number.
__________________________
MEDICAID ID NUMBER
DK ................................................................................................
RF ................................................................................................

-8
-7

(BOX EX10 STEP 1)
(BOX EX10 STEP 1)

EX23B
I'd like to verify the {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} ID
number that I have recorded. I have entered {MEDICAID ID NUMBER}. Is this correct?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(BOX EX10, STEP 2)
(BOX EX10, STEP 1)
(BOX EX10, STEP 1)

EX23C
Let me enter it again. (What {is/was} {SP}'s {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME
FOR MEDICAID)} ID number?)
__________________________ (EX23B)
MEDICAID ID NUMBER
DK ................................................................................................
RF ................................................................................................

-8
-7

(BOX EX10, STEP 1)
(BOX EX10, STEP 1)

1.
BOX
EX10

The first time ever Medicaid is identified as a payment source for an SP, go to
EX24 to attempt resolution; and
2.
The first time Medicare is identified as a payment source for an SP who has not
been identified in Health Insurance (IN12 = 0, -8 or -7) and Health Status
(HA44A = 2 (SP HAS NO MEDICARE NUMBER), -8 or -7) as a
beneficiary of Medicare, go to EX24 to attempt resolution; else
Go to BOX EX11.

EX24
Earlier, I recorded that {SP} was not a {Medicaid/Medicare} {recipient/beneficiary} but I have identified
{Medicaid/Medicare} as a source of payment. Why would {Medicaid/Medicare} be paying for {SP's} care?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

15

EX. EXPENDITURES QUESTIONNAIRE

BOX
EX11

2006 Facility Interview
(Core Only)

If Medicaid is not identified as a payment source for the current billing period but
appears in the preceding billing period (including if the billing period occurred in
the previous round), go to EX25 to attempt resolution; else
Go to BOX EX12.

EX25
It seems that I might have made a mistake in identifying the various sources of payment for {SP's} care. Earlier, I
recorded that {her/his} basic charges from {FIRST BP START DATE WITH MEDICAID AS PAYER} through {LAST
BP END DATE WITH MEDICAID AS PAYER} were paid by Medicaid, and in this billing period, Medicaid is no longer
a payment source. Why didn't Medicaid continue to pay for {her/his} care?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

BOX
EX12

If Medicare is identified as a payment source on the billing matrix, and the amount paid
by Medicare represents less than 10 percent of the total payments received for
the billing period, go to EX26 to attempt resolution; else
Go to BOX EX14.

EX26
TOTAL PAYMENTS:
MEDICARE PAYMENTS:

{TOTAL PAYMENTS}
{MEDICARE PAYMENTS}

Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is
this Medicare payment a Part B payment?
IF NECESSARY, BACK UP TO EX21 TO CORRECT PAYMENTS.
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ...............................................................................................

16

1
0
-8
-7

(BOX EX14)
(EX27)
(EX27)
(BOX EX14)

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX27
TOTAL PAYMENTS:
MEDICARE PAYMENTS:

{TOTAL PAYMENTS}
{MEDICARE PAYMENTS}

Can you tell me why the Medicare payment is so small?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT PAYMENTS.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

BOX
EX14

If EX17 = "YES", go to EX28; else
Go to BOX EX19.

EX28
Have you received all the payments you expect to receive for {SP's} ancillary services during the [READ BILLING
PERIOD ABOVE] billing period?
YES .............................................................................................
NO...............................................................................................

1
0

(EX29)
(BOX EX19)

EX29
Please tell me the sources of payment for {SP}'s ancillary services for [READ BILLING PERIOD ABOVE] and the
total amount each source paid.
{BP START DATE} - {BP END DATE}
# OF BILLED DAYS {EX9}
TOTAL CHARGE:
${
. }
AMOUNT REMAINING:
${
. }
MEDICAID...................................................................................
PRIVATE PAY.............................................................................
SOCIAL SECURITY ....................................................................
SP/FAMILY INCOME ..................................................................
PRIVATE INSURANCE...............................................................
PENSION ....................................................................................
MEDICARE .................................................................................
VA CONTRACT ..........................................................................
HMO CONTRACT .......................................................................
SUPPLEMENTAL SECURITY INCOME (SSI) ............................
OTHER SPECIFY TEXT .............................................................
USE ARROW KEYS. CTRL/A = ADD, CTRL/D = DELETE. TO EXIT, PRESS ESC.

17

$
$
$
$
$
$
$
$
$
$
$

.
.
.
.
.
.
.
.
.
.
.

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX29A
What kind of plan is that?
MEDIGAP PLAN .........................................................................
LONG-TERM CARE PLAN ..........................................................
SOMETHING ELSE ....................................................................
DK ...............................................................................................
RF ...............................................................................................

1
2
3
-8
-7

After collecting all payment information for the billing period,
If this is the first time this round coming to BOX EX15 for this SP, and if the
difference between the "total amount paid" and the "total amount billed" is greater
than 10%,
If Medicaid is one of the sources of payment and the "total payments
received" is 70% or more of the "total amount billed" and less than or equal
to 110% of the "total amount billed", go to BOX EX16;
Else, if the difference between the "total amount billed" and the "total
amount paid" is greater than 10%, go to EX30;
Else, go to BOX EX16;

BOX
EX15

Else, if this is the second time (or greater) this round coming to BOX EX15 for this
SP, and if the difference between the "total amount paid" and the "total amount
billed" is greater than 10%,
If EX30 = 1 (MEDICAID WRITE-OFF) or 2 (OTHER WRITE-OFF) for any
previous billing period and if the "total amount paid" is 70% or more of the
"total amount billed" and less than or equal to 110% of the "total amount
billed", go to BOX EX16;
Else, if Medicaid is one of the sources of payment and the "total payments
received" is 70% or more of the "total amount billed" and less than or equal
to 110% of the "total amount billed", go to BOX EX16.
Else, if the difference between the "total amount billed" and the "total
amount paid" is greater than 10%, go to EX30;
Else, go to BOX EX16.
Else, go to BOX EX16.

EX30
There seems to be a difference between what {FACILITY/[READ FACILITY/UNITS ABOVE]} billed for ancillary
services between {BP START DATE} and {BP END DATE} and the payments received. The total amount billed I
have entered for [READ BILLING PERIOD ABOVE] {EX18} and the total payments for the period are {SUM OF
EX29 PAYMENTS}. Why is that?
MEDICAID WRITE-OFF/ADJUSTMENT.....................................
OTHER WRITE-OFF/ADJUSTMENT..........................................
OTHER (SPECIFY:________________________________).....
DK ...............................................................................................
RF ...............................................................................................
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

18

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91
-8
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EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

19

EX. EXPENDITURES QUESTIONNAIRE

BOX
EX16

2006 Facility Interview
(Core Only)

The first time Medicaid is identified as a payment source for this SP, check REF
DATE and determine from Residence History where the SP was residing at
that time (i.e., in which eligible LTC place) and whether that place was
certified for Medicaid in that round.
If the place is not certified for Medicaid, go to EX31; and
The first time Medicare is identified as a payment source for this SP, check REF
DATE and determine from Residence History where the SP was residing at
that time and whether that place was certified for Medicare (Facility
Questionnaire) in that round.
If the place is not certified for Medicare, go to EX31; else
Go to BOX EX17.

EX31
I seem to have recorded some discrepant information. Earlier, I recorded that {FACILITY/UNITS NOT CERTIFIED
BY MEDICAID/MEDICARE} is not certified by {Medicaid/Medicare} but I have identified {Medicaid/Medicare} as a
payment source. Why would {Medicaid/Medicare} be paying for {SP's} care?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT.
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

BOX
EX16A

For an SP whose Medicaid status in this round is "PENDING" (IN1=2), or whose
Medicaid number is unknown (IN3 = -1, -8, -7 and HA47 = -8, -7, or -5) the
first time Medicaid is identified as a payment source, go to EX31A; else
Go to BOX EX17, STEP 2.

EX31A
Please tell me {SP}'s {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} ID
number.
__________________________
MEDICAID ID NUMBER
DK................................................................................................
RF ................................................................................................

-8
-7

(BOX EX17, STEP 1)
(BOX EX17, STEP 1)

EX31B
I'd like to verify the {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} ID
number that I have recorded. I have entered {MEDICAID ID NUMBER}. Is this correct?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................

20

1
0
-8
-7

(BOX EX17, STEP 2)
(BOX EX17, STEP 1)
(BOX EX17, STEP 1)

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX31C
Let me enter it again. (What {is/was} {SP}'s {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME
FOR MEDICAID)} ID number?)
__________________________ (EX31B)
MEDICAID ID NUMBER
DK ................................................................................................
RF ................................................................................................

-8
-7

(BOX EX17, STEP 1)
(BOX EX17, STEP 1)

1.
BOX
EX17

The first time ever Medicaid is identified as a payment source for an SP, go to
EX32 to attempt resolution, and
2.
The first time ever Medicare is identified as a payment source for an SP who has
not been identified in Health Insurance (IN13 = 0, -8, -7) and Health
Status (HA44A = 2 (SP HAS NO MEDICARE NUMBER), -8 or -7) as a
beneficiary of Medicare, go to EX32; else
Go to BOX EX18.

EX32
Earlier, I recorded that {SP} was not a {Medicaid/Medicare} {recipient/beneficiary} but I have identified
{Medicaid/Medicare} as a source of payment.
Why would {Medicaid/Medicare} be paying for {SP's} ancillaries?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

BOX
EX18

If edit EX25 has not been triggered in BOX EX11 for the current billing period, and
If Medicaid is not identified as payment source for ancillaries for the current billing
period but appears in preceding period (including if the billing period occurred in
the previous round), go to EX33 to attempt resolution; else
Go to BOX EX19.

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EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX33
It seems that I might have made a mistake in identifying the various sources of payment for {SP's} care. Earlier, I
recorded that {her/his} charges for ancillaries from {FIRST BP START DATE WITH MEDICAID AS PAYOR} through
{LAST BP END DATE WITH MEDICAID AS PAYOR} were paid by Medicaid, and in this billing period, Medicaid is
no longer a payment source. Why didn't Medicaid continue to pay for {her/his} ancillary services?
RECORD VERBATIM BELOW; IF NECESSARY, BACK UP TO CORRECT.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

BOX
EX19

If this is CRIN-1 data retrieval for ancillary charges for the next billing period are
needed, go to EX17; else
If this is CRIN-1 data retrieval for payments for basic care or ancillary services for the
next billing period are needed, go to BOX EX7B; else
Go to BOX EX20.

BOX
EX20

If amounts billed for all BPs have been collected but sources of payment for all BPs in
which days billed (EX9) > 0 have not, loop EX20 through BOX EX20 until all
those BPs have been collected, then go to BOX EX21; else
If amounts billed for all BPs have not been collected, loop EX8 through BOX EX20 until
all BPs in which days billed (EX9) > 0 have been accounted for, then go to BOX
EX21; else
Go to BOX EX21.

BOX
EX21

If private pay (Private Pay, Social Security, SSI, SP or Spouse's Own Income/Assets,
Other Family Income/Assets, Private Insurance, Pension, Other Private Pay) has
never been reported as a source of payment and IN20 = "YES", go to EX34; else
Go to BOX EX21A.

EX34
Earlier I was told that {SP} had long-term care insurance {from {NAME OF INSURANCE COMPANY FROM IN28}}.
Is it correct that this policy paid for none of {her/his} care?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

22

1
0
-8
-7

(BOX EX21A)
(EX35)
(BOX EX21A)
(BOX EX21A)

EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

EX35
Can you explain this to me?
RECORD VERBATIM BELOW.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

BOX
EX21A

If IN1 = pending from CRIN-1 and Medicaid has never been reported as a payment
source, go to EX35A; else
Go to EXEND.

EX35A
The last time I was here, I collected information that {SP}'s {"PREFERRED" NAME FOR MEDICAID} {(or
"ALLOWED FOR" NAME FOR MEDICAID)} eligibility status was pending. Is it still pending or has {"PREFERRED"
NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} been denied?
STILL PENDING ..........................................................................
DENIED .......................................................................................
DK ................................................................................................
RF ................................................................................................

EXEND
YOU HAVE COMPLETED THE EXPENDITURES SECTION FOR THIS SP.
PRESS ENTER TO RETURN TO NAVIGATION SCREEN.

23

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EX. EXPENDITURES QUESTIONNAIRE

2006 Facility Interview
(Core Only)

24