Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

MCBS MAIN STUDY
R55 General Specifications for Blaise/WVS
Attachments
Version 07.01.0001
8/14/2009

ATTACHMENTS
Attachments Referred to in Section Specifications

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Introduction (IN)
Attachment CE1: Section Name Display for Restart Screen
SECTION NAME

DISPLAY

IN

INTRODUCTION SECTION

ENS

ENUMERATION SECTION

HA

HOUSING CHARACTERISTICS SECTION

HI or HIS

HEALTH INSURANCE SECTION

DM

DISCOUNT/SAVINGS MEMBERSHIP SECTION

UTS

UTILIZATION SUMMARY SECTION

DU

DENTAL UTILIZATION SECTION

ER

EMERGENCY ROOM UTILIZATION SECTION

IP

INPATIENT UTILIZATION SECTION

OP

OUTPATIENT UTILIZATION SECTION

IU

INSTITUTIONAL UTILIZATION SECTION

HH

HOME HEALTH UTILIZATION SECTION

MP

MEDICAL PROVIDER UTILIZATION SECTION

OM

OTHER MEDICAL EXPENSES SECTION

PM or PMS

PRESCRIBED MEDICINES SECTION

ST

STATEMENT CHARGE SERIES SECTION

PS

POST-STATEMENT CHARGE SECTION

NS

NO STATEMENT CHARGE SERIES SECTION

CPS

CHARGE/PAYMENT SUMMARY SECTION

AC

ACCESS TO CARE SUPPLEMENT

HF

HEALTH STATUS AND FUNCTIONING SUPPLEMENT

SC

SATISFACTION WITH CARE SUPPLEMENT

US

USUAL SOURCE OF CARE SUPPLEMENT

DI

DEMOGRAPHICS/INCOME SECTION

IA

INCOME AND ASSETS SUPPLEMENT

DA

DISCOUNT AWARENESS

CL

CLOSING SECTION

Health Insurance (HI)

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Attachment HI1: State Medicaid Programs
STATE

PROGRAM NAME

Alaska (AK)

Medical Assistance

Alabama (AL)

Medicaid

Arkansas (AR)

Medicaid

Arizona (AZ)

Arizona Health Care Cost Containment System
(AHCCCS)

California (CA)

Medi-Cal

Colorado (CO)

Medicaid

Connecticut (CT)

Medical Assistance

District of Columbia (DC)

Medical Assistance

Delaware (DE)

Medicaid

Florida (FL)

Medicaid

Georgia (GA)

Medicaid

Hawaii (HI)

Medical Assistance

Iowa (IA)

Medical Assistance

Idaho (ID)

Medicaid

Illinois (IL)

Medical Assistance

Indiana (IN)

Medicaid

Kansas (KS)

Medicaid

Kentucky (KY)

KYHealth Choices

Louisiana (LA)

Medicaid

Maine (ME)

MaineCare

Massachusetts (MA)

MassHealth

Maryland (MD)

Medical Assistance

Michigan (MI)

Medicaid

Minnesota (MN)

Minnesota Medical Assistance

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Attachment HI1: State Medicaid Programs (con’t).
STATE

PROGRAM NAME

Missouri (MO)

Medicaid

Mississippi (MS)

Medicaid

Montana (MT)

Medicaid

North Carolina (NC)

Medicaid

North Dakota (ND)

Medicaid

Nebraska (NE)

Medical Assistance

New Hampshire (NH)

Medicaid

New Jersey (NJ)

Medicaid

New Mexico (NM)

Medicaid

Nevada (NV)

Medicaid

New York (NY)

Medicaid

Ohio (OH)

Ohio Health Plans

Oklahoma (OK)

SoonerCare

Oregon (OR)

Medicaid

Pennsylvania (PA)

Medical Assistance

Puerto Rico (PR)

Medicaid

Rhode Island (RI)

Medical Assistance

South Carolina (SC)

Partners for Health

South Dakota (SD)

Medical Assistance

Tennessee (TN)

TennCare

Texas (TX)

Medicaid

Utah (UT)

Medicaid

Vermont (VT)

Medicaid

Virginia (VA)

Virginia Medical Assistance Services

Washington (WA)

Medical Assistance

Wisconsin (WI)

Medical Assistance

West Virginia (WV)

Medicaid

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Attachment HI1: State Medicaid Programs (con’t).
STATE

PROGRAM NAME

Wyoming (WY)

EqualityCare

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Attachment HI2: State Pharmaceutical Programs
PHONE

NAME

Alabama SenioRx

(800) 478-6065 (statewide)
(907) 269-3680 (Anchorage)
(334)240-46

Arizona Medicare Copayment Plan

(800) 770-8014

CT Pharmaceutical Assistance Contract to the Elderly and the
Disabled (ConnPACE)

EDS: (860) 832-9265
In CT: (800) 423-5026

Delaware Prescription Drug Assistance Program (DPAP)

(302) 577-4900
(800) 996-9969 ext. 17
(302) 651-4405
(800) 292-9538

Alaska Senior Care Prescription Drug Benefit Program

Delaware
Nemours Health Clinic Pharmaceutical Assistance Program
Hawaii State Pharmacy Assistance Program
Illinois
Pharmaceutical Assistance Program “CircuitBreaker”
Illinois Cares Rx

(In IL):
(800) 624-2459
(217) 524-0084
(800) 252-8966

“HoosierRx”
Indiana Prescription Drug Fund

(317) 234-1381 (in Indiana)
(866) 267-4679

Maine Low Cost Drugs for the Elderly Program (LCD)

Missouri “MoRx” – Missouri Rx Plan

(888) 600-2466
(207) 287-2674
1-800-226-2142
(410) 767-5394
(800) 492-1974
(800) 243-4636
(617) 727-7750
(800) 375-1406

Montana Big Sky Rx Program

(866) 369-1233

Maryland PAC – Primary Care Program
Maryland Senior Prescription Drug Assistance Program
Massachusetts Prescription Advantage Plan

Nebraska Medicare – Medicaid Dual-Eligible Copayment Plan
Nevada Senior Rx

New Jersey PAAD –
Pharmaceutical Assistance for the Aged and Disabled
New Jersey Senior Gold Prescription Discount Program

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(755) 687-7555
In state:
(866) 303-6323
(609) 588-7048
In NJ:
(800) 792-9745
(609) 588-7048
In NJ:
(800) 792-9745

Attachment HI2: State Pharmaceutical Programs (con’t).
PHONE

NAME

North Carolina Rx

(518) 452-6828
In state:
(800) 332-3742
(888) 488-6279

North Carolina PHARMAssist

(916) 688-4772

Pennsylvania PACE –
Pharmaceutical Assistance Contract for the Elderly

(717) 652-9028
In PA: (800) 225-7223

Pennsylvania PACE Plus Medicare

(717) 787-7313

Pennsylvania PACENET – PACE Needs Enhancement Tier

South Carolina (GAPS) Gap Assistance Pharmacy Program for
Seniors

(717) 652-9028
In PA: (800) 225-7223
(401) 222-2880
(401) 462-4000
(877) 239-5277
(803) 734-1061

Tennessee CoverRx

(866) 268-3786

Vermont VPharm

In state:
(800) 529-4060
Out of state:
(800) 250-8427

New York EPIC –
Elderly Pharmaceutical Insurance Coverage

RIPAE – Rhode Island Pharmaceutical Assistance for the Elderly

Washington Medicare Copayment Plan
Wisconsin SeniorCare Rx

(800) 657-2038

Wyoming Prescription Assistance Program (PDAP)

(307) 777-7531
(800) 442-2766

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