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

Medicare Current Beneficiary Survey (MCBS)

Attachment 4 English Questionnaire Comprehensive Format by SectionPS_04.01.0000

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

OMB: 0938-0568

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BOX PS1

BOX PS1

Page Order # :

20

BOX INSTRUCTIONS
( PSQ1020 )

IF THE SP STILL EXPECTS CHARGES FOR AT LEAST ONE RENTAL ITEM
ENTERED IN A PREVIOUS ROUND THAT IS NOT ALREADY INCLUDED IN
A CURRENT ROUND CHARGE BUNDLE, GO TO PS1A - HADPYMNT (
PSQ1040 ).
ELSE GO TO BOX PSEND - (PSQ1115 ).

ASSIGNMENTS

TECHNICAL NOTES
278

PSEvent

SP still expects charges for a rental item entered in a
previous round =
There is an EVNT where EVNT.EVNTDFLG ^= 1/Yes &
(EVNT.EVNTTYPE = 'OM') & (EVNT.RENTSTILL =2/No,
DK or RF) and (EVNT.RENTENDR < current round) &
(EVNT.RBUYCOST = 1/StillCollectCost).

279

InCurrentChargeBundle

Event included in a current round charge bundle =
For this EVNT, there is an XCEV where
(XCEV.XCEVEVNT = EVNT.EVNTNUM and
XCEV.XCEVCOST = COST.COSTNUM for this charge
bundle & XCEV.XCEVRNDC = current round and
XCEV.DELLINK ^= 1/Yes).

DESIGN NOTES

11:55:27 AMTuesday, November 11, 2008

Page 1 of 9

PS1A

PS1A

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

HADPYMNT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

40

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display OME Rental Item currently being asked about.

Question display:

If PS1A - HADPYMNT has not been asked in the current round,
display "Now".
Else display "Next".
Display OME ITEM TYPE for OME Rental Item currently being
asked about.
If EVNT.RENT2BUY = 2/PurchasedRentToBuy, display "rented and
then bought".
Else if EVNT.EVENDMM, EVNT.EVENDDD, or EVNT.EVENDYY =
DK or RF, display "stopped renting".
Else display "stopped renting on (EVENT END DATE)". Display
Event End Date for OME Rental Item currently being asked about.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (EVENT)

11:55:29 AMTuesday, November 11, 2008

Page 2 of 9

PS1A
Int. Instr I:
(Now/Next), let’s look at the costs for the (OME ITEM TYPE)
[you/(SP)] [rented and then bought/stopped renting/stopped renting
on (EVENT END DATE)].

Question Text:

Since (REFERENCE DATE), were any payments made for the (OME
ITEM TYPE)?
THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE,
INSURANCE, TRICARE, OR ANY OTHER SOURCE OF PAYMENT.

Int. Instr II:

INPUT FIELDS / ROUTING
HADPYMNT

Field1:
Cheshire Name:
Item Text display:

( PSQ1040 )

EVNT.HADPYMNT
EVNT.HADPYMNT may have already been collected in a
previous round. Do not display previously collected
response.

Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
PS2 - EXPPYMNT ( PSQ1080 )

English text: YES
No

PS2 - EXPPYMNT ( PSQ1080 )

English text: NO
Attribute
Don't know

Route
PS2 - EXPPYMNT ( PSQ1080 )

Refusal

PS2 - EXPPYMNT ( PSQ1080 )

BACKGROUND VARIABLE ASSIGNMENTS
PYMNTRND

Set EVNT.PYMNTRND = current round.

NOPYMNT

If PS1A - HADPYMNT = 2/No, DK, or RF, set
EVNT.NOPYMNT = 1/Yes.

11:55:32 AMTuesday, November 11, 2008

Page 3 of 9

PS1A
SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

11:55:32 AMTuesday, November 11, 2008

Page 4 of 9

PS2

PS2

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

EXPPYMNT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

60

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display OME Rental Item currently being asked about.

Question display:

Display OME ITEM TYPE for OME Rental Item currently being
asked about.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (EVENT)

Int. Instr I:
Question Text:

[Do you/Does (SP)] expect any more rental or installment payments
to be made for the (OME ITEM TYPE)?

Int. Instr II:

THIS INCLUDES PAYMENTS MADE BY SP, MEDICARE,
INSURANCE, TRICARE, OR ANY OTHER SOURCE OF PAYMENT.

INPUT FIELDS / ROUTING

11:55:33 AMTuesday, November 11, 2008

Page 5 of 9

PS2
EXPPYMNT

Field1:
Cheshire Name:
Item Text display:

( PSQ1080 )

EVNT.EXPPYMNT
EVNT.EXPPYMNT may have already been collected in a
previous round. Do not display previously collected
response.

Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX PS3 - (PSQ1110 )

English text: YES
No
English text: NO

Attribute
Don't know

Route
BOX PS3 - (PSQ1110 )

Refusal

BOX PS3 - (PSQ1110 )

BOX PS3 - (PSQ1110 )

BACKGROUND VARIABLE ASSIGNMENTS
EVNT.RBUYCOST is initially set to 1/StillCollectCost in the OM section when a rental item
is ended.
RBUYCOST

If PS2 - EXPPYMNT = 2/No, DK or RF, updated
EVNT.RBUYCOST = 2/NotCollectCost.

BUYENDR

If PS2 - EXPPYMNT = 2/No, DK or RF, set
EVNT.BUYENDR = current round.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
11:55:36 AMTuesday, November 11, 2008

Page 6 of 9

PS2

11:55:36 AMTuesday, November 11, 2008

Page 7 of 9

BOX PS3

BOX PS3

Page Order # :

70

BOX INSTRUCTIONS
( PSQ1110 )

IF THE SP STILL EXPECTS CHARGES FOR ANOTHER RENTAL ITEM
ENTERED IN A PREVIOUS ROUND THAT IS NOT ALREADY INCLUDED IN
A CURRENT ROUND CHARGE BUNDLE, GO TO PS1A - HADPYMNT (
PSQ1040 ).
ELSE GO TO BOX PSEND - (PSQ1115 ).

ASSIGNMENTS

TECHNICAL NOTES
278

PSEvent

SP still expects charges for a rental item entered in a
previous round =
There is an EVNT where EVNT.EVNTDFLG ^= 1/Yes &
(EVNT.EVNTTYPE = 'OM') & (EVNT.RENTSTILL =2/No,
DK or RF) and (EVNT.RENTENDR < current round) &
(EVNT.RBUYCOST = 1/StillCollectCost).

279

InCurrentChargeBundle

Event included in a current round charge bundle =
For this EVNT, there is an XCEV where
(XCEV.XCEVEVNT = EVNT.EVNTNUM and
XCEV.XCEVCOST = COST.COSTNUM for this charge
bundle & XCEV.XCEVRNDC = current round and
XCEV.DELLINK ^= 1/Yes).

DESIGN NOTES

11:55:36 AMTuesday, November 11, 2008

Page 8 of 9

BOX PSEND

BOX PSEND

Page Order # :

80

BOX INSTRUCTIONS
( PSQ1115 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

11:55:36 AMTuesday, November 11, 2008

Page 9 of 9


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