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

BOX DM1

BOX DM1

Page Order # :

10

BOX INSTRUCTIONS
( DMQ1010 )

CREATE LIST OF DISCOUNT MEMBERSHIP PLANS SP HAD DURING THE
PREVIOUS ROUND .
IF THE SP HAD AT LEAST ONE DISCOUNT MEMBERSHIP PLAN DURING
THE PREVIOUS ROUND, GO TO DM1INT - DMPREVINT ( DMQ1013 ).
ELSE GO TO DM2INTRO - DMINT ( DMQ1025 ).

ASSIGNMENTS
DISCOUNT MEMBERSHIP PLANS SP HAD DURING THE PREVIOUS ROUND:
If (DMEM.LOSEDMFG ^= EMPTY and
(DMRO.DMRONUM = DMEM.DMEMNUM and
DMRO.DMRORND = previous round and

DMRO.DMHAVE = 1/Yes))

ADD DISCOUNT MEMBERSHIP PLAN TO LIST.

TECHNICAL NOTES
117

DeletedDM

Deleted Discount Membership plans that are not valid for
displays or checks =
Any DMEM where (DMEM.LOSEDMFG ^= EMPTY) is a
deleted DM.

37

DMPreviousRnd

SP had a Discount Membership plan during the previous
round =
There is a DMEM and a DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = previous round and
DMRO.DMHAVE = 1/Yes).
Exclude Deleted DM's. See T.N. 117.

DESIGN NOTES

12:41:35 PM Monday, November 03, 2008

Page 1 of 43

DM1INT

DM1INT

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

DMPREVINT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

13

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:

Int. Instr I:

Question Text:

Now, I'd like to ask about another type of health care coverage that

[you/(SP)] reported during the last interview.

Int. Instr II:
INPUT FIELDS / ROUTING

12:41:36 PM Monday, November 03, 2008

Page 2 of 43

DM1INT
DMPREVINT

Field1:
Cheshire Name:

( DMQ1013 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
DM1_IN - NAVIGATOR ( DMQ1015 )

English text: CONTINUE
Attribute
Empty

Route
DM1_IN - NAVIGATOR ( DMQ1015 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:41:38 PM Monday, November 03, 2008

Page 3 of 43

DM1_IN

DM1_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

15

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display all Discount Membership plans SP had anytime during the
previous round.
Invoke NO TRAVEL I/N.

Multi Field display:

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

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

12:41:39 PM Monday, November 03, 2008

Page 4 of 43

DM1_IN
NAVIGATOR

Field1:
Cheshire Name:

( DMQ1015 )

N/A

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX DM1A - (DMQ1017 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
DM2 - DMEMNEW ( DMQ1040 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS
DM details are collected on DMEM and DMRO:

DMEM key = DMEM.DMEMBASE + DMEM.DMEMNUM

DMEM.DMEMNUM = Number of DM from previous round being asked about.

DMRO key = DMRO.DMROBASE + DMRO.DMRODMEM + DMRO.DMRORND

DMRO.DMRODMEM = DMEM.DMEMNUM of DM from previous round being asked about.

DMRO.DMRORND = current round

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
117

DeletedDM

12:41:41 PM Monday, November 03, 2008

Deleted Discount Membership plans that are not valid for
displays or checks =
Any DMEM where (DMEM.LOSEDMFG ^= EMPTY) is a
deleted DM.

Page 5 of 43

DM1_IN
37

DMPreviousRnd

SP had a Discount Membership plan during the previous
round =
There is a DMEM and a DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = previous round and
DMRO.DMHAVE = 1/Yes).
Exclude Deleted DM's. See T.N. 117.

DESIGN NOTES

12:41:41 PM Monday, November 03, 2008

Page 6 of 43

BOX DM1A

BOX DM1A

Page Order # :

17

BOX INSTRUCTIONS
( DMQ1017 )

CREATE A CURRENT ROUND DISCOUNT MEMBERSHIP RECORD FOR
THIS DISCOUNT MEMBERSHIP PLAN .
GO TO DM1 - DMHAVE ( DMQ1020 ).

ASSIGNMENTS
DM1 - DMHAVE, is asked for each Discount Membership plan the SP had during the
previous round. The response to DM1 - DMHAVE flags whether or not the SP had the
Discount Membership plan anytime since the previous round. If DM1 - DMHAVE=1/Yes,
the SP had the Discount Membership plan anytime during the current round.
DM1 - DMHAVE is stored on the current round DMRO for this DMEM.
Create a current round DMRO for this Discount Membership plan SP had during the
previous round where DMRO.DMRODMEM = DMEM.DMEMNUM of Discount Membership
plan and DMRO.DMRORND = current round.
DMRO key = DMRO.DMROBASE + DMRO.DMRODMEM + DMRO.DMRORND.
Set DMRO variables as specified below.
DMRODMEM

DMRO.DMRODMEM = DMEM.DMEMNUM.

DMRORND

DMRO.DMRORND = current round.

TECHNICAL NOTES

DESIGN NOTES

12:41:41 PM Monday, November 03, 2008

Page 7 of 43

DM1

DM1

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

DMHAVE

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

20

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display the name of the Discount Membership plan being asked
about.
Refering to the last time DM4 - DMSERVIC was asked for this

Discount Membership plan in a previous round, if DMSERVIC ^=

DK and DMSERVIC ^= RF, display "that covered [READ

SERVICES BELOW]".

Else do not display this phrase.

Multi Field display:

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

Refering to the last time DM4 - DMSERVIC was asked for this
Discount Membership plan in a previous round, if DMSERVIC ^= DK
and DMSERVIC ^= RF, display the following report:
Display below question text.
Report Header: DISCOUNT MEMBERSHIP SERVICES

Column 1, no header,

Display responses to DMRO.DMSERVIC the last time DM4 ­
DMSERVIC was asked for this Discount Membership plan in a

previous round.

12:41:43 PM Monday, November 03, 2008

Page 8 of 43

DM1
Display in the following order:

If DMSERVIC includes 1/Drugs, display "RX DRUGS".

If DMSERVIC includes 2/Eyes, display "EYE CARE" .

If DMSERVIC includes 3/Dental, display "DENTAL".

If DMSERVIC includes 4/HearingAids, display "HEARING AID".

If DMSERVIC includes 5/Equipment, display "HH EQUIP".

If DMSERVIC includes 6/VitMins, display "VITAMINS".

If DMSERVIC includes 7/AltMedCare, display "ALTERNATIVE".

If DMSERVIC includes 8/Hospital, display "HOSPITAL".

If DMSERVIC includes 9/NonMed, display "NON-MED ITEMS".

If DMSERVIC includes 91/Other, display other specify response,

DMRO.DMSERVOS.

TEXT:
Context Header:
Int. Instr I:
Question Text:

During the last interview, we recorded that [you/(SP)] had
(DISCOUNT MEMBERSHIP NAME), a discount or savings card or
membership (that covered [READ SERVICES BELOW]). Did
[you/(SP)] have the (DISCOUNT MEMBERSHIP NAME) discount or
savings card or membership at any time [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION)]?
[EXPLAIN IF NECESSARY: A discount or savings card or
membership helps people get a discount on services not covered by
Medicare health plans, such as dental or vision care, hearing aids, or
some prescription drugs.]

Int. Instr II:
INPUT FIELDS / ROUTING

12:41:45 PM Monday, November 03, 2008

Page 9 of 43

DM1
( DMQ1020 )

DMHAVE

Field1:
Cheshire Name:

DMRO.DMHAVE

Item Text display:
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 DM2 - (DMQ1022 )

English text: YES
No

BOX DM3 - (DMQ1160 )

English text: NO
Attribute
Don't know

Route
BOX DM3 - (DMQ1160 )

Refusal

BOX DM3 - (DMQ1160 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
117

DeletedDM

12:41:48 PM Monday, November 03, 2008

Deleted Discount Membership plans that are not valid for
displays or checks =
Any DMEM where (DMEM.LOSEDMFG ^= EMPTY) is a
deleted DM.

Page 10 of 43

DM1
SP had a Discount Membership plan during the previous
round =
There is a DMEM and a DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = previous round and
DMRO.DMHAVE = 1/Yes).
Exclude Deleted DM's. See T.N. 117.

37

DMPreviousRnd

118

DMName

Discount Membership Name = DMEM.DMNAMEX.

LastDMServices

The last time DM4 - DMRO.DMSERVIC was asked for
the Discount Membership plan in a previous round is
stored on the most recent DMRO where
(DMRO.DMRODMEM= DMEM.DMEMNUM and
DMRO.DMSERVIC ^= EMPTY).

44

DESIGN NOTES
The instructions for the report display are based on the last time DM4 ­
DMSERVIC was asked for this Discount Membership plan in a previous
round.
DM4 - DMSERVIC is asked when:
1) The Discount Membership plan is new in the current round.
2) The SP had the Discount Membership plan during the previous round
and still had the Discount Membership plan anytime in the current round,
and if it's a fall round.
Because of these rules, the last time DM4 - DMSERVIC was asked for a
given Discount Membership plan could be stored on any previous round
DMRO.
All previous round DMRO's will be loaded in the database. Excluding the
current round DMRO, check each DMRO, starting with the most recent
previous round DMRO, until DMRO.DMSERVIC ^= empty. The most recent
DMRO where DMRO.DMSERVIC ^= empty is where the last time DM4 ­
DMSERVIC was collected.

12:41:48 PM Monday, November 03, 2008

Page 11 of 43

BOX DM2

BOX DM2

Page Order # :

22

BOX INSTRUCTIONS
( DMQ1022 )

IF THIS IS A FALL ROUND, GO TO DM4 - DMSERVIC ( DMQ1070 ).
ELSE GO TO BOX DM3 - (DMQ1160 ).

ASSIGNMENTS

TECHNICAL NOTES
98

FallRound

If the remainder of (Current round divided by 3) = 1, then
it is a Fall round.

DESIGN NOTES
If DM1 - DMHAVE=1/Yes, the SP still had the Discount Membership plan
that was reported in the previous round anytime in the current round. For
these Discount Membership plans that are ongoing, the Discount
Membership details are asked as follow up questions in the fall round only.

12:41:48 PM Monday, November 03, 2008

Page 12 of 43

DM2INTRO

DM2INTRO

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

DMINT

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

30

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP is in the Exit Sample and previous round interview was not
skipped, display "a" .
Else display "another".

Multi Field display:

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

TEXT:
Context Header:

Int. Instr I:

Question Text:

I’d like to ask about (a/another) type of health care coverage that

some people have.

Int. Instr II:
INPUT FIELDS / ROUTING

12:41:49 PM Monday, November 03, 2008

Page 13 of 43

DM2INTRO
( DMQ1025 )

DMINT

Field1:
Cheshire Name:

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
DM2 - DMEMNEW ( DMQ1040 )

English text: CONTINUE
Attribute
Empty

Route
DM2 - DMEMNEW ( DMQ1040 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
19

ExitNotSkip

If SP is in the Exit Sample and previous round interview
not skipped =
MRES.INTTYPE=8/ExitInterviewHadPrev on MRES
where MRES.MRESRND = current round.

DESIGN NOTES
DM2INTRO is designed to probe for new DM's in the current round.

12:41:51 PM Monday, November 03, 2008

Page 14 of 43

DM2

DM2

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

DMEMNEW

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:
Question display:

NOTE: Line breaks between paragraphs were removed

intentionally. There is a current space issue.

If SP has already reported having a Discount Membership plan

anytime during the current round, display "any other".

Else display "a".

If SP has already reported having a Discount Membership plan

anytime during the current round, display ", besides [READ NAMES

OF DISCOUNT MEMBERSHIPS BELOW]".

Else do not display.

If SP has not already reported having a Discount Membership plan

anytime during the current round, display "[EXPLAIN IF

NECESSARY: A discount ...]".

Else do not display.

If the SP was covered by a Medicare HMO and a private health

insurance plan anytime during the current round, display ",

discounts available through [your/(SP’s)] health insurance plan(s) or
Medicare health plan" . Always display "(s)" in parenthesis.
Else if SP was covered by a private health insurance plan anytime
during the current round, display ", or discounts available through
[your/(SP’s)] health insurance plan(s)". Always display "(s)" in
parenthesis.

Else if SP was covered by a Medicare HMO anytime during the

current round, display ", or discounts available through [your/(SP’s)]
Medicare health care plan".

Else do not display either phrase.

12:41:52 PM Monday, November 03, 2008

Page 15 of 43

DM2
Multi Field display:

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

If SP has already reported having a Discount Membership plan
anytime during the current round, display the following report:
Display report below question text.
Display Discount Membership plans that the SP has already
reported having anytime during the current round.

Display in order of entry.

Report Header: DISCOUNT MEMBERSHIP NAME(S)

Always display "(S)" in parenthesis.

Report Layout: Column 1, no header, Display the Discount

Membership name, DMEM.DMNAMEX.

TEXT:
Context Header:
Int. Instr I:
Question Text:

At any time since (REFERENCE DATE), did [you/(SP)] have (a/any
other) health care discount or savings card or membership that
offered discounts on prescription drug purchases or other health
services (, besides [READ NAMES OF DISCOUNT MEMBERSHIPS
BELOW])?
Do not include any state-run prescription discount programs
[, discounts available through [your/(SP’s)] health insurance plan(s)
or Medicare health plan/, or discounts available through [your/(SP’s)]
health insurance plan(s)/, or discounts available through
[your/(SP’s)] Medicare health plan]. Also do not include discounts
that some stores offer on all items throughout the store or on nonhealth related items.
([EXPLAIN IF NECESSARY: A discount or savings card or
membership is not health insurance. Discount savings cards or
memberships help people get a discount on services not covered by
Medicare health plans, such as dental or vision care, hearing aids, or
some prescription drugs.])

Int. Instr II:
INPUT FIELDS / ROUTING

12:41:54 PM Monday, November 03, 2008

Page 16 of 43

DM2
( DMQ1040 )

DMEMNEW

Field1:
Cheshire Name:

HRND.DMEMNEW

Item Text display:
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
DM3 - DM_NEW ( DMQ1050 )

English text: YES
No

BOX DM4 - (DMQ1180 )

English text: NO
Attribute
Don't know

Route
BOX DM4 - (DMQ1180 )

Refusal

BOX DM4 - (DMQ1180 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
38

DMCurrentRnd

12:41:57 PM Monday, November 03, 2008

SP reported having a Discount Membership plan anytime
during the current round =
There is a DMEM and DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = current round and DMRO.DMHAVE
= 1/Yes).
Exclude Deleted DM's. See T.N. 117.

Page 17 of 43

DM2
46

SPHadMHMO

SP was covered by a MHMO plan anytime during current
round =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVANYTM=1/Yes).
Exclude Deleted Plans. See T.N. 52.

47

SPHadPrivatePlan

SP was covered by a Private plan anytime during current
round =
There is a PLAN where PLAN.PLANTYPE=4/PrivatePlan
& PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round & PLRO.COVTIME ^=
empty).
Exclude Deleted Plans. See T.N. 52.

118

DMName

Discount Membership Name = DMEM.DMNAMEX.

DESIGN NOTES
Ask Discount Membership plan details for any new Discount Membership
plan reported this round.

12:41:57 PM Monday, November 03, 2008

Page 18 of 43

DM3

DM3

Page Order # :

Design Screen Type:

Roster

Fields:

Field 1:

DM_NEW

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

DM Roster

Roster Type:

Multiple Item Select

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:

Add Line
Delete Line

No
No

50

Display as ' Add a DM '
Display as ' Edit a DM '

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Roster/Grid Instructions:

Display all DM's SP has already reported having anytime during the
current round. These include DM's SP had during the previous
round and still had in the current round and DM's already added in
the current round at DM3.
Display all loaded DM's as protected rows.
Display in order of entry.

Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

What is the name of the discount savings membership or coverage?
If you have a card or other paper that shows the name, it would be
helpful for me to enter the name from that.

12:41:57 PM Monday, November 03, 2008

Page 19 of 43

DM3
ADD ALL DISCOUNT MEMBERSHIPS AT THIS ROSTER.

Int. Instr II:
INPUT FIELDS / ROUTING

Field1:
Cheshire Name:

DM_NEW

( DMQ1050 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TDMEMPick255
1

No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:

255

Route
DM3_IN - NAVIGATOR ( DMQ1055 )

BACKGROUND VARIABLE ASSIGNMENTS
DM details are collected on DMEM and DMRO:
DMEM key = DMEM.DMEMBASE + DMEM.DMEMNUM
DMEM.DMEMNUM = Number of DM selected at DM3.
DMRO key = DMRO.DMROBASE + DMRO.DMRODMEM + DMRO.DMRORND
DMRO.DMRODMEM = DMEM.DMEMNUM of DM selected at DM3.
DMRO.DMRORND = current round
For DMs added, see DM ROSTER POP-UP specifications for pop-up window programming
specifications.
Variables collected in DM ROSTER POP-UP:
DMEM.DMEMNUM
DMEM.DMEMRNDC
DMEM.DMNAMEX
Create a current round DMRO for this Discount Membership plan where
DMRO.DMRODMEM = DMEM.DMEMNUM and DMRO.DMRORND = current round.
Set flag that SP had this Discount Membership plan anytime during the current round.
See detailed instructions below.
DMRODMEM

DMRO.DMRODMEM = DMEM.DMEMNUM.

DMRORND

DMRO.DMRORND = current round.

DMHAVE

DMRO.DMHAVE = 1/Yes.

12:41:58 PM Monday, November 03, 2008

Page 20 of 43

DM3
SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
37

DMPreviousRnd

SP had a Discount Membership plan during the previous
round =
There is a DMEM and a DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = previous round and
DMRO.DMHAVE = 1/Yes).
Exclude Deleted DM's. See T.N. 117.

38

DMCurrentRnd

SP reported having a Discount Membership plan anytime
during the current round =
There is a DMEM and DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = current round and DMRO.DMHAVE
= 1/Yes).
Exclude Deleted DM's. See T.N. 117.

DESIGN NOTES

12:41:58 PM Monday, November 03, 2008

Page 21 of 43

DM3_IN

DM3_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

60

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display all DM's added at DM3 Roster.

Multi Field display:

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

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

12:41:59 PM Monday, November 03, 2008

Page 22 of 43

DM3_IN
NAVIGATOR

Field1:
Cheshire Name:

( DMQ1055 )

N/A

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

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
DM4 - DMSERVIC ( DMQ1070 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
DM7 - DMMORE ( DMQ1170 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS
DM details are collected on DMEM and DMRO:
DMEM key = DMEM.DMEMBASE + DMEM.DMEMNUM
DMEM.DMEMNUM = Number of DM selected at DM3.
DMRO key = DMRO.DMROBASE + DMRO.DMRODMEM + DMRO.DMRORND
DMRO.DMRODMEM = DMEM.DMEMNUM of DM selected at DM3.
DMRO.DMRORND = current round

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:42:00 PM Monday, November 03, 2008

Page 23 of 43

DM4

DM4

Page Order # :

Design Screen Type:

Code All

Fields:

Field 1:

DMSERVIC

Field 2:

DMSERVOS

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

Enable Functions:

70

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display the name of the Discount Membership plan being asked
about.

Multi Field display:

Vertical Alignment

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

TEXT:
Context Header:
Int. Instr I:

SHOW CARD DM1

Question Text:

What types of services are covered by [your/(SP’s)] (DISCOUNT
MEMBERSHIP NAME) discount savings membership or coverage?

Int. Instr II:

CHECK ALL THAT APPLY.

INPUT FIELDS / ROUTING

12:42:03 PM Monday, November 03, 2008

Page 24 of 43

DM4

12:42:09 PM Monday, November 03, 2008

Page 25 of 43

DM4
DMSERVIC

Field1:
Cheshire Name:

( DMQ1070 )

NONE.
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1/Drugs = DMRO.DMDRUGS

2/Eyes = DMRO.DMEYES

3/Dental = DMRO.DMTEETH

4/HearingAids = DMRO.DMEARS

5/Equipment = DMRO.DMEQUIP

6/VitMins = DMRO.DMVMINS

7/AltMedCare = DMRO.DMCHIRO

8/Hospital = DMRO.DMHOSP

9/NonMed = DMRO.DMNONMED

91/Other = DMRO.DMSEROTH

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Enumerated
TDMServic
10
No
No

Number Label
1 Drugs

FieldSize:
Min Value:
Max Value:
Mask:

Route
DM5 - DMENROLL ( DMQ1080 )

2

English text: PRESCRIPTION DRUGS
Eyes

DM5 - DMENROLL ( DMQ1080 )

3

English text: OPTICAL/EYE CARE/VISION
Dental

DM5 - DMENROLL ( DMQ1080 )

4

English text: DENTAL/PERIODONTIA/DENTURES/ORTHODONTIA
HearingAids
DM5 - DMENROLL ( DMQ1080 )

5

English text: HEARING AIDS
Equipment

DM5 - DMENROLL ( DMQ1080 )

English text: HOME HEALTH CARE/EQUIPMENT/SUPPLIES

12:42:17 PM Monday, November 03, 2008

Page 26 of 43

DM4

6

VitMins

7

English text: NUTRITIONAL SUPPLEMENTS/VITAMINS
AltMedCare
DM5 - DMENROLL ( DMQ1080 )

8

English text: ALTERNATIVE MEDICAL CARE
Hospital
DM5 - DMENROLL ( DMQ1080 )

9

English text: HOSPITAL EXPENSES
NonMed

91

DM5 - DMENROLL ( DMQ1080 )

DM5 - DMENROLL ( DMQ1080 )

English text: NON-MEDICAL ITEMS OR SERVICES
Other
DM4 - DMSERVOS ( DMQ1075 )
English text: OTHER

Attribute
Don't know

Route
DM5 - DMENROLL ( DMQ1080 )

Refusal

DM5 - DMENROLL ( DMQ1080 )

Field2:
Cheshire Name:

DMSERVOS

( DMQ1075 )

DMRO.DMSERVOS

Item Text display:

Display (SPECIFY) in same blue font used for interviewer
instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TOthrspec
1

No

No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:

Max Value:

Mask:

30

Route
DM5 - DMENROLL ( DMQ1080 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1

Response to DMSERVIC should not only include 9/DMNonMed.

If not true, display message: "PROBE TO BE SURE YOU HAVE

RECORDED ALL COVERED SERVICES DISPLAYED ON SHOW

12:42:22 PM Monday, November 03, 2008

Page 27 of 43

DM4
CARD DM1."
HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
DM4 is called by ST, NS, CPS when a DM is added to the SOP roster.

12:42:22 PM Monday, November 03, 2008

Page 28 of 43

DM5

DM5

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

DMENROLL

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

80

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP is deceased or institutionalized, display "Was".
Else display "Is".
Display the name of the Discount Membership plan being asked
about.

Multi Field display:

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

TEXT:
Context Header:
Int. Instr I:
Question Text:

(Is/Was) there a fee or charge for [your/(SP's)] (DISCOUNT
MEMBERSHIP NAME) discount savings membership or coverage?
This would include any enrollment fee or a premium amount to
obtain the membership or card.

Int. Instr II:

12:42:23 PM Monday, November 03, 2008

Page 29 of 43

DM5
INPUT FIELDS / ROUTING
DMENROLL

Field1:
Cheshire Name:

( DMQ1080 )

DMRO.DMENROLL

Item Text display:
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
DM6 - DMFEEAMT ( DMQ1090 )

English text: YES
No
English text: NO

DM6A - DMSOURCE ( DMQ1120 )

Attribute
Don't know

Route
DM6A - DMSOURCE ( DMQ1120 )

Refusal

DM6A - DMSOURCE ( DMQ1120 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
8

DeceasedInst

SP deceased or institutionalized =
MRES.SPALIVE=2/AliveAndInstitute or 3/Deceased on
MRES where MRES.MRESRND = current round.

DESIGN NOTES

12:42:25 PM Monday, November 03, 2008

Page 30 of 43

DM6

DM6

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

DMFEEAMT

Field 2:

DMFEEPAY

Field 3:

DMFEEOS

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

Enable Functions:

90

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Vertical Alignment

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

TEXT:
Context Header:
Int. Instr I:
Question Text:

What is the fee or charge?

Int. Instr II:
INPUT FIELDS / ROUTING

12:42:29 PM Monday, November 03, 2008

Page 31 of 43

DM6
DMFEEAMT

Field1:
Cheshire Name:

( DMQ1090 )

DMRO.DMFEEAMT

Item Text display:
Item Text:
Label:
Label Position:

AMOUNT:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TDmfamt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
DM6A - DMSOURCE ( DMQ1120 )

Refusal

DM6A - DMSOURCE ( DMQ1120 )

12:42:36 PM Monday, November 03, 2008

FieldSize:
Min Value:
Max Value:
Mask:

1.00
5000.00
Dollars

Route
DM6 - DMFEEPAY ( DMQ1100 )

Page 32 of 43

DM6
DMFEEPAY

Field2:
Cheshire Name:

( DMQ1100 )

DMRO.DMFEEPAY

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TDmfpay
1
No
No

Number Label
1 Year
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
DM6A - DMSOURCE ( DMQ1120 )

English text: PER YEAR
Quarterly

DM6A - DMSOURCE ( DMQ1120 )

4

English text: QUARTERLY/EVERY 3 MONTHS
Bimonthly
DM6A - DMSOURCE ( DMQ1120 )
English text: BIMONTHLY/EVERY 2 MONTHS
PerMonth
DM6A - DMSOURCE ( DMQ1120 )

5

English text: PER MONTH
PerWeek

DM6A - DMSOURCE ( DMQ1120 )

6

English text: PER WEEK
SemiAnnual

DM6A - DMSOURCE ( DMQ1120 )

7

English text: SEMI-ANNUALLY/2 TIMES PER YEAR
SemiMonth
DM6A - DMSOURCE ( DMQ1120 )

8

English text: SEMI-MONTHLY/2 TIMES PER MONTH
OneTime
DM6A - DMSOURCE ( DMQ1120 )

3

91

English text: ONE-TIME FEE/CHARGE
Other

DM6 - DMFEEOS ( DMQ1110 )

English text: OTHER
Attribute
Don't know

Route
DM6A - DMSOURCE ( DMQ1120 )

Refusal

DM6A - DMSOURCE ( DMQ1120 )

12:42:43 PM Monday, November 03, 2008

Page 33 of 43

DM6

Field3:
Cheshire Name:

DMFEEOS

( DMQ1110 )

DMRO.DMFEEOS

Item Text display:

Display "(SPECIFY)" in the same blue font used for

interviewer instructions.

Item Text:

OTHER (SPECIFY)

Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

String

TOthrspec
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

30

Route
DM6A - DMSOURCE ( DMQ1120 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1

If DMFEEAMT ^= DK and DMFEEAMT ^= RF, then:

If DMFEEPAY = 1/ Year, then DMFEEAMT = $10.00 - 1,000.00.

Else if DMFEEPAY = 2/Quarterly, then DMFEEAMT = $1.00 - 250.00.

Else if DMFEEPAY = 3/ Bimonthly, then DMFEEAMT = $2.00 -

200.00.

Else if DMFEEPAY = 4/PerMonth, then DMFEEAMT = $1.00 -

100.00.

Else if DMFEEPAY = 5/PerWeek, then DMFEEAMT = $1.00 - 20.00.

Else if DMFEEPAY = 6/SemiAnnual, then DMFEEAMT = $5.00 -

500.00.

Else if DMFEEPAY = 7/SemiMonth, then DMFEEAMT = $1.00 ­
50.00.

Else if DMFEEPAY = 8/OneTime, then DMFEEAMT = $10.00 -

1,000.00.

Else if DMFEEPAY = 91/ Other, then DMFEEAMT = $1.00 -

1,000.00.

If not true, display message: "THE VALUE ENTERED SEEMS

UNLIKELY. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
12:42:44 PM Monday, November 03, 2008

Page 34 of 43

DM6

12:42:44 PM Monday, November 03, 2008

Page 35 of 43

DM6A

DM6A

Page Order # :

Design Screen Type:

Verbatim Text

Fields:

Field 1:

DMSOURCE

Field 2:

DMSRCVB

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

Enable Functions:

100

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:

Vertical Alignment

Roster/Grid Instructions:

Roster/Grid display:

Report display:

TEXT:

Context Header:
Int. Instr I:

ENTER ANY ADDITIONAL INFORMATION FROM THE DM CARD,
BROCHURE, OR OTHER DOCUMENT THAT WILL HELP
DETERMINE THE SOURCE OR SPONSOR OF THIS DISCOUNT
MEMBERSHIP. INCLUDE ANY PHONE NUMBER, ADDRESS, OR
PLAN SPECIFICS THAT HAVE NOT ALREADY BEEN ENTERED
AT PREVIOUS QUESTIONS.

Question Text:
Int. Instr II:

12:42:46 PM Monday, November 03, 2008

Page 36 of 43

DM6A
INPUT FIELDS / ROUTING
DMSOURCE

Field1:
Cheshire Name:

( DMQ1120 )

DMRO.DMSOURCE

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TDmsrc
1
No
No

Number Label
1 NoInfo
91

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX DM3 - (DMQ1160 )

English text: NO ADDITIONAL INFORMATION
MoreInfo
DM6A - DMSRCVB ( DMQ1130 )
English text: RECORD ADDITIONAL INFORMATION

Attribute
Don't know

Route
BOX DM3 - (DMQ1160 )

Refusal

BOX DM3 - (DMQ1160 )

12:42:50 PM Monday, November 03, 2008

Page 37 of 43

DM6A

Field2:
Cheshire Name:

DMSRCVB

( DMQ1130 )

NONE.
REPLACES CHESHIRE VARIABLES:
DMRO.DMSRCVB1
DMRO.DMSRCVB2
DMRO.DMSRCVB3

Item Text display:

Display "RECORD ALL ADDITIONAL INFORMATION
BELOW:" in same blue font used for interviewer
instructions.

Item Text:

RECORD ALL ADDITIONAL INFORMATION BELOW:

Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:

Open
TOpen270
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

135

Route
BOX DM3 - (DMQ1160 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

12:42:50 PM Monday, November 03, 2008

Page 38 of 43

BOX DM3

BOX DM3

Page Order # :

110

BOX INSTRUCTIONS
( DMQ1160 )

IF CURRENTLY ADMINISTERING ST, GO TO BOX ST69D - (STQ2838 ).
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS69D (NSQ2832 ).
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPS29D ­
(CPS1735 ).
ELSE IF REVIEWING DISCOUNT MEMBERSHIPS THAT THE SP HAD
DURING THE PREVIOUS ROUND, GO TO DM1_IN - NAVIGATOR (
DMQ1015 ).
ELSE GO TO DM3_IN - NAVIGATOR ( DMQ1055 ).

ASSIGNMENTS

TECHNICAL NOTES
117

DeletedDM

Deleted Discount Membership plans that are not valid for
displays or checks =
Any DMEM where (DMEM.LOSEDMFG ^= EMPTY) is a
deleted DM.

37

DMPreviousRnd

SP had a Discount Membership plan during the previous
round =
There is a DMEM and a DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = previous round and
DMRO.DMHAVE = 1/Yes).
Exclude Deleted DM's. See T.N. 117.

DESIGN NOTES
BOX DM3 follows the Discount Membership details that are asked for
both DM's SP had during the previous round and still had anytime in the
current round, DM's added in the current round at DM3, and DM's added
in ST, NS and CPS.
DM details are asked:
1) SP reports a new Discount Membership plan in ST, NS, or CPS. BOX
DM3 routes back to the calling section.
2) SP had a Discount Membership plan during the previous round and still
had the Discount Membership plan anytime in the current round, DM1 ­
DMHAVE=1/Yes, and it is a fall round. BOX DM3 routes back to
DM1_IN.
3) SP reports a new Discount Membership plan at DM3. BOX DM3 routes
back to DM3_IN.

12:42:50 PM Monday, November 03, 2008

Page 39 of 43

DM7

DM7

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

DMMORE

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

120

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

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

Display report below question text.
Display Discount Membership plans that the SP has already
reported having anytime during the current round.
Display in order of entry.
Report Header: DISCOUNT MEMBERSHIP NAME(S)
Always display "(S)" in parenthesis.
Report Layout: Column 1, no header, Display the Discount
Membership name, DMEM.DMNAMEX.

TEXT:
Context Header:
Int. Instr I:

12:42:52 PM Monday, November 03, 2008

Page 40 of 43

DM7
At any time since (REFERENCE DATE), did [you/(SP)] have any
other discount or savings card or membership besides [READ
NAMES OF DISCOUNT MEMBERSHIPS BELOW]?

Question Text:

Int. Instr II:
INPUT FIELDS / ROUTING
( DMQ1170 )

DMMORE

Field1:

TEMP

Cheshire Name:
Item Text display:
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
DM3 - DM_NEW ( DMQ1050 )

English text: YES
No

BOX DM4 - (DMQ1180 )

English text: NO
Attribute
Don't know

Route
BOX DM4 - (DMQ1180 )

Refusal

BOX DM4 - (DMQ1180 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
38

DMCurrentRnd

12:42:55 PM Monday, November 03, 2008

SP reported having a Discount Membership plan anytime
during the current round =
Page 41 of 43

DM7
There is a DMEM and DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = current round and DMRO.DMHAVE
= 1/Yes).
Exclude Deleted DM's. See T.N. 117.
118

DMName

Discount Membership Name = DMEM.DMNAMEX.

DESIGN NOTES

12:42:55 PM Monday, November 03, 2008

Page 42 of 43

BOX DM4

BOX DM4

Page Order # :

130

BOX INSTRUCTIONS
( DMQ1180 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

12:42:55 PM Monday, November 03, 2008

Page 43 of 43