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

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

INQ

IN1AA

All survey information will be kept in strict confidence under the
REVIEW WITH THE
laws prescribed by the Privacy Act of 1974.Medicare benefits will
RESPONDENT THE
FOLLOWING IMPORTANT not be affected in any way by survey responses or participation.
FACTS FROM THE "AT­
THE-DOOR" SHEET:

INQ

IN2

INQ

IN3

VERIFY THE SP’S NAME. FIRST NAME: (SP'S FIRST NAME)MIDDLE INITIAL: (SP'S
MIDDLE INITIAL)
LAST NAME: (SP'S LAST NAME)
IS THE SP’S NAME
CORRECT AND
COMPLETE?
MAKE ALL NECESSARY
CORRECTIONS TO THE
SP'S NAME.

INQ

INS1

INQ

INS2

INQ

INS3

3/30/2010

Question Text

Interviewer Instructions II
REFER TO THE "AT-THE­
DOOR" SHEET IF THE
RESPONDENT NEEDS
ADDITIONAL
REASSURANCE.

IS THE SP CURRENTLY:
What was the first date since (REFERENCE DATE) that (SP)
IF MORE THAN ONE
entered the facility? [EXPLAIN IF NECESSARY: By "facility" we
DATE, ENTER THE
mean a place that provides long term care. By "first date" we mean EARLIEST.
the earliest date that an SP enters any facility and does not enter a
hospital or return home.]
On what date did (SP) die?

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Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

INQ

INS3A

YOU HAVE ENTERED
THAT THE SP, (SP), DIED
BEFORE JANUARY 1ST
OF THIS YEAR. IF THIS
IS NOT CORRECT, GO TO
THE PREVIOUS PAGE
AND ENTER THE
CORRECT DATE AT
INS3.IF THIS IS
CORRECT, YOU WILL
NOT BE CONDUCTING
THE COMMUNITY
INTERVIEW WITH THE
RESPONDENT. GO TO
THE NEXT PAGE TO END
THE INTERVIEW. THIS
CASE WILL BE CODED A
44 ON THE RECORD OF
CALLS. DISCUSS THE
CASE WITH YOUR
SUPERVISOR.

3/30/2010

Question Text

Interviewer Instructions II

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Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

INQ

INS3A1

YOU HAVE ENTERED
THAT THE SP, (SP), WAS
INSTITUTIONALIZED
BEFORE JANUARY 1ST
OF THIS YEAR. IF THIS
IS NOT CORRECT, GO TO
THE PREVIOUS PAGE
AND ENTER THE
CORRECT DATE AT
INS2.IF THIS IS
CORRECT, YOU WILL
NOT BE CONDUCTING
THE COMMUNITY
INTERVIEW WITH THE
RESPONDENT. THIS
CASE WILL BE CODED A
14 ON THE RECORD OF
CALLS. DISCUSS THE
CASE WITH YOUR
SUPERVISOR.

INQ

INS3B

INQ

IN4

3/30/2010

Question Text

Interviewer Instructions II
AFTER CLICKING "NEXT
PAGE", YOU WILL
RETURN TO THE IMS.

I would like to thank you for your time and cooperation during this
interview. We may be contacting you in the future for further
information.
WILL THIS INTERVIEW
BE CONDUCTED WITH
THE SAMPLE PERSON
OR WITH A PROXY?

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Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

INQ

IN4A

SELECT OR ADD THE
NAME/RELATIONSHIP OF
THE PROXY TO THE SP
FOR THIS INTERVIEW.

INQ

IN5

I would like to verify your name and relationship to (SP). I have
you listed as [READ NAME AND RELATIONSHIP LISTED
BELOW]. Is that correct?
FIRST NAME: (PROXY'S FIRST
NAME)
LAST NAME: (PROXY'S LAST NAME)
RELATIONSHIP: (PROXY'S RELATIONSHIP TO SP)

INQ
INQ

IN6
IN6A

[What is your correct name and relationship to (SP)?]

INQ

IN6B

3/30/2010

Question Text

Interviewer Instructions II
SELECT OR ADD ONLY
ONE PERSON.

WHY IS A PROXY
RESPONDENT
NECESSARY?
BRIEFLY EXPLAIN WHY
PROXY MUST ANSWER
QUESTIONS.

CHECK ALL THAT APPLY.

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Category

ItemTag

Interviewer Instructions I

INQ

IN6B1

YOU HAVE ENTERED
THAT THE SP, (SP), IS
DECEASED. IF THIS IS
NOT CORRECT, GO TO
THE PREVIOUS PAGE
AND CORRECT YOUR
RESPONSE AT IN6A.WE
DO NOT CONDUCT A
COMMUNITY INTERVIEW
WHEN THE
SUPPLEMENTAL SAMPLE
SP IS DECEASED. IF
WHAT YOU HAVE
ENTERED IS CORRECT,
YOU WILL NOT BE
CONDUCTING THE
INTERVIEW WITH THE
RESPONDENT. GO TO
THE NEXT PAGE TO END
THE INTERVIEW. THE
CASE WILL BE CODED A
44 ON THE RECORD OF
CALLS. DISCUSS THE
CASE WITH YOUR
SUPERVISOR.

3/30/2010

Question Text

Interviewer Instructions II

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Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

INQ

IN6B2

YOU HAVE ENTERED
THAT THE SP, (SP), IS
INSTITUTIONALIZED. IF
THIS IS NOT CORRECT,
GO TO THE PREVIOUS
PAGE AND CORRECT
YOUR RESPONSE AT
IN6A.WE DO NOT
CONDUCT A COMMUNITY
INTERVIEW WHEN THE
SUPPLEMENTAL SAMPLE
SP IS
INSTITUTIONALIZED. IF
WHAT YOU HAVE
ENTERED IS CORRECT,
YOU WILL NOT BE
CONDUCTING THE
INTERVIEW WITH THE
RESPONDENT. GO TO
THE NEXT PAGE TO END
THE INTERVIEW. THE
CASE WILL BE CODED A
14 ON THE RECORD OF
CALLS. DISCUSS THE
CASE WITH YOUR
SUPERVISOR.

INQ

IN6B3

3/30/2010

Question Text

Interviewer Instructions II

I would like to thank you for your time and cooperation during this
interview. We may be contacting you in the future for further
information.

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Category

ItemTag

INQ

INS6

As you know from all of the interviews that we have conducted [for
(SP)], the Medicare Current Beneficiary Survey has been collecting
data from over 100,000 beneficiaries since 1991. Data from the
study have been extremely useful to many researchers who are
looking at the availability and the cost of medical care for people
such as [you/(SP)].At this time, the survey is going to start
interviewing some new beneficiaries and we will stop interviewing
some of the people who have been with the survey for quite some
time. [You are/(SP) is] one of the people that we will no longer
interview.Therefore, this will be the last interview that will be
conducted [with you/for (SP)]. I will not collect any new health care
visit information. However, I will collect outstanding medical cost
information and we will ask a series of income and assets
questions. This will be a shorter interview, different from most of
the others conducted [for (SP)].

INQ

INS6A

At this time, the survey is going to start interviewing some new
beneficiaries and we will stop interviewing some of the people who
have been with the survey for quite some time. [You are/(SP) is]
one of the people that we will no longer interview.Therefore, this will
be the last interview that will be conducted [with you/for (SP)].
(This interview will be shorter than previous interviews.
Outstanding medical cost information will be collected, and a final
income and assets series will be completed.)

INQ

IN8

INQ
INQ

IN9
IN10

I have [your/(SP’s)] date of birth listed as (CMS BIRTH DATE). Is
that correct?
What is [your/(SP’s)] date of birth?
That makes [you/(SP)] (AGE) today. Is that correct?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

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Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

INQ

IN11

[Are you/Is (SP)] male or female?
THE SP IS LISTED AS A
(MALE/FEMALE). IF SEX
IS OBVIOUS, CODE
BELOW WITHOUT
ASKING. IF SEX IS NOT
OBVIOUS, ASK:

INQ

IN12

YOU JUST CHANGED
SP’S SEX FROM
(MALE/FEMALE) TO
(FEMALE/MALE). DID
YOU INTEND TO DO
THAT?

INQ

IN13

[Are you/Is (SP)/Was (SP)/Is (SP) currently/Are you currently]
married, widowed, divorced, separated, or never married?

INQ

IN14

AVQ

AV1

Including natural, adopted, and stepchildren, how many living
children [did (SP)/does (SP)/do you] have?
Next, I would like to verify [your/(SP's)] home address. I have it
listed as..[READ ADDRESS LISTED BELOW]. Is this
correct?NAME: (SP)STREET ADDRESS 1: (STREET ADDRESS
LINE 1)STREET ADDRESS 2: (STREET ADDRESS LINE 2)CITY:
(CITY) STATE: (STATE) ZIPCODE: (ZIPCODE)

AVQ

AV2

ENTER CORRECT
ADDRESS.

AVQ

AV3

WAS CHANGE MADE TO
SP'S ADDRESS BECAUSE
SP MOVED?

3/30/2010

Question Text

Interviewer Instructions II

CLEAR ADDRESS LINE 2
IF NO LONGER
APPLICABLE.

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Current MCBS Questionnaire

Category

ItemTag

AVQ

AV4

Next, I would like to verify [your/(SP's)] phone number(s). I have
them listed as ..[READ PHONE NUMBER(S) LISTED BELOW]. Are
these correct? PHONE 1: (PRIMARY PHONE NUMBER)PHONE 2:
[(SECONDARY PHONE NUMBER)/NONE)

AVQ
AVQ

AV5
AV6

AVQ

AV7

What is [your/(SP's)] phone number?
Do you/Does (SP)] have a second phone number?[PROBE: What
is that number?]
I would also like to verify [your/(SP's)] mailing address. I have it
listed as ... [READ ADDRESS LISTED BELOW.]Is this the correct
mailing address for [you/(SP)]?NAME: (SP)MAILING ADDRESS 1:
(MAILING ADDRESS LINE 1)MAILING ADDRESS 2: (MAILING
ADDRESS LINE 2)CITY: (MAILING CITY) STATE: (MAILING
STATE) ZIPCODE: (MAILING ZIPCODE)

AVQ

AV8

ENS

ENSINTRO

ENS

ENS1

ENS

ENS2

ENS

ENS2_IN

3/30/2010

Interviewer Instructions I

ENTER CORRECT
ADDRESS.

Question Text

Interviewer Instructions II

What is [your/(SP's)] mailing address?

Now I’d like to [review with you who was living in the household/ask
you a few questions about [your/(SP's)] home and any other people
who may live in the household.].
From our last interview on (REFERENCE DATE), we have listed
that [(READ NAME(S) LISTED BELOW)] lived in the same
household as [you/(SP)].[As of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION), did/Do/Does] [READ NAME(S) LISTED
BELOW] still live in the same household as [you/(SP)]?
PROBE FOR AND
SELECT THOSE PEOPLE
WHO ARE NO LONGER IN
THE HOUSEHOLD.

9

CLEAR ADDRESS LINE 2
IF NO LONGER
APPLICABLE.

Current MCBS Questionnaire

Category

ItemTag

ENS

ENS2A

ENS

ENS3

ENS

ENS4

ENS

ENS4A

ENS
ENS

ENS5
ENS10

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Why (is/was) (HOUSEHOLD MEMBER NAME) no longer in the
household [as of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(At the time of the last interview, [you were living by
yourself/(SP)was living by (himself/herself)]).[Besides [you/(SP)],
(is/was)/(Is/Was)] there anyone else living or staying in the
household [as of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]? Remember to include people
who(are/were) temporarily absent and any children who (may
live/mayhave lived) in the household.
[Who else (is/was) living or staying in the household?]

Now I want to make sure I have everyone who (lives/lived) in the
household [as of (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]. I have listed [READ NAME(S) LISTED
BELOW]. Have I missed any lodgers, boarders, or anyone else
who usually (lives or stays/lived or stayed) in the household but
(is/was) away from home traveling or in the hospital?

ASK THE RESPONDENT
TO PROVIDE
INFORMATION FOR ALL
"DK" AND "RF" ENTRIES
LISTED BELOW. DO NOT
CHANGE THE ENTRIES IF
THE RESPONDENT STILL
DOES NOT KNOW THE
INFORMATION.

10

SELECT OR ADD ALL
PERSONS LIVING IN THE
HOUSEHOLD.

Current MCBS Questionnaire

Category

ItemTag

ENS

ENS10A

ENS

ENS10AA

ENS

ENS11

ENS
ENS

ENS11A_IN
ENS11A

ENS

ENS12

ENS

ENS13

ENS

ENS14

ENS

ENS15

ENS

ENS16

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Who owns or rents [this/(SP’s)] home? [PROBE: Of the people
living (here/there) now, who is the person who is the head of the
household?]
Since (REFERENCE DATE), did [you/(SP)] work at any time at a
job or business?
[Before I continue with the next set of questions, I need to collect
information about [your/(SP’s)] job status.] [Are you/Is (SP)]
currently working at a job or business?

SELECT ONLY ONE.

(Before I continue with the next set of questions, I need to update
information about [your/(HOUSEHOLD MEMBER NAME'S)] job
status.) [Are you/Is (HOUSEHOLD MEMBER NAME)] currently
working at a job or business?
Now we have a few questions about military service.Did [you/(SP)]
ever serve in the Armed Forces of the United States?
SHOW CARD ENS

Looking at this card, in which of these time periods did
CHECK ALL THAT APPLY.
[you/(SP)]serve in the Armed Forces?
[Were you/Was (SP)] ever an active member of a National Guard
ormilitary reserve unit of the United States?
Was all of [your/(SP’s)] active duty related to National Guard
ormilitary reserve training?
[Do you/Does (SP)/Did (SP)] have a disability related to service in
the Armed Forces of the United States?

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Current MCBS Questionnaire

Category

ItemTag

ENS

ENS17

HAQ

HAINTRO

IF THE SP IS HOMELESS, I would like to ask a few questions about [your/(SP’s)] housing
IS TRANSIENT WITH NO situation or living arrangements.
PERMANENT HOME, OR
IS IN JAIL OR PRISON,
SELECT NEXT PAGE
WITHOUT READING THIS
INTRODUCTION.

HAQ

HA1

SHOW CARD HA1IF TYPE [IF HOUSING TYPE IS NOT OBVIOUS, ASK:] Which of these best
describes [your/(SP’s)] home?
OF HOUSING IS
OBVIOUS, CODE
WITHOUT ASKING.
SELECT "SP IS
HOMELESS/TRANSIENT/I
N JAIL OR PRISON"
WITHOUT ASKING.

HAQ

HA2

HAQ

HA3

How many levels are in [your/(SP’s)] (house/apartment or
condominium building/place of residence)?
Does [your/(SP’s)] (house/apartment or condominium building/place
of residence) have an elevator?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

What [is [your/(SP’s)]/was (SP's)] (current) V.A. disability rating?

THE VA DISABILITY
RATING IS A
PERCENTAGE IN
MULTIPLESOF 10 (I.E.,
10%, 20%, ETC.). ENTER
THE NUMBER AS
AWHOLE NUMBER. YOU
DO NOT NEED TO ENTER
THE "%"SIGN.

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Current MCBS Questionnaire

Category

ItemTag

HAQ

HA4

HAQ

HA5

HAQ

HAINTRO2

Next, I would like to ask about access or mobility modifications that
[you/(SP)] may have in (your/his/her) (house/apartment or
condominium building/mobile home/place of residence).

HAQ

HAINTRO2A

HAQ

HA6

When we were here about a year ago, we asked about access or
mobility modifications that may have been a part of [your/(SP’s)]
residence at that time. Now, I would like to update our information
about such modifications.
Does [your/(SP’s)] (house/mobile home/apartment or condominium
building/place of residence) have ramps at (any of) its entrance(s)?

HAQ

HA7

Does [your/(SP’s)] (house/own apartment or condominium/mobile
home/place of residence) have modifications to any bathroom such
as grab bars or a shower seat?

HAQ

HA8

Other than stair railings, does [your/(SP’s)] (house/own apartment
or condominium/mobile home/place of residence) have special
railings to help (you/him/her) move around?

HAQ

HA9

SHOW CARD HA2

HAQ

HA10

SHOW CARD HA2

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Is the living space in [your/(SP’s)] (house/own apartment or
condominium/place of residence) all on one level?
Does [your/(SP’s)] (house/own apartment or condominium/place of
residence) have either a full bathroom or a half bathroom on all
levels?[PROBE: Bathroom facilities must contain at least a flush
toilet, or a bathtub or shower.]

Please look at this card. Is [your/(SP’s)] (house/own apartment or
condominium/mobile home/place of residence) a part of one of
these communities?
[IF NECESSARY, ASK:] Which category best describes
[your/(SP’s)] type of housing?

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Current MCBS Questionnaire

Category

ItemTag

HAQ

HAINTRO3

HAQ

HA11

HAQ

HA12

HAQ

HA13

HAQ

HA14

Would the [(TYPE OF HOUSING)/place] where [you/(SP)] currently
(live/lives) allow (you/him/her) to continue living in (your/his/her)
(house/apartment or condominium/mobile home/home) if
(you/he/she) needed substantial care?[PROBE: Could [you/(SP)]
stay where (you/he/she) (live/lives) now if (you/he/she) needed a
much greater level of care?]

HAQ

HA15

HAQ

HA16

If (you/he/she) needed substantial care, would that care be
provided in another part of [(this/these) same (TYPE OF
HOUSING)/this same place of residence]?
Does the place where [you/(SP)] (live/lives) now require residents
to be a certain age to live there or receive services?

3/30/2010

Interviewer Instructions I

SHOW CARD HA3

Question Text

Interviewer Instructions II

The type of community [you/(SP)] (live/lives) in sometimes gives its
residents access to personal care services. Next, I would like to
update our records regarding [your/(SP’s)] access to such
services.
Does [your/(SP’s)] place of residence give (you/him/her) access to
personal care services like any of those listed on this card?
We are interested in personal services that might be available here
in addition to housing. [In (this/these) (TYPE OF HOUSING)/In
[your/(SP’s)] place of residence], [do you/does (SP)] have access
to…
Are these services included as part of the cost of [your/(SP’s)]
housing or is there a separate charge for them?

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Current MCBS Questionnaire

Category

ItemTag

HAQ

HA17

Now I have a few questions about the rooms in [your/(SP’s)] place
of residence.[Do you/Does (SP)] have (your/his/her) own bathroom
facilities?[EXPLAIN IF NECESSARY: Own bathroom facilities may
be defined as the sink, flush toilet, and bathtub or shower used
primarily by [you/(SP)] and is not used on a regular basis by
someone not living in the household.]

HAQ

HA18

How many rooms are there in [your/(SP’s)] (house/own apartment
or condominium/mobile home/place of residence), not counting
bathrooms, hallways, or unfinished basements?

HAQ

HA19

[Do you/Does (SP)] have (your/his/her) own kitchen?[EXPLAIN IF
NECESSARY: Own kitchen is defined as an area with a sink, nonportable cooking equipment and a refrigerator used primarily by
[you/(SP)] and not on a regular basis by someone not living in the
household. Also includes kitchenettes.]

HIS

HISINTRO

HIS

HIS1

Now I'd like to review with you the information that we have about
health insurance plans that [you/(SP)] had at the time of the last
interview.
[Let’s see if there are any other changes we need to make to
thehealth insurance coverage [you/(SP)] had as of (REFERENCE
DATE).] [(You/(SP)] had Medicare coverage (through a managed
care plan) and (you were/he was/she was) also covered by [READ
PLAN NAMES BELOW]./The only health insurance coverage
[you/(SP)] had was Medicare (through a managed care plan)] on
(REFERENCE DATE). Is that correct?

HIS

HIS2

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

What is the name of the plan that needs deletion?

15

SELECT ONLY ONE PLAN
FOR DELETION AT THIS
ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIS

HIS2A

HIS

HIS2B

What is the name of the plan that is incorrect?

HIS
HIS

HIS3
HISMC1

What type of insurance plan needs to be added?
What is the name of the Medicare Advantage Plan that covered
[you/(SP)]?

HIS

HISMC2

[Were you/Was (SP)] covered by or enrolled in (MEDICARE
MANAGED CARE PLAN NAME) on (REFERENCE DATE)?

HIS

HISMC3

HIS

HISMC4

I recorded previously that (PREVIOUS ROUND CURRENT
MEDICARE MANAGED CARE PLAN NAME) was [your/(SP’s)]
current Medicare Advantage Plan on (REFERENCE DATE). Has
this information changed?
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [you/(SP)] have prescribed medicine coverage through
(MEDICARE MANAGED CARE PLAN NAME)?[PROBE: I am
asking about the type of insurance coverage that [you/(SP)]
personally had, not what the plan offers everyone.]

HIS

HISMC5

HIS

HISMC6

HIS

HISMC7

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II
BRIEFLY EXPLAIN WHY
PLAN NEEDS DELETION.

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [you/(SP)] have dental coverage through (MEDICARE
MANAGED CARE PLAN NAME)?
Did [you/(SP)] have optical coverage through (MEDICARE
MANAGED CARE PLAN NAME), that is, for eyeglasses or contact
lenses?
Did [you/(SP)] have coverage for preventive care such as routine
annual physicals through (MEDICARE MANAGED CARE PLAN
NAME)?

16

EDIT ALL PLAN NAMES
AT THIS ROSTER.

SELECT OR ADD ONLY
ONE MEDICARE
ADVANTAGE PLAN AT
THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIS

HISMC8

Did [your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage include nursing home care over and beyond what
Medicare normally covers?[EXPLAIN IF NECESSARY: Under
regular fee-for-service, Medicare pays for limited skilled nursing
facility (SNF) care during a benefit period. In 2009, the first 20
days are paid in full and the next 80 days require a copayment of
up to $133.50 per day.]

HIS

HISMC9

Besides the cost of [your/(SP’s)] Medicare Part B premium, was
there an additional cost for [your/(SP’s)] (MEDICARE MANAGED
CARE PLAN NAME) coverage? Please do not include any amount
that [you/(SP)] may have paid as a co-payment for an office visit or
a prescribed medicine.[EXPLAIN IF NECESSARY: Some managed
care plans may charge a monthly premium to cover the cost of the
deductibles and coinsurance for Medicare-covered services or
because they provide services that are not covered by Medicare
such as prescribed medicines, routine exams, and dental, eye, or
hearing. Plans that have premiums typically charge from $50 to
$75 per month.]

HIS

HISMC10

Not including the cost of [your/(SP’s)] Medicare Part B premium,
what was the additional amount that [you/(SP)] paid for
(your/his/her) (MEDICARE MANAGED CARE PLAN NAME)
coverage? [Please do not include any copayments or any amount
that may be paid for anyone other than [you/(SP)].][PROBE IF
NECESSARY: Was that per year, per month, per week, or what?]

HIS

HISMC11

Did anyone else, such as an employer, a union or professional
organization pay all or some portion of the additional cost for
[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

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Current MCBS Questionnaire

Category

ItemTag

HIS

HISMC12

HIS

HIS6

HIS

HIS7

HIS

HIS8

HIS

HIS9

On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] Medicaid coverage stop?

HIS

HIS10A

HIS

HIS10B

HIS

HIS10B1

Some states now use managed care plans, such as HMOs (Health
Maintenance Organizations), to provide some or all health care for
Medicaid beneficiaries. [Were you/Was (SP)] enrolled in a
Medicaid Managed Care Plan on [(REFERENCE DATE)/(PLAN
COVERAGE STOP DATE)/the date [your/(SP’s)] Medicaid
coverage stopped]?
As far as you can recall, [were you/was (SP)] given a choice to
enroll in a Medicaid Managed Care Plan, or did (you/he/she) have
to enroll to receive Medicaid benefits?
Some people who receive Medicaid benefits are also enrolled in a
Medicare Prescription Drug plan, or Medicare Part D plan, that
pays for some or all of their prescribed medicines. The Medicare
program automatically enrolls such beneficiaries into a Prescription
Drug plan, although the beneficiary may choose to switch to a
different plan.Between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE), [were you/was (SP)] enrolled in a Medicare
Prescription Drug plan that covered medicines prescribed by a
doctor?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Who else paid all or some portion of the additional cost for
[your/(SP’s)] (MEDICARE MANAGED CARE PLAN NAME)
coverage?
[Were you/Was (SP)] covered by Medicaid the whole time between
(SUMMARY REFERENCE DATE) and (REFERENCE DATE), or
only part of the time?
[Were you/Was (SP)] covered by Medicaid on (REFERENCE
DATE)?
On what date did [your/(SP’s)] Medicaid start between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?

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Current MCBS Questionnaire

Category

ItemTag

HIS

HIS10C

HIS

HIST1

HIS

HIST2

HIS

HIST3

HIS

HIST3AA

HIS

HIS12

HIS
HIS

HIS12_IN
HIS13

HIS

HIS14

HIS

HIS15

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] Medicaid plan cover medicines prescribed
by a doctor?
[Were you/Was (SP)] covered by TRICARE the whole time
between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), or only part of the time?
[Were you/Was (SP)] covered by TRICARE on (REFERENCE
DATE)?
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] TRICARE plan cover medicines prescribed
by a doctor?[PROBE: I am asking about the type of insurance
coverage that [you/(SP)] personally had, not what the plan offers
everyone.]
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), where did [you/(SP)] usually obtain (your/his/her)
medicines? Did [you/(SP)] usually obtain them at a TRICARE mail
order pharmacy (TMOP), a TRICARE retail pharmacy network
pharmacy (TRRx), a military treatment facility pharmacy (MTF), a
non-network retail pharmacy, or somewhere else?
What is the name of the public program that covered [you/(SP)]?

[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) the whole
time between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), or only part of the time?
[Were you/Was (SP)] covered by (PUBLIC PLAN NAME) on
(REFERENCE DATE)?
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage
start between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE)?

19

SELECT OR ADD ALL
PUBLIC PROGRAM
NAMES AT THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIS

HIS16

HIS

HIS16A

HIS

HIS20

HIS
HIS

HIS20_IN
HIS21

HIS

HIS22

HIS

HIS23

HIS

HIS24

HIS

HIS25

HIS

HIS26

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] (PUBLIC PLAN NAME)
coverage stop?
Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did [your/(SP’s)] (PUBLIC PLAN NAME) plan cover
medicines prescribed by a doctor?
What is the name of each of the (other) private plans that provided SELECT OR ADD ALL
[your/(SP’s)] medical insurance coverage between (SUMMARY
PRIVATE PLAN NAMES AT
REFERENCE DATE) and (REFERENCE DATE)?
THIS ROSTER.

[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) the
whole time between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE), or only part of the time?
[Were you/Was (SP)] covered by (PRIVATE PLAN NAME) on
(REFERENCE DATE)?
On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) start between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE)?
On what date between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE) did [your/(SP’s)] coverage under (PRIVATE
PLAN NAME) stop?
CODE WITHOUT ASKING Was this a managed care plan, such as an HMO (Health
IF VOLUNTEERED.
Maintenance Organization) or PPO (Preferred Provider
Organization)?[EXPLAIN IF NECESSARY: Managed care plans
generally provide a full range of health care services for a prepaid
fee. Health care is generally provided by primary care doctors,
specialists, or hospitals on the plan’s list (network) except in an
emergency.]
Who was listed as the main insured person on the (PRIVATE PLAN SELECT OR ADD ONLY
NAME) policy or contract?
ONE PERSON.

20

Current MCBS Questionnaire

Category

ItemTag

HIS

HIS27

For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up
directly with the (insurance company/managed care plan), or did
[you/(MIP)] get this insurance through a current employer, a former
employer, a union, a family business, AARP, or some other way?

HIS

HIS29

How many family members, including [yourself/(SP)], were covered
by [your/(MIP’s)] (PRIVATE PLAN NAME) between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE)?

HIS

HIS31A

Supplemental insurance plans may cover a variety of services or
may be specific to only certain services, such as prescribed
medicines or dental coverage. I’d like to know what [your/(SP’s)]
(PRIVATE PLAN NAME) coverage included between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE).[PROBE: I am
asking about the type of insurance coverage that [you/(SP)]
personally had, not what the plan offered everyone.]Did
[your/(MIP’s)] (PRIVATE PLAN NAME) cover…

HIS

HIS32

Was there a premium or cost for the (PRIVATE PLAN NAME)
coverage?[Do not include the cost of any deductibles [you/(SP)] or
[your/(SP’s)] family may have had to pay.]

HIS

HIS33

How much did [you/(MIP)] pay for the (PRIVATE PLAN NAME)
coverage?[Please do not include any amount that may be paid for
anyone other than [you/(SP)].][PROBE IF NECESSARY: Was that
per year, per month, per week, or what?]

HIS

HIS33A

Between (SUMMARY REFERENCE DATE) and (REFERENCE
DATE), did anyone else, such as an employer, a union or
professional organization pay all or some portion of the premium or
cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

21

Current MCBS Questionnaire

Category

ItemTag

HIS

HIS33B

HIS

HIS33C

HIS

HIS34

What is the name of the Medicare Prescription Drug plan that
covered [you/(SP)]?

HIS

HIS35

[Were you/Was (SP)] covered by or enrolled in (MEDICARE
PRESCRIPTION DRUG PLAN NAME) on (REFERENCE DATE)?

HIS

HIS36

HIS

HIS37

I recorded previously that (PREVIOUS ROUND CURRENT
MEDICARE PRESCRIPTION DRUG PLAN NAME) was
[your/(SP’s)] current Medicare Prescription Drug Plan on
(REFERENCE DATE). Has this information changed?
What is the most important reason [you/(SP)] stopped the
(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Who else paid all or some portion of the cost for [your/[MIP’s)]
(PRIVATE PLAN NAME) coverage?
Some managed care plans offer a point-of-service option which
allows members to receive services from out-of-plan providers
even in non-emergency situations. Between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE), [were you/was
(SP)] enrolled in a point-of-service option offered by (PRIVATE
PLAN NAME)?[EXPLAIN IF NECESSARY: In a point-of-service
option, the member typically pays a higher copayment when seeing
an out-of-plan provider. For example, if a member sees an in-plan
provider, there may only be a $10 copayment. However, the
member may have to pay 20 percent of the cost and the managed
care plan will pay 80 percent of the cost to receive the same
service from an out-of-plan provider.]

22

SELECT OR ADD ONLY
ONE MEDICARE
PRESCRIPTION DRUG
PLAN AT THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIS

HISCLOSE

HIQ

HIMCINTR

HIQ

MC1

As you may know, Medicare allows beneficiaries in certain parts of
the country to enroll in Medicare Advantage plans, such as HMOs
(Health Maintenance Organizations) and PPOs (Preferred Provider
Organizations), to receive their Medicare-covered health care.
According to Medicare records, [you are/(SP) is] currently enrolled
in a Medicare Advantage Plan called (CMS MEDICARE MANAGED
CARE PLAN NAME). Is this information correct?

HIQ

MC2

How is this information incorrect?

HIQ

MC2B

What is the most important reason [you/(SP)] stopped the (CMS
MEDICARE MANAGED CARE PLAN NAME) coverage?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

That covers the health insurance [you/(SP)] had at the time of the
last interview. The next questions are about [your/(SP’s)]
insurance coverage between (REFERENCE DATE) and
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION).
SHOW CARD HIMC

The next questions are about health insurance. It’s important to
understand how beneficiaries cover the costs of their medical care,
such as doctor visits, prescribed medicines, hospital stays, and
other health care. As you know, there are many ways that people
on Medicare receive health insurance benefits. This card outlines
the types of health insurance that I’ll be asking you about. You may
want to refer to this card as we talk about [your/(SP’s)] health
insurance coverage.

23

SELECT ONLY ONE. IF
MORE THAN ONE
RESPONSE IS
APPLICABLE, SELECT
THE RESPONSE THAT IS
CLOSEST TO THE TOP
OF THE LIST.

Current MCBS Questionnaire

Category

ItemTag

HIQ

MC3

HIQ

MC4

HIQ

MC5

HIQ

MC11

HIQ

MC12

HIQ

HIMC1A

At the time of the last interview [you were/(SP) was] covered by
(MEDICARE MANAGED CARE PLAN NAME).[[Are you/Is (SP)] now
covered by (MEDICARE MANAGED CARE PLAN NAME)?] [Was
(SP) covered by (MEDICARE MANAGED CARE PLAN NAME) on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)?]

HIQ

HIMC1B1

HIQ

HIMC1C

What is the most important reason [you/(SP)] stopped the
(MEDICARE MANAGED CARE PLAN NAME) coverage?
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/INSTITUTIONALIZATION)], [have you/has (SP)
been/was (SP)] covered by any other Medicare Advantage Plans
besides (MEDICARE MANAGED CARE PLAN)?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

In many Medicare Advantage Plans, such as HMOs or PPOs, the
health plan gives the patient a list of doctors from which he
chooses a primary care physician. This primary care physician
provides the patient’s usual medical care and can refer the patient
to specialists, if necessary. (Do you/Does SP) have a primary
care physician?
Is it possible that [your/(SP’s)] current insurance plan is just
another name for (CMS MEDICARE MANAGED CARE PLAN
NAME), or are they not the same plans?
What is the name of the Medicare Advantage Plan that provides
[your/(SP’s)] health care?

Do you refer to [your/(SP’s)] Medicare coverage by any name
besides Medicare?
What do you call [your/(SP’s)] coverage?

SHOW CARD HIMC1

24

SELECT OR ADD ONLY
ONE MEDICARE
ADVANTAGE PLAN AT
THIS ROSTER.

SELECT OR ADD ONLY
ONE MEDICARE
ADVANTAGE PLAN AT
THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

HIQ

HIMC1

(SHOW CARD HIMC1)

As you (may) know, Medicare allows beneficiaries in certain parts
of the country to enroll in Medicare Advantage plans, such as
HMOs (Health Maintenance Organizations) and PPOs (Preferred
Provider Organizations), to receive their Medicare-covered health
care.(Please look at this card.) At any time [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has
(SP)/had (SP)] been enrolled in or covered by [any/(one of
these/any)] Medicare Advantage plans?

HIQ

HIMC3

HIQ

HIMC5

HIQ

HIMC6

[Do you/Does (SP)/Did (SP)] have prescribed medicine coverage
through (CURRENT MEDICARE MANAGED CARE
PLAN)?[PROBE: I am asking about the type of insurance
coverage that [you personally have/(SP) personally has/(SP)
personally had], not what the plan offers everyone.]

HIQ

HIMC7

HIQ

HIMC8

HIQ

HIMC9

[Do you/Does (SP)/Did (SP)] have dental coverage through
(CURRENT MEDICARE MANAGED CARE PLAN NAME)?
[Do you/Does (SP)/Did (SP)] have optical coverage through
(CURRENT MEDICARE MANAGED CARE PLAN NAME), that is, for
eyeglasses or contact lenses?
[Do you/Does (SP)/Did (SP)] have coverage for preventive care
such as routine annual physicals through (CURRENT MEDICARE
MANAGED CARE PLAN NAME)?

3/30/2010

Interviewer Instructions II

[Are you/Is (SP)/Was (SP)] (currently) covered by or enrolled in a
Medicare Advantage Plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
[What is the name of the Medicare Advantage Plan that (currently
covers/covered) [you/(SP)] [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?]

25

SELECT OR ADD ONLY
ONE MEDICARE
ADVANTAGE PLAN AT
THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIQ

HIMC10

[Does your/Does (SP’s)/Did (SP’s)] (CURRENT MEDICARE
MANAGED CARE PLAN NAME) coverage include nursing home
care over and beyond what Medicare normally covers?[EXPLAIN
IF NECESSARY: Under regular fee-for-service, Medicare pays for
limited skilled nursing facility (SNF) care during a benefit period. In
2010, the first 20 days are paid in full and the next 80 days require
a copayment of up to $137.50 per day.]

HIQ

HIMC11

Besides the cost of [your/(SP’s)] Medicare Part B premium,
(is/was) there an additional cost for [your/(SP’s)] (CURRENT
MEDICARE MANAGED CARE PLAN NAME) coverage? Please do
not include any amount that [you/(SP)] may (pay/have paid) as a co­
payment for an office visit or a prescribed medicine.[EXPLAIN IF
NECESSARY: Some managed care plans may charge a monthly
premium to cover the cost of the deductibles and coinsurance for
Medicare-covered services or because they provide services that
are not covered by Medicare such as prescribed medicines, routine
exams, and dental, eye, or hearing. Plans that have premiums
typically charge from $50 to $75 per month.]

HIQ

HIMC12

Not including the cost of [your/(SP’s)] Medicare Part B premium,
what (is/was) the additional amount that [you pay/(SP) pays/(SP)
paid] for (your/his/her) (CURRENT MEDICARE MANAGED CARE
PLAN NAME) coverage? [Please do not include any copayments
or any amount that may (be/have been) paid for anyone other than
[you/(SP)].][PROBE IF NECESSARY: Is that per year, per month,
per week, or what?]

HIQ

HIMC12A

(Does/Did) anyone else, such as an employer, a union or
professional organization pay all or some portion of the additional
cost for [your/(SP’s)] (CURRENT MEDICARE MANAGED CARE
PLAN NAME) coverage?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

26

Current MCBS Questionnaire

Category

ItemTag

HIQ

HIMC12B

HIQ

HIMC16

HIQ

HIMC17

HIQ

HIMC19

HIQ

HIMC24

HIQ

HI5INTRO

Would you recommend (CURRENT MEDICARE MANAGED CARE
PLAN NAME) to your family or friends?
How many years [have you/has (SP)] been enrolled in a managed
care plan?
SHOW CARD HI3PLEASE Medicaid (, also known as [READ FROM ABOVE],) is a state
program for low income persons or for persons on public
READ THIS
INTRODUCTION SLOWLY assistance. Sometimes persons with very large medical bills are
also covered by Medicaid. People covered by Medicaid usually
AND CLEARLY:
have a card that looks like this.

HIQ

HI5INTRB

SHOW CARD HI4

HIQ

HI5

3/30/2010

Interviewer Instructions I

SHOW CARD HIMC1

Question Text

Interviewer Instructions II

Who else (pays/paid) all or some portion of the additional cost for
[your/(SP’s)] (CURRENT MEDICARE MANAGED CARE PLAN
NAME) coverage?
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/ DATE OF INSTITUTIONALIZATION)], [have
you/has (SP)/had (SP)] been covered by any other Medicare
Advantage Plans besides (MEDICARE MANAGED CARE PLAN and
MEDICARE MANAGED CARE PLAN)?
[Besides (MEDICARE MANAGED CARE PLAN and MEDICARE
MANAGED CARE PLAN), what other/What] Medicare Advantage
Plans provided [your/(SP’s)] health care since (REFERENCE
DATE)?

Some people receive their Medicaid benefits from plans that have
names like those listed on this card.
At any time [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)]
covered by Medicaid?

27

SELECT OR ADD
MEDICARE ADVANTAGE
PLAN NAMES AT THIS
ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI6

(At the time of the last interview [you were/(SP) was] covered by
Medicaid, (also known as [READ FROM ABOVE].) [Were you/Was
(SP)] covered by Medicaid the whole time between (REFERENCE
DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION), or only part of the time?

HIQ

HI7

HIQ

HI8

HIQ

HI9

[[Are you/Is (SP)] now covered by Medicaid?] [Was (SP) covered
by Medicaid on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]
On what date did [your/(SP’s)] Medicaid start between
(REFERENCE DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?
On what date [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [your/(SP’s)] Medicaid coverage (most recently/last) stop?

HIQ

HI10A

[Some states now use managed care plans, such as HMOs (Health
Maintenance Organizations), to provide some or all health care for
Medicaid beneficiaries.] [At the time of the last interview [you
were/(SP) was] enrolled in a Medicaid Managed Care Plan.] [Are
you now/Is (SP) now/Were you/Was (SP)] enrolled in a Medicaid
Managed Care Plan [as of (DATE OF DEATH)/(DATE OF
INSTITUTIONALIZATION)/(MEDICAID COVERAGE STOP
DATE)/the date [your/(SP’s)] Medicaid coverage stopped]?

HIQ

HI10B

HIQ

HI10C

As far as you can recall, [were you/was (SP)] given a choice to
enroll in a Medicaid Managed Care Plan, or did (you/he/she) have
to enroll to receive Medicaid benefits?
Why [do you/does (SP)] no longer receive (your/his/her) Medicaid
benefits through a managed care plan?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

28

RECORD VERBATIM.

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI10C1

(Some people who receive Medicaid benefits are also enrolled in a
Medicare Prescription Drug plan, or Medicare Part D plan, that
pays for some or all of their prescribed medicines. The Medicare
program automatically enrolls such beneficiaries into a Medicare
Prescription Drug plan, although the beneficiary may choose to
switch to a different prescription plan.)At any time [since
(REFERENCE DATE)/between (REFERENCE DATE) AND (DATE
OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
been/has (SP) been/was (SP)] enrolled in a Medicare Prescription
Drug plan that (covers/covered) medicines prescribed by a doctor?

HIQ

HI10C2

HIQ

HI10C3

[Are you/Is (SP)/Was (SP)] (currently) covered by or enrolled in a
Medicare Prescription Drug plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
[What is the name of the Medicare Prescription Drug plan that
(currently covers/covered) [you/(SP)] [on (DATE OF
DEATH)/(DATE OF INSTITUTIONALIZATION)]?]

HIQ

HI10C4

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Prescription
Drug plans besides (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)?[PROBE IF NECESSARY: Please include Medicare
Prescription Drug plans [you were/(SP) was] automatically enrolled
in through Medicaid as well as any (you/he/she) enrolled in on
(your/his/her) own.]

29

SELECT OR ADD ONLY
ONE MEDICARE
PRESCRIPTION DRUG
PLAN AT THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIQ

Question Text

Interviewer Instructions II

HI10C5

Please tell me the names of (the other/all) Medicare Prescription
Drug plans that (you have/he has/she has) been enrolled in since
(REFERENCE DATE) [besides (CURRENT MEDICARE
PRESCRIPTION DRUG PLAN)].[PROBE IF NECESSARY: Please
include Medicare Prescription Drug plans [you were/(SP) was]
automatically enrolled in through Medicaid as well as any
(you/he/she) enrolled in on (your/his/her) own.]

SELECT OR ADD
MEDICARE
PRESCRIPTION DRUG
PLAN NAMES AT THIS
ROSTER.

HIQ

HI10D

HIQ

HIT1

(Does/Did) [your/(SP’s)] Medicaid plan cover medicines prescribed
by a doctor?
As you (may) know, the Department of Defense sponsors a
regionally managed health care program called TRICARE for active
duty and retired members of the uniformed Armed Forces, their
families, and survivors. Please look at this card. At any time [since
(REFERENCE DATE)/ between (PREVIOUS ROUND INTERVIEW
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
[have you/has (SP) been/was (SP)] enrolled in or covered by any
of these TRICARE plans?[EXPLAIN IF NECESSARY: You may
have received a reference card that looks like this (BACK OF
SHOWCARD HIT1).]

HIQ

HIT2

HIQ

HIT3

HIQ

HIT4

3/30/2010

Interviewer Instructions I

SHOW CARD HIT1

[At the time of the last interview [you were/(SP) was] covered by
TRICARE.] [Were you/Was (SP)] covered by TRICARE the whole
time between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION), or only part of the
time?
[[Are you/Is (SP)] now covered by TRICARE?] [Was (SP) covered
by TRICARE on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION?]
(Does/Did) [your/(SP’s)] TRICARE plan cover medicines prescribed
by a doctor?[PROBE: I am asking about the type of insurance
coverage that [you personally have/(SP) personally has], not what
the plan offers everyone.]

30

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

HIQ

HIT4A1

SHOW CARD HIT2

HIQ

HIT11

Where [do you/does (SP)/did you/did (SP)] usually obtain
(your/his/her) medicines? [Do you/Does (SP)/Did you/Did (SP)]
usually obtain them at a TRICARE mail order pharmacy (TMOP), a
TRICARE retail pharmacy network pharmacy (TRRx), a military
treatment facility pharmacy (MTF), a non-network retail pharmacy,
or somewhere else?
[We recorded that [you/(SP)] served in the Armed Forces of the
United States.] Since (REFERENCE DATE), [have you/has (SP)
received/did (SP) receive] health care or health services or
prescribed medicines at a Military Treatment Facility or MTF?
[EXPLAIN IF NECESSARY: A Military Treatment Facility is any
military hospital, clinic, or NAVCARE clinic.]

HIQ

HI36

HIQ

HI11PREV

3/30/2010

Interviewer Instructions II

[We recorded that [you/(SP)] served in the Armed Forces of the
United States.] Since (REFERENCE DATE), [have you/has (SP)
received/did (SP) receive] health care or health services or
prescribed medicines through the Department of Veterans Affairs or
V.A.?
The next questions are about public plans [you were/(SP) was]
covered by as of (REFERENCE DATE).

31

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI11

At any time [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)]
covered by any public program other than Medicaid that pays for
medical care [for example, a public program that pays for
prescribed medicines/for example (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM), a public program that pays for
prescribed medicines/for example (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM1) or (STATE PHARMACEUTICAL
ASSISTANCE PROGRAM2)/for example (STATE
PHARMACEUTICAL ASSISTANCE PROGRAM1), (STATE
PHARMACEUTICAL ASSISTANCE PROGRAM2), or (STATE
PHARMACEUTICAL ASSISTANCE PROGRAM3), public programs
that pay for prescribed medicines]?

HIQ

HI12

What is the name of each of the public programs other than
Medicaid that covered [you/(SP)]?

HIQ
HIQ

HI12_IN
HI13

HIQ

HI14

HIQ

HI15

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[At the time of the last interview [you were/(SP) was] covered by
(PUBLIC PLAN NAME).] [Were you/Was (SP)] covered by
(PUBLIC PLAN NAME) the whole time between (REFERENCE
DATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION), or only part of the time?
[[Are you/Is (SP)] now covered by (PUBLIC PLAN NAME)?] [Was
(SP) covered by (PUBLIC PLAN NAME) on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?]
On what date did [your/(SP’s)] (PUBLIC PLAN NAME) coverage
start between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?

32

SELECT OR ADD ALL
PUBLIC PROGRAM
NAMES AT THIS ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI16

On what date [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [your/(SP’s)] (PUBLIC PLAN NAME)
coverage (most recently/last) stop?

HIQ

HI16A

HIQ

HI16AB

HIQ

HI16AC

(Does/Did) [your/(SP’s)] (PUBLIC PLAN NAME) plan cover
medicines prescribed by a doctor?
At the time of the last interview [you were/(SP) was] covered by
(MEDICARE PRESCRIPTION DRUG PLAN NAME).[[Are you/Is
(SP)] now covered by (MEDICARE PRESCRIPTION DRUG PLAN
NAME)?] [Was (SP) covered by (MEDICARE PRESCRIPTION
DRUG PLAN NAME) on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)?]
What is the most important reason [you/(SP)] stopped the
(MEDICARE PRESCRIPTION DRUG PLAN NAME) coverage?

HIQ

HI16AD

HIQ

HI16B

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Prescription
Drug plans besides (MEDICARE PRESCRIPTION DRUG PLAN
CURRENT LAST ROUND)?
(Medicare beneficiaries can receive insurance coverage for
prescription drugs through Medicare Prescription Drug plans. These
plans are also called "Medicare Part D" plans.)At any time since
(REFERENCE DATE), [have you/has (SP)/had (SP)] been enrolled
in a Medicare Prescription Drug plan that (covers/covered)
medicines prescribed by a doctor?

33

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI16B1

You mentioned that [you have/(SP) has/(SP) had] not been enrolled
in a Medicare Prescription Drug plan associated with (your/his/her)
Medicaid coverage.At any time since (REFERENCE DATE), [have
you/has (SP)/had (SP)] been enrolled in a Medicare Prescription
Drug plan in any way other than through Medicaid?

HIQ

HI16C

HIQ

HI16E

[Are you/Is (SP)/Was (SP)] (currently) covered by or enrolled in a
Medicare Prescription Drug plan [on (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
[What is the name of the Medicare Prescription Drug plan that
SELECT OR ADD ONLY
(currently covers/covered) [you/(SP)] [on (DATE OF DEATH/DATE ONE MEDICARE
OF INSTITUTIONALIZATION)]?]
PRESCRIPTION DRUG
PLAN AT THIS ROSTER.

HIQ

HI16F

HIQ

HI16G

HIQ

HI17PREV

HIQ

HI17PREV_IN

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/ INSTITUTIONALIZATION)], [have you/has
(SP)/had (SP)] been covered by any other Medicare Prescription
Drug plans besides (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)?
[Besides (CURRENT PRESCRIPTION DRUG PLAN), what
other/Besides (PREVIOUS ROUND PRESCRIPTION DRUG PLAN),
what other/What] Medicare Prescription Drug plans covered
[your/(SP’s)] medicines since (REFERENCE DATE)?
The next questions are about private plans [you were/(SP) was]
covered by as of (REFERENCE DATE).

34

SELECT OR ADD
MEDICARE
PRESCRIPTION DRUG
PLAN NAMES AT THIS
ROSTER.

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI17

We’ve talked about [READ PLAN(S) LISTED ABOVE].(Now, I would
like to ask about other types of health insurance.) At any time
[since (REFERENCE DATE)/between (PREVIOUS ROUND
INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP) been/was (SP)]
covered by (any other) private health insurance or private managed
care (plan/plans)? By "private", I mean a supplemental or Medigap
plan, or a plan that is provided by a former or current employer.
Such plans cover the cost of hospital or doctor visits, prescribed
medicines, or dental care.

HIQ

HI19

HIQ

HI20

Some people who are eligible for Medicare have additional
coverage through a private insurance carrier. This is sometimes
referred to as Medigap or Medicare Supplement. At any time since
(REFERENCE DATE) did [you/(SP)] have this type of health
insurance coverage?
What is the name of each of the (other) private plans that
SELECT OR ADD ALL
(provide/provided) [your/(SP’s)] medical insurance coverage?
PRIVATE PLAN NAMES AT
THIS ROSTER.

HIQ
HIQ

HI20_IN
HI21

HIQ

HI22

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[At the time of the last interview [you were/(SP) was] covered by
(PRIVATE PLAN NAME).] [Were you/Was (SP)] covered by
(PRIVATE PLAN NAME) the whole time between (REFERENCE
DATE) and (today/ DATE OF DEATH/DATE OF
INSTITUTIONALIZATION), or only part of the time?
[[Are you/Is (SP)] now covered by (PRIVATE PLAN NAME)?] [Was
(SP) covered by (PRIVATE PLAN NAME) on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?]

35

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI23

HIQ

HI23A

HIQ

HI24

HIQ

HI25

HIQ

HI26

HIQ

HI27

HIQ

HI29

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

On what date did [your/(SP’s)] coverage under (PRIVATE PLAN
NAME) start between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)?
SHOW CARD HIMC2A

What is the most important reason [you/(SP)] decided to get
coverage through (PRIVATE PLAN NAME)?
On what date since [(REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [your/(SP’s)] coverage under
(PRIVATE PLAN NAME) stop?

CODE WITHOUT ASKING (Is/Was) this a managed care plan, such as an HMO (Health
IF VOLUNTEERED.
Maintenance Organization) or PPO (Preferred Provider
Organization)?[EXPLAIN IF NECESSARY: Managed care plans
generally provide a full range of health care services for a prepaid
fee. Health care is generally provided by primary care doctors,
specialists, or hospitals on the plan’s list (network) except in an
emergency.]
Who (is/was) listed as the main insured person on the (PRIVATE
SELECT OR ADD ONLY
PLAN NAME) policy or contract?
ONE PERSON.
For the (PRIVATE PLAN NAME) plan, did [you/(MIP)] sign up
directly, or did [you/(MIP)] get this insurance through a current
employer, a former employer, a union, a family business, AARP, or
some other way?
How many family members, including [yourself/(SP)], (are/were)
covered by [your/(MIP’s)] (PRIVATE PLAN NAME)?

36

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI30

Supplemental insurance plans may cover a variety of services or
may be specific to only certain services, such as prescribed
medicines or dental coverage. I’d like to know what [your/(SP’s)]
(PLAN NAME) coverage (includes/included).[PROBE: I am asking
about the type of insurance coverage that [you/(SP)] personally
(have/has/had), not what the plan offers everyone.](Does/Did)
[your/(MIP’s)] (PRIVATE PLAN NAME) plan cover prescribed
medicines?

HIQ

HI31A

HIQ

HI32

HIQ

HI33

(Does/Did) [your/(MIP’s)] (PRIVATE PLAN NAME) cover...[PROBE
IF NECESSARY: I am asking about the type of insurance coverage
that [you/(SP)] personally (have/has/had), not what the plan offers
everyone.]
(Do/Does/Did) [you/(MIP)] pay any or all of the premium or cost for
the (PRIVATE PLAN NAME) coverage?[Do not include the cost of
any deductibles [you/(SP)] or [your/(SP’s)] family may (have/have
had) to pay.]
How much (do/does/did) [you/(MIP)] pay for the (PRIVATE PLAN
NAME) coverage?[Please do not include any amount that may be
paid for anyone other than [you/(SP)].][PROBE IF NECESSARY:
(Is/Was) that per year, per month, per week, or what?]

HIQ

HI33A

(Does/Did) anyone else, such as an employer, a union or
professional organization pay all or some portion of the premium or
cost for [your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

HIQ

HI33B

Who else (pays/paid) all or some portion of the cost for
[your/(MIP’s)] (PRIVATE PLAN NAME) coverage?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

37

Current MCBS Questionnaire

Category

ItemTag

HIQ

HI33C

Some managed care plans offer a point-of-service option which
allows members to receive services from out-of-plan providers
even in non-emergency situations. (Are/Were/Is/Was) [you/(SP)]
enrolled in a point-of-service option offered by (PRIVATE PLAN
NAME)?[EXPLAIN IF NECESSARY: In a point-of-service option,
the member typically pays a higher copayment when seeing an outof-plan provider. For example, if a member sees an in-plan
provider, there may only be a $10 copayment. However, the
member may have to pay 20 percent of the cost and the managed
care plan will pay 80 percent of the cost to receive the same
service from an out-of-plan provider.]

HIQ

HI35

HIQ

HI34

We’ve talked about [READ PLAN(S) LISTED ABOVE]. [Do
you/Does (SP)/Did (SP)] have medical coverage under any (other)
private insurance plans we haven’t talked about?
[Other than the plans you have already told me about, [do you/does
(SP)/did (SP)]/[Do you/Does (SP)/Did (SP)]] have any insurance
that (pays/paid) just for nursing home care or other long term care?

DMQ

DM1INT

DMQ

DM1_IN

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Now, I'd like to ask about another type of health care coverage that
[you/(SP)] reported during the last interview.

38

Current MCBS Questionnaire

Category

ItemTag

DMQ

DM1

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.]

DMQ

DM2INTRO

DMQ

DM2

I’d like to ask about (a/another) type of health care coverage that
some people have.
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 non-health 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.])

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

39

Current MCBS Questionnaire

Category

ItemTag

DMQ

DM3

DMQ
DMQ

DM3_IN
DM4

DMQ

DM5

DMQ
DMQ

DM6
DM6A

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

What is the name of the discount savings membership or
ADD ALL DISCOUNT
coverage? If you have a card or other paper that shows the name, MEMBERSHIPS AT THIS
it would be helpful for me to enter the name from that.
ROSTER.
SHOW CARD DM1

What types of services are covered by [your/(SP’s)] (DISCOUNT CHECK ALL THAT APPLY.
MEMBERSHIP NAME) discount savings membership or coverage?
(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.
What is the fee or charge?

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.

40

Current MCBS Questionnaire

Category

ItemTag

DMQ

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]?

DUQ

DUINTRO

The next questions are about any medical care [you/(SP)] may
have had between (REFERENCE DATE) and (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION). (Now would be a
good time to get out the planner that [you/(SP)] may have used to
record health care visits or other medical expenses.)First we’ll talk
about dental care.

DUQ

DU1

DUQ

DU2

DUQ

DU3

DUQ

DU4

DUQ

DU5

DUQ

DU5B

3/30/2010

Interviewer Instructions I

SHOW CARD DU

Question Text

Interviewer Instructions II

Please look at this card. [Since (REFERENCE DATE)/Between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] go to a dentist or any
other person for dental care? [Dental providers include dentists,
dental surgeons, endodontists, periodontists, and dental
hygienists.]
Who did [you/(SP)] see?

SELECT OR ADD ONLY
ONE PROVIDER.

Is (PROVIDER NAME) associated with a Department of Veterans
Affairs, or V.A., facility?
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not see a dental SCROLL DOWN TO SEE
provider associated with [READ MANAGED CARE PLAN NAME(S) RESPONSE
BELOW] or a dental provider that [READ MANAGED CARE PLAN CATEGORIES.
NAME(S) BELOW] would refer [you/(SP)] to?

41

Current MCBS Questionnaire

Category

ItemTag

DUQ

DU6

DUQ
DUQ

DU6_IN
DU7

DUQ
DUQ

DU8
DU9

DUQ
DUQ

DU10
DU10A

DUQ

DU11

Please tell me the names of these medicines.

DUQ

DU14

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other dental care visits to this or any other
provider?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

When did [you/(SP)] see (PROVIDER NAME)? Please tell me all
ENTER ALL DATES.
the dates [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)]
CHECK ALL THAT APPLY.
have done?
Were X-rays taken on (any of these visits/this visit)?
Were any medicines prescribed for [you/(SP)] during (this visit/any
of these visits)?
Were any of the prescriptions filled?
It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which should have that
same information on them.][IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.

42

ENTER ALL
MEDICINES.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

Current MCBS Questionnaire

Category

ItemTag

ERQ

ER1

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
gone/has (SP) gone/did (SP) go] to a hospital emergency room for
medical care?

ERQ

ER2

Where did [you/(SP)] go (to which hospital)?

ERQ

ER3

ERQ

ER3A

ERQ

ER3B

ERQ

ER3D

Is (PROVIDER NAME) a Department of Veterans Affairs, or V.A.,
facility?
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not go to an
emergency room associated with [READ MANAGED CARE PLAN
NAME(S) BELOW] or an emergency room that [READ MANAGED
CARE PLAN NAME(S) BELOW] would refer [you/(SP)] to?

ACQ

AC7

ERQ

ER4

ERQ
ERQ

ER4_IN
ER6

ERQ

ER7

ERQ

ER8

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

SELECT OR ADD ONLY
ONE HOSPITAL.

SCROLL DOWN TO SEE
RESPONSE
CATEGORIES.

[Were you/Was (SP)] admitted to the hospital from the emergency
room?
ENTER ALL DATES.
When did [you/(SP)] go to the emergency room at (PROVIDER
NAME)?Please tell me all the dates [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)].
[Were you/Was (SP)] admitted to (PROVIDER NAME) from the
emergency room?
During [your/(SP’s)] visit to the emergency room, were any
medicines prescribed for [you/(SP)]?
Were any of the prescriptions filled?

43

Current MCBS Questionnaire

Category

ItemTag

ERQ

ER8A

It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which should have that
same information on them.][IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.

ERQ

ER9

Please tell me the names of these medicines.

ERQ

ER10

IPQ

IPS1

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to the emergency room at this or
any other hospital?
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on
(ADMISSION DATE) and (were/was) still a patient there on
(REFERENCE DATE). When [were you/was (SP)] discharged from
(HOSPITAL NAME) for that stay?

IPQ

IP1A

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

You told me [you were/(SP) was] admitted to (HOSPITAL NAME)
from the emergency room on (ADMISSION DATE). When [were
you/was (SP)] discharged from (HOSPITAL NAME) for the stay that
started on (ADMISSION DATE)?

44

ENTER ALL
MEDICINES.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING. INCLUDE
STRENGTH WITH NAME.

Current MCBS Questionnaire

Category

ItemTag

IPQ

Question Text

Interviewer Instructions II

IP1

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
been/has (SP) been/was (SP)] [admitted to a hospital/admitted any
other time to this or any other hospital] as an inpatient -- either for
an overnight stay or for a "same day" procedure?

IF HAD SAME DAY
PROCEDURE AND IS NOT
SURE IF ADMITTED OR
NOT, TREAT AS
OUTPATIENT EVENT AND
ENTER WHEN YOU GET
TO OP UTILIZATION.

IPQ

IP2

Where [were you/was (SP)] admitted -- to which hospital?

SELECT OR ADD ONLY
ONE HOSPITAL.

IPQ

IP3

IPQ

IP3A

IPQ

IP3B

IPQ

IP3D

IPQ

IP4

IPQ

IP4_ERR

IPQ

IP7

IPQ

IP10

Is (HOSPITAL NAME) a Department of Veterans Affairs, or V.A.,
facility?
Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
SCROLL DOWN TO SEE
What is the most important reason [you/(SP)] did not go to a
hospital associated with [READ MANAGED CARE PLAN NAME(S) RESPONSE
CATEGORIES.
BELOW] or a hospital that [READ MANAGED CARE PLAN
NAME(S) BELOW] would refer [you/(SP)] to?
When [were you/was (SP)] admitted to and discharged from
(HOSPITAL NAME)?
INVALID DATE. THIS DATE OVERLAPS AN EXISTING IP STAY
FROM (ADMISSION DATE) TO [(DISCHARGE DATE)/SP STILL IN
HOSPITAL].
Were any operations performed on [you/(SP)] during the hospital
stay that was (ADMISSION DATE) to (DISCHARGE DATE)?
[Operations include surgery and other surgical procedures like
setting bones, stitching or removing growths, or any cutting of the
skin.]
Was this hospital stay for any specific condition?

3/30/2010

Interviewer Instructions I

45

Current MCBS Questionnaire

Category

ItemTag

IPQ

IP12

IPQ

IP13

IPQ
IPQ

IP14
IP14A

IPQ

IP15

IPQ

IP16

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

During this hospitalization, did [you/(SP)] have any special or
private duty nursing care?
At the time [you were /(SP) was] discharged, were any medicines
prescribed for [you/(SP)]?
Were any of the prescriptions filled?
It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which should have that
same information on them.] [IF RESPONDENT HAS BOTTLE,
ASK:] I’ll need that same information for all of the medicines
[you/(SP)] obtained since the last interview, if you’d like to get
those bottles, too.

IF RESPONDENT HAS
ALREADY MENTIONED
ANOTHER INPATIENT
STAY, ENTER “YES”
WITHOUT ASKING.
OTHERWISE, ASK:

Please tell me the names of these medicines.

ENTER ALL
MEDICINES.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
had/has (SP) had/did (SP) have] any other admissions to this or
any other hospital as an inpatient -- either for an overnight stay or
for a "same day" procedure?

IF HAD SAME DAY
PROCEDURE AND IS NOT
SURE IF ADMITTED OR
NOT, TREAT AS
OUTPATIENT EVENT AND
ENTER WHEN YOU GET
TO OP UTILIZATION.

46

Current MCBS Questionnaire

Category

ItemTag

OPQ

OP1

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
gone/has (SP) gone/did (SP) go] to the outpatient department or
the outpatient clinic at any hospital for medical care?

OPQ

OP2

Where did [you/(SP)] go (to which hospital)?

OPQ

OP3

OPQ

OP3A

OPQ

OP3B

OPQ

OP3D

OPQ

OP4

Is (HOSPITAL NAME) a Department of Veterans Affairs, or V.A.,
facility?
Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not go to a
hospital outpatient department associated with [READ MANAGED
CARE PLAN NAME(S) BELOW] or a hospital outpatient department
that [READ MANAGED CARE PLAN NAME(S) BELOW] would refer
[you/(SP)] to?
When did [you/(SP)] go to an outpatient department at (HOSPITAL
NAME)? Please tell me all the dates [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)].

OPQ
OPQ

OP4_IN
OP5

OPQ

OP8

OPQ

OP10

OPQ

OP11

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Were any operations or other surgical procedures performed on
[you/(SP)] during (any of the/the) [VISIT ON EVENT
DATE]?[Operations include surgery and other surgical procedures
like setting bones, stitching or removing growths, or any cutting of
the skin.]
(Was this visit/Were any of these visits) to the outpatient
department for any specific condition?
During (this visit/any of these visits) to the outpatient department,
were any medicines prescribed for [you/(SP)]?
Were any of the prescriptions filled?

47

SELECT OR ADD ONLY
ONE HOSPITAL.

SCROLL DOWN TO SEE
RESPONSE
CATEGORIES.

ENTER ALL DATES.

Current MCBS Questionnaire

Category

ItemTag

OPQ

OP11A

It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which should have that
same information on them.][IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.

OPQ

OP12

Please tell me the names of these medicines.

OPQ

OP15

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to the outpatient department at this
or any other hospital for services?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

48

ENTER ALL
MEDICINES.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

Interviewer Instructions II

IUQ

IU1

SHOW CARD IU

[Since (REFERENCE DATE), [have you/has (SP)] been/Between
(REFERENCE DATE) and (DATE OF DEATH), was (SP)/Other than
the current institutional stay that started on (DATE OF
INSTITUTIONALIZATION), between (REFERENCE DATE) and
(DATE OF INSTITUTIONALIZATION) was (SP)] a patient in
(a/another) nursing home or any similar place that provides longterm care -- such as the places shown on this card?

LONG-TERM CARE
PLACES INCLUDE
SKILLED NURSING
HOMES, INTERMEDIATE
CARE FACILITIES,
BOARD AND CARE
HOMES, NURSING HOME
UNITS IN HOSPITALS,
FACILITIES FOR THE
MENTALLY RETARDED,
PSYCHIATRIC FACILITIES
AND GROUP HOMES.

IUQ

IU2

Where [were you/was (SP)] a patient -- in which nursing home?

SELECT OR ADD ONLY
ONE FACILITY.

IUQ

IU3

IUQ

IU4

IUQ

IU7

3/30/2010

Is (FACILITY NAME) a Department of Veterans Affairs, or V.A.,
facility?
When [were you/was (SP)] admitted to and discharged from
(FACILITY NAME)?
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
IF RESPONDENT HAS
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
ALREADY MENTIONED
had/has (SP) had/did (SP) have] any other stays in this or any
ANOTHER STAY AT A
NURSING HOME, ENTER other nursing home or similar place that provides long-term care?
“YES” WITHOUT ASKING.
OTHERWISE, ASK:

49

Current MCBS Questionnaire

Category

ItemTag

HHS

HHS1

We recorded that [you/(SP)] had been helped at home by
(someone from) [READ PROVIDER BELOW] between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE). Has (anyone
from) [READ PROVIDER BELOW] helped [you/(SP)] at home
(since REFERENCE DATE/between REFERENCE DATE and
DATE OF DEATH/ INSTITUTIONALIZATION)?

HHS

HHS2

HHS

HHS3

We recorded that [you/(SP)] had received personal care or help
with daily needs at home from (someone from) [READ PROVIDER
BELOW] between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE). [Have you/Has (SP)] received personal
care or help with daily needs at home from (anyone from) [READ
PROVIDER BELOW] (since REFERENCE DATE/between
REFERENCE DATE and DATE OF DEATH/
INSTITUTIONALIZATION)?
Since (REFERENCE DATE), has (PROVIDER NAME) provided any
services to [you/(SP)] other than delivering meals?

HHQ

HH1

3/30/2010

Interviewer Instructions I

SHOW CARD HH1

Question Text

Interviewer Instructions II

(Besides what you have already mentioned,) [(Since/since)
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have
you been/has (SP) been/was (SP)] helped at home by any (other)
health or medical professionals, such as those listed on this card?
[Health professionals include nurse (visiting nurse, private duty
nurse, etc.), doctor, social worker, therapist, and hospice worker.]

50

Current MCBS Questionnaire

Category

ItemTag

HHQ

Question Text

Interviewer Instructions II

HH2

What is the name of the health professional who helped [you/(SP)]
at home [since (REFERENCE DATE)/between (PREVIOUS
ROUND INTERVIEW DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?

ENTER NAME OF
PERSON WHO HELPED.
DO NOT ENTER THE
NAME OF PLACE OR
ORGANIZATION.ADD OR
SELECT ONLY ONE
PROVIDER.

HHQ
HHQ

HH3
HH4

HHQ

HH5

HHQ
HHQ

HH6
HH7

What kind of health professional is (PROVIDER NAME)?
Who does (PROVIDER NAME) work for, that is, for what place or
organization?[PROBE: Or does (PROVIDER NAME) work for
himself/herself?]
[Who does (PROVIDER NAME) work for, that is, what place or
organization?][PROBE: Who would (you/SP) call if (PROVIDER
NAME) did not show up?]
What kind of place or organization is (PROVIDER NAME)?
[Between (REFERENCE DATE) and (today/DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], did (PROVIDER NAME)
provide any services to [you/(SP)] other than delivering meals?

HHQ

HH8

HHQ

HH10A

HHQ

HH10B

HHQ

HH10D

3/30/2010

Interviewer Instructions I

Is [(PROVIDER NAME) associated with/(PROVIDER NAME)] a
Department of Veterans Affairs, or V.A., facility?
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not see a home
health provider associated with [READ MANAGED CARE PLAN
NAME(S) BELOW] or a home health provider that [READ
MANAGED CARE PLAN NAME(S) BELOW] would refer [you/(SP)]
to?

51

ADD OR SELECT ONLY
ONE PROVIDER.

SCROLL DOWN TO SEE
RESPONSE
CATEGORIES.

Current MCBS Questionnaire

Category

ItemTag

HHQ

HH11

[Between (REFERENCE DATE) and (today/DATE OF DEATH/
DATE OF INSTITUTIONALIZATION)], how many times (has/did)
[(PROVIDER NAME)/someone from (PROVIDER NAME)] come to
the home to help [you/(SP)]? [Remember to include all home health
providers from (PROVIDER NAME).]

HHQ

HH12

HHQ

HH13

SHOW CARD HH2

(Generally speaking, how long did/Generally speaking, how long
does/How long did)[PROVIDER NAME)/someone from (PROVIDER
NAME)] stay with [you/(SP)]? [INCLUDE TIME SPENT SHOPPING
OR RUNNING ERRANDS.][PROBE: We just need to know in
general.]
(Generally speaking, did/Generally speaking, does/Did)
[(PROVIDER NAME)/someone from (PROVIDER NAME)] help
[you/(SP)] by giving any medical or nursing treatment, such as the
things shown on this card? ["MEDICAL OR NURSING
TREATMENT" MEANS SUCH THINGS AS APPLYING STERILE
BANDAGES OR DRESSINGS, GIVING MEDICATIONS, TAKING
BLOOD PRESSURE, GIVING SHOTS OR INJECTIONS.] [PROBE:
We just need to know in general.]

HHQ

HH14

SHOW CARD HH3

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

(Generally speaking, did/Generally speaking, does/Did)
[(PROVIDER NAME)/someone from (PROVIDER NAME)] help with
[your/(SP’s)] daily needs by doing things, such as the ones shown
on this card? [HELP WITH DAILY NEEDS MEANS HELP IN
USING THE TELEPHONE, DOING HOUSEWORK, PREPARING
MEALS.][PROBE: We just need to know in general.]

52

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

HHQ

HH15

SHOW CARD HH4

(Generally speaking, did/Generally speaking, does/Did)
[(PROVIDER NAME)/someone from (PROVIDER NAME)] help with
[your/(SP’s)] personal care by doing things such as those shown on
this card? [HELP WITH PERSONAL CARE MEANS HELP WITH
BATHING, SHOWERING, DRESSING, EATING, WALKING, USING
THE TOILET.][PROBE: We just need to know in general.]

HHQ

HH16

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have you
been/has (SP) been/was (SP)] helped at home by any other health
professionals?

HHQ

HH17

HHQ

HH18

Other than the persons who (have) visited [you/(SP)] from
(PROVIDER NAME) [or from the other(s) we’ve talked about], [have
you been/has (SP) been/was (SP)] helped at home by any other
health professionals [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]? [DON’T INCLUDE ANY OTHER
PERSONS COMING FROM THE SAME ORG/AGENCY LISTED
BELOW]
(Besides what you have already talked about, [(Since/since)
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
because of health problems [have you/has (SP)/did (SP)]
(received/receive) any personal care or help at home with daily
needs from (any other) persons who (do/did) not live with
(you/him/her), including home health aides, homemakers, friends,
neighbors, or relatives?

3/30/2010

SHOW CARD HH5

Interviewer Instructions II

53

Current MCBS Questionnaire

Category

ItemTag

HHQ

Question Text

Interviewer Instructions II

HH19

Who helped [you/(SP)]? What is the name of the person who
helped (you/him/her)?

ENTER NAME OF
PERSON WHO HELPED.
DO NOT ENTER THE
NAME OF THE PLACE OR
ORGANIZATION.SELECT
OR ADD ONLY ONE
PERSON. DO NOT
ENTER A PERSON WHO
LIVES WITH THE SP.

HHQ

HH20

HHQ
HHQ

HH21
HH28

Is (PROVIDER NAME) a friend or neighbor, a relative, or some
other type of home health provider?
How is (PROVIDER NAME) related to [you/(SP)]?
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], [have
you/has (SP)/did (SP)] (received/receive) personal care or help at
home with daily needs from any other persons who (do/did) not live
with (you/him/her)?

HHQ

HH29

3/30/2010

Interviewer Instructions I

Other than the persons who have visited [you/(SP)] from
(PROVIDER NAME) [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], [have you/has (SP)/did (SP)]
(received/receive) personal care or help at home with daily needs
from any other persons who (do/did) not live with (you/him/her)?
[DON’T INCLUDE ANY OTHER PERSONS COMING FROM THE
SAME ORG/AGENCY LISTED BELOW.]

54

Current MCBS Questionnaire

Category

ItemTag

MPQ

Question Text

Interviewer Instructions II

MP1

(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) any medical doctors?

INCLUDE ANY VISITS
FOR TESTS/X-RAYS.SEE
REFERENCE CARD FOR
TYPES OF MEDICAL
DOCTORS, IF
NECESSARY.

MPQ

MP2

Who did [you/(SP)] see?

SELECT OR ADD ONLY
ONE PROVIDER.

MPQ

MP2A

What kind of (health practitioner/mental health
professional/therapist/medical person) is (PROVIDER NAME)?

MPQ

MP3

MPQ

MP4

MPQ

MP5

MPQ

MP5B

MPQ

MP6

Is (PROVIDER NAME) associated with a Department of Veterans
Affairs, or V.A., facility?
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ
MANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not see a doctor
associated with [READ MANAGED CARE PLAN NAME(S) BELOW]
or a doctor that [READ MANAGED CARE PLAN NAME(S) BELOW]
would refer [you/(SP)] to?
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all
the dates [since (REFERENCE DATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].

MPQ
MPQ

MP6_IN
MP6B

3/30/2010

Interviewer Instructions I

We have recorded that in (EVENT MONTH) [you were/(SP) was]
also in [READ EVENT(S) LISTED BELOW]. Was this visit with
(PROVIDER NAME) a visit while [you were/(SP) was] in [the
[READ EVENT LISTED BELOW]/any of these places]?

55

SCROLL DOWN TO SEE
RESPONSE
CATEGORIES.
ENTER ALL DATES.

Current MCBS Questionnaire

Category

ItemTag

MPQ

MP7

MPQ

MP10

MPQ

MP12

MPQ
MPQ

MP13
MP13A

Were any operations performed on [you/(SP)] during (any of
the/the) [VISIT ON EVENT DATE]?[Operations include surgery and
other surgical procedures like setting bones, stitching or removing
growths, or any cutting of the skin.]
(Was this visit/Were any of these visits) to (PROVIDER NAME) for
any specific condition?
During (this visit/any of these visits) to (PROVIDER NAME), were
any medicines prescribed for [you/(SP)]?
Were any of the prescriptions filled?
It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, please take out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLAN NAME) medicine statements, which should have that
same information on them.][IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.

MPQ

MP14

Please tell me the names of these medicines.

MPQ

MP17

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this doctor or any other medical
doctor?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

56

ENTER ALL MEDICINE
NAMES.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING. INCLUDE
STRENGTH WITH NAME.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

MPQ

MP18

SHOW CARD MP1

INCLUDE ANY VISITS
(Besides what you have already mentioned), [(Since/since
FOR TESTS/X-RAYS.
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) a health practitioner like any of
the ones listed on this card? [Health practitioners include
acupuncturist, audiologist, optometrist, chiropractor, podiatrist (foot
doctor), homeopath, naturopath, or any other kind of health provider
who is not a medical doctor.]

MPQ

MP25

MPQ

MP26

MPQ

MP33

3/30/2010

SHOW CARD MP2

Interviewer Instructions II

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this practitioner or any other
health practitioner?
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) a mental health professional like
any of the ones listed on this card? [Mental health professional
includes psychiatrist, psychologist, clinical social worker, and
licensed professional counselor.]
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this professional or any other
mental health professional?

57

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

MPQ

MP34

SHOW CARD MP3

(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) a therapist like any of the ones
listed on this card? [Therapist includes physical therapist, speech
therapist, intravenous (IV) therapist, massage therapist,
occupational therapist, and respiratory therapist.]

MPQ

MP41

MPQ

MP42

MPQ

MP49

MPQ

MP50

3/30/2010

SHOW CARD MP4

SHOW CARD MP5

Interviewer Instructions II

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this therapist or any other
therapist?
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (seen/see) any other medical persons like
the ones listed on this card? [Other medical persons include nurse,
nurse practitioner, paramedic, and physician’s assistant.]
[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this person or any other medical
person?
(Besides what you have already mentioned), [(Since/since
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION), [have
you/has (SP)/did (SP)] (visited/visit) any other types of medical
places like the ones listed on this card? [Other types of medical
places include health clinic, neighborhood health center, rural health
clinic, infirmary, mental health clinic, urgent care center, or any
other place.]

58

INCLUDE ANY VISITS
FOR TESTS/X-RAYS. DO
NOT INCLUDE
PARAMEDIC IF ONLY
AMBULANCE SERVICES
WERE PROVIDED.

Current MCBS Questionnaire

Category

ItemTag

MPQ

MP56

OMQ

OM1

OMQ

OM2

OMQ
OMQ

OM2_IN
OM2A

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Since (REFERENCE DATE)/Between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)], did
[you/(SP)] have any other visits to this place or any other type of
medical place?
Next I’m going to ask you about other medical expenses that
[you/(SP)] may have had between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION). [Since (REFERENCE DATE/SURVEY
REFERENCE DATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] buy, replace, or pay for
repairs of eyeglasses or contact lenses?
SELECT OR ADD ALL
When did [you/(SP)] buy or repair glasses or contact lenses?
DATES AT THIS ROSTER. Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].
On (EVENT DATE), did [you/(SP)] buy or repair the glasses or
contact lenses at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ
MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This could
include buying or repairing the glasses or lenses at a plan center;
at an optician, optometrist or other place that honors [your/(SP’s)]
plan card; or through a place or service that the plan referred
[you/(SP)] to.]

59

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

OMQ

OM3

OMQ

OM4

[Since (REFERENCE DATE/SURVEY REFERENCE
DATE)/Between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [you/(SP)] buy, replace, or pay for repairs of a hearing aid,
amplifier for a telephone, or similar device to help [you/(SP)] hear
or speak?
SELECT OR ADD ALL
When did [you/(SP)] buy or repair a hearing or speech device?
DATES AT THIS ROSTER. Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].

OMQ
OMQ

OM4_IN
OM4A

OMQ

OMS5INTR

OMQ
OMQ

OMS5_IN
OMS5

3/30/2010

Question Text

Interviewer Instructions II

On (EVENT DATE), did [you/(SP)] buy or repair the hearing or
speech device at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ
MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This could
include buying or repairing the hearing or speech device at a plan
center; from an audiologist, speech pathologist, or other provider
that honors [your/(SP’s)] plan card; or through a place or service
that the plan referred [you/(SP)] to.]
The next questions are about orthopedic items [you were/(SP)
was] renting as of (REFERENCE DATE).
At the time of the last interview, [you were/(SP) was] renting
(ORTHOPEDIC ITEM). As of (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION), (was/were/is/are) the (ORTHOPEDIC
ITEM) being rented?

60

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

OMQ

OM5

SHOW CARD OM1

OMQ
OMQ

OM6
OM6A

OMQ

OM7

OMQ
OMQ

OM7_IN
OM7AA

OMQ

OM7A

OMQ

OM7B

3/30/2010

Question Text

Interviewer Instructions II

(Other than what we already talked about,) [(Since/since)
(REFERENCE DATE/SURVEY REFERENCE
DATE)/(Between/between) (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] buy, repair or rent (other)
orthopedic items, such as any of those listed on this card?
[Orthopedic items include crutches, canes, wheelchairs, walkers,
corrective shoes or inserts, support stockings, and braces or
supports.]
What was the item?
Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did
[you/(SP)] rent (it/them)?
SELECT OR ADD ALL
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)?
DATES AT THIS ROSTER. Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].
On (EVENT DATE), did [you/(SP)] buy (or repair) the
(ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ
MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This could
include buying or repairing the (ORTHOPEDIC ITEM) at a plan
center; at a place or store that honors [your/(SP's)] plan card; or
through a place or store that the plan referred [you/(SP)] to.]
ENTER ONLY ONE DATE
AT THIS ROSTER.

Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION] that [you/(SP)] rented the (ORTHOPEDIC
ITEM).
[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)?

61

Current MCBS Questionnaire

Category

ItemTag

OMQ

OM7C

OMQ

OM7CC

OMQ

OM7CCVB

OMQ

OM7D

Did [you/(SP)] rent the (ORTHOPEDIC ITEM) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount
offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?[PROBE: This could include renting the (ORTHOPEDIC
ITEM) at a plan center; at a place or store that honors [your/(SP’s)]
plan card; or through a place or service that the plan referred
[you/(SP]] to.]

OMQ

OM8

In addition to the orthopedic item(s) you just told me about, did
[you/(SP)] buy, repair, or rent any other orthopedic items [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)].?

OMQ

OM9

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

What was the last date the (ORTHOPEDIC ITEM) (were/was)
rented?
You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is
this because (you/he/she) no longer (have/has) that item or
because (you/he/she) (have/has) purchased it through a rent-to­
buy option?
RECORD VERBATIM.

BRIEFLY EXPLAIN WHY
SP STOPPED RENTING
THE (ORTHOPEDIC
ITEM).

SHOW CARD OM2

[Since (REFERENCE DATE/SURVEY REFERENCE
DATE)/Between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [you/(SP)] buy diabetic equipment or supplies, such as those
listed on this card? [Diabetic equipment or supplies include
syringes, test paper, test strips, and blood monitoring kits.]

62

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

OMQ

OM10

SELECT OR ADD ALL
When did [you/(SP)] buy diabetic equipment or supplies? Please
DATES AT THIS ROSTER. tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)].

OMQ
OMQ

OM10_IN
OM10A

OMQ

OM11

[Since (REFERENCE DATE/SURVEY REFERENCE
DATE)/Between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [you/(SP)] use any ambulance or rescue squad service?

OMQ

OM12

SELECT OR ADD ALL
When did [you/(SP)] use an ambulance? Please tell me all the
DATES AT THIS ROSTER. dates [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].

OMQ
OMQ

OM12_IN
OM12A

3/30/2010

Question Text

Interviewer Instructions II

On (EVENT DATE), did [you/(SP)] buy the diabetic equipment or
supplies at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?[PROBE: This could include
buying the diabetic equipment or supplies at a plan center; at a
place or store that honors [your/(SP’s)] plan card; or through a
place or store that the plan referred [you/(SP)] to.]

Was the ambulance on (EVENT DATE) provided by or approved by
[READ MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This
could mean that the ambulance was sent by the plan, or that
[you/(SP)] or someone for [you/(SP)] contacted the plan for them to
authorize or approve the use of the ambulance. This approval
could have come after the use of the ambulance.]

63

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

OMQ

OM13

SHOW CARD OM3

[Since (REFERENCE DATE/SURVEY REFERENCE
DATE)/Between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [you/(SP)] buy or pay for repairs of any prostheses, such as
those on the card? [Prostheses include artificial leg or arm,
mastectomy prosthesis, and artificial or glass eye.]

OMQ

OM14

SELECT OR ADD ALL
When did [you/(SP)] buy or repair the prosthesis? Please tell me
DATES AT THIS ROSTER. all the dates [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].

OMQ
OMQ

OM14_IN
OM14A

OMQ

OMS19INTR

OMQ
OMQ

OMS19_IN
OMS19

3/30/2010

Interviewer Instructions II

On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at
[READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?[PROBE: This could include buying or repairing
the prosthesis at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan
referred [you/(SP)] to.]
The next questions are about oxygen-related equipment [you
were/(SP) was] renting as of (REFERENCE DATE).
At the time of the last interview, [you were/(SP) was] renting
oxygen-related equipment. As of [today/(DATE OF DEATH)/(DATE
OF INSTITUTIONALIZATION)] (is/was) the oxygen-related
equipment being rented?

64

Current MCBS Questionnaire

Category

ItemTag

OMQ

OM19

OMQ
OMQ

OM19A
OM19B

OMQ

OM20

OMQ
OMQ

OM20_IN
OM20AA

OMQ

OM20A

OMQ

OM20B

OMQ

OM20C

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

(Other than what we already talked about,) [(Since/since)
(REFERENCE DATE/SURVEY REFERENCE
DATE)/(Between/between) (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] have any (other)
expenses for oxygen or supplies or oxygen-related equipment?
What was that?
Did [you/(SP)] buy or repair the oxygen-related equipment, or did
[you/(SP)] rent it?
SELECT OR ADD ALL
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygen­
DATES AT THIS ROSTER. related equipment)]? Please tell me the dates of each purchase
[since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].

On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN
ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?[PROBE: This could include
buying or repairing the (OXYGEN ITEM) at a plan center; at a place
or store that honors [your/(SP’s)] plan card; or through a place or
store that the plan referred [you/(SP)] to.]
SELECT OR ADD ONLY
ONE DATE AT THIS
ROSTER.

Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] that [you/(SP)] rented the oxygenrelated equipment.
[Are you/Is (SP)/Was (SP)] still renting the oxygen-related
equipment?
What was the last date the equipment was rented?

65

Current MCBS Questionnaire

Category

ItemTag

OMQ

OM20CC

OMQ

OM20CCVB

OMQ

OM20D1

OMQ

OM20D

OMQ

OMS21INTR

OMQ
OMQ

OMS21_IN
OMS21

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

You said [you/(SP)] stopped renting the oxygen-related equipment.
Is this because (you/he/she) no longer (have/has) the equipment or
because (you/he/she) (have/has) purchased it through a rent-to­
buy option?
RECORD VERBATIM.

BRIEFLY EXPLAIN WHY
SP STOPPED RENTING
THE OXYGEN-RELATED
EQUIPMENT.
Did [you/(SP)] rent the oxygen equipment at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount
offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?[PROBE: This could include renting the oxygen
equipment at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan
referred [you/(SP)] to.]
In addition to the [(oxygen or supplies)/(oxygen-related equipment)]
that you just told me about, did [you/(SP)] [(buy oxygen or
supplies)/(have any expenses for oxygen-related equipment)]?
The next questions are about kidney dialysis equipment [you
were/(SP) was] renting as of (REFERENCE DATE).
At the time of the last interview, [you were/(SP) was] renting
equipment for kidney dialysis. As of (today/DATE OF DEATH/DATE
OF INSTITUTIONALIZATION), (is/was) the equipment being rented?

66

Current MCBS Questionnaire

Category

ItemTag

OMQ

OM21

OMQ
OMQ

OM21A
OM21B

OMQ

OM22

OMQ
OMQ

OM22_IN
OM22AA

OMQ

OM22A

OMQ

OM22B

OMQ

OM22C

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

(Other than what we already talked about), [(Since/since)
(REFERENCE DATE/SURVEY REFERENCE
DATE)/(Between/between) (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)], did [you/(SP)] buy any (other) kidney
dialysis supplies or buy, rent, or repair any related equipment?
What was that?
Did [you/(SP)] buy or repair the dialysis equipment, or did
[you/(SP)] rent it?
SELECT OR ADD ALL
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or
DATES AT THIS ROSTER. repair kidney dialysis equipment)? Please tell me all the dates
[since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].

On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY
ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED
CARE PLAN NAME(S) BELOW]?[PROBE: This could include
buying (or repairing) the (KIDNEY ITEM) at a plan center; at a place
or store that honors [your/(SP’s)] plan card; or through a place or
store that the plan referred [you/(SP)] to.]
SELECT OR ADD ONLY
ONE DATE AT THIS
ROSTER.

Please tell me the first date [since (REFERENCE DATE/SURVEY
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] that [you/(SP)] rented the kidney dialysis
equipment.
[Are you/Is (SP)/Was (SP)] still renting the kidney dialysis
equipment?
What was the last date the equipment was rented?

67

Current MCBS Questionnaire

Category

ItemTag

OMQ

OM22CC

OMQ

OM22CCVB

OMQ

OM22D1

Did [you/(SP)] rent the kidney dialysis equipment at [READ
MANAGED CARE PLAN NAME(S) BELOW] or through a service or
discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?[PROBE: This could include renting the kidney dialysis
equipment at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan
referred [you/(SP)] to.]

OMQ

OM22D

In addition to the [(kidney dialysis supplies)/(kidney dialysis
equipment)] that you just told me about, did [you/(SP)] [(obtain any
kidney dialysis equipment)/(buy any kidney dialysis supplies)]?

OMQ

OMS23INTR

The next questions are about other medical equipment [you
were/(SP) was] renting as of (REFERENCE DATE).

OMQ
OMQ

OMS23_IN
OMS23

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

You said [you/(SP)] stopped renting the dialysis equipment. Is this
because (you/he/she) no longer (have/has) the equipment or
because (you/he/she) (have/has) purchased it through a rent-to­
buy option?
RECORD VERBATIM.

BRIEFLY EXPLAIN WHY
SP STOPPED RENTING
THE DIALYSIS
EQUIPMENT.

At the time of the last interview, [you were/(SP) was] renting
(OTHER MEDICAL EXPENSE ITEM). As of (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION), (is/was) the (OTHER
MEDICAL EXPENSE ITEM) being rented?

68

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

OMQ

OM23

SHOW CARD OM4

[Since (REFERENCE DATE/SURVEY REFERENCE
DATE)/Between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [you/(SP)] buy, rent, or repair any other medical equipment or
buy any other medical supplies besides what we have talked
about? [Other medical equipment and supplies include portable
commodes or raised toilet seats, portable tub seats, special chairs
or cushions, hospital beds, ostomy supplies, incontenence supplies
such as Depends, Serenity or other brands of disposable
undergarments, pads or briefs, bandages, dressings, tape supplies,
pulmonary equipment such as a Nebulizer or CPAP, and blood
pressure equipment such as cuffs or monitors, etc.]

OMQ
OMQ

OM24
OM24A

OMQ

OM25

What kind of equipment was the item?
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE
ITEM), or did [you/(SP)] rent it?
THIS ITEM AND NUMBER How many times [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
OF PURCHASES HAS
INSTITUTIONALIZATION)] [[have you/has (SP)] bought or
BEEN ENTERED
obtained/did (SP) buy or obtain] (OTHER MEDICAL EXPENSE
ALREADY FOR THIS
ITEM)?
ROUND. PLEASE
CORRECT THE NUMBER
OF TIMES TO BE THE
TOTAL NUMBER OF
TIMES PURCHASED
SINCE (REFERENCE
DATE).

3/30/2010

Interviewer Instructions II

69

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

OMQ

OM26

SELECT OR ADD ALL
When did [you/(SP)] buy or repair the (OTHER MEDICAL
DATES AT THIS ROSTER. EXPENSE ITEM)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]

OMQ
OMQ

OM26_IN
OM26AA

OMQ

OM26A

OMQ

OM26A1

OMQ

OM26B

OMQ

OM26BB

3/30/2010

Question Text

Interviewer Instructions II

On (EVENT DATE), did [you/(SP)] buy or repair the (OTHER
MEDICAL EXPENSE ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through
[READ MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This
could include buying or repairing the (OTHER MEDICAL EXPENSE
ITEM) at a plan center; at a place or store that honors [your/(SP’s)]
plan card; or through a place or store that the plan referred
[you/(SP)] to.]
ADD ONLY ONE DATE AT Please tell me the first date [since (REFERENCE DATE/SURVEY
THIS ROSTER.
REFERENCE DATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] that [you/(SP)] rented the (OTHER
MEDICAL EXPENSE ITEM)
[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE
ITEM)?
What was the last date [you/(SP)] rented the (OTHER MEDICAL
EXPENSE ITEM)?
You said [you/(SP)] stopped renting the (OTHER MEDICAL
EXPENSE ITEM). Is this because (you/he/she) no longer
(have/has) the item or because (you/he/she) (have/has) purchased
it through a rent-to-buy option?

70

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

OMQ

OM26BBVB

BRIEFLY EXPLAIN WHY
SP STOPPED RENTING
THE (OTHER MEDICAL
EXPENSE ITEM).

OMQ

OM26C

Did [you/(SP)] rent the (OTHER MEDICAL EXPENSE ITEM) at
[READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?[PROBE: This could include renting the
(OTHER MEDICAL EXPENSE ITEM) at a plan center; at a place or
store that honors [your/(SP’s)] plan card; or through a place or
service that the plan referred [you/(SP)] to.]

OMQ

OM27

In addition to the medical equipment you just told me about, did
[you/(SP)] buy, rent, or repair any other medical equipment [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

OMQ

OMS28INTR

The next questions are about an alteration [you were/(SP) was]
making as of (REFERENCE DATE).

OMQ
OMQ

OMS28_IN
OMS28

3/30/2010

Question Text

Interviewer Instructions II
RECORD VERBATIM.

Last time [you/(SP)] had started to make an alteration
(ALTERATION) that was not completed as of (REFERENCE
DATE/SURVEY REFERENCE DATE). On what date [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)] was this alteration
completed?

71

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

OMQ

OM28

SHOW CARD OM5

[Since (REFERENCE DATE/SURVEY REFERENCE
DATE)/Between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)],
did [you/(SP)] make any alterations or modify the inside or outside
of (your/his/her) home or car because of some illness or injury?
This card lists some examples. [Alterations include ramps,
handrails, elevator or incline chair, tub seats, tub handrails, and any
car alterations.]

OMQ
OMQ

OM29
OM30

What was the alteration?
On what date [since (REFERENCE DATE/SURVEY REFERENCE
DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]
was this alteration completed?

OMQ

OM31

In addition to the alteration(s) you just told me about, did [you/(SP)]
make any other alterations because of some illness or injury [since
(REFERENCE DATE/SURVEY REFERENCE DATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

PMS

PMSINTRA

During the last interview, we recorded the names of medicines that
[you/(SP)] had obtained between (SUMMARY REFERENCE DATE)
and (REFERENCE DATE). [HAND PM SUMMARY PAGE TO
RESPONDENT.]You may want to refer to the medicine names to
help you recall any medicines that [you/(SP)] may have obtained
since that time, including any refills of these medicines.

3/30/2010

Interviewer Instructions II

72

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

PMS

PMSINTRB

REFER TO SUMMARY
PAGE FOR PRESCRIBED
MEDICINES TO REVIEW
PREVIOUS ROUND
UTILIZATION.

PMS

PMS2

PMS

PMS3

PMS

PMS4

PMS

PMS6A

PMS

PMS6A_IN

3/30/2010

Question Text

Interviewer Instructions II
CODE WITHOUT ASKING:

What is the name of the medicine that needs to be added?

EDIT ALL MEDICINES AT What is the name of the medicine that needs to be edited?
THIS ROSTER.
What is the name of the medicine that needs to be deleted?

IF ALL MEDICINES ARE
How many times between (SUMMARY REFERENCE DATE) and
NOT LISTED, USE
(REFERENCE DATE) did [you/(SP)] obtain (MEDICINE NAME)?
"PREVIOUS PAGE" AND
ADD THE MEDICINE TO
THE ROSTER. REFER TO
STATEMENTS OR
RECEIPTS, IF
AVAILABLE.

73

ADD ALL MEDICINES AT
THIS ROSTER.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

SELECT ALL MEDICINES
FOR DELETION AT THIS
ROSTER.

Current MCBS Questionnaire

Category

ItemTag

PMS

PMS6A1

PMS

PMS6B

PMS

PMSINTB1

[ASK R TO GET BOTTLES Now I need to ask you a few questions about the (MEDICINE
AND/OR STATEMENTS IF NAME).
YOU HAVE NOT ALREADY
DONE SO.]

PMS

PMS8

CODE "YES" WITHOUT
ASKING IF STATEMENT,
RECEIPT, BOTTLE OR
BAG IS PRESENT.

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Did [you/(SP)] obtain (this purchase/any of these purchases) of
(MEDICINE NAME) through the Department of Veterans Affairs or
V.A.?
Did [you/(SP)] obtain (this purchase/any of these purchases) of
(MEDICINE NAME) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ
MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This could
include obtaining the purchases at a plan pharmacy; at a pharmacy
that honors [your/(SP’s)] plan card; or through a mail order service
that the managed care plan referred [you/(SP)] to.]

Do you have the medicine bottle, container, or bag available?

74

IF R DOES NOT HAVE
BOTTLE, PROBE TO
DETERMINE IF R CAN
ANSWER QUESTIONS
ABOUT THE FORM,
STRENGTH, AND
QUANTITY OF THE
MEDICINE.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

PMS

PMSINTRC

COMPLETE PMS9 -­
PMS16 USING
INFORMATION FROM
STATEMENT, RECEIPT,
MEDICINE BOTTLE OR
CONTAINER. IF THERE
IS MORE THAN ONE FOR
THE SAME MEDICINE,
USE THE MOST RECENT
CONTAINER.

PMS

PMS9

PMS

PMS10

IN WHAT FORM WAS THE
MEDICINE?
WHAT WAS THE
STRENGTH OF [EACH
PILL/EACH PATCH/EACH
SUPPOSITORY/THE
(MEDICINE FORM)]?IF
COMPOUND/MORE THAN
ONE MEDICINE
COMBINED: CHECK BOX
BELOW AND THEN
ENTER THE STRENGTH
OF THE 1ST MEDICINE IN
COMPOUND.

PMS

PMS10B

3/30/2010

Question Text

Interviewer Instructions II

WHAT WAS THE
STRENGTH OF THE 2ND
MEDICINE IN THE
COMPOUND?

75

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

PMS

PMS11

HOW MANY
(PILLS/SUPPOSITORIES/
PATCHES) WERE IN THE
CONTAINER WHEN IT
WAS OBTAINED?

PMS

PMS12

HOW MANY
(PILLS/SUPPOSITORIES)
WERE TO BE TAKEN IN A
DAY?

PMS

PMS13

PMS

PMS14

HOW MANY DAYS OR
WEEKS WAS THE
MEDICINE TO BE TAKEN?

PMS

PMS16

HOW MUCH MEDICINE
WAS IN THE CONTAINER
WHEN IT WAS
OBTAINED?

PMQ

PMINTROA

PMQ

PM1

3/30/2010

Question Text

Interviewer Instructions II

How many (pills/suppositories) did [you/(SP)] usually take in a day?

[PLEASE ENTER THE
AMOUNT IN THE
CONTAINER, NOT THE
STRENGTH OF THE
MEDICINE.]
[Now let’s talk about prescribed medicines [you have/(SP) has]
obtained since (REFERENCE DATE).](While talking about medical
visits, you mentioned some medicine(s): [READ MEDICINE
NAME(S) BELOW.]) (Now I’d like to talk about prescribed
medicines.)
[Besides that medicine, /Besides those medicines, ] [(Since/since)
(REFERENCE DATE)/(Between/between) (REFERENCE DATE)
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)] [have
you had/has (SP) had/did (SP) have] any (other) prescriptions
filled?

76

Current MCBS Questionnaire

Category

ItemTag

PMQ

PM1A

PMQ

PM2

PMQ

PM3

PMQ

PM3A

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, pleasetake out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLANNAME) medicine statements, which should have that
sameinformation on them.][IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.
What is the name of the medicine?
SELECT OR ADD ALL
MEDICINES AT THIS
ROSTER.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

People sometimes forget to mention refills of earlier prescriptions.
(In addition to what you’ve told me about, did/Did) [you/(SP)] have
any prescriptions refilled [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, pleasetake out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLANNAME) medicine statements, which should have that
sameinformation on them.] [IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.

77

Current MCBS Questionnaire

Category

ItemTag

PMQ

Question Text

Interviewer Instructions II

PM4

What is the name of the medicine?

SELECT OR ADD ALL
MEDICINES AT THIS
ROSTER.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

PMQ

PM5

People sometimes forget to mention prescriptions that were phoned
in by a doctor. (In addition to what you’ve told me about, did/Did)
[you/(SP)] get any medicine prescribed by a doctor in a telephone
call to a drugstore or pharmacy [since (REFERENCE
DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

PMQ

PM5A

It would be helpful if I could look at any medicine bottle(s),
container(s), or bag(s) that you have so that I can spell the
medicine name correctly and enter the strength of the medicine.
[Also, pleasetake out [your/(SP's)] (MEDICARE PRESCRIPTION
DRUG PLANNAME) medicine statements, which should have that
sameinformation on them.][IF RESPONDENT HAS BOTTLE, ASK:]
I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles,
too.

3/30/2010

Interviewer Instructions I

78

Current MCBS Questionnaire

Category

ItemTag

PMQ

PM6

PMQ

PM6A

IF ALL MEDICINES ARE
NOT LISTED, USE
"PREVIOUS PAGE" AND
ADD THE MEDICINE TO
THE ROSTER. REFER TO
STATEMENTS OR
RECEIPTS, IF
AVAILABLE.

How many times [since (REFERENCE DATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE
NAME)]]?

PMQ

PM6AB

SHOW CARD PM1

Please think about the medicines you have obtained since
(REFERENCE DATE), including [READ MEDICINE NAME(S)
BELOW.] Since (REFERENCE DATE), how often did [you/(SP)] do
any of the following things for these medicines. Did [you/(SP)]
often, sometimes, or never…

PMQ
PMQ

PM6A_IN
PM6A1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

What is the name of the medicine?

SELECT OR ADD ALL
MEDICINES AT THIS
ROSTER.CHECK
STATEMENT OR
MEDICINE BOTTLE FOR
SPELLING.INCLUDE
STRENGTH WITH NAME.

Did [you/(SP)] obtain (this purchase/any of these purchases) of
(MEDICINE NAME) through the Department of Veterans Affairs or
V.A.?

79

Current MCBS Questionnaire

Category

ItemTag

PMQ

PM6B

PMQ

PMINTROB

[ASK R TO GET BOTTLES (Now) I need to ask you a few (more) questions about the
AND/OR STATEMENTS IF (MEDICINE NAME).
YOU HAVE NOT ALREADY
DONE SO.]

PMQ

PM8

CODE “YES” WITHOUT
ASKING IF STATEMENT,
RECEIPT, BOTTLE OR
BAG IS PRESENT.

Do you have the medicine bottle, container, or bag available?

PMQ

PM8A

CODE “YES” WITHOUT
ASKING IF STATEMENT,
RECEIPT, BOTTLE OR
BAG IS PRESENT AND
FORM IS SAME AS
PREVIOUS INTERVIEW.

At the time of the last interview, [you/(SP)] purchased (MEDICINE
NAME) in the form of (MEDICINE FORM). Is this medicine in the
same form?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Did [you/(SP)] obtain (this purchase/any of these purchases) of
(MEDICINE NAME) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ
MANAGED CARE PLAN NAME(S) BELOW]?[PROBE: This could
include obtaining the purchases at a plan pharmacy; at a pharmacy
that honors [your/(SP’s)] plan card; or through a mail order service
that the managed care plan referred [you/(SP)] to.]

80

IF R DOES NOT HAVE
BOTTLE, PROBE TO
DETERMINE IF R CAN
ANSWER QUESTIONS
ABOUT THE FORM,
STRENGTH, AND
QUANTITY OF THE
MEDICINE.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

PMQ

PMINTROC

COMPLETE PM9 -- PM16
USING INFORMATION
FROM STATEMENT,
RECEIPT, MEDICINE
BOTTLE OR CONTAINER.
IF THERE IS MORE THAN
ONE FOR THE SAME
MEDICINE, USE THE
MOST RECENT
CONTAINER.

PMQ

PM9

PMQ

PM9A

IN WHAT FORM IS THE
MEDICINE?
CODE “YES” WITHOUT
ASKING IF STATEMENT,
RECEIPT, BOTTLE OR
BAG IS PRESENT AND
STRENGTH IS SAME AS
PREVIOUS INTERVIEW.

3/30/2010

Question Text

Interviewer Instructions II

At the time of the last interview, the strength of [each pill/each
suppository/each patch/the (MEDICINE FORM)] was [READ
STRENGTH BELOW].(STRENGTH 1)(STRENGTH 2)Is this
medicine in the same strength?

81

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

PMQ

PM10

WHAT IS THE STRENGTH
OF [EACH PILL/EACH
PATCH/THE (MEDICINE
FORM)]?IF
COMPOUND/MORE THAN
ONE MEDICINE
COMBINED: CHECK BOX
BELOW AND THEN
ENTER THE STRENGTH
OF THE 1ST MEDICINE IN
COMPOUND.

PMQ

PM10B

PMQ

PM11

WHAT WAS THE
STRENGTH OF THE 2ND
MEDICINE IN THE
COMPOUND?
HOW MANY
(PILLS/SUPPOSITORIES/
PATCHES) WERE IN THE
CONTAINER WHEN IT
WAS OBTAINED?

PMQ

PM12

PMQ

PM13

PMQ

PM14

3/30/2010

Question Text

Interviewer Instructions II

HOW MANY
(PILLS/SUPPOSITORIES)
ARE TO BE TAKEN IN A
DAY?
How many (pills/suppositories) (do/did/does) [you/(SP)] usually take
in a day?
HOW MANY DAYS OR
WEEKS WAS THE
MEDICINE TO BE TAKEN?

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Interviewer Instructions I

Question Text

PMQ

PM15A

CODE “YES” WITHOUT
ASKING IF STATEMENT,
RECEIPT, BOTTLE OR
BAG IS PRESENT AND
AMOUNT IS SAME AS
PREVIOUS INTERVIEW.

At the time of the last interview, the amount of the (PREVIOUS
ROUND MEDICINE FORM) was (PREVIOUS ROUND MEDICINE
AMOUNT). Is this medicine in the same amount?

PMQ

PM16

HOW MUCH MEDICINE
WAS IN THE CONTAINER
WHEN IT WAS
OBTAINED?

PMQ

PM16A1

SHOW CARD PM1

Since (REFERENCE DATE), how often did [you/(SP)] decide not to
fill or refill (MEDICINE) because it cost too much?

PMQ

PM16A

SHOW CARD PM1

PMQ

PM16B

SHOW CARD PM1

Since (REFERENCE DATE), how often did [you/(SP)] delay filling
or refilling a prescription for (MEDICINE NAME) because it cost
too much?
Since (REFERENCE DATE), how often did [you/(SP)] skip doses of
(MEDICINE NAME) to make the medicine last longer? [IF THE
RESPONSE IS "NEVER", PROBE: Do you mean that [you/(SP)]
never skipped doses of the medicine to make it last longer, or that
(you/he/she) never took the medicine at all?]

PMQ

PM16C

SHOW CARD PM1

3/30/2010

Interviewer Instructions II

[PLEASE ENTER THE
AMOUNT IN THE
CONTAINER, NOT THE
STRENGTH OF THE
MEDICINE.]

Since (REFERENCE DATE), how often did [you/(SP)] take smaller
doses of (MEDICINE NAME) to make the medicine last longer?[IF
THE RESPONSE IS "NEVER", PROBE: Do you mean that
[you/(SP)] never took smaller doses of the medicine to make it last
longer, or that (you/he/she) never took the medicine at all?]

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Interviewer Instructions I

Question Text

PMQ

PM17

([NO MEDICINES HAVE
BEEN REPORTED FOR
(SP) FOR THE CURRENT
REFERENCE
PERIOD/THE NAMES OF
ALL MEDICINES
REPORTED FOR THE
CURRENT REFERENCE
PERIOD ARE DISPLAYED
BELOW.])REVIEW THIS
INFORMATION WITH THE
RESPONDENT.

[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT.
ASK, OR CODE AS APPROPRIATE IF R ALREADY INDICATED:
Are there any (more) medicines since (REFERENCE DATE) that
we haven't talked about?]

STQ

ST1

3/30/2010

Interviewer Instructions II

Now that we have finished talking about medical visits and
prescribed medicines, let’s talk about [your/(SP’s)] medical costs.
We should start by looking at any paperwork or written
explanations of what was paid by Medicare, any insurance
company, or TRICARE. [Do you/Does (SP)] usually receive any
statements or papers from Medicare, insurance, such as
(MANAGED CARE PLAN NAME), or TRICARE that show the
charges for medical visits or equipment?/Last time, we recorded
that [you/(SP)] (always/sometimes/never) received statements or
papers from Medicare, insurance, or TRICARE that show the
charges for medical visits or equipment.] Please tell me if
(currently) [you always receive statements, sometimes receive
statements, or never receive statements/(SP) always receives
statements, sometimes receives statements, or never receives
statements].

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STQ

ST2

STQ

ST3

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Now that we have finished talking about medical visits and
prescribed medicines, let’s talk about [your/(SP’s)] medical costs.
We should start by looking at any paperwork or written
explanations of what costs were paid by Medicare, any insurance
company, or TRICARE.]Do you have any statements or paper from
Medicare, insurance, or TRICARE [that [you/(SP)] received since
the last interview]?[PROBE IF NECESSARY: Please include any
statements received about [your/(SP's)] Medicare prescription drug
benefit.]
BASED ON THE
INFORMATION
RECORDED IN THE
HEALTH INSURANCE
SECTION FOR RECENT
ROUNDS, THE PLAN(S)
LISTED BELOW ARE THE
SOURCES OF
STATEMENTS YOU
MIGHT EXPECT TO FIND
FOR THIS SP.

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STQ

ST4

[MATCH UP MEDICARE,
INSURANCE, TRICARE,
AND MEDICARE
PRESCRIPTION BENEFIT
STATEMENTS BY
PROVIDER AND DATE OF
SERVICE./PRESS ENTER
TO CONTINUE TO THE
NEXT
(STATEMENT/BUNDLE).]

[SELECT "MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENT" AT
THE NEXT SCREEN FOR
ALL STATEMENTS FROM
THE SP’S "(MHMO)" PLAN
OR "(MPDP)" PLAN THAT
REPORT PRESCRIPTION
DRUG CLAIMS.]

STQ

ST5

ADD ONE CHARGE
BUNDLE AT THIS
ROSTER.

STQ

ST7

ADD THE SOURCE(S)
AND TYPE OF
STATEMENT(S) FOR THE
(FIRST/NEXT) BUNDLE
OF EVENTS.
ENTER UP TO FIVE
CLAIM CONTROL
NUMBERS FROM THE
MEDICARE SUMMARY
NOTICE (MSN)
ASSOCIATED WITH ONE
CLAIM TOTAL. IF NO
CLAIM CONTROL
NUMBER(S) LISTED,
ENTER "DON'T KNOW".

3/30/2010

Question Text

Interviewer Instructions II

DO NOT ENTER ANY
CLAIM CONTROL
NUMBERS IN
COMMENTS.

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STQ

ST8

PLEASE ENTER THE
FIRST CLAIM CONTROL
NUMBER FROM THE
MEDICARE SUMMARY
NOTICE (MSN) AGAIN.

STQ

ST9

STQ

ST10

YOU HAVE ENTERED THE FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)SECOND
TIME: (SECOND MSN CLAIM CONTROL NUMBER)
CLAIM CONTROL
NUMBERS FROM THE
MEDICARE SUMMARY
NOTICE (MSN)
DIFFERENTLY.
ENTER THE CLAIM
CONTROL NUMBER
FROM THE INSURANCE
STATEMENT. IF NO
CLAIM CONTROL
NUMBER LISTED, ENTER
"DON'T KNOW".

STQ

ST11

3/30/2010

Question Text

Interviewer Instructions II

ENTER THE CLAIM
CONTROL NUMBER
FROM THE TRICARE
STATEMENT. IF NO
CLAIM CONTROL
NUMBER LISTED, ENTER
"DON'T KNOW".

87

WHICH IS CORRECT?

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Interviewer Instructions I

STQ

ST11B

ENTER THE BEGINNING
AND ENDING DATES OF
SERVICE FROM THE
MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENT.

STQ

ST12

WHAT TYPE(S) OF
EVENT(S) ARE INCLUDED
IN THIS CHARGE BUNDLE
ON THE (TYPE OF
STATEMENT)?

CHECK ALL THAT APPLY.

STQ

ST13

SELECT OR ADD ONLY
ONE PROVIDER.

STQ

ST14

WHICH MEDICAL
PROVIDER IS IN THIS
CHARGE BUNDLE?
THE FOLLOWING EVENT
DATES HAVE BEEN
ENTERED FOR THIS
PROVIDER.

STQ

ST15

STQ

ST16

STQ

ST17

STQ

ST18

3/30/2010

Question Text

Interviewer Instructions II

DO YOU NEED TO ADD
OR EDIT AN EVENT DATE
FOR THIS CHARGE
BUNDLE?
SELECT AND EDIT THE
EVENT DATE THAT
NEEDS CORRECTION.

ADD THE MISSING EVENT
DATE(S) IN THIS CHARGE
BUNDLE.

ADD ALL EVENT DATES
FOR THIS PROVIDER.

Before we continue with this statement, I would like to ask you a
few questions about the visit(s) I just added.
What kind of medical person is (PROVIDER NAME)?

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STQ

ST19

STQ

ST20

STQ

ST21

STQ

ST22A

STQ
STQ

ST22A_IN
ST23

STQ

ST24

STQ

ST24A

STQ

ST25

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Is (PROVIDER NAME) associated with a Department of
VeteransAffairs, or V.A. facility?
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by
[READMANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not see a doctor
associated with [READ MANAGED CARE PLAN NAME(S)
BELOW] or a doctor that [READ MANAGED CARE PLAN NAME(S)
BELOW] would refer [you/(SP)] to?
We have recorded that in (EVENT MONTH) [you were/(SP) was]
also in [READ EVENT(S) LISTED BELOW]. Was this visit with
(PROVIDER NAME) a visit while [you were/(SP) was] in [the
[READ EVENT LISTED BELOW]/any of these places]?
SELECT THE EVENT
DATE(S) THAT ARE
INCLUDED IN THIS
CHARGE BUNDLE.
ENTER THE NUMBER OF
(EVENT TYPE) VISITS IN
(EVENT MONTH, YEAR)
THAT ARE COVERED BY
THIS CHARGE.
ARE ALL THE PROVIDER
EVENTS FROM THE
CHARGE BUNDLE ON
(TYPE OF STATEMENT)
SHOWN BELOW?

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STQ

ST26

STQ

ST27

STQ

ST28

ENTER THE START DATE
AND STOP DATE
COVERED BY THE
CHARGE BUNDLE.

STQ

ST30

IS THE PROVIDER A
HOME HEALTH
PROFESSIONAL OR
SOME OTHER TYPE OF
HOME HEALTH
PROVIDER (HOME
HEALTH AIDE,
HOMEMAKER, ETC.)?

STQ

ST31

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II
SELECT THE EVENT(S)
THAT YOU WOULD LIKE
TO REMOVE FROM THE
CHARGE BUNDLE.

WHICH HOME HEALTH
PROVIDER IS IN THIS
CHARGE BUNDLE?

SELECT OR ADD ONLY
ONE PROVIDER.

Before we continue with this statement, I would like to ask you a
few questions about the home health provider I just added.

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Interviewer Instructions I

STQ

ST32

THE FOLLOWING HOME
HEALTH PROVIDER
EVENT HAS BEEN ADDED
TO THIS CHARGE
BUNDLE.PLEASE ENTER
A COMMENT IF THIS
EVENT WAS ENTERED IN
ERROR OR IF ANOTHER
HOME HEALTH EVENT
SHOULD BE INCLUDED IN
THIS CHARGE BUNDLE.

STQ

ST34

THE FOLLOWING OME
EVENTS HAVE BEEN
ENTERED. DO YOU
NEED TO ADD OR EDIT
AN OME EVENT FOR THIS
CHARGE BUNDLE?

STQ

ST35

SELECT AND EDIT THE
OTHER MEDICAL
EXPENSE EVENT THAT
NEEDS CORRECTION.

STQ

ST36

WHAT TYPE OF OTHER
MEDICAL EXPENSE
NEEDS TO BE ADDED?

3/30/2010

Question Text

Interviewer Instructions II

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STQ

ST37

SELECT OTHER MEDICAL
EXPENSES THAT ARE IN
THIS CHARGE BUNDLE
ON THE (TYPE OF
STATEMENT).

STQ

ST38

HOW MANY MONTHS ARE
COVERED BY THIS
CHARGE BUNDLE?

STQ

ST38A

HOW MANY PURCHASES
OF (NAME OF OME ITEM)
ARE COVERED BY THIS
CHARGE BUNDLE?

STQ

ST39

STQ

ST40

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

ARE ALL THE OTHER
MEDICAL EXPENSES
FROM THE CHARGE
BUNDLE ON THE (TYPE
OF STATEMENT) SHOWN
BELOW?
SELECT THE EVENT(S)
THAT YOU WOULD LIKE
TO REMOVE FROM THE
CHARGE BUNDLE.

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STQ

ST41

SELECT OR ADD ALL
PRESCRIPTION
MEDICINES THAT ARE IN
THIS CHARGE BUNDLE
ON THE (TYPE OF
STATEMENT).

STQ

ST42

HOW MANY PURCHASES
OF EACH MEDICINE
SHOWN BELOW ARE
COVERED BY THIS
CHARGE BUNDLE?

STQ

ST43

STQ

ST44

STQ

ST45

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Before we continue with this statement, I would like to ask you a
few questions about the prescribed medicine(s) I just added. [It
would be very helpful for the following questions if we could look at
the bottle(s) or container(s) for the medicine(s).]
ARE ALL THE
PRESCRIBED
MEDICINES FROM THE
CHARGE BUNDLE ON
THE (TYPE OF
STATEMENT) SHOWN
BELOW?
SELECT THE
PRESCRIBED
MEDICINE(S) THAT YOU
WOULD LIKE TO
REMOVE FROM THE
CHARGE BUNDLE.

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Interviewer Instructions I

STQ

ST46

SINCE ALL EVENTS IN
THIS BUNDLE ARE
OUTSIDE THE SURVEY
REFERENCE PERIOD,
WE DO NOT NEED ANY
CHARGE INFORMATION
ABOUT THE BUNDLE.

STQ

ST47

STQ

ST47A

WAS ASSIGNMENT
TAKEN FOR THIS
CHARGE BUNDLE?
ENTER THE TOTAL COST
OF PRESCRIPTION(S)
FROM THE MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENT. IF
A TOTAL COST IS NOT
LISTED, IT MAY BE
NECESSARY TO
CALCULATE A TOTAL BY
ADDING THE COSTS OF
INDIVIDUAL ITEMS
LISTED ON THE
STATEMENT.

3/30/2010

Question Text

Interviewer Instructions II

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STQ

ST48

ENTER THE FOLLOWING
AMOUNTS FROM THE
(TYPE OF STATEMENT).
IF AMOUNT NOT
AVAILABLE, ENTER
"DON'T KNOW".[SEE
SHOWCARD ST2 FOR
TRICARE STATEMENT
EXAMPLES.]

STQ

ST49

REVIEW CHARGE
BUNDLE ON (TYPE OF
STATEMENT) WITH
RESPONDENT IF YOU
HAVEN'T ALREADY DONE
SO. POINT OUT
PROVIDER NAME,
DATE(S), AND TYPE OF
SERVICE. THEN ASK:

So, I have an amount remaining of $(AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?

STQ

ST50

THESE AMOUNTS WERE
ENTERED FROM THE
(TYPE OF STATEMENT)
STATEMENT:

DO YOU WANT TO MAKE
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE
AMOUNT)TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE ANY CHANGES?
APPROVED AMOUNT)TOTAL MEDICARE PAYMENT:
(MEDICARE PAYMENT)AMOUNT REMAINING AFTER MEDICARE
PAYMENT: (AMOUNT REMAINING)

3/30/2010

Question Text

Interviewer Instructions II

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STQ

ST51

MAKE ALL THE
NECESSARY
CORRECTIONS TO THE
AMOUNTS THAT WERE
ENTERED FROM THE
(TYPE OF STATEMENT).

STQ

ST52

ENTER THE FOLLOWING
AMOUNTS FROM THE
MSN:

STQ

ST53

REVIEW CHARGE
BUNDLE ON THE (TYPE
OF STATEMENT) WITH
RESPONDENT IF YOU
HAVEN'T ALREADY DONE
SO. POINT OUT
PROVIDER NAME,
DATE(S), AND TYPE OF
SERVICE. THEN ASK:

STQ

ST54

STQ

ST55

THESE AMOUNTS WERE AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)MEDICARE
APPROVED: (MEDICARE APPROVED AMOUNT)MEDICARE
ENTERED FROM THE
(TYPE OF STATEMENT) : PAID: (MEDICARE PAYMENT) YOU MAY BE BILLED: (MAY BE
BILLED)
MAKE ALL THE
NECESSARY
CORRECTIONS TO THE
AMOUNTS THAT WERE
ENTERED FROM THE
(TYPE OF STATEMENT).

3/30/2010

Question Text

Interviewer Instructions II

So, I have an amount remaining of $(AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?

96

DO YOU WANT TO MAKE
ANY CHANGES?

Current MCBS Questionnaire

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ItemTag

Interviewer Instructions I

STQ

ST56

ENTER THE FOLLOWING
AMOUNTS FROM THE
MSN.

STQ

ST57

REVIEW CHARGE
BUNDLE ON (TYPE OF
STATEMENT) WITH
RESPONDENT IF YOU
HAVEN'T ALREADY DONE
SO. POINT OUT
PROVIDER NAME,
DATE(S), AND TYPE OF
SERVICE. THEN ASK:

STQ

ST58

STQ

ST59

THESE AMOUNTS WERE BENEFITS DAYS USED: (DAYS USED)NON-COVERED
ENTERED FROM THE
CHARGES: (NON COVERED CHARGES)DEDUCTIBLE AND
MSN:
COINSURANCE: (COINSURANCE)YOU MAY BE BILLED: (MAY
BE BILLED)
MAKE ALL THE
NECESSARY
CORRECTIONS TO THE
AMOUNTS THAT WERE
ENTERED FROM THE
(TYPE OF STATEMENT).

STQ

ST60

3/30/2010

Question Text

Interviewer Instructions II
DISREGARD "AMOUNT
CHARGED" IF IT
APPEARS ON THE
STATEMENT.

So, I have an amount remaining $(AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?

ENTER THE FOLLOWING
AMOUNTS FROM THE
MSN.

97

DO YOU WANT TO MAKE
ANY CHANGES?

Current MCBS Questionnaire

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ItemTag

Interviewer Instructions I

Question Text

STQ

ST61

REVIEW CHARGE
BUNDLE ON (TYPE OF
STATEMENT) WITH
RESPONDENT IF YOU
HAVEN'T ALREADY DONE
SO. POINT OUT
PROVIDER NAME,
DATE(S), AND TYPE OF
SERVICE. THEN ASK:

So, I have an amount remaining (AMOUNT REMAINING) that
Medicare didn't pay. [Have you/Has (SP)] or any other source,
[such as (TRICARE/an insurance plan/TRICARE or an insurance
plan)], paid any of this amount?

STQ

ST62

STQ

ST63

THESE AMOUNTS WERE AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)NON­
ENTERED FROM THE
COVERED CHARGES: (NON COVERED
MSN:
CHARGES)DEDUCTIBLE AND COINSURANCE:
(COINSURANCE)YOU MAY BE BILLED: (MAY BE BILLED)
MAKE ALL THE
NECESSARY
CORRECTIONS TO THE
AMOUNTS THAT WERE
ENTERED FROM THE
(TYPE OF STATEMENT).

3/30/2010

Interviewer Instructions II

98

DO YOU WANT TO MAKE
ANY CHANGES?

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Interviewer Instructions I

Question Text

STQ

ST64

REVIEW CHARGE
BUNDLE ON [TYPE OF
STATEMENT] WITH
RESPONDENT IF YOU
HAVEN'T ALREADY DONE
SO. POINT OUT
(PROVIDER NAME),
DATE(S), AND TYPE OF
SERVICE(S). (THEN
ASK:/SELECT "SP OR
ANY SOURCE PAID" IF
ALREADY KNOWN.
OTHERWISE ASK:)

[The total cost of prescriptions reported on this statement is
(TOTAL CHARGE).] [[Have you/Has (SP)]/Besides Medicare,
[have you/has (SP)]] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid anything for
this?

STQ

ST65

ARE ALL OF THE
SOURCES OF PAYMENT
NECESSARY FOR
COMPLETING THE
STATEMENT SECTION
LISTED BELOW?

STQ

ST66

ADD ALL ADDITIONAL
SOURCES OF PAYMENT.

3/30/2010

Interviewer Instructions II

SELECT "NO" TO ADD A
SOURCE OF PAYMENT.

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STQ

ST67

(REFER TO INSURANCE Who (else) paid besides Medicare? How much did (SOURCE)
STATEMENT/REFER TO pay?
TRICARE
STATEMENT/REFER TO
INSURANCE AND
TRICARE
STATEMENTS/REFER TO
MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENT).

STQ

ST67HE

THE SUM OF ALL
PAYMENT AMOUNTS
MUST BE GREATER THAN
$0.00 OR AT LEAST ONE
PAYMENT AMOUNT MUST
BE 'DON'T KNOW' OR
'REFUSED'.USE
"PREVIOUS PAGE" TO
RETURN TO THE SOP
GRID AND MAKE
CORRECTIONS.

STQ

ST67BINT

STQ
STQ

ST67B_IN
ST68

3/30/2010

Question Text

Interviewer Instructions II

Before we continue, I would like to ask you a few questions about
the health insurance plan(s) you just added.
I recorded previously that (CURRENT MEDICARE MANAGED
CARE PLAN NAME) was [your/(SP's)] current Medicare Managed
Care Plan. Has this information changed?

100

ENTER ALL PAYMENT
AMOUNTS. CORRECT
PAYMENT AMOUNTS AS
NECESSARY.

Current MCBS Questionnaire

Category

ItemTag

STQ

ST69

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (ST66
SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

STQ

ST69A

I recorded previously that (CURRENT MEDICARE
PRESCRIPTIONDRUG PLAN) was [your/(SP's)] current Medicare
Prescription DrugCare Plan.Has this information changed?

STQ

ST69B

STQ

ST69C

STQ

ST70

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (ST66
SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
Before we continue, I would like to ask you a few questions
aboutthe discount membership plan(s) you just added.
There seems to be (some amount still unpaid/more payments than
the amount left after Medicare paid). The total of non-Medicare
payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid)
is $(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT
REMAINING). Is that correct?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

101

IF SOURCE OF PAYMENT
NEEDS ADDITION OR
CORRECTION, USE
"PREVIOUS PAGE" TO
RETURN TO THE SOP
GRID.

Current MCBS Questionnaire

Category

ItemTag

STQ

ST71

THE AMOUNTS ENTERED
FOR THE SOURCES OF
PAYMENT EQUAL OR
EXCEED THE (TOTAL
CHARGE/AMOUNT
REMAINING), WITH AT
LEAST ONE SOP BEING A
MISSING AMOUNT.
VERIFY ALL AMOUNTS
AS ENTERED.IF SOURCE
OF PAYMENT NEEDS
ADDITION OR
CORRECTION, USE
"PREVIOUS PAGE" TO
RETURN TO THE SOP
GRID.

STQ

ST72

[THE TOTAL OF NON­
MEDICARE PAYMENTS IS
$(TOTAL PAYMENTS).
THE AMOUNT
(UNPAID/OVERPAID) IS
$(DIFFERENCE
BETWEEN PAYMENTS
AND AMOUNT
REMAINING).]USE
COMMENTS TO EXPLAIN
WHY THE AMOUNT
REMAINING SEEMS
INCORRECT.

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

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STQ

ST73

STQ

ST74

IS THERE ADDITIONAL
INFORMATION ON THE
MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENT
THAT EXPLAINS THE
AMOUNT STILL UNPAID?

STQ

ST75

USE COMMENTS TO
ENTER ANY
INFORMATION THAT
EXPLAINS THE AMOUNT
STILL UNPAID.

STQ

ST78

STQ
STQ
STQ

ST79
ST80
ST81

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

There seems to be some amount still unpaid. The total of nonMedicare payments is $(TOTAL PAYMENTS). The amount unpaid
is $(DIFFERENCE BETWEEN TOTAL CHARGE AND PAYMENTS).
Is that correct?

IF SOURCE OF PAYMENT
NEEDS ADDITION OR
CORRECTION, USE
"PREVIOUS PAGE" TO
RETURN TO THE SOP
GRID.

I have recorded that [you have/(SP) has] paid $(SP/FAMILY
PAYMENT). Do you expect any source to pay [you/(SP)] back any
or all of that amount?
Do you expect anyone to pay any of this amount?
How much do you expect wil be paid?
IS THERE ANOTHER
CHARGE BUNDLE TO
ENTER FROM THIS (TYPE
OF STATEMENT)?

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Question Text

Interviewer Instructions II

STQ

ST82

IS THERE ANOTHER MSN,
INSURANCE, TRICARE,
OR MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENT TO
ENTER?

PSQ

PS1A

(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)].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.

PSQ

PS2

[Do you/Does (SP)] expect any more rental or installment payments THIS INCLUDES
PAYMENTS MADE BY SP,
to be made for the (OME ITEM TYPE)?
MEDICARE, INSURANCE,
TRICARE, OR ANY
OTHER SOURCE OF
PAYMENT.

NSQ
NSQ

NS1_IN
NS1

3/30/2010

[Now that we're done with [your/(SP's)] statements, let's/Let's] talk
about the medical services and costs for which [you/(SP)] did not
have a statement.]THERE ARE (TOTAL NUMBER OF NS EVENTS)
EVENTS (REMAINING) TO ASK ABOUT.(Let's start with/Next let's
look at) (the/[your/(SP's)]) costs for the (EVENT).

104

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS2

NSQ

NS3

NSQ

NS4

NSQ

NS5

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

As far as you know, is anything expected in the mail from
(Medicare, Insurance, and Tricare/Medicare and Tricare/Medicare
and Insurance/Medicare) about [READ EVENT ABOVE]?[PROBE
IF NECESSARY: Please include any statements received about
[your/(SP’s)] Medicare prescription drug benefit.]
REMINDER: "EVENT
ENTERED IN ERROR"
INSTRUCTS THE HOME
OFFICE TO DELETE THIS
EVENT.IF YOU HAVE
ENTERED THIS CODE IN
ERROR, SELECT
PREVIOUS PAGE AND
ENTER THE CORRECT
CODE AT NS2.
OTHERWISE, EXPLAIN
WHY YOU SELECTED
"EVENT ENTERED IN
ERROR" FOR THIS
EVENT.
[Have you/Has (SP)] received a statement for the [READ EVENT
ABOVE]?
Including any amounts that may be paid by Medicare or anyone
else, what [was the charge for the (OME ITEM TYPE) rented (with
the option to buy) between (REFERENCE DATE) and
(TODAY/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/was the total charge (that is, the total
amount billed)]?

105

IF CHARGE REPORTED
AS HOURLY RATE,
CALCULATE AND ENTER
THE TOTAL CHARGE FOR
THE ENTIRE ROUND.

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS6

NSQ

NS7

NSQ

NS8

NSQ

NS9

NSQ

NS10

NSQ

NS12

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

ENTER 0 IF NO
What was the copayment amount for the [READ EVENT
COPAYMENT FOR THE
ABOVE]?[EXPLAIN IF NECESSARY: Managed care plans
EVENT.
commonly charge a fixed amount, or copayment, for health
services provided. For example, the person may pay $10 for each
office visit and $5 for each drug prescription.]
How many months are covered by the charge for the period of time
[since (REFERENCE DATE)/between (REFERENCE DATE) and
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
How many of the times [you/(SP)] obtained [READ EVENT
ABOVE]since (REFERENCE DATE) [were covered by the total
charge/was there no charge/were covered by the (TOTAL
CHARGE)/were covered by the copayment/was there no
copayment/were covered by the (COPAYMENT)]?
How many of the (NUMBER OF VISITS) (visits to the OPD at/lab
services provided by/visits to) (PROVIDER NAME) during the
month of (EVENT MONTH) [were covered by the total charge/was
there no charge/were covered by the (TOTAL CHARGE)/were
covered by the copayment/was there no copayment/were covered
by the (COPAYMENT)]?
DOES [THE TOTAL
CHARGE/THIS/(TOTAL
CHARGE)] COVER THIS
(EVENT/ITEM/MEDICINE)
ONLY OR DOES IT
INCLUDE OTHER
EVENTS/ITEMS/MEDICIN
ES?
What else was included?

106

CHECK ALL THAT APPLY.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

NSQ

NS13

NSQ

NS14

WHICH MEDICAL
PROVIDER IS IN THIS
CHARGE BUNDLE?
THE FOLLOWING EVENT
DATES HAVE BEEN
ENTERED FOR THIS
PROVIDER.

NSQ

NS15

NSQ

NS16

NSQ

NS17

NSQ
NSQ

NS18
NS19

NSQ

NS20

NSQ

NS21

NSQ

NS22A

NSQ

NS22A_IN

3/30/2010

Question Text

Interviewer Instructions II
SELECT OR ADD ONLY
ONE PROVIDER.
DO YOU NEED TO ADD
OR EDIT AN EVENT DATE
FOR THIS CHARGE
BUNDLE?
SELECT AND EDIT THE
EVENT DATE THAT
NEEDS CORRECTION.

ADD THE MISSING EVENT
DATE(S) IN THIS CHARGE
BUNDLE.

ADD ALL EVENT DATES
FOR THIS PROVIDER.

Before we continue with this statement, I would like to ask you a
few questions about the visit(s) I just added.
What kind of medical person is (PROVIDER NAME)?
Is (PROVIDER NAME) associated with a Department of
VeteransAffairs, or V.A. facility?
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by
[READMANAGED CARE PLAN NAME(S) BELOW]?
What is the most important reason [you/(SP)] did not see a doctor
associated with [READ MANAGED CARE PLAN NAME(S)
BELOW] or a doctor that [READ MANAGED CARE PLAN NAME(S)
BELOW] would refer [you/(SP)] to?

107

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS23

NSQ

NS24

NSQ

NS24A

NSQ

NS25

NSQ

NS26

NSQ

NS27

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

We have recorded that in (EVENT MONTH) [you were/(SP) was]
also in [READ EVENT(S) LISTED BELOW]. Was this visit with
(PROVIDER NAME) a visit while [you were/(SP) was] in [the
[READ EVENT LISTED BELOW]/any of these places]?
SELECT THE EVENT
DATE(S) THAT ARE
INCLUDED IN THIS
CHARGE BUNDLE.
ENTER THE NUMBER OF
(EVENT TYPE) VISITS IN
(EVENT MONTH, YEAR)
THAT ARE COVERED BY
THIS CHARGE.
ARE ALL THE PROVIDER
EVENTS FROM THE
CHARGE BUNDLE
SHOWN BELOW?
SELECT THE EVENT(S)
THAT YOU WOULD LIKE
TO REMOVE FROM THE
CHARGE BUNDLE.
SELECT OR ADD ONLY
ONE PROVIDER.

WHICH HOME HEALTH
PROVIDER IS IN THIS
CHARGE BUNDLE?

108

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS30

NSQ

NS31

NSQ

NS32

THE FOLLOWING HOME
HEALTH PROVIDER
EVENT HAS BEEN ADDED
TO THIS CHARGE
BUNDLE.

PLEASE ENTER A
COMMENT IF THIS EVENT
WAS ENTERED IN
ERROR OR IF ANOTHER
HOME HEALTH EVENT
SHOULD BE INCLUDED IN
THIS CHARGE BUNDLE.

NSQ

NS34

THE FOLLOWING OME
EVENTS HAVE BEEN
ENTERED.

NSQ

NS35

DO YOU NEED TO ADD
OR EDIT AN OME EVENT
FOR THIS CHARGE
BUNDLE?
SELECT AND EDIT THE
OTHER MEDICAL
EXPENSE EVENT THAT
NEEDS CORRECTION.

NSQ

NS36

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II
IS THE PROVIDER A
HOME HEALTH
PROFESSIONAL OR
SOME OTHER TYPE OF
HOME HEALTH
PROVIDER (HOME
HEALTH AIDE,
HOMEMAKER, ETC.)?

Before we continue with this statement, I would like to ask you a
few questions about the home health provider I just added.

WHAT TYPE OF OTHER
MEDICAL EXPENSE
NEEDS TO BE ADDED?

109

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS37

SELECT OTHER MEDICAL
EXPENSES THAT ARE IN
THIS CHARGE BUNDLE.

NSQ

NS38

HOW MANY MONTHS ARE
COVERED BY THIS
CHARGE BUNDLE?

NSQ

NS38A

HOW MANY PURCHASES
OF (NAME OF OME ITEM)
ARE COVERED BY THIS
CHARGE BUNDLE?

NSQ

NS39

NSQ

NS40

SELECT THE EVENT(S)
THAT YOU WOULD LIKE
TO REMOVE FROM THE
CHARGE BUNDLE.

NSQ

NS41

SELECT OR ADD ALL
PRESCRIPTION
MEDICINES THAT ARE IN
THIS CHARGE BUNDLE.

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

ARE ALL THE OTHER
MEDICAL EXPENSES
FROM THE CHARGE
BUNDLE SHOWN
BELOW?

110

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS42

NSQ

NS43

NSQ

NS44

NSQ

NS45

NSQ

NS64

NSQ

NS65

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II
HOW MANY PURCHASES
OF EACH MEDICINE
SHOWN BELOW ARE
COVERED BY THIS
CHARGE BUNDLE?

Before we continue with this statement, I would like to ask you a
few questions about the prescribed medicine(s) I just added. [It
would be very helpful for the following questions if we could look at
the bottle(s) or container(s) for the medicine(s).]
ARE ALL THE
PRESCRIBED
MEDICINES FROM THE
CHARGE BUNDLE
SHOWN BELOW?
SELECT THE
PRESCRIBED
MEDICINE(S) THAT YOU
WOULD LIKE TO
REMOVE FROM THE
CHARGE BUNDLE.
[[Have you/Has (SP)] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] already paid any of
[the charge/the total charge/the copayment amount/this (TOTAL
CHARGE)]?
SELECT "NO" TO ADD A
SOURCE OF PAYMENT.

ARE ALL OF THE
SOURCES OF PAYMENT
FOR THIS CHARGE
BUNDLE LISTED
BELOW?

111

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

Interviewer Instructions II

NSQ

NS66

ADD ALL ADDITIONAL
SOURCES OF PAYMENT
FOR THIS CHARGE
BUNDLE.

NSQ

NS67

Who (else) paid? How much did (SOURCE) pay?

ENTER ALL PAYMENT
AMOUNTS. CORRECT
PAYMENT AMOUNTS AS
NECESSARY.

NSQ

NS67BINT

Before we continue, I would like to ask you a few questions about
the health insurance plan(s) you just added.

NSQ
NSQ

NS67B_IN
NS68

NSQ

NS69

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66
SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?

NSQ

NS69A

I recorded previously that (CURRENT MEDICARE
PRESCRIPTIONDRUG PLAN) was [your/(SP's)] current Medicare
Prescription DrugCare Plan.Has this information changed?

NSQ

NS69B

NSQ

NS69C

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66
SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
Before we continue, I would like to ask you a few questions
aboutthe discount membership plan(s) you just added.

NSQ

NS69C_IN

3/30/2010

I recorded previously that (CURRENT MEDICARE MANAGED
CARE PLAN NAME) was [your/(SP's)] current Medicare Managed
Care Plan. Has this information changed?

112

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS70

NSQ

NS71

THE AMOUNTS ENTERED
FOR THE SOURCES OF
PAYMENT EQUAL OR
EXCEED THE (TOTAL
CHARGE/COPAYMENT),
WITH AT LEAST ONE SOP
BEING A MISSING
AMOUNT. VERIFY ALL
AMOUNTS AS ENTERED.

NSQ

NS72

[THE TOTAL OF
PAYMENTS IS $(TOTAL
PAYMENTS). THE
AMOUNT
(UNPAID/OVERPAID) IS
$(DIFFERENCE
BETWEEN PAYMENTS
AND TOTAL
CHARGE).]USE
COMMENTS TO EXPLAIN
WHY THE AMOUNT
REMAINING SEEMS
INCORRECT.

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

There seems to be (some amount still unpaid/more payments than
the charge).[REVIEW WITH RESPONDENT.] The total of all
payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid)
is $(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).
Is that correct?

113

Current MCBS Questionnaire

Category

ItemTag

NSQ

NS78

NSQ
NSQ
NSQ

NS79
NS80
NSL1

NSQ

NSL3

Which ones are the same?

REVIEW LIST WITH
RESPONDENT AND
SELECT ALL
PRESCRIPTION
MEDICINES WHERE THE
COSTS AND PAYMENTS
ARE THE SAME.

NSQ

NSL4

How many times are the same?

NSQ

NSL5

Which ones are the same?

ENTER THE NUMBER OF
PURCHASES OF EACH
MEDICINE SHOWN
BELOW THAT ARE THE
SAME.
REVIEW LIST WITH THE
RESPONDENT AND
SELECT ALL PROVIDER
EVENTS WHERE THE
COST AND PAYMENTS
ARE THE SAME.

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

I have recorded that [you have/(SP) has] paid $(SP/FAMILY
PAYMENT). Do you expect any source to pay [you/(SP)] back any
or all of that amount?
Do you expect anyone to pay any of this amount?
How much do you expect wil be paid?
You told me earlier that [you/(SP)] had other [visits to (PROVIDER
NAME)/prescribed medicine purchases].Are any other [visits to
(PROVIDER NAME)/prescribed medicine purchases] the same -that is the [total charge was (TOTAL CHARGE)/copayment was
(TOTAL CHARGE)] per (visit/purchase) with the following
payments: [READ PAYMENTS LISTED ABOVE]?

114

Current MCBS Questionnaire

Category

ItemTag

NSQ

NSL6

NSQ

NS81

CPS
CPS

CPS1_IN
CPS1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How many times are the same for (EVENT)?

ENTER THE NUMBER OF
(EVENT TYPE) VISITS IN
(EVENTMONTH, YEAR)
THAT ARE THE SAME.

YOU HAVE ENTERED ALL
CHARGE/PAYMENT DATA
FOR ALL EVENTS
REPORTED. DO YOU
HAVE ANY MSN,
INSURANCE, TRICARE,
OR MEDICARE
PRESCRIPTION DRUG
BENEFIT STATEMENTS
THAT YOU HAVE NOT YET
ENTERED?

(Next, I will ask about some medical care that we talked about in a
previous interview.)THERE ARE (TOTAL NUMBER OF CPS
EVENTS) EVENTS OR BUNDLES (REMAINING) FOR
SUMMARY.(First/Next), I want to ask about [READ EVENT(S)
ABOVE].

115

Current MCBS Questionnaire

Category

ItemTag

CPS

CPS2

CPS

CPS3

CPS

CPS4

CPS

CPS5

CPS

CPS6

CPS

CPS7

CPS

CPS8

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[At the last interview, [you were/(SP) was] expecting to receive a
statement or paper from (Medicare, Insurance, and
TRICARE/Medicare and TRICARE/Medicare and
Insurance/Medicare).] [Have you/Has (SP)] received a statement
for the [READ EVENT(S) ABOVE] (since then/since the last
interview)?([PROBE IF NECESSARY: Please include any
statements received about (your/(SP's)] Medicare prescription drug
benefit.])
Do you happen to know the (total charge/copayment amount) for
the [READ EVENT(S) ABOVE]?
Including any amounts that may be paid by Medicare or anyone
ENTER 0 IF NO CHARGE
else, what was the total charge [that is, the amount billed]?
FOR THE EVENT.
ENTER 0 IF NO
What was the copayment amount for the [READ EVENT(S)
COPAYMENT FOR THE
ABOVE]?[EXPLAIN IF NECESSARY: Managed care plans
EVENT.
commonly charge a fixed amount, or copayment, for health
services provided. For example, the person may pay $10 for each
office visit and $5 for each drug prescription.]
For the [READ OME ITEM ABOVE], how many months are covered
by the charge for the period of time between (CHARGE BUNDLE
REFERENCE PERIOD)?
How many of the times [you/(SP)] obtained (MEDICINE
NAME/OME ITEM TYPE) for the period between (CHARGE
BUNDLE REFERENCE PERIOD) [were covered by the total
charge/were covered by the (CPS4 - TOTAL CHARGE)/was there
no charge/were covered by the copayment/were covered by the
(CPS5 - COPAYMENT)/was there no copayment]?
How many of the [READ EVENT ABOVE] [were covered by the
total charge/were covered by the (CPS4 - TOTAL CHARGE)/was
there no charge/were covered by the copayment/were covered by
the (CPS5 - COPAYMENT)/was there no copayment]?

116

Current MCBS Questionnaire

Category

ItemTag

CPS

CPS9

CPS

CPS10

CPS

CPS11

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Last time, we recorded that the (total charge/copayment amount)
for the [READ EVENT(S) ABOVE] was (TOTAL CHARGE)), and that
no payment had been made.] [Have you/Has (SP)] or any other
source [, such as (an insurance plan/TRICARE/TRICARE or an
insurance plan),] now paid any of [the total charge/the copayment
amount/this (TOTAL CHARGE)]?
YOU CANNOT CORRECT
THE TOTAL CHARGE
HERE. THE ERROR HAS
BEEN NOTED. ANSWER
“YES” OR “NO” AS
APPROPRIATE AS TO
WHETHER ANY SOURCE
HAS PAID ANY PORTION
OF THE CHARGE.

Last time, we recorded that [Medicare had paid
[nothing/(MEDICARE PAYMENT AMOUNT)] and] after Medicare
paid, there was an amount remaining of (AMOUNT REMAINING) for
the [READ EVENT(S) ABOVE.] [Have you/Has (SP)] or any other
source [, such as (an insurance plan/TRICARE/TRICARE or an
insurance plan),] now paid any of this (AMOUNT REMAINING)?

117

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

CPS

CPS12

YOU CANNOT CORRECT
THE AMOUNT REMAINING
HERE. THE ERROR HAS
BEEN NOTED. ANSWER
“YES” OR “NO” AS
APPROPRIATE AS TO
WHETHER ANY SOURCE
HAS PAID.

CPS

CPS13

CPS

CPS14

3/30/2010

Question Text

Interviewer Instructions II

Let me review what we recorded last time. [REVIEW WITH
RESPONDENT.] The total of all payments is $(TOTAL
PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN
PAYMENTS AND TOTAL CHARGE).[Have you/Has (SP)] or any
other source [, such as (an insurance plan/TRICARE/TRICARE or
an insurance plan),] paid any additional amount?
YOU CANNOT CORRECT
THE TOTAL CHARGE
HERE. THE ERROR HAS
BEEN NOTED. ANSWER
“YES” OR “NO” AS
APPROPRIATE AS TO
WHETHER ANY SOURCE
HAS PAID ANY
ADDITIONAL AMOUNT.

118

Current MCBS Questionnaire

Category

ItemTag

CPS

CPS15

CPS

CPS16

CPS

CPS17

Do you expect that [you/(SP)] or any other source will pay any (of
this amount/additional amount for [READ EVENT(S) ABOVE])?

CPS
CPS

CPS18
CPS19

CPS

CPS20

How much do you expect will be paid?
Last time, [you/(SP)] [expected some source to pay/
(weren’t/wasn't) sure whether some source would pay [you/(SP)]
back] some or all of the (SP/FAMILY PAYMENT) (you/he/she) had
paid for [READ EVENT(S) ABOVE].
Has any source [, such as (an insurance plan/TRICARE/TRICARE
or an insurance plan),] paid [you/(SP)] back any of that
amount?([PROBE IF NECESSARY: Please include any payments
received from (your/(SP's)] Medicare prescription drug benefit.])

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Let me review what we recorded last time. [REVIEW ABOVE
WITH RESPONDENT.] There seems to be some amount still
unpaid. The total of non-Medicare payments is $(TOTAL
PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN
PAYMENTS AND AMOUNT REMAINING).[Have you/Has (SP)] or
any other source [, such as (an insurance plan/TRICARE/TRICARE
or an insurance plan),] paid any additional amount?
YOU CANNOT CORRECT
THE AMOUNT REMAINING
HERE. THE ERROR HAS
BEEN NOTED. ANSWER
“YES” OR “NO” AS
APPROPRIATE AS TO
WHETHER ANY SOURCE
HAS PAID ANY
ADDITIONAL AMOUNT.

119

Current MCBS Questionnaire

Category

ItemTag

CPS

CPS21

CPS
CPS

CPS22
CPS23

CPS

CPS24

CPS

CPS25

CPS

CPS26

CPS

CPS27

CPS

CPS27BINT

CPS
CPS

CPS27B_IN
CPS28

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Do you still expect any source to pay [you/(SP)] back any amount
for [READ EVENT(S) ABOVE]?
How much do you expect will be paid?
DID RESPONDENT
MENTION (AN
INSURANCE/A) REFUND
OR REIMBURSEMENT
ABOUT WHICH HE/SHE IS
NOT SURE OF THE
DETAILS?
DO YOU WANT TO ADD A
REFUND OR
REIMBURSEMENT?
ARE ALL OF THE
SOURCES OF PAYMENT
FOR THIS CHARGE
BUNDLE LISTED
BELOW?
ADD ALL ADDITIONAL
SOURCES OF PAYMENT
FOR THIS CHARGE
BUNDLE.

SELECT "NO" TO ADD A
SOURCE OF PAYMENT.

Who (else) paid (besides Medicare)? How much did (SOURCE)
ENTER ALL
pay?REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT) REIMBURESMENT
AMOUNTS.
Before we continue, I would like to ask you a few questions about
the health insurance plan(s) you just added.
I recorded previously that (CURRENT MEDICARE MANAGED
CARE PLAN NAME) was [your/(SP's)] current Medicare Managed
Care Plan. Has this information changed?

120

Current MCBS Questionnaire

Category

ItemTag

CPS

CPS29

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in
(CPS26 SOP MEDICARE MANAGED CARE PLAN NAME) [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

CPS

CPS29A

I recorded previously that (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN) was [your/(SP's)] current Medicare Prescription Drug
Care Plan.Has this information changed?

CPS

CPS29B

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in
(CPS26 SOP MEDICARE PRESCRIPTION DRUG PLAN) [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

CPS

CPS29C

Before we continue, I would like to ask you a few questions about
the discount membership plan(s) you just added.

CPS
CPS

CPS29C_IN
CPS30

CPS

CPS31

CPS

CPS32

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

DOES THIS
REIMBURSEMENT
AMOUNT COVER ANY
OTHER EVENTS BESIDES
THOSE SHOWN ABOVE?
CHECK ALL THAT APPLY.

WHAT OTHER TYPE(S)
OF EVENT(S) ARE
COVERD BY THIS
REIMBURSEMENT?
PLEASE ENTER A
COMMENT TO RECORD
ANYTHING ELSE YOU
KNOW ABOUT THIS
REFUND (PROVIDER(S),
DATE(S), ETC.)

121

Current MCBS Questionnaire

Category

ItemTag

ACQ

ACINTRO

ACQ

AC1

ACQ

AC6A

ACQ

AC8

ACQ

AC9

ACQ
ACQ

AC10
AC12

ACQ

AC13

ACQ

AC14

ACQ

AC16A

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

The next questions are about health care services [you/(SP)] may
have used since (REFERENCE DATE).
Since (REFERENCE DATE), did [you/(SP)] go to a hospital
emergency room?
Think about the most recent time [you/(SP)] went to the hospital
emergency room. How long did [you/(SP)] have to wait during
(your/his/her) visit before (you/he/she) saw a doctor or some other
medical person? Please include the time spent in the waiting room
and exam room.
Since (REFERENCE DATE), did [you/(SP)] go to a hospital clinic or DO NOT INCLUDE
HOSPITAL INPATIENT
outpatient department?
STAYS.
[I have a few more questions about visits that [you/(SP)] had in the CHECK ALL THAT APPLY.
past.]Think about the most recent time [you/(SP)] went to a hospital
clinic or outpatient department. What was the reason [you/(SP)]
went to the hospital clinic or outpatient department?[PROBE: Any
other reason?]
Was that for a specific condition?
Did [you/(SP)] have an appointment for this visit to the hospital
clinic or outpatient department, or did (you/he/she) just walk in?
Did someone at the hospital clinic or outpatient department tell
[you/(SP)] when to come back during an earlier visit, or did
[you/(SP)] call for an appointment?
How long did [you/(SP)] have to wait for the appointment -- about
how many days, weeks, or months?
[Think about the most recent time [you/(SP)] went to a hospital
clinic or outpatient department.]How long did [you/(SP)] have to
wait during (your/his/her) most recent visit before (you/he/she) saw
a doctor or some other medical person? Please include the time
spent in the waiting room and exam room.

122

Current MCBS Questionnaire

Category

ItemTag

ACQ

AC17

ACQ

AC18

ACQ

AC19

ACQ

AC20

ACQ

AC21

ACQ
ACQ

AC22
AC24

ACQ

AC25

ACQ

AC26

ACQ

AC28A1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Have you/Has (SP)] ever been a resident or patient in a nursing
home or similar place?
When [were you/was (SP)] last a resident or patient in a nursing
home or similar place?
Next, I want to ask about [your/(SP)’s] visits to doctors since
(REFERENCE DATE). [Have you/Has (SP)] seen a medical doctor
since (REFERENCE DATE)? Please do not include a doctor seen
at home, at an emergency room or outpatient department, or while
an inpatient at a hospital.
[I have a few more questions about visits that [you/(SP)] had in the
past.]Think about the most recent time [you/(SP)] saw a medical
doctor somewhere other than at home or at a hospital. What was
the doctor’s specialty?
What was the reason [you/(SP)] saw the doctor?[PROBE: Any
CHECK ALL THAT
other reason?]
APPLY.
Was that for a specific condition?
Did [you/(SP)] have an appointment for this visit with the doctor, or
did (you/he/she) just walk in?
Did someone in the doctor’s office tell [you/(SP)] when to come
back during an earlier visit, or did [you/(SP)] call for an
appointment?
How long did [you/(SP)] have to wait for the appointment with the
medical doctor -- about how many days, weeks, or months?
[Think about the most recent time [you/(SP)] saw a medical doctor
somewhere other than at home or at a hospital.] How long did
[you/(SP)] have to wait during (your/his/her) most recent visit
before (you/he/she) saw a doctor or some other medical person?
Please include the time spent in the waiting room and exam room.

123

Current MCBS Questionnaire

Category

ItemTag

ACQ

AC33

The following questions are about health care that [you/(SP)]
received through (CURRENT MEDICARE MANAGED CARE PLAN
NAME). While a member of (CURRENT MEDICARE MANAGED
CARE PLAN NAME), [have you/has (SP)] had difficulty in obtaining
referrals for the services of a specialist or other medical person
within (CURRENT MEDICARE MANAGED CARE PLAN NAME) that
[you/(SP)] thought were necessary?

ACQ
ACQ

AC34A
AC35

ACQ

AC36

HFQ

HFA1

HFQ

HFA2

What kind of specialist or medical person was this?
What kind of difficulty did [you/(SP)] have?[PROBE: Any other
CHECK ALL THAT APPLY.
difficulty?]
Has (CURRENT MEDICARE MANAGED CARE PLAN NAME) ever
refused to pay for emergency treatment that [you/(SP)] felt was
necessary?
Now, I would like to ask you about [your/(SP's)] health. In general,
compared to other people [your/(SP's)] age, would you say that
(your/his/her) health is . . .
Compared to one year ago, how would you rate [your/(SP's)] health
in general now? Would you say [your/(SP's)] health is . . .

HFQ

HFA3

HFQ
HFQ

HFB1
HFB2

HFQ

HFB3

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How much of the time during the past month has [your/(SP's)]
health limited [your/(SP's)] social activities, like visiting with friends
or close relatives? Would you say . . .
[Do you/Does (SP)] wear eyeglasses or contact lenses?
Which statement best describes [your/(SP's)] vision (while wearing
glasses or contact lenses): no trouble seeing, a little trouble, a lot
of trouble, or no usable vision?
Because of [your/(SP's)] difficulty seeing, how much trouble [do
you/does (SP)] have with prescription labels or medical
instructions? Would you say (you have/she has/he has) no
trouble, a little trouble, or a lot of trouble?

124

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFB4

Because of [your/(SP's)] difficulty seeing, how much trouble [do
you/does (SP)] have finding out things (you need/he needs/she
needs) to know about Medicare? Would you say (you have/she
has/he has) no trouble, a little trouble, or a lot of trouble?

HFQ

HFB5

HFQ

HFB6

Because of [your/(SP's)] difficulty seeing, how much trouble [do
you/does (SP)] have obtaining medical care, such as finding care
or getting there when (you need/he needs/she needs) it? Would
you say (you have/she has/he has) no trouble, a little trouble, or a
lot of trouble?
[Have you/Has (SP)] had an eye examination by an eye doctor
since (LAST HF MONTH YEAR)?

HFQ

HFB7

HFQ
HFQ
HFQ

HFB10
HFC1
HFC2

HFQ

HFC3

HFQ

HFC4

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How long has it been since [your/(SP's)] last eye examination by an
eye doctor?
[Have you/Has (SP)] ever had an operation for cataracts?
[Do you/Does (SP)] use a hearing aid?
Which statement best describes [your/(SP's)] hearing (with a
hearing aid): no trouble hearing, a little trouble, a lot of trouble, or
deaf?
How much trouble [do you/does (SP)] have finding out things (you
need/he needs/she needs) to know about Medicare because [of
(your/his/her) difficulty hearing/(you are/he is/she is) deaf]? Would
you say (you have/she has/he has) no trouble, a little trouble, or a
lot of trouble?
How much trouble [do you/does (SP)] have communicating with
(your/his/her) doctor or other medical personnel because [of
(your/his/her) difficulty hearing/(you are/he is/she is) deaf]? Would
you say (you have/she has/he has) no trouble, a little trouble, or a
lot of trouble?

125

INCLUDE
OPHTHALMOLOGISTS
AND OPTOMETRISTS.

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFD1A

HFQ
HFQ

HFE1
HFFINTRO

HFQ

HFF1

HFQ

HFF2

HFQ

HFF3

HFQ

HFF5

HFQ

HFF6

HFQ

HFF8

HFQ
HFQ

HFF9
HFF10

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How much trouble [do you/does (SP)] have eating solid foods
because of problems with (your/his/her) mouth or teeth? Would
you say (you have/she has/he has) no trouble, a little trouble, or a
lot of trouble?
These next few questions are about preventive health care
measures some people take.
When was the most recent time [you/(SP)] had (your/his/her) blood
pressure taken by a doctor or other health professional?
When was the most recent time [you/(SP)] had (your/his/her) blood
cholesterol checked?
(These next few questions are about preventive health care
measures some people take). [Have you/Has (SP)] had a
mammogram or a breast X-ray since (LAST HF MONTH YEAR)?
What is the reason that [you have/(SP) has] not had a mammogram CHECK ALL THAT APPLY.
since (LAST HF MONTH YEAR)?
[Have you/Has (SP)] had a Pap smear test since (LAST HF
MONTH YEAR)?
What is the reason that [you have/(SP) has] not had a Pap smear CHECK ALL THAT APPLY.
test since (LAST HF MONTH YEAR)?
[Have you/Has (SP)] ever had a hysterectomy?
[Since (LAST HF MONTH YEAR), [have you/has (SP)/[Have
you/has (SP)] ever] had surgery on (your/his) prostate?[EXPLAIN
IF NECESSARY: Surgery on the prostate gland is typically used as
a treatment for prostate cancer or to correct urinary problems.
Surgery can include complete or partial removal of the prostate.]

126

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFF11

These next few questions are about (preventive health care
measures some people take/follow-up care sometimes prescribed
after prostate surgery). [Have you/Has (SP)] had a digital rectal
examination (of the prostate) since (LAST HF MONTH YEAR)?
[EXPLAIN IF NECESSARY: The exam may be used to detect
prostate cancer, to determine whether cancer has spread beyond
the prostate, and as part of follow-up care after prostate surgery.]

HFQ

HFF12

[Have you/Has (SP)] had a blood test for detection of prostate
cancer, known as a PSA, since (LAST HF MONTH YEAR)? PSA =
PROSTATE-SPECIFIC ANTIGEN [EXPLAIN IF NECESSARY: The
test may be used to detect prostate cancer, to determine whether
cancer has spread beyond the prostate, and as part of follow-up
care after prostate surgery.]

HFQ

HFF14

What is the reason that [you have/(SP) has] not had a prostate
blood test or PSA since (LAST HF MONTH YEAR)?

HFQ

HFF15

On a different topic ... Did [you/(SP)] have a flu shot for last winter?
[EXPLAIN IF NECESSARY: Did [you/(SP)] get a flu shot any time
during the period from September (PREVIOUS YEAR) through
December (PREVIOUS YEAR)?]

HFQ

HFF17

HFQ

HFF18

Why didn't [you/(SP)] get a flu shot last winter? [PROBE: Any other CHECK ALL THAT APPLY.
reason?]
Where did [you/(SP)] go for (your/his/her) most recent flu shot, was
that a managed care plan center or HMO, a clinic, a doctor’s office,
a hospital, a health fair, shopping mall, or some other place?[IF
CLINIC, ASK: Was it a hospital outpatient clinic, or some other kind
of clinic? IF SOME OTHER PLACE, ASK: Where was this?]

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

127

CHECK ALL THAT APPLY.

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFF20

HFQ

HFF21

HFQ
HFQ

HFF22
HFF23

HFQ

HFG1

HFQ

HFG2

HFQ
HFQ

HFG3
HFG4

HFQ
HFQ

HFG5
HFG5A

HFQ

HFG6

HFQ

HFG7

HFQ

HFG8

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Did [you/(SP)] have any trouble getting a flu shot when
(you/he/she) wanted to because the vaccine was in short supply or
unavailable?
Was one reason that [you/(SP)] did not get a flu shot last winter
because the vaccine was in short supply or unavailable?
[Have you/Has (SP)] ever had a shot for pneumonia?
Why didn't [you/(SP)] ever have a shot for pneumonia? [PROBE:
CHECK ALL THAT APPLY.
Any other reason?]
[Have you/Has (SP)] ever smoked cigarettes, cigars, or pipe
tobacco?
[Do you/Does (SP)] smoke cigarettes, cigars, or pipe tobacco
now?
How many years did [you/(SP)] smoke?
About how long has it been since [you/(SP)] last smoked regularly?
How many years [have you/has (SP)] smoked?
Since (LAST HF MONTH YEAR), has a doctor or other health
professional advised [you/(SP)] to quit smoking?
During the past 12 months, [have you/has (SP)] stopped smoking
for one day or longer because (you were/he was/she was) trying to
quit smoking?
ENTER "0" FOR "NEVER
The next questions are about drinking alcoholic beverages.
DRANK" OR "NONE".
Included are liquor such as whiskey or gin, mixed drinks, wine,
beer, and any other type of alcoholic beverage.Please think about
a typical month in the past year. On how many days did [you/(SP)]
drink any type of alcoholic beverage?
[Please think about a typical month in the past year.] On those
days that [you/(SP)] drank alcohol, how many drinks did
(you/he/she) have?

128

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFG9

[Please think about a typical month in the past year.] On how many ENTER "0" FOR "NEVER"
days did [you/(SP)] have 4 or more drinks in a single day?
OR "NONE".

HFQ

HFHINTRO

HFQ

HFH1

SHOW CARD HF1

HFQ

HFH2

SHOW CARD HF1

HFQ

HFH3

SHOW CARD HF1

Now, I'm going to ask about how difficult it is, on the average, for
[you/(SP)] to do certain kinds of activities. Please tell me for each
activity whether [you have/(SP) has] no difficulty at all, a little
difficulty, some difficulty, a lot of difficulty, or (is/are) not able to do
it.
How much difficulty, if any, [do you/does (SP)] have stooping,
crouching, or kneeling? Would you say [you have/(SP) has] no
difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or
(is/are) not able to do it?
How much difficulty, if any, [do you/does (SP)] have lifting or
carrying objects as heavy as 10 pounds, like a sack of potatoes?
Would you say [you have/(SP) has] no difficulty at all, a little
difficulty, some difficulty, a lot of difficulty, or (is/are) not able to do
it?
What about reaching or extending arms above shoulder level?

HFQ

HFH4

SHOW CARD HF1

HFQ

HFH5

SHOW CARD HF1

HFQ

HFH10INT

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How much difficulty, if any, [do you/does (SP)] have either writing
or handling and grasping small objects? Would you say [you
have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or (is/are) not able to do it?
What about walking a quarter of a mile - that is, about 2 or 3
blocks?
We are interested in two types of physical activity - vigorous and
moderate. Vigorous activities cause large increases in breathing or
heart rate. Moderate activities cause small increases in breathing
or heart rate. First I will ask about the vigorous activities that [you
do/(SP) does].

129

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFH10

HFQ

HFH11

HFQ

HFH12

HFQ

HFJINTRO

HFQ

HFJ1

HFQ

HFJ2

HFQ

HFJ3

Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) still had hypertension or high blood pressure?

HFQ

HFJ4

HFQ

HFJ5

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] a myocardial infarction or heart
attack?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had a myocardial infarction or heart attack?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

In a typical week, how much time [do you/does (SP)] spend doing
vigorous activities, such as team sports, running, aerobics, heavy
house or yard work, or anything else that causes large increases in
breathing or heart rate?
In a typical week, how much time [do you/does (SP)] spend doing
moderate activities, such as brisk walking, bicycling, gardening,
golf, swimming, or vacuuming?

IF TIME REPORTED IN
BOTH MINUTES AND
HOURS, ROUND TO
NEAREST HOUR.
IF TIME REPORTED IN
BOTH MINUTES AND
HOURS, ROUND TO
NEAREST HOUR.
IF TIME REPORTED IN
Now I’m going to ask you about activities [you/(SP)] may do to
BOTH MINUTES AND
increase (your/his/her) muscle strength or flexibility.In a typical
week, how much time [do you/does (SP)] spend doing exercises to HOURS, ROUND TO
increase (your/his/her) muscle strength or flexibility, such as lifting NEAREST HOUR.
weights, push-ups, sit-ups, stretching, or yoga?
Next, I'm going to read a list of medical conditions. [Since (LAST
HF MONTH YEAR) has/Has] a doctor (ever) told [you/(SP)] that
(you/he/she) had any of these conditions?
[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had... hardening of the arteries or
arteriosclerosis?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) (still have/still has/have/had)...]
hypertension, sometimes called high blood pressure?

130

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFJ6

HFQ

HFJ7

HFQ

HFJ8

HFQ

HFJ9

HFQ

HFJ10

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] (a new episode of) problems
with the valves of the heart, such as aortic stenosis?

HFQ

HFJ11

HFQ

HFJ12

HFQ

HFJ13

HFQ

HFJ14

HFQ

HFJ15

Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had an episode of problems with the valves of the
heart, such as aortic stenosis?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] (a new episode of) problems
with the rhythm of (your/his/her) heartbeat, such as atrial
fibrillation?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had an episode of problems with the rhythm of
(your/his/her) heart, such as atrial fibrillation?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] (a new episode of) any other
heart condition?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had an episode of any other heart condition?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] (a new episode of) angina
pectoris or coronary heart disease?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had an episode of angina pectoris or coronary heart
disease?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] (a new episode of) congestive
heart failure?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had an episode of congestive heart failure?

131

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFJ16

HFQ

HFJ17

HFQ

HFJ17A

HFQ

HFJ17B

HFQ

HFJ18

HFQ

HFJ19

HFQ

HFJ20

HFQ

HFJ21

HFQ

HFJ22

HFQ

HFJ24

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] a stroke, a brain hemorrhage, or
a cerebrovascular accident?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had a stroke, a brain hemorrhage, or a
cerebrovascular accident?
Has a doctor ever told [you/(SP)] that (you/he/she) had high
cholesterol?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had high cholesterol?
[I've recorded that [you/(SP)] previously reported having had skin
cancer.] [[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever)
told [you/(SP)] that (you/he/she) had...] (a new occurrence of) skin
cancer?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had an occurrence of skin cancer?
INCLUDE BENIGN OR
[I've recorded that [you/(SP)] previously reported having had a
NON-MALIGNANT
tumor, growth, or cancer of the [READ RESPONSES BELOW].]
TUMORS OR GROWTHS.
[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] any (other) kind of cancer,
malignancy, or tumor other than skin cancer?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had any kind of cancer, malignancy, or tumor other
than skin cancer?
[Since the first time a doctor told [you/(SP)] that (you/he/she) had a CHECK ALL THAT APPLY.
cancer, malignancy, or tumor, on/On] what part or parts of
[your/(SP's)] body was the cancer or tumor found? [PROBE: Any
other part?]
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] rheumatoid arthritis?

132

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFJ25

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] arthritis, other than rheumatoid
arthritis? [EXPLAIN IF NECESSARY: This includes osteoarthritis.]

HFQ

HFJ26

HFQ

HFJ28

Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had arthritis in any part of (your/his/her) body, other
than rheumatoid arthritis?
[Has a doctor ever told [you/(SP)] that (you/he/she) had...] an
intellectual disability, sometimes called mental retardation?

HFQ

HFJ29A

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] Alzheimer's disease?

HFQ

HFJ29B

HFQ

HFJ30AA

HFQ

HFJ30BB

HFQ

HFJ30A

HFQ

HFJ31A

HFQ

HFJ32

HFQ

HFJ33

HFQ

HFJ34

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] any type of dementia other than
Alzheimer's disease?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] depression?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had depression?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] a mental or psychiatric disorder
other than depression?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had a mental or psychiatric disorder other than
depression?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] osteoporosis, sometimes called
fragile or soft bones?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] a broken hip?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had a broken hip?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

133

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFJ35

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] Parkinson's disease?

HFQ

HFJ36

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] emphysema, asthma, or
COPD?

HFQ

HFJ37

HFQ

HFJ38

HFQ

HFJ39

HFQ

HFJ40

HFQ

HFJ41

HFQ

HFJ41A

3/30/2010

Interviewer Instructions I

[IF SP IS OBVIOUSLY
PARTIALLY OR
COMPLETELY
PARALYZED, SELECT
"YES" AND DO NOT ASK.
OTHERWISE, ASK:]

IF SP IS OBVIOUSLY
MISSING ONE OR MORE
LIMBS, SELECT "YES"
AND DO NOT ASK.
OTHERWISE, ASK:

Question Text

Interviewer Instructions II

[[Since (LAST HF MONTH YEAR) has/Has] a doctor (ever) told
[you/(SP)] that (you/he/she) had...] complete or partial paralysis?

Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he/she) had complete or partial paralysis?
What about absence or loss of an arm or a leg?

[[Before [you/(SP)] had prostate surgery, did a doctor ever
tell/Since (LAST HF MONTH YEAR), has/Has]] a doctor (ever) told ]
[you/(SP)] that (you/he) had...] an enlarged prostate or benign
prostatic hypertrophy (BPH)?
Since (LAST HF MONTH YEAR), did a doctor tell [you/(SP)] that
(you/he) had an enlarged prostate or benign prostatic hypertrophy
(BPH)?
Has a doctor ever told [you/(SP)] that (you/he/she) had any type of
diabetes, including: sugar diabetes, high blood sugar, (borderline
diabetes, pre-diabetes, or pregnancy-related diabetes/borderline
diabetes, or pre-diabetes)?

134

COPD=CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

HFQ

HFJ41B

SHOW CARD HF6

HFQ

HFJ41C

HFQ

HFJ42

Looking at this card, please tell me which type of diabetes the
doctor said that [you have/(SP) has].
[Were you/Was (SP)] told on two or more different visits that
(you/he/she) had diabetes?
You told me that [you have/(SP) has] had [READ CONDITIONS
LISTED BELOW]. (Was this/Were any of these) the original cause
of [your/(SP's)] becoming eligible for Medicare?

HFQ

HFJ43

HFQ

HFJ44

HFQ

HFPINTRO

HFQ

HFP1

HFQ
HFQ

HFP2
HFP4

HFQ
HFQ

HFP5
HFP6

HFQ

HFP7

3/30/2010

Interviewer Instructions II

What was the original cause of [your/(SP's)] becoming eligible for RECORD VERBATIM.
Medicare?
Which of these conditions was the cause of [your/(SP's)] becoming CHECK UP TO 8
eligible for Medicare? [PROBE: Any other condition?]
CONDITIONS.
Now I want to ask you about some things that [you/(SP)] may be
doing to maintain (your/his/her) health, either by getting tested for
health problems or by taking care of conditions that (you have/she
has/he has).
I recorded that [you were/(SP) was] told by a doctor that (you
have/she has/he has) (Type 1 diabetes/Type 2 diabetes/borderline
diabetes/pre-diabetes/diabetes). How old [were you/was (SP)]
when (you were/he was/she was) first told that (you/he/she) had
diabetes?
Did [you/(SP)] have diabetes only during a pregnancy?
Please tell me whether (you use/SP uses) any of the following
ways to manage (your/his/her) diabetes. [Do you/Does (SP)]…
How often [do you/does (SP)] take insulin?
How often [do you/does (SP)] take prescription diabetes pills or
oral diabetes medicine?
How often [do you/does (SP)] test (your/his/her) blood for sugar or
glucose? [PROBE: Include times when it is tested by a family
member or friend, but do not include times when it is tested by a
health professional.]

135

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFP8

HFQ

HFP10

HFQ

HFP11

HFQ

HFP13

HFQ

HFP14

HFQ

HFP14A

HFQ

HFP15

HFQ

HFP16

HFQ

HFP17

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How often [do you/does (SP)] check (your/his/her) feet for sores or
irritations? [PROBE: Include times when they are checked by a
family member or friend, but do not include times when they are
checked by a health professional.]
In the past year has a doctor or other medical professional
examined (your/his/her) feet for sores or irritations?
About how many times in the past year [have you/has (SP)] seen a
doctor or other health professional for (your/his/her) diabetes?

SHOW CARD HF4

A test of hemoglobin "A one C" measures the average level of
blood sugar over the past three months. It is usually done in a
doctor's office. About how many times in the past year has a
doctor or other health professional checked [you/(SP)] for
hemoglobin "A one C"?
Would you say that [your/(SP's)] blood sugar is well controlled all of
the time, most of the time, some of the time, a little of the time, or
none of the time? By "well controlled" we mean a recent
hemoglobin "A one C" result of 7.5 or less or an average fasting
blood test of 140 or less.
[Do you/Does (SP)] have any problems with (your/his/her) feet as a
result of (your/his/her) diabetes?
[Do you/Does (SP)] have any problems with (your/his/her) eyes as
a result of (your/his/her) diabetes?
[Do you/Does (SP)] have any problems with (your/his/her) kidneys
as a result of (your/his/her) diabetes? [EXPLAIN IF NECESSARY:
This is tested by looking for protein in the urine.]
[Have you/Has (SP)] ever participated in a diabetes selfmanagement course or class, or received special training on how
(you/he/she) can manage (your/his/her) diabetes?

136

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFP18

HFQ

HFP19

HFQ

HFP20

HFQ

HFP21

HFQ

HFP22

HFQ

HFP23

HFQ

HFP24

HFQ

HFP25

In the past year, [have you/has (SP)] received any information
about the signs, symptoms, or risk factors for diabetes?

HFQ

HFR1

Now I'd like to talk about a different illness, colorectal or colon
cancer, a disease of the lower intestines. Before today, had you
ever heard of colorectal or colon cancer?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

When was the most recent time that [you/(SP)] participated in a
diabetes self-management course or class or received special
training on how (you/he/she) can manage (your/his/her) diabetes?
SHOW CARD HF3

How much do you think you know about managing your diabetes?
Do you know . . .
Before today, did you know that Medicare now helps pay the cost
of diabetic testing supplies and self-management education for
people with diabetes?
[I have recorded that [you have/(SP) has] never been told by a
doctor that (you have/she has/he has) diabetes.] [Have you/Has
(SP)] ever had a blood test to see if (you have/she has/he has)
diabetes?
When was the most recent time [you were/(SP) was] tested for
diabetes?
Before today, were you aware that there is a blood test to
determine if a person has diabetes?
Has a doctor or other health professional ever told [you/(SP)] that
(you are/he is/she is) at high risk for diabetes?

137

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFR3

The fecal occult blood test is a simple test for early signs of colon
cancer. It detects invisible traces of blood found in the stool. The
doctor or other health professional can give the patient a kit to
collect stool samples at the patient's home. The test is then sent to
a laboratory for the results to be determined. Has a doctor or other
health professional ever given [you/(SP)] a home testing kit to test
for blood in the stool?

HFQ
HFQ

HFR4
HFR5

HFQ

HFR7

HFQ

HFR8

Have you ever heard of this home testing kit?
Did [you/(SP)] complete the samples and send the card in for
(your/his/her) most recent test?
When did [you/(SP)] have (your/his/her) most recent blood stool
test using a home testing kit?
Another test for early signs of colon cancer is performed in the
doctor's office. The doctor uses a flexible lighted tube to examine
the colon and rectum directly. This is called a sigmoidoscopy or
colonoscopy. [Have you/Has (SP)] ever had this exam?

HFQ

HFR9

HFQ

HFR10

HFQ

HFR11

HFQ

HFR13

HFQ

HFSINTRO

HFQ

HFS1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

When did [you/(SP)] have (your/his/her) most recent
sigmoidoscopy or colonoscopy?
Before today, had you ever heard of a sigmoidoscopy or
colonoscopy?
Has a doctor ever recommended that [you/(SP)] have this test?
Before today, did you know that Medicare now helps pay the cost
of screening tests for colorectal cancer?
Now I'd like to talk about a disease called osteoporosis, which can
be treated if found early. In osteoporosis, the bones lose their
calcium and become fragile and more easily broken.
[Have you/Has (SP)] ever talked with (your/his/her) doctor or other
health professional about osteoporosis?

138

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFS2

Has a doctor or other health professional ever told [you/(SP)] that
(you are/he is/she is) at high risk for osteoporosis?

HFQ

HFS3

HFQ
HFQ

HFS4
HFS5

HFQ

HFS6

HFQ

HFAC29

There is a test to detect osteoporosis at an early stage, called
Bone Mass Measurement or Bone Density Measurement, or DEXA
scan. [Have you/Has (SP)] ever had a Bone Mass or Bone Density
Measurement test?
Before today, had you ever heard of this test?
When was the most recent time that [you/(SP)] had a Bone Mass
or Bone Density Measurement test?
Before today, did you know that Medicare would pay for Bone
Mass or Bone Density Measurement tests for Medicare
beneficiaries who are at risk for osteoporosis?
Next, we are going to ask some questions about [your/(SP's)]
health care needs during the past year. Since (LAST HF MONTH
YEAR), [have you/has (SP)] had any trouble getting health care
that (you/he/she) wanted or needed?

HFQ

HFAC30A

Why was that? [PROBE: Any other reason?]

HFQ

HFAC30B

HFQ

HFAC30C

HFQ

HFAC30D

HFQ

HFAC30E

Since (LAST HF MONTH YEAR), [have you/has (SP)] been told by
a doctor’s office that they cannot schedule an appointment with
[you/(SP)]?
CHECK ALL THAT APPLY
What were the reasons the doctor’s office offered as an
explanation for not scheduling an appointment with
[you/(SP)]?[PROBE: Any other reason?]
Did the doctor’s office explain why (it is difficult for Medicare
patients to get an appointment/Medicare is not accepted) at that
practice?
What was that explanation?
RECORD VERBATIM.

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

139

CHECK ALL THAT APPLY.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

HFQ

HFAC30F

SHOW CARD HF7

In some situations your doctor or other health care provider may
give you a form called either an Advance Beneficiary Notice or
notice of noncoverage.This form is used when the health care
provider has some doubt that a service will be covered by
Medicare, and expects that you may have to pay for the service. In
such cases, you can make a choice. You can choose to get or not
get the service. If you sign the form, you can get the service right
away; and, usually, the provider will collect payment from you.You
can still ask the provider to bill Medicare, in case the provider is
wrong and the service is covered. If the service is covered, then
the money you paid the provider is returned to you. Since (LAST
HF MONTH YEAR), has any doctor or other health care provider
given you a form like one shown on this card?

HFQ

HFAC30G

HFQ
HFQ

HFAC30G1
HFAC30H

HFQ

HFAC30I

HFQ
HFQ

HFAC30J
HFAC30K

3/30/2010

Interviewer Instructions II

CHECK ALL THAT
Think about the most recent time you received an Advance
Beneficiary Notice, or "ABN". What items or services did the health APPLY.
care provider expect would not be paid by Medicare?[PROBE:
What type(s) of health care items or services were described on
the ABN?]
Did you read the Advance Beneficiary Notice?
How much trouble did you have understanding the Advance
Beneficiary Notice for (the item or service/these items or
services)? Would you say you had no trouble, a little trouble, or a
lot of trouble?
[Think about the most recent time you received an Advance
Beneficiary Notice.] Did you sign the form?
Why didn’t you sign the form?
RECORD VERBATIM.
You mentioned that you received an ABN for [READ HEALTH
CARE ITEMS AND SERVICES LISTED BELOW]. Did you choose
to get (the item or service/these items or services) even though the
health care provider expected Medicare would not pay?

140

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFAC30K1

HFQ

HFAC30L

HFQ

HFAC30M

HFQ

HFAC31

HFQ

HFKINTRO

HFQ

HFKA1

HFQ

HFKA2

HFQ

HFKB1

HFQ

HFKB2

HFQ

HFKC1

HFQ

HFKC2

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Did you ask that Medicare be billed for (the item or service/these
items or services)?
Did Medicare deny payment for (the item or service/these items or
services)?
What sources paid any part of the cost for (the item or
CHECK ALL THAT APPLY.
service/these items or services)?[PROBE: Who else paid?]
Since (LAST HF MONTH YEAR), [have you/has (SP)] delayed
seeking medical care because (you were/he was/she was) worried
about the cost?
Now I'm going to ask about some everyday activities and whether
[you have/(SP) has] any difficulty doing them by
(yourself/himself/herself).
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... using the telephone?
[You said that using the telephone is something that [you don't/(SP)
doesn't] do.] Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... doing light housework (like washing dishes,
straightening up, or light cleaning)?
[You said that doing light housework (like washing dishes,
straightening up, or light cleaning) is something that [you don't/(SP)
doesn't] do.] Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... doing heavy housework (like scrubbing floors or
washing windows)?
[You said that doing heavy housework (like scrubbing floors or
washing windows) is something that [you don't/(SP) doesn't] do.] Is
this because of a health or physical problem?

141

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFKD1

Because of a health or physical problem, [do you/does (SP)] have
any difficulty... preparing (your/his/her) own meals?

HFQ

HFKD2

HFQ

HFKE1

HFQ

HFKE2

[You said that preparing (your/his/her) own meals is something that
[you don't/(SP) doesn't] do.] Is this because of a health or physical
problem?
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... shopping for personal items (such as toilet items or
medicines)?
[You said that shopping for personal items (such as toilet items or
medicines) is something that [you don't/(SP) doesn't] do.] Is this
because of a health or physical problem?

HFQ

HFKF1

HFQ

HFKF2

HFQ

HFKA3

[[You said that [your/(SP's)] health makes using the telephone
difficult./You said that using the telephone is something that [you
don't do/(SP) doesn't do].]] [Do you/Does (SP)] receive help from
another person with... using the telephone?

HFQ

HFKA4

You mentioned that [you receive/(SP) receives] help with using the ENTER ALL HELPERS.
telephone. Who gives that help?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Because of a health or physical problem, [do you/does (SP)] have
any difficulty... managing money (like keeping track of expenses or
paying bills)?
[You said that managing money (like keeping track of expenses or
paying bills) is something that [you don't/(SP) doesn't] do.] Is this
because of a health or physical problem?

142

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFKB3

[[You said that [your/(SP's)] health makes doing light housework
(like washing dishes, straightening up, or light cleaning)
difficult./You said that doing light housework (like washing dishes,
straightening up, or light cleaning) is something that [you don't
do/(SP) doesn't do].]] [Do you/Does (SP)] receive help from
another person with... doing light housework (like washing dishes,
straightening up, or light cleaning)?

HFQ

HFKB4

HFQ

HFKC3

You mentioned that [you receive/(SP) receives] help with doing
ENTER ALL HELPERS.
light housework (like washing dishes, straightening up, or light
cleaning). Who gives that help?
[[You said that [your/(SP's)] health makes doing heavy housework
(like scrubbing floors or washing windows) difficult./You said that
heavy housework (like scrubbing floors or washing windows) is
something that [you don't do/(SP) doesn't do].]] [Do you/Does (SP)]
receive help from another person with... doing heavy housework
(like scrubbing floors or washing windows)?

HFQ

HFKC4

HFQ

HFKD3

HFQ

HFKD4

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

You mentioned that [you receive/(SP) receives] help with doing
ENTER ALL HELPERS.
heavy housework (like scrubbing floors or washing windows). Who
gives that help?
[[You said that [your/(SP's)] health makes preparing (your/his/her)
own meals difficult./You said that preparing (your/his/her) own
meals is something that [you don't do/(SP) doesn't do].]] [Do
you/Does (SP)] receive help from another person with... preparing
(your/his/her) own meals?
You mentioned that [you receive/(SP) receives] help with preparing ENTER ALL HELPERS.
(your/his/her) own meals. Who gives that help?

143

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFKE3

[[You said that [your/(SP's)] health makes shopping for personal
items (such as toilet items or medicines) difficult./You said that
shopping for personal items (such as toilet items or medicines) is
something that [you don't do/(SP) doesn't do].]] [Do you/Does (SP)]
receive help from another person with... shopping for personal
items (such as toilet items or medicines)?

HFQ

HFKE4

HFQ

HFKF3

You mentioned that [you receive/(SP) receives] help with shopping ENTER ALL HELPERS.
for personal items (such as toilet items or medicines). Who gives
that help?
[[You said that [your/(SP's)] health makes managing money (like
keeping track of expenses or paying bills) difficult./You said that
managing money (like keeping track of expenses or paying bills) is
something that [you don't do/(SP) doesn't do].]] [Do you/Does (SP)]
receive help from another person with... managing money (like
keeping track of expenses or paying bills)?

HFQ

HFKF4

HFQ

HFLINTRO

HFQ

HFLA1

HFQ

HFLA2

HFQ

HFLB1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

You mentioned that [you receive/(SP) receives] help with managing ENTER ALL HELPERS.
money (like keeping track of expenses or paying bills). Who gives
that help?
Now I'll ask about some other everyday activities. I'd like to know
whether [you have/(SP) has] any difficulty doing each one by
(yourself/himself/herself) and without special equipment.
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... bathing or showering?
[You said that bathing or showering is something that [you
don't/(SP) doesn't] do.] Is this because of a health or physical
problem?
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... dressing?

144

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFLB2

[You said that dressing is something that [you don't/(SP) doesn't]
do.] Is this because of a health or physical problem?

HFQ

HFLC1

HFQ

HFLC2

Because of a health or physical problem, [do you/does (SP)] have
any difficulty... eating?
[You said that eating is something that [you don't/(SP) doesn't] do.]
Is this because of a health or physical problem?

HFQ

HFLD1

HFQ

HFLD2

HFQ

HFLE1

HFQ

HFLE2

HFQ

HFLF1

HFQ

HFLF2

HFQ

HFLA3

HFQ

HFLA4

HFQ

HFLA5

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Because of a health or physical problem, [do you/does (SP)] have
any difficulty... getting in or out of bed or chairs?
[You said that getting in or out of bed or chairs is something that
[you don't/(SP) doesn't] do.] Is this because of a health or physical
problem?
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... walking?
[You said that walking is something that [you don't/(SP) doesn't]
do.] Is this because of a health or physical problem?
Because of a health or physical problem, [do you/does (SP)] have
any difficulty... using the toilet?
[You said that using the toilet is something that [you don't/(SP)
doesn't] do.] Is this because of a health or physical problem?
[[You said [your/(SP's)] health makes bathing or showering
difficult./You said that bathing or showering is something [you
don't/(SP) doesn't] do.]] [Do you/Does (SP)] receive help from
another person with bathing or showering?
Does someone usually stay nearby just in case [you need/(SP)
needs] help with bathing or showering? [That is, does someone
usually stay or come into the room to check on (you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help
(you/him/her) with bathing or showering?

145

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFLA6

HFQ

HFLA7

HFQ

HFLB3

HFQ

HFLB4

Does someone usually stay nearby just in case [you need/(SP)
needs] help with dressing? [That is, does someone usually stay or
come into the room to check on (you/him/her)?]

HFQ

HFLB5

HFQ

HFLB6

HFQ

HFLB7

HFQ

HFLC3

[Do you/Does (SP)] use special equipment or aids to help
(you/him/her) with dressing?
How long [have you/has (SP)] needed help with dressing? Has it
been . . .
Do you expect that [you/(SP)] will still need help with dressing three
months from now?
[[You said [your/(SP's)] health makes eating difficult./You said that
eating is something [you don't/(SP) doesn't] do.]] [Do you/Does
(SP)] receive help from another person with eating?

HFQ

HFLC4

Does someone usually stay nearby just in case [you need/(SP)
needs] help with eating? [That is, does someone usually stay or
come into the room to check on (you/him/her)?]

HFQ

HFLC5

HFQ

HFLC6

HFQ

HFLC7

[Do you/Does (SP)] use special equipment or aids to help
(you/him/her) with eating?
How long [have you/has (SP)] needed help with eating? Has it been
...
Do you expect that [you/(SP)] will still need help with eating three
months from now?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

How long [have you/has (SP)] needed help with bathing or
showering? Has it been . . .
Do you expect that [you/(SP)] will still need help with bathing or
showering three months from now?
[[You said [your/(SP's)] health makes dressing difficult./You said
that dressing is something [you don't/(SP) doesn't] do.]] [Do
you/Does (SP)] receive help from another person with dressing?

146

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFLD3

HFQ

HFLD4

HFQ

HFLD5

HFQ

HFLD6

HFQ

HFLD7

HFQ

HFLE3

HFQ

HFLE4

Does someone usually stay nearby just in case [you need/(SP)
needs] help with walking? [That is, does someone usually stay or
come into the room to check on (you/him/her)?]

HFQ

HFLE5

HFQ

HFLE6

HFQ

HFLE7

HFQ

HFLF3

[Do you/Does (SP)] use special equipment or aids to help
(you/him/her) with walking?
How long [have you/has (SP)] needed help with walking? Has it
been . . .
Do you expect that [you/(SP)] will still need help with walking three
months from now?
[[You said [your/(SP's)] health makes using the toilet difficult./You
said that using the toilet is something [you don't/(SP) doesn't] do.]]
[Do you/Does (SP)] receive help from another person with using
the toilet?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[[You said [your/(SP's)] health makes getting in or out of bed or
chairs difficult./You said that getting in or out of bed or chairs is
something [you don't/(SP) doesn't] do.]] [Do you/Does (SP)]
receive help from another person with getting in or out of bed or
chairs?
Does someone usually stay nearby just in case [you need/(SP)
needs] help with getting in or out of bed or chairs? [That is, does
someone usually stay or come into the room to check on
(you/him/her)?]
[Do you/Does (SP)] use special equipment or aids to help
(you/him/her) with getting in or out of bed or chairs?
How long [have you/has (SP)] needed help with getting in or out of
bed or chairs? Has it been . . .
Do you expect that [you/(SP)] will still need help with getting in or
out of bed or chairs three months from now?
[[You said [your/(SP's)] health makes walking difficult./You said that
walking is something [you don't/(SP) doesn't] do.]] [Do you/Does
(SP)] receive help from another person with walking?

147

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFLF4

Does someone usually stay nearby just in case [you need/(SP)
needs] help with using the toilet? [That is, does someone usually
stay or come into the room to check on (you/him/her)?]

HFQ

HFLF5

HFQ

HFLF6

HFQ

HFLF7

HFQ

HFLA9

HFQ

HFLB9

HFQ

HFLC9

[Do you/Does (SP)] use special equipment or aids to help
(you/him/her) with using the toilet?
How long [have you/has (SP)] needed help with using the toilet?
Has it been . . .
Do you expect that [you/(SP)] will still need help with using the toilet
three months from now?
ENTER ALL HELPERS.
You mentioned that [[you receive/(SP) receives] help/someone
stays nearby in case [you need/(SP) needs] help] with bathing and
showering. Who [gives that help/stays nearby in case [you
need/(SP) needs] help]?
ENTER ALL HELPERS.
You mentioned that [[you receive/(SP) receives] help/someone
stays nearby in case [you need/(SP) needs] help] with dressing.
Who [gives that help/stays nearby in case [you need/(SP) needs]
help]?
You mentioned that [[you receive/(SP) receives] help/someone
ENTER ALL HELPERS.
stays nearby in case [you need/(SP) needs] help] with eating. Who
[gives that help/stays nearby in case [you need/(SP) needs] help]?

HFQ

HFLD9

HFQ

HFLE9

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

ENTER ALL HELPERS.
You mentioned that [[you receive/(SP) receives] help/someone
stays nearby in case [you need/(SP) needs] help] with getting in or
out of bed or chairs. Who [gives that help/stays nearby in case
[you need/(SP) needs] help]?
ENTER ALL HELPERS.
You mentioned that [[you receive/(SP) receives] help/someone
stays nearby in case [you need/(SP) needs] help] with walking.
Who [gives that help/stays nearby in case [you need/(SP) needs]
help]?

148

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFLF9

HFQ

HFL10

HFQ

HFM1

HFQ

HFM2

Since (LAST HF MONTH YEAR), how many times [have you/has
(SP)] fallen down?

HFQ

HFM3A

HFQ

HFM3B

HFQ

HFM3C

HFQ

HFM3D

HFQ

HFM3E

HFQ

HFN1

HFQ

HFN2

HFQ

HFN3

HFQ

HFN4

Thinking about the [most recent) time that [you/(SP)] fell, did
(you/he/she) hurt (yourself/himself/herself) badly enough to get
medical help?
What kind of injury did [you/(SP)] have in that (most recent)
CHECK ALL THAT APPLY.
fall?[PROBE: Anything else?]
Did [your/(SP's)] (most recent) fall cause (you/him/her) to limit
(your/his/her) regular acivities?
How long did it take [you/(SP)] to get back to regular activities after
(your/his/her) (most recent) fall?
How would you rate [your/(SP's)] fear of falling on a scale of 1 to 6,
where 1 is "Not at all afraid of falling" and 6 is "Extremely afraid of
falling"?
[Do you/Does (SP)] experience memory loss such that it interferes
with daily activities?
[Do you/Does (SP)] have problems making decisions to the point
that it interferes with daily activities?
[Do you/Does (SP)] have trouble concentrating or keeping
(your/his/her) mind on what (you are/he is/she is) doing?
In the past 12 months, how much of the time did [you/(SP)] feel
sad, blue, or depressed? Would you say [you were/(SP) was] sad
or depressed all of the time, most of the time, some of the time, a
little of the time, or none of the time?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

ENTER ALL HELPERS.
You mentioned that [[you receive/(SP) receives] help/someone
stays nearby in case [you need/(SP) needs] help] with using the
toilet. Who [gives that help/stays nearby in case [you need/(SP)
needs] help]?
Which of these persons gives [you/(SP)] the most help with these SELECT ONLY ONE.
things?
Since (LAST HF MONTH YEAR), [have you/has (SP)] fallen down?

SHOW CARD HF4

149

ENTER "95" IF 95 OR
MORE FALLS
REPORTED.

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFN5

HFQ

HFQ1

HFQ

HFT1

We have recorded that [you were/(SP) was] told by a doctor that
(you had/he had/she had) hypertension, also called high blood
pressure. [Were you/Was (SP)] told on two or more different
medical visits that (you/he/she) had high blood pressure or
hypertension?[EXPLAIN IF NECESSARY: We are interested in
knowing whether [your/(SP’s)] blood pressure was high for more
than one reading.]

HFQ

HFT2

HFQ

HFT6D

How old [were you/was (SP)] when (you were/he was/she was)
first told that (you/he/she) had high blood pressure?
Because of (your/his/her) high blood pressure, [are you/is (SP)]
now measuring (your/his/her) blood pressure at home?

HFQ

HFT6G

HFQ

HFT6J

HFQ

HFT7

HFQ

HFT8

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

SHOW CARD HF2

In the past 12 months, [have you/has (SP)] had 2 weeks or more
when (you/he/she) lost interest or pleasure in things that
(you/he/she) usually cared about or enjoyed?
I'd like to ask about a health problem that is more common than
people think. Please look at this card and tell me how often, if at
all, since (LAST HF MONTH YEAR) [you have/(SP) has] lost urine
because (you/he/she) could not control (your/his/her) bladder.

Because of (your/his/her) high blood pressure, [are you/is (SP)]
now taking prescribed medicine for (your/his/her) high blood
pressure?
(You mentioned that in a typical month in the past year [you/(SP)]
did not drink alcohol. Is that because of (your/his/her) high blood
pressure?/[Have you/Has (SP)] cut down on drinking alcoholic
beverages because of (your/his/her) high blood pressure?)
How long [have you/has (SP)] been treated with prescribed
medicines for (your/his/her) high blood pressure?
How many different prescribed medicines [do you/does (SP)] take
for (your/his/her) high blood pressure?

150

Current MCBS Questionnaire

Category

ItemTag

HFQ

HFT11A

How often [do you/does (SP)] have trouble with side effects from
(your/his/her) blood pressure (medicine/medicines)? Please tell me
if (you/he/she) always, sometimes, or never (have/has) trouble with
side effects.[EXPLAIN IF NECESSARY: By "side effects", I mean
that the medicine causes any condition such as fatigue, headache,
or coughing.]

HFQ

HFT12A

Doctors often recommend changing your habits or lifestyle, such as
changing your diet, or getting regular exercise in order to control
blood pressure. How confident are you that [you/(SP)] can follow
these recommendation?Would you say that you are very confident,
confident, somewhat confident, or not at all confident?

HFQ

HFT13

HFQ

HFT14

SCQ

SC1

SHOW CARD SC1

[Do you/Does (SP)] have difficulty paying for the
(medicine/medicines) (your/his/her) doctor prescribes for
(your/his/her) high blood pressure?
[Do you/Does (SP)] ever skip taking (your/his/her) medicine, take
less medicine than prescribed, or share medicine because of the
cost of the medicine?
We’re interested in how you feel about the health care [you
have/(SP) has] received [over the past year/since (SURVEY
REFERENCE MONTH AND YEAR)] from doctors and hospitals.
Please tell me how satisfied you have been with the following: The
overall quality of the health care [you have /(SP) has] received
[over the past year/since (SURVEY REFERENCE DATE)].

SCQ

SC2

SHOW CARD SC1

SCQ

SC3

SHOW CARD SC1

SCQ

SC4

SHOW CARD SC1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[Please tell me how satisfied you have been with . . .] The
availability of health care at night and on weekends.
[Please tell me how satisfied you have been with . . .] The ease
and convenience of getting to a doctor from where [you/(SP)]
(live/lives).
[Please tell me how satisfied you have been with . . .] The out-of­
pocket costs [you/(SP)] paid for health care.

151

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

SCQ

SC5

SHOW CARD SC1

SCQ

SC6

SHOW CARD SC1

[Please tell me how satisfied you have been with . . .] The
information given to [you/you or (SP)] about what was wrong with
[you/(SP)].
[Please tell me how satisfied you have been with . . .] The follow-up
care [you/(SP)] received after an initial treatment or operation.

SCQ

SC7

SHOW CARD SC1

SCQ

SC8

SHOW CARD SC1

SCQ

SC8A

SHOW CARD SC1

SCQ

SC8B

SHOW CARD SC1

SCQ

SC8C

SHOW CARD SC1

SCQ

SC8D

SHOW CARD SC1

[Please tell me how satisfied you have been with . . .][Your/(SP's)]
prescription drug plan's formulary or the list of drugs covered by the
plan.[EXPLAIN IF NECESSARY: By prescription drug plan, we
mean any health insurance plan that provides drug coverage.]

SCQ

SC8E

SHOW CARD SC1

[Please tell me how satisfied you have been with . . .]The ease of
finding a pharmacy which accepts your prescription drug
plan.[EXPLAIN IF NECESSARY: By prescription drug plan, we
mean any health insurance plan that provides drug coverage.]

3/30/2010

Interviewer Instructions II

[Please tell me how satisfied you have been with . . .] The concern
of doctors for [your/(SP’s)] overall health rather than just for an
isolated symptom or disease.
[Please tell me how satisfied you have been with . . .] Getting all
[your/(SP’s)] health care needs taken care of at the same location.
[Please tell me how satisfied you have been with . . .] The
availability of care by specialists when [you/(SP)] (feel/feels)
(you/he/she) (need/needs) it.
[Please tell me how satisfied you have been with . . .] The ease of
obtaining answers to questions over the telephone about
[your/(SP’s)] treatment or prescriptions.
[Please tell me how satisfied you have been with . . .]The amount
[you have/(SP) has] to pay for [your/(SP's)] prescribed medicines.

152

Current MCBS Questionnaire

Category

ItemTag

SCQ

SC8F

SCQ

SC8G

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Would [you/(SP)] recommend (your/his/her) prescription drug plan
to other people like (you/him/her)?[EXPLAIN IF NECESSARY: By
prescription drug plan, we mean any health insurance plan that
provides your drug coverage.]
[Some Medicare beneficiaries receive their prescription drug
coverage through Medicare Prescription Drug plans, also called
"Medicare Part D" plans./[You receive/(SP) receives] (your/his/her)
prescription drug coverage through a (Medicare Prescription Drug
plan/Medicare Advantage plan).] And, in most Medicare drug plans
there is a coverage gap, sometimes called a “doughnut hole”. I
have a picture to help explain this term.SHOW CARD
SC1ACoverage is divided into four phases in most Medicare drug
plans. Depending on the plan, in the first phase, the beneficiary
may pay a deductible. In the second phase, the beneficiary pays a
portion of the total cost of each prescription and the drug plan pays
a portion of the cost. In the third phase, there is a gap in coverage,
when most people must pay 100 percent of their drug costs out of
their own pockets. This phase is commonly known as the coverage
gap, or “doughnut hole”. After paying a certain amount of out-ofpocket costs, the fourth phase of coverage begins. In the fourth
phase, the beneficiary pays a small percentage of the total cost of
each prescription and the drug plan pays the remaining amount.
Before today, have you heard about the coverage gap or “doughnut
hole” that is part of most Medicare drug plans?

153

Current MCBS Questionnaire

Category

ItemTag

SCQ

SC8H

SCQ

SC8I

SCQ

SC8J

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

As you may know, there are Federal and state programs that help
beneficiaries pay for the costs associated with a Medicare drug
plan and the purchase of prescription drugs. The help provided is
referred to as a “low-income subsidy” or “extra help”. Beneficiaries
who qualify for these programs receive help paying for the
Medicare drug plan’s monthly premium, help paying any yearly
deductible, help paying coinsurance and copayments for
prescription drugs, and have no coverage gap.[Are you/Is (SP)]
receiving this type of help to pay for (your/his/her) Medicare
prescription drug coverage?]
SHOW CARD SC1A

Does [your/(SP's)] [(CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)/(CURRENT MEDICARE ADVANTAGE PLAN)] plan
have a coverage gap, or “doughnut hole”?[EXPLAIN IF
NECESSARY: The coverage gap, or "doughnut hole", is a phase in
coverage when (your/his/her) plan will either stop paying for all
prescription drugs or it will offer only limited coverage.]
For the next several questions, it would be helpful if I could look at
[your/(SP)'s] [(CURRENT MEDICARE PRESCRIPTION DRUG
PLAN)/(CURRENT MEDICARE ADVANTAGE PLAN)] medicine
statements. The statements often contain the information required
by these questions.First, once [you reach/(SP) reaches] the
coverage gap, does (your/his/her) [(CURRENT MEDICARE
PRESCRIPTION DRUG PLAN)/(CURRENT MEDICARE
ADVANTAGE PLAN)] plan stop paying for all prescription drugs or
does (your/his/her) plan offer some type of coverage for
prescription drug costs?

154

REFER TO THE MOST
RECENT MEDICARE
PRESCRIPTION DRUG
PLAN STATEMENT TO
HELP THE RESPONDENT
VERIFY THIS
INFORMATION.

Current MCBS Questionnaire

Category

ItemTag

SCQ

SC8K

SCQ

SC8L

SCQ

SC8M

SCQ

SC8N

SCQ

SC8O

3/30/2010

Interviewer Instructions I

SHOW CARD SC1A

SHOW CARD SC1A

Question Text

Interviewer Instructions II

What type of coverage does [your/(SP's)] [(CURRENT MEDICARE
PRESCRIPTION DRUG PLAN)/(CURRENT MEDICARE
ADVANTAGE PLAN)] plan offer once [you reach/(SP) reaches] the
start of the coverage gap?Does it cover generic drugs only, brandname and generic drugs, or does it provide some other type of
coverage?

REFER TO THE MOST
RECENT MEDICARE
PRESCRIPTION DRUG
PLAN STATEMENT TO
HELP THE RESPONDENT
VERIFY THIS
INFORMATION.

[Have you/Has (SP)] reached the start of the coverage gap during
[CURRENT YEAR]?[EXPLAIN IF NECESSARY: If [you have/(SP)
has] reached the start of the coverage gap, it means (you have/he
has/she has) reached a phase in coverage when (your/his/her)
plan will either stop paying for all prescription drugs or it will offer
only limited coverage.]

REFER TO THE MOST
RECENT MEDICARE
PRESCRIPTION DRUG
PLAN STATEMENT TO
HELP THE RESPONDENT
VERIFY THIS
INFORMATION.

How did [you/(SP)] fist find out that (you/he/she) reached the start
of the coverage gap?
[Have you/Has (SP)] reached the end of the coverage gap during
[CURRENT YEAR]?[EXPLAIN IF NECESSARY: If [you have/(SP)
has] reached the end of the coverage gap, it means (you have/he
has/she has) reached a phase in coverage when [you pay/(he/she)
pays] a small percentage of the total cost of each prescription and
(your/his/her) drug plan pays the remaining amoung.]

For [CURRENT YEAR], how worried (are/is/were/was) [you/(SP)]
about (your/his/her) ability to pay for (your/his/her) medicines
during the coverage gap?Would you say that [you/(SP)]
(are/is/were/was) very worried, somewhat worried, or not at all
worried?

155

REFER TO THE MOST
RECENT MEDICARE
PRESCRIPTION DRUG
PLAN STATEMENT TO
HELP THE RESPONDENT
VERIFY THIS
INFORMATION.

Current MCBS Questionnaire

Category

ItemTag

SCQ

SC9

SCQ

SC10A

SCQ

SC11

SCQ

SC12AA

What was the health problem or condition?

SCQ

SC12A

Did [you/(SP)] attempt to see a doctor about this [READ
CONDITION(S) BELOW]?(CONDITION 1 FROM
SC12AA)(CONDITION 2 FROM SC12AA)(CONDITION 3 FROM
SC12AA)[PROBE: By "attempt" I mean, did [you/(SP)] contact a
doctor’s office or other medical place in order to set an
appointment or talk to someone about the condition(s)?]

SCQ

SC13A

SCQ

SC14A

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

RECORD VERBATIM.
Please think about all of the health care services [you/(SP)]
(receive/receives), including services provided by doctors,
hospitals and pharmacies.What things, if anything, about the health
care services [you/(SP)] (receive/receives) are you dissatisfied
with?
Please tell me whether each of the following statements is true or
false.
During (CURRENT YEAR), did [you/(SP)] have any health problem
or condition about which you think (you/he/she) should have seen a
doctor or other medical person, but did not?

SHOW CARD SC2

This card lists some reasons people have given for not seeing a
doctor or other medical person about a health problem or
condition.Which of these reasons explains why [you/(SP)] did not
see a doctor about the [READ CONDITION(S) BELOW]?
(CONDITION 1 FROM SC12AA)(CONDITION 2 FROM
SC12AA)(CONDITION 3 FROM SC12AA)[PROBE: Any other
reason?]
Which of these was the main reason [you/(SP)] did not see a
doctor about (this condition/these conditions) during (CURRENT
YEAR)? [READ REASONS BELOW IF
NECESSARY.](CONDITION 1 FROM SC12AA)(CONDITION 2
FROM SC12AA)(CONDITION 3 FROM SC12AA)

156

ENTER ALL CONDITIONS.

CHECK ALL THAT APPLY.

Current MCBS Questionnaire

Category

ItemTag

SCQ

SC15

SCQ

SC16

SCQ

SC17INTR

SCQ

SC17A

SCQ

SC18A

SCQ

Interviewer Instructions I

Question Text

Interviewer Instructions II

During (CURRENT YEAR), were any medicines prescribed for
[you/(SP)] that (you/he/she) did not get? Please include refills of
earlier prescriptions as well as prescriptions that were written or
phoned in by a doctor.
What were the names of those medicines?

ENTER ALL MEDICINES.

SHOW CARD SC3

This card lists some reasons people have given for not having
prescriptions filled or refilled.
Which of these reasons explains why [you/(SP)] did not obtain the CHECK ALL THAT APPLY.
[READ MEDICINE(S) BELOW]?[MEDICINE 1 FROM
SC16][MEDICINE 2 FROM SC16][MEDICINE 3 FROM
SC16][MEDICINE 4 FROM SC16][MEDICINE 5 FROM
SC16][PROBE: Any other reason?]
Which of these was the main reason [you/(SP)] did not obtain (this
medicine/these medicines) during (CURRENT YEAR)? [READ
REASONS BELOW IF NECESSARY.][MEDICINE 1 FROM
SC16][MEDICINE 2 FROM SC16][MEDICINE 3 FROM
SC16][MEDICINE 4 FROM SC16][MEDICINE 5 FROM SC16]

SC20

SHOW CARD SC4

SCQ

SC21

SHOW CARD SC4

SCQ

SC22

SHOW CARD SC4

USQ

US1

Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] done any of the following things. [Have you/has (SP)] often,
sometimes, or never…
Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] done any of the following things. [Have you/has (SP)] often,
sometimes, or never…
Please tell me how often during (CURRENT YEAR) [you have /(SP)
has] done any of the following things. [Have you/has (SP)] often,
sometimes, or never…
Is there a particular medical person or a clinic [you/(SP)] usually
(go/goes) to when (you are/he is/she is) sick or for advice about
(your/his/her) health?

3/30/2010

157

Current MCBS Questionnaire

Category

ItemTag

USQ

US2

USQ

US2A

USQ

US3A

USQ

US4

USQ
USQ
USQ

US5A
US6A
US7

USQ

US8

USQ

US9

About how long does it usually take for [you/(SP)] to get there?

USQ

US10

USQ

US11

[Do you/Does (SP)] usually have someone accompany
(you/him/her) there?
Who usually goes with [you/(SP)]?

USQ

US11A1

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

What kind of place [do you/does (SP)] usually go to when (you
are/he is/she is) sick or for advice about (your/his/her) health -- is
that a managed care plan center or HMO, a clinic, a doctor's office,
a hospital, or some other place?IF CLINIC, ASK: Is it a hospital
outpatient clinic, or some other kind of clinic?IF SOME OTHER
PLACE, ASK: Where is this?
Is this (doctor/medical clinic) associated with (your/his/her) [READ
MANAGED CARE PLAN NAME(S) BELOW] plan?
What is the complete name of the [place/HMO/(US2 RESPONSE)]
that [you/(SP)] (go to/goes to)?
Is there a particular doctor [you/(SP)] (usually see/usually sees] at
this [place/HMO/(US2 RESPONSE)] ?
What is the complete name of that doctor?
What is (US5A PROVIDER NAME'S) specialty?
Does [(US5A PROVIDER NAME)/a doctor from (US3A PROVIDER
NAME)] make house calls?
How [do you/does (SP)] usually get to [(US5A PROVIDER NAME)'S
office/(US3A PROVIDER NAME)]?[EXPLAIN IF NECESSARY: [Do
you/Does (SP)] get there by walking, driving, being driven by
someone else, by ambulance or other special vehicle for disabled
people, by taxi, other public transportation, or some other way?]

How often (are you/is that person) with [you/(SP)] while [you/(SP)]
(see/sees) the doctor or other medical person? Would you say
always, sometimes, or never?

158

SELECT OR ADD ONLY
ONE PERSON.

Current MCBS Questionnaire

Category

ItemTag

USQ

US11AA

USQ

US15

USQ

US17

USQ

Interviewer Instructions I

Question Text

Interviewer Instructions II

What are the reasons [you accompany (SP)/this person
CHECK ALL THAT APPLY.
accompanies you/this person accompanies (SP)] there? What (do
you/does this person) do?[PROBE: Any other reason?]
SHOW CARD US1

How long [have you/has (SP)] been [seeing (US5A PROVIDER
NAME)/going to (US3A PROVIDER NAME)]?
Before [you/(SP)] started [seeing (US5A PROVIDER NAME)/going
to (US3A PROVIDER NAME)], had [you/(SP)] usually been going to
some other place or seeing some other doctor for medical care?

US27

SHOW CARD US2

Now I am going to read some statements people have made about
their health care. Think about the care [you/(SP)]
(receive/receives) from (US5A PROVIDER NAME/US3A
PROVIDER NAME). For each statement, please tell me whether
you strongly agree, agree, disagree, or strongly disagree.

USQ

US32

SHOW CARD US2

USQ

US37

SHOW CARD US2

USQ

US39

USQ

US42

USQ

US43

DIQ
DIQ
DIQ

DIINTROA
DI1A
DI2A

[Think about the care [you/(SP)] (receive/receives) from (US5A
PROVIDER NAME/US3A PROVIDER NAME).]
[Think about the care [you/(SP)] (receive/receives) from (US5A
PROVIDER NAME/US3A PROVIDER NAME).]
I am going to read some reasons that people have given for not
having a usual source of health care. For each one, please tell me
whether or not it is a reason [you do/(SP) does] not have a usual
place for health care.
Why is [your/(SP’s)] usual source of health care no longer
available?
Thinking about other possible reasons that people have for not
having a usual source of health, please tell me if this statement
applies to [you/(SP)]:
The next two questions are about ethnicity and race.
[Are you/Is (SP)] of Hispanic or Latino origin?
Looking at this card, what is [your/(SP's)] race?
CHECK ALL THAT APPLY.

3/30/2010

SHOW CARD DI

159

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

DIQ
DIQ

DI3INTRO
DI3A

SHOW CARD DI1A

DIQ

DI4INTRO

DIQ

DI4

DIQ

DI5A

3/30/2010

SHOW CARD (DI2/DI3)

Question Text

Interviewer Instructions II

The next two questions are about education and income.
What is the highest degree or level of school [you have/(SP) has]
completed?
In studies like this, people are sometimes grouped together
according to income.
Was [your and your spouse's/(SP's) and (his/her)
spouse's/[your/(SP's)]] total income during the past 12 months less
than $25,000 or $25,000 or more, before taxes? Include income
from jobs, Social Security, Railroad Retirement, other retirement
income, Supplemental Security Income (SSI), pensions, interest,
and any other sources. [PROBE IF NECESSARY: In estimating
[your/(SP's)] total income, you can respond for all of the past 12
months, or provide a one month estimate.][EXPLAIN IF
NECESSARY: Income is important in analyzing the information we
collect. For example, this information helps us learn whether
persons in one income group use certain types of medical care
services or have certain medical conditions more or less often than
those in another group.]
Looking at this card, which letter best represents [your and your
spouse's/(SP's) and (his/her) spouse's/[your/(SP's)]] total income
before taxes during the past 12 months? Include income from jobs,
Social Security, Railroad Retirement, other retirement income, and
the other sources of income we just talked about.[EXPLAIN IF
NECESSARY: Income is important in analyzing the information we
collect. For example, this information helps us learn whether
persons in one income group use certain types of medical care
services or have certain medical conditions more or less often than
those in another group.]

160

Current MCBS Questionnaire

Category

ItemTag

KNQ

KNINTRO

KNQ

KN1

SHOW CARD KN1

KNQ

KN2

SHOW CARD KN2

KNQ

KN24A

SHOW CARD KN4

KNQ

KN25A

SHOW CARD KN9

KNQ

KN25B

KNQ

KN25C

SHOW CARD KN13

KNQ

KN26

SHOW CARD KN6

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Now I have some questions about how you get information about
the Medicare program. Your answers will help Medicare provide the
information that people need. Keep in mind that, generally, there
are no right or wrong answers to these questions. Your opinions
and experiences are important to us.
Overall, how easy or difficult do you think the Medicare program is
to understand? Would you say it is very easy to understand,
somewhat easy to understand, somewhat difficult to understand, or
very difficult to understand?
How much do you think you know about the Medicare program?Do
you know just about everything you need to know, most of what you
need to know, some of what you need to know, a little of what you
need to know or almost none of what you need to know about the
Medicare program?
This card lists different health care topics and programs. Which of PROBE FOR TOP THREE.
these topics would be the most important for you to have more
information about? Which would be the next most important? Which
would be the next most important?
This card lists some sources of information that people might use to CHECK ALL THAT APPLY.
keep up with developments in Medicare. Looking at this card,
please tell me all of the sources you would prefer to use to keep up
with Medicare. [PROBE: Any other source?]
In the past year, have you tried to find any information [for (SP)]
about Medicare?
How interested are you in getting (more) information [for (SP)]
about Medicare?
How satisfied are you in general with the availability of information
about the Medicare program when you need it [for (SP)]?

161

Current MCBS Questionnaire

Category

ItemTag

KNQ

KN27INT

KNQ

KN27

KNQ

KN28

KNQ

KN29

KNQ

KN34B1

KNQ
KNQ
KNQ

KN34B2
KN34B3
KNTFINT1

KNQ

KNTF4

3/30/2010

Interviewer Instructions I

SHOW CARD KN7

SHOW CARD KN1

Question Text

Interviewer Instructions II

We've talked about [different topics that you [or (SP)] may have
wanted information about and] how you [or (SP)] may want to
receive information about the Medicare program. Now I would like
to ask you about publications that are available to you [and (SP)]
about the Medicare program.
Did [you/(SP)] receive a copy of this book, called "Medicare and
You 2010", which gives an overview of the Medicare program?
This handbook is sent to Medicare beneficiaries every fall, and the
cover looks like this.
Would you say you have read this book thoroughly, that you have
read parts of it, or that you haven't read it at all?
How easy to understand did you find (the parts you read/this book) ­
would you say (they were/it was) very easy to understand,
somewhat easy to understand, somewhat difficult to understand, or
very difficult to understand?
We're interested in what people understand about the Medicare
program. I'm going to read a list of health care services. For each
item, please tell me whether Medicare covers the service, or does
not cover it. [READ IF NECESSARY: This is not a test. Your
answers allow the Medicare agency to know how well information
about the program is understood. At the end of the interview, I'll
give you a fact sheet that explains these issues.] Does Medicare
cover…
Does Medicare cover…
Does Medicare cover…
Now, I'm going to read a series of statements about Medicare. For
each one, please tell me whether you think it is true or false, or
whether you aren't sure.
Medicare usually covers non-emergency care received while a
beneficiary is traveling outside the United States. [PROBE: Do you
think this is true or false or are you not sure?]

162

Current MCBS Questionnaire

Category

ItemTag

KNQ

KNTF5

KNQ

KNTF6A

KNQ

KNTF7

KNQ

KNTF10

KNQ

KNTF13

KNQ

KNTF14

KNQ

KNTF16

KNQ

KNTF18

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

People are eligible for Medicare because they have low or
moderate incomes. [PROBE: Do you think this is true or false, or
are you not sure?]
Most people covered by Medicare have choices about how they
get their Medicare health and prescription drug coverage; for
example, they can choose between fee-for-service coverage and
coverage provided by a managed care plan.[PROBE: Do you think
this is true or false, or are you not sure?]
The premium or monthly payment that Medicare beneficiaries have
to pay for Medicare Part B can change at any time during the
year.[PROBE: Do you think this is true or false, or are you not
sure?]
People with limited income and resources may save money on their
Medicare costs with the help of Medicare Savings Programs.
[PROBE: Do you think this is true or false or are you not sure?]
Medicare Advantage plans, such as HMOs and PPOs, often cover
more health services, like eye exams or hearing aids, than original
Medicare. [PROBE: Do you think this is true or false, or are you not
sure?]
Most people enrolled in a Medicare Advantage plan can change to
another plan any time during the year.[PROBE: Do you think this is
true or false, or are you not sure?]
If you are enrolled in a Medicare Advantage plan, your choice of
doctors or hospitals may be limited. [PROBE: Do you think this is
true or false, or are you not sure?]
If your Medicare Advantage plan leaves the Medicare program and
you do not choose another one, you will be covered by the Original
Medicare plan. [PROBE: Do you think this is true or false, or are
you not sure?]

163

Current MCBS Questionnaire

Category

ItemTag

KNQ

KNTF19

KNQ

KNTF21

KNQ

KNTF25

KNQ

KNTF28

KNQ

KNTF29

KNQ

KNTFINT2

KNQ

KNTF30

KNQ

KNTF32

KNQ

KNTF33

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

A Medicare Advantage plan can raise its fees or change its
benefits each year. [PROBE: Do you think this is true or false, or
are you not sure?]
Medicare offers a free counseling service in your state that
beneficiaries can use to help them understand and compare health
insurance options. [PROBE: Do you think this is true or false, or
are you not sure?]
People can report complaints to Medicare about their Medicare
Advantage plans or supplemental insurance policies if they are not
satisfied with them. [PROBE: Do you think this is true or false, or
are you not sure?]
You have a right to file an appeal if you disagree with decisions
that are made by Medicare or your Medicare Advantage plan.
[PROBE: Do you think this is true or false, or are you not sure?]
No matter which Medicare health insurance option you choose,
your out-of-pocket costs will be the same.[PROBE: Do you think
this is true or false, or are you not sure?]
The next series of statements are about Medicare prescription drug
coverage. Again, for each one, please tell me whether you think it
is true or false, or whether you aren't sure.
Everyone with Medicare can choose to enroll in the voluntary
Medicare prescription drug coverage regardless of their income or
health. [PROBE: Do you think this is true or false, or are you not
sure?]
All Medicare prescription drug plans cover the same list of
prescription drugs. [PROBE: Do you think this is true or false, or
are you not sure?]
Medicare prescription drug plans can change the price of
prescription drugs only once per year.[PROBE: Do you think this is
true or false, or are you not sure?]

164

Current MCBS Questionnaire

Category

ItemTag

KNQ

KNTF35

KNQ

KNTF36

KNQ

KNTF37

If you have limited income and resources, you may get extra help
to cover prescription drugs for little or no cost to you. [PROBE: Do
you think this is true or false, or are you not sure?]

KNQ

KNTF38

KNQ

KNTF39

KNQ

KN50

Generally, once you join a Medicare prescription drug plan, you can
only change to another plan during the "Open Enrollment period"
each year.[PROBE: Do you think this is true or false, or are you
not sure?]
Your out-of-pocket costs are the same in all Medicare prescription
drug plans. [PROBE: Do you think this is true or false, or are you
not sure?]
Next, I'd like to ask about [your/(SP's)] use of computers. [Do
you/Does (SP)] have a personal computer in (your/his/her) home?

KNQ

KN51INT

KNQ

KN51A

KNQ

KN51B

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

If you join a Medicare prescription drug plan, your plan must be
accepted at all pharmacies in the U.S. [PROBE: Do you think this
is true or false, or are you not sure?]
Medicare prescription drug plans can change the list of prescription
drugs that they cover at any time during the year.[PROBE: Do you
think this is true or false, or are you not sure?]

Some people use the Internet to get different kinds of information.
The next questions ask about the Internet. [EXPLAIN IF
NECESSARY: The Internet includes web sites, e-mail, newsgroups,
and other forums.]
[Do you/Does (SP)] personally ever use the Internet to get
information of any kind?
[Do you/Does(SP)] have someone else, such as a friend, relative,
or anyone else, get information for (you/him/her) on the Internet?

165

Current MCBS Questionnaire

Category

ItemTag

KNQ

KN51B1

KNQ

KN51C

KNQ

KN53

KNQ

KN53A

KNQ

KN53B

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

When ([you have/(SP) has] someone use the Internet for
[you/him/her]/[you use/(SP) uses] the Internet) (do they/[do
you/does (he/she)]) use a dial-up connection or (do they/[do
you/does (he/she)]) use a high-speed connection? [EXPLAIN IF
NECESSARY: A dial-up service connects to the Internet through a
phone line and is generally slower. A high-speed service often
connects to the Internet through a cable or satellite Internet
provider and is generally faster.]
How often [do you/does (SP)] access the Internet to seek
information, either on (your/his/her) own or with someone else's
help? Please do not include any time spent reading or sending email.
(Has anyone/[Have you/Has (SP)]) ever visited or ever accessed
the official website for Medicare information - www.medicare.gov (­
for [you/(SP)])?
"Hospital Compare" is a tool on the Medicare website that helps
beneficiaries compare the quality of care and patient experiences
at hospitals in their area. In the past year, (has anyone/[have
you/has (SP)]) visited the Medicare website to use "Hospital
Compare" (for [you/(SP)])?
The "Medicare Prescription Drug Plan Finder" is a tool on the
Medicare website that helps beneficiaries compare Medicare
prescription drug plans in their area. In the past year, (has
anyone/[have you/has (SP)]) visited the Medicare website to
compare the quality and performance of Medicare prescription drug
plans (for [you/(SP)])?

166

Current MCBS Questionnaire

Category

ItemTag

KNQ

KN53D

KNQ

KN53E

SHOW CARD KN14

KNQ

KN53F

SHOW CARD KN14

KNQ

KN53G

SHOW CARD KN14

KNQ

KN54

Most of the time, do you make decisions about Medicare health
insurance on your own, do you get help from someone in making
these decisions, or do you rely on someone else to make decisions
about health insurance for you?

KNQ

KN56

Before today, were you aware of the 1-800-MEDICARE toll-free
line?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Many health care providers are beginning to use electronic or
computer-based medical records instead of using paper-based
records. When [you/(SP)] (visit/visits) (your/his/her) usual doctor,
does the doctor generally enter [your/(SP's)] health information into
a computer while (you are/he is/she is) present?[EXPLAIN IF
NECESSARY: "Health Information" includes information such as
symptoms, vital signs, test results, or prescribed medicines.]
I'm going to read three statements about computer-based medical
records. Please tell me how strongly you agree or disagree with
each statement.If the United States adopted a system where
medical records were kept electronically and could be shared
online, the overall quality of medical care in the country would be
improved. Do you strongly agree, agree, disagree or strongly
disagree with this statement?
If the United States. adopted a system where medical records were
kept electronically and could be shared online, an unauthorized
person could get access to [your/(SP's)] medical records. Do you
strongly agree, agree, disagree or strongly disagree?
If the United States adopted a system where medical records were
kept electronically and could be shared online, [your/(SP's)]
doctors could do a better job coordinating (your/his/her) care. Do
you strongly agree, agree, disagree or strongly disagree?

167

Current MCBS Questionnaire

Category

ItemTag

KNQ

KN57

KNQ

KN58

KNQ

KNEND

SHOW THE "MEDICARE
INFORMATION" SHEET
TO THE RESPONDENT
AND ALLOW TIME FOR
REVIEW. IT PROVIDES
ANSWERS TO SOME OF
THE QUESTIONS ASKED
DURING THIS
SUPPLEMENT. COLLECT
THE SHEET FOR USE
DURING THE NEXT
INTERVIEW UNLESS THE
RESPONDENT
REQUESTS TO KEEP IT.

IAQ

IAINT8

WAS SP'S SPOUSE
LIVING IN THE
HOUSEHOLD DURING
THIS ROUND?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Have you ever called 1-800-MEDICARE to get information about
Medicare?
As you know, this survey is sponsored by the Centers for Medicare RECORD VERBATIM.
and Medicaid Services, which is the government agency that runs
Medicare. What are your suggestions or concerns about
Medicare?

168

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

Interviewer Instructions II

IAQ

IAINT9

BESIDES SP (AND SP'S
SPOUSE), WAS ANY
OTHER ADULT, AGE 15
OR OLDER, LIVING IN
THE HOUSEHOLD
DURING THIS ROUND?

IAQ

IAINTRO

Now I have some questions about (PREVIOUS YEAR) income and
other financial resources for [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)].Your answers will
be combined with those of other respondents, and (your/his/her)
Medicare benefits will not be affected in any way by your answers
to these questions.

GIVE BROCHURE TO
RESPONDENT. ALLOW A
FEW MINUTES FOR
RESPONDENT TO
REVIEW BROCHURE IF
NECESSARY.

IAQ

IAINTRO1

As the brochure explains, your responses to these questions can
help us determine the impact of income on (your/his/her) use and
access to health care. I will be asking a series of questions about
[your/(SP’s)/you and your (wife’s/husband’s)/(SP) and (his/her)
(wife’s/husband’s)] income and other financial resources. First, I
will ask whether [you/(SP)/you and your (wife/husband)/(SP) and
(his/her) (wife/husband)] had particular types of income or other
resources. All these questions can be answered with a "yes" or a
"no." Then, I will ask you to estimate [your/(SP's)/their] total
income. [Please answer all questions for [you and your
(wife/husband)/(SP) and (his/her) (wife/husband)]. Please feel free
to refer to any records or other persons who may be of assistance
to you.

IAQ

IA1A

IAQ

IA1C

In (PREVIOUS YEAR), did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her) (wife/husband)]. . .
In (PREVIOUS YEAR), did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her) (wife/husband)]. . .

3/30/2010

169

Current MCBS Questionnaire

Category

ItemTag

IAQ

IA13

IAQ

IA14

IAQ
IAQ
IAQ

IA15
IA16
IA17

3/30/2010

Interviewer Instructions I

SHOW CARD IA1

Question Text

Interviewer Instructions II

Not including anything you've already told me about, did
[you/(SP)/you or your (wife/husband)/(SP) or (his/her)
(wife/husband)] receive income from any other sources, such as
Department of Veterans Affairs payments, worker's or
unemployment compensation, child support, or alimony?
Taking all of these income sources into account, please estimate
[your/(SP’s)/you and your (wife’s/husband’s)/(SP) and (his/her)
(wife’s/husband’s)] income for (PREVIOUS YEAR).[PROBE: In
estimating (your/his/her/their) total income you can respond for all
of (PREVIOUS YEAR), or, if you prefer, provide a one month
estimate.] [PROBE: REVIEW THESE SOURCES WITH
RESPONDENT: [Social Security or Railroad
Retirement/(SSI/SSDI)/disability/pensions/job, business,
professional practice, farm/public assistance programs/assistance
from relatives or friends/withdrawal from retirement or
savings/dividends/lump sum payments/other regular
payments/rental properties/other sources]]

Was it more than ($20,000/$1,700/$40,000/$3,300)?
Was it more than ($12,000/$1,000/$25,000/$2,000)?
Was it more than ($7,700/$640/$17,000/$1,400)?

170

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

IAQ

IA17A

SHOW CARD IA1A

According to our records, other than [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)], at least one
person 15 years of age or older lives in (your household/the
household). Including their income as well as [your/(SP’s)/you and
your (wife’s/husband’s)/(SP) and (his/her) (wife’s/husband’s)]
income, please look at this card and tell me which letter represents
the total combined income of all the members of [your
household/(SP’s) household]. This includes income from jobs,
Social Security, Railroad Retirement, other retirement, and any
other money income received by all members of (your
household/the household).

IAQ

IA18

IAQ

IA19

IAQ

IA20

IAQ

IA21

IAQ

IA22

3/30/2010

Interviewer Instructions II

The next questions are about the place where [you/(SP)/you and
your (wife/husband)/(SP) and (his/her) (wife/husband)]
(live/lives/lived).(Do/Did/Does) [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)]] own the place
where (you/he/she/they) (live/lives/lived), or (do/did/does)
(you/he/she/they) rent it?
Please tell me the present value of [your/(SP’s)/you and your
(wife’s/husband’s)/(SP) and (his/her) (wife’s/husband’s)] home.
About how much do you think this (house and lot/condominium unit)
would sell for if it were for sale? Please give your best estimate.
(Do/Did/Does) [you/(SP)/you or your (wife/husband)/(SP) or
(his/her) (wife/husband)] have a mortgage, deed of trust, home
equity loan, or a land contract on the property?
How much (do/did/does) [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)] owe, in total, on
any mortgages, deeds, loans, or land contracts for this property?
How much monthly rent (do/did/does) [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)] pay for the place
where (you/he/she/they) (live/lives/lived)?

171

Current MCBS Questionnaire

Category

ItemTag

IAQ

IAINTRO4

Now, let's turn to savings or other assets which can be used to
provide income. I will ask whether [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)] had particular
types of assets in (PREVIOUS YEAR). All these questions can be
answered with a "yes" or a "no". [Please answer for [you and your
(wife/husband)/(SP) and (his/her) (wife/husband)].

IAQ

IA23A

IAQ

IA23B

IAQ

IA30

For all or part of (PREVIOUS YEAR), did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her) (wife/husband)]. . .
For all or part of (PREVIOUS YEAR), did [you/(SP)/you or your
(wife/husband)/(SP) or (his/her) (wife/husband)] . . .
What type of asset is it?

IAQ

IA31

3/30/2010

Interviewer Instructions I

SHOW CARD IA2

Question Text

Interviewer Instructions II

You've mentioned [READ ASSETS LISTED BELOW]. Please
estimate [your/(SP’s)/you and your (wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)] assets for (PREVIOUS YEAR). Do not
include interest or dividend payments already reported as income.
[Please exclude the value of (your/his/her/their) home.][(retirement
savings accounts/other bank accounts/stocks, mutual funds,
bonds/life insurance policies/other property/vehicles/other assets)]

172

CHECK ALL THAT APPLY.

Current MCBS Questionnaire

Category

ItemTag

IAQ

IA31A

IAQ

IA31B

IAQ

IA32

(Do/Did/Does) [you/(SP)/you or your (wife/husband)/(SP) or
(his/her) (wife/husband)] have any outstanding debts associated
with the [READ ASSETS LISTED BELOW]?[(retirement savings
accounts/other bank accounts/stocks, mutual funds, bonds/life
insurance policies/other property/vehicles/other assets)]

IAQ

IA33

IAQ

IA34

How much (do/did/does) [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)] owe, in total, on
these debts?
(Do/Did/Does) [you/(SP)/you or your (wife/husband)/(SP) or
(his/her) (wife/husband)] have any (other) outstanding debts (that
we haven't talked about), such as credit card charges, loans,
medical bills, or legal bills?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

It is often difficult to place an exact dollar amount on the value of
assets. Thinking about all of the assets that you mentioned, [READ
ASSETS LISTED BELOW], would you say that the total value of
[your/(SP’s)/you and your (wife’s/husband’s)/(SP) and (his/her)
(wife’s/husband’s)] assets for (PREVIOUS YEAR) was less than
$40,000.00 or was it $40,000.00 or more?[(retirement savings
accounts/other bank accounts/stocks, mutual funds, bonds/life
insurance policies/other property/vehicles/other assets)][READ IF
NECESSARY: Again do not include interest or dividend payments
already reported as income [, and please exclude the value of
(your/his/her/their) home]].
SHOW CARD (IA3/IA4)

Which of these categories do you think is a good estimate of the
total value of [your/(SP’s)/you and your (wife’s/husband’s)/(SP) and
(his/her) (wife’s/husband’s)] assets for (PREVIOUS YEAR)?[READ
IF NECESSARY: You mentioned the following assets: [READ
ASSETS LISTED BELOW].][(retirement savings accounts/other
bank accounts/stocks, mutual funds, bonds/life insurance
policies/other property/vehicles/other assets)]

173

Current MCBS Questionnaire

Category

ItemTag

IAQ

IA35

IAQ

IA36

PAQ

PAINTRO

PAQ

PA1

SHOW CARD PA1

PAQ

PA2

SHOW CARD PA1

PAQ

PA3

SHOW CARD PA1

PAQ

PA4

SHOW CARD PA1

Doctors also often give instructions about changing your habits or
lifestyle, such as changing your diet, stopping smoking, or getting
regular exercise. How confident are you that you can follow this
kind of instruction, to change your habits or lifestyle?

PAQ

PA5

SHOW CARD PA2

PAQ

PA6

SHOW CARD PA2

Please use this card to respond to the following statements.How
likely are you to change doctors if you are dissatisfied with the way
you and your doctor communicate?
How likely are you to tell your doctor when you disagree with him or
her?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

If you added up all of these other debts for [you/(SP)/you and your
(wife/husband)/(SP) and (his/her) (wife/husband)], about how much
would they amount to right now?
How much of the (AMOUNT FROM IA35) is for medical care costs?
Now I have some questions about how you make health care
decisions. Answers to questions like these will help Medicare
better understand how people use medical services.Please keep in
mind that there are no right or wrong answers to these questions.
Your opinions and experiences are important to us.
Please tell me how confident you are that you can identify when it
is necessary for you to get medical care.
[How confident are you that you can...] Identify when you are
having side effects from your medications?
Doctors often give instructions about how you should care for
yourself at home, like changing a bandage, taking medicines on
schedule, or applying ice packs. How confident are you that you
can follow instructions to care for yourself at home?

174

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

PAQ

PA9

SHOW CARD PA4

These next questions are about practices sometimes associated
with receiving medical care. Please tell me if you always, usually,
sometimes, or never do the following:Do you always, usually,
sometimes, or never read about health conditions in newspapers,
magazines, or on the Internet?

PAQ

PA10

SHOW CARD PA4

[Do you always, usually, sometimes, or never...] Read information
about a new prescription, such as side effects and precautions?

PAQ

PA11

SHOW CARD PA4

PAQ

PA12

SHOW CARD PA4

PAQ

PA13

SHOW CARD PA4

PAQ

PA14

SHOW CARD PA4

PAQ

PA15

SHOW CARD PA4

[Do you always, usually, sometimes, or never...] Bring with you to
your doctor visits a list of questions or concerns you want to
cover?
[Do you always, usually, sometimes, or never...] Leave your
doctor's office feeling that all of your concerns or questions have
been fully answered?
[Do you always, usually, sometimes, or never...] Take a list of all
of your prescribed medicines to your doctor visits?
[Do you always, usually, sometimes, or never...] Make sure you
understand the results of any medical test or procedure such as an
x-ray, blood test, or EKG for heart conditions?
[Do you always, usually, sometimes, or never...] Talk with your
doctor or other medical person about your options if you need
tests, follow-up care, or a referral for care by a medical specialist?

PAQ

PA16

SHOW CARD PA4

Now I am going to read some statements that may describe your
relationship with your doctor. Please tell me if the following
statements always, usually, sometimes, or never happen.My doctor
listens to what I have to say about my symptoms and concerns.
[Does that always, usually, sometimes, or never happen?]

PAQ

PA20

SHOW CARD PA4

My doctor explains things to me in terms that I can easily
understand. Does that always, usually, sometimes, or never
happen?

3/30/2010

Interviewer Instructions II

175

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

PAQ

PA21

SHOW CARD PA4

I can call my doctor's office to get medical advice when I need it.
Does that always, usually, sometimes, or never happen?

RXQ

RX1

RXQ

RXPD2

SHOW CARD PD1

RXQ

RXPD3

SHOW CARD PD2

RXQ

RXPD8A

[You/(SP)] currently (have/has) drug coverage through [READ
PLAN(S) LISTED ABOVE]. Did [you/(SP), or someone for (SP),]
compare the (CURRENT YEAR) drug coverage offered by [READ
PLAN(S) LISTED ABOVE] with any Medicare Prescription Drug
plans?[EXPLAIN IF NECESSARY: A Medicare Prescription Drug
plan adds drug coverage to Original Medicare.]

RXQ

RXPD9

([You/(SP)] currently (have/has] drug coverage through (CURRENT
MEDICARE ADVANTAGE PLAN). Medicare calls this type of plan a
Medicare Advantage plan. Medicare also offers separate plans
that provide only drug coverage.)Did [you/(SP), or someone for
(SP),] consider enrolling (her/him) in a separate Medicare
Prescription Drug plan for (CURRENT YEAR)?[EXPLAIN IF
NECESSARY: A separate Medicare Prescription Drug plan is
typically used together with medical benefits from Original
Medicare.]

3/30/2010

Interviewer Instructions II

Do you help (SP) make decisions regarding (his/her) health
insurance coverage?
Now I have a few questions regarding the Medicare Prescription
Drug benefit.Overall, how easy or difficult do you think the
Medicare Prescription Drug benefit is to understand?Would you
say it is very easy to understand, somewhat easy, somewhat
difficult, or very difficult to understand?
How much do you think you know about the Medicare Prescription
Drug benefit?Do you know just about everything you need to know,
most of what you need to know, some of what you need to know, a
little of what you need to know, or almost none of what you need to
know about the Medicare Prescription Drug benefit?

176

Current MCBS Questionnaire

Category

ItemTag

RXQ

RXPD10

RXQ

RXPD11

RXQ

RXPD12

[Were you/Was (SP)] automatically enrolled in (your/his/her)
current Medicare Prescription Drug plan - that is, (your/his/her)
(CURRENT MEDICARE PRESCRIPTION DRUG PLAN)
plan?([EXPLAIN IF NECESSARY: Some people with Medicare
were automatically enrolled in a Medicare Prescription Drug plan.
By "automatically enrolled," I mean that the beneficiary was
assigned to a plan by Medicare as opposed to selecting a plan on
his or her own.])

RXQ

RXPD14

Before today, did you know that people who are automatically
enrolled by Medicare in a Medicare Prescription Durg plan can
switch plans at any time without a penalty?

RXQ

RXPD15

Did [you/(SP), or someone for (SP),] compare (CURRENT YEAR)
drug coverage offered by [your/(SP's) (CURRENT MEDICARE
PRESCRIPTION DRUG PLAN) plan with any other Medicare
Prescription Drug plans?

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Did [you/(SP), or someone for (SP),] compare the (CURRENT
YEAR) drug coverage offered by [your/(SP's)] (CURRENT
MEDICARE ADVANTAGE PLAN) plan with any other Medicare
Advantage plans in [your/(SP's)] area?
Some people were automatically enrolled in a Medicare
Prescription Drug plan. By "automatically enrolled", I mean that the
beneficiary was assiged to a plan by Medicare, as opposed to
selecting a plan on his or her own.[Were you/Was (SP)] ever
automatically enrolled in a Medicare Prescription Drug plan?

177

Current MCBS Questionnaire

Category

ItemTag

RXQ

RXPD18

RXQ

RXPD18A

RXQ

RXPD18B

RXQ

RXPD20

RXQ

RXPD21

RXQ

RXINTRO

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

The next questions are about different things [you or (SP)/you] may
have thought about when considering [your/(SP's)] options for
(CURRENT YEAR) drug coverage. At the time that [you/(SP)]
decided to have (CURRENT YEAR) drug coverage through
[(CURRENT MEDICARE ADVANTAGE PLAN)/(CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)], did you consider [for
(SP)]…
Which of these was the most important consideration when [you or
(SP)]/you] thought about [your/(SP's)] options for (CURRENT
YEAR) prescription drug coverage?[READ ITEMS BELOW IF
NECESSARY.]
As you may know, the government has programs that help
beneficiaries pay for the costs associated with a Medicare drug
plan and the purchase of prescription drugs. The help provided is
referred to as a "low-income subsidy" or "extra help".[Are you/Is
(SP)] receiving this type of help to pay for (your/his/her)
(CURRENT YEAR) Medicare prescription drug coverage?[EXPLAIN
IF NECESSARY: Beneficiaries who qualify for these programs
receive help paying for the Medicare drug plan's monthly premium,
help paying any yearly deductible, help paying coinsurance and
copayments for prescription drugs, and have no coverage gap.]

Did [you/(SP)] apply to the Social Security Administration for extra
help with (CURRENT YEAR) drug coverage?
Was [your/(SP's)] application for extra help accepted or denied?
I have a few questions regarding the prescribed drug coverage that
[you now receive/(SP) now receives] through [(CURRENT
MEDICARE MANAGED CARE PLAN NAME)/(CURRENT
MEDICARE PRESCRIPTION DRUG PLAN NAME)/(CURRENT
PRIVATE PLAN NAMES WITH RX)].

178

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

Question Text

RXQ

RXPD23A

SHOW CARD RX2

RXQ

RX2

SHOW CARD RX1

RXQ

RX3

At the time that [you/(SP)] decided to have (CURRENT YEAR) drug
coverage through ([CURRENT MEDICARE ADVANTAGE
PLAN)/(CURRENT MEDICARE PRESCRIPTION DRUG PLAN)],
how satisfied were you with the information that you had to make
that decision?
How confident are you that [you now have/(SP) now has] the drug
coverage that best meets (your/his/her) needs? Would you say you
are…
[Have you/Has (SP)] used (your/his/her) [(CURRENT MEDICARE
ADVANTAGE PLAN) drug/(CURRENT MEDICARE PRESCRIPTION
DRUG PLAN NAME)/(CURRENT PRIVATE PLAN NAMES WITH
RX)] coverage when purchasing medicines since January 1 of this
year?

RXQ

RX4

RXQ

RX5

RXQ

RX7

3/30/2010

Interviewer Instructions II

Compared to last year, is the cost of the monthly premium for
[your/(SP's)] drug coverage more, less, or the same?
Are the amounts that [you pay/(SP) pays] for medicines at the
pharmacy using (your/his/her) [(CURRENT MEDICARE
ADVANTAGE PLAN) drug/(CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)/(CURRENT PRIVATE PLAN NAMES WITH RX)]
coverage more, less, or the same compared to what (you/he/she)
paid last year?
Are there any prescribed medicines that [you regularly take/(SP)
regularly takes] that are not covered by (your/his/her) (CURRENT
YEAR) [(CURRENT MEDICARE ADVANTAGE PLAN)
drug/(CURRENT MEDICARE PRESCRIPTION DRUG
PLAN)/(CURRENT PRIVATE PLAN NAMES WITH RX)] coverage?

179

Current MCBS Questionnaire

Category

ItemTag

RXQ

RX8

[Have you/Has (SP)] had to change any of (your/his/her) prescribed
medicines from a brand name to a generic medicine because of
(your/his/her) (CURRENT YEAR) [(CURRENT MEDICARE
ADVANTAGE PLAN) drug/(CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)/(CURRENT PRIVATE PLAN NAMES WITH RX)]
coverage?

RXQ

RX9

RXQ

RX10

[Have you/Has (SP)] had to switch to a different medication
because a drug (you/he/she) needed was not available through
(your/his/her) (CURRENT YEAR) [(CURRENT MEDICARE
ADVANTAGE PLAN) drug/(CURRENT MEDICARE PRESCRIPTION
DRUG PLAN)/(CURRENT PRIVATE PLAN NAMES WITH RX)]
coverage?
When purchasing prescribed medicines through [your/(SP's)]
[(CURRENT MEDICARE ADVANTAGE PLAN) drug
coverage/(CURRENT MEDICARE PRESCRIPTION DRUG PLAN)
plan/(CURRENT PRIVATE PLAN NAMES WITH RX) plan(s)] in
(CURRENT YEAR), [do you/does (SP)] pay more than you
expected, about as much as expected, or less than expected?

RXQ

RX16

RXQ

RX17

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Does the [(CURRENT MEDICARE ADVANTAGE PLAN)/(CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)/(CURRENT PRIVATE
PLAN NAMES WITH RX)] drug plan network include the pharmacy
that [you generally prefer/(SP) generally prefers] to use?
SHOW CARD RX2

Overall, how satisfied are you with [your/(SP's)] drug plan through
[(CURRENT MEDICARE ADVANTAGE PLAN)/(CURRENT
MEDICARE PRESCRIPTION DRUG PLAN)/(CURRENT PRIVATE
PLAN NAMES WITH RX)]?

180

Current MCBS Questionnaire

Category

ItemTag

RXQ

Question Text

Interviewer Instructions II

RX18

Why [haven't you/hasn't (SP)] used (your/his/her) [(CURRENT
MEDICARE ADVANTAGE PLAN)/(CURRENT MEDICARE
PRESCRIPTION DRUG PLAN)/(CURRENT PRIVATE PLAN
NAMES WITH RX)] coverage in (CURRENT YEAR)?

CHECK ALL THAT APPLY.

RXQ

RX19

CHECK ALL THAT APPLY.

CLQ
CLQ
CLQ

CL1
CL2
CL3

CLQ

CL4

You said that [you are/(SP) is] not enrolled in a Medicare
Prescription Drug plan. What is the reason (you are/he is/she is)
not enrolled in such a plan?
What is your address?
What is your phone number?
Do you have a second phone number?[PROBE: What is that
number?]
I'd like to verify your address. I have it listed as .. [READ
ADDRESS LISTED BELOW]. Is this correct?STREET ADDRESS
1: (STREET ADDRESS LINE 1)STREET ADDRESS 2: (STREET
ADDRESS LINE 2)CITY: (CITY) STATE: (STATE) ZIPCODE:
(ZIPCODE)

CLQ

CL5

CLQ

CL6

Next, I would like to verify your phone number(s). I have them
listed as ... [READ PHONE NUMBER(S) LISTED BELOW]. Are
these correct? PHONE 1: (PRIMARY PHONE NUMBER)PHONE 2:
[(SECONDARY PHONE NUMBER)/NONE]

CLQ
CLQ

CL7
CL8

What is your phone number?
Do you have a second phone number?[PROBE: What is that
number?]

3/30/2010

Interviewer Instructions I

ENTER CORRECT
ADDRESS.

CLEAR ADDRESS LINE 2
IF NO LONGER
APPLICABLE.

181

Current MCBS Questionnaire

Category

ItemTag

CLQ

CL9

As you may know, the Medicare Current Beneficiary Survey
involves another interview. The next interview will be similar to the
one we had today. We will be calling in about 4 months to set up a
convenient time for the next interview.Is (PREVIOUS BEST PHONE
NUMBER FOR NEXT INTERVIEW) the best phone number to call
to arrange for the next interview?

CLQ

CL10

As you may know, the Medicre Current Beneficiary Survey involves
another interview. The next interview will be similar to the one we
had today. We will be calling in about 4 months to set up a
convenient time for the next interview.Is there a phone number to
call to arrange for the next interview?

CLQ
CLQ
CLQ

CL12
CL13
CL14

And where is that phone located?
What is this (CL12 RESPONSE) name?
Under what name is that telephone number likely to be listed?

CLQ

CL15

During our last interview we recorded name and address
information for [READ NAME(S) BELOW], who would know where
[you/(SP)] could be contacted in case we have trouble arranging for
the next interview.CONTACT 1: (FIRST CONTACT NAME FROM
PREVIOUS ROUND)CONTACT 2: [(SECOND CONTACT NAME
FROM PREVIOUS ROUND)/NONE]

CLQ

CL16

I'd like to verify (FIRST CONTACT NAME)' s address. I have it
listed as...[READ ADDRESS LISTED BELOW]. Is this
correct?STREET ADDRESS 1: (STREET ADDRESS LINE
1)STREET ADDRESS 2: (STREET ADDRESS LINE 2)CITY: (CITY)
STATE: (STATE) ZIPCODE: (ZIPCODE)

CLQ

CL17

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

ENTER CORRECT
ADDRESS.

ENTER ONLY ONE.

IS CONTACT ONE
INFORMATION
CORRECT?REFER TO
INFORMATION SHEET
AND VERIFY
INFORMATION WITH
RESPONDENT.

CLEAR ADDRESS LINE 2
IF NO LONGER
APPLICABLE.

182

Current MCBS Questionnaire

Category

ItemTag

CLQ

CL18

CLQ

CL19

CLQ

CL20

CLQ

CL21

CLQ

CL22

CLQ

CL23

CLQ

CL24

CLQ

CL25

CLQ

CL26

CLQ

CL27

CLQ

CL28

CLQ

CL29

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Next, I would like to verify (FIRST CONTACT NAME)'s phone
number(s). I have them listed as ... [READ PHONE NUMBER(S)
LISTED BELOW]. Are these correct? PHONE 1: (PRIMARY
PHONE NUMBER)PHONE 2: [(SECONDARY PHONE
NUMBER)/NONE]
Please give me a phone number for contacting (FIRST CONTACT
NAME)
Under what name is that telephone number likely to be listed?
Is there a second phone number for contacting (FIRST CONTACT
NAME)?[PROBE: What is that number?]
Under what name is the second telephone number likely to be
listed?
(Besides yourself, please/Please) give me the name, address, and
telephone number of a relative or close friend who would know
where [(you/(SP)] would be in case we have trouble arranging for
the next interview. Please give me the name of someone who is
not living with [you/(SP)].
[Please give me the name of a relative or close friend who would
ENTER ONLY ONE
know where [you/(SP)] would be. Please give me the name of
CONTACT.
someone who is not living with [you/(SP)].]
[Please give me an address for contacting (FIRST CONTACT
NAME).]
Please give me a phone number for contacting (FIRST CONTACT
NAME)
Under what name is that telephone number likely to be listed?
Is there a second phone number for contacting (FIRST CONTACT
NAME)?[PROBE: What is that number?]
Under what name is the second telephone number likely to to be
listed?

183

Current MCBS Questionnaire

Category

ItemTag

CLQ

Question Text

Interviewer Instructions II

CL30

You also named [READ NAME BELOW] as someone who would
know where [you/(SP)] could be contacted in case we have trouble
arranging for the next inteview.Is this correct?CONTACT 2:
(SECOND CONTACT NAME FROM PREVIOUS ROUND)

IS CONTACT TWO
INFORMATION
CORRECT?REFER TO
INFORMATION SHEET
AND VERIFY
INFORMATION WITH
RESPONDENT.

CLQ

CL31

I'd like to verify (SECOND CONTACT NAME)' s address. I have it
listed as...[READ ADDRESS LISTED BELOW]. Is this
correct?STREET ADDRESS 1: (STREET ADDRESS LINE
1)STREET ADDRESS 2: (STREET ADDRESS LINE 2)CITY: (CITY)
STATE: (STATE) ZIPCODE: (ZIPCODE)

CLQ

CL32

CLQ

CL33

CLQ

CL34

CLQ

CL35

CLQ

CL36

CLQ

CL37

CLQ

CL38

3/30/2010

Interviewer Instructions I

ENTER CORRECT
ADDRESS.

CLEAR ADDRESS LINE 2
IF NO LONGER
APPLICABLE.
Next, I would like to verify (SECOND CONTACT NAME)'s phone
number(s). I have them listed as ... [READ PHONE NUMBER(S)
LISTED BELOW]. Are these correct? PHONE 1: (PRIMARY
PHONE NUMBER)PHONE 2: [(SECONDARY PHONE
NUMBER)/NONE]
Please give me a phone number for contacting (SECOND
CONTACT NAME).
Under what name is that telephone number likely to be listed?
Is there a second phone number for contacting (SECOND
CONTACT NAME)?[PROBE: What is that number?]
Under what name is the second telephone number likely to be
listed?
(Besides yourself, please/Please) give me another name, address,
and telephone number of a relative or close friend who would know
where (you/(SP)] would be in case we have trouble arranging for
the next interview. Again, please give me the name of someone
who is not living with [you/(SP)].

184

Current MCBS Questionnaire

Category

ItemTag

CLQ

CL39

[Please give me the name of another relative or close friend who
ENTER ONLY ONE
would know where [you/(SP)] would be. Again, please give me the CONTACT.
name of someone who is not living with [you/(SP)].]

CLQ

CL40

CLQ

CL41

CLQ

CL42

[Please give me an address for contacting (SECOND CONTACT
NAME).]
Please give me a phone number for contacting (SECOND
CONTACT NAME).
Under what name is that telephone number likely to be listed?

CLQ

CL43

CLQ

CL44

CLQ

CL45

CLQ
CLQ
CLQ

CL46
CL47
CL48

CLQ

CL49

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

Is there a second phone number for contacting (SECOND
CONTACT NAME)?[PROBE: What is that number?]
Under what name is the second phone number likely to be listed?
[Do you/Does (SP)] spend more than one month away, during the
year, at another home other than your primary home?
[Please give me an address for this home.]
Please give me a phone number for this home.
CODE "YES" IF ALREADY I would like to verify the address of the place where [you/(SP)]
KNOWN, OTHERWISE
(spend/spends) some portion of the year. I have it listed as…
ASK.
[READ ADDRESS LISTED BELOW].Is this correct?STREET
ADDRESS 1: (VACATION HOME ADDRESS LINE 1)STREET
ADDRESS 2: (VACATION HOME ADDRESS LINE 2)CITY:
(VACATION HOME CITY) STATE: (VACATION HOME STATE)
ZIPCODE: (VACATION HOME ZIPCODE)
[What is the correct address of that place?]

185

CLEAR ADDRESS LINE 2
IF NO LONGER
APPLICABLE.

Current MCBS Questionnaire

Category

ItemTag

Interviewer Instructions I

CLQ

CL50

CODE "YES" IF ALREADY I would like to verify the phone number of the place where
KNOWN. OTHERWISE
[you/(SP)] (spend/spends) some portion of the year.PHONE
ASK:
NUMBER: (VACATION HOME PHONE NUMBER)

CLQ
CLQ

CL51
CL52

Please give me a phone number for this home.
During our remainng interviews, we will continue to collect
information about health care visits and the costs of any health
care [you/(SP}] may receive. If for some reason you could not do
the interview, please give me the name of someone who would be
able to provide the information for [you/SP)].

CLQ

CL53

CLQ

CL54

CLQ

CL55

CLQ

CL56

[Please give me the name of someone who would be able to
provide this information for [you/(SP)].]
[Please give me an address for contacting (FUTURE PROXY
NAME).]
Please give me a phone number for contacting (FUTURE PROXY
NAME).
Under what name is that telephone number likely to be listed?

CLQ

CL57

CLQ

CL58

CLQ

CL59

3/30/2010

Question Text

Interviewer Instructions II

Is there a second phone number for contacting (FUTURE PROXY
NAME)?[PROBE: What is that number?]
Under what name is the second telephone number likely to be
listed?
[I would like to thank you for keeping the planner for this interview.]
I would [also] appreciate it if you would [continue to] record health
care visits and keep information about medical expenses for the
next interview. Thank you for your time and cooperatoin during this
interview.

186

ENTER ONLY ONE
PERSON.

CIRCLE TODAY'S DATE
IN THE PLANNER AS A
REFERENCE FOR THE
RESPONDENT. EXPLAIN
PLANNER SECTIONS AS
NECESSARY.

Current MCBS Questionnaire

Category

ItemTag

CLQ

Question Text

Interviewer Instructions II

CL60

I would like to give you this planner [HAND PLANNER TO
RESPONDENT] to record any health care visits [you have/(SP)
has] with any kind of medical professional or facility.Here is a folder
to keep any medical bills, receipts, Medicare statements, and
insurance statements that would be connected to [your/(SP)'s]
health care visits and other medical expenses so that we can talk
about them during the next interview. I'd like to thank you for your
time and cooperation and I look forward to seeing you soon.

CIRCLE TODAY'S DATE
IN PLANNER AS A
REFERENCE FOR THE
RESPONDENT. EXPLAIN
PLANNER SECTIONS IN
DETAIL TO
RESPONDENT.

CLQ

CL61

I would like to make sure you are aware of the planner we use to
record health care visits as well as the folder for keeping
information about medical expenses for the next interview.

CIRCLE TODAY'S DATE
IN PLANNER AS A
REFERENCE FOR THE
RESPONDENT. EXPLAIN
PLANNER SECTIONS IN
DETAIL TO
RESPONDENT.

CLQ

CL62

EXQ

EX1

I would like to thank you for your time and cooperation during this
interview. We may be contacting you in the future for further
information.
As I mentioned earlier, this is [your/(SP's)] final interview with this
study. We have learned much from [your/(SP's)] participation in
the MCBS. Data from the study have already been used to inform
Congress of the problems Medicare beneficiaries might face
regarding their access to health care. [Your/(SP's)] participation in
this study has given the United States government a much clearer
picture of [your/(SP's)] health care needs and those of more than
42 million Medicare participants.

3/30/2010

Interviewer Instructions I

187

Current MCBS Questionnaire

Category

ItemTag

EXQ

EX1A

END

END1

END

END2

3/30/2010

Interviewer Instructions I

Question Text

Interviewer Instructions II

[RESPONDENT MAY
I thank you sincerely for all the time and effort that you have put
into this study. You have made a very important contribution to the KEEP THE CALENDAR.]
Medicare program and all of its beneficiaries by sharing
[your/(SP's)] health care experiences with us. Even though
[you/(SP)] will no longer be a participant in our survey, [your/(SP's)]
health care needs will continue to be covered through the Medicare
program. I'd like to express to [you/you and (SP)] appreciation on
behalf of the Centers for Medicare and Medicaid Services. Both
Westat and the Centers for Medicare and Medicaid Services wish
[you/you and (SP)] the very best for the future.

WAS THIS INTERVIEW
CONDUCTED MOSTLY IN
ENGLISH,SPANISH, OR
SOME OTHER
LANGUAGE?
(Someone from the home office may be calling to verify that I was
here to conduct this interview.)

188

THIS CASE IS CODED
(CASE RESULT CODE)
(CASE DISPOSITION)
(CASE
EXPLAINATION).PRESS
ENTER TO COMPLETE
THE INTERVIEW.