Cms-p-0015a Mcbs

Medicare Current Beneficiary Survey (MCBS)

R69_INF

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

OMB: 0938-0568

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Medicare Current Beneficiary Survey

Section Specifications for INF

Round 69

HEALTH INSURANCE

Created on 5/9/2014 6:12:57 PM

BOX INBEG



Box Instructions

IF INDISP = 1/ConsentRequired OR INDISP = 4/InitialRefusal, GO TO INCONREF - CONREFFN.

ELSE GO TO IN1PRE2 - IN1PR2CT.

Variable Name

Assignment Instructions

INMCDFLG

If INMCDFLG = EMPTY, then INMCDFLG = 0/NotIndicated



INCONREF Code 1



Question Text

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.

Field 1: CONREFFN

Field 1 Routing

Value

Label

Route

1

CONSENT OBTAINED (CONTINUE INTERVIEW)

IN1PRE2 - IN1PR2CT

2

FINAL CONSENT DENIED

INEND - INENDCT

3

REFUSAL CONVERTED (CONTINUE INTERVIEW)

IN1PRE2 - IN1PR2CT

4

FINAL REFUSAL

INEND - INENDCT





IN1PRE2 Code 1



Question Text

The following questions are about (SP's) health insurance.

IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

Field 1: IN1PR2CT

Field 1 Routing

Value

Label

Route

1

CONTINUE

BOX IN3

2

CONSENT REQUIRED

INEND - INENDCT

3

INITIAL REFUSAL

INEND - INENDCT





Other Programming Instructions

Report Display

Display report above question text.
Display all stays where STAY.XSTPLAC <> 000 that were reported for this SP in
chronological order by start date of the stay.
Report header: STAY TIMELINE
Report layout:
Column 1, header="Place Name", display PLAC.PLACNAME of
PLAC where PLAC.PLACNUM = STAY.XSTPLAC.
Column 2, header="Start Date", display
STAY.STAYSMM+STAY.STAYSDD+STAY.STAYSYY in month, day
year format.
Column 3, header="End Date", display
STAY.STAYEMM+STAY.STAYEDD+STAY.STAYEYY in month, day
year format.
Column 4, header="Stay Type", display STAY.STAYCLAS.

BOX IN3



Box Instructions

IF THIS IS A BASELINE INTERVIEW AND MEDICAID NOT COLLECTED OR INMCDFLG = 1/Indicated, GO TO IN1 - ICAIDECO.

ELSE IF THIS IS A BASELINE INTERVIEW AND MEDICAID COLLECTED AND INMCDFLG = 0/NotIndicated, GO TO IN5A - MCAIDHMO.

ELSE IF THIS IS NOT A BASELINE INTERVIEW AND MEDICAID NOT COLLECTED OR INMCDFLG = 1/Indicated, GO TO IN1A - ICAIDNOW.

ELSE GO TO IN18 - IGAPCOV.

IN1 Yes/No



Question Text

Has (SP) ever been covered by [READ NAME(S) FROM ABOVE]?

Field 1: ICAIDECO

Field 1 Routing

Value

Label

Route

0

NO

IN13A - ICAREPTD

1

YES

IN2 - ICAIDDOC

2

PENDING

IN13A - ICAREPTD


Don't Know

IN13A - ICAREPTD


Refused

IN13A - ICAREPTD





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

INCAID

PERS.INCAID = IN1 - ICAIDECO

CAIDECO

PERS.CAIDECO = IN1 - ICAIDECO

INMCDFLG

INMCDFLG = 1/Indicated



IN1A Yes/No



Question Text

(The last time we asked about (SP's) health insurance, (he/she) was not covered by [READ NAME(S) FROM ABOVE].) Is (SP) now covered by [READ NAME(S) FROM ABOVE]?

Field 1: ICAIDNOW

Field 1 Routing

Value

Label

Route

0

NO

IN18 - IGAPCOV

1

YES

IN2 - ICAIDDOC

2

PENDING

IN18 - IGAPCOV


Don't Know

IN18 - IGAPCOV


Refused

IN18 - IGAPCOV





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

INCAID

PERS.INCAID = IN1A - ICAIDNOW

XCAIDFLG

PERS.XCAIDFLG = 0/No

INMCDFLG

INMCDFLG = 1/Indicated



IN2 Yes/No



Question Text

Do you have a document that shows (SP's) most current [READ NAME(S) FROM ABOVE] ID number?

Field 1: ICAIDDOC

Field 1 Routing

Value

Label

Route

0

NO

IN3 - ICAIDNUM

1

YES

IN3 - ICAIDNUM


Don't Know

IN3 - ICAIDNUM


Refused

IN3 - ICAIDNUM





IN3 Text



Question Text

[Please read me (SP's) [READ NAME(S) FROM ABOVE] ID number from the document/Please tell me (SP's) [READ NAME(S) FROM ABOVE] ID number.]

Field 1: ICAIDNUM

Field 1 Routing

Value

Label

Route

1

[Continuous answer.]

IN4 - ICAIDVER


Don't Know

IN5A - MCAIDHMO


Refused

IN5A - MCAIDHMO





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

ICAIDNM

PERS.ICAIDNM = IN3 - ICAIDNUM

MCAIDFLG

If IN3 - ICAIDNUM = RF, then PERS.MCAIDFLG = 1/RForNWK
Else if IN3 - ICAIDNUM = DK, then PERS.MCAIDFLG = 2/NumIsDK



IN4 Yes/No



Question Text

I'd like to verify the [READ NAME(S) FROM ABOVE] ID number that I have recorded. I have entered (MEDICAID ID NUMBER). Is this correct?

Field 1: ICAIDVER

Field 1 Routing

Value

Label

Route

0

NO

IN3 - ICAIDNUM

1

YES

IN5A - MCAIDHMO





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

MCAIDFLG

If IN4 - ICAIDVER = 1/Yes, then PERS.MCAIDFLG = 3/ValidNumber



IN5A Yes/No



Question Text

Some states now use HMOs (health maintenance organizations) to provide some or all health care for Medicaid beneficiaries. (Is/Was) (SP) enrolled in a [READ NAME(S) FROM ABOVE] HMO?

Field 1: MCAIDHMO

Field 1 Routing

Value

Label

Route

0

NO

BOX IN3A

1

YES

BOX IN3A


Don't Know

BOX IN3A


Refused

BOX IN3A





BOX IN3A



Box Instructions

IF THIS IS A BASELINE INTERVIEW, GO TO IN6 - ICDCRCOV.

ELSE GO TO IN18 - IGAPCOV.

IN6 Yes/No



Question Text

Was (SP) covered by [READ NAME(S) FROM ABOVE] [on September 1, (CURRENT YEAR)?/when (he/she) was admitted on (FAD/RAD)?]

Field 1: ICDCRCOV

Field 1 Routing

Value

Label

Route

0

NO

IN13A - ICAREPTD

1

YES

IN13A - ICAREPTD


Don't Know

IN13A - ICAREPTD


Refused

IN13A - ICAREPTD





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

XCAIDFLG

If IN6-ICDCRCOV <> 1/Yes, then PERS.XCAIDFLG = 1/Yes



IN13A Yes/No



Question Text

Our records show that (SP) is covered by Medicare. I'd like to ask some questions about (his/her) Medicare coverage.

Was (SP) covered by Part D of Medicare on [September 1, (CURRENT YEAR)/(FAD/RAD)]?

PRESS F1 FOR PART D DEFINITIONS.

Field 1: ICAREPTD

Field 1 Routing

Value

Label

Route

0

NO

IN18 - IGAPCOV

1

YES

IN18 - IGAPCOV


Don't Know

IN18 - IGAPCOV


Refused

IN18 - IGAPCOV





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

CAREPTD

PERS.CAREPTD=IN13A-ICAREPTD



IN18 Yes/No



Question Text

On [September 1, (CURRENT YEAR)/(FAD/RAD)], was (SP) covered by private health insurance that pays for some or all charges for inpatient and outpatient hospital and physician services and/or supplements Medicare (Medigap policy)?

Field 1: IGAPCOV

Field 1 Routing

Value

Label

Route

0

NO

IN20 - ILTCCOV

1

YES

IN19 - IGAPNAME


Don't Know

IN20 - ILTCCOV


Refused

IN20 - ILTCCOV





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

GAPCOV

PERS.GAPCOV = IN18-IGAPCOV



IN19 Text



Question Text

What is the name of the insurance company?

[PROBE: Any others?]

IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

Field 1: IGAPNAME

Field 1 Routing

Value

Label

Route

1

[Continuous answer.]

IN19 - IGAPNAM2





Field 2: IGAPNAM2

Field 2 Routing

Value

Label

Route

1

[Continuous answer.]

IN19 - IGAPNAM3





Field 3: IGAPNAM3

Field 3 Routing

Value

Label

Route

1

[Continuous answer.]

IN19 - IGAPNAM4





Field 4: IGAPNAM4

Field 4 Routing

Value

Label

Route

1

[Continuous answer.]

IN19 - IGAPNAM5





Field 5: IGAPNAM5

Field 5 Routing

Value

Label

Route

1

[Continuous answer.]

IN20 - ILTCCOV





IN20 Yes/No



Question Text

On [September 1, (CURRENT YEAR)/(FAD/RAD)], was (SP) covered by private health insurance that pays for some or all charges for more than 100 days of nursing home care, that is, a long-term care policy?

Field 1: ILTCCOV

Field 1 Routing

Value

Label

Route

0

NO

IN22 - ICHACOV

1

YES

IN21 - ILTCNAME


Don't Know

IN22 - ICHACOV


Refused

IN22 - ICHACOV





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

LTCCOV

PERS.LTCCOV = IN20 - ILTCCOV

LTCNAME

If IN20-ILTCCOV <> 1/Yes, then PERS.LTCNAME = EMPTY



IN21 Text



Question Text

What is the name of the insurance company?

[PROBE: Any others?]

Field 1: ILTCNAME

Field 1 Routing

Value

Label

Route

1

[Continuous answer.]

IN21 - ILTCNAM2





Field 2: ILTCNAM2

Field 2 Routing

Value

Label

Route

1

[Continuous answer.]

IN21 - ILTCNAM3





Field 3: ILTCNAM3

Field 3 Routing

Value

Label

Route

1

[Continuous answer.]

IN21 - ILTCNAM4





Field 4: ILTCNAM4

Field 4 Routing

Value

Label

Route

1

[Continuous answer.]

IN21 - ILTCNAM5





Field 5: ILTCNAM5

Field 5 Routing

Value

Label

Route

1

[Continuous answer.]

IN22 - ICHACOV





Other Programming Instructions

Background Variable Assignments

Variable Name

Assignment Instructions

LTCNAME

PERS.LTCNAME = IN21-ILTCNAME



IN22 Yes/No



Question Text

Was (SP) covered by either TRICARE or CHAMPVA for hospital or physician care on [September 1, (CURRENT YEAR)/(FAD/RAD)]?

PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.

Field 1: ICHACOV

Field 1 Routing

Value

Label

Route

0

NO

IN23 - IDVACOV

1

YES

IN23 - IDVACOV


Don't Know

IN23 - IDVACOV


Refused

IN23 - IDVACOV





IN23 Yes/No



Question Text

Was (SP) covered by any other Department of Veterans Affairs (VA) program or contract on [September 1, (CURRENT YEAR)/(FAD/RAD)]?

Field 1: IDVACOV

Field 1 Routing

Value

Label

Route

0

NO

IN24 - IPUBCOV

1

YES

IN24 - IPUBCOV


Don't Know

IN24 - IPUBCOV


Refused

IN24 - IPUBCOV





IN24 Yes/No



Question Text

(Besides [READ NAME(S) FROM ABOVE], was/Was) (SP) covered by any other public assistance health insurance program on [September 1, (CURRENT YEAR)/(FAD/RAD)]?

Field 1: IPUBCOV

Field 1 Routing

Value

Label

Route

0

NO

BOX IN9

1

YES

IN25 - IPUBNAME


Don't Know

BOX IN9


Refused

BOX IN9





IN25 Text



Question Text

What (is/was) the name of the public assistance health insurance program?

Field 1: IPUBNAME

Field 1 Routing

Value

Label

Route

1

[Continuous answer.]

BOX IN9





BOX IN9



Box Instructions

IF SP ALIVE, AND A CFR, FFC, OR FCF, AND IS A FALL ROUND, GO TO INBQ13A - IMARSTAT.

ELSE GO TO INEND - INENDCT.

INBQ13A Code 1



Question Text

Is (SP) currently married, widowed, divorced, separated, or never married?

Field 1: IMARSTAT

Field 1 Routing

Value

Label

Route

1

MARRIED

INEND - INENDCT

2

WIDOWED

INEND - INENDCT

3

DIVORCED

INEND - INENDCT

4

SEPARATED

INEND - INENDCT

5

NEVER MARRIED

INEND - INENDCT


Don't Know

INEND - INENDCT


Refused

INEND - INENDCT





INEND Code 1



Question Text

(YOU HAVE COMPLETED THE HEALTH INSURANCE SECTION FOR THIS SP.)

PRESS "1" TO RETURN TO NAVIGATION SCREEN.

Field 1: INENDCT

Field 1 Routing

Value

Label

Route

1

CONTINUE

BOX INEND





Other Programming Instructions

Background Variable Assignments

INDISP:
If IN1PRE2-IN1PR2CT = 2/ConsentRequired, INDISP = 1/ConsentRequired.
Else if IN1PRE2-IN1PR2CT = 3/InitialRefusal, INDISP = 4/InitialRefusal.
Else if INCONREF-CONREFFN = 2/FinalConsentDenied, INDISP = 11/FinalConsentDenied.
Else if INCONREF-CONREFFN = 4/FinalRefusal, INDISP = 12/FinalRefusal.
Else INDISP = 96/Complete.

BOX INEND



Box Instructions

GO TO NAVIGATOR




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorRyan Hubbard
File Modified0000-00-00
File Created2021-01-22

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