CMS-P-0015A Fac2019R85IN

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) CONSENT OBTAINED (CONTINUE
INTERVIEW)
(02) FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE
INTERVIEW)
(04) FINAL REFUSAL

(01) IN1PRE2 - IN1PR2CT
(02) INEND - INENDCT
(03) IN1PRE2 - IN1PR2CT
(04) INEND - INENDCT

(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL

(01) BOX IN3
(02) INEND - INENDCT
(03) INEND - INENDCT

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

(00) NO
(01) YES
(02) PENDING
(-8) Don't Know
(-9) Refused

(00) IN13A - ICAREPTD
(01) IN2 - ICAIDDOC IN5AMCAIDHMO
(02) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD

(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]?

(00) NO
(01) YES
(02) PENDING
(-8) Don't Know
(-9) Refused

(00) IN18 - IGAPCOV
(01) IN2 - ICAIDDOC IN5AMCAIDHMO
(02) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

HEALTH INSURANCE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
SEASON
If SAMPLE_TYPE= CFR, then SEASON=FALL
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.

BOX INBEG

routing

CONREFFN

INCONREF

code one

IN1PR2CT

IN1PRE2

code one

IF INDISP = 1/ConsentRequired OR INDISP = 4/InitialRefusal, GO TO INCONREF - CONREFFN.
ELSE GO TO IN1PRE2 - IN1PR2CT.

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

The following questions are about (SP's) health insurance.
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

BOX IN3

ICAIDECO

ICAIDNOW

IN1

IN1A

routing

yes/no

yes/no

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.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) IN3 - ICAIDNUM
(01) IN3 - ICAIDNUM
(-8) IN3 - ICAIDNUM
(-9) IN3 - ICAIDNUM
(01) IN4 - ICAIDVER
(-8) IN5A - MCAIDHMO
(-9) IN5A - MCAIDHMO

(00) NO
(01) YES

(00) IN3 - ICAIDNUM
(01) IN5A - MCAIDHMO

ICAIDDOC

IN2

yes/no

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

ICAIDNUM

IN3

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.]

ICAIDVER

IN4

yes/no

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?

IN5A

yes/no

(00) NO
Some states now use HMOs (health maintenance organizations) to provide some or all health
(01) YES
care for Medicaid beneficiaries. (Is/Was) (SP) enrolled in a [READ NAME(S) FROM ABOVE] HMO? (-8) Don't Know
(-9) Refused

BOX IN3A

routing

IF THIS IS A BASELINE INTERVIEW, GO TO IN6 - ICDCRCOV.
ELSE GO TO IN18 - IGAPCOV.

MCAIDHMO

ICDCRCOV

ICAREPTD

IGAPCOV

IN6

IN13A

IN18

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

yes/no

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

yes/no

Our records show that (SP) is covered by Medicare. I'd like to ask some questions about (his/her)
Medicare coverage.
(00) NO
(01) YES
Was (SP) covered by Part D of Medicare on [September 1, (CURRENT YEAR)/(FAD/RAD)]?
(-8) Don't Know
(-9) Refused
PRESS F1 FOR PART D DEFINITIONS.

yes/no

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)?

(00) BOX IN3A
(01) BOX IN3A
(-8) BOX IN3A
(-9) BOX IN3A

(00) IN13A - ICAREPTD
(01) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD

(00) IN18 - IGAPCOV
(01) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(01) Continuous Answer

(01) IN19 - IGAPNAM2

(01) Continuous Answer

(01) IN19 - IGAPNAM3

(01) Continuous Answer

(01) IN19 - IGAPNAM4

What is the name of the insurance company?
IGAPNAME

IN19

Text

IGAPNAM2

IN19

Text

IGAPNAM3

IN19

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) Continuous Answer

(01) IN19 - IGAPNAM5

(01) Continuous Answer

(01) IN19 - IN20 - ILTCCOV

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) IN22 - ICHACOV
(01) IN21 - ILTCNAME
(-8) IN22 - ICHACOV
(-9) IN22 - ICHACOV

(01) Continuous Answer

(01) IN21 - ILTCNAM2

(01) Continuous Answer

(01) IN21 - ILTCNAM3

(01) Continuous Answer

(01) IN21 - ILTCNAM4

(01) Continuous Answer

(01) IN21 - ILTCNAM5

(01) Continuous Answer

(01) IN22 - ICHACOV

What is the name of the insurance company?
IGAPNAM4

IN19

Text

IGAPNAM5

IN19

Text

ILTCCOV

IN20

yes/no

ILTCNAME

IN21

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
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 longterm care policy?
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?

ILTCNAM2

IN21

Text
[PROBE: Any others?]
What is the name of the insurance company?

ILTCNAM3

IN21

Text
[PROBE: Any others?]
What is the name of the insurance company?

ILTCNAM4

IN21

Text
[PROBE: Any others?]
What is the name of the insurance company?

ILTCNAM5

IN21

Text

ICHACOV

IN22

Yes/No

IDVACOV

IN23

Yes/No

IPUBCOV

IN24

Yes/No

IPUBNAME

IN25

Text

BOX IN9

routing

[PROBE: Any others?]
Was (SP) covered by either TRICARE or CHAMPVA for hospital or physician care on [September 1, (00) NO
(CURRENT YEAR)/(FAD/RAD)]?
(01) YES
(-8) Don't Know
PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.
(-9) Refused
(00) NO
Was (SP) covered by any other Department of Veterans Affairs (VA) program or contract on
(01) YES
[September 1, (CURRENT YEAR)/(FAD/RAD)]?
(-8) Don't Know
(-9) Refused
(00) NO
(Besides [READ NAME(S) FROM ABOVE], was/Was) (SP) covered by any other public assistance
(01) YES
health insurance program on [September 1, (CURRENT YEAR)/(FAD/RAD)]?
(-8) Don't Know
(-9) Refused
What (is/was) the name of the public assistance health insurance program?
(01) Continuous Answer
IF SP ALIVE, AND A CFR, FFC, OR FCF AND IS A FALL ROUND, GO TO INBQ13A - IMARSTAT.
ELSE GO TO INEND - INENDCT.

(00) IN23 - IDVACOV
(01) IN23 - IDVACOV
(-8) IN23 - IDVACOV
(-9) IN23 - IDVACOV
(00) IN24 - IPUBCOV
(01) IN24 - IPUBCOV
(-8) IN24 - IPUBCOV
(-9) IN24 - IPUBCOV
(00) BOX IN9
(01) IN25 - IPUBNAME
(-8) BOX IN9
(-9) BOX IN9
(01) BOX IN9

Variable Name

MR Screen Name

Question type

IMARSTAT

INBQ13A

code one

INENDCT

INEND

code one

BOX INEND

routing

Question text/description

Code list

Routing

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

(05) (01)NEVER MARRIED
(01) (02) MARRIED
(02) (03) WIDOWED
(03) (04) DIVORCED
(04) (05) SEPARATED
(-8) Don't Know
(-9) Refused

(01) INEND - INENDCT
(02) INEND - INENDCT
(03) INEND - INENDCT
(04) INEND - INENDCT
(05) INEND - INENDCT
(-8) INEND - INENDCT
(-9) INEND - INENDCT

(01) CONTINUE

(01) BOX INEND

(YOU HAVE COMPLETED THE HEALTH INSURANCE SECTION FOR THIS SP.)
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
GO TO NAVIGATOR