Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Attachment 54 MEPS-HC Core Interview	Form and Instruction	Modified	Available
Form Attachment 21 3. Veteran SAQ	Form and Instruction	New	Available
Form Attachment 18 Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Modified	Available
Form Attachment 19 Attachment 20 HC Adult SAQ Female	Form and Instruction	Modified	Available
Form 9 Medical Organizations Survey Questionaire	Form and Instruction	Removed	Available
Form Attachment 72 MPC Contact Guide/Screening Call	Form and Instruction	Modified	Available
Form Attachment 26 MEPS-HC Validation Interview	Form and Instruction	Modified	Available
Form Attachment 24 Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	Modified	Available
Form Attachment 25 Authorization form for the MEPS-MPC Provider Survey	Form and Instruction	Modified	Available
Form Attachment 98 Pharmacies questionnaire	Form and Instruction	Modified	Available
Form Attachment 96 Institutions (non-hospital) questionnaire	Form and Instruction	Modified	Available
Form Attachment 91 Hospitals questionnaire	Form and Instruction	Modified	Available
Form Attachment 87 Separately billing doctors questionnaire	Form and Instruction	Modified	Available
Form Attachment 83 Office based providers questionnaire	Form and Instruction	Modified	Available
Form Attachment 82 Home care for non health care providers questionnaire	Form and Instruction	Modified	Available
Form Attachment 78 Home care for health care providers questionnaire	Form and Instruction	Modified	Available
Form Attachment 22 Diabetes Care SAQ	Form and Instruction	Modified	Available
Attachment 104 – MPC Veterans Affairs Authorization Form Package.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 103 – MPC Pharmacy Provider Letters., Email Templates, and Other Documents.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 102 – MPC Durable Medical Equipment Provider Authorization Form Package.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 101 – MPC Pharmacy Provider Overflow Patient List.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 100 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 99 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 97 – MPC Letters, Emal Templates, and Other Documents.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 95 – MPC Hospital Provider Overflow Patient List.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 94 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 93 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 92 – MPC Institution Provider Questionnaire.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 90 – MPC Separately Billing Doctor Provider Overflow Patient List.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 89 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 88 – MPC Hospital Provider Authorization Form Package,.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 86 – MPC Office-Based Doctor Provider Overflow Patient List.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 85 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 84 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 81 – MPC Home Care Provider Overflow Patient List.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 80 – MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 79 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated.doc	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 28 HC Tips for Making Your MEPS Interview Easier.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 27 HC MEPS Tip Sheet.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 17 HC Who Uses MEPS Data.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 16 HC Certificate of Appreciation.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 15 HC Validation Letter.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 14 HC Showcards.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 13 HC MEPS Record Keeper.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 12 HC MEPS Monthly Planner.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 11 HC MEPS FAQs Brochure.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 10 HC Respondent Letters, Postcards and Notes.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 9 HC Data Example and FAQs.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 8 HC Important Information About Your Participation in MEPS.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 7 HC Respondent Recruitment Video Transcript.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 6 HC Data Protection is word ONE with MEPS.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 5 HC About the MEPS MPC Authorization form.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 4 HC What MEPS tells us about Charts.docx	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 3 HC MEPS A Survey of Health Care Use and Spending.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 2 HC Why is Participation in MEPS so Important.pdf	Supplementary Document	Uploaded 2018-09-12	Available
Attachment 1 final draft.09052018..docx	Supplementary Document	Uploaded 2018-09-12	Available
Supporting Statement Part B -- MEPS HC 09072018v4.mns (002) (002).docx	Supporting Statement B	Uploaded 2018-09-12	Available
Supporting Statement Part A -- MEPS FINALCLEAN v12. 11192018..docx	Supporting Statement A	Uploaded 2018-11-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37877	MEPS-HC Core Interview	Form and Instruction	Modified
232925	3. Veteran SAQ	Form and Instruction	New
230227	Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Modified
230226	Attachment 20 HC Adult SAQ Female	Form and Instruction	Modified
218173	Medical Organizations Survey Questionaire	Form and Instruction	Removed
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified
204199	MEPS-HC Validation Interview	Form and Instruction	Modified
204198	Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	Modified
204197	Authorization form for the MEPS-MPC Provider Survey	Form and Instruction	Modified
191107	Pharmacies questionnaire	Form and Instruction	Modified
191106	Institutions (non-hospital) questionnaire	Form and Instruction	Modified
191105	Hospitals questionnaire	Form and Instruction	Modified
191104	Separately billing doctors questionnaire	Form and Instruction	Modified
191103	Office based providers questionnaire	Form and Instruction	Modified
191102	Home care for non health care providers questionnaire	Form and Instruction	Modified
191101	Home care for health care providers questionnaire	Form and Instruction	Modified
191099	Diabetes Care SAQ	Form and Instruction	Modified

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 201808-0935-001
Status: Historical Active	Previous ICR Reference No: 201802-0935-002
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/20/2018
	Date Received in OIRA: 09/14/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2021	36 Months From Approved	05/31/2019
Responses	311,519	0	339,044
Time Burden (Hours)	77,666	0	86,702
Cost Burden (Dollars)	0	0	0

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Abstract: Medical Expenditure Panel Survey (MEPS) Household Component (HC) The MEPS provides information about the current state of the health care system as well as to track changes over time. The MEPS permits annual estimates of use of health care and expenditures and sources of payment for that health care. It also permits tracking individual change in employment, income, health insurance and health status over two years. Households selected for participation in the MEPS-HC are interviewed five times in person. Medical Expenditure Panel Survey (MEPS) Medical Provider Component (MPC) For a sample of those who participate in the MEPS HC, the MEPS-MPC contacts medical providers (hospitals, physicians, home health agencies and institutions) identified by household respondents in the MEPS-HC as sources of medical care for the time period covered by the interview, and all pharmacies providing prescription drugs to household members during the covered time period.. Since the previous OMB Clearance request for the MEPS, the MEPS-HC has had a number of changes to the survey instrument itself and the survey administration in an effort to increase data quality, decrease respondent burden and to simplify instrument administration. The current request includes a burden reduction due to a reduction in sample size necessary to accommodate the new NHIS design while maintaining the precision level necessary for MEPS estimates.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Agency for Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 25671	06/04/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 44877	09/04/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 16

table that charts list of burden

IC Title	Form No.	Form Name
Medical Organizations Survey Questionaire	9	Attachment 100 – MPC Medical Organizations Survey Draft Questionnaire
Attachment 20 HC Adult SAQ Female	Attachment 20 , Attachment 19	Attachment 19 HC Adult SAQ Male ,   Attachment 20 HC Adult SAQ Female
Attachment 19 – HC Adult SAQ – Male	Attachment 19 , Attachment 18	Attachment 18 HC Adult SAQ ,   Attachment 19 – HC Adult SAQ – Male
MEPS-HC Core Interview	Attachment 29, Attachment 30 , Attachment 31 , Attachment 32 , Attachment 33 , Attachment 34, Attachment 35 , Attachment 36 , Attachment 37 , Attachment 39 , Attachment 40 , Attachment 41 , Attachment 42 , Attachment 43 , Attachment 44 , Attachment 46 , Attachment 47 , Attachment 48 , Attachment 49 , Attachment 50 , Attachment 51 , Attachment 53 , Attachment 52 HC, Attachment 54 , Attachment 55 , Attachment 56 , Attachment 57 , Attachment 58 , Attachment 59 , Attachment 60 , Attachment 61 , Attachment 62 , Attachment 63 , Attachment 64 , Attachment 65 , Attachment 66 , Attachment 67 , Attachment 68 , Attachment 69 , Attachment 70 , Attachment 71 , Attachment 38 , Attachment 45	Attachment 54 HC Managed Care (MC) Section ,   Attachment 55 HC Old Employment Health Insurance (OE) Section ,   Attachment 56 HC Old Public Related Insurance (PR) Section ,   Attachment 57 HC Hospital Stay Section ,   Attachment 58 HC Income Section ,   Attachment 59 HC Medical Provider Section ,   Attachment 60 HC Other Medical Expense Section ,   Attachment 61 HC Outpatient Department Section ,   Attachment 62 HC Quality Supplement Section ,   Attachment 63 HC Respondent Forms Section ,   Attachment 64 HC Priority Conditions Enumeration Section ,   Attachment 65 HC Prescribed Medicines Section ,   Attachment 66 HC Provider Probes Section ,   Attachment 67 HC Provider Roster Section ,   Attachment 68 HC Reenumeration Subsection ,   Attachment 69 HC Reenumeration Subsection B ,   Attachment 70 HC RU Information Screener ,   Attachment 71 HC Event Follow Up Section ,   Attachment 48 Health Status Section ,   Attachment 49 HC Help Text ,   Attachment 50 Home Health Section ,   Attachment 51 Health Insurance (HX) Section ,   Attachment 52 HC Private Health Insurance Detail (HP) Section ,   Attachment 53 HC Time Covered Detail (HQ) Section ,   Attachment 39 – HC Institutional Care Section ,   Attachment 40 – HC Dental Care Section ,   Attachment 41 – HC Event Driver Section ,   Attachment 42 – HC Employment (EM) Section ,   Attachment 43 – HC Review of Employment Information (RJ) Section ,   Attachment 44 – HC Employment Driver (OE) Section ,   Attachment 45 – HC Employment Wage (EW) Section ,   Attachment 46 – HC Emergency Room Section ,   Attachment 47 Event Roster Section ,   Attachment 29 –HC Access to Care Section ,   Attachment 30 – HC Condition Enumeration Section ,   Attachment 31 – Attachment 31 HC Assets Section. ,   Attachment 32 – Attachment 32 HC Calendar Section ,   Attachment 33 Additional healthcare Section ,   Attachment 34 HC Closing Section ,   Attachment 35 HC Start_Restart ,   Attachment 36 HC Charge Payment Section ,   Attachment 37 HC Flat Fee Section ,   Attachment 38 – HC Child Preventive Health Supplement Section
Diabetes Care SAQ	Attachment 22, Attachment 23	Attachment 22 -- HC Diabetes SAQ - Proxy ,   Attachment 23 -- HC Diabetes SAQ - Self
Home care for health care providers questionnaire	Attachment 78	Attachment 78 – MPC Home Care Provider Questionnaire for Health Care Providers
Home care for non health care providers questionnaire	Attachment 82	Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
Office based providers questionnaire	Attachment 83	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Separately billing doctors questionnaire	Attachment 87	Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
Hospitals questionnaire	Attachment 91	Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire	Attachment 96	Attachment 96 – MPC Institution Provider Questionnaire
Pharmacies questionnaire	Attachment 98	Attachment 98 – MPC Pharmacy Provider Questionnaire
Authorization form for the MEPS-MPC Provider Survey	Attachment 25	Attachment 25 HC Authorization Form for the MEPS MPC Provider
Authorization form for the MEPS-MPC Pharmacy Survey	Attachment 24	Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
MEPS-HC Validation Interview	Attachment 26	Attachment 26 HC MEPS Validation Interview
MPC Contact Guide/Screening Call	Attachment 72 , Attachment 73 , Attachment 74 , Attachment 75 , Attachment 76 , Attachment 77	Attachment 72 – MPC Hospital Contact Guide ,   Attachment 73 – MPC Office-Based Doctor Contact Guide ,   Attachment 74 – MPC Home Care Contact ,   Attachment 75 – MPC Institution Contact Guide ,   Attachment 76 – MPC Pharmacy Contact Guide ,   Attachment 77 – MPC Separate Billing Doctor Contact Guide
3. Veteran SAQ	Attachment 21	Attachment 21 Veteran SAQ

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	311,519	339,044	0	-21,525	-6,000	0
Annual Time Burden (Hours)	77,666	86,702	0	-7,536	-1,500	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total estimated annual burden hours for the MEPS have been decreased from 86,702 hours in the previous clearance to 77,666 hours in this clearance request, a decrease of 9,036 hours.

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Annual Cost to Federal Government: $51,382,086

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/14/2018

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