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 71 Attachment 71 HC Event Follow Up Section	Form and Instruction	Unchanged	Available
Form Attachment 70 Attachment 70 HC RU Information Screener	Form and Instruction	Unchanged	Available
Form Attachment 69 Attachment 69 HC Reenumeration Subsection B	Form and Instruction	Unchanged	Available
Form Attachment 68 Attachment 68 HC Reenumeration Subsection	Form and Instruction	Unchanged	Available
Form Attachment 67 Attachment 67 HC Provider Roster Section	Form and Instruction	Unchanged	Available
Form Attachment 66 Attachment 66 HC Provider Probes Section	Form and Instruction	Unchanged	Available
Form Attachment 65 Attachment 65 HC Prescribed Medicines Section	Form and Instruction	Unchanged	Available
Form Attachment 64 Attachment 64 HC Priority Conditions Enumeration Section	Form and Instruction	Unchanged	Available
Form Attachment 63 Attachment 63 HC Respondent Forms Section	Form and Instruction	Unchanged	Available
Form Attachment 62 Attachment 62 HC Quality Supplement Section	Form and Instruction	Unchanged	Available
Form Attachment 61 Attachment 61 HC Outpatient Department Section	Form and Instruction	Unchanged	Available
Form Attachment 60 Attachment 60 HC Other Medical Expense Section	Form and Instruction	Unchanged	Available
Form Attachment 59 Attachment 59 HC Medical Provider Section	Form and Instruction	Unchanged	Available
Form Attachment 58 Attachment 58 HC Income Section	Form and Instruction	Unchanged	Repair queued
Form Attachment 57 Attachment 57 HC Hospital Stay Section	Form and Instruction	Unchanged	Available
Form Attachment 56 Attachment 56 HC Old Public Related Insurance (PR) Section	Form and Instruction	Unchanged	Available
Form Attachment 55 Attachment 55 HC Old Employment Health Insurance (OE) Section	Form and Instruction	Unchanged	Available
Form Attachment 54 Attachment 54 HC Managed Care (MC) Section	Form and Instruction	Unchanged	Available
Form Attachment 53 Attachment 53 HC Time Covered Detail (HQ) Section	Form and Instruction	Unchanged	Available
Form Attachment 52 HC Attachment 52 HC Private Health Insurance Detail (HP) Section	Form and Instruction	Unchanged	Available
Form Attachment 51 Attachment 51 Health Insurance (HX) Section	Form and Instruction	Unchanged	Available
Form Attachment 50 Attachment 50 Home Health Section	Form and Instruction	Unchanged	Available
Form Attachment 49 Attachment 49 HC Help Text	Form and Instruction	Unchanged	Available
Form Attachment 48 Attachment 48 Health Status Section	Form and Instruction	Unchanged	Available
Form Attachment 47 Attachment 47 Event Roster Section	Form and Instruction	Unchanged	Available
Form Attachment 46 Attachment 46 – HC Emergency Room Section	Form and Instruction	Unchanged	Available
Form Attachment 45 Attachment 45 – HC Employment Wage (EW) Section	Form and Instruction	Unchanged	Available
Form Attachment 44 Attachment 44 – HC Employment Driver (OE) Section	Form and Instruction	Unchanged	Available
Form Attachment 43 Attachment 43 – HC Review of Employment Information (RJ) Section	Form and Instruction	Unchanged	Available
Form Attachment 42 Attachment 42 – HC Employment (EM) Section	Form and Instruction	Unchanged	Repair queued
Form Attachment 41 Attachment 41 – HC Event Driver Section	Form and Instruction	Unchanged	Available
Form Attachment 40 Attachment 40 – HC Dental Care Section	Form and Instruction	Unchanged	Available
Form Attachment 39 Attachment 39 – HC Institutional Care Section	Form and Instruction	Unchanged	Available
Form Attachment 38 Attachment 38 – HC Child Preventive Health Supplement Section	Form and Instruction	Unchanged	Available
Form Attachment 37 Attachment 37 HC Flat Fee Section	Form and Instruction	Unchanged	Available
Form Attachment 36 Attachment 36 HC Charge Payment Section	Form and Instruction	Unchanged	Available
Form Attachment 35 Attachment 35 HC Start_Restart	Form and Instruction	Unchanged	Available
Form Attachment 34 Attachment 34 HC Closing Section	Form and Instruction	Unchanged	Available
Form Attachment 33 Attachment 33 Additional healthcare Section	Form and Instruction	Unchanged	Available
Form Attachment 32 Attachment 32 – Attachment 32 HC Calendar Section	Form and Instruction	Unchanged	Available
Form Attachment 31 Attachment 31 – Attachment 31 HC Assets Section.	Form and Instruction	Unchanged	Available
Form Attachment 30 Attachment 30 – HC Condition Enumeration Section	Form and Instruction	Unchanged	Available
Form Attachment 29 Attachment 29 –HC Access to Care Section	Form and Instruction	Unchanged	Available
Form 106b Attachment106b.REV_Male PSAQ with Mental Health Content	Form and Instruction	New	Available
Form 106a Attachment 106a.REV_Female PSAQ with Mental Health Content	Form and Instruction	New	Available
Form 107d Attachment 107d.Protocol D (Other)	Form and Instruction	New	Available
Form 107c Attachment 107c.Protocol C (Private with Medicare)_	Form and Instruction	New	Available
Form 107b Attachment 107b.Protocol B (Employer)	Form and Instruction	New	Available
Form 107a Attachment 107a.Protocol A (Medicare)	Form and Instruction	New	Available
Form 108 Attachment 108 - Household Component Core Instrument Link	Form and Instruction	New	Available
Form Attachment 21 Attachment 21 Veteran SAQ	Form and Instruction	Removed	Available
Form Attachment 18 Attachment 18 HC Adult SAQ	Form and Instruction	Unchanged	Available
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Unchanged	Available
Form Attachment 19 Attachment 19 HC Adult SAQ Male	Form and Instruction	Unchanged	Available
Form Attachment 20 Attachment 20 HC Adult SAQ Female	Form and Instruction	Unchanged	Available
Form Attachment 77 Attachment 77 – MPC Separate Billing Doctor Contact Guide	Form and Instruction	Unchanged	Available
Form Attachment 76 Attachment 76 – MPC Pharmacy Contact Guide	Form and Instruction	Unchanged	Available
Form Attachment 75 Attachment 75 – MPC Institution Contact Guide	Form and Instruction	Unchanged	Available
Form Attachment 74 Attachment 74 – MPC Home Care Contact	Form and Instruction	Unchanged	Available
Form Attachment 73 Attachment 73 – MPC Office-Based Doctor Contact Guide	Form and Instruction	Unchanged	Available
Form Attachment 72 Attachment 72 – MPC Hospital Contact Guide	Form and Instruction	Unchanged	Available
Form Attachment 26 Attachment 26 HC MEPS Validation Interview	Form and Instruction	Unchanged	Available
Form Attachment 24 Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy	Form and Instruction	Unchanged	Available
Form Attachment 25 Attachment 25 HC Authorization Form for the MEPS MPC Provider	Form and Instruction	Unchanged	Available
Form Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire	Form and Instruction	Unchanged	Available
Form Attachment 96 Attachment 96 – MPC Institution Provider Questionnaire	Form and Instruction	Unchanged	Available
Form Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire	Form and Instruction	Unchanged	Available
Form Attachment 87 Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire	Form and Instruction	Unchanged	Available
Form Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questionnaire	Form and Instruction	Unchanged	Available
Form Attachment 82 Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers	Form and Instruction	Unchanged	Available
Form Attachment 78 Attachment 78 – MPC Home Care Provider Questionnaire for Health Care Providers	Form and Instruction	Unchanged	Available
Form Attachment 23 Attachment 23 -- HC Diabetes SAQ - Self	Form and Instruction	Unchanged	Available
Form Attachment 22 Attachment 22 -- HC Diabetes SAQ - Proxy	Form and Instruction	Unchanged	Available
response Nurse Pract FRN Comment.msg	Supplementary Document	Uploaded 2019-07-15	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 -- Clean.docx	Supporting Statement B	Uploaded 2019-11-07	Available
Supporting Statement Part A -- Clean.docx	Supporting Statement A	Uploaded 2019-11-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 71 HC Event Follow Up Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 70 HC RU Information Screener
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 69 HC Reenumeration Subsection B
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 68 HC Reenumeration Subsection
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 67 HC Provider Roster Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 66 HC Provider Probes Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 65 HC Prescribed Medicines Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 64 HC Priority Conditions Enumeration Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 63 HC Respondent Forms Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 62 HC Quality Supplement Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 61 HC Outpatient Department Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 60 HC Other Medical Expense Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 59 HC Medical Provider Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 58 HC Income Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 57 HC Hospital Stay Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 56 HC Old Public Related Insurance (PR) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 55 HC Old Employment Health Insurance (OE) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 54 HC Managed Care (MC) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 53 HC Time Covered Detail (HQ) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 52 HC Private Health Insurance Detail (HP) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 51 Health Insurance (HX) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 50 Home Health Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 49 HC Help Text
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 48 Health Status Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 47 Event Roster Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 46 – HC Emergency Room Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 45 – HC Employment Wage (EW) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 44 – HC Employment Driver (OE) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 43 – HC Review of Employment Information (RJ) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 42 – HC Employment (EM) Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 41 – HC Event Driver Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 40 – HC Dental Care Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 39 – HC Institutional Care Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 38 – HC Child Preventive Health Supplement Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 37 HC Flat Fee Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 36 HC Charge Payment Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 35 HC Start_Restart
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 34 HC Closing Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 33 Additional healthcare Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 32 – Attachment 32 HC Calendar Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 31 – Attachment 31 HC Assets Section.
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 30 – HC Condition Enumeration Section
37877	MEPS-HC Core Interview	Form and Instruction	Unchanged	Attachment 29 –HC Access to Care Section
236894	HC Adult SAQ that includes Mental Health Questions	Form and Instruction	New	Attachment106b.REV_Male PSAQ with Mental Health Content
236894	HC Adult SAQ that includes Mental Health Questions	Form and Instruction	New	Attachment 106a.REV_Female PSAQ with Mental Health Content
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	New	Attachment 107d.Protocol D (Other)
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	New	Attachment 107c.Protocol C (Private with Medicare)_
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	New	Attachment 107b.Protocol B (Employer)
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	New	Attachment 107a.Protocol A (Medicare)
236883	Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	Form and Instruction	New	Attachment 108 - Household Component Core Instrument Link
232925	3. Veteran SAQ	Form and Instruction	Removed	Attachment 21 Veteran SAQ
230227	Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Unchanged	Attachment 18 HC Adult SAQ
230227	Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Unchanged	Attachment 19 – HC Adult SAQ – Male
230226	Attachment 20 HC Adult SAQ Female	Form and Instruction	Unchanged	Attachment 19 HC Adult SAQ Male
230226	Attachment 20 HC Adult SAQ Female	Form and Instruction	Unchanged	Attachment 20 HC Adult SAQ Female
204200	MPC Contact Guide/Screening Call	Form and Instruction	Unchanged	Attachment 77 – MPC Separate Billing Doctor Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Unchanged	Attachment 76 – MPC Pharmacy Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Unchanged	Attachment 75 – MPC Institution Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Unchanged	Attachment 74 – MPC Home Care Contact
204200	MPC Contact Guide/Screening Call	Form and Instruction	Unchanged	Attachment 73 – MPC Office-Based Doctor Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Unchanged	Attachment 72 – MPC Hospital Contact Guide
204199	MEPS-HC Validation Interview	Form and Instruction	Unchanged	Attachment 26 HC MEPS Validation Interview
204198	Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	Unchanged	Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
204197	Authorization form for the MEPS-MPC Provider Survey	Form and Instruction	Unchanged	Attachment 25 HC Authorization Form for the MEPS MPC Provider
191107	Pharmacies questionnaire	Form and Instruction	Unchanged	Attachment 98 – MPC Pharmacy Provider Questionnaire
191106	Institutions (non-hospital) questionnaire	Form and Instruction	Unchanged	Attachment 96 – MPC Institution Provider Questionnaire
191105	Hospitals questionnaire	Form and Instruction	Unchanged	Attachment 91 – MPC Hospital Provider Questionnaire
191104	Separately billing doctors questionnaire	Form and Instruction	Unchanged	Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
191103	Office based providers questionnaire	Form and Instruction	Unchanged	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
191102	Home care for non health care providers questionnaire	Form and Instruction	Unchanged	Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
191101	Home care for health care providers questionnaire	Form and Instruction	Unchanged	Attachment 78 – MPC Home Care Provider Questionnaire for Health Care Providers
191099	Diabetes Care SAQ	Form and Instruction	Unchanged	Attachment 23 -- HC Diabetes SAQ - Self
191099	Diabetes Care SAQ	Form and Instruction	Unchanged	Attachment 22 -- HC Diabetes SAQ - Proxy

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 201907-0935-002
Status: Historical Active	Previous ICR Reference No: 201808-0935-001
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: 11/08/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/16/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	11/30/2021
Responses	338,980	0	311,519
Time Burden (Hours)	84,930	0	77,666
Cost Burden (Dollars)	0	0	0

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Abstract: This request is for an update to previously submitted OMB supporting statements for the renewal of the OMB clearance for the data collections of the Household and Medical Provider Components of the Medical Expenditure Panel Survey (MEPS) which was approved in November 2018 and has an expiration date of November 30, 2020. The MEPS Household Component (MEPS-HC) and Medical Provider Component (MEPS-MPC) are two of three components of the MEPS. • Household Component: A sample of households participating in the National Health Interview Survey (NHIS) in the prior calendar year are interviewed 5 times over a 2 and one half (2.5) year period. These 5 interviews yield two years of information on use of, and expenditures for, health care, sources of payment for that health care, insurance status, employment, health status and health care quality. • Medical Provider Component: The MEPS-MPC collects information from medical and financial records maintained by hospitals, physicians, pharmacies and home health agencies named as sources of care by household respondents. • Insurance Component (MEPS-IC): The MEPS-IC collects information on establishment characteristics, insurance offerings and premiums from employers. The MEPS-IC is conducted by the Census Bureau for AHRQ and is cleared separately. The previous OMB clearance request for the MEPS was approved November, 2018 with an expiration date of November 30, 2021. We propose updating the MEPS –HC by 1) adding a section to the 2020 self-administered questionnaire (SAQ, Male/Female) that will include questions on mental health, 2) collecting a health insurance cost-sharing document and 3) implementing a pilot study to evaluate the potential effectiveness of including a sample of NHIS nonrespondents in future MEPS panels as a strategy to improve the overall MEPS response rate. The total estimated annual burden hours for the MEPS will increase from 77,666 hours in the previous clearance to 84,930 hours in this clearance request, an increase of 7,264 hours. These are one time additions due to available funding in FY2019. If additional funds are available in 2020 (or futures years), response rates and data quality, as well as competing funding priorities will be the metrics used to determine if similar activities should be funded.

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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:
	84 FR 18544	05/01/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 33069	07/11/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
Attachment 20 HC Adult SAQ Female	Attachment 20 , Attachment 19	Attachment 20 HC Adult SAQ Female ,   Attachment 19 HC Adult SAQ Male
3. Veteran SAQ	Attachment 21	Attachment 21 Veteran SAQ
Attachment 19 – HC Adult SAQ – Male	Attachment 19 , Attachment 18	Attachment 19 – HC Adult SAQ – Male ,   Attachment 18 HC Adult SAQ
Authorization form for the MEPS-MPC Pharmacy Survey	Attachment 24	Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
Authorization form for the MEPS-MPC Provider Survey	Attachment 25	Attachment 25 HC Authorization Form for the MEPS MPC Provider
Diabetes Care SAQ	Attachment 22, Attachment 23	Attachment 22 -- HC Diabetes SAQ - Proxy ,   Attachment 23 -- HC Diabetes SAQ - Self
HC Adult SAQ that includes Mental Health Questions	106a, 106b	Attachment 106a.REV_Female PSAQ with Mental Health Content ,   Attachment106b.REV_Male PSAQ with Mental Health Content
Health Insurance Cost Sharing Collection- 2020	107b, 107a, 107c, 107d	Attachment 107a.Protocol A (Medicare) ,   Attachment 107b.Protocol B (Employer) ,   Attachment 107c.Protocol C (Private with Medicare)_ ,   Attachment 107d.Protocol D (Other)
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
Hospitals questionnaire	Attachment 91	Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire	Attachment 96	Attachment 96 – MPC Institution Provider Questionnaire
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 45 , 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 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 ,   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 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 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
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
Office based providers questionnaire	Attachment 83	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Pharmacies questionnaire	Attachment 98	Attachment 98 – MPC Pharmacy Provider Questionnaire
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	108	Attachment 108 - Household Component Core Instrument Link
Separately billing doctors questionnaire	Attachment 87	Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire

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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	338,980	311,519	0	27,461	0	0
Annual Time Burden (Hours)	84,930	77,666	0	7,264	0	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: No

Burden Reduction Due to:

Short Statement: The total estimated annual burden hours for the MEPS has increased from 77,666 hours in the previous clearance to 84,930 hours in this clearance request, an increase of 7,264 hours. This burden increase is due to the addition of a Mental Health SAQ, estimated at 1,194 hours, and the health insurance cost sharing collection, estimated at 6,101 in hours of burden, and the pilot test on sampling NHIS nonrespondents, estimated at 307 hours of burden. While the burden associated with these added tasks totals 7,602 hours, reductions in other burden estimates leave a net difference of 7,264 hours overall.

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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: 07/16/2019

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