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

Forms and Documents

Document Name	Status
Form Attachment 29 MEPS-HC Core Interview Form and Instruction	Unchanged
Form 106a HC Adult SAQ that includes Mental Health Questions Form and Instruction	New
Form 107a Health Insurance Cost Sharing Collection- 2020 Form and Instruction	New
Form 108 Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction	New
Form Attachment 21 3. Veteran SAQ Form and Instruction	Removed
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male Form and Instruction	Unchanged
Form Attachment 20 Attachment 20 HC Adult SAQ Female Form and Instruction	Unchanged
Form Attachment 72 MPC Contact Guide/Screening Call Form and Instruction	Unchanged
Form Attachment 26 MEPS-HC Validation Interview Form and Instruction	Unchanged
Form Attachment 24 Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	Unchanged
Form Attachment 25 Authorization form for the MEPS-MPC Provider Survey Form and Instruction	Unchanged
Form Attachment 98 Pharmacies questionnaire Form and Instruction	Unchanged
Form Attachment 96 Institutions (non-hospital) questionnaire Form and Instruction	Unchanged
Form Attachment 91 Hospitals questionnaire Form and Instruction	Unchanged
Form Attachment 87 Separately billing doctors questionnaire Form and Instruction	Unchanged
Form Attachment 83 Office based providers questionnaire Form and Instruction	Unchanged
Form Attachment 82 Home care for non health care providers questionnaire Form and Instruction	Unchanged
Form Attachment 78 Home care for health care providers questionnaire Form and Instruction	Unchanged
Form Attachment 22 Diabetes Care SAQ Form and Instruction	Unchanged
response Nurse Pract FRN Comment.msg Supplementary Document	2019-07-15
Attachment 104 – MPC Veterans Affairs Authorization Form Package.docx Supplementary Document	2018-09-12
Attachment 103 – MPC Pharmacy Provider Letters., Email Templates, and Other Documents.doc Supplementary Document	2018-09-12
Attachment 102 – MPC Durable Medical Equipment Provider Authorization Form Package.docx Supplementary Document	2018-09-12
Attachment 101 – MPC Pharmacy Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 100 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 99 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated.doc Supplementary Document	2018-09-12
Attachment 97 – MPC Letters, Emal Templates, and Other Documents.docx Supplementary Document	2018-09-12
Attachment 95 – MPC Hospital Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 94 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records.doc Supplementary Document	2018-09-12
Attachment 93 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records.doc Supplementary Document	2018-09-12
Attachment 92 – MPC Institution Provider Questionnaire.docx Supplementary Document	2018-09-12
Attachment 90 – MPC Separately Billing Doctor Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 89 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 88 – MPC Hospital Provider Authorization Form Package,.doc Supplementary Document	2018-09-12
Attachment 86 – MPC Office-Based Doctor Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 85 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 84 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers.docx Supplementary Document	2018-09-12
Attachment 81 – MPC Home Care Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 80 – MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated.doc Supplementary Document	2018-09-12
Attachment 79 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 28 HC Tips for Making Your MEPS Interview Easier.pdf Supplementary Document	2018-09-12
Attachment 27 HC MEPS Tip Sheet.pdf Supplementary Document	2018-09-12
Attachment 17 HC Who Uses MEPS Data.pdf Supplementary Document	2018-09-12
Attachment 16 HC Certificate of Appreciation.pdf Supplementary Document	2018-09-12
Attachment 15 HC Validation Letter.pdf Supplementary Document	2018-09-12
Attachment 14 HC Showcards.pdf Supplementary Document	2018-09-12
Attachment 13 HC MEPS Record Keeper.pdf Supplementary Document	2018-09-12
Attachment 12 HC MEPS Monthly Planner.pdf Supplementary Document	2018-09-12
Attachment 11 HC MEPS FAQs Brochure.pdf Supplementary Document	2018-09-12
Attachment 10 HC Respondent Letters, Postcards and Notes.docx Supplementary Document	2018-09-12
Attachment 9 HC Data Example and FAQs.docx Supplementary Document	2018-09-12
Attachment 8 HC Important Information About Your Participation in MEPS.pdf Supplementary Document	2018-09-12
Attachment 7 HC Respondent Recruitment Video Transcript.pdf Supplementary Document	2018-09-12
Attachment 6 HC Data Protection is word ONE with MEPS.pdf Supplementary Document	2018-09-12
Attachment 5 HC About the MEPS MPC Authorization form.pdf Supplementary Document	2018-09-12
Attachment 4 HC What MEPS tells us about Charts.docx Supplementary Document	2018-09-12
Attachment 3 HC MEPS A Survey of Health Care Use and Spending.pdf Supplementary Document	2018-09-12
Attachment 2 HC Why is Participation in MEPS so Important.pdf Supplementary Document	2018-09-12
Attachment 1 final draft.09052018..docx Supplementary Document	2018-09-12
Supporting Statement Part B -- Clean.docx Supporting Statement B	2019-11-07
Supporting Statement Part A -- Clean.docx Supporting Statement A	2019-11-07

IC Document Collections

IC ID	Document Title	Status
37877	MEPS-HC Core Interview Form and Instruction	Unchanged
236894	HC Adult SAQ that includes Mental Health Questions Form and Instruction	New
236893	Health Insurance Cost Sharing Collection- 2020 Form and Instruction	New
236883	Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction	New
232925	3. Veteran SAQ Form and Instruction	Removed
230227	Attachment 19 – HC Adult SAQ – Male Form and Instruction	Unchanged
230226	Attachment 20 HC Adult SAQ Female Form and Instruction	Unchanged
204200	MPC Contact Guide/Screening Call Form and Instruction	Unchanged
204199	MEPS-HC Validation Interview Form and Instruction	Unchanged
204198	Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	Unchanged
204197	Authorization form for the MEPS-MPC Provider Survey Form and Instruction	Unchanged
191107	Pharmacies questionnaire Form and Instruction	Unchanged
191106	Institutions (non-hospital) questionnaire Form and Instruction	Unchanged
191105	Hospitals questionnaire Form and Instruction	Unchanged
191104	Separately billing doctors questionnaire Form and Instruction	Unchanged
191103	Office based providers questionnaire Form and Instruction	Unchanged
191102	Home care for non health care providers questionnaire Form and Instruction	Unchanged
191101	Home care for health care providers questionnaire Form and Instruction	Unchanged
191099	Diabetes Care SAQ Form and Instruction	Unchanged

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
	Date Received in OIRA: 07/16/2019
Terms of Clearance:

	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

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
Attachment 19 – HC Adult SAQ – Male	Attachment 19 , Attachment 18	Attachment 19 – HC Adult SAQ – Male ,   Attachment 18 HC Adult SAQ
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
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
MEPS-HC Validation Interview	Attachment 26	Attachment 26 HC MEPS Validation Interview
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
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
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)
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	108	Attachment 108 - Household Component Core Instrument Link
3. Veteran SAQ	Attachment 21	Attachment 21 Veteran SAQ

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ICR Summary 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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