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pdf2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
NO STATEMENT COST SERIES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: At least one event entered in the current round is not associated with charge data already entered
PLACEMENT
Administer after PSQ.
CREATE LIST OF EVENTS ENTERED IN THE CURRENT ROUND THAT ARE NOT ASSOCIATED WITH
CHARGE DATA ALREADY ENTERED
IF AT LEAST ONE EVENT ENTERED IN THE CURRENT ROUND IS NOT ASSOCIATED WITH CHARGE
DATA ALREADY ENTERED, GO TO NS1 - NSINT.
ELSE GO TO NS81 - NSTATEMENT.
BOX NSBEG
[Now that we're done with [your/(SP's)] statements, let's/Let's] talk about the medical services and costs for
which [you/(SP)] did not have a statement.]
NSINT
NS1
no entry
BOX NS1
THERE ARE (TOTAL NUMBER OF NS EVENTS) EVENTS (REMAINING) TO ASK ABOUT.
(Let's start with/Next let's look at) (the/[your/(SP's)]) costs for the (EVENT).
BOX NS1
NSEXMCMAIL
NS2
routing
code one
IF (ST1 - MHMOSTMT = 3/Never AND ((SP HAS A MEDICARE MANAGED CARE PLAN THAT DOES NOT
HAVE RX COVERAGE ANYTIME IN THE CURRENT ROUND) OR (SP HAS A PRIVATE PLAN THAT IS A
MANAGED CARE PLAN ANYTIME IN THE CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE) OR
(EVENT IS ASSOCIATED WITH A MANAGED CARE PLAN))) OR (EVENT TYPE = 'OM' AND EVENT IS A
RENTAL ITEM AND PS1 - HADPYMNT = 1/Yes) OR ((EVNTTYPE = 'DU' OR 'PM' OR 'VU' OR 'HU') AND SP
DOES NOT HAVE ANY OTHER HEALTH INSURANCE PLAN BESIDES MEDICARE IN THE CURRENT
ROUND) , GO TO BOX NS4.
ELSE GO TO NS2 - NSEXMCMAIL.
As far as you know, is anything expected in the mail from (Medicare, Insurance, and Tricare/Medicare and
Tricare/Medicare and Insurance/Medicare) about [READ EVENT ABOVE]?
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(04) HAVE STATEMENT FOR EVENT
(05) YES, BUT CAN ANSWER QUESTIONS
(09) FLAG COST FOR CPS DO NOT DISPLAY.
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS4
(02) BOX NS4
(03) NS3 - EVERRVB
(04) ST4 - MATCHST
(05) BOX NS4
(09) DO NOT DISPLAY
(-8) BOX NS4
(-9) BOX NS4
REMINDER: "EVENT ENTERED IN ERROR" INSTRUCTS THE HOME OFFICE TO DELETE THIS EVENT.
EVERRVB
TOTALCHG
NS3
verbatim text
BOX NS4
routing
CREATE A NEW CHARGE BUNDLE FOR THIS EVENT
IF NS2 - NSEXMCMAIL = 1/Yes or 3/EventEnteredInError, GO TO BOX NS80.
ELSE GO TO BOX NS4A.
BOX NS4A
routing
IF (EVENT TYPE IS NOT AN OTHER MEDICAL EXPENSE) AND (EVENT IS ASSOCIATED WITH A
MANAGED CARE PLAN), GO TO NS6 - TOTALCHG.
ELSE GO TO NS5 - TOTALCHG.
NS5
dollar
IF YOU HAVE ENTERED THIS CODE IN ERROR, SELECT PREVIOUS PAGE AND ENTER THE CORRECT (01) CONTINUOUS ANSWER
CODE AT NS2. OTHERWISE, EXPLAIN WHY YOU SELECTED "EVENT ENTERED IN ERROR" FOR THIS
EVENT.
Including any amounts that may be paid by Medicare or anyone else, what [was the charge for the (OME ITEM
TYPE) rented (with the option to buy) for the time period between (REFERENCE DATE/UTILDATE) and
(TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/was the total charge (that is, the total amount
billed)]?
(01) CONTINUOUS ANSWER
IF CHARGE REPORTED AS HOURLY RATE, CALCULATE AND ENTER THE TOTAL CHARGE FOR THE
(-8) DON'T KNOW
ENTIRE ROUND.
(-9) REFUSED
BOX NS4
BOX NS5
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF
THE CHARGE. IF THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE
THE DISCOUNT IS APPLIED.]
Page 1 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
BOX NS5
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
routing
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
ELSE IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO NS7 - MONTHCOV.
ELSE IF (EVENT TYPE = 'PM' OR 'OM') AND NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS >
1, GO TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
Code List
Routing
What was the copayment amount for the [READ EVENT ABOVE]?
TOTALCHG
NS6
BOX NS6
dollar
routing
(01) CONTINUOUS ANSWER
[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time
(-8) DON'T KNOW
health services are provided. For example, the person may pay $20 for each office visit and $10 for each drug
(-9) REFUSED
prescription.]
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
IF EVENT TYPE = 'PM' AND THE TOTAL OF NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS >
1, GO TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
How many months are covered by the charge for the period of time [since (REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND (-9) REFUSED
UP. (E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
MONTHCOV
NS7
numeric
MONCOV96
NS7
code one
NUMLINKS
NS8
numeric
How many of the times [you/(SP)] obtained [READ EVENT ABOVE] since (REFERENCE DATE/UTILDATE)
[were covered by the total charge/was there no charge/were covered by the (TOTAL CHARGE)/were covered
by the copayment/was there no copayment/were covered by the (COPAYMENT)]?
RVLINKS
INCOTHER
INCTYPE
PROVIDER_NSDATE
BOX NS6
NS7 - MONCOV96
(01) LESS THAN 1 MONTH
(-7) EMPTY
BOX NS9
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS9
numeric
How many of the (NUMBER OF VISITS) (visits to the OPD at/lab services provided by/visits to) (PROVIDER
(01) CONTINUOUS ANSWER
NAME) during the month of (EVENT MONTH) [were covered by the total charge/was there no charge/were
(-8) DON'T KNOW
covered by the (TOTAL CHARGE)/were covered by the copayment/was there no copayment/were covered by
(-9) REFUSED
the (COPAYMENT)]?
BOX NS9
BOX NS9
routing
IF (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE INSTEAD OF A TOTAL CHARGE), GO TO
BOX NS45.
ELSE GO TO NS10 - INCOTHER.
NS10
code one
[READ IF NECESSARY: Does [the total charge/TOTAL CHARGE)] cover this (medicine/item/event) only or
does it include other (medicine/item/event)s.]
(01) ONLY THIS EVENT/ITEM/MEDICINE
(02) OTHER EVENTS/ITEMS/MEDICINES
(03) CAN'T TELL
(01) BOX NS45
(02) NS12 - INCTYPE
(03) BOX NS45
NS12
code all
What else was included?
CHECK ALL THAT APPLY.
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES
BOX NS12
BOX NS12
routing
IF THE RESPONSE TO NS12 - INCTYPE INCLUDES 1/ProvDates, GO TO NS13 - PROVIDER_NSDATE.
ELSE GO TO BOX NS26.
NS9
NS13
roster
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.
IF EXISTING PROVIDER SELECTED, GO TO BOX
DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO PROV
Page 2 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
PROVNAME
NS13
verbatim
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER
THE GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
NS13-GROUPNAM
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:
GROUPNAM
NS13
verbatim
GROUP:
NSDATEUPD
NS14
code one
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?
EVENT_NSDATEDIT
NS15
roster
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
VISITYPE
VISTYPE
select one
SELECT TYPE OF VISIT TO ADD:
[When did [you/(SP)] see (PROVIDER NAME)?/When [were you/was (SP)] admitted to and discharged from
(HOSPITAL NAME)?] Please tell me all the dates [since (REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].
ENTER ALL DATES.
EVENT
NS16
verbatim
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.
(01) NO, DO NOT NEED TO ADD OR EDIT EVENT
DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE
(01) CONTINUOUS ANSWER
NS14- NSDATEUPD
(01) NS24 - EVENT_NSDATE
(02) NS16 - EVENT_NSDATEADD
(03) NS15 - EVENT_NSDATEDIT
NS14 - NSDATEUPD
(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(08) Vision (VU)
(09) Hearing (HU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(10) All other visits to Medical Provider (MP)
EVENT
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
BOX NS16A
[IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT
"REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.]
NSDATEINTRO
BOX NS16A
routing
IF AT LEAST ONE EVENT DATE ADDED AT NS16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD,
GO TO BOX NS16B.
ELSE GO TO NS14 - NSDATEUPD.
BOX NS16B
routing
GO TO BOX NS17.
NS17
no entry
Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just added.
routing
IF AT LEAST ONE EVENT ADDED AT NS16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO NS18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU' EVENT TYPE AND THE PROVIDER
SPECIALTY HAS NOT BEEN COLLECTED, GO TO NS18A - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'VU' EVENT TYPE AND THE PROVIDER
SPECIALTY HAS NOT BEEN COLLECTED, GO TO NS18B - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'HU' EVENT TYPE AND THE PROVIDER
SPECIALTY HAS NOT BEEN COLLECTED, GO TO NS18C - PROVSPEC.
ELSE GO TO BOX NS18.
BOX NS17
BOX NS17
Page 3 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
PROVSPEC
NSQ - NO STATEMENT COST SERIES
Question Type
NS18
code one
Question Text/Description
Code List
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
What kind of medical person is (PROVIDER NAME)?
(18) PARAMEDIC
(42) PHARMACIST
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY
(19) PHYSICAL THERAPIST (PT)
NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES
FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT (20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
LISTED BELOW, BUT LISTED ON SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL
(22) PSYCHOLOGIST
DOCTOR.']
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
PROVSPOS
NS18
text
OTHER MEDICAL PROVIDER (SPECIFY)
PROVSPEC
NS18A
code one
What kind of dental provider is [PROVNAME]?
PROVSPEC
NS18A1
code one
What kind of dental provider is [PROVNAME]?
PROVPOS
NS18A
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
Routing
(01)-(34), (42), (-8), (-9) BOX NS18
(91) NS18 - PROVSPOS
(01) CONTINUOUS ANSWER
BOX NS18
(01) [Continuous answer.]
BOX NS18
Page 4 of 15
2019 MCBS Community Questionnaire
Variable Name
PROVSPEC
MR Screen Name
NS18B
PROVSPEC
PROVPOS
PROVSPEC
NS18C
Question Type
code one
NS18B1
NS18B
NSQ - NO STATEMENT COST SERIES
code one
verbatim text
code one
Question Text/Description
Code List
Routing
What kind of eye care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX NS18
(16) BOX NS18
(43) BOX NS18
(91) NS18B1- PROVSPEC
(-8) BOX NS18
(-9) BOX NS18
What kind of eye care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01)-(34), (-8), (-9) BOX NS18
(91) NS18B - PROVSPOS
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX NT18
What kind of hearing care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
(02) BOX NS18
(03) BOX NS18
(44) BOX NS18
(45) BOX NS18
(91) NS18C1- PROVSPEC
(-8) BOX NS18
(-9) BOX NS18
Page 5 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
PROVSPEC
PROVPOS
HMOASSOC
HMOREFER
Question Type
NS18C1
NS18C
BOX NS18
VAPLACE
NSQ - NO STATEMENT COST SERIES
Question Text/Description
code one
Code List
What kind of hearing care provider is [PROVNAME]?
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
routing
IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', 'IU', OR 'MP' EVENT TYPE)
AND (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND
OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO
TO NS19 - VAPLACE.
ELSE GO TO BOX NS19.
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(01)-(34), (-8), (-9) BOX NS18
(21) PODIATRIST (FOOT DOCTOR)
(91) NS18C - PROVSPOS
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
BOX NS18
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS19
NS19
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?
BOX NS19
routing
GO TO BOX NS22A.
yes/no
(01) YES
(02) NO
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(-8) DON'T KNOW
(-9) REFUSED
NS20
NS21
yes/no
BOX NS22A
routing
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS22A
(02) NS21 - HMOREFER
(-8) NS21 - HMOREFER
(-9) NS21 - HMOREFER
BOX NS22A
IF TYPE OF EVENT = 'MP', GO TO BOX NS22B.
ELSE GO TO BOX NS23B.
Page 6 of 15
2019 MCBS Community Questionnaire
Variable Name
MPSDVIS
EVENT_NSDATE
RVLINKS
NSQ - NO STATEMENT COST SERIES
MR Screen Name
Question Type
Question Text/Description
BOX NS22B
routing
IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE OVERLAPS AN EXISTING IP
EVENT) OR (EVENT DATE MATCHES AN EXISTING ER OR OP EVENT) GO TO NS23 - MPSDVIS.
ELSE GO TO BOX NS23A
NS23
yes/no
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW].
Was this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED
BELOW]/any of these places]?
BOX NS23A
routing
GO TO BOX NS23B.
BOX NS23B
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER AT NS16, GO TO BOX NS22A.
ELSE GO TO NS24-EVENT_NSDATE.
NS24
check all
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
BOX NS24
routing
IF AT LEAST ONE EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY
THIS CHARGE.
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS23A
(01) CONTINUOUS ANSWER
BOX NS24
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS24A
NS24A
numeric
BOX NS24A
routing
IF ANOTHER EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
NSDATEMTCH
NS25
code one
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT
(01) BOX NS26
(02) NS13 - PROVIDER_NSDATE
(03) NS26 - EVENT_NSDATEDEL
EVENT_NSDATEDEL
NS26
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS25 - NSDATEMTCH
BOX NS26
routing
IF NS12 – INCTYPE INCLUDES 2/HHVisits, GO TO NS27 - PROVIDER_HH.
ELSE GO TO BOX NS33.
NS27
roster
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
(01) CONTINUOUS ANSWER
BOX NS28A
BOX NS28A
routing
IF (HOME HEALTH PROVIDER WAS ADDED AT NS27) OR (AN EXISTING PROVIDER WAS SELECTED AT
NS27 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO NS30 - HHEVNTTYPE.
ELSE GO TO BOX NS31B.
HHEVNTTYPE
NS30
code one
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH
PROVIDER (HOME HEALTH AIDE, HOMEMAKER, ETC.)?
(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER
BOX NS31B
NSHHINTRO
NS31
no entry
Before we continue with this statement, I would like to ask you a few questions about the home health provider I
just added.
BOX NS31A
routing
IF NS30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
BOX NS31B
routing
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO NS32 - NSHHMTCH.
NS32
no entry
BOX NS33
routing
PROVIDER_HH
NSHHMTCH
[A REPEAT VISIT MEANS THAT THE RESPONDENT HAD AT LEAST 5 VISITS TO THE PROVIDER
DURING THE CURRENT ROUND REFERENCE PERIOD.]
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.
BOX NS31A
(01) CONTINUE
(-7) EMPTY
BOX NS33
IF NS12 – INCTYPE INCLUDES 3/OMExpenses, GO TO NS34 - NSOMUPD.
ELSE GO TO BOX NS40.
Page 7 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
(01) NO, DO NOT NEED TO ADD OR EDIT OM
EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) NS37 - EVENT_NSOM
(02) NS36 - NSOMADD
(03) NS35 - EVENT_NSOMEDIT
NSOMUPD
NS34
code one
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
EVENT_NSOMEDIT
NS35
roster
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.
(01) CONTINUOUS ANSWER
(01) GLASSES/CONTACTS
(11) HEARING AID
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES
BOX NS36
(01) CONTINUOUS ANSWER
BOX NS37
NSOMADD
NS36
code one
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?
EVENT_NSOM
BOX NS36
NS37
routing
roster
BOX NS37
routing
GO TO NS34 - NSOMUPD.
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE.
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 MONTHCOV.
ELSE GO TO BOX NS38B.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?
(01) CONTINUOUS ANSWER
(-7) EMPTY
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND (-8) DON'T KNOW
(-9) REFUSED
UP. (E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
(01) LESS THAN 1 MONTH
(-7) EMPTY
MONTHCOV
NS38
numeric
MONCOV96
NS38
code one
BOX NS38A
routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
BOX NS38B
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES,
INCONTINENCE SUPPLIES OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.
NS38A
numeric
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?
BOX NS38AA
routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.
NSOMMTCH
NS39
code one
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE SHOWN BELOW?
EVENT_NSOMDEL
NS40
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
BOX NS40
routing
IF NS12 – INCTYPE INCLUDES 4/PMS, GO TO NS41 - EVENT_NSPM.
ELSE GO TO BOX NS45.
NS41
roster
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE.
BOX PM2
routing
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS
CASE, GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
NUMLINKS
EVENT_NSPM
MEDICINE_PM1
MEDICINE_PM1
code one
What is the name of the medicine?
NS38 - MONCOV96
BOX NS38A
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS38AA
(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) CONTINUOUS ANSWER
(01) BOX NS40
(02) NS34 - NSOMUPD
(03) NS40 - EVENT_NSOMDEL
NS39 - NSOMMTCH
(01) CONTINUOUS ANSWER
BOX PM2
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM,
AND QUANTITY FOR EACH.
BOX PM3
Page 8 of 15
2019 MCBS Community Questionnaire
Variable Name
NSQ - NO STATEMENT COST SERIES
MR Screen Name
Question Type
Question Text/Description
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
(01) YES
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
(02) NO
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
(03) NO BUT R CAN ANSWER QUESTIONS
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED
MEDICINE LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND
CORRECT, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Medicine Form [MCBS FORM]
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
(01) CONTINUOUS ANSWER
Page 9 of 15
2019 MCBS Community Questionnaire
NSQ - NO STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
Medicine strength unit
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-MEDID
(-9) MED-MEDID
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) BOX PM5
(20) PMCOND-PMCONDOS
(-8) BOX PM5
(-9) BOX PM5
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
OTHER (SPECIFY)
BOX PM5
routing
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD
CONTAINS ("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
TABNUM
numeric
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
TABNUM
Routing
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
Page 10 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN (01) CONTINUOUS ANSWER
IN A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PM13
PM13
PMSATHMO
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
(-8) DON'T KNOW
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
code one
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
BOX PM7
PMSATVA
numeric
PMSATHMO
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
PLAN NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-PMMORE
Page 11 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE
PMMORE
yes/no
NUMLINKS
NS42
grid
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE
BUNDLE?
NSPMMTCH
NS44
code one
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE SHOWN BELOW?
EVENT_NSPMDEL
NS45
roster
BOX NS45
routing
NSTCHGPAID
NS64
code one
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF
R ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we
haven't talked about?]
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE
BUNDLE.
IF TOTAL CHARGE OR COPAY COLLECTED GE 0, DK OR RF, GO TO NS64 - NSTCHGPAID.
ELSE GO TO BOX NS64B.
[[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
plan),] already paid any of [the charge/the total charge/the copayment amount/this (TOTAL CHARGE)]?
[IF COPAYMENT AMOUNT IS ZERO, SELECT “NO.”]
IF SP OR ANY SOURCE HAS PAID, GO TO BOX NS64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN
PAID), GO TO BOX NS78B.
ELSE GO TO BOX NS80.
CREATE SOURCE OF PAYMENT ROSTER
GO TO NS65 - NSADDSOP1.
ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
BOX NS64A
routing
BOX NS64B
routing
NSADDSOP1
NS65
yes/no
SOP_NS1
NS66
roster
ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.
NS67
grid
Who (else) paid? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.
BOX NS67HE
routing
IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT VALUES FOR THIS COST >
0.00, GO TO BOX NS67A.
ELSE GO TO NS67HE - PAYMHE.
TSOPAMT
PAYMHE
NS67HE
no entry
THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER
THAN $0.00 OR AT LEAST ONE PAYMENT AMOUNT MUST BE
'DON'T KNOW' OR 'REFUSED'.
Code List
Routing
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) NS42 - NUMLINKS
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) CONTINUOUS ANSWER
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
NS44-NSPMMTCH
(01) BOX NS45
(02) NS41 - EVENT_NSPM
(03) NS45 - EVENT_NSPMDEL
NS44 - NSPMMTCH
BOX NS64A
(01) NS67 - TSOPAMT
(02) NS66 - SOP_NS1
NS67 - TSOPAMT
BOX NS67HE
NS67HE - PAYMHE
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND
MAKE CORRECTIONS.
PLANINTRO_NS
BOX NS67A
routing
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT NS66, GO TO BOX NS67B.
ELSE GO TO BOX NS69F.
BOX NS67B
routing
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT NS66 IS A HEALTH INSURANCE PLAN, GO TO
NS67BINT - PLANINTRO_NS.
ELSE GO TO BOX NS69E.
NS67BINT
no entry
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.
BOX NS67C
Page 12 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NS69 - NSSOPCURR1
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT NS66.
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE
MANAGED CARE PLAN THAT IS CURRENT, GO TO NS68 -NSMHMOCHNG1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP DOES NOT HAVE A
MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO NS69 -NSSOPCURR1.
BOX NS67C
routing
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A
MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO NS69A -NSMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN AND SP DOES NOT HAVE A
MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO NS69B - NSSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 -COVTIME.
NSMHMOCHNG1
NSSOPCURR1
NSMPDPCHNG
NS68
NS69
NS69A
yes/no
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current
Medicare Managed Care Plan. Has this information changed?
yes/no
(01) YES
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (NS66 SOP MEDICARE MANAGED CARE PLAN (02) NO
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-8) DON'T KNOW
(-9) REFUSED
yes/no
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
Medicare Prescription Drug Care Plan.
Has this information changed?
NSSOPCURR2
NS69B
yes/no
BOX NS69A
routing
BOX NS69E
routing
BOX NS69F
routing
(01) YES
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66 SOP MEDICARE PRESCRIPTION DRUG (02) NO
(-8) DON'T KNOW
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-9) REFUSED
IF ANOTHER SOP WAS ADDED AT NS66, GO TO BOX NS67C.
ELSE GO TO BOX NS69E.
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT NS66, CREATE AN OSOP FOR EACH SOURCE OF
PAYMENT ADDED AT NS66 THAT IS AN "OTHER SOURCE OF PAYMENT" .
GO TO BOX NS69F.
AMTSCORR
NS70
NS71
code one
code one
(01) NS69B - NSSOPCURR2
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
BOX NS69A
IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (AT LEAST ONE PAYMENT ENTERED AT
NS67 = DK OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 ^= DK AND ^= RF AND ^= 0) AND
(TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT NS67 >= TOTAL CHARGE), GO TO NS71 AMTSCORR.
ELSE IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (ALL PAYMENTS ENTERED AT NS67
^= DK AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL
PAYMENTS ENTERED AT NS67 AND TOTAL CHARGE IS > $1.00), GO TO NS70 - AMTSCORR.
ELSE GO TO BOX NS77C.
There seems to be [some amount still unpaid/more payments than the charge].
AMTSCORR
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) HIMC6A - MHMORXTM
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount
[unpaid/overpaid] is $(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE [TOTAL
CHARGE/COPAYMENT], WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL
AMOUNTS AS ENTERED.
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C
Page 13 of 15
2019 MCBS Community Questionnaire
Variable Name
ENTERCOM
MR Screen Name
NS72
NSQ - NO STATEMENT COST SERIES
Question Type
no entry
Question Text/Description
Code List
[THE TOTAL OF PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT [UNPAID/OVERPAID] IS
$(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).]
Routing
BOX NS77C
USE THE BOX BELOW TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
EXPPAYBK
EXPAYOUT
BOX NS77C
routing
BOX NS77D
routing
CREATE PAYMENTS FOR AMOUNTS ENTERED AT NS67
GO TO BOX NS77D.
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO NS78 EXPPAYBK.
ELSE GO TO BOX NS80.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS78A
Do you expect anyone to pay any of this amount?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NS80 - EXPAYUNT
(02) BOX NS80
(-8) BOX NS80
(-9) BOX NS80
How much do you expect will be paid?
(01) PERCENTAGE NS80 - EXPAYPCT
(02) DOLLARS NS80 - EXPAYAMT
(-8) DON'T KNOW
(-9) REFUSED
(01) NS80 - EXPAYPCT
(02) NS80 - EXPAYAMT
(-8) BOX NS80
(-9) BOX NS80
NS78
yes/no
I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay
[you/(SP)] back any or all of that amount?
BOX NS78A
routing
IF NS78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST
COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND)), GO TO NS80 - EXPAYUNT.
ELSE GO TO BOX NS80.
BOX NS78B
routing
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS
PREVIOUS TO CURRENT ROUND), GO TO NS79 - EXPAYOUT.
ELSE GO TO BOX NS80.
NS79
yes/no
EXPAYUNT
NS80
quantity unit
EXPAYPCT
NS80
numeric
(01) CONTINUOUS ANSWER
BOX NS80
EXPAYAMT
NS80
numeric
(01) CONTINUOUS ANSWER
BOX NS80
BOX NS80
routing
IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO BOX NSL1.
GO TO BOX NSBEG
IF (CHARGE DATA WAS COLLECTED IN NS FOR THIS NS CHARGE BUNDLE) AND (NS CHARGE
BUNDLE IS LINKED TO ONLY ONE EVENT) AND (SP OR ANY OTHER SOURCE HAS PAID) AND
BOX NSL1
routing
((EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (THE TOTAL CHARGE ^=
RF) AND (PM WAS PURCHASED THROUGH AN HMO) AND (THERE ARE OTHER CURRENT ROUND
PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE THAT
WERE PURCHASED THROUGH AN HMO))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (TOTAL CHARGE ^= RF)
AND (PM WAS NOT PURCHASED THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION)
AND (THERE ARE OTHER CURRENT ROUND PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A
CURRENT ROUND CHARGE BUNDLE THAT WERE NOT PURCHASED THROUGH AN HMO OR HAD AN
UNKNOWN PURCHASE LOCATION))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'VU', 'HU', 'ER', 'OP', 'MP', 'SD',
OR 'SL' AND (THE TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP REFERRED TO
PROVIDER BY HMO FOR THIS EVENT) AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH
THE SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS REFERRED TO THE PROVIDER
BY THE HIMO THAT ARE NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'VU', 'HU', 'ER', 'OP', 'MP', 'SD',
OR 'SL' AND (THE TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP WAS NOT REFERRED
TO PROVIDER BY HMO OR REFERRAL IS UNKNOWN FOR THE EVENT) AND (THERE ARE OTHER
CURRENT ROUND EVENTS WITH THE SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS
NOT REFERRED TO PROVIDER BY HMO OR REFERRAL IS UNKNOWN FOR THE EVENT THAT ARE
NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE)),
), GO TO NSL1 - NSEVSAME.
ELSE GO TO BOX NSBEG.
Page 14 of 15
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
NSQ - NO STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
You told me earlier that [you/(SP)] had other [visits to (PROVIDER NAME)/prescribed medicine purchases].
NSEVSAME
NSL1
code one
BOX NSL2
routing
NSL3
roster
(01) YES
(02) NO
Are any other [visits to (PROVIDER NAME)/prescribed medicine purchases] the same -- where the [total charge
(-8) DON'T KNOW
was (TOTAL CHARGE TEXT)/copayment was (TOTAL CHARGE TEXT)] per (visit/purchase) and payments
(-9) REFUSED
were: [READ PAYMENTS LISTED ABOVE]?
IF EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM', GO TO NSL3 EVENT_PMSAME.
ELSE GO TO NSL5 - EVENT_VISITSAME.
Which ones are the same?
REVIEW LIST WITH RESPONDENT AND SELECT ALL PRESCRIPTION MEDICINES WHERE THE COSTS
AND PAYMENTS ARE THE SAME.
Routing
(01) BOX NSL2
(02) BOX NSBEG
(-8) BOX NSBEG
(-9) BOX NSBEG
(01) CONTINUOUS ANSWER
BOX NSL3
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NSBEG
(01) CONTINUOUS ANSWER
BOX NSL5
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NSL6
(01) YES
(02) NO
(01) ST5 - ST_CHARGEBUNDLE
(02) BOX NSEND
IF NO PRESCRIPTION MEDICINES HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT
SELECTING ANY MEDICINES.
NUMLINKS
EVENT_VISITSAME
BOX NSL3
routing
IF AT LEAST ONE PRESCRIBED MEDICINE SELECTED AT NSL3 HAS NUMBER OF PURCHASES BEING
ASKED ABOUT IN NS > 1, GO TO NSL4 - NUMLINKS.
ELSE GO TO BOX NSBEG.
NSL4
grid
How many times are the same?
ENTER THE NUMBER OF PURCHASES OF EACH MEDICINE SHOWN BELOW THAT ARE THE SAME.
NSL5
roster
Which ones are the same?
REVIEW LIST WITH THE RESPONDENT AND SELECT ALL PROVIDER EVENTS WHERE THE COST AND
PAYMENTS ARE THE SAME.
IF NO PROVIDER EVENTS HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT
SELECTING ANY EVENTS.
RVLINKS
BOX NSL5
routing
IF AT LEAST ONE EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
NSL6
numeric
How many times are the same for (EVENT)?
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE THE SAME.
BOX NSL6
routing
IF ANOTHER EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
YOU HAVE ENTERED ALL CHARGE/PAYMENT DATA FOR ALL EVENTS REPORTED.
NSTATEMENT
NS81
yes/no
BOX NSEND
routing
DO YOU HAVE ANY MSN, INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENTS THAT YOU HAVE NOT YET ENTERED?
IF INTTYPE in(C001, C004, C005), GO TO CPS.
IF INTTYPE in(C002, C006, C007, C010), GO TO MBQ.
Page 15 of 15
| File Type | application/pdf |
| Author | Shena Patel |
| File Modified | 2019-03-21 |
| File Created | 2019-03-21 |