CMS-P-0015A Other Medical Expense

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing

(01) CONTINUE

OM3-OMHRSPCH

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM4 - EVENT_OMHRSP
(02) BOX OMA1
(03) DO NOT DISPLAY.
(-8) BOX OMA1
(-9) BOX OMA1

OTHER MEDICAL EXPENSES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=ALL
Other: N/A
PLACEMENT
Administer after PMQ.

OMINTRO

OMHRSPCH

OMINTRO

OM3

routing

yes/no

Next I’m going to ask you about other medical expenses that [you/(SP)] may have had [between
(REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].

[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, replace, or pay for repairs of an amplifier for a
telephone, or similar device to help [you/(SP)] hear or speak?
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A HEARING AID OR SPEAKING DEVICE]
[DO NOT INCLUDE HEARING AID PURCHASES, REPAIRS, OR WARRENTIES AT THIS QUESTION.]

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair a hearing or speech device?
EVENT_OMHRSP

OM4

roster

OMADD

OM4AA

code one

BOX OM1BB

routing

OMSATHMO

ORTHINTRO

Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM4AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM4-EVENT_OMHRSP
(02) BOX OM1BB

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

BOX OM1BB2

(01) continuous answer
(-7) Empty

OMS5 - RENTSTIL

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) BOX OM4
(-8) BOX OM4
(-9) BOX OM4

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM4A - OMSATHMO
ELSE GO TO BOX OM1BB2.
On (EVENT DATE), did [you/(SP)] buy or repair the hearing or speech device at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?

OM4A

yes/no

BOX OM1BB2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA1.

BOX OMA1

routing

IF SP WAS STILL RENTING AT LEAST ONE ORTHOPEDIC ITEM AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS5INTR - ORTHINTRO.
ELSE GO TO OM5 - OMPRORTH.

OMS5INTR

no entry

The next questions are about orthopedic items [you were/(SP) was] renting as of (REFERENCE DATE).

[PROBE: This could include buying or repairing the hearing or speech device at a plan center; from an
audiologist, speech pathologist, or other provider that honors [your/(SP’s)] plan card; or through a place or
service that the plan referred [you/(SP)] to.]

At the time of the last interview, [you were/(SP) was] renting (ORTHOPEDIC ITEM). As of (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION), (was/were/is/are) the (ORTHOPEDIC ITEM) being rented?

RENTSTIL

OMS5

code one

[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]

Page 1 of 10

2019 MCBS Community Questionnaire

Variable Name

OMPRORTH

MR Screen Name

OM5

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

yes/no

SHOW CARD OM1
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
(01) YES
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(02) NO
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, repair or rent (other) orthopedic
(03) INDICATED YES BY DATAPREP
items, such as any of those listed on this card?
(-8) Don't Know
(-9) Refused
[Orthopedic items include crutches, canes, wheelchairs, walkers, corrective shoes or inserts, support stockings,
and braces or supports.]

Routing

(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) DO NOT DISPLAY.
(-8) OM9 - OMPRDIAB
(-9) OM9 - OMPRDIAB

(01) OM7 - EVENT_OMORTH
(02) OM7 - EVENT_OMORTH
(03) OM7 - EVENT_OMORTH
(04) OM6A - RENTPROB
(05) OM6A - RENTPROB
(06) OM6A - RENTPROB
(07) OM7 - EVENT_OMORTH
(91) OM6 - EVOSTEXT

ORTHTYPE

OM6

code one

What was the item?

(01) BRACES/SUPPORTS
(02) CANE
(03) CORRECTIVE SHOES/INSERTS
(04) CRUTCHES
(05) WALKER
(06) WHEELCHAIR/CART
(07) STOCKINGS
(91) OTHER

EVOSTEXT

OM6

verbatim text

OTHER (SPECIFY)

(01) continuous answer

OM6A - RENTPROB

(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND
RENTED EQUIPMENT
(-8) Don't Know
(-9) Refused

(01) OM7 - EVENT_OMORTH
(02) OM7A - EVENT_OMORTHRENT
(03) DO NOT DISPLAY.
(-8) OM7 - EVENT_OMORTH
(-9) OM7 - EVENT_OMORTH

Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did [you/(SP)] rent (it/them)?
RENTPROB

OM6A

EVENT_OMORTH

OM7

OMADD

OM7AAA

BOX OM1CC

OMSATHMO

EVENT_OMORTHRENT

OM7AA

OM7A

code one

roster

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM
WITHIN THE SAME ROUND, SELECT "RENT."]

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

routing

yes/no

yes/no

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE

OM7AAA-OMADD

(01) OM7-EVENT_OMORTH
(02) BOX OM1CC

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM7AA - OMSATHMO
ELSE GO TO BOX OM1EE1.
On (EVENT DATE), did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?

(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the (ORTHOPEDIC ITEM) at a plan center; at a place or store (-9) Refused
that honors [your/(SP's)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
ENTER ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (ORTHOPEDIC ITEM).
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT
ENTER A SEPARATE RENTAL EVENT FOR EACH MONTH.]

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM8- MOREORTH

OM7B - RENTSTIL

[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
RENTSTIL

OM7B

yes/no

[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?

EVENDMM

OM7C

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?

EVENDDD

OM7C

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?

EVENDYY

OM7C

BOX OM3A

date

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
IF SP IS NOT DECEASED, GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.

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

(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1EE1
(-9) BOX OM1EE1

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM7C - EVENDDD

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM7C - EVENDYY

DD:
(01) continuous answer
(-8) Don't Know
(-9) Refused

BOX OM3A

YYYY:

Page 2 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing
(01) BOX OM1EE
(02) BOX OM1EE
(03) OM7CCVB - REN2BVB
(-8) BOX OM1EE
(-9) BOX OM1EE

RENT2BUY

OM7CC

code one

You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is this because (you/he/she) no longer
(have/has) that item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM7CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (ORTHOPEDIC ITEM).
RECORD VERBATIM.

(01) continuous answer

OMADD

OM7CC1

code one

BOX OM1EE

routing

OMSATHMO

MOREORTH

OMPRDIAB

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

Did [you/(SP)] rent the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?

(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include renting the (ORTHOPEDIC ITEM) at a plan center; at a place or store that honors
(-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP]] to.]

yes/no

BOX OM1EE1

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.

BOX OM4

routing

IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS5 - RENTSTIL
ELSE GO TO OM8 - MOREORTH.

yes/no

In addition to the orthopedic item(s) you just told me about, did [you/(SP)] buy, repair, or rent any other
orthopedic items [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].?

OM9

yes/no

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

SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
(01) YES
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy diabetic equipment or supplies, such as those listed (02) NO
(03) INDICATED YES BY DATAPREP
on this card?
(-8) Don't Know
(-9) Refused
[Diabetic equipment or supplies include syringes, test paper, test strips, and blood monitoring kits.]
[DO NOT INCLUDE INSULIN.]
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy diabetic equipment or supplies? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

OM10

roster

OMADD

OM10AA

code one

BOX OM1FF

routing

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM10A-OMSATHMO
ELSE GO TO BOX OM1FF2.

OM10A

yes/no

On (EVENT DATE), did [you/(SP)] buy the diabetic equipment or supplies at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying the diabetic equipment or supplies at a plan center; at a place or store that (-9) Refused
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]

BOX OM1FF2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.

yes/no

[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] use any ambulance or rescue squad service?

OMPRAMBL

OM11

(01) OM7A-EVENT_OMORTHRENT
(02) BOX OM1EE

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

BOX OM1EE1

(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) OM9 - OMPRDIAB
(04) OM9 - OMPRDIAB

(01) OM10 - EVENT_OMDIAB
(02) OM11 - OMPRAMBL
(03) DO NOT DISPLAY.
(-8) OM11 - OMPRAMBL
(-9) OM11 - OMPRAMBL

(01) continuous answer
(-8) Don't Know
(-9) Refused

EVENT_OMDIAB

OMSATHMO

OM7CC-OMADD

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM7D - OMSATHMO.
ELSE GO TO BOX OM1EE1.

OM7D

OM8

(01) ADD ANOTHER
(02) ALL DONE

BOX OM1EE

MM:
DD:
YYYY:

OM10AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM10-EVENT_OMDIAB
(02) BOX OM1FF

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

BOX OM1FF2

(01) OM12 - EVENT_OMAMBL
(02) OM13 - OMPRPROS
(03) DO NOT DISPLAY.
(-8) OM13 - OMPRPROS
(-9) OM13 - OMPRPROS

Page 3 of 10

2019 MCBS Community Questionnaire

Variable Name

EVENT_OMAMBL

OMADD

MR Screen Name

OM12

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing

roster

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] use an ambulance? Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE
OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM12AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM12-EVENT_OMAMBL
(02) BOX OM1GG

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

BOX OM1GG2

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM14 - EVENT_OMPROS
(02) BOX OMA4
(03) DO NOT DISPLAY.
(-8) BOX OMA4
(-9) BOX OMA4

OM12AA

code one

BOX OM1GG

routing

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM12A - OMSATHMO
Was the ambulance on (EVENT DATE) provided by or approved by [READ MANAGED CARE PLAN
NAME(S) BELOW]?

OMSATHMO

OMPRPROS

OM12A

yes/no

BOX OM1GG2

routing

OM13

yes/no

[PROBE: This could mean that the ambulance was sent by the plan, or that [you/(SP)] or someone for
[you/(SP)] contacted the plan for them to authorize or approve the use of the ambulance. This approval could
have come after the use of the ambulance.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.
SHOW CARD OM3
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy or pay for repairs of any prostheses, such as those
on the card?
[Prostheses include artificial leg or arm, mastectomy prosthesis, and artificial or glass eye.]

EVENT_OMPROS

OM14

roster

OMADD

OM14AA

code one

BOX OM1HH

routing

OMSATHMO

OXGNINTRO

OM14A

yes/no

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the prosthesis? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM14A-OMSATHMO
ELSE GO TO BOX OM1HH2.

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM14AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM14-EVENT_OMPROS
(02) BOX OM1HH

On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?

(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the prosthesis at a plan center; at a place or store that honors (-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]

BOX OM1HH2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA4.

BOX OMA4

routing

IF SP WAS STILL RENTING OXYGEN-RELATED EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS19INTR - OXGNINTRO.
ELSE GO TO OM19 - OMPROXGN.

OMS19INTR

no entry

The next questions are about oxygen-related equipment [you were/(SP) was] renting as of (REFERENCE
DATE).

BOX OM1HH2

OMS19 - RENTSTIL

At the time of the last interview, [you were/(SP) was] renting oxygen-related equipment. As of [today/(DATE OF
DEATH)/(DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (is/was) the oxygen-related equipment being
rented?

RENTSTIL

OMS19

code one

[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM9
(-8) BOX OM9
(-9) BOX OM9

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OXYGEN/SUPPLIES
(02) OXYGEN-RELATED EQUIPMENT

(01) OM19A - OXGNTYPE
(02) BOX OMA11
(03) DO NOT DISPLAY.
(-8) BOX OMA11
(-9) BOX OMA11
(01) OM20 - EVENT_OMOXGN
(02) OM19B - RENTPROB

[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]

OMPROXGN

OM19

yes/no

(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any (other) expenses for
oxygen or supplies or oxygen-related equipment?

OXGNTYPE

OM19A

code one

What was that?

Page 4 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM
RENTED EQUIPMENT
WITHIN THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
(01) continuous answer
SELECT OR ADD ALL DATES AT THIS ROSTER.
(-8) Don't Know
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygen-related equipment)]? Please tell me the dates (-9) Refused
of each purchase [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
MM:
INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM20AA - OMSATHMO
ELSE GO TO BOX OM7.
Did [you/(SP)] buy or repair the oxygen-related equipment, or did [you/(SP)] rent it?

RENTPROB

OM19B

code one

EVENT_OMOXGN

OM20

roster

OMADD

OM20AAA

code one

BOX OM1II

routing

OMSATHMO

OM20AA

yes/no

On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN ITEM) 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 buying or repairing the (OXYGEN ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]

BOX OM7

EVENT_OMOXGNRENT

OM20A

routing

roster

Routing
(01) OM20 - EVENT_OMOXGN
(02) OM20A - EVENT_OMOXGNRENT
(03) OM20 - EVENT_OMOXGN
(-8) OM20 - EVENT_OMOXGN
(-9) OM20 - EVENT_OMOXGN

OM20AAA-OMADD

(01) OM20-EVENT_OMOXGN
(02) BOX OM1II

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

BOX OM7

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM20B - RENTSTIL

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM1KK1
(-8) BOX OM1KK1
(-9) BOX OM1KK1

IF OM19B - RENTPROB = 3/BoughtAndRented, GO TO OM20A - EVENT_OMOXGNRENT.
ELSE GO TO BOX OM1KK1.

SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the oxygen-related equipment.
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT
ENTER A SEPARATE RENTAL EVENT FOR EACH MONTH.]

[Are you/Is (SP)/Was (SP)] still renting the oxygen-related equipment?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
RENTSTIL

OM20B

yes/no

[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]

What was the last date the equipment was rented?
EVENDMM

OM20C

date

EVENDDD

OM20C

date

EVENDYY

OM20C

date

BOX OM8A

routing

(01) continuous answer
(02) Don't Know
(03) Refused

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
MM:
THE RENTAL PERIOD.]
DD:
YYYY:
What was the last date the equipment was rented?
(01) continuous answer
(02) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
(03) Refused
THE RENTAL PERIOD.]
What was the last date the equipment was rented?
(01) continuous answer
(02) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
(03) Refused
THE RENTAL PERIOD.]

OM20C - EVENDDD

OM20C - EVENDYY

BOX OM8A

IF SP IS NOT DECEASED, GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.

RENT2BUY

OM20CC

code one

You said [you/(SP)] stopped renting the oxygen-related equipment. Is this because (you/he/she) no longer
(have/has) the equipment or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM20CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE OXYGEN-RELATED EQUIPMENT.
RECORD VERBATIM.

(01) continuous answer

OMADD

OM20CC1

code one

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX OM1KK
(02) BOX OM1KK
(03) OM20CCVB - REN2BVB
(04) BOX OM1KK
(05) BOX OM1KK

OM20CC1-OMADD

(01) OM20A-EVENT_OMOXGNRENT
(02) BOX OM1KK

Page 5 of 10

2019 MCBS Community Questionnaire

Variable Name

OMSATHMO

MOREOXGN

KDNYINTRO

OMQ - OTHER MEDICAL EXPENSES

MR Screen Name

Question Type

Question Text/Description

BOX OM1KK

routing

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM20D1 - OMSATHMO.
ELSE GO TO BOX OM1KK1.

OM20D1

yes/no

Did [you/(SP)] rent the oxygen equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
(01) YES
service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include renting the oxygen equipment at a plan center; at a place or store that honors
(-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]

BOX OM1KK1

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM9.

BOX OM9

routing

IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS19_IN - NAVIGATOR.
ELSE GO TO BOX OM10.

BOX OM10

routing

IF OM20D HAS NOT BEEN ASKED, GO TO OM20D - MOREOXGN.
ELSE GO TO BOX OMA11.

OM20D

yes/no

In addition to the [(oxygen or supplies)/(oxygen-related equipment)] that you just told me about, did [you/(SP)]
[(buy oxygen or supplies)/(have any expenses for oxygen-related equipment)]?

BOX OM11

routing

BOXOMA11

routing

OMS21INTR

no entry

IF OM19A - OXYGTYPE = 1/Supplies, SET NEXT OXYGEN TYPE TO EQUIPMENT AND GO TO OM19B RENTPROB.
ELSE SET NEXT OXYGEN TYPE TO SUPPLIES AND GO TO OM20 - EVENT_OMOXGN.
IF SP WAS RENTING AT LEAST ONE KIDNEY DIALYSIS EQUIPMENT AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS21INTR - KDNYINTRO.
ELSE GO TO OM21 - OMPRKDNY.

Code List

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

The next questions are about kidney dialysis equipment [you were/(SP) was] renting as of (REFERENCE
DATE).

Routing

BOX OM1KK1

(01) BOX OM11
(02) BOX OMA11
(-8) BOX OMA11
(-9) BOX OMA11

OMS21 - RENTSTIL

At the time of the last interview, [you were/(SP) was] renting equipment for kidney dialysis. As of (today/DATE
OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)], (is/was) the equipment being rented?

RENTSTIL

OMS21

code one

[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1NN
(02) OM22C - EVENDMM
(03) BOX OM16
(-8) BOX OM16
(-9) BOX OM16

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM21A - KDNYTYPE
(02) BOX OMA18
(03) DO NOT DISPLAY.
(-8) BOX OMA18
(-9) BOX OMA18

(01) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND
RENTED EQUIPMENT
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused

(01) OM22 - EVENT_OMKDNY
(02) OM21B - RENTPROB

MM:
DD:
YYYY:

OM22AAA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM22-EVENT_OMKDNY
(02) BOX OM1LL

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

BOX OM1NN1

[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]

OMPRKDNY

OM21

yes/no

(Other than what we already talked about), [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy any (other) kidney dialysis
supplies or buy, rent, or repair any related equipment?

KDNYTYPE

OM21A

code one

What was that?
Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)] rent it?

RENTPROB

OM21B

code one

EVENT_OMKDNY

OM22

roster

OMADD

OM22AAA

code one

BOX OM1LL

routing

OMSATHMO

OM22AA

yes/no

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM
WITHIN THE SAME ROUND, SELECT "RENT."]
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or repair kidney dialysis equipment)? Please
tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM22AA - OMSATHMO
ELSE GO TO BOX OM1NN1.
On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY ITEM) 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 buying (or repairing) the (KIDNEY ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]

(01) OM22 - EVENT_OMKDNY
(02) OM22A - EVENT_OMKDNYRENT
(03) DO NOT DISPLAY.
(-8) OM22 - EVENT_OMKDNY
(-9) OM22 - EVENT_OMKDNY

Page 6 of 10

2019 MCBS Community Questionnaire

Variable Name

EVENT_OMKDNYRENT

MR Screen Name

OM22A

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

roster

SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the kidney dialysis equipment.
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT
ENTER A SEPARATE RENTAL EVENT FOR EACH MONTH.]

Code List

Routing

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM22B - RENTSTIL

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1NN
(02) OM22C - EVENDYY
(03) DO NOT DISPLAY.
(-8) BOX OM1NN1
(-9) BOX OM1NN1

[Are you/Is (SP)/Was (SP)] still renting the kidney dialysis equipment?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
RENTSTIL

OM22B

yes/no

[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]

What was the last date the equipment was rented?
EVENDMM

OM22C

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the equipment was rented?

EVENDDD

OM22C

date

EVENDYY

OM22C

date

BOX OM15A

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the equipment was rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
IF SP IS NOT DECEASED, GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) continuous answer
(-8) Don't Know
(-9) Refused

OM22C - EVENDYY

(01) continuous answer
(-8) Don't Know
(-9) Refused

BOX OM15A

RENT2BUY

OM22CC

code one

You said [you/(SP)] stopped renting the dialysis equipment. Is this because (you/he/she) no longer (have/has)
the equipment or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM22CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS EQUIPMENT.
RECORD VERBATIM.

(01) continuous answer

OMADD

OMSATHMO

MOREKDNY

OTHRINTRO

OM22CC1

code one

BOX OM1NN

routing

OM22D1

yes/no

BOX OM1NN1

routing

BOX OM16

routing

BOX OM17

routing

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM22D1 - OMSATHMO.
ELSE GO TO BOX OM1NN1.
Did [you/(SP)] rent the kidney dialysis equipment 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 renting the kidney dialysis equipment at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM16.
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS21 - RENTSTIL
ELSE GO TO BOX OM17.
IF OM22D HAS NOT BEEN ASKED, GO TO OM22D - MOREKDNY.
ELSE GO TO BOX OMA18.

OM22D

yes/no

In addition to the [(kidney dialysis supplies)/(kidney dialysis equipment)] that you just told me about, did
[you/(SP)] [(obtain any kidney dialysis equipment)/(buy any kidney dialysis supplies)]?

BOX OM18

routing

IF OM21A - KDNYTYPE = 1/Supplies, SET NEXT KIDNEY TYPE TO EQUIPMENT AND GO TO OM21B RENTPROB.
ELSE SET NEXT KIDNEY TYPE TO SUPPLIES AND GO TO OM22 - EVENT_OMKDNY.

BOX OMA18

routing

IF SP WAS STILL RENTING AT LEAST ONE OTHER MEDICAL EQUIPMENT AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO OMS23INTR - OTHRINTRO.
ELSE GO TO OM23 - OMPROTHR.

OMS23INTR

no entry

The next questions are about other medical equipment [you were/(SP) was] renting as of (REFERENCE
DATE).

OM22C - EVENDDD

(01) BOX OM1NN
(02) BOX OM1NN
(03) OM22CCVB - REN2BVB
(-8) BOX OM1NN
(-9) BOX OM1NN
BOX OM1NN
OM22CC1-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM22A-EVENT_OMKDNYRENT
(02) BOX OM1NN

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

BOX OM1NN1

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

(01) BOX OM18
(02) BOX OMA18
(-8) BOX OMA18
(-9) BOX OMA18

OMS23 - RENTSTIL

Page 7 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) BOX OM23
(-8) BOX OM23
(-9) BOX OM23

At the time of the last interview, [you were/(SP) was] renting (OTHER MEDICAL EXPENSE ITEM). As of
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD), (is/was) the (OTHER MEDICAL
EXPENSE ITEM) being rented?

RENTSTIL

OMS23

code one

[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]

OMPROTHR

OM23

yes/no

SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, rent, or repair any other medical equipment or buy
(02) NO
any other medical supplies besides what we have talked about?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Other medical equipment and supplies include portable commodes or raised toilet seats, portable tub seats,
(-9) Refused
special chairs or cushions, hospital beds, ostomy supplies, incontenence supplies such as Depends, Serenity
or other brands of disposable undergarments, pads or briefs, bandages, dressings, tape supplies, pulmonary
equipment such as a Nebulizer or CPAP, and blood pressure equipment such as cuffs or monitors, etc.]

OTHRTYPE

OM24

code one

What kind of equipment was the item?

EVOSTEXT

OM24

verbatim text

OTHER (SPECIFY)
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM), or did [you/(SP)] rent it?

RENTPROB

GETNUM

EVENT_OMOTHR

OMADD

OMSATHMO

OM24A

code one

BOX OM18B

routing

IF NOT ADMINISTERING ST AND NOT ADMINISTERING NS, GO TO OM25 - GETNUM.
ELSE GO TO BOX OM1QQ1.

numeric

THIS ITEM AND NUMBER OF PURCHASES HAS BEEN ENTERED ALREADY FOR THIS ROUND.
PLEASE CORRECT THE NUMBER OF TIMES TO BE THE TOTAL NUMBER OF TIMES PURCHASED
SINCE (REFERENCE DATE/UTILDATE).
How many times [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] [[have you/has (SP)] bought or obtained/did (SP)
buy or obtain] (OTHER MEDICAL EXPENSE ITEM)?

roster

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM)? Please tell me all the dates
[since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]

OM25

OM26

OM26AAA

code one

BOX OM1OO

routing

OM26AA

yes/no

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM
WITHIN THE SAME ROUND, SELECT "RENT."]

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) PORTABLE COMMODE OR RAISED TOILET
SEAT
(02) PORTABLE TUB SEAT
(03) SPECIAL CHAIR/CUSHION/MATTRESS
(04) HOSPITAL BED/BED SIDES
(05) OSTOMY SUPPLIES
(06) INCONTINENCE SUPPLIES (I.E. DEPENDS,
SERENITY DISPOSABLE DIAPERS OR PADS)
(07) BANDAGES, DRESSINGS, TAPE SUPPLIES
(08) PULMONARY EQUIPMENT
(09) BLOOD PRESSURE EQUIPMENT
(91) OTHER
(01) continuous answer
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND
RENTED EQUIPMENT
(-8) Don't Know
(-9) Refused

(01) continuous answer
(-8) Don't Know
(-9) Refused

(01) OM24 - OTHRTYPE
(02) BOX OM24
(03) DO NOT DISPLAY.
(04) BOX OM24
(05) BOX OM24

(01) OM24A - RENTPROB
(02) OM24A - RENTPROB
(03) OM24A - RENTPROB
(04) OM24A - RENTPROB
(05) BOX OM18B
(06) BOX OM18B
(07) BOX OM18B
(08) OM24A - RENTPROB
(09) OM26 - EVENT_OMOTHR
(91) OM24 - EVOSTEXT
OM24A - RENTPROB
(01) OM26 - EVENT_OMOTHR
(02) OM26A - EVENT_OMOTHRRENT
(03) DO NOT DISPLAY.
(-8) OM26 - EVENT_OMOTHR
(-9) OM26 - EVENT_OMOTHR

BOX OM1QQ1

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM27AAA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM26-EVENT_OMOTHR
(02) BOX OM1OO

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

BOX OM21

IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM26AA - OMSATHMO
ELSE GO TO BOX OM1QQ1.
On (EVENT DATE), did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM) 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 buying or repairing the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at
a place or store that honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)]
to.]

Page 8 of 10

2019 MCBS Community Questionnaire

Variable Name

EVENT_OMOTHRRENT

MR Screen Name

OM26A

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

roster

ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM).
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT
ENTER A SEPARATE RENTAL EVENT FOR EACH MONTH.]

Code List

Routing

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM26A1 - RENTSTIL

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1QQ1
(-9) BOX OM1QQ1

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM26B - EVENDDD

MM:
(01) continuous answer
(-8) Don't Know
(-9) Refused

OM26B - EVENDYY

DD:
(01) continuous answer
(-8) Don't Know
(-9) Refused

BOX OM22A

[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE ITEM)?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT
"NO."]
RENTSTIL

OM26A1

yes/no

[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT
"YES" AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF
THE ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?

EVENDMM

OM26B

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?

EVENDDD

OM26B

date

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?

EVENDYY

OM26B

BOX OM22A

date

routing

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
IF SP IS NOT DECEASED, GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.

YYYY:

RENT2BUY

OM26BB

code one

You said [you/(SP)] stopped renting the (OTHER MEDICAL EXPENSE ITEM). Is this because (you/he/she)
no longer (have/has) the item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM26BBVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER MEDICAL EXPENSE ITEM).
RECORD VERBATIM.

(01) continuous answer

OMADD

OMSATHMO

OM26BB1

code one

BOX OM1QQ

routing

OM26C

yes/no

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM26C - OMSATHMO.
ELSE GO TO BOX OM1QQ1.
Did [you/(SP)] rent the (OTHER MEDICAL EXPENSE ITEM) 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 renting the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a place or
store that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]

MOREOTHR

ALTRINTRO

BOX OM1QQ1

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM23.

BOX OM23

routing

IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS23 - RENTSTIL
ELSE GO TO OM27 - MOREOTHR.

OM27

yes/no

In addition to the medical equipment you just told me about, did [you/(SP)] buy, rent, or repair any other
medical equipment [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?

BOX OM24

routing

IF SP HAD AT LEAST ONE ALTERATION THAT WAS NOT COMPLETE AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO OMS28INTR - ALTRINTRO.
ELSE GO TO OM28 - OMPRALTR.

OMS28INTR

no entry

The next questions are about an alteration [you were/(SP) was] making as of (REFERENCE DATE).
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).

EVENDMM

OMS28

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?

(01) BOX OM1QQ
(02) BOX OM1QQ
(03) OM26BBVB - REN2BVB
(-8) BOX OM1QQ
(-9) BOX OM1QQ
BOX OM1QQ
OM26BB1-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM26A-EVENT_OMOTHRRENT
(02) BOX OM1QQ

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

BOX OM1QQ1

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

(01) OM24 - OTHRTYPE
(02) BOX OM24
(-8) BOX OM24
(-9) BOX OM24

OMS28 - EVENDMM

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMS28 - EVENDDD

Page 9 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ - OTHER MEDICAL EXPENSES

Question Type

Question Text/Description
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).

EVENDDD

OMS28

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).

EVENDYY

OMNOTDONE

OMPRALTR

OMS28

date

OMS28

code one

OM28

yes/no

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?

SHOW CARD OM5
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] make any alterations or modify the inside or outside of
(your/his/her) home or car because of some illness or injury? This card lists some examples.
[Alterations include ramps, handrails, elevator or incline chair, tub seats, tub handrails, and any car alterations.]

Code List

Routing

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMS28 -EVENDYY

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OMS28 - OMNOTDONE

(01) ALTERATION NOT YET COMPLETED
(-7) Empty

OM28 - OMPRALTR

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) OM29 - ALTRTYPE
(02) BOX OM26
(03) DO NOT DISPLAY.
(-8) BOX OM26
(-9) BOX OM26

(01) OM30 - EVBEGMM
(02) OM30 - EVBEGMM
(03) OM30 - EVBEGMM
(04) OM30 - EVBEGMM
(05) OM30 - EVBEGMM
(06) OM30 - EVBEGMM
(91) OM29 - EVOSTEXT
OM30 - EVENDMM

ALTRTYPE

OM29

code one

What was the alteration?

(01) ELEVATOR OR INCLINE CHAIR
(02) HANDRAILS (OTHER THAN TUB)
(03) RAMPS
(04) TUB HANDRAILS
(05) TUB SEAT
(06) ANY CAR ALTERATION
(91) OTHER

EVOSTEXT

OM29

verbatim text

OTHER (SPECIFY)

(01) continuous answer

EVENDMM

EVENDDD

OM30

OM30

date

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] was this alteration completed?

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] was this alteration completed?

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
MM:
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OM30 - EVENDDD

OM30 - EVENDDD

DD:

EVENDYY

OM30

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] was this alteration completed?

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OM30 - OMNOTDONE

YYYY:

OMNOTDONE

OM30

OMADD

OM30B

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.

OM31

yes/no

In addition to the alteration(s) you just told me about, did [you/(SP)] make any other alterations because of
some illness or injury [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?

BOX OM26

routing

GO TO STQ.

BOX OM25A

MOREALTR

(01) ALTERATION NOT YET COMPLETED
(-7) Empty

code one

OM30B-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM30-EVBEGMM
(02) BOX OM25A

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

(01) OM29 - ALTRTYPE
(02) BOX OM26
(-8) BOX OM26
(-9) BOX OM26

Page 10 of 10