CMS-P-0015A Health_Insurance

2018 MCBS Facility Instrument

Variable Name

IN-Health Insurance

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE INTERVIEW)
(04) FINAL REFUSAL

(01) IN1PRE2 - IN1PR2CT
(02) INEND - INENDCT
(03) IN1PRE2 - IN1PR2CT
(04) INEND - INENDCT

(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL

(01) BOX IN3
(02) INEND - INENDCT
(03) INEND - INENDCT

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

(00) IN13A - ICAREPTD
(01) IN5A-MCAIDHMO
(02) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD
(00) IN18 - IGAPCOV
(01) IIN5A-MCAIDHMO
(02) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV
(00) BOX IN3A
(01) BOX IN3A
(-8) BOX IN3A
(-9) BOX IN3A

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

(00) IN13A - ICAREPTD
(01) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD

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

(00) IN18 - IGAPCOV
(01) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

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

(00) IN 20-ILTCCOV
(01) IN19-IGAPNAME
(-8) IN20-ILTCCOV
(-9) IN20-ILTCCOV

(01) Continuous Answer

(01) IN19 - IGAPNAM2

(01) Continuous Answer

(01) IN19 - IGAPNAM3

(01) Continuous Answer

(01) IN19 - IGAPNAM4

HEALTH INSURANCE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
SEASON
If SAMPLE_TYPE= CFR, then SEASON=FALL
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL

BOX INBEG

CONREFFN

INCONREF

routing

code one

PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
IF INDISP = 1/ConsentRequired OR INDISP = 4/InitialRefusal, GO TO INCONREF - CONREFFN.
ELSE GO TO IN1PRE2 - IN1PR2CT.

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.

The following questions are about (SP's) health insurance.
IN1PR2CT

IN1PRE2

BOX IN3

code one

routing

IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.
IF THIS IS A BASELINE INTERVIEW AND MEDICAID NOT COLLECTED OR INMCDFLG = 1/Indicated, GO TO
IN1 - ICAIDECO.
ELSE IF THIS IS A BASELINE INTERVIEW AND MEDICAID COLLECTED AND INMCDFLG = 0/NotIndicated, GO
TO IN5A - MCAIDHMO.
ELSE IF THIS IS NOT A BASELINE INTERVIEW AND MEDICAID NOT COLLECTED OR INMCDFLG =
1/Indicated, GO TO IN1A - ICAIDNOW.
ELSE GO TO IN18 - IGAPCOV.

ICAIDECO

IN1

yes/no

Has (SP) ever been covered by [READ NAME(S) FROM ABOVE]?

ICAIDNOW

IN1A

yes/no

(The last time we asked about (SP's) health insurance, (he/she) was not covered by [READ NAME(S) FROM
ABOVE].) Is (SP) now covered by [READ NAME(S) FROM ABOVE]?

MCAIDHMO

IN5A

yes/no

Some states now use HMOs (health maintenance organizations) to provide some or all health care for Medicaid
beneficiaries. (Is/Was) (SP) enrolled in a [READ NAME(S) FROM ABOVE] HMO?

BOX IN3A

routing

IF THIS IS A BASELINE INTERVIEW, GO TO IN6 - ICDCRCOV.
ELSE GO TO IN18 - IGAPCOV.

yes/no

Was (SP) covered by [READ NAME(S) FROM ABOVE] [on September 1, (CURRENT YEAR)?/when (he/she) was
admitted on (FAD/RAD)?]

ICDCRCOV

IN6

Our records show that (SP) is covered by Medicare. I'd like to ask some questions about (his/her) Medicare
coverage.
ICAREPTD

IN13A

yes/no

Was (SP) covered by Part D of Medicare on [September 1, (CURRENT YEAR)/(FAD/RAD)]?
PRESS F1 FOR PART D DEFINITIONS.

IGAPCOV

IN18

yes/no

On [September 1, (CURRENT YEAR)/(FAD/RAD)], was (SP) covered by private health insurance that pays for
some or all charges for inpatient and outpatient hospital and physician services and/or supplements Medicare
(Medigap policy)?
What is the name of the insurance company?

IGAPNAME

IN19

Text

IGAPNAM2

IN19

Text

IGAPNAM3

IN19

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

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2018 MCBS Facility Instrument

Variable Name

IN-Health Insurance

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continuous Answer

(01) IN19 - IGAPNAM5

(01) Continuous Answer

(01) IN20 - ILTCCOV

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

(00) IN22 - ICHACOV
(01) IN21 - ILTCNAME
(-8) IN22 - ICHACOV
(-9) IN22 - ICHACOV

(01) Continuous Answer

(01) IN21 - ILTCNAM2

(01) Continuous Answer

(01) IN21 - ILTCNAM3

(01) Continuous Answer

(01) IN21 - ILTCNAM4

(01) Continuous Answer

(01) IN21 - ILTCNAM5

(01) Continuous Answer

(01) IN22 - ICHACOV

What is the name of the insurance company?
IGAPNAM4

IN19

Text

IGAPNAM5

IN19

Text

ILTCCOV

IN20

yes/no

ILTCNAME

IN21

Text

ILTCNAM2

IN21

Text

ILTCNAM3

IN21

Text

ILTCNAM4

IN21

Text

ILTCNAM5

IN21

Text

ICHACOV

IN22

Yes/No

IDVACOV

IN23

Yes/No

IPUBCOV

IN24

Yes/No

IPUBNAME

IN25

Text

BOX IN9

routing

IMARSTAT

INBQ13A

code one

INENDCT

INEND

code one

BOX INEND

routing

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
On [September 1, (CURRENT YEAR)/(FAD/RAD)], was (SP) covered by private health insurance that pays for
some or all charges for more than 100 days of nursing home care, that is, a long-term care policy?
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
Was (SP) covered by either TRICARE or CHAMPVA for hospital or physician care on [September 1, (CURRENT
YEAR)/(FAD/RAD)]?

(00) NO
(01) YES
(-8) Don't Know
PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.
(-9) Refused
(00) NO
Was (SP) covered by any other Department of Veterans Affairs (VA) program or contract on [September 1,
(01) YES
(CURRENT YEAR)/(FAD/RAD)]?
(-8) Don't Know
(-9) Refused
(00) NO
(Besides [READ NAME(S) FROM ABOVE], was/Was) (SP) covered by any other public assistance health insurance (01) YES
program on [September 1, (CURRENT YEAR)/(FAD/RAD)]?
(-8) Don't Know
(-9) Refused
What (is/was) the name of the public assistance health insurance program?
(01) Continuous Answer
IF SP ALIVE, AND A CFR, FFC, OR FCF AND IS A FALL ROUND, GO TO INBQ13A - IMARSTAT.
ELSE GO TO INEND - INENDCT.
(01)NEVER MARRIED
(02) MARRIED
(03) WIDOWED
Is (SP) currently married, widowed, divorced, separated, or never married?
(04) DIVORCED
(05) SEPARATED
(-8) Don't Know
(-9) Refused
(YOU HAVE COMPLETED THE HEALTH INSURANCE SECTION FOR THIS SP.)
(01) CONTINUE
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
GO TO NAVIGATOR

(00) IN23 - IDVACOV
(01) IN23 - IDVACOV
(-8) IN23 - IDVACOV
(-9) IN23 - IDVACOV
(00) IN24 - IPUBCOV
(01) IN24 - IPUBCOV
(-8) IN24 - IPUBCOV
(-9) IN24 - IPUBCOV
(00) BOX IN9
(01) IN25 - IPUBNAME
(-8) BOX IN9
(-9) BOX IN9
(01) BOX IN9
(01) INEND - INENDCT
(02) INEND - INENDCT
(03) INEND - INENDCT
(04) INEND - INENDCT
(05) INEND - INENDCT
(-8) INEND - INENDCT
(-9) INEND - INENDCT
(01) BOX INEND

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