Form CMS-P-0015A Cost Payment Summary

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

CPS-COST PAYMENT SUMMARY

Question Type

Question Text/Description

Code List

Routing

COST PAYMENT SUMMARY SPECIFICATIONS
CRITERIA
INTTYPE=C001, C004, C005
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: Prior round events flagged for CPS
PLACEMENT
Administer after NSQ.

CPS REASON HAS ALREADY BEEN ASSIGNED TO ALL CHARGE BUNDLES ENTERED IN THE PAST 2 ROUNDS THAT
HAVE MISSING CHARGE DATA.
CPS REASON 1 = NO STATEMENT CHARGE BUNDLE, SP EXPECTED TO RECEIVE A STATEMENT
CPS REASON 2 = NO STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 3 = STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 4 = NO STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN TOTAL CHARGE. - NO EVENTS
FLAGGED AS REASON 4 IN ROUND 71.
CPS REASON 5 = STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN AMOUNT REMAINING. - NO EVENTS
FLAGGED AS REASON 5 IN ROUND 71.
BOX CPSBEG

routing

CPS REASON 9 = R70 CHARGE BUNDLE, NO STATEMENT ENTERED, FOLLOW CPS REASON 1 PATH
IN CPS, WE WILL REVIEW THIS LIST OF CHARGE BUNDLES AND WILL EXCLUDE ANY CHARGE BUNDLE WITH AN
EVENT THAT HAS BEEN DELETED, HAS BEEN LINKED TO A STATEMENT CHARGE BUNDLE IN THE CURRENT ROUND,
OR WAS ASKED ABOUT IN THE CURRENT ROUND NO STATEMENT SECTION AND THE SP IS NOT EXPECTING TO
RECEIVE A STATEMENT FOR THIS EVENT.
THE REMAINING LIST OF CHARGE BUNDLES WILL BE ELIGIBLE FOR CPS. WE WILL SORT THIS LIST IN THE
FOLLOWING WAY: REASON 9, 1, 2...ETC. ENDING WITH REASON 8. IN ROUND 73 REASONS 4-8 WERE SKIPPED. WE
ONLY COLLECTED DATA FOR EVENTS WITH REASONS 9, 1, 2, AND 3. WE WILL THEN COLLECT CPS DETAILS FOR
THE FIRST CHARGE BUNDLE IN THIS LIST.
AFTER COMPLETING THE CPS DETAILS FOR THIS CHARGE BUNDLE, WE WILL RETURN TO BOX CPSBEG. BECAUSE
THE DATA THAT DETERMINES IF A CHARGE BUNDLE IS ELIGIBLE FOR CPS MAY BE UPDATED WHILE ADMINISTERING
CPS, THE LIST OF ELIGIBLE CHARGE BUNDLES WILL BE RECREATED AT THE BEGINNING OF EACH LOOP IN CPS
IF AT LEAST ONE CHARGE BUNDLE HAS BEEN IDENTIFIED AS ELIGIBLE FOR CPS, GO TO CPS1-CPSINT.
ELSE GO TO BOX CPSEND.

[Next, I will ask about some medical care that we talked about in a previous interview.]
CPSINT

CPS1

no entry

THERE ARE (TOTAL NUMBER OF CPS EVENTS) EVENTS OR BUNDLES [REMAINING] FOR SUMMARY.

BOX CPS1A

[First/Next], I want to ask about [READ EVENT(S) ABOVE].
BOX CPS1A

routing

IF CPS REASON = 1 OR 8 OR 9, GO TO CPS2 - RECDSTAT.
ELSE GO TO BOX CPS1B.

BOX CPS1B

routing

CREATE SOURCE OF PAYMENT ROSTER
IF CPS REASON = 2, 6 OR 7, GO TO BOX CPS2.
ELSE IF CPS REASON = 3, GO TO CPS11 - CPTCHGPAID2.
ELSE IF CPS REASON = 4, GO TO CPS13 - CPTCHGPAID3.
ELSE IF CPS REASON = 5, GO TO CPS15 - CPTCHGPAID4.

[IF CPS REASON=9 THEN DISPLAY IN BOLD: "EVENT REPORTED IN ROUND 70"]
[At the last interview, [you were/(SP) was] expecting to receive a statement or paper from [Medicare, Insurance, and
TRICARE/Medicare and TRICARE/Medicare and Insurance/Medicare).]
RECDSTAT

CPS2

code one

[At the last interview, [you/(SP)] reported [READ EVENT(S) ABOVE].
[Have you/Has (SP)] received a statement for the [READ EVENT(S) ABOVE] (since then/since the last interview)?

(01) STATEMENT RECEIVED AND AVAILABLE
(02) STATEMENT RECEIVED, NOT AVAILABLE
(03) STATEMENT NOT RECEIVED
(-8) Don't Know
(-9) Refused

(01) ST4 - MATCHST
(02) BOX NS4A
(03) BOX NS4A
(-8) BOX NS4A
(-9) BOX CPS32

[PROBE IF NECESSARY: Please include any statements received about (your/(SP's)] Medicare prescription drug benefit.]

BOX CPS2

routing

IF TOTAL CHARGE = DK OR RF AND ((ASKING ABOUT A NO STATEMENT CHARGE BUNDLE) OR (ASKING ABOUT A
STATEMENT CHARGE BUNDLE AND TYPE OF STATEMENT IS NOT A MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT)), GO TO CPS3 - KNOWTOTL.
ELSE IF CPS REASON = 2, GO TO CPS9 - CPTCHGPAID1.

Page 1 of 5

2019 MCBS Community Questionnaire

Variable Name

KNOWTOTL

TOTALCHG

MR Screen Name

CPS-COST PAYMENT SUMMARY

Question Type

Question Text/Description

Code List

Routing

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

BOX CPS3

CPS3

yes/no

Do you happen to know the (total charge/copayment amount) for the [READ EVENT(S) ABOVE]?

BOX CPS3

routing

IF CPS3 - KNOWTOTL = 1/Yes AND (TOTAL CHARGE WAS COLLECTED FOR CHARGE BUNDLE), GO TO CPS4 TOTALCHG.
ELSE IF CPS3 - KNOWTOTL = 1/Yes AND (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE), GO TO CPS5 TOTALCHG.
ELSE IF (CPS3 - KNOWTOTL = 2/No OR RF) AND (CPS REASON = 2), GO TO CPS9 - CPTCHGPAID1.

CPS4

numeric

Including any amounts that may be paid by Medicare or anyone else, what was the total charge (that is, the amount billed)?
(01) continuous answer
ENTER 0 IF NO CHARGE FOR THE EVENT.
(-8) Don't Know
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF THE CHARGE. IF
(-9) Refused
THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE THE DISCOUNT IS APPLIED.]

BOX CPS5A

What was the copayment amount for the [READ EVENT(S) ABOVE]?
TOTALCHG

CPS5

numeric

[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time health services
are provided. For example, the person may pay $20 for each office visit and $10 for each drug prescription.]

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

BOX CPS5A

ENTER 0 IF NO COPAYMENT FOR THE EVENT.

routing

IF (CPS REASON = 2) AND (TOTAL CHARGE = 0) AND (SP IS CURRENTLY COVERED BY MEDICAID), GO TO BOX CPS32.
ELSE GO TO BOX CPS5B.

BOX CPS5B

routing

FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL
ITEM, GO TO CPS6 - MONTHCOV.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT TYPE = 'PM') OR (EVENT TYPE =
'OM' AND (OTHER MEDICAL EXPENSE IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES OR BANDAGES)), GO TO CPS7
- NUMLINKS.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT WAS ENTERED AS A REPEAT
VISIT), GO TO CPS8 - RVLINKS.
ELSE GO TO BOX CPS8A.

MONTHCOV

CPS6

numeric

For the [READ OME ITEM ABOVE], how many months are covered by the charge for the period of time between (CHARGE
BUNDLE REFERENCE PERIOD)?
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP. (E.G., FOR 2
½ MONTHS, ENTER “3”.)]

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

CPS6 - MONCOV96

NUMLINKS

CPS7

numeric

How many of the times [you/(SP)] obtained (MEDICINE NAME/OME ITEM TYPE) for the period between (CHARGE BUNDLE
REFERENCE PERIOD) [were covered by the total charge/were covered by the (CPS4 - TOTAL CHARGE)/was there no
charge/were covered by the copayment/were covered by the (CPS5 - COPAYMENT)/was there no copayment]?

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

BOX CPS8A

RVLINKS

CPS8

numeric

(01) continuous answer
How many of the [READ EVENT ABOVE] [were covered by the total charge/were covered by the (CPS4 - TOTAL CHARGE)/was
(-8) Don't Know
there no charge/were covered by the copayment/were covered by the (CPS5 - COPAYMENT)/was there no copayment]?
(-9) Refused

BOX CPS8B

BOX CPS8A

routing

IF ANOTHER EVENT IS INCLUDED IN THE CHARGE BUNDLE, GO TO BOX CPS5B.
ELSE GO TO BOX CPS8B.

BOX CPS8B

routing

IF CPS REASON = 2 AND TOTAL CHARGE ^= 0, GO TO CPS9 - CPTCHGPAID1.
ELSE IF CPS REASON = 2 AND TOTAL CHARGE = 0, GO TO BOX CPS10.

code one

[Last time, we recorded that the (total charge/copayment amount) for the [READ EVENT(S) ABOVE] was (TOTAL CHARGE)),
and that no payment had been made.] [Have you/Has (SP)] or any other source[, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] now paid any of [the total charge/the copayment amount/this (TOTAL
CHARGE)]?

BOX CPS5A

CPTCHGPAID1

CPS9

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) (TOTAL CHARGE/COPAYMENT AMOUNT) IS
WRONG
(-8) Don't Know
(-9) Refused

(01) BOX CPS10
(02) BOX CPS10
(03) CPS10 - TCHGWRONG
(-8) BOX CPS10
(-9) BOX CPS10

Page 2 of 5

2019 MCBS Community Questionnaire

CPS-COST PAYMENT SUMMARY

Variable Name

MR Screen Name

Question Type

Question Text/Description

TCHGWRONG

CPS10

no entry

YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY PORTION OF THE CHARGE.

BOX CPS10

routing

IF (CPS9 - CPTCHGPAID1 = 1/SomeonePaid) OR (TOTAL CHARGE = 0), GO TO NS65 - NSADDSOP1.
ELSE IF (CPS9 - CPTCHGPAID1 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE GO TO BOX CPS32.

CPTCHGPAID2

CPS11

code one

Last time, we recorded that [Medicare had paid [nothing and/(MEDICARE PAYMENT AMOUNT) and after Medicare paid,]] there (01) SP OR ANY SOURCE PAID
was an amount remaining of (CPS AMOUNT REMAINING) for the [READ EVENT(S) ABOVE.]
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] now paid any (-8) Don't Know
of this (AMOUNT REMAINING)?
(-9) Refused

(01) BOX CPS12
(02) BOX CPS12
(03) CPS12 - TCHGWRONG
(-8) BOX CPS12
(-9) BOX CPS12

TCHGWRONG

CPS12

no entry

YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID.

CPS11 - CPTCHGPAID2

BOX CPS12

routing

IF (CPS11 - CPTCHGPAID2 = 1/SomeonePaid), GO TO ST65 - STADDSOP1.
ELSE IF (CPS11 - CPTCHGPAID2 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS11 - CPTCHGPAID2 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.

Let me review what we recorded last time.
CPTCHGPAID3

CPS13

code one

[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE
BETWEEN PAYMENTS AND TOTAL CHARGE).
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] paid any
additional amount?

TCHGWRONG

CPS14

no entry

YOU CANNOT CORRECT THE AMOUNT HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY ADDITIONAL AMOUNT.

BOX CPS14

routing

IF CPS13 - CPTCHGPAID3 = 1/Yes, GO TO NS65 - NSADDSOP1.
ELSE IF CPS13 - CPTCHGPAID3 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS13 - CPTCHGPAID3 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.

Code List

CPS9 - CPTCHGPAID1

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) TOTAL CHARGE SEEMS WRONG
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
(-9) Refused

(01) BOX CPS14
(02) BOX CPS14
(03) CPS14 - TCHGWRONG
(04) BOX CPS14
(-8) BOX CPS14
(-9) BOX CPS14

CPS13 - CPTCHGPAID3

Let me review what we recorded last time.
CPTCHGPAID4

CPS15

code one

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
[REVIEW ABOVE WITH RESPONDENT.] There seems to be some amount still unpaid. The total of non-Medicare payments is
(03) AMOUNT REMAINING SEEMS WRONG
$(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN PAYMENTS AND CPS AMOUNT REMAINING).
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] paid any
(-9) Refused
additional amount?

TCHGWRONG

CPS16

no entry

YOU CANNOT CORRECT THE AMOUNT HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY ADDITIONAL AMOUNT.

BOX CPS16

routing

IF CPS15 - CPTCHGPAID4 = 1/Yes, GO TO ST65 - STADDSOP1.
ELSE IF CPS15 - CPTCHGPAID4 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS15 - CPTCHGPAID4 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.

CPS17

yes/no

Do you expect that [you/(SP)] or any other source will pay any [of this amount/additional amount for [READ EVENT(S) ABOVE]]?

BOX CPS17

routing

IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND), GO TO CPS18 - EXPAYUNT.
ELSE GO TO BOX CPS32.

EXPAYOUT

Routing

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

(01) BOX CPS16
(02) BOX CPS16
(03) CPS16 - TCHGWRONG
(04) BOX CPS16
(-8) BOX CPS16
(-9) BOX CPS16

CPS15 - CPTCHGPAID4

(01) BOX CPS17
(02) BOX CPS32
(-8) BOX CPS32
(-9) BOX CPS32

Page 3 of 5

2019 MCBS Community Questionnaire

CPS-COST PAYMENT SUMMARY

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

EXPAYUNT

CPS18

code one

How much do you expect will be paid?

(91) PERCENTAGE
(02) DOLLARS
(-8) Don't Know
(-9) Refused

(01) CPS18 - EXPAYAMT
(02) CPS18 - EXPAYPCT
(-8) BOX CPS32
(-9) BOX CPS32

EXPAYPCT

CPS18

numeric

How much do you expect will be paid?

(01) continuous answer

BOX CPS32

EXPAYAMT

CPS18

numeric

How much do you expect will be paid?

(01) continuous answer

BOX CPS32

RRDETAIL

CPS23

yes/no

DID RESPONDENT MENTION (AN INSURANCE/A) REFUND OR REIMBURSEMENT ABOUT WHICH HE/SHE IS NOT SURE
OF THE DETAILS?
[DO NOT ENTER A COMMENT HERE TO EXPLAIN THE SITUATION.]

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

(01) CPS24 - RRADD
(02) BOX CPS32
(-8) BOX CPS32

RRADD

CPS24

yes/no

DO YOU WANT TO ADD A REFUND OR REIMBURSEMENT?
(01) YES
[DO NOT SELECT “YES” IF THE RESPONDENT KNOWS A REIMBURSEMENT AMOUNT, BUT DOES NOT KNOW WHO PAID
(02) NO
IT.]

(01) CPS25 - CPADDSOP
(02) BOX CPS32

CPADDSOP

CPS25

yes/no

ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.

(01) CPS27 - TSOPREIM
(02) CPS26 - SOP_CP

SOP_CP

CPS26

roster

ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.

TSOPREIM_NAME

CPS27

grid

Who (else) paid (besides Medicare)? How much did (SOURCE) pay?

TSOPREIM_AMT

CPS27

grid

BOX CPS27A

routing

BOX CPS27B

routing

IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT CPS26 IS A HEALTH INSURANCE PLAN AND CPREASON=3, GO TO
CPS27BINT - PLANINTRO_CPS.
ELSE GO TO BOX CPS29E.

CPS27BINT

no entry

Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.

BOX CPS27C

routing

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT CPS26
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED CARE PLAN
THAT IS CURRENT, GO TO CPS28 - CPMHMOCHNG.
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 CPS29 - CPSOPCURR.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE PRESCRIPTION
DRUG PLAN THAT IS CURRENT, GO TO CPS29A - CPMPDPCHNG.
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 CPS29B - CPSOPCURR2.
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.

CPMHMOCHNG

CPS28

yes/no

(01) YES
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current Medicare Managed (02) NO
(-8) Don't Know
Care Plan. Has this information changed?
(-9) Refused

(01) CPS29 - CPSOPCURR
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A

CPSOPCURR

CPS29

yes/no

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26 SOP MEDICARE MANAGED CARE PLAN NAME) [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

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

(01) HIMC6A - MHMORXTM
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A

CPMPDPCHNG

CPS29A

yes/no

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

(01) CPS29B - CPSOPCURR2
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A

How much did (SOURCE) pay?

PLANINTRO_CPS

REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)
ENTER ALL REIMBURESMENT AMOUNTS.

(01) YES
(02) NO
(01) continuous answer

CPS27 - TSOPREIM

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

BOX CPS27A

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

BOX CPS27A

GO TO BOX CPS27B.

I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current Medicare
Prescription Drug Care Plan.
Has this information changed?

BOX CPS27C

Page 4 of 5

2019 MCBS Community Questionnaire

CPS-COST PAYMENT SUMMARY

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

CPSOPCURR2

CPS29B

yes/no

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26 SOP MEDICARE PRESCRIPTION DRUG PLAN) [on
(DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

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

BOX CPS29A

BOX CPS29A

routing

IF ANOTHER SOP WAS ADDED AT CPS26, GO TO BOX CPS27C.
ELSE GO TO BOX CPS29E.

BOX CPS29E

routing

IF AN "OTHER SOURCE OF PAYMENT" ADDED AT CPS26, CREATE AN OSOP FOR EACH SOURCE OF PAYMENT ADDED
AT CPS26 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX CPS29F.

BOX CPS32

routing

GO TO BOX CPSBEG.

BOX CPSEND

routing

GO TO NEXT SECTION.

Page 5 of 5