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pdf2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
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
THERE ARE (TOTAL NUMBER OF NS EVENTS) EVENTS (REMAINING) TO ASK ABOUT.
BOX NS1
(Let's start with/Next let's look at) (the/[your/(SP's)]) costs for the (EVENT).
BOX NS1
routing
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]?
NSEXMCMAIL
NS2
code one
EVERRVB
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.
(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
(01) CONTINUOUS ANSWER
BOX NS4
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS5
REMINDER: "EVENT ENTERED IN ERROR" INSTRUCTS THE HOME OFFICE TO DELETE THIS EVENT.
TOTALCHG
NS5
dollar
IF YOU HAVE ENTERED THIS CODE IN ERROR, SELECT PREVIOUS PAGE AND ENTER THE CORRECT
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)]?
IF CHARGE REPORTED AS HOURLY RATE, CALCULATE AND ENTER THE TOTAL CHARGE FOR THE
ENTIRE ROUND.
[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.]
BOX NS5
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.
Page 1 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
TOTALCHG
NS6
dollar
BOX NS6
routing
MONTHCOV
NS7
numeric
MONCOV96
NS7
code one
NSQ- NO STATEMENT COST SERIES
Question Text/Description
What was the copayment amount for the [READ EVENT ABOVE]?
Code List
(01) CONTINUOUS ANSWER
[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time health
(-8) DON'T KNOW
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.
Routing
BOX NS6
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 UP.
(-9) REFUSED
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
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)]?
(01) LESS THAN 1 MONTH
(-7) EMPTY
BOX NS9
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS9
NUMLINKS
NS8
numeric
RVLINKS
NS9
numeric
BOX NS9
routing
INCOTHER
NS10
code one
(01) ONLY THIS EVENT/ITEM/MEDICINE
[READ IF NECESSARY: Does [the total charge/TOTAL CHARGE)] cover this (medicine/item/event) only or does it
(02) OTHER EVENTS/ITEMS/MEDICINES
include other (medicine/item/event)s.]
(03) CAN'T TELL
INCTYPE
NS12
code all
What else was included?
CHECK ALL THAT APPLY.
BOX NS12
routing
IF THE RESPONSE TO NS12 - INCTYPE INCLUDES 1/ProvDates, GO TO NS13 - PROVIDER_NSDATE.
ELSE GO TO BOX NS26.
PROVIDER_NSDA
NS13
TE
roster
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 covered
(-8) DON'T KNOW
by the (TOTAL CHARGE)/were covered by the copayment/was there no copayment/were covered by the
(-9) REFUSED
(COPAYMENT)]?
IF (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE INSTEAD OF A TOTAL CHARGE), GO TO BOX
NS45.
ELSE GO TO NS10 - INCOTHER.
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
NS7 - MONCOV96
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES
[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.
BOX NS9
(01) BOX NS45
(02) NS12 - INCTYPE
(03) BOX NS45
BOX NS12
IF EXISTING PROVIDER SELECTED, GO TO NS14NSDATEUPD.
ELSE IF "ADD ANOTHER" SELECTED, GO TO PROV
[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
NSDATEUPD
NS13
NS14
EVENT_NSDATE
NS15
DIT
verbatim
GROUP:
NS14- NSDATEUPD
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?
(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
roster
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
(01) CONTINUOUS ANSWER
(01) NS24 - EVENT_NSDATE
(02) NS16 - EVENT_NSDATEADD
(03) NS15 - EVENT_NSDATEDIT
NS14 - NSDATEUPD
Page 2 of 14
2020 MCBS Community Questionnaire
Variable Name
VISITYPE
EVENT
MR Screen Name Question Type
VISTYPE
NS16
select one
verbatim
NSQ- NO STATEMENT COST SERIES
Question Text/Description
Code List
Routing
SELECT TYPE OF VISIT TO ADD:
(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
[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)].
MM:
ENTER ALL DATES.
DD:
YYYY:
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
REPEAT VISIT: YES/NO
ADD ALL EVENT DATES FOR THIS PROVIDER.
# 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.]
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 NS16A
NSDATEINTRO
BOX NS17
BOX NS17
Page 3 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
Question Text/Description
What kind of medical person is (PROVIDER NAME)?
PROVSPEC
NS18
code one
PROVSPOS
PROVSPEC
PROVSPEC
PROVPOS
NS18
NS18A
NS18A1
NS18A
text
code one
code one
verbatim text
PROVSPEC
NS18B
code one
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES
THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT
PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT
LISTED ON MPQ JOB AID 1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
OTHER MEDICAL PROVIDER (SPECIFY)
What kind of dental provider is [PROVNAME]?
What kind of dental provider is [PROVNAME]?
OTHER MEDICAL PROVIDER (SPECIFY)
What kind of eye care provider is [PROVNAME]?
Code List
Routing
(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)
(18) PARAMEDIC
(42) PHARMACIST
(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), (42), (-8), (-9) BOX NS18
(91) NS18 - PROVSPOS
(01) CONTINUOUS ANSWER
BOX NS18
(01) [Continuous answer.]
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS18
(02) BOX NS18
(16) BOX NS18
(43) BOX NS18
(91) NS18B1- PROVSPEC
(-8) BOX NS18
(-9) BOX NS18
Page 4 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
Question Text/Description
Code List
Routing
(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
PROVSPEC
NS18B1
code one
What kind of eye care provider is [PROVNAME]?
PROVPOS
NS18B
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
PROVSPEC
NS18C
code one
What kind of hearing care provider is [PROVNAME]?
(01) [Continuous answer.]
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
BOX NT18
(02) BOX NS18
(03) BOX NS18
(44) BOX NS18
(45) BOX NS18
(91) NS18C1- PROVSPEC
(-8) BOX NS18
(-9) BOX NS18
Page 5 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
Question Text/Description
PROVSPEC
NS18C1
code one
What kind of hearing care provider is [PROVNAME]?
PROVPOS
NS18C
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
BOX NS18
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.
NS19
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?
BOX NS19
routing
GO TO BOX NS22A.
HMOASSOC
NS20
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFER
NS21
yes/no
VAPLACE
[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).]
MPSDVIS
BOX NS22A
routing
IF TYPE OF EVENT = 'MP', GO TO BOX NS22B.
ELSE GO TO BOX NS23B.
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
BOX NS23A
routing
BOX NS23B
routing
Code List
Routing
(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
(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) NS18C - PROVSPOS
(01) [Continuous answer.]
BOX NS18
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS19
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NS22A
(02) NS21 - HMOREFER
(-8) NS21 - HMOREFER
(-9) NS21 - HMOREFER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS22A
(01) YES
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW]. Was
(02) NO
this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED BELOW]/any of
(-8) DON'T KNOW
these places]?
(-9) REFUSED
GO TO BOX NS23B.
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER AT NS16, GO TO BOX NS22A.
ELSE GO TO NS24-EVENT_NSDATE.
BOX NS23A
Page 6 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
EVENT_NSDATE NS24
check all
RVLINKS
BOX NS24
routing
NS24A
numeric
NSQ- NO STATEMENT COST SERIES
Question Text/Description
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
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.
[A REPEAT VISIT MEANS THAT THE RESPONDENT HAD AT LEAST 5 VISITS TO THE PROVIDER DURING
THE CURRENT ROUND REFERENCE PERIOD.]
IF ANOTHER EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.
Code List
(01) CONTINUOUS ANSWER
Routing
BOX NS24
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS24A
BOX NS24A
routing
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
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(01) HOME HEALTH PROFESSIONAL
(HOME HEALTH AIDE, HOMEMAKER, ETC.)?
(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
BOX NS31A
routing
IF NS30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
BOX NS31B
routing
NS32
no entry
NSDATEMTCH
EVENT_NSDATE
NS26
DEL
PROVIDER_HH
NSHHMTCH
NSOMUPD
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO NS32 - NSHHMTCH.
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.
(01) CONTINUE
(-7) EMPTY
BOX NS33
BOX NS33
routing
IF NS12 – INCTYPE INCLUDES 3/OMExpenses, GO TO NS34 - NSOMUPD.
ELSE GO TO BOX NS40.
NS34
code one
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
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
EVENT_NSOMEDI
NS35
T
NSOMADD
NS36
code one
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?
EVENT_NSOM
BOX NS36
NS37
routing
roster
GO TO NS34 - NSOMUPD.
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE.
BOX NS37
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.
MONTHCOV
NS38
numeric
MONCOV96
NS38
code one
(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT (01) NS37 - EVENT_NSOM
(02) YES, NEED TO ADD AN OME EVENT
(02) NS36 - NSOMADD
(03) YES, NEED TO EDIT AN OME EVENT
(03) NS35 - EVENT_NSOMEDIT
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 UP. (-8) DON'T KNOW
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY
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.
NS38 - MONCOV96
BOX NS38A
Page 7 of 14
2020 MCBS Community Questionnaire
Variable Name
NUMLINKS
NSOMMTCH
MR Screen Name Question Type
Code List
Routing
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX NS38AA
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.
NS39
code one
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) BOX NS40
(02) NS34 - NSOMUPD
(03) NS40 - EVENT_NSOMDEL
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
NS39 - NSOMMTCH
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.
(01) CONTINUOUS ANSWER
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 NS42-NUMLINKS.
BOX PM2
MEDICINE_PM1
Question Text/Description
NS38A
EVENT_NSOMDE
NS40
L
EVENT_NSPM
NSQ- NO STATEMENT COST SERIES
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
BOX PM3
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
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).
The strength was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
PMBOTTLE
BOX PM4
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.
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 ABOUT
(-8) DON'T KNOW
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.
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.
PMEDNAME
MED
lookup
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Page 8 of 14
2020 MCBS Community Questionnaire
NSQ- NO STATEMENT COST SERIES
Variable Name
MR Screen Name Question Type
Question Text/Description
PMFORMMC
MED
code one
Medicine Form [MCBS FORM]
PMFORMOS
PMFORMFN
MED
MED
verbatim
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
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
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
Medicine strength unit
PMCOND
PMCOND
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
code one
verbatim
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
(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
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
Routing
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
What condition is this medicine prescribed for or what is its primary use?
PMCOND
Code List
(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) CONTINUOUS ANSWER
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
Page 9 of 14
2020 MCBS Community Questionnaire
Variable Name
TABNUM
MR Screen Name Question Type
BOX PM5
routing
TABNUM
numeric
AMTUNIT
PM16
quantity unit
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
BOX PM6
routing
NSQ- NO STATEMENT COST SERIES
Question Text/Description
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
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.
Code List
Routing
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
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
(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
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
BOX PM6
OTHER (SPECIFY)
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 IN A (01) CONTINUOUS ANSWER
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.]
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
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".
TABTAKE
PM13
numeric
TABTAKE96
PM13
code one
BOX PM7
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
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
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.
PMSATVA
PMSATHMO
PMSATHMO
yes/no
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
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.]
PM13 - TABTAKE96
BOX PM7
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
Page 10 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
Question Text/Description
Code List
Routing
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) NS42 - NUMLINKS
([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
NSPMMTCH
NS44
code one
EVENT_NSPMDE
NS45
L
roster
[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?]
(01) CONTINUOUS ANSWER
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE BUNDLE? (-8) DON'T KNOW
(-9) REFUSED
(01) YES
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE SHOWN BELOW?
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE
(01) CONTINUOUS ANSWER
BUNDLE.
routing
IF TOTAL CHARGE OR COPAY COLLECTED GE 0, DK OR RF, GO TO NS64 - NSTCHGPAID.
ELSE GO TO BOX NS64B.
NS64
code one
(01) SP OR ANY SOURCE PAID
[[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),]
(02) NOTHING HAS BEEN PAID
already paid any of [the charge/the total charge/the copayment amount/this (TOTAL CHARGE)]?
(-8) DON'T KNOW
(-9) REFUSED
[IF COPAYMENT AMOUNT IS ZERO, SELECT “NO.”]
BOX NS64A
routing
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.
BOX NS64B
routing
NSADDSOP1
NS65
yes/no
SOP_NS1
NS66
roster
BOX NS45
NSTCHGPAID
TSOPAMT
PAYMHE
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.
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.
NS67HE
no entry
(01) YES
(02) NO
(01) CONTINUOUS ANSWER
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'.
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
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
BOX NS67HE
NS67HE - PAYMHE
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND
MAKE CORRECTIONS.
BOX NS67A
PLANINTRO_NS
routing
BOX NS67B
routing
NS67BINT
no entry
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT NS66, GO TO BOX NS67B.
ELSE GO TO BOX NS69F.
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.
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.
BOX NS67C
Page 11 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NS69 - NSSOPCURR1
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
(01) HIMC6A - MHMORXTM
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A
(01) NS69B - NSSOPCURR2
(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 NS68
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?
NSSOPCURR1
NS69
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (NS66 SOP MEDICARE MANAGED CARE PLAN
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
NSMPDPCHNG
NS69A
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
[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (NS66 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
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.
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
NS70
code one
AMTSCORR
NS71
code one
ENTERCOM
NS72
no entry
BOX NS77C
routing
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.
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE [TOTAL
(01) ENTRIES ABOVE ARE CORRECT
CHARGE/COPAYMENT], WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL AMOUNTS AS
(02) NO, SOP NEEDS ADDITION OR CORRECTION
ENTERED.
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
(-9) REFUSED
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
[THE TOTAL OF PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT [UNPAID/OVERPAID] IS $(DIFFERENCE
BETWEEN PAYMENTS AND TOTAL CHARGE).]
(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C
(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C
BOX NS77C
USE THE BOX BELOW TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
CREATE PAYMENTS FOR AMOUNTS ENTERED AT NS67
GO TO BOX NS77D.
Page 12 of 14
2020 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
NSQ- NO STATEMENT COST SERIES
Question Text/Description
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO NS78 EXPPAYBK.
ELSE GO TO BOX NS80.
BOX NS77D
routing
NS78
yes/no
BOX NS78A
routing
BOX NS78B
routing
EXPAYOUT
NS79
yes/no
Do you expect anyone to pay any of this amount?
EXPAYUNT
NS80
quantity unit
How much do you expect will be paid?
EXPAYPCT
EXPAYAMT
NS80
NS80
numeric
numeric
BOX NS80
routing
EXPPAYBK
BOX NSL1
routing
NSL1
code one
BOX NSL2
routing
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?
NSL3
roster
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX NS78A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NS80 - EXPAYUNT
(02) BOX NS80
(-8) BOX NS80
(-9) BOX NS80
(01) PERCENTAGE NS80 - EXPAYPCT
(02) DOLLARS NS80 - EXPAYAMT
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) NS80 - EXPAYPCT
(02) NS80 - EXPAYAMT
(-8) BOX NS80
(-9) BOX NS80
BOX NS80
BOX NS80
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.
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND), GO TO NS79 - EXPAYOUT.
ELSE GO TO BOX NS80.
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
((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.
You told me earlier that [you/(SP)] had other [visits to (PROVIDER NAME)/prescribed medicine purchases].
NSEVSAME
Code List
Are any other [visits to (PROVIDER NAME)/prescribed medicine purchases] the same -- where the [total charge
was (TOTAL CHARGE TEXT)/copayment was (TOTAL CHARGE TEXT)] per (visit/purchase) and payments were:
[READ PAYMENTS LISTED ABOVE]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX NSL2
(02) BOX NSBEG
(-8) BOX NSBEG
(-9) BOX NSBEG
(01) CONTINUOUS ANSWER
BOX NSL3
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.
IF NO PRESCRIPTION MEDICINES HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT
SELECTING ANY MEDICINES.
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.
Page 13 of 14
2020 MCBS Community Questionnaire
Variable Name
NUMLINKS
MR Screen Name Question Type
Question Text/Description
NSL4
How many times are the same?
ENTER THE NUMBER OF PURCHASES OF EACH MEDICINE SHOWN BELOW THAT ARE THE SAME.
EVENT_VISITSAM
NSL5
E
RVLINKS
NSQ- NO STATEMENT COST SERIES
grid
roster
BOX NSL5
routing
NSL6
numeric
BOX NSL6
routing
NS81
yes/no
BOX NSEND
routing
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.
IF AT LEAST ONE EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
How many times are the same for (EVENT)?
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE THE SAME.
IF ANOTHER EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.
Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
Routing
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
YOU HAVE ENTERED ALL CHARGE/PAYMENT DATA FOR ALL EVENTS REPORTED.
NSTATEMENT
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 (C007, C010), GO TO PVQ.
IF SEASON= FALL AND INTTYPE in(C002, C006, C007, C010), GO TO MBQ.
Page 14 of 14
| File Type | application/pdf |
| File Title | NSQ.xlsx |
| Author | Wishart-Marisa |
| File Modified | 2020-03-27 |
| File Created | 2020-03-27 |