CMS-P-0015A Statement Cost Series

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

STATEMENT COST SERIES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after OMQ.

BOX STBEG

routing

IF ((SP WAS COVERED BY A MEDICARE MANAGED CARE PLAN WITHOUT RX COVERAGE ANYTIME
DURING THE CURRENT ROUND) OR (SP WAS COVERED BY A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND)) AND (SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION DRUG
PLAN ANYTIME DURING THE CURRENT ROUND), GO TO ST1 - MHMOSTMT.
ELSE GO TO ST2 - MCSAVAIL.
Now that we have finished talking about medical visits and prescribed medicines, let’s talk about [your/(SP’s)]
medical costs. We should start by looking at any paperwork or written explanations of what was paid by Medicare,
any insurance company, or TRICARE.

MHMOSTMT

ST1

code one

(01) ST2 - MCSAVAIL
[Do you/Does (SP)] usually receive any statements or papers from Medicare, insurance, such as (MANAGED CARE
(02) ST2 - MCSAVAIL
PLAN NAME), or TRICARE that show the charges for medical visits or equipment?/Last time, we recorded that
(03) BOX STEND
[you/(SP)] (always/sometimes/never) received statements or papers from Medicare, insurance, or TRICARE that
(-8) ST2 - MCSAVAIL
show the charges for medical visits or equipment.]
(-9) ST2 - MCSAVAIL
Please tell me if (currently) [you always receive statements, sometimes receive statements, or never receive
statements/(SP) always receives statements, sometimes receives statements, or never receives statements].
[Now that we have finished talking about medical visits and prescribed medicines, let’s talk about [your/(SP’s)]
medical costs. We should start by looking at any paperwork or written explanations of what costs were paid by
Medicare, any insurance company, or TRICARE.]

MCSAVAIL

ST2

yes/no
[PROBE IF NECESSARY: Do you have any statements or paper from Medicare, insurance, or TRICARE [that
[you/(SP)] received since the last interview]? (Please include any statements received about [your/(SP's)]
prescription drug benefit.)]

STHIREP

ST3

no entry

MATCHST

ST4

no entry

ST_CHARGEBUN
ST5
DLE

roster

(01)
(02)
(-8)
(-9)

ST3 - STHIREP
BOX STEND
BOX STEND
BOX STEND

BASED ON THE INFORMATION RECORDED IN THE HEALTH INSURANCE SECTION FOR RECENT ROUNDS, ST4 - MATCHST
THE PLAN(S) LISTED BELOW ARE THE SOURCES OF STATEMENTS YOU MIGHT EXPECT TO FIND FOR
THIS SP.
[MATCH UP MEDICARE, INSURANCE, TRICARE, AND MEDICARE PRESCRIPTION BENEFIT STATEMENTS
BY PROVIDER AND DATE OF SERVICE./PRESS ENTER TO CONTINUE TO THE NEXT
ST5 - ST_CHARGEBUNDLE
(STATEMENT/BUNDLE).]
ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE (FIRST/NEXT) BUNDLE OF EVENTS.
STTYPE (HAD BEEN BOX ST5A)
ADD ONE CHARGE BUNDLE AT THIS ROSTER.

STTYPE

ST5AA

code one

SELECT SOURCE OF THE STATEMENT(S) FOR THIS CHARGE BUNDLE

(01) ST5AA-MCARTYPE
(02) BOX ST5A
(03) ST5AA-MCARTYPE
(04) BOX ST5A
(05) ST5AA-MCARTYPE
(06) BOX ST5A
(07) ST5AA-MCARTYPE
(08) BOX ST5A

MCARTYPE

ST5AAA

code one

WHICH TYPE OF MEDICARE STATEMENT DO YOU HAVE TO ENTER? [SEE REFERENCE CARDS FOR
MEDICARE STATEMENT EXAMPLES]

BOX ST5A

BOX ST5A

routing

IF ST5 – STTYPE = 8/MPDPorMAorTricare THEN GO TO ST5A - PDPTYPE.
ELSE GO TO BOX ST5B.

ST5A

code one

SELECT THE TYPE OF PRESCRIPTION DRUG STATEMENT FOR THIS BUNDLE.

BOX ST5B

routing

SET STATEMENT TYPE.
GO TO BOX ST5.

BOX ST5

routing

IF TYPE OF STATEMENT = 1/Medicare, 3/MedicareAndInsurance, 5/MedicareAndTricare, OR
7/MedicareAndTricareAndInsurance, GO TO ST7 - MSNCLNUM.
ELSE IF TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance, GO TO ST10 - INSCLNUM.
ELSE IF TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE = 4/Tricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST11B - PDPBEGMM.

PDPTYPE

BOX ST5B

Page 1 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

ENTER THE CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN) ASSOCIATED
WITH THE CLAIM TOTAL.
IF NO CLAIM CONTROL NUMBER(S) LISTED, USE F8 TO SELECT 'DON'T KNOW .
MSNCLNUM

ST7

text

DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN COMMENTS.

ST7 - MSNCLNM2

[INSERT TEXT BOX 1 FOR CLAIM 1]
IF THERE ARE MULTIPLE CLAIM NUMBERS ASSOCIATED WITH THE CLAIM TOTAL, ENTER BELOW:
[INSERT REMAINING TEXT BOXES]
MSNCLNM2
MSNCLNM3
MSNCLNM4
MSNCLNM5

MSCLVER1

ST7
ST7
ST7
ST7

text
text
text
text

ST7 - MSNCLNM3
ST7 - MSNCLNM4
ST7 - MSNCLNM5
BOX ST7

BOX ST7

routing

IF ST7 - MSNCLNUM = DK, GO TO BOX ST9.
ELSE GO TO ST8 - MSCLVER1.

ST8

text

PLEASE ENTER THE FIRST CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN)
AGAIN.

BOX ST8

routing

IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM THE MEDICARE SUMMARY NOTICE (MSN)
DIFFERENTLY.
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)

WHICHNUM

ST9

code one
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)

BOX ST8

(01) BOX ST9
(02) BOX ST9
(03) ST9 - NEWCLNUM

WHICH IS CORRECT?
NEWCLNUM

text

ENTER CORRECT MSN CLAIM CONTROL NUMBER:

BOX ST9

routing

IF TYPE OF STATEMENT = 3/MedicareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST10 INSCLNUM.
ELSE IF TYPE OF STATEMENT = 5/MedicareAndTricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST12 - INCTYPE.

ST10

text

ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE STATEMENT. IF NO CLAIM CONTROL
NUMBER LISTED, USE F8 TO SELECT 'DON'T KNOW .

BOX ST10

routing

IF TYPE OF STATEMENT = 6/TricareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST11 TRICLNUM.
ELSE GO TO ST12 - INCTYPE.

TRICLNUM

ST11

text

ENTER THE CLAIM CONTROL NUMBER FROM THE TRICARE STATEMENT. IF NO CLAIM CONTROL
NUMBER LISTED, ENTER "DON'T KNOW".

ST12 - INCTYPE

PDPBEGMM

ST11B

date

ENTER THE BEGINNING AND ENDING DATES OF SERVICE FROM THE PRESCRIPTION DRUG BENEFIT
STATEMENT.
BEGINNING DATE:

ST11B - PDPBEGDD

PDPBEGDD
PDPBEGYY
PDPENDMM
PDPENDDD
PDPENDYY

ST11B
ST11B
ST11B
ST11B
ST11B

date
date
date
date
date

ENDING DATE:

ST11B - PDPBEGYY
ST11B - PDPENDMM
ST11B - PDPENDDD
ST11B - PDPENDYY
ST12 - INCTYPE

INCTYPE

ST12

code all

WHAT TYPE(S) OF EVENT(S) ARE INCLUDED IN THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT)?
CHECK ALL THAT APPLY.

BOX ST12

BOX ST12

routing

IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates, GO TO ST13 - PROVIDER_STDATE.
ELSE GO TO BOX ST26.

roster

WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.

INSCLNUM

ST9

PROVIDER_STDA
ST13
TE

BOX ST9

BOX ST10

"IF EXISTING PROVIDER SELECTED, GO TO ST14 STDATEUPD.
ELSE IF ""ADD ANOTHER"" SELECTED, GO TO PROV"

Page 2 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

[PROVIDER LOOKUP CAN BE CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

PROVNAME

ST13

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.

ST13-GROUPNAM

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:
GROUPNAM
STDATEUPD

ST13
ST14

VISITYPE
VISTYPE
EVENT_STDATED
ST15
IT

verbatim

GROUP:

ST14 - STDATEUPD

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) ST24 - EVENT_STDATE
(02) EVENT DATE ST16 - EVENT_STDATEADD
(03) ST15 - EVENT_STDATEDIT

select one

SELECT TYPE OF VISIT TO ADD:

ST16 - EVENT

roster

SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.

ST16-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/ENDUTILD)].
ENTER ALL DATES.
EVENT

ST16

roster

ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.

BOX ST16A

[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.]

STDATEINTRO

BOX ST16A

routing

IF AT LEAST ONE EVENT DATE ADDED AT ST16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO
TO BOX ST16B.
ELSE GO TO ST14 - STDATEUPD.

BOX ST16B

routing

IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU' , 'IP', 'OP', OR 'MP' EVENT TYPE, GO TO ST17 STDATEINTRO.
ELSE GO TO BOX ST17.

ST17

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 ST16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS
NOT BEEN COLLECTED, GO TO ST18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO ST18A - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'VU' EVENT TYPE AND THE PROVIDER SPECIALTY HAS
NOT BEEN COLLECTED, GO TO ST18B - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'HU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO ST18C - PROVSPEC.
ELSE GO TO BOX ST18.

BOX ST17

BOX ST17

What kind of medical person is (PROVIDER NAME)?
PROVSPEC

ST18

code one

PROVSPOS

ST18

text

[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.']

(01)-(34), (42), (-8), (-9) BOX ST18
(91) ST18 - PROVSPOS

OTHER MEDICAL PROVIDER (SPECIFY)

BOX ST18

Page 3 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

PROVSPEC

ST18A

code one

What kind of dental provider is [PROVNAME]?

(01) BOX ST18
(35) BOX ST18
(36) BOX ST18
(37) BOX ST18
(38) BOX ST18
(39) BOX ST18
(40) BOX ST18
(41) BOX ST18
(91) ST18A - PROVSPOS
(-8) BOX ST18
(-9) BOX ST18

PROVSPEC

ST18A1

code one

What kind of dental provider is [PROVNAME]?

(01)-(34), (-8), (-9) BOX ST18
(91) ST18A - PROVSPOS

PROVPOS

ST18A

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

BOX ST18

PROVSPEC

ST18B

code one

What kind of eye care provider is [PROVNAME]?

(02) BOX ST18
(16) BOX ST18
(43) BOX ST18
(91) ST18B1- PROVSPEC
(-8) BOX ST18
(-9) BOX ST18

PROVSPEC

ST18B1

code one

What kind of eye care provider is [PROVNAME]?

(01)-(34), (-8), (-9) BOX ST18
(91) ST18B - PROVSPOS

PROVPOS

ST18B

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

BOX ST18

PROVSPEC

ST18C

code one

What kind of hearing care provider is [PROVNAME]?

(02) BOX ST18
(03) BOX ST18
(44) BOX ST18
(45) BOX ST18
(91) ST18C1- PROVSPEC
(-8) BOX ST18
(-9) BOX ST18

PROVSPEC

ST18C1

code one

What kind of hearing care provider is [PROVNAME]?

(01)-(34), (-8), (-9) BOX ST18
(91) ST18C - PROVSPOS

PROVPOS

ST18C

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

BOX ST18

BOX ST18

routing

Routing

IF (AT LEAST ONE EVENT ADDED AT ST16 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 ST19 VAPLACE.
ELSE GO TO BOX ST19.

VAPLACE

ST19

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?

BOX ST19

routing

IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU'', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND
(SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ST20 - HMOASSOC.
ELSE IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE)
AND (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ST21 - HMOREFER.
ELSE GO TO BOX ST22A.

HMOASSOC

ST20

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

ST21

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?

BOX ST19

(01) BOX ST22A
(02) ST21 - HMOREFER
(-8) ST21 - HMOREFER
(-9) ST21 - HMOREFER
BOX ST22A

Page 4 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

BOX ST22A

routing

FOR THIS EVENT ADDED AT ST16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX ST22B.
ELSE IF TYPE OF EVENT = 'DU', GO TO DU7 - DVPROCDR.
ELSE IF TYPE OF EVENT = 'VU', GO TO VU7 - VUPROCDR.
ELSE IF TYPE OF EVENT = 'HU', GO TO HU7 - HUPROCDR.
ELSE GO TO BOX ST23B.

BOX ST22B

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 ST23 - MPSDVIS.
ELSE GO TO BOX ST23A.

ST23

yes/no

We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW]. Was
this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED BELOW]/any of BOX ST23A
these places]?

BOX ST23A

routing

IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B.
ELSE GO TO BOX MP2C.

BOX ST23B

routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER AT ST16, GO TO BOX ST22A.
ELSE GO TO ST24-EVENT_STDATE.

ST24

roster

SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.

BOX ST24

routing

IF AT LEAST ONE EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.

ST24A

numeric

ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS
CHARGE.

BOX ST24A

routing

IF ANOTHER EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.

ST25

code one

ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE ON (TYPE OF STATEMENT) SHOWN
BELOW?

(01) BOX ST26
(02) ST13 - PROVIDER_STDATE
(03) ST26 - EVENT_STDATEDEL

roster

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

ST25 - STDATEMTCH

routing

IF ST12 – INCTYPE INCLUDES 2/HHVisits, GO TO ST27 - PROVIDER_STHH.
ELSE GO TO BOX ST33.

PROVIDER_STHH ST27

roster

WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.

COSTBEGM

numeric

MPSDVIS

EVENT_STDATE

RVLINKS

STDATEMTCH

EVENT_STDATED
ST26
EL
BOX ST26

Code List

Routing

BOX ST24

BOX ST24A

ST28 - COSTBEGM

ENTER THE START DATE AND STOP DATE COVERED BY THE CHARGE BUNDLE.
ST28

ST28 - COSTBEGD
START DATE:

COSTBEGD
COSTBEGY
COSTENDM
COSTENDD
COSTENDY

ST28
ST28
ST28
ST28
ST28

numeric
numeric
numeric
numeric
numeric

STOP DATE:

ST28 - COSTBEGY
ST28 - COSTENDM
ST28 - COSTENDD
ST28 - COSTENDY
BOX ST28A

BOX ST28A

routing

IF (HOME HEALTH PROVIDER WAS ADDED AT ST27) OR (AN EXISTING PROVIDER WAS SELECTED AT
ST27 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO ST30 - HHEVNTTYPE.
ELSE GO TO BOX ST31B.

HHEVNTTYPE

ST30

code one

IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH PROVIDER
ST31 - STHHINTRO
(HOME HEALTH AIDE, HOMEMAKER, ETC.)?

STHHINTRO

ST31

no entry

Before we continue with this statement, I would like to ask you a few questions about the home health provider I just
BOX ST31A
added.

Page 5 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

STHHMTCH

MR Screen Name Question Type

Question Text/Description

BOX ST31A

routing

IF ST30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.

BOX ST31B

routing

LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO ST32 - STHHMTCH.

ST32

code one

THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.

BOX ST33

routing

IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD.
ELSE GO TO BOX ST40.

ST34

code one

THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
STOMUPD

DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
EVENT_STOMEDI
ST35
T

STOMADD

MONTHCOV
MONCOV96

NUMLINKS

STOMMTCH

ST36

Routing

BOX ST33

(01) ST37 - EVENT_STOM
(02) ST36 - STOMADD
(03) ST35 - EVENT_STOMEDIT

SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.

(01) OM1B-VUTYPE
(11) OM3B-INLEFT
(02) OM33-EVENT_OMHRSP
(03) OM6 - ORTHTYPE
(04) OM10 - EVENT_OMDIAB
(05) OM12 - EVENT_OMAMBL
(06) OM14 - EVENT_OMPROS
(07) OM29 - ALTRTYPE
(08) OM19A - OXGNTYPE
(09) OM21A - KDNYTYPE
(10) OM24 - OTHRTYPE

code one

WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?

BOX ST36

routing

GO TO ST34 - STOMUPD.

ST37

roster

SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF
STATEMENT).

BOX ST37

routing

IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.

ST38
ST38

numeric

HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?

BOX ST38A

routing

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.

BOX ST38B

routing

IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.

ST38A

numeric

HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?

BOX ST38AA

routing

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.

ST39

code one

(01) BOX ST40
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
(02) ST34 - STOMUPD
SHOWN BELOW?
(03) ST40 - EVENT_STOMDEL

roster

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

BOX ST40

routing

IF ST12 – INCTYPE INCLUDES 4/PMS, GO TO ST41 - EVENT_STPM.
ELSE GO TO BOX ST45.

ST41

roster

SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF
BOX PM2
STATEMENT).

BOX PM2

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO
TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

EVENT_STOMDE
ST40
L

EVENT_STPM

roster

Code List

BOX ST37

ST38 - MONCOV96
BOX ST38A

BOX ST38AA

Page 6 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name
MEDICINE_PM1

MR Screen Name Question Type
MEDICINE_PM1 code one

Question Text/Description
What is the name of the medicine?

BOX PM3

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

routing

Code List
BOX PM3

Routing

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

BOX PM4
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

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) MED-PMEDNAME
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
(02) PMKNWNM-PMKNWNM
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
(03) MED-PMEDNAME
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT
(-8) PMKNWNM-PMKNWNM
THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(-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

[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]

PMFORMMC

MED

code one

Medicine Form [MCBS FORM]

PMFORMOS

MED

verbatim

PMFORMFN
PMSTRNFD
STRNNUMBB

MED
MED
MED

verbatim
verbatim
numeric

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

ookup

PMEDID

MED

numeric

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD

[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
Medicine Strength
Medicine strength number

Medicine strength unit

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-MEDID
(-9) MED-MEDID

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]

Page 7 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

FAMILYID

MED

numeric

PMKNWNM

PMKNWNM

code one

PMCOND

PMCOND

code one

Question Text/Description
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

PMCONDOS

TABNUM

PMCOND

Code List

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

(01)-(19) BOX PM5
(20) PMCOND-PMCONDOS
(-8) BOX PM5
(-9) BOX PM5

verbatim

OTHER (SPECIFY)

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
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.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

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) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

OTHER (SPECIFY)

Routing

BOX PM5

PM16 - AMTNUM
BOX PM6

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 PM12 - TABSADAY95
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".
PM13-TABTAKE
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often the
medicine is prescribed to be taken.]

TABTAKE

PM13

numeric

TABTAKE96

PM13

code one

PM13 - TABTAKE96
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".

BOX PM7

Page 8 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

PMSATVA

PMSATHMO

MR Screen Name Question Type

Question Text/Description

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.

PMSATHMO

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?

Code List

Routing

BOX PM8

PMMORE-PMMORE

[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.]

([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.])
(01) BOX PM2
(02) ST42 - NUMLINKS

PMMORE

PMMORE

yes/no

NUMLINKS

ST42

grid

HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE BUNDLE? ST44-STPMMTCH

STPMMTCH

ST44

code one

ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
SHOWN BELOW?

(01) BOX ST45
(02) ST41 - EVENT_STPM
(03) ST45 - EVENT_STPMDEL

roster

SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE
BUNDLE.

ST44 - STPMMTCH

BOX ST45

routing

IF ALL EVENT DATES SELECTED FOR THIS CHARGE BUNDLE ARE OUTSIDE THE SURVEY REFERENCE
PERIOD, GO TO ST46 - ORPMESSAGE.
ELSE GO TO BOX ST46.

ST46

no entry

SINCE ALL EVENTS IN THIS BUNDLE ARE OUTSIDE THE SURVEY REFERENCE PERIOD, WE DO NOT NEED
BOX ST80
ANY CHARGE INFORMATION ABOUT THE BUNDLE.

BOX ST46

routing

IF (TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance) OR (TYPE OF STATEMENT = 4/Tricare AND
ST5 – STTTYPE = 4/Tricare) OR (ST5 - MCARTYPE = 4/MSNPartB), GO TO ST47 - ASGNTAKE.
ELSE GO TO BOX ST47.

ST47

code one

WAS ASSIGNMENT TAKEN FOR THIS CHARGE BUNDLE?

BOX ST47

routing

IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)), GO TO ST47A - TOTALCHG.
ELSE IF (TYPE OF STATEMENT = 2/Insurance) OR (TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE =
4/Tricare) OR (TYPE OF STATEMENT = 6/TricareAndInsurance), GO TO ST48 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 4/MSNPartB, GO TO ST52 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 6/MSNPartAInpatient, GO TO ST56 - DAYSUSED.
ELSE GO TO ST60 - TOTALCHG.

TOTALCHG

ST47A

dollar

ENTER THE TOTAL COST OF PRESCRIPTION(S) FROM THE PRESCRIPTION DRUG BENEFIT STATEMENT.
IF A TOTAL COST IS NOT LISTED, IT MAY BE NECESSARY TO CALCULATE A TOTAL BY ADDING THE COSTSST64 - STTCHGPAID2
OF INDIVIDUAL ITEMS LISTED ON THE STATEMENT.

TOTALCHG

ST48

numeric

ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF STATEMENT). IF AMOUNT NOT AVAILABLE,
ENTER "DON'T KNOW".

EVENT_STPMDEL ST45

ORPMESSAGE

ASGNTAKE

[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?]

BOX ST47

ST48 - MCAPPAMT

Page 9 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name
MCAPPAMT
MCPAYAMT

STTCHGPAID1

MR Screen Name Question Type
ST48
numeric
ST48
numeric

Question Text/Description

Code List
ST48 - MCPAYAMT
BOX ST48

BOX ST48

routing

IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST51.
ELSE IF (AMOUNT REMAINING < $1.00) OR ((ST48 - MCAPPAMT ^= DK OR RF) AND (AMOUNT REMAINING <
.02 * ST48 - MCAPPAMT)), GO TO BOX ST80.
ELSE GO TO ST49 - STTCHGPAID1.

ST49

code one

(01) BOX ST64A
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
(02) BOX ST64A
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
(03) ST50 - CHANGAMT
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any
(-8) BOX ST64A
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount?
(-9) BOX ST64A

Routing

THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) STATEMENT:
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE AMOUNT)
TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
CHANGAMT

ST50

yes/no

(01) ST51 - TOTALCHG
(02) BOX ST51

TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)
AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?

MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE
OF STATEMENT).

TOTALCHG

ST51

numeric

MCAPPAMT
MCPAYAMT

ST51
ST51

numeric
numeric

BOX ST51

routing

ST52
ST52
ST52
ST52

numeric
numeric
numeric
numeric

BOX ST52

routing

IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST55.
ELSE IF (AMOUNT REMAINING < $1.00), GO TO BOX ST80.
ELSE GO TO ST53 - STTCHGPAID1.

code one

(01) BOX ST64A
REVIEW CHARGE BUNDLE ON THE (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T
(02) BOX ST64A
ALREADY DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
(03) ST54 - CHANGAMT
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any
(-8) BOX ST64A
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount?
(-9) BOX ST64A

TOTALCHG
MCAPPAMT
MCPAYAMT
MAYBBILL

STTCHGPAID1

ST53

ST51 - MCAPPAMT
ST51 - MCPAYAMT
BOX ST51

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND ((AMOUNT REMAINING < $1.00)
OR ((ST51 - MCAPPAMT ^= DK AND ST51 - MCAPPAMT ^= RF) AND (AMOUNT REMAINING < .02 * ST51 MCAPPAMT))), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:

ST52 - MCAPPAMT
ST52 - MCPAYAMT
ST52 - MAYBBILL
BOX ST52

THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) :
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)
CHANGAMT

ST54

yes/no

(01) ST55 - TOTALCHG
(02) BOX ST55

MEDICARE PAID: (MEDICARE PAYMENT)
YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?

TOTALCHG

ST55

numeric

MCAPPAMT
MCPAYAMT
MAYBBILL

ST55
ST55
ST55

numeric
numeric
numeric

BOX ST55

routing

MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE
OF STATEMENT).

ST55 - MCAPPAMT
ST55 - MCPAYAMT
ST55 - MAYBBILL
BOX ST55

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.

Page 10 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

DAYSUSED

ST56

numeric

ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE STATEMENT.

ST56 - NONCOVRD

NONCOVRD
MCPAYAMT
MAYBBILL

ST56
ST56
ST56

numeric
numeric
numeric

BOX ST56

routing

IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST59.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST57 - STTCHGPAID1.

ST57

code one

REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount?

STTCHGPAID1

Routing

ST56 - MCPAYAMT
ST56 - MAYBBILL
BOX ST56

(01) BOX ST64A
(02) BOX ST64A
(03) ST58 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A

THESE AMOUNTS WERE ENTERED FROM THE MSN:
BENEFITS DAYS USED: (DAYS USED)
NON-COVERED CHARGES: (NON COVERED CHARGES)
CHANGAMT

ST58

yes/no
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)

(01) ST59 - DAYSUSED
(02) BOX ST59

MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?

DAYSUSED

ST59

numeric

NONCOVRD
MCPAYAMT
MAYBBILL

ST59
ST59
ST59

numeric
numeric
numeric

BOX ST59

routing

ST60
ST60
ST60
ST60

numeric
numeric
numeric
numeric

TOTALCHG
MCAPPAMT
MCPAYAMT
MAYBBILL

STTCHGPAID1

MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE
OF STATEMENT).
ST59 - MCPAYAMT
ST59 - MAYBBILL
BOX ST59
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ST60 - NONCOVRD
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.

BOX ST60

IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST63.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST61 - STTCHGPAID1.

ST61

REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining (AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount?

code one

ST60 -MCAPPAMT
ST60 - MCPAYAMT
ST60 - MAYBBILL
BOX ST60

(01) BOX ST64A
(02) BOX ST64A
(03) ST62 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A

THESE AMOUNTS WERE ENTERED FROM THE MSN:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
CHANGAMT

ST62

yes/no
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)

(01) ST63 - TOTALCHG
(02) BOX ST63

MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
MCAPPAMT
MCPAYAMT
MAYBBILL

ST63
ST63
ST63
ST63

numeric
numeric
numeric
numeric

BOX ST63

routing

ENTER THE FOLLOWING AMOUNTS FROM THE MSN.

ST63- MCAPPAMT
ST63 - MCPAYAMT
ST63 - MAYBBILL
BOX ST63

IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.

Page 11 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

ST64

code one

REVIEW CHARGE BUNDLE ON [TYPE OF STATEMENT] WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT (PROVIDER NAME), DATE(S), AND TYPE OF SERVICE(S). (THEN ASK:/SELECT "SP
OR ANY SOURCE PAID" IF ALREADY KNOWN. OTHERWISE ASK:)
BOX ST64A
[The total cost of prescriptions reported on this statement is (TOTAL CHARGE TEXT).] [[Have you/Has
(SP)]/Besides Medicare, [have you/has (SP)]] or any other source [, such as (an insurance plan/TRICARE/TRICARE
or an insurance plan),] paid anything for this?

BOX ST64A

routing

IF SP OR ANY SOURCE HAS PAID, GO TO BOX ST64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID),
GO TO BOX ST78B.
ELSE GO TO BOX ST80.

BOX ST64B

routing

CREATE SOURCE OF PAYMENT ROSTER
IF ADMINISTERING ST AND (ONE OR MORE CHARGE BUNDLES ENTERED IN ST SECTION) AND (ST65 –
STADDSOP1 HAS BEEN ASKED IN THE CURRENT ROUND) AND (PAYMENTS HAVE BEEN COLLECTED AT
ST67), GO TO ST67 - TSOPAMT.

STADDSOP1

ST65

yes/no

ARE ALL OF THE SOURCES OF PAYMENT NECESSARY FOR COMPLETING THE STATEMENT SECTION
LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.

SOP_ST1

ST66

roster

ADD ALL ADDITIONAL SOURCES OF PAYMENT.

STTCHGPAID2

TSOPAMT

PAYMHE

ST67

grid

BOX ST67HE

routing

ST67HE

no entry

(REFER TO INSURANCE STATEMENT/REFER TO TRICARE STATEMENT/REFER TO INSURANCE AND
TRICARE STATEMENTS/REFER TO MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT).
Who (else) paid besides Medicare? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.

Code List

Routing

(01) ST67 - TSOPAMT
(02) ST66 - SOP_ST1

BOX ST67HE

IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT
VALUES FOR THIS COST > 0.00, GO TO BOX ST67A.
ELSE GO TO ST67HE - PAYMHE.

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'.

ST67HE-PAYMHE

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND MAKE CORRECTIONS.

PLANINTRO

BOXST67A

routing

IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT ST66, GO TO BOX ST67B.
ELSE GO TO BOX ST69F.

BOX ST67B

routing

IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A HEALTH INSURANCE PLAN, GO TO
ST67BINT - PLANINTRO. ELSE GO TO BOX ST69E.

ST67BINT

no entry

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

routing

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT ST66
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS CURRENT, GO TO ST68 - STMHMOCHNG1.
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 ST69 - STSOPCURR1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO ST69A - STMPDPCHNG.
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 ST69B - STSOPCURR2.
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.

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?

BOX ST67C

STMHMOCHNG1 ST68

BOX ST67C

(01) ST69 - STSOPCURR1
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A

Page 12 of 14

STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

STSOPCURR1

ST69

yes/no

STMPDPCHNG

ST69A

yes/no

Question Text/Description

Code List

[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE MANAGED CARE PLAN
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

(01) HIMC6A - MHMORXTM
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A

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

STSOPCURR2

AMTSCORR

AMTSCORR

yes/no

[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?

BOX ST69A

routing

IF ANOTHER SOP WAS ADDED AT ST66, GO TO BOX ST67C.
ELSE GO TO BOX ST69E.

BOX ST69E

routing

IF AN "OTHER SOURCE OF PAYMENT" ADDED AT ST66, CREATE AN OSOP FOR EACH SOURCE OF
PAYMENT ADDED AT ST66 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX ST69F.

routing

IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)) and ((TOTAL CHARGE ^= DK and TOTAL CHARGE ^= RF) and (ALL PAYMENTS
ENTERED AT ST67 ^= DK AND ^= RF)) AND ((TOTAL CHARGE IS > TOTAL PAYMENTS ENTERED AT ST67)
AND (THE DIFFERENCE BETWEEN TOTAL CHARGE AND TOTAL PAYMENTS ENTERED AT ST67 IS > $1.00)),
GO TO ST73 - AMTSCORR.
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AT LEAST ONE PAYMENT
ENTERED AT ST67 = DK OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT ST67 ^= DK AND ^= RF) AND
(TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT ST67 IS >= AMOUNT REMAINING), GO TO ST71 AMTSCORR.
ELSE IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (ALL PAYMENTS ENTERED
AT ST67 ^= DK AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL
PAYMENTS ENTERED AT ST67 AND AMOUNT REMAINING IS > $1.00), GO TO ST70 - AMTSCORR.
ELSE GO TO BOX ST77C.

code one

(01) BOX ST77C
There seems to be (some amount still unpaid/more payments than the amount left after Medicare paid). The total of
(02) DO NOT DISPLAY.
non-Medicare payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid) is $(DIFFERENCE BETWEEN
(03) ST72 - ENTERCOM
PAYMENTS AND AMOUNT REMAINING). Is that correct?
(-8) BOX ST77C
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO
(-9) BOX ST77C
THE SOP GRID.

ST70

ST71

code one

THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE (TOTAL
CHARGE/AMOUNT REMAINING), WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL
AMOUNTS AS ENTERED.
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO
THE SOP GRID.

ENTERCOM

(01) ST69B - STSOPCURR2
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A

ST69B

BOX ST69F

ST72

no entry

[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT (UNPAID/OVERPAID)
IS $(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT REMAINING).]

Routing

BOX ST69A

(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C

BOX ST77C

USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
(01) ST74 - INFOEXPLAIN
(02) DO NOT DISPLAY.
(03) DO NOT DISPLAY.
(-8) BOX ST77C
(-9) BOX ST77C

AMTSCORR

ST73

yes/no

There seems to be some amount still unpaid. The total of non-Medicare payments is $(TOTAL PAYMENTS). The
amount unpaid is $(DIFFERENCE BETWEEN TOTAL CHARGE AND PAYMENTS). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO
THE SOP GRID.

INFOEXPLAIN

ST74

yes/no

IS THERE ADDITIONAL INFORMATION ON THE DRUG BENEFIT STATEMENT THAT EXPLAINS THE AMOUNT (01) ST75 - ENTERCOM2
STILL UNPAID?
(02) BOX ST77C

ENTERCOM2

ST75

verbatim text

USE THE BOX BELOW TO ENTER ANY INFORMATION THAT EXPLAINS THE AMOUNT STILL UNPAID.

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STQ- STATEMENT COST SERIES

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

BOX ST77C

routing

CREATE PAYMENTS FOR AMOUNTS ENTERED AT ST67
GO TO BOX ST77D.

BOX ST77D

routing

IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO ST78 EXPPAYBK.
ELSE GO TO BOX ST80.

ST78

yes/no

I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay
[you/(SP)] back any or all of that amount?

BOX ST78A

routing

IF ST78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST
COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) , GO TO ST80 - EXPAYUNT.
ELSE GO TO BOX ST80.

BOX ST78B

routing

IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND), GO TO ST79 - EXPAYOUT.
ELSE GO TO BOX ST80.

EXPAYOUT

ST79

yes/no

Do you expect anyone to pay any of this amount?

EXPAYUNT

ST80

quantity unit

How much do you expect will be paid?

EXPAYPCT
EXPAYAMT

ST80
ST80

numeric
numeric

BOX ST80

routing

IF CURRENTLY ADMINISTERING NS, GO TO BOX NSBEG.
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO ASTATEMENT.

ST82

yes/no

IS THERE ANOTHER CHARGE BUNDLE FROM THIS (TYPE OF STATEMENT) OR ANOTHER MSN,
INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT TO ENTER?

BOX STEND

routing

GO TO PSQ.

EXPPAYBK

ASTATEMENT

Code List

Routing

BOX ST78A

(01) ST80 - EXPAYUNT
(02) BOX ST80
(-8) BOX ST80
(-9) BOX ST80
(01) ST80 - EXPAYPCT
(02) ST80 - EXPAYAMT
(-8) BOX ST80
(-9) BOX ST80
BOX ST80
BOX ST80

(01) ST4 - MATCHST
(02) BOX STEND

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