Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)

Forms and Documents

Document Name	Status
Form Attachment 37 MEPS-HC Core Interview Form and Instruction	Unchanged
Form Attachment A – COV COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Form and Instruction	New
Form Attachment C Attachment C – Social and Health Experiences Self-Administered Questionnaire Form and Instruction	New
Form 106a HC Adult SAQ that includes Mental Health Questions Form and Instruction	Unchanged
Form 107a Health Insurance Cost Sharing Collection- 2020 Form and Instruction	Unchanged
Form 108 Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction	Unchanged
Form Attachment 18 Attachment 19 – HC Adult SAQ – Male Form and Instruction	Unchanged
Form Attachment 19 Attachment 20 HC Adult SAQ Female Form and Instruction	Unchanged
Form Attachment 72 MPC Contact Guide/Screening Call Form and Instruction	Unchanged
Form Attachment 26 MEPS-HC Validation Interview Form and Instruction	Unchanged
Form Attachment 24 Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	Unchanged
Form Attachment 25 Authorization form for the MEPS-MPC Provider Survey Form and Instruction	Unchanged
Form Attachment 98 Pharmacies questionnaire Form and Instruction	Unchanged
Form Attachment 96 Institutions (non-hospital) questionnaire Form and Instruction	Unchanged
Form Attachment 91 Hospitals questionnaire Form and Instruction	Unchanged
Form Attachment 87 Separately billing doctors questionnaire Form and Instruction	Unchanged
Form Attachment 83 Office based providers questionnaire Form and Instruction	Unchanged
Form Attachment 82 Home care for non health care providers questionnaire Form and Instruction	Unchanged
Form Attachment 78 Home care for health care providers questionnaire Form and Instruction	Unchanged
Form Attachment 22 Diabetes Care SAQ Form and Instruction	Unchanged
Attachment D - MEPS New Social Determinates of Care SAQ Items Crosswalk v2.docx Supplementary Document	2020-11-17
Attachment A1 - MEPS New COVID-19 Delays in Receiving Care Items Corsswalk.docx Supplementary Document	2020-11-17
response Nurse Pract FRN Comment.msg Supplementary Document	2019-07-15
Attachment 104 – MPC Veterans Affairs Authorization Form Package.docx Supplementary Document	2018-09-12
Attachment 103 – MPC Pharmacy Provider Letters., Email Templates, and Other Documents.doc Supplementary Document	2018-09-12
Attachment 102 – MPC Durable Medical Equipment Provider Authorization Form Package.docx Supplementary Document	2018-09-12
Attachment 101 – MPC Pharmacy Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 100 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 99 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated.doc Supplementary Document	2018-09-12
Attachment 97 – MPC Letters, Emal Templates, and Other Documents.docx Supplementary Document	2018-09-12
Attachment 95 – MPC Hospital Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 94 – MPC Hospital Provider Authorization Form Package, Point of Contact for Patient Account Records.doc Supplementary Document	2018-09-12
Attachment 93 – MPC Hospital Provider Authorization Form Package, Point of Contact for Medical Records.doc Supplementary Document	2018-09-12
Attachment 92 – MPC Institution Provider Questionnaire.docx Supplementary Document	2018-09-12
Attachment 90 – MPC Separately Billing Doctor Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 89 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 88 – MPC Hospital Provider Authorization Form Package,.doc Supplementary Document	2018-09-12
Attachment 86 – MPC Office-Based Doctor Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 85 – MPC Separately Billing Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 84 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers.docx Supplementary Document	2018-09-12
Attachment 81 – MPC Home Care Provider Overflow Patient List.docx Supplementary Document	2018-09-12
Attachment 80 – MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated.doc Supplementary Document	2018-09-12
Attachment 79 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated.doc Supplementary Document	2018-09-12
Attachment 28 HC Tips for Making Your MEPS Interview Easier.pdf Supplementary Document	2018-09-12
Attachment 27 HC MEPS Tip Sheet.pdf Supplementary Document	2018-09-12
Attachment 17 HC Who Uses MEPS Data.pdf Supplementary Document	2018-09-12
Attachment 16 HC Certificate of Appreciation.pdf Supplementary Document	2018-09-12
Attachment 15 HC Validation Letter.pdf Supplementary Document	2018-09-12
Attachment 14 HC Showcards.pdf Supplementary Document	2018-09-12
Attachment 13 HC MEPS Record Keeper.pdf Supplementary Document	2018-09-12
Attachment 12 HC MEPS Monthly Planner.pdf Supplementary Document	2018-09-12
Attachment 11 HC MEPS FAQs Brochure.pdf Supplementary Document	2018-09-12
Attachment 10 HC Respondent Letters, Postcards and Notes.docx Supplementary Document	2018-09-12
Attachment 9 HC Data Example and FAQs.docx Supplementary Document	2018-09-12
Attachment 8 HC Important Information About Your Participation in MEPS.pdf Supplementary Document	2018-09-12
Attachment 7 HC Respondent Recruitment Video Transcript.pdf Supplementary Document	2018-09-12
Attachment 6 HC Data Protection is word ONE with MEPS.pdf Supplementary Document	2018-09-12
Attachment 5 HC About the MEPS MPC Authorization form.pdf Supplementary Document	2018-09-12
Attachment 4 HC What MEPS tells us about Charts.docx Supplementary Document	2018-09-12
Attachment 3 HC MEPS A Survey of Health Care Use and Spending.pdf Supplementary Document	2018-09-12
Attachment 2 HC Why is Participation in MEPS so Important.pdf Supplementary Document	2018-09-12
Attachment 1 final draft.09052018..docx Supplementary Document	2018-09-12
Supporting Statement Part B -- MEPS SDOH SAQ and covid.after 30 day frn and sept 30 omb call.final 100820.docx Supporting Statement B	2020-11-17
Supporting Statement Part A -- MEPS SDOH SAQ and covid.after 30 day frn and sept 30 omb call.final 100820.v2.docx Supporting Statement A	2020-11-17

IC Document Collections

IC ID	Document Title	Status
37877	MEPS-HC Core Interview Form and Instruction	Unchanged
242880	COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire Form and Instruction	New
242879	Attachment C – Social and Health Experiences Self-Administered Questionnaire Form and Instruction	New
236894	HC Adult SAQ that includes Mental Health Questions Form and Instruction	Unchanged
236893	Health Insurance Cost Sharing Collection- 2020 Form and Instruction	Unchanged
236883	Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core Form and Instruction	Unchanged
230227	Attachment 19 – HC Adult SAQ – Male Form and Instruction	Unchanged
230226	Attachment 20 HC Adult SAQ Female Form and Instruction	Unchanged
204200	MPC Contact Guide/Screening Call Form and Instruction	Unchanged
204199	MEPS-HC Validation Interview Form and Instruction	Unchanged
204198	Authorization form for the MEPS-MPC Pharmacy Survey Form and Instruction	Unchanged
204197	Authorization form for the MEPS-MPC Provider Survey Form and Instruction	Unchanged
191107	Pharmacies questionnaire Form and Instruction	Unchanged
191106	Institutions (non-hospital) questionnaire Form and Instruction	Unchanged
191105	Hospitals questionnaire Form and Instruction	Unchanged
191104	Separately billing doctors questionnaire Form and Instruction	Unchanged
191103	Office based providers questionnaire Form and Instruction	Unchanged
191102	Home care for non health care providers questionnaire Form and Instruction	Unchanged
191101	Home care for health care providers questionnaire Form and Instruction	Unchanged
191099	Diabetes Care SAQ Form and Instruction	Unchanged

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 202007-0935-001
Status: Active	Previous ICR Reference No: 201907-0935-002
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/18/2020
	Date Received in OIRA: 08/04/2020
Terms of Clearance: *

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved	11/30/2022
Responses	379,377	0	338,980
Time Burden (Hours)	88,309	0	84,930
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of this request is to integrate several items into MEPS including several new questions related to COVID-19 (Attachment A) including telehealth (telemedicine) questions (Attachment B) into the CAPI questionnaire and a new self-administered questionnaire (SAQ) entitled, “Social and Health Experiences,” (see Attachment C). The questions on COVID-19 capture information on any delay in care due to COVID-19. The questions will be administered through an RU level gate question with follow up questions asked at the person level as appropriate. Telehealth (telemedicine) will be administered as its own event type with questions and probes mirroring those used for in-person medical provider visits. The Social and Health Experiences SAQ will include questions in a dual mode (web and paper) self-administered questionnaire about social and behavioral determinants of health including questions about housing affordability and quality, neighborhood characteristics, food security, transportation needs, financial strain, smoking and physical activity, and experiences with discrimination, social support, general well-being, personal safety, and adverse circumstances in childhood. Data collection will be for eligible adults (aged 18 and over). AHRQ proposes a mixed-mode (web and paper) primarily to further protect respondent’s privacy due to the sensitive nature of some of the items. Web completion will be the main mode with paper offered to those with barriers to internet access. In addition, due to COVID-19, in March of 2020, MEPS moved to telephone interviewing for all panels and rounds currently in the field with increased use of the web to facilitate respondent reporting; for example the use of showcards. The current plan is resume at least some face-to-face interviewing during the fall rounds for Panels 23, 24, and 25. Moreover, Panels 23 and 24 are to be extended one year with the creation of Round 6 and 7 interviews in order to contribute to the data collected for data years 2020 and 2021. The data collected will offset any impact on response rates due to the pandemic or changes in primary mode for data collection.

---

Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Agency for Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 27225	05/07/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 47214	08/04/2020
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 20

IC Title	Form No.	Form Name
Office based providers questionnaire	Attachment 83	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Separately billing doctors questionnaire	Attachment 87	Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
Hospitals questionnaire	Attachment 91	Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire	Attachment 96	Attachment 96 – MPC Institution Provider Questionnaire
Attachment 20 HC Adult SAQ Female	Attachment 20 , Attachment 19	Attachment 19 HC Adult SAQ Male ,   Attachment 20 HC Adult SAQ Female
Attachment 19 – HC Adult SAQ – Male	Attachment 19 , Attachment 18	Attachment 18 HC Adult SAQ ,   Attachment 19 – HC Adult SAQ – Male
MEPS-HC Core Interview	Attachment 32 , Attachment 33 , Attachment 34, Attachment 35 , Attachment 36 , Attachment 37 , Attachment 39 , Attachment 40 , Attachment 41 , Attachment 42 , Attachment 43 , Attachment 57 , Attachment 58 , Attachment 59 , Attachment 60 , Attachment 44 , Attachment 46 , Attachment 47 , Attachment 48 , Attachment 49 , Attachment 50 , Attachment 51 , Attachment 53 , Attachment 52 HC, Attachment 54 , Attachment 55 , Attachment 56 , Attachment 29, Attachment 30 , Attachment 31 , Attachment 61 , Attachment 62 , Attachment 63 , Attachment 64 , Attachment 65 , Attachment 66 , Attachment 38 , Attachment 67 , Attachment 68 , Attachment 69 , Attachment 70 , Attachment 71 , Attachment 45	Attachment 37 HC Flat Fee Section ,   Attachment 38 – HC Child Preventive Health Supplement Section ,   Attachment 39 – HC Institutional Care Section ,   Attachment 40 – HC Dental Care Section ,   Attachment 41 – HC Event Driver Section ,   Attachment 42 – HC Employment (EM) Section ,   Attachment 43 – HC Review of Employment Information (RJ) Section ,   Attachment 44 – HC Employment Driver (OE) Section ,   Attachment 45 – HC Employment Wage (EW) Section ,   Attachment 46 – HC Emergency Room Section ,   Attachment 47 Event Roster Section ,   Attachment 48 Health Status Section ,   Attachment 49 HC Help Text ,   Attachment 50 Home Health Section ,   Attachment 51 Health Insurance (HX) Section ,   Attachment 52 HC Private Health Insurance Detail (HP) Section ,   Attachment 53 HC Time Covered Detail (HQ) Section ,   Attachment 54 HC Managed Care (MC) Section ,   Attachment 55 HC Old Employment Health Insurance (OE) Section ,   Attachment 56 HC Old Public Related Insurance (PR) Section ,   Attachment 57 HC Hospital Stay Section ,   Attachment 58 HC Income Section ,   Attachment 59 HC Medical Provider Section ,   Attachment 60 HC Other Medical Expense Section ,   Attachment 61 HC Outpatient Department Section ,   Attachment 62 HC Quality Supplement Section ,   Attachment 63 HC Respondent Forms Section ,   Attachment 64 HC Priority Conditions Enumeration Section ,   Attachment 65 HC Prescribed Medicines Section ,   Attachment 66 HC Provider Probes Section ,   Attachment 67 HC Provider Roster Section ,   Attachment 68 HC Reenumeration Subsection ,   Attachment 69 HC Reenumeration Subsection B ,   Attachment 70 HC RU Information Screener ,   Attachment 71 HC Event Follow Up Section ,   Attachment 29 –HC Access to Care Section ,   Attachment 30 – HC Condition Enumeration Section ,   Attachment 31 – Attachment 31 HC Assets Section. ,   Attachment 32 – Attachment 32 HC Calendar Section ,   Attachment 33 Additional healthcare Section ,   Attachment 34 HC Closing Section ,   Attachment 35 HC Start_Restart ,   Attachment 36 HC Charge Payment Section
Diabetes Care SAQ	Attachment 22, Attachment 23	Attachment 22 -- HC Diabetes SAQ - Proxy ,   Attachment 23 -- HC Diabetes SAQ - Self
Home care for health care providers questionnaire	Attachment 78	Attachment 78 – MPC Home Care Provider Questionnaire for Health Care Providers
Home care for non health care providers questionnaire	Attachment 82	Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
Attachment C – Social and Health Experiences Self-Administered Questionnaire	Attachment C	Attachment C
COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire	Attachment B, Attachment A – COVID-19 Questions	Attachment A – COVID-19 Questions ,   Attachment B
Pharmacies questionnaire	Attachment 98	Attachment 98 – MPC Pharmacy Provider Questionnaire
Authorization form for the MEPS-MPC Provider Survey	Attachment 25	Attachment 25 HC Authorization Form for the MEPS MPC Provider
Authorization form for the MEPS-MPC Pharmacy Survey	Attachment 24	Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
MEPS-HC Validation Interview	Attachment 26	Attachment 26 HC MEPS Validation Interview
MPC Contact Guide/Screening Call	Attachment 72 , Attachment 73 , Attachment 74 , Attachment 75 , Attachment 76 , Attachment 77	Attachment 72 – MPC Hospital Contact Guide ,   Attachment 73 – MPC Office-Based Doctor Contact Guide ,   Attachment 74 – MPC Home Care Contact ,   Attachment 75 – MPC Institution Contact Guide ,   Attachment 76 – MPC Pharmacy Contact Guide ,   Attachment 77 – MPC Separate Billing Doctor Contact Guide
HC Adult SAQ that includes Mental Health Questions	106a, 106b	Attachment 106a.REV_Female PSAQ with Mental Health Content ,   Attachment106b.REV_Male PSAQ with Mental Health Content
Health Insurance Cost Sharing Collection- 2020	107b, 107a, 107c, 107d	Attachment 107a.Protocol A (Medicare) ,   Attachment 107b.Protocol B (Employer) ,   Attachment 107c.Protocol C (Private with Medicare)_ ,   Attachment 107d.Protocol D (Other)
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	108	Attachment 108 - Household Component Core Instrument Link

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	379,377	338,980	0	40,397	0	0
Annual Time Burden (Hours)	88,309	84,930	0	3,379	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total estimated annual burden hours for the MEPS increased 3,379 hours is due to the addition of the COVID-19 related questions, including telehealth (telemedicine) questions, and the Social and Health Experiences Adult SAQ. This is a one-time increase for 2021 only.

---

Annual Cost to Federal Government: $1,182,500

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/04/2020

---