Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 202011-0938-011 · OMB 0938-0568.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0568 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form
CMS-P-0015A Cost Payment Summary 2021_Cost_Payment_Summary_CPS.pdf	Form
CMS-P-0015A Cost Payment Summary 2021_Cost_Payment_Summary_CPS.pdf	Form
CMS-P-0015A Demographic Income 2020_Demographics_and_Income_DIQ.pdf	Form
CMS-P-0015A Demographic Income 2020_Demographics_and_Income_DIQ.pdf	Form
CMS-P-0015A End Questionaire 2020_End_END.pdf	Form
CMS-P-0015A End Questionaire 2020_End_END.pdf	Form
CMS-P-0015A Enumeration Summary 2019_Enumeration_Summary_ENS.pdf	Form
CMS-P-0015A Enumeration Summary 2019_Enumeration_Summary_ENS.pdf	Form
CMS-P-0015A Home Health Summary 2018_Home_Health_Summary_HHS.pdf	Form
CMS-P-0015A Home Health Summary 2018_Home_Health_Summary_HHS.pdf	Form
CMS-P-0015A interviewer Remarks 2019_Interviewer_Remarks_IRQ.pdf	Form
CMS-P-0015A interviewer Remarks 2019_Interviewer_Remarks_IRQ.pdf	Form
CMS-P-0015A Mobility of Beneficiaries 2020_Mobility_of_Beneficiaries_MBQ.pdf	Form
CMS-P-0015A Mobility of Beneficiaries 2020_Mobility_of_Beneficiaries_MBQ.pdf	Form
CMS-P-0015A Post Statement Cost 2019_Post_Statement_Cost_PSQ.pdf	Form
CMS-P-0015A Post Statement Cost 2019_Post_Statement_Cost_PSQ.pdf	Form
CMS-P-0015A Access to Care 2020_Access_to_Care_ACQ.pdf	Form
CMS-P-0015A Access to Care 2020_Access_to_Care_ACQ.pdf	Form
CMS-P-0015A Chronic Pain 2020_Chronic_Pain_CPQ.pdf	Form
CMS-P-0015A Chronic Pain 2020_Chronic_Pain_CPQ.pdf	Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2021_Dental_Vision_and_Hearing_Utilization_DVH.pdf	Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2021_Dental_Vision_and_Hearing_Utilization_DVH.pdf	Form
CMS-P-0015A Drug Coverage 2020_Drug_Coverage_RXQ.pdf	Form
CMS-P-0015A Drug Coverage 2020_Drug_Coverage_RXQ.pdf	Form
CMS-P-0015A Emergency Utilization 2019_Emergency_Utilization_ERQ.pdf	Form
CMS-P-0015A Emergency Utilization 2019_Emergency_Utilization_ERQ.pdf	Form
CMS-P-0015A Health Insurance 2020_Health_Insurance_HIQ.pdf	Form
CMS-P-0015A Health Insurance 2020_Health_Insurance_HIQ.pdf	Form
CMS-P-0015A Home Health 2020_Home_Health_Utilization_HHQ.pdf	Form
CMS-P-0015A Home Health 2020_Home_Health_Utilization_HHQ.pdf	Form
CMS-P-0015A Housing_Characteristics 2021_Housing_Charcs_HAQ.pdf	Form
CMS-P-0015A Housing_Characteristics 2021_Housing_Charcs_HAQ.pdf	Form
CMS-P-0015A Income_and_ Assets 2019_Income_and_ Assets_IAQ.pdf	Form
CMS-P-0015A Income_and_ Assets 2019_Income_and_ Assets_IAQ.pdf	Form
CMS-P-0015A Inpatient Utilization 2021_Inpatient_Utilization_IPQ.pdf	Form
CMS-P-0015A Inpatient Utilization 2021_Inpatient_Utilization_IPQ.pdf	Form
CMS-P-0015A Institutional Utilization 2020_Institutional_Utilization_IUQ.pdf	Form
CMS-P-0015A Institutional Utilization 2020_Institutional_Utilization_IUQ.pdf	Form
CMS-P-0015A Introduction 2020_Introduction_INQ.pdf	Form
CMS-P-0015A Introduction 2020_Introduction_INQ.pdf	Form
CMS-P-0015A Medical Provider Utilzation 2021_Medical_Provider_Utilization_MPQ.pdf	Form
CMS-P-0015A Medical Provider Utilzation 2021_Medical_Provider_Utilization_MPQ.pdf	Form
CMS-P-0015A Nicotine Alcohol 2019_Nicotine_Alcohol_Use_NAQ.pdf	Form
CMS-P-0015A Nicotine Alcohol 2019_Nicotine_Alcohol_Use_NAQ.pdf	Form
CMS-P-0015A No Statement Cost 2021_No_Statement_Cost_Series_NSQ.pdf	Form
CMS-P-0015A No Statement Cost 2021_No_Statement_Cost_Series_NSQ.pdf	Form
CMS-P-0015A Other Medical Expense 2019_Other_Medical_Expenses_OMQ.pdf	Form
CMS-P-0015A Other Medical Expense 2019_Other_Medical_Expenses_OMQ.pdf	Form
CMS-P-0015A Outpatient Utilization 2019_Outpatient_Util_OPQ.pdf	Form
CMS-P-0015A Outpatient Utilization 2019_Outpatient_Util_OPQ.pdf	Form
CMS-P-0015A Prescribed Medicine Utilization 2021_Prescribed_Medicine_Utilization_PMQ.pdf	Form
CMS-P-0015A Prescribed Medicine Utilization 2021_Prescribed_Medicine_Utilization_PMQ.pdf	Form
CMS-P-0015A Satisfaction Care 2020_Satisfaction_with_Care_SCQ.pdf	Form
CMS-P-0015A Satisfaction Care 2020_Satisfaction_with_Care_SCQ.pdf	Form
CMS-P-0015A Statement Cost Series 2021_Statement_Cost_Series_STQ.pdf	Form
CMS-P-0015A Statement Cost Series 2021_Statement_Cost_Series_STQ.pdf	Form
CMS-P-0015A Beneficiary Knowledge 2021_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf	Form
CMS-P-0015A Beneficiary Knowledge 2021_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf	Form
CMS-P-0015A Preventive Care 2021_Preventive_Care_PVQ.pdf	Form
CMS-P-0015A Preventive Care 2021_Preventive_Care_PVQ.pdf	Form
CMS-P-0015A Usual Source of Care 2021_Usual_Source_of_Care_USQ.pdf	Form
CMS-P-0015A Usual Source of Care 2021_Usual_Source_of_Care_USQ.pdf	Form
CMS-P-0015A Showcards and Reference Cards 2021CommShowcards.pdf	Form
CMS-P-0015A Showcards and Reference Cards 2021CommShowcards.pdf	Form
CMS-P-0015A Facility Showcards 2019FacilityShowcards508.pdf	Form
CMS-P-0015A Facility Showcards 2019FacilityShowcards508.pdf	Form
CMS-P-0015A Facility Screener Fac2019_Fac_Screener_FACSCREEN.pdf	Form
CMS-P-0015A Facility Screener Fac2019_Fac_Screener_FACSCREEN.pdf	Form
CMS-P-0015A Residence History Missing Data Fac2019_Residence_Missing_RHM.pdf	Form
CMS-P-0015A Residence History Missing Data Fac2019_Residence_Missing_RHM.pdf	Form
CMS-P-0015A Residence History Fac2021_Residence_History_RH.pdf	Form
CMS-P-0015A Residence History Fac2021_Residence_History_RH.pdf	Form
CMS-P-0015A Use of Health Services Fac2020_Health_Status_HS.pdf	Form
CMS-P-0015A Use of Health Services Fac2020_Health_Status_HS.pdf	Form
CMS-P-0015A Background_Questionnaire Fac2019_Background_Questionnaire_BQ.pdf	Form
CMS-P-0015A Background_Questionnaire Fac2019_Background_Questionnaire_BQ.pdf	Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2019_Background_Questionnaire_Missing_Data_BQM.pdf	Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2019_Background_Questionnaire_Missing_Data_BQM.pdf	Form
CMS-P-0015A Expenditures Fac2019_Expenditures_EX.pdf	Form
CMS-P-0015A Expenditures Fac2019_Expenditures_EX.pdf	Form
CMS-P-0015A Questionaire Missing Data Fac2020_Facility_Missing_FQM.pdf	Form
CMS-P-0015A Questionaire Missing Data Fac2020_Facility_Missing_FQM.pdf	Form
CMS-P-0015A Questionaire Fac2020_Facility_Quex_FQ.pdf	Form
CMS-P-0015A Questionaire Fac2020_Facility_Quex_FQ.pdf	Form
CMS-P-0015A Health_Insurance Fac2019_Health_Insurance_IN.pdf	Form
CMS-P-0015A Health_Insurance Fac2019_Health_Insurance_IN.pdf	Form
CMS-P-0015A Health_Status Fac2020_Health_Status_HS.pdf	Form
CMS-P-0015A Health_Status Fac2020_Health_Status_HS.pdf	Form
CMS-P-0015A Health Status Attachment A - R88 HFQ.PDF	Form
CMS-P-0015A Health Status Attachment A - R88 HFQ.PDF	Form
CMS-P-0015A Cognitive Measures 2020_Cognitive_Measures_CMQ.pdf	Form
CMS-P-0015A Cognitive Measures 2020_Cognitive_Measures_CMQ.pdf	Form
CMS-P-0015A Health_Status_and_Functioning 2021_Health_Status_and_Functioning_HFQ.pdf	Form
CMS-P-0015A Health_Status_and_Functioning 2021_Health_Status_and_Functioning_HFQ.pdf	Form
CMS-P-0015A Physical_Measures 2021_Physical_Measures_PXQ.pdf	Form
CMS-P-0015A Physical_Measures 2021_Physical_Measures_PXQ.pdf	Form
CMS-P-0015A interviewer Remarks Fac2019_Interviewer_Remarks_IR.pdf	Form
CMS-P-0015A interviewer Remarks Fac2019_Interviewer_Remarks_IR.pdf	Form
P-0015A COVID-19 Questionnaire Specifications 2021_COVID19_CVQ.pdf	Form
P-0015A COVID-19 Questionnaire Specifications 2021_COVID19_CVQ.pdf	Form
P-0015A MCBS COVID-19 Winter 2021 Facility Supplement Fac2021_COVID19_CV.pdf	Form
P-0015A MCBS COVID-19 Winter 2021 Facility Supplement Fac2021_COVID19_CV.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-P-0015A	Cost Payment Summary	2021_Cost_Payment_Summary_CPS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Demographic Income	2020_Demographics_and_Income_DIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	End Questionaire	2020_End_END.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Enumeration Summary	2019_Enumeration_Summary_ENS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health Summary	2018_Home_Health_Summary_HHS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	interviewer Remarks	2019_Interviewer_Remarks_IRQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Mobility of Beneficiaries	2020_Mobility_of_Beneficiaries_MBQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Post Statement Cost	2019_Post_Statement_Cost_PSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Access to Care	2020_Access_to_Care_ACQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Chronic Pain	2020_Chronic_Pain_CPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Dental, Vision, and Hearing Care Utilization	2021_Dental_Vision_and_Hearing_Utilization_DVH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Drug Coverage	2020_Drug_Coverage_RXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Emergency Utilization	2019_Emergency_Utilization_ERQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Insurance	2020_Health_Insurance_HIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health	2020_Home_Health_Utilization_HHQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Housing_Characteristics	2021_Housing_Charcs_HAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Income_and_ Assets	2019_Income_and_ Assets_IAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Inpatient Utilization	2021_Inpatient_Utilization_IPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Institutional Utilization	2020_Institutional_Utilization_IUQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Introduction	2020_Introduction_INQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Medical Provider Utilzation	2021_Medical_Provider_Utilization_MPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Nicotine Alcohol	2019_Nicotine_Alcohol_Use_NAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	No Statement Cost	2021_No_Statement_Cost_Series_NSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Other Medical Expense	2019_Other_Medical_Expenses_OMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Outpatient Utilization	2019_Outpatient_Util_OPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Prescribed Medicine Utilization	2021_Prescribed_Medicine_Utilization_PMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Satisfaction Care	2020_Satisfaction_with_Care_SCQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Statement Cost Series	2021_Statement_Cost_Series_STQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Beneficiary Knowledge	2021_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Preventive Care	2021_Preventive_Care_PVQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Usual Source of Care	2021_Usual_Source_of_Care_USQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Showcards and Reference Cards	2021CommShowcards.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Showcards	2019FacilityShowcards508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Screener	Fac2019_Fac_Screener_FACSCREEN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History Missing Data	Fac2019_Residence_Missing_RHM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History	Fac2021_Residence_History_RH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Use of Health Services	Fac2020_Health_Status_HS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire	Fac2019_Background_Questionnaire_BQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire MIssing Data	Fac2019_Background_Questionnaire_Missing_Data_BQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Expenditures	Fac2019_Expenditures_EX.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire Missing Data	Fac2020_Facility_Missing_FQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire	Fac2020_Facility_Quex_FQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Insurance	Fac2019_Health_Insurance_IN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status	Fac2020_Health_Status_HS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Status	Attachment A - R88 HFQ.PDF	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Cognitive Measures	2020_Cognitive_Measures_CMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status_and_Functioning	2021_Health_Status_and_Functioning_HFQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Physical_Measures	2021_Physical_Measures_PXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	interviewer Remarks	Fac2019_Interviewer_Remarks_IR.pdf	Yes	Yes	Fillable Fileable
Form	P-0015A	COVID-19 Questionnaire Specifications	2021_COVID19_CVQ.pdf	Yes	Yes	Fillable Fileable
Form	P-0015A	MCBS COVID-19 Winter 2021 Facility Supplement	Fac2021_COVID19_CV.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35,998

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	35,998	0	35,998
Annual IC Time Burden (Hours)	54,426	10,063	44,363
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.