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pdf2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
(01) ALWAYS
(02) SOMETIMES
(03) NEVER
(01) ST2 - MCSAVAIL
(02) ST2 - MCSAVAIL
(03) BOX STEND
[996] LEAVE COST SERIES AND SKIP TO MBQ
(‐8) DON'T KNOW
(‐9) REFUSED
[996] MBQ
(‐8) ST2 ‐ MCSAVAIL
(‐9) ST2 ‐ MCSAVAIL
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
[Do you/Does (SP)] usually receive any statements or papers from Medicare, insurance, such as (MANAGED
CARE PLAN NAME), or TRICARE that show the charges for medical visits or equipment?/Last time, we
recorded that [you/(SP)] (always/sometimes/never) received statements or papers from Medicare, insurance, or
TRICARE that show the charges for medical visits or equipment.]
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].
MCSAVAIL
ST2
yes/no
[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 (01) YES
(02) NO
Medicare, any insurance company, or TRICARE.]
(01) ST3 - STHIREP
(02) BOX STEND
[996] LEAVE COST SERIES AND SKIP TO MBQ
[PROBE IF NECESSARY: Do you have any statements or paper from Medicare, insurance, or TRICARE [that (‐8) DON'T KNOW
[you/(SP)] received since the last interview]? (Please include any statements received about [your/(SP's)]
(‐9) REFUSED
[996] MBQ
(‐8) BOX STEND
(‐9) BOX STEND
BASED ON THE INFORMATION RECORDED IN THE HEALTH INSURANCE SECTION FOR RECENT
ROUNDS, THE PLAN(S) LISTED BELOW ARE THE SOURCES OF STATEMENTS YOU MIGHT EXPECT TO
FIND FOR THIS SP.
ST4 - MATCHST
prescription drug benefit.)]
STHIREP
ST3
no entry
MATCHST
ST4
no entry
[MATCH UP MEDICARE, INSURANCE, TRICARE, AND MEDICARE PRESCRIPTION BENEFIT
STATEMENTS BY PROVIDER AND DATE OF SERVICE./PRESS ENTER TO CONTINUE TO THE NEXT
(STATEMENT/BUNDLE).]
ST5 - ST_CHARGEBUNDLE
ST_CHARGEBUNDLE
ST5
roster
ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE (FIRST/NEXT) BUNDLE OF EVENTS.
ADD ONE CHARGE BUNDLE AT THIS ROSTER.
STTYPE (HAD BEEN BOX ST5A)
Page 1 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
(01) MEDICARE SUMMARY NOTICE (MSN) ONLY
(02) INSURANCE STATEMENT ONLY
(03) BOTH MEDICARE SUMMARY NOTICE (MSN)
STTYPE
MCARTYPE
PDPTYPE
ST5AA
code one
SELECT SOURCE OF THE STATEMENT(S) FOR THIS CHARGE BUNDLE
ST5AAA
code one
WHICH TYPE OF MEDICARE STATEMENT DO YOU HAVE TO ENTER? [SEE REFERENCE CARDS FOR
MEDICARE STATEMENT EXAMPLES]
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.
(01) ST5AA-MCARTYPE
AND INSURNACE STATEMENT
(02) BOX ST5A
(04) TRICARE STATEMENT ONLY
(03) ST5AA-MCARTYPE
(05) BOTH MEDICARE SUMMARY NOTICE (MSN) AND (04) BOX ST5A
TRICARE STATEMENTS
(05) ST5AA-MCARTYPE
(06) BOX ST5A
(06) BOTH TRICARE AND INSURNACE STATEMENTS
(07) ST5AA-MCARTYPE
(07) MEDICARE SUMMARY NOTICE (MSN) AND
(08) BOX ST5A
TRICARE AND INSURANCE STATEMENTS
(08) MPDP STATEMENT OR MA/TRICARE PRESCIRPTION [996] MBQ
DRUG BUNDLE
[996] LEAVE COST SERIES AND SKIP TO MBQ
(01) MEDICARE SUMMARY NOTICE: PART B
MEDICAL INSURANCE - ASSIGNED OR
UNASSIGNED (EXAMPLE 1)
(02) MEDICARE SUMMARY NOTICE: PART B
MEDICAL INSURNACE OUTPATIENT FACILITY
CLAIMS (EXAMPLE 2)
(03) MEDICARE SUMMARY NOTICE: PART A
BOX ST5A
HOSPITAL INSURANCE INPATIENT CLAIMS
(EXAMPLE 3)
(04) MEDICARE SUMMARY NOTICE: HOME HEALTH
CARE CLAIMS (EXAMPLE 4)
(05) MEDICARE SUMMARY NOTICE: PART A
HOSPICE FACILITY CLAIMS (EXAMPLE 5)
(01) MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT
(02) MEDICARE ADVANTAGE STATEMENT
(03) TRICARE STATEMENT
BOX ST5B
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.
[INSERT TEXT BOX 1 FOR CLAIM 1]
(01) CONTINUOUS ANSWER
[996] LEAVE COST SERIES AND SKIP TO MBQ
(‐8) DON'T KNOW
ST7 - MSNCLNM2
[996] MBQ
IF THERE ARE MULTIPLE CLAIM NUMBERS ASSOCIATED WITH THE CLAIM TOTAL, ENTER BELOW:
[INSERT REMAINING TEXT BOXES]
MSNCLNM2
ST7
text
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ST7 - MSNCLNM3
Page 2 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
MSNCLNM3
ST7
text
MSNCLNM4
ST7
text
MSNCLNM5
ST7
text
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.
(01) CONTINUOUS ANSWER
BOX ST8
routing
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM,
GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
MSCLVER1
Question Text/Description
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM THE MEDICARE SUMMARY NOTICE
(MSN) DIFFERENTLY.
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)
WHICHNUM
ST9
Code List
code one
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)
Routing
ST7 - MSNCLNM4
ST7 - MSNCLNM5
BOX ST7
BOX ST8
(01) FIRST
(02) SECOND
(03) NEITHER
(01) BOX ST9
(02) BOX ST9
(03) ST9 - NEWCLNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST9
WHICH IS CORRECT?
NEWCLNUM
INSCLNUM
ST9
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
(01) CONTINUOUS ANSWER
ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE STATEMENT. IF NO CLAIM CONTROL
[996] LEAVE COST SERIES AND SKIP TO MBQ
NUMBER LISTED, USE F8 TO SELECT 'DON'T KNOW .
(‐8) DON'T KNOW
BOX ST10
[996] MBQ
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".
PDPBEGMM
ST11B
date
ENTER THE BEGINNING AND ENDING DATES OF SERVICE FROM THE PRESCRIPTION DRUG BENEFIT (01) CONTINUOUS ANSWER
STATEMENT.
(-8) DON'T KNOW
BEGINNING DATE:
(-9) REFUSED
ST11B - PDPBEGDD
PDPBEGDD
ST11B
date
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST11B - PDPBEGYY
PDPBEGYY
ST11B
date
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST11B - PDPENDMM
PDPENDMM
ST11B
date
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST11B - PDPENDDD
PDPENDDD
ST11B
date
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST11B - PDPENDYY
PDPENDYY
ST11B
date
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST12 - INCTYPE
ENDING DATE:
(01) CONTINUOUS ANSWER
[996] LEAVE COST SERIES AND SKIP TO MBQ
(‐8) DON'T KNOW
ST12 - INCTYPE
[996] MBQ
Page 3 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
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.
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES
BOX ST12
BOX ST12
routing
IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates OR 2/HOME HEALTH VISITS, GO TO
ST13 - PROVIDER_STDATE.
ELSE GO TO BOX ST33.
PROVIDER_STDATE
ST13
roster
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
[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.
"IF EXISTING PROVIDER SELECTED, GO TO ST14 STDATEUPD.
ELSE IF ""ADD ANOTHER"" SELECTED, GO TO
PROV"
[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
ST13
verbatim
GROUP:
ST14 - STDATEUPD
STDATEUPD
ST14
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
(01) ST24 - EVENT_STDATE
(02) VISTYPE-VISITYPE
(03) ST15 - EVENT_STDATEDIT
ST16 - EVENT
ST16-EVENT
VISITYPE
VISTYPE
select one
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)
(11) Home Health Professional (HP)
(12) Home Health Friend, Neighbor. or Relative (HF)
EVENT_STDATEDIT
ST15
roster
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
(01) CONTINUOUS ANSWER
Page 4 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
[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.
Code List
Routing
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
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.]
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 FOR THIS PROVIDER IS 'HP' OR 'HF' AND [(VISITYPE IS
11/HP AND THE PROVIDER SPECIALTY HAS BEEN COLLECTED) OR (VISITYPE IS 12/HF AND HHFTYPE
IS KNOWN (HHFTYPE =1 OR 2))], GO TO ST24-EVENT_STDATE.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU' , 'IP', 'OP', 'HP', 'HF', 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 IF VISITYPE is 11/HP AND THE PROVIDER SPECIALTY HAS NOT BEEN COLLECTED, GO TO ST4PROFWORK.
ELSE IF VISITYPE IS 12/HF AND HHFTYPE IS UNKNOWN (HHFTYPE = ., -7, -9), GO TO ST18EHHFTYPE.
ELSE GO TO BOX ST18.
BOX ST16A
STDATEINTRO
BOX ST17
BOX ST17
Page 5 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
PROVSPEC
ST18
code one
PROVSPOS
ST18
text
PROVSPEC
ST18A
code one
Question Text/Description
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)
What kind of medical person is (PROVIDER NAME)?
(17) OSTEOPATH (DO)
(18) PARAMEDIC
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY
(01)-(34), (42), (-8), (-9) BOX ST18
(42) PHARMACIST
NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES
(91) ST18 - PROVSPOS
FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT (19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
LISTED BELOW, BUT LISTED ON MPQ JOB AID 1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL
(21) PODIATRIST (FOOT DOCTOR)
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
OTHER MEDICAL PROVIDER (SPECIFY)
(01) CONTINUOUS ANSWER
BOX ST18
What kind of dental provider is [PROVNAME]?
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(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
Page 6 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
(01) DENTIST/DENTAL PROVIDER (DO NOT
DISPLAY)
(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)
(01)-(34), (-8), (-9) BOX ST18
(18) PARAMEDIC
(91) ST18A - PROVSPOS
(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
PROVSPEC
ST18A1
code one
What kind of dental provider is [PROVNAME]?
PROVPOS
ST18A
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX ST18
What kind of eye care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX ST18
(16) BOX ST18
(43) BOX ST18
(91) ST18B1- PROVSPEC
(-8) BOX ST18
(-9) BOX ST18
PROVSPEC
ST18B
code one
Page 7 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
PROVSPEC
ST18B1
code one
What kind of eye care provider is [PROVNAME]?
(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
(01)-(34), (-8), (-9) BOX ST18
(19) PHYSICAL THERAPIST (PT)
(91) ST18B - PROVSPOS
(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
PROVPOS
ST18B
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX ST18
What kind of hearing care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
(02) BOX ST18
(03) BOX ST18
(44) BOX ST18
(45) BOX ST18
(91) ST18C1- PROVSPEC
(-8) BOX ST18
(-9) BOX ST18
PROVSPEC
ST18C
code one
Page 8 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
PROVSPEC
ST18C1
code one
What kind of hearing care provider is [PROVNAME]?
(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
(01)-(34), (-8), (-9) BOX ST18
(19) PHYSICAL THERAPIST (PT)
(91) ST18C - PROVSPOS
(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
PROVPOS
ST18C
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX ST18
ST4
code one
(01) WORKS FOR ORGANIZATION
(02) WORKS FOR SELF
(-8) DON'T KNOW
(-9) REFUSED
ST18D-PROVSPEC
PROFWORK
Does this health or medical professional work for a place or organization?
[PROBE: Or does this health or medical professional work for himself/herself?]
Page 9 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
What kind of health professional [is (PROVIDER NAME)/did [you/(SP)] see from (PROVIDER NAME)]?
[SELECT THE RESPONSE 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.']
PROVSPEC
ST18D
code one
PROVSPOS
ST18D
text
OTHER MEDICAL PROVIDER (SPECIFY)
BOX STHH1AA
routing
IF ST4 -PROFWORK = 1/Works for Organization, GO TO ST6 - HHPLACE.
ELSE GO TO BOX ST18.
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
(01)-(34), (-8), (-9) BOX ST18 BOX STHH1AA
(19) PHYSICAL THERAPIST (PT)
(91) ST16D - PROVSPOS
(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
BOX STHH1AA
HHPLACE
ST6
code one
PROVIDER NAME: (PROVIDER NAME)
What kind of place or organization is (PROVIDER NAME)?
(01) MANAGED CARE PLAN (SUCH AS HMO)
(02) MEAL PROGRAM (SUCH AS MEALS ON
WHEELS)
(03) VISITING NURSE ASSOCIATION
(04) HOME HEALTH AGENCY
(05) HOSPITAL
(06) PRIVATE PHYSICIAN/GROUP PRACTICE
(07) HOSPICE
(08) REHABILITATION OR SPORTS MEDICINE
THERAPY
(09) LOCAL GOVERNMENT ORGANIZATION
(10) CHURCH OR COMMUNITY ORGANIZATION
(11) ASSISTED LIVING/RETIREMENT HOME
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
HHPLACOS
ST6
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
(01) BOX ST18
(02) ST7-OTHMEALS
(03) BOX ST18
(04) BOX ST18
(05) BOX ST18
(06) BOX ST18
(07) BOX ST18
(08) BOX ST18
(09) BOX ST18
(10) BOX ST18
(11) BOX ST18
(91) ST6 - HHPLACOS
(-8) BOX ST18
(-9) BOX ST18
BOX ST18
Page 10 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
OTHMEALS
ST7
yes/no
[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did (PROVIDER NAME) provide any services to [you/(SP)] other than
delivering meals?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST18
Is (PROVIDER NAME) a friend, neighbor, or a relative?
(01) FRIEND OR NEIGHBOR
(02) RELATIVE
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST18
(02) HHFRELAT
(03) BOX ST18
(-8) BOX ST18
(-9) BOX ST18
HHFTYPE
ST18E
code one
HHFRELAT
ST18F
code one
How is (PROVIDER NAME) related to [you/(SP)]?
[CLASSIFY ANY “STEP” RELATIONSHIP WITH THE RELATED “NON-STEP” RELATIONSHIP (E.G., STEPDAUGHTER = DAUGHTER).]
HHFRELOS
ST18F
text
OTHER (SPECIFY)
BOX ST18
routing
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX ST18
(03) BOX ST18
(04) BOX ST18
(05) BOX ST18
(06) BOX ST18
(07) BOX ST18
(08) BOX ST18
(09) BOX ST18
(10) BOX ST18
(11) BOX ST18
(12) BOX ST18
(13) BOX ST18
(14) BOX ST18
(51) BOX ST18
(52) BOX ST18
(53) BOX ST18
(54) BOX ST18
(55) BOX ST18
(56) BOX ST18
(57) BOX ST18
(91) HH21 ‐ HHFRELOS
(‐8) BOX ST18
(‐9) BOX ST18
(01) CONTINUOUS ANSWER
BOX ST18
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST19
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', 'IU', 'HP', 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
BOX ST19
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?
routing
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU'', 'ER', 'IP', 'OP,' 'HP', 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', 'HP', 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.
Page 11 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
HMOASSOC
ST20
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST22A
(02) ST21 - HMOREFER
(-8) ST21 - HMOREFER
(-9) ST21 - HMOREFER
HMOREFER
ST21
yes/no
(01) YES
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]? (02) NO
(-8) DON'T KNOW
(-9) REFUSED
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 IF TYPE OF EVENT = 'HP' OR 'HF' AND NEEDNURS HAS NOT BEEN ASKED IN THE CURRENT
ROUND FOR THIS PROVIDER, GO TO HH13-NEEDNURS.
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 TELEHLTH-TELEHLTH.
MPSDVIS
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 these places]?
TELEHLTH
TELEHLTH
yes/no
BOX ST23A
routing
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?
[Was this visit/Were any of these visits] to (PROVIDER NAME) a telephone or video visit?
EVENT_STDATE
RVLINKS
STDATEMTCH
IF NEEDED: Telephone or video visits are also referred to as “telehealth visits”, “virtual check-ins”, or “evisits”. These types of visits allow you to have a medical appointment without physically visiting your doctor’s
office.
BOX ST22A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST23A
(02) TELEHLTH‐TELEHLTH
(‐8) TELEHLTH‐TELEHLTH
(‐9) TELEHLTH‐TELEHLTH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX ST23A
(01) CONTINUOUS ANSWER
BOX ST24
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST24A
(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT
(01) BOX ST33
(02) ST13 - PROVIDER_STDATE
(03) ST26 - EVENT_STDATEDEL
IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B.
ELSE GO TO BOX MP2C.
Page 12 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
EVENT_STDATEDEL
ST26
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
ST25 - STDATEMTCH
BOX ST33
routing
IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD.
ELSE GO TO BOX ST40.
ST34
code one
(01) NO, DO NOT NEED TO ADD OR EDIT OM
EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) ST37 - EVENT_STOM
(02) ST36 - STOMADD
(03) ST35 - EVENT_STOMEDIT
(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
(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
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
STOMUPD
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
EVENT_STOMEDIT
STOMADD
ST35
roster
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.
ST36
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.
MONTHCOV
ST38
numeric
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?
MONCOV96
ST38
NUMLINKS
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.
BOX ST37
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
ST38 - MONCOV96
(01) LESS THAN 1 MONTH
(-7) EMPTY
BOX ST38A
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST38AA
Page 13 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
STOMMTCH
ST39
code one
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE ON THE (TYPE OF
STATEMENT) SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) BOX ST40
(02) ST34 - STOMUPD
(03) ST40 - EVENT_STOMDEL
EVENT_STOMDEL
ST40
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
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
(01) CONTINUOUS ANSWER
OF STATEMENT).
BOX PM2
routing
EVENT_STPM
MEDICINE_PM1
BOX PM2
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.
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 PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM,
AND QUANTITY FOR EACH.
BOX PM3
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.
BOX PM4
PMBOTTLE
PMBOTTLE
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.
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
(-8) DON'T KNOW
ABOUT 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
Page 14 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
(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)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
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
MED
lookup
[PM BRAND NAME]
PMGNNAME
MED
lookup
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[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
Medicine Form [MCBS FORM]
[MEDICINE FORM OTHER SPECIFY]
Medicine strength unit
PMSTRNOS
MED
verbatim
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
PMSTRUNI
MED
ookup
[FINAL CONCATENATED MEDICINE STRENGTH]
PMEDID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
FAMILYID
MED
numeric
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
(01) CONTINUOUS ANSWER
(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
Page 15 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
PMKNWNM
PMKNWNM
code one
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(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
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX PM5
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
TABNUM
AMTUNIT
PMCOND
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?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
quantity unit
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
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
(01) CONTINUOUS ANSWER
BOX PM6
PM16
AMTUNOS
PM16
text
AMTNUM
PM16
numeric
BOX PM6
routing
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
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 (01) CONTINUOUS ANSWER
IN A 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".
PM12 - TABSADAY95
Page 16 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
TABSADAY95
PM12
code one
Question Text/Description
Code List
Routing
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
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 (-8) DON'T KNOW
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".
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
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
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.]
([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
[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?]
PM13 - TABTAKE96
BOX PM7
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) ST42 - NUMLINKS
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST44-STPMMTCH
NUMLINKS
ST42
grid
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE
BUNDLE?
STPMMTCH
ST44
code one
(01) YES
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
(02) NO, NEED TO ADD A MEDICINE NAME
SHOWN BELOW?
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) BOX ST45
(02) ST41 - EVENT_STPM
(03) ST45 - EVENT_STPMDEL
EVENT_STPMDEL
ST45
roster
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE
BUNDLE.
ST44 - STPMMTCH
(01) CONTINUOUS ANSWER
Page 17 of 24
2021 MCBS Community Questionnaire
Variable Name
STQ-Statement Cost Series
MR Screen Name
Question Type
Question Text/Description
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 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 COSTS OF INDIVIDUAL ITEMS LISTED ON THE STATEMENT.
TOTALCHG
ST48
numeric
(01) CONTINUOUS ANSWER
ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF STATEMENT). IF AMOUNT NOT AVAILABLE,
(-8) DON'T KNOW
ENTER "DON'T KNOW".
(-9) REFUSED
ST48 - MCAPPAMT
MCAPPAMT
ST48
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST48 - MCPAYAMT
MCPAYAMT
ST48
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
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
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 of $(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?
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST64A
(02) BOX ST64A
(03) ST50 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
ORPMESSAGE
ASGNTAKE
STTCHGPAID1
Code List
Routing
BOX ST80
(01) YES
(02) NO
(03) CAN'T TELL
BOX ST47
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST64 - STTCHGPAID2
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
TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST51 - TOTALCHG
(02) BOX ST51
AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST51
numeric
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE
(TYPE OF STATEMENT).
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST51 - MCAPPAMT
Page 18 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
ST51 - MCPAYAMT
MCAPPAMT
ST51
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
MCPAYAMT
ST51
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST51
BOX ST51
routing
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.
TOTALCHG
ST52
numeric
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST52 - MCAPPAMT
MCAPPAMT
ST52
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST52 - MCPAYAMT
MCPAYAMT
ST52
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST52 - MAYBBILL
MAYBBILL
ST52
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX ST52
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.
ST53
code one
REVIEW CHARGE BUNDLE ON THE (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 of $(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?
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST64A
(02) BOX ST64A
(03) ST54 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
STTCHGPAID1
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) :
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)
CHANGAMT
ST54
yes/no
MEDICARE PAID: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST55 - TOTALCHG
(02) BOX ST55
YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST55 - MCAPPAMT
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST55 - MCPAYAMT
ST55
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST55 - MAYBBILL
ST55
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX ST55
BOX ST55
routing
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING <
$1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ST56
numeric
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE STATEMENT.
(01) CONTINUOUS ANSWER
ST56 - NONCOVRD
TOTALCHG
ST55
numeric
MCAPPAMT
ST55
MCPAYAMT
MAYBBILL
DAYSUSED
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE
(TYPE OF STATEMENT).
Page 19 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ-Statement Cost Series
Question Type
Question Text/Description
Code List
Routing
ST56 - MCPAYAMT
NONCOVRD
ST56
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
MCPAYAMT
ST56
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST56 - MAYBBILL
MAYBBILL
ST56
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX ST56
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?
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST64A
(02) BOX ST64A
(03) ST58 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
(01) YES
(02) NO
(01) ST59 - DAYSUSED
(02) BOX ST59
STTCHGPAID1
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)
MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE
(TYPE OF STATEMENT).
DAYSUSED
ST59
numeric
NONCOVRD
ST59
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST59 - MCPAYAMT
MCPAYAMT
ST59
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST59 - MAYBBILL
MAYBBILL
ST59
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST59
BOX ST59
routing
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING <
$1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST60 - NONCOVRD
TOTALCHG
ST60
numeric
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST60 -MCAPPAMT
MCAPPAMT
ST60
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST60 - MCPAYAMT
MCPAYAMT
ST60
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST60 - MAYBBILL
MAYBBILL
ST60
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST60
BOX ST60
(01) CONTINUOUS ANSWER
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.
Page 20 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
STTCHGPAID1
ST61
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?
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST64A
(02) BOX ST64A
(03) ST62 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
(01) YES
(02) NO
(01) ST63 - TOTALCHG
(02) BOX ST63
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63- MCAPPAMT
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)
MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST63
numeric
MCAPPAMT
ST63
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63 - MCPAYAMT
MCPAYAMT
ST63
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63 - MAYBBILL
MAYBBILL
ST63
numeric
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST63
BOX ST63
routing
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING <
$1.00), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
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:)
[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
(01) YES
LISTED BELOW?
(02) NO
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
SOP_ST1
ST66
roster
ADD ALL ADDITIONAL SOURCES OF PAYMENT.
TSOPAMT
ST67
grid
STTCHGPAID2
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED
BOX ST64A
(01) ST67 - TSOPAMT
(02) ST66 - SOP_ST1
(01) CONTINUOUS ANSWER
(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.
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
BOX ST67HE
Page 21 of 24
2021 MCBS Community Questionnaire
Variable Name
PAYMHE
STQ-Statement Cost Series
MR Screen Name
Question Type
Question Text/Description
BOX ST67HE
routing
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.
ST67HE
no entry
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'.
Code List
Routing
(01) CONTINUOUS ANSWER
ST67HE-PAYMHE
(01) CONTINUOUS ANSWER
BOX ST67C
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ST69 - STSOPCURR1
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND MAKE CORRECTIONS.
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.
BOX ST67C
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.
STMHMOCHNG1
ST68
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?
STSOPCURR1
ST69
yes/no
(01) YES
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE MANAGED CARE PLAN (02) NO
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(-8) DON'T KNOW
(-9) REFUSED
(01) HIMC6A - MHMORXTM
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
STMPDPCHNG
ST69A
yes/no
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
Medicare Prescription Drug Care Plan.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ST69B - STSOPCURR2
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST69A
PLANINTRO
Has this information changed?
STSOPCURR2
ST69B
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.
Page 22 of 24
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
BOX ST69F
AMTSCORR
AMTSCORR
ST70
ST71
STQ-Statement Cost Series
Question Type
Question Text/Description
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
There seems to be (some amount still unpaid/more payments than the amount left after Medicare paid). The
total of non-Medicare payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid) is $(DIFFERENCE
BETWEEN PAYMENTS AND AMOUNT REMAINING). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN
TO THE SOP GRID.
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
ST72
no entry
[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT
(UNPAID/OVERPAID) IS $(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT REMAINING).]
Code List
Routing
(01) ENTRIES ABOVE ARE CORRECT
(02) DO NOT DISPLAY
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED
(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
DO NOT DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED
(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C
(01) CONTINUOUS ANSWER
BOX ST77C
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
DO NOT DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT DO
NOT DISPLAY.
(-8)
(-9) REFUSED
(01) ST74 - INFOEXPLAIN
(02) DO NOT DISPLAY.
(03) DO NOT DISPLAY.
(-8) BOX ST77C
(-9) BOX ST77C
(01) ST75 - ENTERCOM2
(02) BOX ST77C
USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
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 STILL UNPAID?
(01) YES
(02) NO
ENTERCOM2
ST75
verbatim text
USE THE BOX BELOW TO ENTER ANY INFORMATION THAT EXPLAINS THE AMOUNT STILL UNPAID.
(01) CONTINUOUS ANSWER
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.
EXPPAYBK
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST78A
Page 23 of 24
2021 MCBS Community Questionnaire
STQ-Statement Cost Series
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
EXPAYOUT
ST79
yes/no
Do you expect anyone to pay any of this amount?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ST80 - EXPAYUNT
(02) BOX ST80
(-8) BOX ST80
(-9) BOX ST80
EXPAYUNT
ST80
quantity unit
How much do you expect will be paid?
(01) PERCENTAGE
(02) DOLLARS
(-8) DON'T KNOW
(-9) REFUSED
(01)
(02)
(-8)
(-9)
EXPAYPCT
ST80
numeric
(01) CONTINUOUS ANSWER
BOX ST80
EXPAYAMT
ST80
numeric
(01) CONTINUOUS ANSWER
BOX ST80
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?
(01) YES
(02) NO
(01) ST4 - MATCHST
(02) BOX STEND
[996] LEAVE COST SERIES AND SKIP TO MBQ
[996] MBQ
ASTATEMENT
BOX STEND
routing
ST80 - EXPAYPCT
ST80 - EXPAYAMT
BOX ST80
BOX ST80
GO TO PSQ.
Page 24 of 24
| File Type | application/pdf |
| File Title | STQ.xlsx |
| Author | Wishart-Marisa |
| File Modified | 2020-08-26 |
| File Created | 2020-08-26 |