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pdf2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) CONTINUE
OM3-OMHRSPCH
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM4 - EVENT_OMHRSP
(02) BOX OMA1
(03) DO NOT DISPLAY.
(-8) BOX OMA1
(-9) BOX OMA1
OTHER MEDICAL EXPENSES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=ALL
Other: N/A
PLACEMENT
Administer after PMQ.
OMINTRO
OMHRSPCH
OMINTRO
OM3
routing
yes/no
Next I’m going to ask you about other medical expenses that [you/(SP)] may have had [between (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, replace, or pay for repairs of an amplifier for a
telephone, or similar device to help [you/(SP)] hear or speak?
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A HEARING AID OR SPEAKING DEVICE]
[DO NOT INCLUDE HEARING AID PURCHASES, REPAIRS, OR WARRENTIES AT THIS QUESTION.]
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair a hearing or speech device?
(01) continuous answer
(-8) Don't Know
(-9) Refused
EVENT_OMHRSP
OM4
roster
OMADD
OM4AA
code one
BOX OM1BB
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM4A - OMSATHMO
ELSE GO TO BOX OM1BB2.
OM4A
yes/no
On (EVENT DATE), did [you/(SP)] buy or repair the hearing or speech device at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the hearing or speech device at a plan center; from an
(-9) Refused
audiologist, speech pathologist, or other provider that honors [your/(SP’s)] plan card; or through a place or service
that the plan referred [you/(SP)] to.]
BOX OM1BB2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA1.
BOX OMA1
routing
IF SP WAS STILL RENTING AT LEAST ONE ORTHOPEDIC ITEM AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS5INTR - ORTHINTRO.
ELSE GO TO OM5 - OMPRORTH.
OMS5INTR
no entry
The next questions are about orthopedic items [you were/(SP) was] renting as of (REFERENCE DATE).
OMSATHMO
ORTHINTRO
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
MM:
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE
DD:
OF INSTITUTIONALIZATION/ENDUTILD)].
YYYY:
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) ADD ANOTHER
(02) ALL DONE
(01) continuous answer
(-7) Empty
OM4AA-OMADD
(01) OM4-EVENT_OMHRSP
(02) BOX OM1BB
BOX OM1BB2
OMS5 - RENTSTIL
Page 1 of 14
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) BOX OM4
(-8) BOX OM4
(-9) BOX OM4
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) DO NOT DISPLAY.
(-8) OM9 - OMPRDIAB
(-9) OM9 - OMPRDIAB
(01) OM7 - EVENT_OMORTH
(02) OM7 - EVENT_OMORTH
(03) OM7 - EVENT_OMORTH
(04) OM6A - RENTPROB
(05) OM6A - RENTPROB
(06) OM6A - RENTPROB
(07) OM7 - EVENT_OMORTH
(91) OM6 - EVOSTEXT
OM6A - RENTPROB
At the time of the last interview, [you were/(SP) was] renting (ORTHOPEDIC ITEM). As of (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION), (was/were/is/are) the (ORTHOPEDIC ITEM) being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OMS5
code one
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPRORTH
OM5
yes/no
SHOW CARD OM1
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, repair or rent (other) orthopedic
items, such as any of those listed on this card?
[Orthopedic items include crutches, canes, wheelchairs, walkers, corrective shoes or inserts, support stockings,
and braces or supports.]
ORTHTYPE
OM6
code one
What was the item?
(01) BRACES/SUPPORTS
(02) CANE
(03) CORRECTIVE SHOES/INSERTS
(04) CRUTCHES
(05) WALKER
(06) WHEELCHAIR/CART
(07) STOCKINGS
(91) OTHER
EVOSTEXT
OM6
verbatim text
OTHER (SPECIFY)
(01) continuous answer
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did [you/(SP)] rent (it/them)?
RENTPROB
OM6A
EVENT_OMORTH
OM7
OMADD
OM7AAA
BOX OM1CC
OMSATHMO
OM7AA
code one
roster
(01) OM7 - EVENT_OMORTH
(02) OM7A - EVENT_OMORTHRENT
(03) DO NOT DISPLAY.
(-8) OM7 - EVENT_OMORTH
(-9) OM7 - EVENT_OMORTH
(01) continuous answer
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE
MM:
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) ADD ANOTHER
(02) ALL DONE
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM7AA - OMSATHMO
ELSE GO TO BOX OM1EE1.
yes/no
On (EVENT DATE), did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) (01) YES
BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the (ORTHOPEDIC ITEM) at a plan center; at a place or store
(-9) Refused
that honors [your/(SP's)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
OM7AAA-OMADD
(01) OM7-EVENT_OMORTH
(02) BOX OM1CC
OM8- MOREORTH
Page 2 of 14
2021 MCBS Community Questionnaire
Variable Name
EVENT_OMORTHRENT
MR Screen Name
OM7A
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
yes/no
ENTER ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (ORTHOPEDIC ITEM).
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER DD:
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
YYYY:
Routing
OM7B - RENTSTIL
[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM7B
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1EE1
(-9) BOX OM1EE1
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM7C - EVENDDD
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDMM
OM7C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDDD
OM7C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDYY
OM7C
BOX OM3A
RENT2BUY
OM7CC
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
(01) continuous answer
(-8) Don't Know
(-9) Refused
DD:
(01) continuous answer
(-8) Don't Know
(-9) Refused
IF SP IS NOT DECEASED, GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.
code one
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is this because (you/he/she) no longer (have/has)
(03) OTHER
that item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?
(-8) Don't Know
(-9) Refused
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (ORTHOPEDIC ITEM).
RECORD VERBATIM.
(01) continuous answer
REN2BVB
OM7CCVB
verbatim text
OMADD
OM7CC1
code one
BOX OM1EE
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM7D - OMSATHMO.
ELSE GO TO BOX OM1EE1.
OM7D
yes/no
Did [you/(SP)] rent the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or through
(01) YES
a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include renting the (ORTHOPEDIC ITEM) at a plan center; at a place or store that honors
(-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP]] to.]
BOX OM1EE1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.
OMSATHMO
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
BOX OM3A
YYYY:
routing
HAVE ALL DATES BEEN ENTERED?
OM7C - EVENDYY
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX OM1EE
(02) BOX OM1EE
(03) OM7CCVB - REN2BVB
(-8) BOX OM1EE
(-9) BOX OM1EE
BOX OM1EE
OM7CC-OMADD
(01) OM7A-EVENT_OMORTHRENT
(02) BOX OM1EE
BOX OM1EE1
Page 3 of 14
2021 MCBS Community Questionnaire
Variable Name
MOREORTH
OMPRDIAB
OMQ-OTHER MEDICAL EXPENSES
MR Screen Name
Question Type
Question Text/Description
BOX OM4
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS5 - RENTSTIL
ELSE GO TO OM8 - MOREORTH.
yes/no
In addition to the orthopedic item(s) you just told me about, did [you/(SP)] buy, repair, or rent any other orthopedic
items [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].?
OM8
OM9
yes/no
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) OM9 - OMPRDIAB
(04) OM9 - OMPRDIAB
SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy diabetic equipment or supplies, such as those listed on (02) NO
this card?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Diabetic equipment or supplies include syringes, test paper, test strips, and blood monitoring kits.]
(-9) Refused
(01) OM10 - EVENT_OMDIAB
(02) OM11 - OMPRAMBL
(03) DO NOT DISPLAY.
(-8) OM11 - OMPRAMBL
(-9) OM11 - OMPRAMBL
[DO NOT INCLUDE INSULIN.]
EVENT_OMDIAB
OM10
roster
OMADD
OM10AA
code one
BOX OM1FF
routing
OMSATHMO
OM10A
yes/no
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy diabetic equipment or supplies? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
OMPRAMBL
OM11
MM:
DD:
YYYY:
OM10AA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM10-EVENT_OMDIAB
(02) BOX OM1FF
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM10A-OMSATHMO
ELSE GO TO BOX OM1FF2.
On (EVENT DATE), did [you/(SP)] buy the diabetic equipment or supplies 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 buying the diabetic equipment or supplies at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
BOX OM1FF2
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] use any ambulance or rescue squad service?
SELECT OR ADD ALL DATES AT THIS ROSTER.
(01) continuous answer
When did [you/(SP)] use an ambulance? Please tell me all the dates [since (REFERENCE DATE/SURVEY
(-8) Don't Know
REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(-9) Refused
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
EVENT_OMAMBL
OM12
roster
OMADD
OM12AA
code one
BOX OM1GG
routing
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) ADD ANOTHER
(02) ALL DONE
BOX OM1FF2
(01) OM12 - EVENT_OMAMBL
(02) OM13 - OMPRPROS
(03) DO NOT DISPLAY.
(-8) OM13 - OMPRPROS
(-9) OM13 - OMPRPROS
OM12AA-OMADD
(01) OM12-EVENT_OMAMBL
(02) BOX OM1GG
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM12A - OMSATHMO
Page 4 of 14
2021 MCBS Community Questionnaire
Variable Name
OMSATHMO
OMPRPROS
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
OM12A
yes/no
Was the ambulance on (EVENT DATE) provided by or approved by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
(01) YES
(02) NO
[PROBE: This could mean that the ambulance was sent by the plan, or that [you/(SP)] or someone for [you/(SP)] (-8) Don't Know
contacted the plan for them to authorize or approve the use of the ambulance. This approval could have come
(-9) Refused
after the use of the ambulance.]
BOX OM1GG2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.
OM13
yes/no
SHOW CARD OM3
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy or pay for repairs of any prostheses, such as those on
the card?
[Prostheses include artificial leg or arm, mastectomy prosthesis, and artificial or glass eye.]
EVENT_OMPROS
OM14
roster
OMADD
OM14AA
code one
BOX OM1HH
routing
OMSATHMO
OXGNINTRO
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the prosthesis? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OM14A
yes/no
BOX OM1HH2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA4.
BOX OMA4
routing
IF SP WAS STILL RENTING OXYGEN-RELATED EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS19INTR - OXGNINTRO.
ELSE GO TO OM19 - OMPROXGN.
OMS19INTR
no entry
The next questions are about oxygen-related equipment [you were/(SP) was] renting as of (REFERENCE DATE).
OMS19
code one
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
Routing
BOX OM1GG2
(01) OM14 - EVENT_OMPROS
(02) BOX OMA4
(03) DO NOT DISPLAY.
(-8) BOX OMA4
(-9) BOX OMA4
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM14AA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM14-EVENT_OMPROS
(02) BOX OM1HH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1HH2
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM14A-OMSATHMO
ELSE GO TO BOX OM1HH2.
[PROBE: This could include buying or repairing the prosthesis at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
At the time of the last interview, [you were/(SP) was] renting oxygen-related equipment. As of [today/(DATE OF
DEATH)/(DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (is/was) the oxygen-related equipment being
rented?
RENTSTIL
Code List
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
OMS19 - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM9
(-8) BOX OM9
(-9) BOX OM9
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
Page 5 of 14
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM19A - OXGNTYPE
(02) BOX OMA11
(03) DO NOT DISPLAY.
(-8) BOX OMA11
(-9) BOX OMA11
(01) OXYGEN/SUPPLIES
(02) OXYGEN-RELATED EQUIPMENT
(01) OM20 - EVENT_OMOXGN
(02) OM19B - RENTPROB
OMPROXGN
OM19
yes/no
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any (other) expenses for oxygen
or supplies or oxygen-related equipment?
OXGNTYPE
OM19A
code one
What was that?
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygen-related equipment)]? Please tell me the dates of
each purchase [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
Did [you/(SP)] buy or repair the oxygen-related equipment, or did [you/(SP)] rent it?
RENTPROB
OM19B
EVENT_OMOXGN
OM20
roster
OMADD
OM20AAA
code one
BOX OM1II
routing
OMSATHMO
OM20AA
yes/no
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
EVENT_OMOXGNRENT
OM20A
routing
roster
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM20AAA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM20-EVENT_OMOXGN
(02) BOX OM1II
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM7
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM20B - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM1KK1
(-8) BOX OM1KK1
(-9) BOX OM1KK1
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM20AA - OMSATHMO
ELSE GO TO BOX OM7.
On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN ITEM) 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 buying or repairing the (OXYGEN ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
BOX OM7
(01) OM20 - EVENT_OMOXGN
(02) OM20A - EVENT_OMOXGNRENT
(03) OM20 - EVENT_OMOXGN
(-8) OM20 - EVENT_OMOXGN
(-9) OM20 - EVENT_OMOXGN
IF OM19B - RENTPROB = 3/BoughtAndRented, GO TO OM20A - EVENT_OMOXGNRENT.
ELSE GO TO BOX OM1KK1.
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the oxygen-related equipment.
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
[Are you/Is (SP)/Was (SP)] still renting the oxygen-related equipment?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM20B
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
Page 6 of 14
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
What was the last date the equipment was rented?
EVENDMM
OM20C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the equipment was rented?
EVENDDD
OM20C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the equipment was rented?
EVENDYY
OM20C
date
BOX OM8A
routing
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
Code List
(01) continuous answer
(02) Don't Know
(03) Refused
MM:
DD:
YYYY:
OM20C - EVENDYY
(01) continuous answer
(02) Don't Know
(03) Refused
BOX OM8A
(01) BOX OM1KK
(02) BOX OM1KK
(03) OM20CCVB - REN2BVB
(04) BOX OM1KK
(05) BOX OM1KK
IF SP IS NOT DECEASED, GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.
RENT2BUY
OM20CC
code one
You said [you/(SP)] stopped renting the oxygen-related equipment. Is this because (you/he/she) no longer
(have/has) the equipment or because (you/he/she) (have/has) purchased it through a rent-to-buy option?
REN2BVB
OM20CCVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE OXYGEN-RELATED EQUIPMENT.
RECORD VERBATIM.
(01) continuous answer
OMADD
OM20CC1
code one
BOX OM1KK
routing
MOREOXGN
OM20C - EVENDDD
(01) continuous answer
(02) Don't Know
(03) Refused
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
OMSATHMO
Routing
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
OM20CC1-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM20A-EVENT_OMOXGNRENT
(02) BOX OM1KK
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1KK1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX OM11
(02) BOX OMA11
(-8) BOX OMA11
(-9) BOX OMA11
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM20D1 - OMSATHMO.
ELSE GO TO BOX OM1KK1.
Did [you/(SP)] rent the oxygen equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OM20D1
yes/no
BOX OM1KK1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM9.
BOX OM9
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS19_IN - NAVIGATOR.
ELSE GO TO BOX OM10.
BOX OM10
routing
IF OM20D HAS NOT BEEN ASKED, GO TO OM20D - MOREOXGN.
ELSE GO TO BOX OMA11.
OM20D
yes/no
In addition to the [(oxygen or supplies)/(oxygen-related equipment)] that you just told me about, did [you/(SP)]
[(buy oxygen or supplies)/(have any expenses for oxygen-related equipment)]?
BOX OM11
routing
IF OM19A - OXYGTYPE = 1/Supplies, SET NEXT OXYGEN TYPE TO EQUIPMENT AND GO TO OM19B RENTPROB.
ELSE SET NEXT OXYGEN TYPE TO SUPPLIES AND GO TO OM20 - EVENT_OMOXGN.
[PROBE: This could include renting the oxygen equipment at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
Page 7 of 14
2021 MCBS Community Questionnaire
Variable Name
KDNYINTRO
OMQ-OTHER MEDICAL EXPENSES
MR Screen Name
Question Type
Question Text/Description
BOXOMA11
routing
IF SP WAS RENTING AT LEAST ONE KIDNEY DIALYSIS EQUIPMENT AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS21INTR - KDNYINTRO.
ELSE GO TO OM21 - OMPRKDNY.
OMS21INTR
no entry
The next questions are about kidney dialysis equipment [you were/(SP) was] renting as of (REFERENCE
DATE).
Code List
Routing
OMS21 - RENTSTIL
At the time of the last interview, [you were/(SP) was] renting equipment for kidney dialysis. As of (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)], (is/was) the equipment being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OMS21
code one
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1NN
(02) OM22C - EVENDMM
(03) BOX OM16
(-8) BOX OM16
(-9) BOX OM16
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPRKDNY
OM21
yes/no
(01) YES
(Other than what we already talked about), [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
(02) NO
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(03) INDICATED YES BY DATAPREP
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy any (other) kidney dialysis supplies
(-8) Don't Know
or buy, rent, or repair any related equipment?
(-9) Refused
KDNYTYPE
OM21A
code one
What was that?
(01) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or repair kidney dialysis equipment)? Please tell
me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)] rent it?
RENTPROB
OM21B
EVENT_OMKDNY
OM22
roster
OMADD
OM22AAA
code one
BOX OM1LL
OMSATHMO
OM22AA
routing
yes/no
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) OM21A - KDNYTYPE
(02) BOX OMA18
(03) DO NOT DISPLAY.
(-8) BOX OMA18
(-9) BOX OMA18
(01) OM22 - EVENT_OMKDNY
(02) OM21B - RENTPROB
(01) OM22 - EVENT_OMKDNY
(02) OM22A - EVENT_OMKDNYRENT
(03) DO NOT DISPLAY.
(-8) OM22 - EVENT_OMKDNY
(-9) OM22 - EVENT_OMKDNY
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM22AAA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM22-EVENT_OMKDNY
(02) BOX OM1LL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1NN1
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM22AA - OMSATHMO
ELSE GO TO BOX OM1NN1.
On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY ITEM) 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 buying (or repairing) the (KIDNEY ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
Page 8 of 14
2021 MCBS Community Questionnaire
Variable Name
EVENT_OMKDNYRENT
MR Screen Name
OM22A
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
roster
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the kidney dialysis equipment.
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
Code List
Routing
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM22B - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1NN
(02) OM22C - EVENDYY
(03) DO NOT DISPLAY.
(-8) BOX OM1NN1
(-9) BOX OM1NN1
[Are you/Is (SP)/Was (SP)] still renting the kidney dialysis equipment?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM22B
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date the equipment was rented?
EVENDMM
OM22C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the equipment was rented?
EVENDDD
OM22C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date the equipment was rented?
EVENDYY
OM22C
date
BOX OM15A
routing
IF SP IS NOT DECEASED, GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM22C - EVENDYY
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM15A
RENT2BUY
OM22CC
code one
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
You said [you/(SP)] stopped renting the dialysis equipment. Is this because (you/he/she) no longer (have/has) the
(03) OTHER
equipment or because (you/he/she) (have/has) purchased it through a rent-to-buy option?
(-8) Don't Know
(-9) Refused
REN2BVB
OM22CCVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS EQUIPMENT.
RECORD VERBATIM.
OMADD
OM22CC1
code one
BOX OM1NN
routing
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
OM22C - EVENDDD
(01) continuous answer
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX OM1NN
(02) BOX OM1NN
(03) OM22CCVB - REN2BVB
(-8) BOX OM1NN
(-9) BOX OM1NN
BOX OM1NN
OM22CC1-OMADD
(01) OM22A-EVENT_OMKDNYRENT
(02) BOX OM1NN
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM22D1 - OMSATHMO.
ELSE GO TO BOX OM1NN1.
Page 9 of 14
2021 MCBS Community Questionnaire
Variable Name
OMSATHMO
MOREKDNY
OTHRINTRO
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Did [you/(SP)] rent the kidney dialysis equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include renting the kidney dialysis equipment at a plan center; at a place or store that honors
(-9) Refused
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
OM22D1
yes/no
BOX OM1NN1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM16.
BOX OM16
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS21 - RENTSTIL
ELSE GO TO BOX OM17.
BOX OM17
routing
IF OM22D HAS NOT BEEN ASKED, GO TO OM22D - MOREKDNY.
ELSE GO TO BOX OMA18.
yes/no
(01) YES
In addition to the [(kidney dialysis supplies)/(kidney dialysis equipment)] that you just told me about, did [you/(SP)] (02) NO
[(obtain any kidney dialysis equipment)/(buy any kidney dialysis supplies)]?
(-8) Don't Know
(-9) Refused
BOX OM18
routing
IF OM21A - KDNYTYPE = 1/Supplies, SET NEXT KIDNEY TYPE TO EQUIPMENT AND GO TO OM21B RENTPROB.
ELSE SET NEXT KIDNEY TYPE TO SUPPLIES AND GO TO OM22 - EVENT_OMKDNY.
BOX OMA18
routing
IF SP WAS STILL RENTING AT LEAST ONE OTHER MEDICAL EQUIPMENT AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO OMS23INTR - OTHRINTRO.
ELSE GO TO OM23 - OMPROTHR.
OMS23INTR
no entry
The next questions are about other medical equipment [you were/(SP) was] renting as of (REFERENCE DATE).
OM22D
At the time of the last interview, [you were/(SP) was] renting (OTHER MEDICAL EXPENSE ITEM). As of
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD), (is/was) the (OTHER MEDICAL
EXPENSE ITEM) being rented?
RENTSTIL
Code List
OMS23
code one
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
Routing
BOX OM1NN1
(01) BOX OM18
(02) BOX OMA18
(-8) BOX OMA18
(-9) BOX OMA18
OMS23 - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) BOX OM23
(-8) BOX OM23
(-9) BOX OM23
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPROTHR
OM23
yes/no
SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, rent, or repair any other medical equipment or buy any
(02) NO
other medical supplies besides what we have talked about?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Other medical equipment and supplies include portable commodes or raised toilet seats, portable tub seats,
(-9) Refused
special chairs or cushions, hospital beds, ostomy supplies, incontenence supplies such as Depends, Serenity or
other brands of disposable undergarments, pads or briefs, bandages, dressings, tape supplies, pulmonary
equipment such as a Nebulizer or CPAP, and blood pressure equipment such as cuffs or monitors, etc.]
(01) OM24 - OTHRTYPE
(02) BOX OM24
(03) DO NOT DISPLAY.
(04) BOX OM24
(05) BOX OM24
Page 10 of 14
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) OM24A - RENTPROB
(02) OM24A - RENTPROB
(03) OM24A - RENTPROB
(04) OM24A - RENTPROB
(05) BOX OM18B
(06) BOX OM18B
(07) BOX OM18B
(08) OM24A - RENTPROB
(09) OM26 - EVENT_OMOTHR
(91) OM24 - EVOSTEXT
OM24A - RENTPROB
OTHRTYPE
OM24
code one
What kind of equipment was the item?
(01) PORTABLE COMMODE OR RAISED TOILET
SEAT
(02) PORTABLE TUB SEAT
(03) SPECIAL CHAIR/CUSHION/MATTRESS
(04) HOSPITAL BED/BED SIDES
(05) OSTOMY SUPPLIES
(06) INCONTINENCE SUPPLIES (I.E. DEPENDS,
SERENITY DISPOSABLE DIAPERS OR PADS)
(07) BANDAGES, DRESSINGS, TAPE SUPPLIES
(08) PULMONARY EQUIPMENT
(09) BLOOD PRESSURE EQUIPMENT
(91) OTHER
EVOSTEXT
OM24
verbatim text
OTHER (SPECIFY)
(01) continuous answer
OM24A
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
BOX OM18B
routing
IF NOT ADMINISTERING ST AND NOT ADMINISTERING NS, GO TO OM25 - GETNUM.
ELSE GO TO BOX OM1QQ1.
numeric
THIS ITEM AND NUMBER OF PURCHASES HAS BEEN ENTERED ALREADY FOR THIS ROUND. PLEASE
CORRECT THE NUMBER OF TIMES TO BE THE TOTAL NUMBER OF TIMES PURCHASED SINCE
(01) continuous answer
(REFERENCE DATE/UTILDATE).
(-8) Don't Know
How many times [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF
(-9) Refused
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] [[have you/has (SP)] bought or obtained/did (SP) buy
or obtain] (OTHER MEDICAL EXPENSE ITEM)?
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM), or did [you/(SP)] rent it?
RENTPROB
GETNUM
OM25
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
OM26
roster
OMADD
OM26AAA
code one
BOX OM1OO
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM26AA - OMSATHMO
ELSE GO TO BOX OM1QQ1.
yes/no
On (EVENT DATE), did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
(01) YES
PLAN NAME(S) BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a
(-9) Refused
place or store that honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
OMSATHMO
EVENT_OMOTHRRENT
OM26AA
OM26A
roster
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM).
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
BOX OM1QQ1
(01) continuous answer
(-8) Don't Know
(-9) Refused
EVENT_OMOTHR
HAVE ALL DATES BEEN ENTERED?
(01) OM26 - EVENT_OMOTHR
(02) OM26A - EVENT_OMOTHRRENT
(03) DO NOT DISPLAY.
(-8) OM26 - EVENT_OMOTHR
(-9) OM26 - EVENT_OMOTHR
MM:
DD:
YYYY:
OM27AAA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM26-EVENT_OMOTHR
(02) BOX OM1OO
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM21
OM26A1 - RENTSTIL
Page 11 of 14
2021 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1QQ1
(-9) BOX OM1QQ1
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM26B - EVENDDD
[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE ITEM)?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM26A1
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDMM
OM26B
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDDD
OM26B
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDYY
OM26B
BOX OM22A
date
routing
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF
THE RENTAL PERIOD.]
MM:
(01) continuous answer
(-8) Don't Know
(-9) Refused
DD:
(01) continuous answer
(-8) Don't Know
(-9) Refused
IF SP IS NOT DECEASED, GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.
RENT2BUY
OM26BB
code one
You said [you/(SP)] stopped renting the (OTHER MEDICAL EXPENSE ITEM). Is this because (you/he/she) no
longer (have/has) the item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?
REN2BVB
OM26BBVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER MEDICAL EXPENSE ITEM).
RECORD VERBATIM.
(01) continuous answer
OMSATHMO
OM26BB1
code one
BOX OM1QQ
routing
BOX OM22A
YYYY:
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(03) OTHER
(-8) Don't Know
(-9) Refused
OMADD
OM26B - EVENDYY
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX OM1QQ
(02) BOX OM1QQ
(03) OM26BBVB - REN2BVB
(-8) BOX OM1QQ
(-9) BOX OM1QQ
BOX OM1QQ
OM26BB1-OMADD
(01) OM26A-EVENT_OMOTHRRENT
(02) BOX OM1QQ
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM26C - OMSATHMO.
ELSE GO TO BOX OM1QQ1.
Did [you/(SP)] rent the (OTHER MEDICAL EXPENSE ITEM) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
(01) YES
(02) NO
(-8) Don't Know
[PROBE: This could include renting the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a place or store
(-9) Refused
that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
OM26C
yes/no
BOX OM1QQ1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM23.
BOX OM23
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS23 - RENTSTIL
ELSE GO TO OM27 - MOREOTHR.
BOX OM1QQ1
Page 12 of 14
2021 MCBS Community Questionnaire
Variable Name
MOREOTHR
ALTRINTRO
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
OM27
yes/no
In addition to the medical equipment you just told me about, did [you/(SP)] buy, rent, or repair any other medical
equipment [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) OM24 - OTHRTYPE
(02) BOX OM24
(-8) BOX OM24
(-9) BOX OM24
BOX OM24
routing
IF SP HAD AT LEAST ONE ALTERATION THAT WAS NOT COMPLETE AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS28INTR - ALTRINTRO.
ELSE GO TO OM28 - OMPRALTR.
OMS28INTR
no entry
The next questions are about an alteration [you were/(SP) was] making as of (REFERENCE DATE).
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDMM
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDDD
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDYY
OMS28
date
OMNOTDONE
OMS28
code one
OMPRALTR
OM28
yes/no
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
SHOW CARD OM5
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] make any alterations or modify the inside or outside of
(your/his/her) home or car because of some illness or injury? This card lists some examples.
[Alterations include ramps, handrails, elevator or incline chair, tub seats, tub handrails, and any car alterations.]
OMS28 - EVENDMM
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
OMS28 - EVENDDD
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
OMS28 -EVENDYY
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
OMS28 - OMNOTDONE
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
OM28 - OMPRALTR
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM29 - ALTRTYPE
(02) BOX OM26
(03) DO NOT DISPLAY.
(-8) BOX OM26
(-9) BOX OM26
(01) OM30 - EVENDMM
(02) OM30 - EVENDMM
(03) OM30 - EVENDMM
(04) OM30 - EVENDMM
(05) OM30 - EVENDMM
(06) OM30 - EVENDMM
(91) OM29 - EVOSTEXT
OM30 - EVENDMM
ALTRTYPE
OM29
code one
What was the alteration?
(01) ELEVATOR OR INCLINE CHAIR
(02) HANDRAILS (OTHER THAN TUB)
(03) RAMPS
(04) TUB HANDRAILS
(05) TUB SEAT
(06) ANY CAR ALTERATION
(91) OTHER
EVOSTEXT
OM29
verbatim text
OTHER (SPECIFY)
(01) continuous answer
Page 13 of 14
2021 MCBS Community Questionnaire
Variable Name
EVENDMM
MR Screen Name
OM30
OMQ-OTHER MEDICAL EXPENSES
Question Type
date
Question Text/Description
Code List
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
(-9) Refused
was this alteration completed?
Routing
OM30 - EVENDDD
MM:
EVENDDD
OM30
date
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
(-9) Refused
was this alteration completed?
OM30 - EVENDDD
DD:
EVENDYY
OM30
date
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
(-9) Refused
was this alteration completed?
OM30 - OMNOTDONE
YYYY:
OMNOTDONE
OM30
OMADD
OM30B
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.
OM31
yes/no
In addition to the alteration(s) you just told me about, did [you/(SP)] make any other alterations because of some
illness or injury [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)]?
BOX OM26
routing
GO TO STQ.
BOX OM25A
MOREALTR
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
code one
OM30B-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM30-EVBEGMM
(02) BOX OM25A
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) OM29 - ALTRTYPE
(02) BOX OM26
(-8) BOX OM26
(-9) BOX OM26
Page 14 of 14
| File Type | application/pdf |
| File Title | Medicare Current Beneficiary Survey Section Specifications for OMQ |
| Subject | Medicare beneficiaries, MCBS community questionnaire, 2021, Other medical expenses utilization, OMQ |
| Author | NORC |
| File Modified | 2021-08-17 |
| File Created | 2021-08-11 |