CMS-P-0015A Health_Insurance

2021 MCBS Facility Instrument

Variable Name

MR Screen Name

IN-Health Insurance

Question Type

Question Text/Description

Code List

Routing

(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE
INTERVIEW)
(04) FINAL REFUSAL

(01) IN1PRE2 - IN1PR2CT
(02) INEND - INENDCT
(03) IN1PRE2 - IN1PR2CT
(04) INEND - INENDCT

(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL

(01) BOX IN3
(02) INEND - INENDCT
(03) INEND - INENDCT

Has (SP) ever been covered by [READ NAME(S) FROM ABOVE]?

(00) NO
(01) YES
(02) PENDING
(-8) Don't Know
(-9) Refused

(00) IN13A - ICAREPTD
(01) IN5A-MCAIDHMO
(02) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD
(00) IN18 - IGAPCOV
(01) IN5A-MCAIDHMO
(02) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

HEALTH INSURANCE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
SEASON
If SAMPLE_TYPE= CFR, then SEASON=FALL
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX INBEG

routing

CONREFFN

INCONREF

code one

IN1PR2CT

IN1PRE2

code one

BOX IN3

routing

IN1

yes/no

IF INDISP = 1/ConsentRequired OR INDISP = 4/InitialRefusal, GO TO INCONREF - CONREFFN.
ELSE GO TO IN1PRE2 - IN1PR2CT.

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.

The following questions are about (SP's) health insurance.

ICAIDECO

IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.

IF THIS IS A BASELINE INTERVIEW GO TO IN1 - ICAIDECO.
ELSE IF THIS IS NOT A BASELINE INTERVIEW GO TO IN1A - ICAIDNOW.

ICAIDNOW

IN1A

yes/no

Is (SP) now covered by [READ NAME(S) FROM ABOVE]?

(00) NO
(01) YES
(02) PENDING
(-8) Don't Know
(-9) Refused

MCAIDHMO

IN5A

yes/no

Some states now use HMOs (health maintenance organizations) to provide some or all health care for Medicaid
beneficiaries. (Is/Was) (SP) enrolled in a [READ NAME(S) FROM ABOVE] HMO?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX IN3A
(01) BOX IN3A
(-8) BOX IN3A
(-9) BOX IN3A

BOX IN3A

routing

IF THIS IS A BASELINE INTERVIEW, GO TO IN6 - ICDCRCOV.
ELSE GO TO IN18 - IGAPCOV.

IN6

yes/no

Was (SP) covered by [READ NAME(S) FROM ABOVE] [on September 1, (CURRENT YEAR)?/when (he/she)
was admitted on (FAD/RAD)?]

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) IN13A - ICAREPTD
(01) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) IN18 - IGAPCOV
(01) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) IN 20-ILTCCOV
(01) IN19-IGAPNAME
(-8) IN20-ILTCCOV
(-9) IN20-ILTCCOV

ICDCRCOV

Our records show that (SP) is covered by Medicare. I'd like to ask some questions about (his/her) Medicare
coverage.
ICAREPTD

IN13A

yes/no

Was (SP) covered by Part D of Medicare on [September 1, (CURRENT YEAR)/(FAD/RAD)]?
PRESS F1 FOR PART D DEFINITIONS.

IGAPCOV

IN18

yes/no

On [September 1, (CURRENT YEAR)/(FAD/RAD)], was (SP) covered by private health insurance that pays for
some or all charges for inpatient and outpatient hospital and physician services and/or supplements Medicare
(Medigap policy)?

Page 1 of 3

2021 MCBS Facility Instrument

Variable Name

MR Screen Name

IN-Health Insurance

Question Type

Question Text/Description

Code List

Routing

(01) Continuous Answer

(01) IN19 - IGAPNAM2

(01) Continuous Answer

(01) IN19 - IGAPNAM3

(01) Continuous Answer

(01) IN19 - IGAPNAM4

(01) Continuous Answer

(01) IN19 - IGAPNAM5

(01) Continuous Answer

(01) IN20 - ILTCCOV

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) IN22 - ICHACOV
(01) IN21 - ILTCNAME
(-8) IN22 - ICHACOV
(-9) IN22 - ICHACOV

(01) Continuous Answer

(01) IN21 - ILTCNAM2

(01) Continuous Answer

(01) IN21 - ILTCNAM3

(01) Continuous Answer

(01) IN21 - ILTCNAM4

(01) Continuous Answer

(01) IN21 - ILTCNAM5

(01) Continuous Answer

(01) IN22 - ICHACOV

What is the name of the insurance company?
IGAPNAME

IN19

Text

IGAPNAM2

IN19

Text

IGAPNAM3

IN19

Text

IGAPNAM4

IN19

Text

IGAPNAM5

IN19

Text

ILTCCOV

IN20

yes/no

ILTCNAME

IN21

Text

ILTCNAM2

IN21

Text

ILTCNAM3

IN21

Text

ILTCNAM4

IN21

Text

ILTCNAM5

IN21

Text

ICHACOV

IN22

Yes/No

Was (SP) covered by either TRICARE or CHAMPVA for hospital or physician care on [September 1, (CURRENT (00) NO
YEAR)/(FAD/RAD)]?
(01) YES
(-8) Don't Know
PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.
(-9) Refused

(00) IN23 - IDVACOV
(01) IN23 - IDVACOV
(-8) IN23 - IDVACOV
(-9) IN23 - IDVACOV

IDVACOV

IN23

Yes/No

Was (SP) covered by any other Department of Veterans Affairs (VA) program or contract on [September 1,
(CURRENT YEAR)/(FAD/RAD)]?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) IN24 - IPUBCOV
(01) IN24 - IPUBCOV
(-8) IN24 - IPUBCOV
(-9) IN24 - IPUBCOV

IPUBCOV

IN24

Yes/No

(Besides [READ NAME(S) FROM ABOVE], was/Was) (SP) covered by any other public assistance health
insurance program on [September 1, (CURRENT YEAR)/(FAD/RAD)]?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX IN9
(01) IN25 - IPUBNAME
(-8) BOX IN9
(-9) BOX IN9

IPUBNAME

IN25

Text

What (is/was) the name of the public assistance health insurance program?

(01) Continuous Answer

(01) BOX IN9

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

On [September 1, (CURRENT YEAR)/(FAD/RAD)], was (SP) covered by private health insurance that pays for
some or all charges for more than 100 days of nursing home care, that is, a long-term care policy?

What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]

Page 2 of 3

2021 MCBS Facility Instrument

Variable Name

MR Screen Name
BOX IN9

IN-Health Insurance

Question Type

Question Text/Description

routing

IF SP ALIVE, AND A CFR, FFC, OR FCF AND IS A FALL ROUND, GO TO INBQ13A - IMARSTAT.
ELSE GO TO INEND - INENDCT.

Code List

Routing

(01) INEND - INENDCT
(02) INEND - INENDCT
(03) INEND - INENDCT
(04) INEND - INENDCT
(05) INEND - INENDCT
(-8) INEND - INENDCT
(-9) INEND - INENDCT

(01) BOX INEND

IMARSTAT

INBQ13A

code one

Is (SP) currently married, widowed, divorced, separated, or never married?

(01)NEVER MARRIED
(02) MARRIED
(03) WIDOWED
(04) DIVORCED
(05) SEPARATED
(-8) Don't Know
(-9) Refused

INENDCT

INEND

code one

YOU HAVE COMPLETED THE HEALTH INSURANCE SECTION FOR THIS SP.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(01) CONTINUE

BOX INEND

routing

GO TO NAVIGATOR

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