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

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

OMB: 0938-0568

IC ID: 8171

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A) Form
CMS-P-0015A Cost Payment Summary 2021_Cost_Payment_Summary_CPS.pdf Form
CMS-P-0015A Cost Payment Summary 2021_Cost_Payment_Summary_CPS.pdf Form
CMS-P-0015A Demographic Income 2023_Demographics_Income_DIQ.pdf Form
CMS-P-0015A Demographic Income 2023_Demographics_Income_DIQ.pdf Form
CMS-P-0015A End Questionaire 2023_End_END.pdf Form
CMS-P-0015A End Questionaire 2023_End_END.pdf Form
CMS-P-0015A Enumeration Summary 2021_Enumeration_Summary_ENS.pdf Form
CMS-P-0015A Enumeration Summary 2021_Enumeration_Summary_ENS.pdf Form
CMS-P-0015A Home Health Summary 2018_Home_Health_Summary_HHS.pdf Form
CMS-P-0015A Home Health Summary 2018_Home_Health_Summary_HHS.pdf Form
CMS-P-0015A interviewer Remarks 2019_Interviewer_Remarks_IRQ.pdf Form
CMS-P-0015A interviewer Remarks 2019_Interviewer_Remarks_IRQ.pdf Form
CMS-P-0015A Mobility of Beneficiaries 2021_Mobility_MBQ.pdf Form
CMS-P-0015A Mobility of Beneficiaries 2021_Mobility_MBQ.pdf Form
CMS-P-0015A Post Statement Cost 2021_Post_Statement_Cost_PSQ.pdf Form
CMS-P-0015A Post Statement Cost 2021_Post_Statement_Cost_PSQ.pdf Form
CMS-P-0015A Access to Care 2021_Access_To_Care_ACQ.pdf Form
CMS-P-0015A Access to Care 2021_Access_To_Care_ACQ.pdf Form
CMS-P-0015A Chronic Pain 2023_Chronic_Pain_CPQ.pdf Form
CMS-P-0015A Chronic Pain 2023_Chronic_Pain_CPQ.pdf Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2023_Den_Vis_Hear_Care_Utl_DVH.pdf Form
CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2023_Den_Vis_Hear_Care_Utl_DVH.pdf Form
CMS-P-0015A Drug Coverage 2021_Drug_Coverage_RXQ.pdf Form
CMS-P-0015A Drug Coverage 2021_Drug_Coverage_RXQ.pdf Form
CMS-P-0015A Emergency Utilization 2021_Emergency_Utilization_ERQ.pdf Form
CMS-P-0015A Emergency Utilization 2021_Emergency_Utilization_ERQ.pdf Form
CMS-P-0015A Health Insurance 2021_Health_Insurance_HIQ.pdf Form
CMS-P-0015A Health Insurance 2021_Health_Insurance_HIQ.pdf Form
CMS-P-0015A Home Health 2021_Home_Health_Util_HHQ.pdf Form
CMS-P-0015A Home Health 2021_Home_Health_Util_HHQ.pdf Form
CMS-P-0015A Housing_Characteristics 2021_Housing_Charcs_HAQ.pdf Form
CMS-P-0015A Housing_Characteristics 2021_Housing_Charcs_HAQ.pdf Form
CMS-P-0015A Income_and_ Assets 2021_Income_and_Assets_IAQ.pdf Form
CMS-P-0015A Income_and_ Assets 2021_Income_and_Assets_IAQ.pdf Form
CMS-P-0015A Inpatient Utilization 2021_Inpatient_Utilization_IPQ.pdf Form
CMS-P-0015A Inpatient Utilization 2021_Inpatient_Utilization_IPQ.pdf Form
CMS-P-0015A Institutional Utilization 2021_Institutional_Util_IUQ.pdf Form
CMS-P-0015A Institutional Utilization 2021_Institutional_Util_IUQ.pdf Form
CMS-P-0015A Introduction 2023_Introduction_INQ.pdf Form
CMS-P-0015A Introduction 2023_Introduction_INQ.pdf Form
CMS-P-0015A Medical Provider Utilzation 2021_Medical_Provider_Utilization_MPQ.pdf Form
CMS-P-0015A Medical Provider Utilzation 2021_Medical_Provider_Utilization_MPQ.pdf Form
CMS-P-0015A Nicotine Alcohol 2021_Nicotine_Alcohol_Use_NAQ.pdf Form
CMS-P-0015A Nicotine Alcohol 2021_Nicotine_Alcohol_Use_NAQ.pdf Form
CMS-P-0015A No Statement Cost 2021_No_Statement_Cost_Series_NSQ.pdf Form
CMS-P-0015A No Statement Cost 2021_No_Statement_Cost_Series_NSQ.pdf Form
CMS-P-0015A Other Medical Expense 2021_Other_Medical_Expense_OMQ.pdf Form
CMS-P-0015A Other Medical Expense 2021_Other_Medical_Expense_OMQ.pdf Form
CMS-P-0015A Outpatient Utilization 2021_Outpatient_Util_OPQ.pdf Form
CMS-P-0015A Outpatient Utilization 2021_Outpatient_Util_OPQ.pdf Form
CMS-P-0015A Prescribed Medicine Utilization 2021_Prescribed_Medicine_Utilization_PMQ.pdf Form
CMS-P-0015A Prescribed Medicine Utilization 2021_Prescribed_Medicine_Utilization_PMQ.pdf Form
CMS-P-0015A Satisfaction Care 2023_Satisfaction_with_Care_SCQ.pdf Form
CMS-P-0015A Satisfaction Care 2023_Satisfaction_with_Care_SCQ.pdf Form
CMS-P-0015A Statement Cost Series 2021_Statement_Cost_Series_STQ.pdf Form
CMS-P-0015A Statement Cost Series 2021_Statement_Cost_Series_STQ.pdf Form
CMS-P-0015A Beneficiary Knowledge 2023_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf Form
CMS-P-0015A Beneficiary Knowledge 2023_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf Form
CMS-P-0015A Preventive Care 2023_Preventive_Care_PVQ.pdf Form
CMS-P-0015A Preventive Care 2023_Preventive_Care_PVQ.pdf Form
CMS-P-0015A Usual Source of Care 2023_Usual_Source_Of_Care_USQ.pdf Form
CMS-P-0015A Usual Source of Care 2023_Usual_Source_Of_Care_USQ.pdf Form
CMS-P-0015A Showcards and Reference Cards 2023CommShowcards508.pdf Form
CMS-P-0015A Showcards and Reference Cards 2023CommShowcards508.pdf Form
CMS-P-0015A Facility Showcards 2021FacilityShowcards508.pdf Form
CMS-P-0015A Facility Showcards 2021FacilityShowcards508.pdf Form
CMS-P-0015A Facility Screener Fac2021_Facility_Screener_FACSCREEN.pdf Form
CMS-P-0015A Facility Screener Fac2021_Facility_Screener_FACSCREEN.pdf Form
CMS-P-0015A Residence History Missing Data Fac2021_Residence_Missing_RHM.pdf Form
CMS-P-0015A Residence History Missing Data Fac2021_Residence_Missing_RHM.pdf Form
CMS-P-0015A Residence History Fac2022_Residence_History_RH.pdf Form
CMS-P-0015A Residence History Fac2022_Residence_History_RH.pdf Form
CMS-P-0015A Use of Health Services Fac2021_Health_Status_HS.pdf Form
CMS-P-0015A Use of Health Services Fac2021_Health_Status_HS.pdf Form
CMS-P-0015A Background_Questionnaire Fac2022_Background_BQ.pdf Form
CMS-P-0015A Background_Questionnaire Fac2022_Background_BQ.pdf Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2021_Background_Missing_BQM.pdf Form
CMS-P-0015A Background_Questionnaire MIssing Data Fac2021_Background_Missing_BQM.pdf Form
CMS-P-0015A Expenditures Fac2021_Expenditures_EX.pdf Form
CMS-P-0015A Expenditures Fac2021_Expenditures_EX.pdf Form
CMS-P-0015A Questionaire Missing Data Fac2021_Facility_Missing_FQM.pdf Form
CMS-P-0015A Questionaire Missing Data Fac2021_Facility_Missing_FQM.pdf Form
CMS-P-0015A Questionaire Fac2021_Facility_Quex_FQ.pdf Form
CMS-P-0015A Questionaire Fac2021_Facility_Quex_FQ.pdf Form
CMS-P-0015A Health_Insurance Fac2021_Health_Insurance_IN.pdf Form
CMS-P-0015A Health_Insurance Fac2021_Health_Insurance_IN.pdf Form
CMS-P-0015A Health_Status Fac2020_Health_Status_HS.pdf Form
CMS-P-0015A Health_Status Fac2020_Health_Status_HS.pdf Form
CMS-P-0015A Cognitive Measures 2023_Cognitive_Measures_CMQ.pdf Form
CMS-P-0015A Cognitive Measures 2023_Cognitive_Measures_CMQ.pdf Form
CMS-P-0015A Health Status and Functioning Questionnaire Specificatio 2023_Health_Status_HFQ.pdf Form
CMS-P-0015A Health Status and Functioning Questionnaire Specificatio 2023_Health_Status_HFQ.pdf Form
CMS-P-0015A Physical_Measures 2023_Physical_Measures_PXQ.pdf Form
CMS-P-0015A Physical_Measures 2023_Physical_Measures_PXQ.pdf Form
CMS-P-0015A interviewer Remarks Fac2019_Interviewer_Remarks_IR.pdf Form
CMS-P-0015A interviewer Remarks Fac2019_Interviewer_Remarks_IR.pdf Form
P-0015A COVID-19 Questionnaire Specifications 2023_COVID_19_CVQ.pdf Form
P-0015A COVID-19 Questionnaire Specifications 2023_COVID_19_CVQ.pdf Form
P-0015A COVID-19 Facility-Level Supplement Fac2022_COVID_19_Fac_Supp_FC.pdf Form
P-0015A COVID-19 Facility-Level Supplement Fac2022_COVID_19_Fac_Supp_FC.pdf Form
CMS-P-0015A CV-COVID-19 Beneficiary Supplement Fac2022_COVID_19_Bene_Supp_CV.pdf Form
CMS-P-0015A CV-COVID-19 Beneficiary Supplement Fac2022_COVID_19_Bene_Supp_CV.pdf Form
CMS-P-0015A Use of Health Services Section Specifications Fac2022_Use_Health_Services_US.pdf Form
CMS-P-0015A Use of Health Services Section Specifications Fac2022_Use_Health_Services_US.pdf Form
CMS-P-0015A Telemedicine Questionnaire 2023_Telemedicine_TLQ.pdf Form
CMS-P-0015A Telemedicine Questionnaire 2023_Telemedicine_TLQ.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-P-0015A	Cost Payment Summary	2021_Cost_Payment_Summary_CPS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Demographic Income	2023_Demographics_Income_DIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	End Questionaire	2023_End_END.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Enumeration Summary	2021_Enumeration_Summary_ENS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health Summary	2018_Home_Health_Summary_HHS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	interviewer Remarks	2019_Interviewer_Remarks_IRQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Mobility of Beneficiaries	2021_Mobility_MBQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Post Statement Cost	2021_Post_Statement_Cost_PSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Access to Care	2021_Access_To_Care_ACQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Chronic Pain	2023_Chronic_Pain_CPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Dental, Vision, and Hearing Care Utilization	2023_Den_Vis_Hear_Care_Utl_DVH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Drug Coverage	2021_Drug_Coverage_RXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Emergency Utilization	2021_Emergency_Utilization_ERQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Insurance	2021_Health_Insurance_HIQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Home Health	2021_Home_Health_Util_HHQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Housing_Characteristics	2021_Housing_Charcs_HAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Income_and_ Assets	2021_Income_and_Assets_IAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Inpatient Utilization	2021_Inpatient_Utilization_IPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Institutional Utilization	2021_Institutional_Util_IUQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Introduction	2023_Introduction_INQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Medical Provider Utilzation	2021_Medical_Provider_Utilization_MPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Nicotine Alcohol	2021_Nicotine_Alcohol_Use_NAQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	No Statement Cost	2021_No_Statement_Cost_Series_NSQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Other Medical Expense	2021_Other_Medical_Expense_OMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Outpatient Utilization	2021_Outpatient_Util_OPQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Prescribed Medicine Utilization	2021_Prescribed_Medicine_Utilization_PMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Satisfaction Care	2023_Satisfaction_with_Care_SCQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Statement Cost Series	2021_Statement_Cost_Series_STQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Beneficiary Knowledge	2023_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Preventive Care	2023_Preventive_Care_PVQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Usual Source of Care	2023_Usual_Source_Of_Care_USQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Showcards and Reference Cards	2023CommShowcards508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Showcards	2021FacilityShowcards508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Facility Screener	Fac2021_Facility_Screener_FACSCREEN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History Missing Data	Fac2021_Residence_Missing_RHM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Residence History	Fac2022_Residence_History_RH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Use of Health Services	Fac2021_Health_Status_HS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire	Fac2022_Background_BQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Background_Questionnaire MIssing Data	Fac2021_Background_Missing_BQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Expenditures	Fac2021_Expenditures_EX.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire Missing Data	Fac2021_Facility_Missing_FQM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Questionaire	Fac2021_Facility_Quex_FQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Insurance	Fac2021_Health_Insurance_IN.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health_Status	Fac2020_Health_Status_HS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Cognitive Measures	2023_Cognitive_Measures_CMQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Health Status and Functioning Questionnaire Specification	2023_Health_Status_HFQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Physical_Measures	2023_Physical_Measures_PXQ.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	interviewer Remarks	Fac2019_Interviewer_Remarks_IR.pdf	Yes	Yes	Fillable Fileable
Form	P-0015A	COVID-19 Questionnaire Specifications	2023_COVID_19_CVQ.pdf	Yes	Yes	Fillable Fileable
Form	P-0015A	COVID-19 Facility-Level Supplement	Fac2022_COVID_19_Fac_Supp_FC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	CV-COVID-19 Beneficiary Supplement	Fac2022_COVID_19_Bene_Supp_CV.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Use of Health Services Section Specifications	Fac2022_Use_Health_Services_US.pdf	Yes	Yes	Fillable Fileable
Form	CMS-P-0015A	Telemedicine Questionnaire	2023_Telemedicine_TLQ.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35,998	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	35,998	0	35,998
Annual IC Time Burden (Hours)	46,513	-7,913	54,426
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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