CMS-P-0015A Health_Insurance

2023 MCBS Facility Instrument

Variable Name

IN-Health Insurance

MR Screen Name 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

yes/no

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

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

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

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.

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

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

CONREFFN

INCONREF

routing

code one

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.
IN1PR2CT

IN1PRE2

code one

BOX IN3

routing

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.

ICAIDECO

ICAIDNOW

MCAIDHMO

ICDCRCOV

IN1

IN1A

IN6

yes/no

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2023 MCBS Facility Instrument

Variable Name

IN-Health Insurance

MR Screen Name Question Type

Question Text/Description

Code List

Routing

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

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

(00) NO
On [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD], was (SP) covered by private health insurance that pays for
(01) YES
some or all charges for inpatient and outpatient hospital and physician services and/or supplements Medicare
(-8) Don't Know
(Medigap policy)?
(-9) Refused

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

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)/DOD]?
PRESS F1 FOR PART D DEFINITIONS.

IGAPCOV

IN18

yes/no

What is the name of the insurance company?
IGAPNAME

IN19

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

(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

What is the name of the insurance company?
IGAPNAM2

IN19

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

What is the name of the insurance company?
IGAPNAM3

IN19

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

What is the name of the insurance company?
IGAPNAM4

IN19

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

What is the name of the insurance company?
IGAPNAM5

IN19

Text

ILTCCOV

IN20

yes/no

ILTCNAME

IN21

Text

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

(00) NO
On [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD], was (SP) covered by private health insurance that pays for (01) YES
some or all charges for more than 100 days of nursing home care, that is, a long-term care policy?
(-8) Don't Know
(-9) Refused

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

What is the name of the insurance company?
(01) Continuous Answer

(01) IN21 - ILTCNAM2

(01) Continuous Answer

(01) IN21 - ILTCNAM3

(01) Continuous Answer

(01) IN21 - ILTCNAM4

(01) Continuous Answer

(01) IN21 - ILTCNAM5

[PROBE: Any others?]

What is the name of the insurance company?
ILTCNAM2

IN21

Text
[PROBE: Any others?]

What is the name of the insurance company?
ILTCNAM3

IN21

Text
[PROBE: Any others?]

What is the name of the insurance company?
ILTCNAM4

IN21

Text
[PROBE: Any others?]

Page 2 of 3

2023 MCBS Facility Instrument

IN-Health Insurance

Variable Name

MR Screen Name Question Type

ILTCNAM5

IN21

Question Text/Description

Code List

Routing

(01) Continuous Answer

(01) IN22 - ICHACOV

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

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

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

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

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

ICHACOV

IN22

Yes/No

Was (SP) covered by either TRICARE or CHAMPVA for hospital or physician care on [September 1, (CURRENT
YEAR)/(FAD/RAD)/DOD]?
PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.

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)/DOD]?

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

(01) Continuous Answer

(01) BOX IN9

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

(01) BOX INEND

IPUBCOV

IN24

Yes/No

(00) NO
(Besides [READ NAME(S) FROM ABOVE], was/Was) (SP) covered by any other public assistance health insurance (01) YES
program on [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD]?
(-8) Don't Know
(-9) Refused

IPUBNAME

IN25

Text

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

BOX IN9

routing

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

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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