Medical Expenditure Panel Survey - Household and Medical Provider Components

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2a Cancer SAQ	Form and Instruction	New	Available
Form 2a Cancer SAQ	Form and Instruction	New	Repair queued
Form 5a Preventative Care SAQ	Form and Instruction	New	Available
Form 5a Preventive Care SAQ	Form and Instruction	New	Repair queued
Form 1a Adult SAQ	Form and Instruction	New	Available
Form 1a Adult SAQ	Form and Instruction	New	Repair queued
Form 1 PE COVID-19	Form and Instruction	Removed	Available
Form 1 COVID-19 Questions	Form and Instruction	Removed	Repair queued
Form Attachment B Attachment B	Form and Instruction	Removed	Available
Form Attachment A – COV Attachment A – COVID-19 Questions	Form and Instruction	Removed	Available
Form Attachment A – COV COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire	Form and Instruction	Removed	Repair queued
Form Attachment C Attachment C	Form and Instruction	Removed	Available
Form Attachment C Attachment C – Social and Health Experiences Self-Administered Questionnaire	Form and Instruction	Removed	Repair queued
Form 106b Attachment106b.REV_Male PSAQ with Mental Health Content	Form and Instruction	Removed	Available
Form 106a Attachment 106a.REV_Female PSAQ with Mental Health Content	Form and Instruction	Removed	Available
Form 106a HC Adult SAQ that includes Mental Health Questions	Form and Instruction	Removed	Repair queued
Form 107d Attachment 107d.Protocol D (Other)	Form and Instruction	Removed	Available
Form 107c Attachment 107c.Protocol C (Private with Medicare)_	Form and Instruction	Removed	Repair queued
Form 107b Attachment 107b.Protocol B (Employer)	Form and Instruction	Removed	Available
Form 107a Attachment 107a.Protocol A (Medicare)	Form and Instruction	Removed	Available
Form 107a Health Insurance Cost Sharing Collection- 2020	Form and Instruction	Removed	Repair queued
Form 108 Attachment 108 - Household Component Core Instrument Link	Form and Instruction	Removed	Available
Form 108 Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	Form and Instruction	Removed	Repair queued
Form Attachment 18 Attachment 18 HC Adult SAQ	Form and Instruction	Removed	Available
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Removed	Available
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Removed	Repair queued
Form Attachment 19 Attachment 19 HC Adult SAQ Male	Form and Instruction	Removed	Available
Form Attachment 20 Attachment 20 HC Adult SAQ Female	Form and Instruction	Removed	Available
Form Attachment 20 Attachment 20 HC Adult SAQ Female	Form and Instruction	Removed	Repair queued
Form Attachment 77 Attachment 77 – MPC Separate Billing Doctor Contact Guide	Form and Instruction	Modified	Available
Form Attachment 76 Attachment 76 – MPC Pharmacy Contact Guide	Form and Instruction	Modified	Available
Form Attachment 75 Attachment 75 – MPC Institution Contact Guide	Form and Instruction	Modified	Available
Form Attachment 74 Attachment 74 – MPC Home Care Contact	Form and Instruction	Modified	Available
Form Attachment 73 Attachment 73 – MPC Office-Based Doctor Contact Guide	Form and Instruction	Modified	Available
Form Attachment 72 Attachment 72 – MPC Hospital Contact Guide	Form and Instruction	Modified	Available
Form Attachment 72 MPC Contact Guide/Screening Call	Form and Instruction	Modified	Repair queued
Form Attachment 26 Attachment 26 HC MEPS Validation Interview	Form and Instruction	Modified	Repair queued
Form Attachment 26 MEPS-HC Validation Interview	Form and Instruction	Modified	Repair queued
Form Attachment 24 Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy	Form and Instruction	Removed	Available
Form Attachment 24 Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	Removed	Repair queued
Form Attachment 24 Authorization Form for the MEPS MPC Pharmacy Survey	Form and Instruction	Modified	Available
Form Attachment 25 Attachment 25 HC Authorization Form for the MEPS MPC Provider	Form and Instruction	Modified	Available
Form Attachment 25 Authorization form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction	Modified	Available
Form Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire	Form and Instruction	Modified	Available
Form Attachment 98 Pharmacies questionnaire	Form and Instruction	Modified	Available
Form Attachment 96 Attachment 96 – MPC Institution Provider Questionnaire	Form and Instruction	Modified	Available
Form Attachment 96 Institutions (non-hospital) questionnaire	Form and Instruction	Modified	Repair queued
Form Attachment 91 Attachment 91 – MPC Hospital Provider Questionnaire	Form and Instruction	Modified	Available
Form Attachment 91 Hospitals questionnaire	Form and Instruction	Modified	Repair queued
Form Attachment 87 Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire	Form and Instruction	Modified	Available
Form Attachment 87 Separately billing doctors questionnaire	Form and Instruction	Modified	Repair queued
Form Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questionnaire	Form and Instruction	Modified	Available
Form Attachment 83 Office based providers questionnaire	Form and Instruction	Modified	Repair queued
Form Attachment 82 Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers	Form and Instruction	Removed	Available
Form Attachment 82 Home care for non health care providers questionnaire	Form and Instruction	Removed	Repair queued
Form 5a Home Health Event Form for Non-Health Care Providers	Form and Instruction	Modified	Available
Form 4a Home Health Event Form for Health Care Providers	Form and Instruction	Modified	Available
Form 4a Home Care Providers Event Form	Form and Instruction	Modified	Repair queued
Form Attachment 23 Attachment 23 -- HC Diabetes SAQ - Self	Form and Instruction	Modified	Available
Form Attachment 22 Attachment 22 -- HC Diabetes SAQ - Proxy	Form and Instruction	Modified	Available
Form Attachment 22 Diabetes Care SAQ	Form and Instruction	Modified	Repair queued
SS Part A - MEPS-HC MPC 01122024.docx	Supporting Statement A	Uploaded 2024-01-12	Available
SS Part B - MEPS HC MPC - 2024.docx	Supporting Statement B	Uploaded 2024-01-09	Repair queued
Attachment 6 - Federal Register Notice.pdf	Supplementary Document	Uploaded 2024-01-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37877	MEPS-HC Core Interview	Other-Explanatory	Modified
264332	Cancer SAQ	Form and Instruction	New	Cancer SAQ
264332	Cancer SAQ	Form and Instruction	New
264315	Preventive Care SAQ	Form and Instruction	New	Preventative Care SAQ
264315	Preventive Care SAQ	Form and Instruction	New
264201	Adult SAQ	Form and Instruction	New	Adult SAQ
264201	Adult SAQ	Form and Instruction	New
256163	COVID-19 Questions	Form and Instruction	Removed	PE COVID-19
256163	COVID-19 Questions	Form and Instruction	Removed
242880	COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire	Form and Instruction	Removed	Attachment B
242880	COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire	Form and Instruction	Removed	Attachment A – COVID-19 Questions
242880	COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire	Form and Instruction	Removed
242879	Attachment C – Social and Health Experiences Self-Administered Questionnaire	Form and Instruction	Removed	Attachment C
242879	Attachment C – Social and Health Experiences Self-Administered Questionnaire	Form and Instruction	Removed
236894	HC Adult SAQ that includes Mental Health Questions	Form and Instruction	Removed	Attachment106b.REV_Male PSAQ with Mental Health Content
236894	HC Adult SAQ that includes Mental Health Questions	Form and Instruction	Removed	Attachment 106a.REV_Female PSAQ with Mental Health Content
236894	HC Adult SAQ that includes Mental Health Questions	Form and Instruction	Removed
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	Removed	Attachment 107d.Protocol D (Other)
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	Removed	Attachment 107c.Protocol C (Private with Medicare)_
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	Removed	Attachment 107b.Protocol B (Employer)
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	Removed	Attachment 107a.Protocol A (Medicare)
236893	Health Insurance Cost Sharing Collection- 2020	Form and Instruction	Removed
236883	Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	Form and Instruction	Removed	Attachment 108 - Household Component Core Instrument Link
236883	Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	Form and Instruction	Removed
230227	Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Removed	Attachment 18 HC Adult SAQ
230227	Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Removed	Attachment 19 – HC Adult SAQ – Male
230227	Attachment 19 – HC Adult SAQ – Male	Form and Instruction	Removed
230226	Attachment 20 HC Adult SAQ Female	Form and Instruction	Removed	Attachment 19 HC Adult SAQ Male
230226	Attachment 20 HC Adult SAQ Female	Form and Instruction	Removed	Attachment 20 HC Adult SAQ Female
230226	Attachment 20 HC Adult SAQ Female	Form and Instruction	Removed
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified	Attachment 77 – MPC Separate Billing Doctor Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified	Attachment 76 – MPC Pharmacy Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified	Attachment 75 – MPC Institution Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified	Attachment 74 – MPC Home Care Contact
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified	Attachment 73 – MPC Office-Based Doctor Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified	Attachment 72 – MPC Hospital Contact Guide
204200	MPC Contact Guide/Screening Call	Form and Instruction	Modified
204199	MEPS-HC Validation Interview	Form and Instruction	Modified	Attachment 26 HC MEPS Validation Interview
204199	MEPS-HC Validation Interview	Form and Instruction	Modified
204198	Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	Removed	Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
204198	Authorization form for the MEPS-MPC Pharmacy Survey	Form and Instruction	Removed
204197	Authorization form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction	Modified	Authorization Form for the MEPS MPC Pharmacy Survey
204197	Authorization form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction	Modified	Attachment 25 HC Authorization Form for the MEPS MPC Provider
204197	Authorization form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction	Modified
191107	Pharmacies questionnaire	Form and Instruction	Modified	Attachment 98 – MPC Pharmacy Provider Questionnaire
191107	Pharmacies questionnaire	Form and Instruction	Modified
191106	Institutions (non-hospital) questionnaire	Form and Instruction	Modified	Attachment 96 – MPC Institution Provider Questionnaire
191106	Institutions (non-hospital) questionnaire	Form and Instruction	Modified
191105	Hospitals questionnaire	Form and Instruction	Modified	Attachment 91 – MPC Hospital Provider Questionnaire
191105	Hospitals questionnaire	Form and Instruction	Modified
191104	Separately billing doctors questionnaire	Form and Instruction	Modified	Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire
191104	Separately billing doctors questionnaire	Form and Instruction	Modified
191103	Office based providers questionnaire	Form and Instruction	Modified	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
191103	Office based providers questionnaire	Form and Instruction	Modified
191102	Home care for non health care providers questionnaire	Form and Instruction	Removed	Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
191102	Home care for non health care providers questionnaire	Form and Instruction	Removed
191101	Home Care Providers Event Form	Form and Instruction	Modified	Home Health Event Form for Non-Health Care Providers
191101	Home Care Providers Event Form	Form and Instruction	Modified	Home Health Event Form for Health Care Providers
191101	Home Care Providers Event Form	Form and Instruction	Modified
191099	Diabetes Care SAQ	Form and Instruction	Modified	Attachment 23 -- HC Diabetes SAQ - Self
191099	Diabetes Care SAQ	Form and Instruction	Modified	Attachment 22 -- HC Diabetes SAQ - Proxy
191099	Diabetes Care SAQ	Form and Instruction	Modified

ICR Details

OMB Control No: 0935-0118	ICR Reference No: 202401-0935-001
Status: Historical Active	Previous ICR Reference No: 202209-0935-003
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Expenditure Panel Survey - Household and Medical Provider Components
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/27/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/12/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2027	36 Months From Approved	11/30/2025
Responses	642,279	0	392,715
Time Burden (Hours)	76,499	0	88,531
Cost Burden (Dollars)	0	0	0

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Abstract: The MEPS was initiated in 1996. Each year a new panel of sample households is selected. Recent annual MEPS-HC sample sizes average about 13,500 households. Data can be analyzed at either the person, family, or event level. The panel design of the survey, which includes 5 Rounds of interviews covering 2 full calendar years, provides data for examining person level changes in selected variables such as expenditures, health insurance coverage, and health status (see Medical Expenditure Panel Survey Content Summary of the Household Interview (ahrq.gov) for information on how the Covid-19 pandemic impacted this design). Using a combination of computer assisted personal interviewing (CAPI), computer assisted video interviewing (CAVI), and self-administered paper and web questionnaires, information about each household member is collected, and the survey builds on this information from interview to interview. CAVI is a new data collection technology and offers the best of both telephone and in-person interviewing, while offering opportunities for cost savings and more accurate reporting.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Agency for Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 67291	09/29/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 86650	12/14/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Attachment 20 HC Adult SAQ Female	Attachment 19 , Attachment 20	Attachment 20 HC Adult SAQ Female ,   Attachment 19 HC Adult SAQ Male
COVID-19 Questions	1	PE COVID-19
Adult SAQ	1a	Adult SAQ
Attachment 19 – HC Adult SAQ – Male	Attachment 19 , Attachment 18	Attachment 19 – HC Adult SAQ – Male ,   Attachment 18 HC Adult SAQ
Attachment C – Social and Health Experiences Self-Administered Questionnaire	Attachment C	Attachment C
Authorization form for the MEPS-MPC Pharmacy Survey	Attachment 24	Attachment 24 HC Authorization Form for the MEPS MPC Pharmacy
Authorization form for the MEPS-MPC Provider and Pharmacy Survey	Attachment 25 , Attachment 24	Attachment 25 HC Authorization Form for the MEPS MPC Provider ,   Authorization Form for the MEPS MPC Pharmacy Survey
COVID-19 and Telehealth (telemedicine) questions included in the MEPS questionnaire	Attachment B, Attachment A – COVID-19 Questions	Attachment A – COVID-19 Questions ,   Attachment B
Cancer SAQ	2a	Cancer SAQ
Diabetes Care SAQ	Attachment 22, Attachment 23	Attachment 22 -- HC Diabetes SAQ - Proxy ,   Attachment 23 -- HC Diabetes SAQ - Self
HC Adult SAQ that includes Mental Health Questions	106a, 106b	Attachment 106a.REV_Female PSAQ with Mental Health Content ,   Attachment106b.REV_Male PSAQ with Mental Health Content
Health Insurance Cost Sharing Collection- 2020	107b, 107a, 107c, 107d	Attachment 107a.Protocol A (Medicare) ,   Attachment 107b.Protocol B (Employer) ,   Attachment 107c.Protocol C (Private with Medicare)_ ,   Attachment 107d.Protocol D (Other)
Home Care Providers Event Form	4a, 5a	Home Health Event Form for Health Care Providers ,   Home Health Event Form for Non-Health Care Providers
Home care for non health care providers questionnaire	Attachment 82	Attachment 82 – MPC Home Care Provider Questionnaire for Non-Health Care Providers
Hospitals questionnaire	Attachment 91	Attachment 91 – MPC Hospital Provider Questionnaire
Institutions (non-hospital) questionnaire	Attachment 96	Attachment 96 – MPC Institution Provider Questionnaire
MEPS-HC Core Interview
MEPS-HC Validation Interview	Attachment 26	Attachment 26 HC MEPS Validation Interview
MPC Contact Guide/Screening Call	Attachment 73 , Attachment 72 , Attachment 74 , Attachment 75 , Attachment 76 , Attachment 77	Attachment 72 – MPC Hospital Contact Guide ,   Attachment 73 – MPC Office-Based Doctor Contact Guide ,   Attachment 74 – MPC Home Care Contact ,   Attachment 75 – MPC Institution Contact Guide ,   Attachment 76 – MPC Pharmacy Contact Guide ,   Attachment 77 – MPC Separate Billing Doctor Contact Guide
Office based providers questionnaire	Attachment 83	Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Pharmacies questionnaire	Attachment 98	Attachment 98 – MPC Pharmacy Provider Questionnaire
Pilot Test on Sampling NHIS Nonrespondents – 2020, R1 only of MEPS Core	108	Attachment 108 - Household Component Core Instrument Link
Preventive Care SAQ	5a	Preventative Care SAQ
Separately billing doctors questionnaire	Attachment 87	Attachment 87 – MPC Separately Billing Doctor Provider Questionnaire

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	642,279	392,715	0	249,564	0	0
Annual Time Burden (Hours)	76,499	88,531	0	-12,032	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden is decreased by 12,032 hours through a reduction in sample size and revised burden estimates.

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Annual Cost to Federal Government: $64,851,222

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/12/2024

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