CMS-P-0015A Other Medical Expense

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ-OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing

(01) CONTINUE

OM3-OMHRSPCH

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)]
(01) YES
buy, replace, or pay for repairs of an amplifier for a telephone, or similar device to help [you/(SP)] hear or speak?
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A HEARING AID OR SPEAKING DEVICE]
(-9) Refused

(01) OM4 - EVENT_OMHRSP
(02) BOX OMA1
(03) DO NOT DISPLAY.
(-8) BOX OMA1
(-9) BOX OMA1

[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.

OMSATHMO

Please tell me the dates of each purchase or repair [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]

MM:
DD:
YYYY:

OM4AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM4-EVENT_OMHRSP
(02) BOX OM1BB

BOX OM1BB2

Page 1 of 16

2022 MCBS Community Questionnaire

Variable Name

ORTHINTRO

MR Screen Name

OMQ-OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

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).

Code List

Routing

(01) continuous answer
(-7) Empty

OMS5 - RENTSTIL

(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

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

OM6A - RENTPROB

(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused

(01) OM7 - EVENT_OMORTH
(02) OM7A - EVENT_OMORTHRENT
(03) DO NOT DISPLAY.
(-8) OM7 - EVENT_OMORTH
(-9) OM7 - EVENT_OMORTH

Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did [you/(SP)] rent (it/them)?
RENTPROB

OM6A

EVENT_OMORTH

OM7

OMADD

OM7AAA

code one

roster

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN
THE SAME ROUND, SELECT "RENT."]

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 DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

(01) ADD ANOTHER
(02) ALL DONE

OM7AAA-OMADD

(01) OM7-EVENT_OMORTH
(02) BOX OM1CC

Page 2 of 16

2022 MCBS Community Questionnaire

Variable Name

OMSATHMO

OMQ-OTHER MEDICAL EXPENSES

MR Screen Name

Question Type

Question Text/Description

BOX OM1CC

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.

OM7AA

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)
BELOW]?
[PROBE: This could include buying or repairing the (ORTHOPEDIC 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.]

EVENT_OMORTHRE
OM7A
NT

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).
[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) YES
(02) NO
(-8) Don't Know
(-9) Refused

OM8- MOREORTH

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

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

[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.]

(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1EE1
(-9) BOX OM1EE1

What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDMM

OM7C

date

(01) continuous answer
(-8) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(-9) Refused
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

date

routing

[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

OM7C - EVENDDD

OM7C - EVENDYY

DD:

(01) continuous answer
(-8) Don't Know
(-9) Refused

BOX OM3A

YYYY:

IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.

RENT2BUY

OM7CC

code one

You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is this because (you/he/she) no longer
(have/has) that item or because (you/he/she) (have/has) purchased it through a rent-to-buy option?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM7CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (ORTHOPEDIC ITEM).
RECORD VERBATIM.

(01) continuous answer

(01) BOX OM1EE
(02) BOX OM1EE
(03) OM7CCVB - REN2BVB
(-8) BOX OM1EE
(-9) BOX OM1EE

BOX OM1EE
OM7CC-OMADD

Page 3 of 16

2022 MCBS Community Questionnaire

OMQ-OTHER MEDICAL EXPENSES

Variable Name

MR Screen Name

Question Type

OMADD

OM7CC1

code one

BOX OM1EE

routing

OMSATHMO

MOREORTH

OMPRDIAB

Question Text/Description
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

Did [you/(SP)] rent 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) BELOW]?

yes/no

BOX OM1EE1

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.

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)].?

OM9

yes/no

Routing

(01) ADD ANOTHER
(02) ALL DONE

(01) OM7A-EVENT_OMORTHRENT
(02) BOX OM1EE

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

BOX OM1EE1

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

(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) OM9 - OMPRDIAB
(04) OM9 - OMPRDIAB

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

OM8

Code List

[PROBE: This could include renting the (ORTHOPEDIC ITEM) 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.]

SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(01) YES
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(02) NO
buy diabetic equipment or supplies, such as those listed on 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

(01) continuous answer
(-8) Don't Know
(-9) Refused

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)
MM:
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

OM10AA-OMADD

(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.]

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

BOX OM1FF2

Page 4 of 16

2022 MCBS Community Questionnaire

Variable Name

OMPRAMBL

OMQ-OTHER MEDICAL EXPENSES

MR Screen Name

Question Type

Question Text/Description

BOX OM1FF2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.

yes/no

(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY (02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(03) INDICATED YES BY DATAPREP
use any ambulance or rescue squad service?
(-8) Don't Know
(-9) Refused

SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] use an ambulance? 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)].

OM11

EVENT_OMAMBL

OM12

roster

OMADD

OM12AA

code one

BOX OM1GG

routing

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

Code List

Routing

(01) OM12 - EVENT_OMAMBL
(02) OM13 - OMPRPROS
(03) DO NOT DISPLAY.
(-8) OM13 - OMPRPROS
(-9) OM13 - OMPRPROS

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM12AA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(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

Was the ambulance on (EVENT DATE) provided by or approved by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO

OMPRPROS

EVENT_OMPROS

OMADD

(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.]

OM12A

yes/no

BOX OM1GG2

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.

yes/no

SHOW CARD OM3
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(03) INDICATED YES BY DATAPREP
buy or pay for repairs of any prostheses, such as those on the card?
(-8) Don't Know
(-9) Refused
[Prostheses include artificial leg or arm, mastectomy prosthesis, and artificial or glass eye.]

OM13

OM14

roster

OM14AA

code one

BOX OM1HH

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

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)
MM:
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

OM14AA-OMADD

(01) OM14-EVENT_OMPROS
(02) BOX OM1HH

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.

Page 5 of 16

2022 MCBS Community Questionnaire

Variable Name

OMSATHMO

OXGNINTRO

MR Screen Name

OMQ-OTHER MEDICAL EXPENSES

Question Type

Question Text/Description
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).

[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

OMS19

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.]

Code List

Routing

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

BOX OM1HH2

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

(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

(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused

(01) OM20 - EVENT_OMOXGN
(02) OM20A - EVENT_OMOXGNRENT
(03) OM20 - EVENT_OMOXGN
(-8) OM20 - EVENT_OMOXGN
(-9) OM20 - EVENT_OMOXGN

[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.]

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?

Did [you/(SP)] buy or repair the oxygen-related equipment, or did [you/(SP)] rent it?
RENTPROB

EVENT_OMOXGN

OMADD

OM19B

OM20

OM20AAA

code one

roster

code one

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN
THE SAME ROUND, SELECT "RENT."]

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)].

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(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

Page 6 of 16

2022 MCBS Community Questionnaire

Variable Name

OMSATHMO

OMQ-OTHER MEDICAL EXPENSES

MR Screen Name

Question Type

Question Text/Description

BOX OM1II

routing

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.

OM20AA

yes/no

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

EVENT_OMOXGNRE
OM20A
NT

routing

roster

Code List

Routing

(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 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.]

What was the last date the equipment was rented?
EVENDMM

OM20C

date

(01) continuous answer
(02) Don't Know
(03) Refused

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
MM:
RENTAL PERIOD.]
DD:
YYYY:

OM20C - EVENDDD

What was the last date the equipment was rented?
EVENDDD

OM20C

date

(01) continuous answer
(02) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(03) Refused
RENTAL PERIOD.]

OM20C - EVENDYY

What was the last date the equipment was rented?
EVENDYY

OM20C

date

(01) continuous answer
(02) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(03) Refused
RENTAL PERIOD.]

BOX OM8A

routing

IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.

BOX OM8A

Page 7 of 16

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ-OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing

(01) BOX OM1KK
(02) BOX OM1KK
(03) OM20CCVB - REN2BVB
(04) BOX OM1KK
(05) 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?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused

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

OMSATHMO

MOREOXGN

KDNYINTRO

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.

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).

[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.]

OMS21 - RENTSTIL

Page 8 of 16

2022 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 OM1NN
(02) OM22C - EVENDMM
(03) BOX OM16
(-8) BOX OM16
(-9) BOX OM16

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.]
[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?

Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)] rent it?
RENTPROB

OM21B

code one

EVENT_OMKDNY

OM22

roster

OMADD

OM22AAA

code one

BOX OM1LL

OMSATHMO

OM22AA

routing

yes/no

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN
THE SAME ROUND, SELECT "RENT."]

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)].

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) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT

(01) OM22 - EVENT_OMKDNY
(02) OM21B - RENTPROB

(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused

(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 9 of 16

2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

EVENT_OMKDNYRE
OM22A
NT

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

(01) continuous answer
(-8) Don't Know
(-9) Refused

[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
MM:
RENTAL PERIOD.]
DD:
YYYY:

OM22C - EVENDDD

What was the last date the equipment was rented?
EVENDDD

OM22C

date

(01) continuous answer
(-8) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(-9) Refused
RENTAL PERIOD.]

OM22C - EVENDYY

What was the last date the equipment was rented?
EVENDYY

OM22C

date

(01) continuous answer
(-8) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(-9) Refused
RENTAL PERIOD.]

BOX OM15A

routing

IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.

RENT2BUY

OM22CC

code one

You said [you/(SP)] stopped renting the dialysis 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?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused

REN2BVB

OM22CCVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS EQUIPMENT.
RECORD VERBATIM.

(01) continuous answer

OMADD

OM22CC1

code one

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) ADD ANOTHER
(02) ALL DONE

BOX OM15A

(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

Page 10 of 16

2022 MCBS Community Questionnaire

Variable Name

OMSATHMO

MOREKDNY

OTHRINTRO

OMQ-OTHER MEDICAL EXPENSES

MR Screen Name

Question Type

Question Text/Description

BOX OM1NN

routing

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.

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]?

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.

OM22D

yes/no

In addition to the [(kidney dialysis supplies)/(kidney dialysis equipment)] that you just told me about, did
[you/(SP)] [(obtain any kidney dialysis equipment)/(buy any kidney dialysis supplies)]?

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).

[PROBE: This could include renting the kidney dialysis 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.]

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

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.]

Code List

Routing

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

BOX OM1NN1

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

(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.]

Page 11 of 16

2022 MCBS Community Questionnaire

Variable Name

OMPROTHR

MR Screen Name

OM23

OMQ-OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

yes/no

SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(01) YES
buy, rent, or repair any other medical equipment or buy any other medical supplies besides what we have talked
(02) NO
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.]

Routing

(01) OM24 - OTHRTYPE
(02) BOX OM24
(03) DO NOT DISPLAY.
(04) BOX OM24
(05) BOX OM24

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 - RENTPROB

(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
EQUIPMENT
(-8) Don't Know
(-9) Refused

(01) OM26 - EVENT_OMOTHR
(02) OM26A - EVENT_OMOTHRRENT
(03) DO NOT DISPLAY.
(-8) OM26 - EVENT_OMOTHR
(-9) OM26 - EVENT_OMOTHR

(01) continuous answer
(-8) Don't Know
(-9) Refused

BOX OM1QQ1

Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM), or did [you/(SP)] rent it?
RENTPROB

GETNUM

OM24A

code one

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
(REFERENCE DATE/UTILDATE).
How many times [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] [[have you/has (SP)] bought or obtained/did (SP) buy
or obtain] (OTHER MEDICAL EXPENSE ITEM)?

OM25

EVENT_OMOTHR

OM26

roster

OMADD

OM26AAA

code one

[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN
THE SAME ROUND, SELECT "RENT."]

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)]

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(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

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

OM27AAA-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM26-EVENT_OMOTHR
(02) BOX OM1OO

Page 12 of 16

2022 MCBS Community Questionnaire

Variable Name

OMSATHMO

OMQ-OTHER MEDICAL EXPENSES

MR Screen Name

Question Type

Question Text/Description

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.

OM26AA

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
PLAN NAME(S) BELOW]?
[PROBE: This could include buying or repairing the (OTHER MEDICAL EXPENSE 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.]

EVENT_OMOTHRRE
OM26A
NT

roster

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.]

Code List

Routing

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

BOX OM21

(01) continuous answer
(-8) Don't Know
(-9) Refused

OM26A1 - RENTSTIL

(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

RENT2BUY

OM26BB

date

routing

code one

[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

OM26B - EVENDYY

DD:

(01) continuous answer
(-8) Don't Know
(-9) Refused

BOX OM22A

YYYY:

IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.

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?

(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX OM1QQ
(02) BOX OM1QQ
(03) OM26BBVB - REN2BVB
(-8) BOX OM1QQ
(-9) BOX OM1QQ

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2022 MCBS Community Questionnaire

OMQ-OTHER MEDICAL EXPENSES

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

REN2BVB

OM26BBVB

verbatim text

BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER MEDICAL EXPENSE ITEM).
RECORD VERBATIM.

(01) continuous answer

OMADD

OM26BB1

code one

BOX OM1QQ

routing

OMSATHMO

MOREOTHR

ALTRINTRO

OM26C

yes/no

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

Routing
BOX OM1QQ
OM26BB1-OMADD

(01) ADD ANOTHER
(02) ALL DONE

(01) OM26A-EVENT_OMOTHRRENT
(02) BOX OM1QQ

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

BOX OM1QQ1

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]?
[PROBE: This could include renting the (OTHER MEDICAL EXPENSE ITEM) 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.]

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.

OM27

yes/no

(01) YES
In addition to the medical equipment you just told me about, did [you/(SP)] buy, rent, or repair any other medical
(02) NO
equipment [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

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).

(01) OM24 - OTHRTYPE
(02) BOX OM24
(-8) BOX OM24
(-9) BOX OM24

OMS28 - EVENDMM

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

(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (-9) Refused
was this alteration completed?

OMS28 - EVENDDD

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2022 MCBS Community Questionnaire

Variable Name

MR Screen Name

OMQ-OTHER MEDICAL EXPENSES

Question Type

Question Text/Description

Code List

Routing

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

(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (-9) Refused
was this alteration completed?

OMS28 -EVENDYY

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

(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (-9) Refused
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.]

(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

EVENDMM

OM30

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
was this alteration completed?

OMS28 - OMNOTDONE

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OM30 - EVENDDD

MM:

EVENDDD

OM30

date

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
was this alteration completed?

(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

OM30 - EVENDDD

DD:

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2022 MCBS Community Questionnaire

Variable Name

EVENDYY

MR Screen Name

OM30

OMQ-OTHER MEDICAL EXPENSES

Question Type

date

Question Text/Description

On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
was this alteration completed?

Code List
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused

Routing

OM30 - OMNOTDONE

YYYY:

OMNOTDONE

OM30

OMADD

OM30B

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

(01) ADD ANOTHER
(02) ALL DONE

routing

IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.

OM31

yes/no

(01) YES
In addition to the alteration(s) you just told me about, did [you/(SP)] make any other alterations because of some
(02) NO
illness or injury [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

BOX OM26

routing

GO TO STQ.

BOX OM25A

MOREALTR

(01) ALTERATION NOT YET COMPLETED
(-7) Empty

code one

OM30B-OMADD

(01) OM30-EVBEGMM
(02) BOX OM25A

(01) OM29 - ALTRTYPE
(02) BOX OM26
(-8) BOX OM26
(-9) BOX OM26

Page 16 of 16