CMS-P-0015A Expenditures

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EXS2

EXPENDITURES SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF
SEASON= ALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.

BOX EXS1

routing

IF COST DATA FROM THE PREVIOUS ROUND REMAINS TO BE COLLECTED, GO TO BOX EXS1A.
ELSE GO TO BOX EXBEG.

BOX EXS1A

routing

IF FIRST/NEXT PRELOAD BPER HAS PreloadBPRO.ANCLPOST = 0/No, DK or PreloadBPRO.ANYANCIL =
DK, GO TO EX15PRES1 - EX15PRCT.
ELSE GO TO EX20S1PRE - BASSMINT.

The next questions are about health-related services received by (SP) for which there was a separate charge,
that is, your (facility/home)'s ancillary services.
EX15PRCT

EX15PRES1

code one

(Please do not include non-health-related services such as hairdressing, television, or telephone).
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS "1" TO CONTINUE.

BOX EXS2

routing

If PreloadBPRO.ANCLPOST = 0/No, DK, GO TO EX16S1 - ANCLPOST.
ELSE GO TO EX17S1 - ANYANCIL.

ANCLPOST

EX16S1

yes/no

Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END DATE)?

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

(00) BOX EX7BS1
(01) EX17S1 - ANYANCIL
(-8) BOX EX7BS1
(-9) BOX EX7BS1

ANYANCIL

EX17S1

yes/no

Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?

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

(00) BOX EX7BS1
(01) EX18S1 - ANCILAMT
(-8) BOX EX7BS1
(-9) BOX EX7BS1

ANCILAMT

EX18S1

dollar

Altogether, what was the total charge for those health-related ancillary services?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX7BS1
(-8) BOX EX7BS1
(-9) BOX EX7BS1

BASSMINT

EX20S1PRE

code one

The next questions are about (SP)'s expenditures for room and board while a resident of (FACILITY).

(01) Continue

(01) BOX EX7BS1

BOX EX7BS1

routing

IF PreloadBPRO.RECDBASP = 0/No, GO TO EX20S1 - RECDBASP.
ELSE IF PreloadBPRO.RECDANCP = 0/No or EX17S1 - ANYANCIL = 1/Yes, GO TO EX28S1 - RECDANCP.
ELSE GO TO EX33BS1 - EXSBKCT.

RECDBASP

EX20S1

yes/no

Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING (00) NO
PERIOD ABOVE] billing period?
(01) YES

ADDSOP1

EX21AAS1

yes/no

Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?

(00) NO
(01) YES

(00) BOX EX14S1
(01) EX21AAS1 - ADDSOP1

(00) EX21ACS1 - BASRATE
(01) EX21ABS1 - PAYMPLN1

Page 1 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

What Source(s) of Payment do you need to add for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?
PAYMPLN1

EX21ABS1

code one

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

Code List

Routing

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX21ACS1 - BASRATE
(02) EX21ACS1 - BASRATE
(03) EX21ACS1 - BASRATE
(04) EX21ACS1 - BASRATE
(05) EX21ACS1 - BASRATE
(06) EX21ACS1 - BASRATE
(07) EX21ACS1 - BASRATE
(08) EX21ACS1 - BASRATE
(09) EX21ABS1 - HMOOS1
(10) EX21ACS1 - BASRATE
(91) EX21ABS1 - SOPOS1
(-8) EX21ACS1 - BASRATE
(-9) EX21ACS1 - BASRATE

HMOOS1

EX21ABS1

verbatim

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACS1 - BASRATE

SOPOS1

EX21ABS1

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACS1 - BASRATE

BASRATE

EX21ACS1

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX7CS1
(-8) BOX EX7CS1
(-9) BOX EX7CS1

BOX EX7CS1

routing

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY
IN A HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) AND THIS WAS
NOT EXPLAINED THIS ROUND, GO TO EX21BS1 - VEXPTXTB.
ELSE GO TO BOX EX8S1.

(01) [Continuous answer.]

(01) BOX EX8S1

(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX9S1
(02) BOX EX9S1
(91) EX22S1 - BAS10POS
(-8) BOX EX9S1
(-9) BOX EX9S1

(01) [Continuous answer.]

(01) BOX EX9S1

Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD
ABOVE], but I have not recorded any preceding hospital stays for (him/her).
VEXPTXTB

EX21BS1

verbatim

Please tell me why Medicare paid for (SP) during this billing period.
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.
IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.

BOX EX8S1

BAS10PCT

EX22S1

routing

code one

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND
(BASICPAY <= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED
AND EX22S1 - BAS10PCT WAS ASKED THIS BP ROUND AND (BASICPAY >= BASICAMT*0.7) AND
(BASICPAY <= BASICAMT*1.1)), GO TO BOX EX9S1.
ELSE GO TO EX22S1 - BAS10PCT.

There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP END
DATE) and the payments received. The total amount billed I have entered for this billing period is (TOTAL
AMOUNT BILLED FOR THIS BILLING PERIOD) and the total payments for the period are (SUM OF EX21
PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BAS10POS

EX22S1

verbatim

OTHER (SPECIFY)

BOX EX9S1

routing

IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A1S1 - EX23A1S1C.
ELSE GO TO BOX EX9AAS1.

Page 2 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EX9AAS1

(01) Continue

(01) BOX EX10S1

(01) Continue

(01) BOX EX11S1

(01) Continue

(01) BOX EX12S1

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.
EX23A1S1C

EX23A1S1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX9AAS1

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A2S1 - EX23A2S1C.
ELSE GO TO BOX EX10S1.

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.
EX23A2S1C

EX23A2S1

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX10S1

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX24AS1 - EX24AS1C.
ELSE GO TO BOX EX11S1.

Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a source of
payment.
EX24AS1C

EX24AS1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX11S1

routing

IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25S1 - EX25S1C.
ELSE GO TO BOX EX12S1.

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care.
Earlier, I recorded that (his/her) basic charges from a previous billing period were paid by Medicaid, and in this
billing period, Medicaid is no longer a payment source.
EX25S1C

EX25S1

code one

Is Medicaid indeed no longer paying for (her/his) care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

CAREPRTB

BOX EX12S1

routing

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING
PERIOD, GO TO EX26S1 - CAREPRTB.
ELSE GO TO BOX EX14S1.

EX26S1

yes/no

Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. (00) NO
Is this Medicare payment a Part B payment?
(01) YES
(-8) Don't Know
(-9) Refused
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

(00) EX27S1 - VBPETXTE
(01) BOX EX14S1
(-8) EX27S1 - VBPETXTE
(-9) BOX EX14S1

Page 3 of 21

2022 MCBS Facility Instrument

Variable Name
VBPETXTE

EX-Expenditures

MR Screen Name Question Type

Question Text/Description
Can you tell me why the Medicare payment is so small?

Code List

Routing

(01) [Continuous answer.]

(01) BOX EX14S1

EX27S1

verbatim

BOX EX14S1

routing

IF PreloadBPRO.RECDANCP = 0/No or EX17S1 – ANYANCIL = 1/Yes, GO TO EX28S1 - RECDANCP.
ELSE GO TO EX33BS1 - EXSBKCT.

RECDANCP

EX28S1

yes/no

Have you received all the payments you expect to receive for (SP)'s ancillary services during the [READ
BILLING PERIOD ABOVE] billing period?

(00) NO
(01) YES

(00) EX33BS1 - EXSBKCT
(01) EX29AAS1 - ADDSOP2

ADDSOP2

EX29AAS1

yes/no

Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?

(00) NO
(01) YES

(00) EX29ACS1 - ANCRATE
(01) EX29ABS1 - PAYMPLN2

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX29ACS1 - ANCRATE
(02) EX29ACS1 - ANCRATE
(03) EX29ACS1 - ANCRATE
(04) EX29ACS1 - ANCRATE
(05) EX29ACS1 - ANCRATE
(06) EX29ACS1 - ANCRATE
(07) EX29ACS1 - ANCRATE
(08) EX29ACS1 - ANCRATE
(09) EX29ABS1 - HMOOS2
(10) EX29ACS1 - ANCRATE
(91) EX29ABS1 - SOPOS2
(-8) EX29ACS1 - ANCRATE
(-9) EX29ACS1 - ANCRATE

RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?
PAYMPLN2

EX29ABS1

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS2

EX29ABS1

verbatim

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACS1 - ANCRATE

SOPOS2

EX29ABS1

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACS1 - ANCRATE

ANCRATE

EX29ACS1

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX15S1
(-8) BOX EX15S1
(-9) BOX EX15S1

routing

IF BPER.ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= BPER.ANCILAMT*0.9)
AND (BPER.ANCILPAY <= BPER.ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND
(BPER.ANCILPAY >= BPER.ANCILAMT*0.7) AND (BPER.ANCILPAY <= BPER.ANCILAMT*1.1)) OR (A
WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30S1 - ANC10PCT WAS ASKED THIS BP ROUND
AND (BPER.ANCILPAY >= BPER.ANCILAMT*0.7) AND (BPER.ANCILPAY <= BPER.ANCILAMT*1.1)), GO
TO BOX EX16S1.
ELSE GO TO EX30S1 - ANC10PCT.

(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX16S1
(02) BOX EX16S1
(91) EX30S1 - ANC10POS
(-8) BOX EX16S1
(-9) BOX EX16S1

(01) [Continuous answer.]

(01) BOX EX16S1

BOX EX15S1

ANC10PCT

EX30S1

code one

There seems to be a difference between what (FACILITY) billed for ancillary services between (BP START
DATE) and (BP END DATE) and the payments received. The total amount billed I have entered for [READ
BILLING PERIOD ABOVE] is (TOTAL AMOUNT BILLED FOR BILLING PERIOD) and the total payments for
the period are (SUM OF ANCILLARY PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

ANC10POS

EX30S1

verbatim

OTHER (SPECIFY)

Page 4 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX16S1

(IF MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A1S1 - EX31A1S1C.
ELSE GO TO BOX EX16AAS1.

routing

Code List

Routing

(01) Continue

(01) BOX EX16AAS1

(01) Continue

(01) BOX EX17S1

(01) Continue

(01) BOX EX18S1

(01) Continue

(01) EX33BS1 - EXSBKCT

(01) Continue

(01) BOX EX20S1

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.
EX31A1S1C

EX31A1S1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

EX31A2S1C

BOX EX16AAS1

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A2S1 - EX31A2S1C.
ELSE GO TO BOX EX17S1.

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.
EX31A2S1C

EX31A2S1

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX17S1

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX32AS1 - EX32AS1C.
ELSE GO TO BOX EX18S1.

Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source of
payment.
EX32AS1C

EX32AS1

code one

Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX18S1

routing

IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR
ANCILLARIES FOR THE CURRENT BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD, GO
TO EX33S1 - EX33S1C.
ELSE GO TO EX33BS1 - EXSBKCT.

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care.
Earlier, I recorded that (his/her) charges for ancillaries in a previous billing period were paid by Medicaid, and
in this billing period, Medicaid is no longer a payment source.
EX33S1C

EX33S1

code one

Is Medicaid indeed no longer paying for (his/her) ancillary services?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS..

EXSBKCT

EX33BS1

code one

THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD WHERE YOU CAN BACK UP TO MAKE
CORRECTIONS.
PRESS "1" TO CONTINUE.

Page 5 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX20S1

routing

IF THERE IS ADDITIONAL PREVIOUS ROUND DATA THAT HAS NOT BEEN ANOTHER BPER IN
PreloadBPER COLLECTED, GO TO BOX EXS1A.
ELSE IF THERE IS CURRENT ROUND BILLING TO COLLECT, GO TO BOX EXSEND.
ELSE GO TO BOX EX21S1.

BOX EX21S1

routing

IF PRIVATE PAY HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT AND SP WAS COVERED
BY A LONG-TERM CARE POLICY, GO TO EX34S1 - USENOLTC.
ELSE GO TO BOX EX21AS1.

EX34S1

VEXPTXTG

Code List

Routing

Earlier I was told that (SP) had long-term care insurance from (NAME OF FIRST LTC INSURANCE
COMPANY REPORTED). Is it correct that this policy paid for none of (his/her) care?

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

(00) EX35S1 - VEXPTXTG
(01) BOX EX21AS1
(-8) BOX EX21AS1
(-9) BOX EX21AS1

(01) [Continuous answer.]

(01) BOX EX21AS1

EX35S1

verbatim

Can you explain this to me?
RECORD VERBATIM BELOW.

BOX EX21AS1

routing

IF IT IS PENDING WHETHER SP HAS BEEN COVERED BY MEDICAID FROM CRIN-1 AND MEDICAID
HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT, GO TO EX35AS1 - ECAIDECO.
ELSE TO TO BOX EXSEND.

EX35AS1

code one

(01) STILL PENDING
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR
(02) DENIED
MEDICAID)/MEDICAID] eligibility status was pending. Is it still pending or has [(PREFERRED NAME(S) FOR
(-8) Don't Know
MEDICAID)/MEDICAID] been denied?
(-9) Refused

BOX EXSEND

routing

IF THERE IS CURRENT ROUND BILLING TO COLLECT, GO TO BOX EXBEG.
ELSE GO TO BOX EXEND.

BOX EXBEG

routing

GO TO EX1PRE - EX1PRECT.

(01) BOX EXSEND
(02) BOX EXSEND
(-8) BOX EXSEND
(-9) BOX EXSEND

This series of questions asks about (SP)'s expenditures for room and board and ancillary charges while a
resident of (FACILITY).
EX1PRECT

EX1PRE

code one

[The first few questions are about billing and sources of payment when (he/she) first became a resident here
on (FAD/RAD).]
PRESS "1" TO CONTINUE.

The following questions are about (SP)'s basic care between (EX REFERENCE START DATE) and (EX
REFERENCE END DATE).
ANYBASIC

EX2

yes/no

EX2ANAME

EX2A

roster

Was there a charge for (her/his) room and board and basic care between (EX REFERENCE START DATE)
and (EX REFERENCE END DATE)? Please include any charges to (SP), (her/his) family, or a third party,
such as Medicaid, Medicare, or a legal guardian.

Please tell me the name of someone in (FACILITY) who could give me that information.
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

(01) Continue

(01) EX2 - ANYBASIC

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

(00) EX3 - VEXPTXTA
(01) BOX EX1A
(-8) EX2A - EX2ANAME
(-9) EXEND - EXENDCNT

(01) [Continuous answer.]

(01) EXEND - EXENDCNT

Page 6 of 21

2022 MCBS Facility Instrument

Variable Name

VEXPTXTA

EX-Expenditures

MR Screen Name Question Type

EX3

verbatim

Question Text/Description
Why were there no charges?
IF ANSWER IS "MEDICAID PAID", BACK UP TO EX2 AND ENTER "1".

Code List

Routing

(01) [Continuous answer.]

(01) EXEND - EXENDCNT

RECORD VERBATIM.

BOX EX1A

ANCILSEP

EX4

routing

yes/no

If FQ.ANCNVSEP = 1/Indicated, GO TO EX5 - COMRECMM.
ELSE GO TO EX4 - ANCILSEP.

Between (EX REFERENCE START DATE) and (EX REFERENCE END DATE), was (SP) billed separately for
health-related ancillary services? (That is, were there charges for ancillary services that were not included in
(00) NO
the basic rate?)
(01) YES
IF FACILITY NEVER BILLS SEPARATELY FOR ANCILLARIES, ENTER 96.
(96) NEVER BILLS SEPARATELY

(00) EX5 - COMRECMM
(01) EX5 - COMRECMM
(96) EX5 - COMRECMM

PRESS F1 FOR DEFINITION OF ANCILLARY SERVICES.

COMRECMM

EX5

date

COMRECDD

EX5

date

COMRECYY

EX5

BOX EX2AA

Through what date do you have complete billing records for the services provided to (SP)?

(01) [Continuous answer.]

(01) EX5 - COMRECDD

DAY

(01) [Continuous answer.]

(01) EX5 - COMRECYY

date

YEAR

(01) [Continuous answer.]

(01) BOX EX2AA

routing

IF BILLING PERIOD LENGTH IS UNKNOWN, GO TO EX6 - BPLENCUR.
ELSE GO TO BOX EX2AA1.

(01) BOX EX2AA1
(02) BOX EX2AA1
(03) BOX EX2AA1
(04) BOX EX2AA1
(91) EX6 - BPLNCROS

MONTH

BPLENCUR

EX6

code one

What is the length of the (facility/home)'s billing period? Is it…

(01) monthly,
(02) every two weeks,
(03) every week, or
(04) quarterly?
(91) OTHER

BPLNCROS

EX6

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX EX2AA1

BOX EX2AA1

routing

GO TO BOX EX2A.

BOX EX2A

routing

IF EX REFERENCE START DATE IS LATER THAN THE DATE FOR WHICH THE FACILITY HAS
COMPLETE BILLING RECORDS FOR THE SERVICES PROVIDED TO RESIDENTS, GO TO EXEND EXENDCNT.
ELSE GO TO EX7PRE - EX7PCNT.

(01) Continue

(01) FEX2 - BILLINFO

FACILITY HAS UP-TO-DATE RECORDS THROUGH (COMPLETED RECORDS DATE)

EX7PCNT

EX7PRE

code one

LENGTH OF BILLING PERIOD: (LENGTH OF BILLING PERIOD.)
START WITH EARLIEST BILLING PERIOD.
COLLECT BILLING INFORMATION FROM (EX REFERENCE START DATE) THROUGH (EX REFERENCE
END DATE).
PRESS "1" TO CONTINUE.

Page 7 of 21

2022 MCBS Facility Instrument

Variable Name

BILLINFO

BPBEGDATE

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

FEX2

code one

Do you prefer to report billing information for all billing periods before reporting any payment information or do
you prefer to report billing and then payment information for a billing period, then billing and payment
information for each remaining billing period?

(01) ALL BILLING AND THEN ALL PAYMENT
INFORMATION
(02) BILLING AND PAYMENT INFORMATION BY
BILLING PERIOD
(-8) Don't Know
(-9) Refused

(01) BOX EX3AB2
(02) BOX EX3A
(-8) BOX EX3A
(-9) EXEND - EXENDCNT

BOX EX3A

routing

GO TO EX8 - BPBEGDATE.

EX8

Date

(01) [Continuous answer.]

(01) EX8 - BPENDDATE

(01) [Continuous answer.]

(01) BOX EX3A2

(01) [Continuous answer.]

(01) BOX EX3

ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
ENTER DATES IN "MM DD YY" FORMAT.
BP START DATE[: (BILLSTARTDATE)]

BPENDDATE

BILLDAYS

EX8

Date

BP END DATE[: (BILLENDDATE)]

BOX EX3A2

routing

GO TO EX9 - BILLDAYS.

EX9

Numeric

BOX EX3

Between (BP START DATE) and (BP END DATE), how many days was (SP) billed for care?
PRESS F1 FOR HELP ENTERING FLAT-RATE BILLING.

routing

IF EX9 - BILLDAYS = 0, GO TO EX33B - EXABKCT.
ELSE IF (RHDAYS = DK) OR (EX9 - BILLDAYS = RHDAYS AND (BPDAYS = EX9 - BILLDAYS OR (RHDAYS
< BPDAYS))), GO TO EX11 - BRATRATE.
ELSE IF BPDAYS = RHDAYS AND RHDAYS > EX9 - BILLDAYS, GO TO EX10 - EX10CODE.
ELSE IF (BPDAYS > EX9 - BILLDAYS AND EX9 - BILLDAYS > RHDAYS) OR (BPDAYS > RHDAYS AND
RHDAYS > EX9 - BILLDAYS) OR (BPDAYS = EX9 - BILLDAYS AND EX9 - BILLDAYS > RHDAYS), GO TO
EX10A - EX10ACOD.
ELSE GO TO EX10 - EX10CODE.

(01) BOX EX3B
(02) BOX EX3B
(03) BOX EX3B
(04) BOX EX3B
(05) BOX EX3B
(91) EX10 - EX10OS
(-8) BOX EX3B
(-9) BOX EX3B

(01) [Continuous answer.]

(01) BOX EX3B

(01) SP SENT TO HOSPITAL, BED HELD
(02) SP NOT BILLED ON ADMISSION DAY
(03) SP NOT BILLED ON DISCHARGE DAY
(04) SP NOT BILLED ON DATE OF DEATH
(05) FACILITY CHARGES FLAT-RATE BILLING
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX3B
(02) BOX EX3B
(03) BOX EX3B
(04) BOX EX3B
(05) BOX EX3B
(91) EX10A - EX10AOS
(-8) BOX EX3B
(-9) BOX EX3B

(01) [Continuous answer.]

(01) BOX EX3B

EX10CODE

EX10

Code one

(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
Can you tell me why I have a discrepancy between the number of days in this billing period, that is, (DAYS IN
(03) SP DECEASED
BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS BILLED)?
(04) SP ADMITTED AFTER BP START DATE
(05) SP DISCHARGED TO ANOTHER NH
SELECT ALL THAT APPLY.
(91) OTHER
SEPARATE RESPONSES BY USING THE SPACEBAR.
(-8) Don't Know
(-9) Refused

EX10OS

EX10

Code one

OTHER (SPECIFY)

Earlier, I collected information that (SP) was a resident of this (facility/home) for (NUMBER OF DAYS SP IN
ELIGIBLE FACILITY) days during this billing period. Yet, (he/she) was billed for (DAYS BILLED) days.
EX10ACOD

EX10A

code all

Can you tell me why I have this discrepancy?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

EX10AOS

EX10A

verbatim

OTHER (SPECIFY)

Page 8 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX3B

GO TO EX11 - BRATRATE

routing

Between (BP START DATE) and (BP END DATE), what rates were billed for (SP)'s care? (I'll ask about billing
for ancillary services later.)
BRATRATE

EX11

Quantity Unit

[PROBE: If more than one rate was billed, let's start with the first rate within the billing period.]

Code List

Routing

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX11 - BRATUNIT
(-8) EX11 - BRATUNIT
(-9) EX11 - BRATUNIT

(01) EX11 - BRATDAYS
(02) EX11 - BRATDAYS
(03) EX11 - BRATDAYS
(91) EX11 - BRATUNOS
(-8) EX11 - BRATDAYS
(-9) EX11 - BRATDAYS

What is the amount?

BRATUNIT

EX11

Quantity Unit

Is that per day, per month, per quarter, or some other amount of time?

(01) DAY
(02) MONTH
(03) QUARTER
(91) OTHER
(-8) Don't Know
(-9) Refused

BRATUNOS

EX11

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX11 - BRATDAYS

BRATDAYS

EX11

Numeric

How many days were billed at that rate?

(01) [Continuous answer.]

(01) BOX EX4

BOX EX4

routing

IF ALL BILLED DAYS IN THE BILLING PERIOD HAVE BEEN ACCOUNTED FOR, GO TO BOX EX5.
ELSE GO TO BOX EX3B.

BOX EX5

routing

IF SP BILLED SEPARATELY FOR ANCILLARIES, GO TO EX15PRE - EX15PRCT.
ELSE GO TO BOX EX7B.

(01) Continue

(01) EX16 - ANCLPOST

The next questions are about health-related services received by (SP) for which there was a separate charge,
that is, your (facility/home)'s ancillary services.
EX15PRCT

EX15PRE

code one

(Please do not include non-health-related services such as hairdressing, television, or telephone).
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS "1" TO CONTINUE.

ANCLPOST

EX16

yes/no

Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END DATE)?

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

(00) BOX EX7B
(01) EX17 - ANYANCIL
(-8) BOX EX7B
(-9) BOX EX7B

ANYANCIL

EX17

yes/no

Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?

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

(00) BOX EX7B
(01) EX18 - ANCILAMT
(-8) BOX EX7B
(-9) BOX EX7B

ANCILAMT

EX18

dollar

Altogether, what was the total charge for those health-related ancillary services?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX7B
(-8) BOX EX7B
(-9) BOX EX7B

BOX EX7B

routing

GO TO EX20 - RECDBASP

Page 9 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

RECDBASP

EX20

yes/no

Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING (00) NO
PERIOD ABOVE] billing period?
(01) YES

ADDSOP1

EX21AA

yes/no

Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?

What Source(s) of Payment do you need to add for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?
PAYMPLN1

EX21AB

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

Code List

Routing
(00) BOX EX14
(01) EX21AA - ADDSOP1

(00) NO
(01) YES

(00) EX21AC - BASRATE
(01) EX21AB - PAYMPLN1

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX21AC - BASRATE
(02) EX21AC - BASRATE
(03) EX21AC - BASRATE
(04) EX21AC - BASRATE
(05) EX21AC - BASRATE
(06) EX21AC - BASRATE
(07) EX21AC - BASRATE
(08) EX21AC - BASRATE
(09) EX21AB - HMOOS1
(10) EX21AC - BASRATE
(91) EX21AB - SOPOS1
(-8) EX21AC - BASRATE
(-9) EX21AC - BASRATE

HMOOS1

EX21AB

verbatim

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX21AC - BASRATE

SOPOS1

EX21AB

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX21AC - BASRATE

BASRATE

EX21AC

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX7C
(-8) BOX EX7C
(-9) BOX EX7C

BOX EX7C

routing

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY
IN A HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) AND THIS WAS
NOT EXPLAINED THIS ROUND, GO TO EX21B - VEXPTXTB.
ELSE GO TO BOX EX8.

(01) [Continuous answer.]

(01) BOX EX8

(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX9
(02) BOX EX9
(91) EX22 - BAS10POS
(-8) BOX EX9
(-9) BOX EX9

Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD
ABOVE], but I have not recorded any preceding hospital stays for (him/her).
VEXPTXTB

EX21B

Verbatim Text

Please tell me why Medicare paid for (SP) during this billing period.
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.
IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.

BOX EX8

BAS10PCT

EX22

routing

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND
(BASICPAY <= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED
AND EX22 - BAS10PCT WAS ASKED THIS ROUND AND (BASICPAY >= BASICAMT*0.7) AND (BASICPAY
<= BASICAMT*1.1)), GO TO BOX EX9.
ELSE GO TO EX22 - BAS10PCT.

code one

There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP END
DATE) and the payments received. The total amount billed I have entered for this billing period is (TOTAL
AMOUNT BILLED FOR THIS BILLING PERIOD) and the total payments for the period are (SUM OF EX21
PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

Page 10 of 21

2022 MCBS Facility Instrument

EX-Expenditures

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

BAS10POS

EX22

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX EX9

BOX EX9

routing

IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A1 - EX23A1C.
ELSE GO TO BOX EX9AA.

(01) Continue

(01) BOX EX9AA

(01) Continue

(01) BOX EX10

(01) Continue

(01) BOX EX11

(01) Continue

(01) BOX EX12

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.
EX23A1C

EX23A1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX9AA

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A2 - EX23A2C.
ELSE GO TO BOX EX10.

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.
EX23A2C

EX23A2

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX10

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX24A - EX24AC.
ELSE GO TO BOX EX11.

Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a source of
payment.
EX24AC

EX24A

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX11

routing

IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25 - EX25C.
ELSE GO TO BOX EX12.

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care.
Earlier, I recorded that (his/her) basic charges from a previous billing period were paid by Medicaid, and in this
billing period, Medicaid is no longer a payment source.
EX25C

EX25

code

Is Medicaid indeed no longer paying for (her/his) care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

Page 11 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX12

routing

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING
PERIOD, GO TO EX26 - CAREPRTB.
ELSE GO TO BOX EX14.

CAREPRTB

EX26

yes/no

Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. (00) NO
Is this Medicare payment a Part B payment?
(01) YES
(-8) Don't Know
(-9) Refused
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

VBPETXTE

EX27

Verbatim Text

BOX EX14

routing

IF SP HAS ANY ANCILLARY CHARGES BETWEEN THE BILLING PERIOD START DATE AND THE
BILLING PERIOD END DATE, GO TO EX28 - RECDANCP.
ELSE GO TO EX33B - EXABKCT.

RECDANCP

EX28

yes/no

ADDSOP2

EX29AA

yes/no

Can you tell me why the Medicare payment is so small?

EX29AB

code all

Routing

(00) EX27 - VBPETXTE
(01) BOX EX14
(-8) EX27 - VBPETXTE
(-9) BOX EX14

(01) [Continuous answer.]

(01) BOX EX14

Have you received all the payments you expect to receive for (SP)'s ancillary services during the [READ
BILLING PERIOD ABOVE] billing period?

(00) NO
(01) YES

(00) EX33B - EXABKCT
(01) EX29AA - ADDSOP2

Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?

(00) NO
(01) YES

(00) EX29AC - ANCRATE
(01) EX29AB - PAYMPLN2

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX29AC - ANCRATE
(02) EX29AC - ANCRATE
(03) EX29AC - ANCRATE
(04) EX29AC - ANCRATE
(05) EX29AC - ANCRATE
(06) EX29AC - ANCRATE
(07) EX29AC - ANCRATE
(08) EX29AC - ANCRATE
(09) EX29AB - HMOOS2
(10) EX29AC - ANCRATE
(91) EX29AB - SOPOS2
(-8) EX29AC - ANCRATE
(-9) EX29AC - ANCRATE

RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?
PAYMPLN2

Code List

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS2

EX29AB

Verbatim Text

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX29AC - ANCRATE

SOPOS2

EX29AB

Verbatim Text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX29AC - ANCRATE

ANCRATE

EX29AC

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX15
(-8) BOX EX15
(-9) BOX EX15

Page 12 of 21

2022 MCBS Facility Instrument

Variable Name

ANC10PCT

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX15

IF EX18 - ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= EX18 ANCILAMT*0.9) AND (BPER.ANCILPAY <= EX18 - ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF
PAYMENT AND (BPER.ANCILPAY >= EX18 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18 ANCILAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30 - ANC10PCT WAS ASKED
THIS BP ROUND AND (BPER.ANCILPAY >= EX18 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18 ANCILAMT*1.1)), GO TO BOX EX16.
ELSE GO TO EX30 - ANC10PCT.

EX30

routing

code one

There seems to be a difference between what (FACILITY) billed for ancillary services between (BP START
DATE) and (BP END DATE) and the payments received. The total amount billed I have entered for [READ
BILLING PERIOD ABOVE] is (TOTAL AMOUNT BILLED FOR BILLING PERIOD) and the total payments for
the period are (SUM OF ANCILLARY PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

ANC10POS

EX30

verbatim text

OTHER (SPECIFY)

BOX EX16

routing

IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A1 - EX31A1C.
ELSE GO TO BOX EX16AA.

Code List

Routing

(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX16
(02) BOX EX16
(91) EX30 - ANC10POS
(-8) BOX EX16
(-9) BOX EX16

(01) [Continuous answer.]

(01) BOX EX16

(01) Continue

(01) BOX EX16AA

(01) Continue

(01) BOX EX17

(01) Continue

(01) BOX EX18

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.
EX31A1C

EX31A1

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX16AA

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A2 - EX31A2C.
ELSE GO TO BOX EX 17.

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.
EX31A2C

EX31A2

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX17

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX32A - EX32AC.
ELSE GO TO BOX EX18.

Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source of
payment.
EX32AC

EX32A

code one

Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

Page 13 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX18

IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR ANCILLARIES FOR THE CURRENT
BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD (INCLUDING IF THE BILLING PERIOD
OCCURRED IN THE PREVIOUS ROUND), GO TO EX33 - EX33C.
ELSE GO TO EX33B - EXABKCT.

routing

Code List

Routing

(01) Continue

(01) EX33B - EXABKCT

(01) Continue

(01) BOX EX20

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

(00) EX35 - VEXPTXTG
(01) BOX EX21A
(-8) BOX EX21A
(-9) BOX EX21A

(01) [Continuous answer.]

(01) BOX EX21A

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care.
Earlier, I recorded that (his/her) charges for ancillaries in a previous billing period were paid by Medicaid, and
in this billing period, Medicaid is no longer a payment source.
EX33C

EX33

code one

Is Medicaid indeed no longer paying for (his/her) ancillary services?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

EXABKCT

EX33B

code one

THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD WHERE YOU CAN BACK UP TO MAKE
CORRECTIONS.
PRESS "1" TO CONTINUE.

BOX EX20

routing

IF AMOUNTS BILLED FOR ALL BILLING PERIODS HAVE NOT BEEN COLLECTED, GO TO BOX EX3A.
ELSE GO TO BOX EX21.

BOX EX21

routing

IF PRIVATE PAY HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT AND SP WAS COVERED
BY A LONG-TERM CARE POLICY, GO TO EX34 - USENOLTC.
ELSE GO TO BOX EX21A.

USENOLTC

EX34

yes/no

Earlier I was told that (SP) had long-term care insurance from (NAME OF FIRST LTC INSURANCE
COMPANY REPORTED). Is it correct that this policy paid for none of (his/her) care?

VEXPTXTG

EX35

verbatim text

BOX EX21A

routing

IF IT IS PENDING WHETHER SP HAS BEEN COVERED BY MEDICAID FROM CRIN-1 AND MEDICAID
HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT, GO TO EX35A - ECAIDECO.
ELSE GO TO EXEND - EXENDCNT.

EX35A

code one

(01) STILL PENDING
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR
(02) DENIED
MEDICAID)/MEDICAID] eligibility status was pending. Is it still pending or has [(PREFERRED NAME(S) FOR
(-8) Don't Know
MEDICAID)/MEDICAID] been denied?
(-9) Refused

BOX EX3AB2

routing

GO TO EX8B2 - BPBEGDATE.

EX8B2

Date

Can you explain this to me?

ECAIDECO

BPBEGDATE

RECORD VERBATIM BELOW.

ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
BP START DATE[: (BILLSTARTDATE)]

(01) [Continuous answer.]

(01) EXEND - EXENDCNT
(02) EXEND - EXENDCNT
(-8) EXEND - EXENDCNT
(-9) EXEND - EXENDCNT

(01) EX8B2 - BPENDDATE

Page 14 of 21

2022 MCBS Facility Instrument

Variable Name
BPENDDATE

BILLDAYS

EX-Expenditures

MR Screen Name Question Type
EX8B2

Date

BOX EX3A2B2

routing

EX9B2

Numeric

BOX EX3B2

Question Text/Description
ENTER THE START AND END DATES FOR THE (NEXT) BILLING PERIOD.
BP END DATE[: (BILLENDDATE)]

Code List

Routing

(01) [Continuous answer.]

(01) BOX EX3A2B2

(01) [Continuous answer.]

(01) BOX EX3B2

GO TO EX9B2 - BILLDAYS.

Between (BP START DATE) and (BP END DATE), how many days was (SP) billed for care?
PRESS F1 FOR HELP ENTERING FLAT-RATE BILLING.

routing

IF EX9B2 - BILLDAYS = 0, THEN GO TO BOX EX6B2.
ELSE IF (RHDAYS = DK) OR (EX9B2 - BILLDAYS = RHDAYS AND (BPDAYS = EX9B2 - BILLDAYS OR
(RHDAYS < BPDAYS))), GO TO EX11B2 - BRATRATE.
ELSE IF BPDAYS = RHDAYS AND RHDAYS > EX9B2 - BILLDAYS, GO TO EX10B2 - EX10CODE.
ELSE IF (BPDAYS > EX9B2 - BILLDAYS AND EX9B2 - BILLDAYS > RHDAYS) OR (BPDAYS > RHDAYS
AND RHDAYS > EX9B2 - BILLDAYS) OR (BPDAYS = EX9B2 - BILLDAYS AND EX9B2 - BILLDAYS >
RHDAYS), GO TO EX10AB2 - EX10ACOD.
ELSE GO TO EX10B2 - EX10CODE.

(01) BOX EX3BB2
(02) BOX EX3BB2
(03) BOX EX3BB2
(04) BOX EX3BB2
(05) BOX EX3BB2
(91) EX10B2 - EX10OS
(-8) BOX EX3BB2
(-9) BOX EX3BB2

(01) [Continuous answer.]

(01) BOX EX3BB2

(01) SP SENT TO HOSPITAL, BED HELD
(02) SP NOT BILLED ON ADMISSION DAY
(03) SP NOT BILLED ON DISCHARGE DAY
(04) SP NOT BILLED ON DATE OF DEATH
(05) FACILITY CHARGES FLAT-RATE BILLING
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX3BB2
(02) BOX EX3BB2
(03) BOX EX3BB2
(04) BOX EX3BB2
(05) BOX EX3BB2
(91) EX10AB2 - EX10AOS
(-8) BOX EX3BB2
(-9) BOX EX3BB2

(01) [Continuous answer.]

(01) BOX EX3BB2

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) EX11B2 - BRATUNIT
(-8) EX11B2 - BRATUNIT
(-9) EX11B2 - BRATUNIT

EX10CODE

EX10B2

code all

(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
Can you tell me why I have a discrepancy between the number of days in this billing period, that is, (DAYS IN
(03) SP DECEASED
BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS BILLED)?
(04) SP ADMITTED AFTER BP START DATE
(05) SP DISCHARGED TO ANOTHER NH
SELECT ALL THAT APPLY.
(91) OTHER
SEPARATE RESPONSES BY USING THE SPACEBAR.
(-8) Don't Know
(-9) Refused

EX10OS

EX10B2

Verbatim Text

OTHER (SPECIFY)

Earlier, I collected information that (SP) was a resident of this (facility/home) for (NUMBER OF DAYS SP IN
ELIGIBLE FACILITY) days during this billing period. Yet, (he/she) was billed for (DAYS BILLED) days.
EX10ACOD

EX10AB2

code all

Can you tell me why I have this discrepancy?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

EX10AOS

EX10AB2

Verbatim Text

OTHER (SPECIFY)

BOX EX3BB2

routing

GO TO EX11B2 - BRATRATE.
Between (BP START DATE) and (BP END DATE), what rates were billed for (SP)'s care? (I'll ask about billing
for ancillary services later.)

BRATRATE

EX11B2

Quantity Unit

[PROBE: If more than one rate was billed, let's start with the first rate within the billing period.]
What is the amount?

Page 15 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing
(01) EX11B2 - BRATDAYS
(02) EX11B2 - BRATDAYS
(03) EX11B2 - BRATDAYS
(91) EX11B2 - BRATUNOS
(-8) EX11B2 - BRATDAYS
(-9) EX11B2 - BRATDAYS

BRATUNIT

EX11B2

Quantity Unit

Is that per day, per month, per quarter, or some other amount of time?

(01) DAY
(02) MONTH
(03) QUARTER
(91) OTHER
(-8) Don't Know
(-9) Refused

BRATUNOS

EX11B2

Quantity Unit

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX11B2 - BRATDAYS

BRATDAYS

EX11B2

Quantity Unit

How many days were billed at that rate?

(01) [Continuous answer.]

(01) BOX EX4B2

BOX EX4B2

routing

IF ALL BILLED DAYS IN THE BILLING PERIOD HAVE BEEN ACCOUNTED FOR, GO TO BOX EX5B2.
ELSE GO TO BOX EX3BB2.

BOX EX5B2

routing

IF SP BILLED SEPARATELY FOR ANCILLARIES, GO TO EX15PREB2 - EX15PRCT.
ELSE GO TO BOX EX6B2.

(01) Continue

(01) EX16B2 - ANCLPOST

The next questions are about health-related services received by (SP) for which there was a separate charge,
that is, your (facility/home)'s ancillary services.
EX15PRCT

EX15PREB2

code one

(Please do not include non-health-related services such as hairdressing, television, or telephone).
PRESS F1 FOR EXAMPLES OF NON-HEALTH-RELATED ANCILLARIES.
PRESS "1" TO CONTINUE.

ANCLPOST

EX16B2

yes/no

Have all charges for ancillaries been posted for the period from (BP START DATE) to (BP END DATE)?

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

(00) BOX EX6B2
(01) EX17B2 - ANYANCIL
(-8) BOX EX6B2
(-9) BOX EX6B2

ANYANCIL

EX17B2

Yes/No

Does (SP) have any ancillary charges between (BP START DATE) and (BP END DATE)?

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

(00) BOX EX6B2
(01) EX18B2 - ANCILAMT
(-8) BOX EX6B2
(-9) BOX EX6B2

ANCILAMT

EX18B2

dollar

Altogether, what was the total charge for those health-related ancillary services?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX6B2
(-8) BOX EX6B2
(-9) BOX EX6B2

BOX EX6B2

routing

IF AMOUNTS BILLED FOR ALL BILLING PERIODS HAVE NOT BEEN COLLECTED, GO TO BOX EX3AB2.
ELSE GO TO BOX EX6BB2.

BOX EX6BB2

routing

IF THERE ARE ANY BILLING PERIODS FOR WHICH BILLED DAYS > 0 AND FOR WHICH PAYMENT
DATA HAS NOT ALREADY BEEN COLLECTED, GO TO BOX EX7BB2.
ELSE GO TO BOX EX21B2.

BOX EX7BB2

routing

GO TO EX20B2 - RECDBASP.

Page 16 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

RECDBASP

EX20B2

yes/no

Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING (00) NO
PERIOD ABOVE] billing period?
(01) YES

ADDSOP1

EX21AAB2

yes/no

Do you need to add any Source(s) of Payment for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?

What Source(s) of Payment do you need to add for (SP)'s basic care for [READ BILLING PERIOD ABOVE]?
PAYMPLN1

EX21ABB2

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

Code List

Routing
(00) BOX EX14B2
(01) EX21AAB2 - ADDSOP1

(00) NO
(01) YES

(00) EX21ACB2 - BASRATE
(01) EX21ABB2 - PAYMPLN1

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX21ACB2 - BASRATE
(02) EX21ACB2 - BASRATE
(03) EX21ACB2 - BASRATE
(04) EX21ACB2 - BASRATE
(05) EX21ACB2 - BASRATE
(06) EX21ACB2 - BASRATE
(07) EX21ACB2 - BASRATE
(08) EX21ACB2 - BASRATE
(09) EX21ABB2 - HMOOS1
(10) EX21ACB2 - BASRATE
(91) EX21ABB2 - SOPOS1
(-8) EX21ACB2 - BASRATE
(-9) EX21ACB2 - BASRATE

HMOOS1

EX21ABB2

Verbatim Text

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACB2 - BASRATE

SOPOS1

EX21ABB2

Verbatim Text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACB2 - BASRATE

BASRATE

EX21ACB2

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX7CB2
(-8) BOX EX7CB2
(-9) BOX EX7CB2

BOX EX7CB2

routing

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY
IN A HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) DATE AND
THIS WAS NOT EXPLAINED THIS ROUND, GO TO EX21BB2 - VEXPTXTB.
ELSE GO TO BOX EX8B2.

(01) [Continuous answer.]

(01) BOX EX8B2

Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD
ABOVE], but I have not recorded any preceding hospital stays for (him/her).
VEXPTXTB

EX21BB2

Verbatim Text

Please tell me why Medicare paid for (SP) during this billing period.
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT.
IF HOSPITAL STAY IS REPORTED, RECORD DATES OF STAY BELOW.

BOX EX8B2

routing

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND
(BASICPAY <= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >=
BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED
AND EX22B2 - BAS10PCT WAS ASKED THIS ROUND AND (BASICPAY >= BASICAMT*0.7) AND
(BASICPAY <= BASICAMT*1.1)), GO TO BOX EX9B2.
ELSE GO TO EX22B2 - BAS10PCT.

Page 17 of 21

2022 MCBS Facility Instrument

Variable Name

BAS10PCT

EX-Expenditures

MR Screen Name Question Type

EX22B2

code one

Question Text/Description
There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP END
DATE) and the payments received. The total amount billed I have entered for this billing period is (TOTAL
AMOUNT BILLED FOR THIS BILLING PERIOD) and the total payments for the period are (SUM OF EX21
PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BAS10POS

EX22B2

verbatim text

OTHER (SPECIFY)

BOX EX9B2

routing

IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A1B2 - EX23A1B2C.
ELSE GO TO BOX EX9AAB2.

Code List

Routing

(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX9B2
(02) BOX EX9B2
(91) EX22B2 - BAS10POS
(-8) BOX EX9B2
(-9) BOX EX9B2

(01) [Continuous answer.]

(01) BOX EX9B2

(01) Continue

(01) BOX EX9AAB2

(01) Continue

(01) BOX 10B2

(01) Continue

(01) BOX EX11B2

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.
EX23A1B2C

EX23A1B2

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX9AAB2

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX23A2B2 - EX23A2B2C.
ELSE GO TO BOX EX10B2.

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.
EX23A2B2C

EX23A2B2

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX10B2

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX24AB2 - EX24AB2C.
ELSE GO TO BOX EX11B2.

Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a source of
payment.
EX24AB2C

EX24AB2

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX11B2

routing

IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25B2 - EX25B2C.
ELSE GO TO BOX EX12B2.

Page 18 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EX12B2

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care.
Earlier, I recorded that (his/her) basic charges from a previous billing period were paid by Medicaid, and in this
billing period, Medicaid is no longer a payment source.
EX25B2C

EX25B2

code one

Is Medicaid indeed no longer paying for (her/his) care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX12B2

routing

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING
PERIOD, GO TO EX26B2 - CAREPRTB.
ELSE GO TO BOX EX14B2.

CAREPRTB

EX26B2

yes/no

Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. (00) NO
Is this Medicare payment a Part B payment?
(01) YES
(-8) Don't Know
(-9) Refused
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

(00) EX27B2 - VBPETXTE
(01) BOX EX14B2
(-8) EX27B2 - VBPETXTE
(-9) BOX EX14B2

VBPETXTE

EX27B2

Verbatim Text

Can you tell me why the Medicare payment is so small?
RECORD VERBATIM BELOW. IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

(01) [Continuous answer.]

(01) BOX EX14B2

BOX EX14B2

routing

IF SP HAS ANY ANCILLARY CHARGES BETWEEN THE BILLING PERIOD START DATE AND THE
BILLING PERIOD END DATE, GO TO EX28B2 - RECDANCP.
ELSE GO TO EX33BB2 - EXBBKCT.

RECDANCP

EX28B2

yes/no

Have you received all the payments you expect to receive for (SP)'s ancillary services during the [READ
BILLING PERIOD ABOVE] billing period?

(00) NO
(01) YES

(00) EX33BB2 - EXBBKCT
(01) EX29AAB2 - ADDSOP2

ADDSOP2

EX29AAB2

yes/no

Do you need to add any Source(s) of Payment for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?

(00) NO
(01) YES

(00) EX29ACB2 - ANCRATE
(01) EX29ABB2 - PAYMPLN2

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
(05) PRIVATE INSURANCE
(06) PENSION
(07) MEDICARE
(08) VA CONTRACT
(09) HMO CONTRACT
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) EX29ACB2 - ANCRATE
(02) EX29ACB2 - ANCRATE
(03) EX29ACB2 - ANCRATE
(04) EX29ACB2 - ANCRATE
(05) EX29ACB2 - ANCRATE
(06) EX29ACB2 - ANCRATE
(07) EX29ACB2 - ANCRATE
(08) EX29ACB2 - ANCRATE
(09) EX29ABB2 - HMOOS2
(10) EX29ACB2 - ANCRATE
(91) EX29ABB2 - SOPOS2
(-8) EX29ACB2 - ANCRATE
(-9) EX29ACB2 - ANCRATE

What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING PERIOD
ABOVE]?
PAYMPLN2

EX29ABB2

code all

SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.

HMOOS2

EX29ABB2

Verbatim Text

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACB2 - ANCRATE

SOPOS2

EX29ABB2

Verbatim Text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACB2 - ANCRATE

ANCRATE

EX29ACB2

Grid

What is the total amount each source paid for [READ BILLING PERIOD ABOVE]?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX EX15B2
(-8) BOX EX15B2
(-9) BOX EX15B2

Page 19 of 21

2022 MCBS Facility Instrument

Variable Name

ANC10PCT

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX15B2

IF EX18B2 - .ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= EX18B2 ANCILAMT*0.9) AND (BPER.ANCILPAY <= EX18B2 - ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF
PAYMENT AND (BPER.ANCILPAY >= EX18B2 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18B2 ANCILAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30B2 - ANC10PCT WAS
ASKED THIS BP ROUND AND (BPER.ANCILPAY >= EX18B2 - ANCILAMT*0.7) AND (BPER.ANCILPAY <=
EX18B2 - ANCILAMT*1.1)), GO TO BOX EX16B2.
ELSE GO TO EX30B2 - ANC10PCT.

EX30B2

routing

code one

There seems to be a difference between what (FACILITY) billed for ancillary services between (BP START
DATE) and (BP END DATE) and the payments received. The total amount billed I have entered for [READ
BILLING PERIOD ABOVE] is (TOTAL AMOUNT BILLED FOR BILLING PERIOD) and the total payments for
the period are (SUM OF ANCILLARY PAYMENTS). Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

ANC10POS

EX30B2

Verbatim Text

OTHER (SPECIFY)

BOX EX16B2

routing

IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A1B2 - EX31A1B2C.
ELSE GO TO BOX EX16AAB2.

Code List

Routing

(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX EX16B2
(02) BOX EX16B2
(91) EX30B2 - ANC10POS
(-8) BOX EX16B2
(-9) BOX EX16B2

(01) [Continuous answer.]

(01) BOX EX16B2

(01) Continue

(01) BOX EX16AAB2

(01) Continue

(01) BOX EX17B2

(01) Continue

(01) BOX EX18B2

I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.
EX31A1B2C

EX31A1B2

code one

Is Medicaid indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX16AAB2

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED
AND FACILITY HAS NEVER CONFIRMED), GO TO EX31A2B2 - EX31A2B2C.
ELSE GO TO BOX EX17B2 .
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.

EX31A2B2C

EX31A2B2

code one

Is Medicare indeed paying for (SP)'s care?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

BOX EX17B2

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX32AB2 - EX32AB2C.
ELSE GO TO BOX EX18B2.

Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source of
payment.
EX32AB2C

EX32AB2

code one

Is Medicaid indeed paying for (SP)'s ancillaries?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

Page 20 of 21

2022 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX18B2

IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR ANCILLARIES FOR THE CURRENT
BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD (INCLUDING IF THE BILLING PERIOD
OCCURRED IN THE PREVIOUS ROUND), GO TO EX33B2 - EX33B2C.
ELSE GO TO EX33BB2 - EXBBKCT.

routing

Code List

Routing

(01) Continue

(01) EX33BB2 - EXBBKCT

(01) Continue

(01) BOX EX20B2

It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care.
Earlier, I recorded that (his/her) charges for ancillaries in a previous billing period were paid by Medicaid, and
in this billing period, Medicaid is no longer a payment source.
EX33B2C

EX33B2

code one

Is Medicaid indeed no longer paying for (his/her) ancillary services?
IF YES, PRESS '1' TO CONTINUE.
IF NO, BACK UP TO MAKE APPROPRIATE CORRECTIONS.

EXBBKCT

THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD .

EX33BB2

code one

BOX EX20B2

routing

IF THERE ARE ANY ADDITIONAL BILLING PERIODS FOR WHICH BILLED DAYS > 0 AND FOR WHICH
PAYMENT DATA HAS NOT ALREADY BEEN COLLECTED, GO TO BOX EX7BB2.
ELSE GO TO BOX EX21B2.

BOX EX21B2

routing

IF PRIVATE PAY HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT AND SP WAS COVERED
BY A LONG-TERM CARE POLICY, GO TO EX34B2 - USENOLTC.
ELSE GO TO BOX EX21AB2.

USENOLTC

EX34B2

yes/no

Earlier I was told that (SP) had long-term care insurance from (NAME OF FIRST LTC INSURANCE
COMPANY REPORTED). Is it correct that this policy paid for none of (his/her) care?

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

(00) EX35B2 - VEXPTXTG
(01) BOX EX21AB2
(-8) BOX EX21AB2
(-9) BOX EX21AB2

VEXPTXTG

EX35B2

Verbatim Text

Can you explain this to me?
RECORD VERBATIM BELOW.

(01) [Continuous answer.]

(01) BOX EX21AB2

BOX EX21AB2

routing

IF IT IS PENDING WHETHER SP HAS BEEN COVERED BY MEDICAID FROM CRIN-1 AND MEDICAID
HAS NEVER BEEN REPORTED AS A SOURCE OF PAYMENT, GO TO EX35AB2 - ECAIDECO.
ELSE GO TO EXEND - EXENDCNT.

ECAIDECO

EX35AB2

code one

(01) STILL PENDING
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR
(02) DENIED
MEDICAID)/MEDICAID] eligibility status was pending. Is it still pending or has [(PREFERRED NAME(S) FOR
(-8) Don't Know
MEDICAID)/MEDICAID] been denied?
(-9) Refused

EXENDCNT

EXEND

code one

PRESS "1" TO CONTINUE.

(Thank you for your time, I will need to talk to this person to complete these questions.)
YOU HAVE COMPLETED THE EXPENDITURES SECTION FOR THIS SP.

(01) Continue

(01) EXEND - EXENDCNT
(02) EXEND - EXENDCNT
(-8) EXEND - EXENDCNT
(-9) EXEND - EXENDCNT

(01) BOX EXEND

PRESS "1" TO RETURN TO NAVIGATION SCREEN.
BOX EXEND

routing

GO TO NAVIGATOR

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