Form CMS-P-0015A Cost Payment Summary

2024 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

CPS-COST PAYMENT SUMMARY

Question Text/Description

Code List

Routing

COST PAYMENT SUMMARY SPECIFICATIONS
CRITERIA
INTTYPE=C001, C004, C005
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: Prior round events flagged for CPS
PLACEMENT
Administer after NSQ.

CPS REASON HAS ALREADY BEEN ASSIGNED TO ALL CHARGE BUNDLES ENTERED IN THE PAST 2
ROUNDS THAT HAVE MISSING CHARGE DATA.
CPS REASON 1 = NO STATEMENT CHARGE BUNDLE, SP EXPECTED TO RECEIVE A STATEMENT
CPS REASON 2 = NO STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 3 = STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE BEEN MADE.
CPS REASON 4 = NO STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN TOTAL CHARGE. - NO
EVENTS FLAGGED AS REASON 4 IN ROUND 71.
CPS REASON 5 = STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS LESS THAN AMOUNT REMAINING. NO EVENTS FLAGGED AS REASON 5 IN ROUND 71.
BOX CPSBEG

routing

CPS REASON 9 = R70 CHARGE BUNDLE, NO STATEMENT ENTERED, FOLLOW CPS REASON 1 PATH
IN CPS, WE WILL REVIEW THIS LIST OF CHARGE BUNDLES AND WILL EXCLUDE ANY CHARGE BUNDLE
WITH AN EVENT THAT HAS BEEN DELETED, HAS BEEN LINKED TO A STATEMENT CHARGE BUNDLE IN
THE CURRENT ROUND, OR WAS ASKED ABOUT IN THE CURRENT ROUND NO STATEMENT SECTION AND
THE SP IS NOT EXPECTING TO RECEIVE A STATEMENT FOR THIS EVENT.
THE REMAINING LIST OF CHARGE BUNDLES WILL BE ELIGIBLE FOR CPS. WE WILL SORT THIS LIST IN
THE FOLLOWING WAY: REASON 9, 1, 2...ETC. ENDING WITH REASON 8. IN ROUND 73 REASONS 4-8
WERE SKIPPED. WE ONLY COLLECTED DATA FOR EVENTS WITH REASONS 9, 1, 2, AND 3. WE WILL
THEN COLLECT CPS DETAILS FOR THE FIRST CHARGE BUNDLE IN THIS LIST.
AFTER COMPLETING THE CPS DETAILS FOR THIS CHARGE BUNDLE, WE WILL RETURN TO BOX CPSBEG.
BECAUSE THE DATA THAT DETERMINES IF A CHARGE BUNDLE IS ELIGIBLE FOR CPS MAY BE UPDATED
WHILE ADMINISTERING CPS, THE LIST OF ELIGIBLE CHARGE BUNDLES WILL BE RECREATED AT THE
BEGINNING OF EACH LOOP IN CPS
IF AT LEAST ONE CHARGE BUNDLE HAS BEEN IDENTIFIED AS ELIGIBLE FOR CPS, GO TO CPS1-CPSINT.
ELSE GO TO BOX CPSEND.

[Next, I will ask about some medical care that we talked about in a previous interview.]
CPSINT

CPS1

no entry

THERE ARE (TOTAL NUMBER OF CPS EVENTS) EVENTS OR BUNDLES [REMAINING] FOR SUMMARY.

BOX CPS1A

[First/Next], I want to ask about [READ EVENT(S) ABOVE].
BOX CPS1A

routing

IF CPS REASON = 1 OR 8 OR 9, GO TO CPS2 - RECDSTAT.
ELSE GO TO BOX CPS1B.

BOX CPS1B

routing

CREATE SOURCE OF PAYMENT ROSTER
IF CPS REASON = 2, 6 OR 7, GO TO BOX CPS2.
ELSE IF CPS REASON = 3, GO TO CPS11 - CPTCHGPAID2.
ELSE IF CPS REASON = 4, GO TO CPS13 - CPTCHGPAID3.
ELSE IF CPS REASON = 5, GO TO CPS15 - CPTCHGPAID4.

Page 1 of 5

2024 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

CPS-COST PAYMENT SUMMARY

Question Text/Description

Code List

Routing

(01) STATEMENT RECEIVED AND AVAILABLE
(02) STATEMENT RECEIVED, NOT AVAILABLE
(03) STATEMENT NOT RECEIVED
(-8) Don't Know
(-9) Refused

(01) ST4 - MATCHST
(02) BOX NS4A
(03) BOX NS4A
(-8) BOX NS4A
(-9) BOX CPS32

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

BOX CPS3

[IF CPS REASON=9 THEN DISPLAY IN BOLD: "EVENT REPORTED IN ROUND 70"]
[At the last interview, [you were/(SP) was] expecting to receive a statement or paper from [Medicare, Insurance,
and TRICARE/Medicare and TRICARE/Medicare and Insurance/Medicare).]
RECDSTAT

CPS2

code one

[At the last interview, [you/(SP)] reported [READ EVENT(S) ABOVE].
[Have you/Has (SP)] received a statement for the [READ EVENT(S) ABOVE] (since then/since the last interview)?
[PROBE IF NECESSARY: Please include any statements received about (your/(SP's)] Medicare prescription drug
benefit.]

KNOWTOTL

TOTALCHG

BOX CPS2

routing

IF TOTAL CHARGE = DK OR RF AND ((ASKING ABOUT A NO STATEMENT CHARGE BUNDLE) OR (ASKING
ABOUT A STATEMENT CHARGE BUNDLE AND TYPE OF STATEMENT IS NOT A MEDICARE PRESCRIPTION
DRUG BENEFIT STATEMENT)), GO TO CPS3 - KNOWTOTL.
ELSE IF CPS REASON = 2, GO TO CPS9 - CPTCHGPAID1.

CPS3

yes/no

Do you happen to know the (total charge/copayment amount) for the [READ EVENT(S) ABOVE]?

BOX CPS3

routing

IF CPS3 - KNOWTOTL = 1/Yes AND (TOTAL CHARGE WAS COLLECTED FOR CHARGE BUNDLE), GO TO
CPS4 - TOTALCHG.
ELSE IF CPS3 - KNOWTOTL = 1/Yes AND (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE), GO TO
CPS5 - TOTALCHG.
ELSE IF (CPS3 - KNOWTOTL = 2/No OR RF) AND (CPS REASON = 2), GO TO CPS9 - CPTCHGPAID1.

numeric

Including any amounts that may be paid by Medicare or anyone else, what was the total charge (that is, the amount
billed)?
(01) continuous answer
ENTER 0 IF NO CHARGE FOR THE EVENT.
(-8) Don't Know
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF THE
(-9) Refused
CHARGE. IF THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE THE
DISCOUNT IS APPLIED.]

CPS4

BOX CPS5A

What was the copayment amount for the [READ EVENT(S) ABOVE]?
TOTALCHG

CPS5

numeric

[EXPLAIN IF NECESSARY: Managed care plans commonly charge a fixed amount, or copayment, each time
health services are provided. For example, the person may pay $20 for each office visit and $10 for each drug
prescription.]

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

BOX CPS5A

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

CPS6 - MONCOV96

ENTER 0 IF NO COPAYMENT FOR THE EVENT.

routing

IF (CPS REASON = 2) AND (TOTAL CHARGE = 0) AND (SP IS CURRENTLY COVERED BY MEDICAID), GO TO
BOX CPS32.
ELSE GO TO BOX CPS5B.

BOX CPS5B

routing

FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF EVENT TYPE = 'OM' AND EVENT IS A
RENTAL ITEM, GO TO CPS6 - MONTHCOV.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT TYPE = 'PM') OR
(EVENT TYPE = 'OM' AND (OTHER MEDICAL EXPENSE IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES
OR BANDAGES)), GO TO CPS7 - NUMLINKS.
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF (EVENT WAS ENTERED AS A
REPEAT VISIT), GO TO CPS8 - RVLINKS.
ELSE GO TO BOX CPS8A.

MONTHCOV

CPS6

numeric

For the [READ OME ITEM ABOVE], how many months are covered by the charge for the period of time between
(CHARGE BUNDLE REFERENCE PERIOD)?
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND UP.
(E.G., FOR 2 ½ MONTHS, ENTER “3”.)]

NUMLINKS

CPS7

numeric

How many of the times [you/(SP)] obtained (MEDICINE NAME/OME ITEM TYPE) for the period between (CHARGE
(01) continuous answer
BUNDLE REFERENCE PERIOD) [were covered by the total charge/were covered by the (CPS4 - TOTAL
(-8) Don't Know
CHARGE)/was there no charge/were covered by the copayment/were covered by the (CPS5 - COPAYMENT)/was
(-9) Refused
there no copayment]?

BOX CPS5A

BOX CPS8A

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2024 MCBS Community Questionnaire

Variable Name
RVLINKS

MR Screen Name

CPS-COST PAYMENT SUMMARY

Question Type

Question Text/Description

Code List

Routing

CPS8

numeric

How many of the [READ EVENT ABOVE] [were covered by the total charge/were covered by the (CPS4 - TOTAL
CHARGE)/was there no charge/were covered by the copayment/were covered by the (CPS5 - COPAYMENT)/was
there no copayment]?

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

BOX CPS8B

BOX CPS8A

routing

IF ANOTHER EVENT IS INCLUDED IN THE CHARGE BUNDLE, GO TO BOX CPS5B.
ELSE GO TO BOX CPS8B.

BOX CPS8B

routing

IF CPS REASON = 2 AND TOTAL CHARGE ^= 0, GO TO CPS9 - CPTCHGPAID1.
ELSE IF CPS REASON = 2 AND TOTAL CHARGE = 0, GO TO BOX CPS10.
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) (TOTAL CHARGE/COPAYMENT AMOUNT) IS
WRONG
(-8) Don't Know
(-9) Refused

(01) BOX CPS10
(02) BOX CPS10
(03) CPS10 - TCHGWRONG
(-8) BOX CPS10
(-9) BOX CPS10

CPTCHGPAID1

CPS9

code one

[Last time, we recorded that the (total charge/copayment amount) for the [READ EVENT(S) ABOVE] was (TOTAL
CHARGE)), and that no payment had been made.] [Have you/Has (SP)] or any other source[, such as (an
insurance plan/TRICARE/TRICARE or an insurance plan),] now paid any of [the total charge/the copayment
amount/this (TOTAL CHARGE)]?

TCHGWRONG

CPS10

no entry

YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR
“NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY PORTION OF THE CHARGE.

BOX CPS10

routing

IF (CPS9 - CPTCHGPAID1 = 1/SomeonePaid) OR (TOTAL CHARGE = 0), GO TO NS65 - NSADDSOP1.
ELSE IF (CPS9 - CPTCHGPAID1 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE GO TO BOX CPS32.

CPS9 - CPTCHGPAID1
DESIGN NOTES
Calls NS SOP roster.
NS returns to CPS at BOX CPSBEG.

CPTCHGPAID2

CPS11

code one

Last time, we recorded that [Medicare had paid [nothing and/(MEDICARE PAYMENT AMOUNT) and after Medicare (01) SP OR ANY SOURCE PAID
paid,]] there was an amount remaining of (CPS AMOUNT REMAINING) for the [READ EVENT(S) ABOVE.]
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] (-8) Don't Know
(-9) Refused
now paid any of this (AMOUNT REMAINING)?

(01) BOX CPS12
(02) BOX CPS12
(03) CPS12 - TCHGWRONG
(-8) BOX CPS12
(-9) BOX CPS12

TCHGWRONG

CPS12

no entry

YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE ERROR HAS BEEN NOTED. ANSWER
“YES” OR “NO” AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID.

CPS11 - CPTCHGPAID2

BOX CPS12

routing

IF (CPS11 - CPTCHGPAID2 = 1/SomeonePaid), GO TO ST65 - STADDSOP1.
ELSE IF (CPS11 - CPTCHGPAID2 = 2/NothingPaid), GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS11 - CPTCHGPAID2 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
Let me review what we recorded last time.

CPTCHGPAID3

CPS13

code one

[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount unpaid is
$(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),]
paid any additional amount?

TCHGWRONG

CPS14

no entry

YOU CANNOT CORRECT THE AMOUNT HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO”
AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY ADDITIONAL AMOUNT.

BOX CPS14

routing

IF CPS13 - CPTCHGPAID3 = 1/Yes, GO TO NS65 - NSADDSOP1.
ELSE IF CPS13 - CPTCHGPAID3 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS13 - CPTCHGPAID3 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.
Let me review what we recorded last time.

(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) TOTAL CHARGE SEEMS WRONG
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
(-9) Refused

(01) SP OR ANY SOURCE PAID
[REVIEW ABOVE WITH RESPONDENT.] There seems to be some amount still unpaid. The total of non-Medicare (02) NOTHING HAS BEEN PAID
payments is $(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE BETWEEN PAYMENTS AND CPS
(03) AMOUNT REMAINING SEEMS WRONG
AMOUNT REMAINING).
(04) PAYMENT AMOUNTS WRONG
(-8) Don't Know
[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance plan),] (-9) Refused
paid any additional amount?

CPTCHGPAID4

CPS15

code one

TCHGWRONG

CPS16

no entry

YOU CANNOT CORRECT THE AMOUNT HERE. THE ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO”
AS APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY ADDITIONAL AMOUNT.

BOX CPS16

routing

IF CPS15 - CPTCHGPAID4 = 1/Yes, GO TO ST65 - STADDSOP1.
ELSE IF CPS15 - CPTCHGPAID4 = 2/NothingPaid, GO TO CPS17 - EXPAYOUT.
ELSE IF (CPS15 - CPTCHGPAID4 = DK), GO TO CPS23 - RRDETAIL.
ELSE GO TO BOX CPS32.

(01) BOX CPS14
(02) BOX CPS14
(03) CPS14 - TCHGWRONG
(04) BOX CPS14
(-8) BOX CPS14
(-9) BOX CPS14
CPS13 - CPTCHGPAID3

(01) BOX CPS16
(02) BOX CPS16
(03) CPS16 - TCHGWRONG
(04) BOX CPS16
(-8) BOX CPS16
(-9) BOX CPS16

CPS15 - CPTCHGPAID4

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2024 MCBS Community Questionnaire

Variable Name

MR Screen Name

CPS-COST PAYMENT SUMMARY

Question Type

Question Text/Description

Code List

Routing

CPS17

yes/no

Do you expect that [you/(SP)] or any other source will pay any [of this amount/additional amount for [READ
EVENT(S) ABOVE]]?

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

(01) BOX CPS17
(02) BOX CPS32
(-8) BOX CPS32
(-9) BOX CPS32

BOX CPS17

routing

IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND), GO TO CPS18 EXPAYUNT.
ELSE GO TO BOX CPS32.

EXPAYUNT

CPS18

code one

How much do you expect will be paid?

(91) PERCENTAGE
(02) DOLLARS
(-8) Don't Know
(-9) Refused

(01) CPS18 - EXPAYAMT
(02) CPS18 - EXPAYPCT
(-8) BOX CPS32
(-9) BOX CPS32

EXPAYPCT

CPS18

numeric

How much do you expect will be paid?

(01) continuous answer

BOX CPS32

EXPAYAMT

CPS18

numeric

How much do you expect will be paid?

(01) continuous answer

BOX CPS32

RRDETAIL

CPS23

yes/no

DID RESPONDENT MENTION (AN INSURANCE/A) REFUND OR REIMBURSEMENT ABOUT WHICH HE/SHE
IS NOT SURE OF THE DETAILS?
[DO NOT ENTER A COMMENT HERE TO EXPLAIN THE SITUATION.]

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

(01) CPS24 - RRADD
(02) BOX CPS32
(-8) BOX CPS32

RRADD

CPS24

yes/no

DO YOU WANT TO ADD A REFUND OR REIMBURSEMENT?
[DO NOT SELECT “YES” IF THE RESPONDENT KNOWS A REIMBURSEMENT AMOUNT, BUT DOES NOT
KNOW WHO PAID IT.]

(01) YES
(02) NO

(01) CPS25 - CPADDSOP
(02) BOX CPS32

CPADDSOP

CPS25

yes/no

ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.

(01) YES
(02) NO

(01) CPS27 - TSOPREIM
(02) CPS26 - SOP_CP

SOP_CP

CPS26

roster

ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.

EXPAYOUT

TSOPREIM_NAM
CPS27
E

grid

TSOPREIM_AMT

CPS27

grid

BOX CPS27A

routing

BOX CPS27B

routing

IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT CPS26 IS A HEALTH INSURANCE PLAN AND
CPREASON=3, GO TO CPS27BINT - PLANINTRO_CPS.
ELSE GO TO BOX CPS29E.

no entry

Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.

BOX CPS27C

routing

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT CPS26
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS CURRENT, GO TO CPS28 - CPMHMOCHNG.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP DOES NOT HAVE A
MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO HIMC3-COVTIME.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO CPS29A - CPMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN AND SP DOES NOT HAVE A
MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO HIMPDP-COVTIME.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.

CPMHMOCHNG

CPS28

yes/no

I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current
Medicare Managed Care Plan. Has this information changed?

CPMPDPCHNG

CPS29A

yes/no

Who (else) paid (besides Medicare)? How much did (SOURCE) pay?

How much did (SOURCE) pay?

PLANINTRO_CPS CPS27BINT

REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)
ENTER ALL REIMBURESMENT AMOUNTS.

(01) continuous answer

CPS27 - TSOPREIM

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

BOX CPS27A

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

BOX CPS27A

GO TO BOX CPS27B.

I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
Medicare Prescription Drug Care Plan.
Has this information changed?

BOX CPS27C

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

(01) HIMC3-COVTIME
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A

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

(01) HIMPDP-COVTIME
(02) BOX CPS29A
(-8) BOX CPS29A
(-9) BOX CPS29A

Page 4 of 5

2024 MCBS Community Questionnaire

Variable Name

CPS-COST PAYMENT SUMMARY

MR Screen Name

Question Type

Question Text/Description

BOX CPS29A

routing

IF ANOTHER SOP WAS ADDED AT CPS26, GO TO BOX CPS27C.
ELSE GO TO BOX CPS29E.

BOX CPS29E

routing

IF AN "OTHER SOURCE OF PAYMENT" ADDED AT CPS26, CREATE AN OSOP FOR EACH SOURCE OF
PAYMENT ADDED AT CPS26 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX CPS29F.

BOX CPS32

routing

GO TO BOX CPSBEG.

routing

IF SEASON=SUMMER, GO TO PXQ.
ELSE GO TO END.

BOX CPSEND

Code List

Routing

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