CMS-P-0015A No Statement Cost

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

Routing

[996] LEAVE COST SERIES

BOX NS1
[996]END

(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(04) HAVE STATEMENT FOR EVENT
(05) YES, BUT CAN ANSWER QUESTIONS
(09) FLAG COST FOR CPS DO NOT DISPLAY
[996] LEAVE COST SERIES
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS4
(02) BOX NS4
(03) NS3 - EVERRVB
(04) ST4 - MATCHST
(05) BOX NS4
(09) DO NOT DISPLAY
[996] END
(-8) BOX NS4
(-9) BOX NS4

(01) CONTINUOUS ANSWER

BOX NS4

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS5

NO STATEMENT COST SERIES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: At least one event entered in the current round is not associated with charge data already entered
PLACEMENT
Administer after PSQ.

BOX NSBEG

routing

CREATE LIST OF EVENTS ENTERED IN THE CURRENT ROUND THAT ARE NOT ASSOCIATED WITH
CHARGE DATA ALREADY ENTERED
IF AT LEAST ONE EVENT ENTERED IN THE CURRENT ROUND IS NOT ASSOCIATED WITH CHARGE
DATA ALREADY ENTERED, GO TO NS1 - NSINT.
ELSE GO TO NS81 - NSTATEMENT.
[Now that we're done with [your/(SP's)] statements, let's/Let's] talk about the medical services and costs for
which [you/(SP)] did not have a statement.]

NSINT

NS1

no entry

THERE ARE (TOTAL NUMBER OF NS EVENTS) EVENTS (REMAINING) TO ASK ABOUT.
(Let's start with/Next let's look at) (the/[your/(SP's)]) costs for the (EVENT).

BOX NS1

routing

IF (ST1 - MHMOSTMT = 3/Never AND ((SP HAS A MEDICARE MANAGED CARE PLAN THAT DOES NOT
HAVE RX COVERAGE ANYTIME IN THE CURRENT ROUND) OR (SP HAS A PRIVATE PLAN THAT IS A
MANAGED CARE PLAN ANYTIME IN THE CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE) OR (EVENT
IS ASSOCIATED WITH A MANAGED CARE PLAN))) OR (EVENT TYPE = 'OM' AND EVENT IS A RENTAL
ITEM AND PS1 - HADPYMNT = 1/Yes) OR ((EVNTTYPE = 'DU' OR 'PM' OR 'VU' OR 'HU') AND SP DOES NOT
HAVE ANY OTHER HEALTH INSURANCE PLAN BESIDES MEDICARE IN THE CURRENT ROUND) , GO TO
BOX NS4.
ELSE GO TO NS2 - NSEXMCMAIL.

As far as you know, is anything expected in the mail from (Medicare, Insurance, and Tricare/Medicare and
Tricare/Medicare and Insurance/Medicare) about [READ EVENT ABOVE]?

NSEXMCMAIL

NS2

code one

EVERRVB

NS3

verbatim text

BOX NS4

routing

CREATE A NEW CHARGE BUNDLE FOR THIS EVENT
IF NS2 - NSEXMCMAIL = 1/Yes or 3/EventEnteredInError, GO TO BOX NS80.
ELSE GO TO BOX NS4A.

BOX NS4A

routing

IF (EVENT TYPE IS NOT AN OTHER MEDICAL EXPENSE) AND (EVENT IS ASSOCIATED WITH A
MANAGED CARE PLAN), GO TO NS6 - TOTALCHG.
ELSE GO TO NS5 - TOTALCHG.

REMINDER: "EVENT ENTERED IN ERROR" INSTRUCTS THE HOME OFFICE TO DELETE THIS EVENT.

TOTALCHG

NS5

dollar

IF YOU HAVE ENTERED THIS CODE IN ERROR, SELECT PREVIOUS PAGE AND ENTER THE CORRECT
CODE AT NS2. OTHERWISE, EXPLAIN WHY YOU SELECTED "EVENT ENTERED IN ERROR" FOR THIS
EVENT.

Including any amounts that may be paid by Medicare or anyone else, what [was the charge for the (OME ITEM
TYPE) rented (with the option to buy) for the time period between (REFERENCE DATE/UTILDATE) and
(TODAY/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/was the total charge (that is, the total amount
billed)]?
IF CHARGE REPORTED AS HOURLY RATE, CALCULATE AND ENTER THE TOTAL CHARGE FOR THE
ENTIRE ROUND.
[PROBE FOR TOTAL BILLED AMOUNT, REGARDLESS OF WHO PAID (OR WILL PAY) ANY PORTION OF
THE CHARGE. IF THE RESPONDENT RECEIVES A DISCOUNT, RECORD THE TOTAL CHARGE BEFORE
THE DISCOUNT IS APPLIED.]

BOX NS5

routing

IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
ELSE IF EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO NS7 - MONTHCOV.
ELSE IF (EVENT TYPE = 'PM' OR 'OM') AND NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1,
GO TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.

Page 1 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

Routing

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS6

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED

NS7 - MONCOV96

(01) LESS THAN 1 MONTH
(-7) EMPTY

BOX NS9

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

MONTHCOV

NS6

dollar

BOX NS6

routing

NS7

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.]
ENTER 0 IF NO COPAYMENT FOR THE EVENT.
IF TOTALCHG = 0 AND SP CURRENTLY COVERED BY MEDICAID, GO TO BOX NS80.
IF EVENT TYPE = 'PM' AND THE TOTAL OF NUMBER OF PURCHASES BEING ASKED ABOUT IN NS IS > 1,
GO TO NS8 - NUMLINKS.
ELSE IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO NS9 - RVLINKS.
ELSE GO TO BOX NS9.
How many months are covered by the charge for the period of time [since (REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)]?
[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND
UP. (E.G., FOR 2 ½ MONTHS, ENTER “3”.)]

MONCOV96

NS7

code one

NUMLINKS

NS8

numeric

How many of the times [you/(SP)] obtained [READ EVENT ABOVE] since (REFERENCE DATE/UTILDATE)
(01) CONTINUOUS ANSWER
[were covered by the total charge/was there no charge/were covered by the (TOTAL CHARGE)/were covered by (-8) DON'T KNOW
the copayment/was there no copayment/were covered by the (COPAYMENT)]?
(-9) REFUSED

BOX NS9

RVLINKS

NS9

numeric

How many of the (NUMBER OF VISITS) (visits to the OPD at/lab services provided by/visits to) (PROVIDER
NAME) during the month of (EVENT MONTH) [were covered by the total charge/was there no charge/were
covered by the (TOTAL CHARGE)/were covered by the copayment/was there no copayment/were covered by
the (COPAYMENT)]?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS9

BOX NS9

routing

IF (COPAYMENT WAS COLLECTED FOR CHARGE BUNDLE INSTEAD OF A TOTAL CHARGE), GO TO BOX
NS45.
ELSE GO TO NS10 - INCOTHER.

INCOTHER

NS10

code one

[READ IF NECESSARY: Does [the total charge/TOTAL CHARGE)] cover this (medicine/item/event) only or
does it include other (medicine/item/event)s.]

(01) ONLY THIS EVENT/ITEM/MEDICINE
(02) OTHER EVENTS/ITEMS/MEDICINES
(03) CAN'T TELL

(01) BOX NS45
(02) NS12 - INCTYPE
(03) BOX NS45

INCTYPE

NS12

code all

What else was included?
CHECK ALL THAT APPLY.

(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES

BOX NS12

BOX NS12

routing

IF THE RESPONSE TO NS12 - INCTYPE INCLUDES 1/ProvDates or 2/Home Health Visits, GO TO NS13 PROVIDER_NSDATE.
ELSE GO TO BOX NS33.

PROVIDER_NSDAT
NS13
E

roster

WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
IF EXISTING PROVIDER SELECTED, GO TO NS142. [PROVIDER 2]
NSDATEUPD.
…
ELSE IF "ADD ANOTHER" SELECTED, GO TO PROV
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

PROVNAME

NS13

verbatim

YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.

NS13-GROUPNAM

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:
GROUPNAM
NSDATEUPD

NS13
NS14

verbatim
code one

GROUP:
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?

NS14- NSDATEUPD
(01) NO, DO NOT NEED TO ADD OR EDIT EVENT
DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE

(01) NS24 - EVENT_NSDATE
(02) VISTYPE-VISITYPE
(03) NS15 - EVENT_NSDATEDIT

Page 2 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

EVENT_NSDATEDIT NS15

VISITYPE

VISTYPE

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

Routing

roster

SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.

(01) CONTINUOUS ANSWER

NS14 - NSDATEUPD

SELECT TYPE OF VISIT TO ADD:

(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(08) Vision (VU)
(09) Hearing (HU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(10) All other visits to Medical Provider (MP)
(11) Home Health Professional (HP)
(12) Home Health Friend, Neighbor, or Relative (HF)

select one

[When did [you/(SP)] see (PROVIDER NAME)?/When [were you/was (SP)] admitted to and discharged from
(HOSPITAL NAME)?] Please tell me all the dates [since (REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)].
ENTER ALL DATES.
EVENT

NS16

verbatim

ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.

MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

NS16-EVENT

BOX NS16A

[IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.]

NSDATEINTRO

BOX NS16A

routing

IF AT LEAST ONE EVENT DATE ADDED AT NS16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD,
GO TO BOX NS16B.
ELSE GO TO NS14 - NSDATEUPD.

BOX NS16B

routing

IF AT LEAST ONE EVENT ADDED AT NS16 FOR THIS PROVIDER IS 'HP' OR 'HF' AND [(VISITYPE IS 11/HP
AND THE PROVIDER SPECIALTY HAS BEEN COLLECTED) OR (VISITYPE IS 12/HF AND HHFTYPE IS
KNOWN (HHFTYPE =1 OR 2))], GO TO NS24-EVENT_NSDATE.
ELSE GO TO BOX NS17.

NS17

no entry

Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just added.

routing

IF AT LEAST ONE EVENT ADDED AT NS16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS
NOT BEEN COLLECTED, GO TO NS18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO NS18A - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'VU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO NS18B - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT NS16 IS A 'HU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO NS18C - PROVSPEC.
ELSE IF VISITYPE is 11/HP AND THE PROVIDER SPECIALTY HAS NOT BEEN COLLECTED, GO TO NS4PROFWORK.
ELSE IF VISITYPE IS 12/HF AND HHFTYPE IS UNKNOWN (HHFTYPE = ., -7, -9), GO TO NS18E-HHFTYPE.
ELSE GO TO BOX NS18.

BOX NS17

BOX NS17

Page 3 of 16

2023 MCBS Community Questionnaire

NSQ-NO STATEMENT COST SERIES

Variable Name

MR Screen Name

Question Type

PROVSPEC

NS18

code one

PROVSPOS

NS18

text

PROVSPEC

NS18A

code one

Question Text/Description

Code List
Routing
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
What kind of medical person is (PROVIDER NAME)?
(18) PARAMEDIC
(42) PHARMACIST
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES
(01)-(34), (42), (-8), (-9) BOX NS18
(19) PHYSICAL THERAPIST (PT)
THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT
(91) NS18 - PROVSPOS
(20) PHYSICIAN'S ASSISTANT
PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT
(21) PODIATRIST (FOOT DOCTOR)
LISTED ON MPQ JOB AID 1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
OTHER MEDICAL PROVIDER (SPECIFY)

(01) CONTINUOUS ANSWER

BOX NS18

What kind of dental provider is [PROVNAME]?

(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS18
(35) BOX NS18
(36) BOX NS18
(37) BOX NS18
(38) BOX NS18
(39) BOX NS18
(40) BOX NS18
(41) BOX NS18
(91) NS18A - PROVSPOS
(-8) BOX NS18
(-9) BOX NS18

Page 4 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

(01) DENTIST/DENTAL PROVIDER (DO NOT
DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(01)-(34), (-8), (-9) BOX NS18
(19) PHYSICAL THERAPIST (PT)
(91) NS18A - PROVSPOS
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

Routing

PROVSPEC

NS18A1

code one

What kind of dental provider is [PROVNAME]?

PROVPOS

NS18A

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX NS18

What kind of eye care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(02) BOX NS18
(16) BOX NS18
(43) BOX NS18
(91) NS18B1- PROVSPEC
(-8) BOX NS18
(-9) BOX NS18

PROVSPEC

NS18B

code one

Page 5 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

Routing

PROVSPEC

NS18B1

code one

What kind of eye care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(01)-(34), (-8), (-9) BOX NS18
(19) PHYSICAL THERAPIST (PT)
(91) NS18B - PROVSPOS
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

PROVPOS

NS18B

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX NT18

What kind of hearing care provider is [PROVNAME]?

(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused

(02) BOX NS18
(03) BOX NS18
(44) BOX NS18
(45) BOX NS18
(91) NS18C1- PROVSPEC
(-8) BOX NS18
(-9) BOX NS18

PROVSPEC

NS18C

code one

Page 6 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

Routing

PROVSPEC

NS18C1

code one

What kind of hearing care provider is [PROVNAME]?

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(01)-(34), (-8), (-9) BOX NS18
(19) PHYSICAL THERAPIST (PT)
(91) NS18C - PROVSPOS
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

PROVPOS

NS18C

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX NS18

PROFWORK

NS4

code one

(01) WORKS FOR ORGANIZATION
(02) WORKS FOR SELF
(-8) DON'T KNOW
(-9) REFUSED

NS18D-PROVSPEC

Does this health or medical professional work for a place or organization?
[PROBE: Or does this health or medical professional work for himself/herself?]

Page 7 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

What kind of health professional [is (PROVIDER NAME)/did [you/(SP)] see from (PROVIDER NAME)]?
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT
SPECIFICALLY NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL
SPECIALTY NOT LISTED BELOW, BUT LISTED ON MPQ JOB AID 1, SUCH AS ‘CARDIOLOGY,’ SELECT
'MEDICAL DOCTOR.']

PROVSPEC

NS18D

code one

PROVSPOS

NS18D

text

OTHER MEDICAL PROVIDER (SPECIFY)

BOX NSHH1AA

routing

IF NS4 -PROFWORK = 1/Works for Organization, GO TO NS6 - HHPLACE.
ELSE GO TO BOX NS18.

Code List

Routing

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(01)-(34), (-8), (-9) BOX NSHH1AA
(19) PHYSICAL THERAPIST (PT)
(91) NS16D - PROVSPOS
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
BOX NSHH1AA

HHPLACE

NS6

code one

PROVIDER NAME: (PROVIDER NAME)
What kind of place or organization is (PROVIDER NAME)?

(01) MANAGED CARE PLAN (SUCH AS HMO)
(02) MEAL PROGRAM (SUCH AS MEALS ON
WHEELS)
(03) VISITING NURSE ASSOCIATION
(04) HOME HEALTH AGENCY
(05) HOSPITAL
(06) PRIVATE PHYSICIAN/GROUP PRACTICE
(07) HOSPICE
(08) REHABILITATION OR SPORTS MEDICINE
THERAPY
(09) LOCAL GOVERNMENT ORGANIZATION
(10) CHURCH OR COMMUNITY ORGANIZATION
(11) ASSISTED LIVING/RETIREMENT HOME
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

HHPLACOS

NS6

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

BOX NS18
BOX NS18
(01) BOX NS18
(02) HHFRELAT
(-8) BOX NS18
(-9) BOX NS18

OTHMEALS

NS7

yes/no

[Between (REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/ DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did (PROVIDER NAME) provide any services to [you/(SP)] other than
delivering meals?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

HHFTYPE

NS18E

code one

Is (PROVIDER NAME) a friend, neighbor, or a relative?

(01) FRIEND OR NEIGHBOR
(02) RELATIVE
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS18
(02) NS7-OTHMEALS
(03) BOX NS18
(04) BOX NS18
(05) BOX NS18
(06) BOX NS18
(07) BOX NS18
(08) BOX NS18
(09) BOX NS18
(10) BOX NS18
(11) BOX NS18
(91) NS6 - HHPLACOS
(-8) BOX NS18
(-9) BOX NS18

Page 8 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

HHFRELAT

NS18F

code one

How is (PROVIDER NAME) related to [you/(SP)]?

HHFRELOS

NS18F

text

OTHER (SPECIFY)

BOX NS18

routing

IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', 'IU', 'HP', OR 'MP' EVENT
TYPE) AND (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT
ROUND OR ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN),
GO TO NS19 - VAPLACE.
ELSE GO TO BOX NS19.

NS19

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?

BOX NS19

routing

IF (AT LEAST ONE EVENT ADDED AT NS16 IS A 'DU', 'VU', 'HU'', 'ER', 'IP', 'OP,' 'HP', OR 'MP' EVENT
TYPE) AND (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(IF THIS PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO ST20 HMOASSOC.
ELSE IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', 'HP', OR 'MP' EVENT
TYPE) AND (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO ST21 - HMOREFER.
ELSE GO TO BOX NS22A.

HMOASSOC

NS20

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

NS21

yes/no

VAPLACE

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

BOX NS22A

routing

FOR THIS EVENT ADDED AT NS16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX NS22B.
ELSE IF TYPE OF EVENT = 'DU', GO TO DU7 - DVPROCDR.
ELSE IF TYPE OF EVENT = 'VU', GO TO VU7 - VUPROCDR.
ELSE IF TYPE OF EVENT = 'HU', GO TO HU7 - HUPROCDR.
ELSE IF TYPE OF EVENT = 'HP' OR 'HF' AND NEEDNURS HAS NOT BEEN ASKED IN THE CURRENT
ROUND FOR THIS PROVIDER, GO TO HH13-NEEDNURS.
ELSE GO TO BOX NS23B.

BOX NS22B

routing

IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT DATE OVERLAPS AN EXISTING IP
EVENT) OR (EVENT DATE MATCHES AN EXISTING ER OR OP EVENT) GO TO NS23 - MPSDVIS.
ELSE GO TO TELEHLTH-TELEHLTH.

MPSDVIS

NS23

yes/no

We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW].
Was this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED
BELOW]/any of these places]?

TELEHLTH

TELEHLTH

yes/no

Code List
(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

Routing

(02) 56, 58-61 BOX NS18
(91) HHFRELOS

(01) CONTINUOUS ANSWER

BOX NS18

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX NS19

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS22A
(02) NS21 - HMOREFER
(-8) NS21 - HMOREFER
(-9) NS21 - HMOREFER

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX NS22A

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS23A
(02) TELEHLTH-TELEHLTH
(-8) TELEHLTH-TELEHLTH
(-9) TELEHLTH-TELEHLTH

[Was this visit/Were any of these visits] to (PROVIDER NAME) a telephone or video visit?

EVENT_NSDATE

(01) YES
(02) NO
IF NEEDED: Telephone or video visits are also referred to as “telehealth visits”, “virtual check-ins”, or “e-visits”. (-8) Don't Know
These types of visits allow you to have a medical appointment without physically visiting your doctor’s office.
(-9) Refused

BOX NS23A

routing

GO TO BOX NS23B.

BOX NS23B

routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER AT NS16, GO TO BOX NS22A.
ELSE GO TO NS24-EVENT_NSDATE.

NS24

check all

SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.

BOX NS24

routing

IF AT LEAST ONE EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.

(01) CONTINUOUS ANSWER

BOX NS23A

BOX NS24

Page 9 of 16

2023 MCBS Community Questionnaire

Variable Name

RVLINKS

NSDATEMTCH

MR Screen Name

Question Type

Question Text/Description

NS24A

numeric

ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS
CHARGE.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
[A REPEAT VISIT MEANS THAT THE RESPONDENT HAD AT LEAST 5 VISITS TO THE PROVIDER DURING (-9) REFUSED
THE CURRENT ROUND REFERENCE PERIOD.]

BOX NS24A

routing

IF ANOTHER EVENT SELECTED AT NS24 IS A REPEAT VISIT, GO TO NS24A - RVLINKS.
ELSE GO TO NS25 - NSDATEMTCH.

NS25

code one

ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE SHOWN BELOW?

(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT

(01) BOX NS33
(02) NS13 - PROVIDER_NSDATE
(03) NS26 - EVENT_NSDATEDEL

roster

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

(01) CONTINUOUS ANSWER

NS25 - NSDATEMTCH

BOX NS33

routing

IF NS12 – INCTYPE INCLUDES 3/OMExpenses, GO TO NS34 - NSOMUPD.
ELSE GO TO BOX NS40.

NS34

code one

THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?

(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT (01) NS37 - EVENT_NSOM
(02) NS36 - NSOMADD
(02) YES, NEED TO ADD AN OME EVENT
(03) NS35 - EVENT_NSOMEDIT
(03) YES, NEED TO EDIT AN OME EVENT

roster

SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.

(01) CONTINUOUS ANSWER

WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?

(01) GLASSES/CONTACTS
(11) HEARING AID
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES

BOX NS36

(01) CONTINUOUS ANSWER

BOX NS37

EVENT_NSDATEDE
NS26
L

NSOMUPD

EVENT_NSOMEDIT NS35

NSOMADD

NSQ-NO STATEMENT COST SERIES

NS36

code one

BOX NS36

routing

GO TO NS34 - NSOMUPD.

NS37

roster

SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE.

BOX NS37

routing

IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 MONTHCOV.
ELSE GO TO BOX NS38B.

MONTHCOV

NS38

numeric

MONCOV96

NS38

code one

BOX NS38A

routing

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS RENTED, GO TO NS38 - MONTHCOV.
ELSE GO TO BOX NS38B.

BOX NS38B

routing

IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES,
INCONTINENCE SUPPLIES OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.

NS38A

numeric

HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?

BOX NS38AA

routing

IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT NS37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO NS38A - NUMLINKS.
ELSE GO TO NS39 - NSOMMTCH.

NSOMMTCH

NS39

code one

ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE SHOWN BELOW?

EVENT_NSOMDEL

NS40

roster

SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.

BOX NS40

routing

IF NS12 – INCTYPE INCLUDES 4/PMS, GO TO NS41 - EVENT_NSPM.
ELSE GO TO BOX NS45.

NS41

roster

SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE.

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO NS42-NUMLINKS.

EVENT_NSOM

HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?

NUMLINKS

EVENT_NSPM

BOX PM2

[IF THE RESPONDENT DOES NOT REPORT THE NUMBER OF MONTHS AS A WHOLE NUMBER, ROUND
UP. (E.G., FOR 2 ½ MONTHS, ENTER “3”.)]

Code List

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY

Routing

BOX NS24A

NS38 - MONCOV96
BOX NS38A

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NS38AA

(01) YES
(02) NO, NEED TO ADD AN OME EVENT
(03) NO, NEED TO REMOVE AN OME EVENT
(01) CONTINUOUS ANSWER

(01) BOX NS40
(02) NS34 - NSOMUPD
(03) NS40 - EVENT NSOMDEL
NS39 - NSOMMTCH

(01) CONTINUOUS ANSWER

BOX PM2

Page 10 of 16

2023 MCBS Community Questionnaire

NSQ-NO STATEMENT COST SERIES

Variable Name

MR Screen Name

Question Type

Question Text/Description

MEDICINE_PM1

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

Code List
Routing
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
BOX PM3
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

PMBOTTLE

BOX PM4

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

PMBOTTLE

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.

PMEDNAME

MED

lookup

ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]

PMBRNAME

MED

lookup

[PM BRAND NAME]

PMGNNAME

MED

lookup

[PM GENERIC NAME]

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

Medicine Form [MCBS FORM]

[MEDICINE FORM OTHER SPECIFY]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD

(01) CONTINUOUS ANSWER

[FINAL CONCATENATED MEDICINE FORM]

Page 11 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

ookup

Medicine strength unit

Routing

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-MEDID
(-9) MED-MEDID

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) BOX PM5
(91) PMCOND-PMCONDOS
(-8) BOX PM5
(-9) BOX PM5

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX PM5

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

[FINAL CONCATENATED MEDICINE STRENGTH]

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

What condition is this medicine prescribed for or what is its primary use?

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

OTHER (SPECIFY)

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) PM16 - AMTNUM
(-9) PM16 - AMTNUM

TABNUM

AMTUNIT

PM16

quantity unit

IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

Page 12 of 16

2023 MCBS Community Questionnaire

NSQ-NO STATEMENT COST SERIES

Variable Name
AMTUNOS

MR Screen Name
PM16

Question Type
text

AMTNUM

PM16

numeric

BOX PM6

routing

Question Text/Description
OTHER (SPECIFY)

Code List
(01) CONTINUOUS ANSWER

Routing
PM16 - AMTNUM

(01) CONTINUOUS ANSWER

BOX PM6

IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN (01) CONTINUOUS ANSWER
A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]

TABTAKE

TABTAKE96

PMSATVA

PMSATHMO

PM13

numeric

IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

PM13

code one

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMSATHMO

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])

PMMORE

PMMORE

yes/no

NUMLINKS

NS42

grid

HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE
BUNDLE?

NSPMMTCH

NS44

code one

ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE SHOWN BELOW?

EVENT_NSPMDEL

NS45

roster

SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE
BUNDLE.

routing

IF TOTAL CHARGE OR COPAY COLLECTED GE 0, DK OR RF, GO TO NS64 - NSTCHGPAID.
ELSE GO TO BOX NS64B.

BOX NS45

[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) ADD ANOTHER
(02) ALL DONE

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) CONTINUOUS ANSWER

PM13 - TABTAKE96

BOX PM7

BOX PM8

PMMORE-PMMORE

(01) BOX PM2
(02) NS42 - NUMLINKS

NS44-NSPMMTCH
(01) BOX NS45
(02) NS41 - EVENT_NSPM
(03) NS45 - EVENT NSPMDEL
NS44 - NSPMMTCH

Page 13 of 16

2023 MCBS Community Questionnaire

Variable Name

NSTCHGPAID

MR Screen Name

NS64

NSQ-NO STATEMENT COST SERIES

Question Type

code one

Question Text/Description
[[Have you/Has (SP)] or any other source [, such as (an insurance plan/TRICARE/TRICARE or an insurance
plan),] already paid any of [the charge/the total charge/the copayment amount/this (TOTAL CHARGE)]?
[IF COPAYMENT AMOUNT IS ZERO, SELECT “NO.”]

BOX NS64A

routing

IF SP OR ANY SOURCE HAS PAID, GO TO BOX NS64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN
PAID), GO TO BOX NS78B.
ELSE GO TO BOX NS80.

BOX NS64B

routing

CREATE SOURCE OF PAYMENT ROSTER
GO TO NS65 - NSADDSOP1.

NSADDSOP1

NS65

yes/no

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

SOP_NS1

NS66

roster

ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS CHARGE BUNDLE.

TSOPAMT

PAYMHE

NS67

grid

Who (else) paid? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.

BOX NS67HE

routing

IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT VALUES FOR THIS COST >
0.00, GO TO BOX NS67A.
ELSE GO TO NS67HE - PAYMHE.

NS67HE

no entry

Code List
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED

THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER
THAN $0.00 OR AT LEAST ONE PAYMENT AMOUNT MUST BE
'DON'T KNOW' OR 'REFUSED'.

Routing

BOX NS64A

(01) NS67 - TSOPAMT
(02) NS66 - SOP_NS1
NS67 - TSOPAMT

BOX NS67HE

NS67HE - PAYMHE

USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND
MAKE CORRECTIONS.

PLANINTRO_NS

BOX NS67A

routing

IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT NS66, GO TO BOX NS67B.
ELSE GO TO BOX NS69F.

BOX NS67B

routing

IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT NS66 IS A HEALTH INSURANCE PLAN, GO TO
NS67BINT - PLANINTRO_NS.
ELSE GO TO BOX NS69E.

NS67BINT

no entry

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

BOX NS67C

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT NS66.
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS CURRENT, GO TO NS68 -NSMHMOCHNG1.
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.
BOX NS67C

routing

ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO NS69A -NSMPDPCHNG.
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.

NSMHMOCHNG1

NS68

yes/no

NSMPDPCHNG

NS69A

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

BOX NS69A

routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) HIMC3-COVTIME
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) HIMPDP-COVTIME
(02) BOX NS69A
(-8) BOX NS69A
(-9) BOX NS69A

IF ANOTHER SOP WAS ADDED AT NS66, GO TO BOX NS67C.
ELSE GO TO BOX NS69E.

Page 14 of 16

2023 MCBS Community Questionnaire

Variable Name

NSQ-NO STATEMENT COST SERIES

MR Screen Name

Question Type

BOX NS69E

routing

BOX NS69F

routing

Question Text/Description
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT NS66, CREATE AN OSOP FOR EACH SOURCE OF
PAYMENT ADDED AT NS66 THAT IS AN "OTHER SOURCE OF PAYMENT" .
GO TO BOX NS69F.

AMTSCORR

NS70

NS71

code one

code one

[REVIEW WITH RESPONDENT.] The total of all payments is $(TOTAL PAYMENTS). The amount
[unpaid/overpaid] is $(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE [TOTAL
CHARGE/COPAYMENT], WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL AMOUNTS
AS ENTERED.
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION,
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID.

ENTERCOM

NS72

no entry

Routing

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C

(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX NS77C
(02) DO NOT DISPLAY.
(03) NS72 - ENTERCOM
(-8) BOX NS77C
(-9) BOX NS77C

IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (AT LEAST ONE PAYMENT ENTERED AT
NS67 = DK OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT NS67 ^= DK AND ^= RF AND ^= 0) AND
(TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT NS67 >= TOTAL CHARGE), GO TO NS71 AMTSCORR.
ELSE IF (TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (ALL PAYMENTS ENTERED AT NS67 ^=
DK AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE TOTAL PAYMENTS
ENTERED AT NS67 AND TOTAL CHARGE IS > $1.00), GO TO NS70 - AMTSCORR.
ELSE GO TO BOX NS77C.
There seems to be [some amount still unpaid/more payments than the charge].

AMTSCORR

Code List

[THE TOTAL OF PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT [UNPAID/OVERPAID] IS
$(DIFFERENCE BETWEEN PAYMENTS AND TOTAL CHARGE).]

BOX NS77C

USE THE BOX BELOW TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
BOX NS77C

routing

CREATE PAYMENTS FOR AMOUNTS ENTERED AT NS67
GO TO BOX NS77D.

BOX NS77D

routing

IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO NS78 EXPPAYBK.
ELSE GO TO BOX NS80.

NS78

yes/no

I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay
[you/(SP)] back any or all of that amount?

BOX NS78A

routing

IF NS78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST
COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND)), GO TO NS80 - EXPAYUNT.
ELSE GO TO BOX NS80.

BOX NS78B

routing

IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS
TO CURRENT ROUND), GO TO NS79 - EXPAYOUT.
ELSE GO TO BOX NS80.

EXPAYOUT

NS79

yes/no

Do you expect anyone to pay any of this amount?

EXPAYUNT

NS80

quantity unit

How much do you expect will be paid?

EXPAYPCT
EXPAYAMT

NS80
NS80

numeric
numeric

BOX NS80

routing

EXPPAYBK

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX NS78A

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PERCENTAGE NS80 - EXPAYPCT
(02) DOLLARS NS80 - EXPAYAMT
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

(01) NS80 - EXPAYUNT
(02) BOX NS80
(-8) BOX NS80
(-9) BOX NS80
(01) NS80 - EXPAYPCT
(02) NS80 - EXPAYAMT
(-8) BOX NS80
(-9) BOX NS80
BOX NS80
BOX NS80

IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO BOX NSL1.
GO TO BOX NSBEG

Page 15 of 16

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name

NSQ-NO STATEMENT COST SERIES

Question Type

Question Text/Description

Code List

Routing

IF (CHARGE DATA WAS COLLECTED IN NS FOR THIS NS CHARGE BUNDLE) AND (NS CHARGE BUNDLE
IS LINKED TO ONLY ONE EVENT) AND (SP OR ANY OTHER SOURCE HAS PAID) AND
((EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (THE TOTAL CHARGE ^=
RF) AND (PM WAS PURCHASED THROUGH AN HMO) AND (THERE ARE OTHER CURRENT ROUND
PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE THAT WERE
PURCHASED THROUGH AN HMO))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM' AND (TOTAL CHARGE ^= RF) AND
(PM WAS NOT PURCHASED THROUGH AN HMO OR HAD AN UNKNOWN PURCHASE LOCATION) AND
(THERE ARE OTHER CURRENT ROUND PRESCRIPTION MEDICINE EVENTS NOT LINKED TO A
CURRENT ROUND CHARGE BUNDLE THAT WERE NOT PURCHASED THROUGH AN HMO OR HAD AN
UNKNOWN PURCHASE LOCATION))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'VU', 'HU', 'ER', 'OP', 'MP', 'SD',
'SL', OR 'HP' AND (THE TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP REFERRED TO
PROVIDER BY HMO FOR THIS EVENT) AND (THERE ARE OTHER CURRENT ROUND EVENTS WITH THE
SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP WAS REFERRED TO THE PROVIDER BY THE
HIMO THAT ARE NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE))
OR
(EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'DU', 'VU', 'HU', 'ER', 'OP', 'MP', 'SD',
'SL', OR 'HP' AND (THE TOTAL CHARGE ^= DK AND TOTAL CHARGE ^= RF) AND (SP WAS NOT
REFERRED TO PROVIDER BY HMO OR REFERRAL IS UNKNOWN FOR THE EVENT) AND (THERE ARE
OTHER CURRENT ROUND EVENTS WITH THE SAME EVENT TYPE FOR THIS PROVIDER WHERE THE SP
WAS NOT REFERRED TO PROVIDER BY HMO OR REFERRAL IS UNKNOWN FOR THE EVENT THAT ARE
NOT LINKED TO A CURRENT ROUND CHARGE BUNDLE)),
), GO TO NSL1 - NSEVSAME.
ELSE GO TO BOX NSBEG.

BOX NSL1

routing

NSL1

code one

(01) YES
(02) NO
Are any other [visits to (PROVIDER NAME)/prescribed medicine purchases] the same -- where the [total charge
(-8) DON'T KNOW
was (TOTAL CHARGE TEXT)/copayment was (TOTAL CHARGE TEXT)] per (visit/purchase) and payments
(-9) REFUSED
were: [READ PAYMENTS LISTED ABOVE]?

BOX NSL2

routing

IF EVENT LINKED TO NS CHARGE BUNDLE HAS EVNT.EVNTTYPE = 'PM', GO TO NSL3 EVENT_PMSAME.
ELSE GO TO NSL5 - EVENT_VISITSAME.

You told me earlier that [you/(SP)] had other [visits to (PROVIDER NAME)/prescribed medicine purchases].
NSEVSAME

NSL3

roster

Which ones are the same?
REVIEW LIST WITH RESPONDENT AND SELECT ALL PRESCRIPTION MEDICINES WHERE THE COSTS
AND PAYMENTS ARE THE SAME.

(01) BOX NSL2
(02) BOX NSBEG
(-8) BOX NSBEG
(-9) BOX NSBEG

(01) CONTINUOUS ANSWER

BOX NSL3

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NSBEG

(01) CONTINUOUS ANSWER

BOX NSL5

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX NSL6

(01) YES
(02) NO
[996] LEAVE COST SERIES

(01) ST5 - ST_CHARGEBUNDLE
(02) BOX NSEND
[996] END

IF NO PRESCRIPTION MEDICINES HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT
SELECTING ANY MEDICINES.

NUMLINKS

BOX NSL3

routing

IF AT LEAST ONE PRESCRIBED MEDICINE SELECTED AT NSL3 HAS NUMBER OF PURCHASES BEING
ASKED ABOUT IN NS > 1, GO TO NSL4 - NUMLINKS.
ELSE GO TO BOX NSBEG.

NSL4

grid

How many times are the same?
ENTER THE NUMBER OF PURCHASES OF EACH MEDICINE SHOWN BELOW THAT ARE THE SAME.

EVENT_VISITSAME NSL5

roster

Which ones are the same?
REVIEW LIST WITH THE RESPONDENT AND SELECT ALL PROVIDER EVENTS WHERE THE COST AND
PAYMENTS ARE THE SAME.
IF NO PROVIDER EVENTS HAD THE SAME COST AND PAYMENTS, PRESS ENTER WITHOUT SELECTING
ANY EVENTS.

RVLINKS

BOX NSL5

routing

IF AT LEAST ONE EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.

NSL6

numeric

How many times are the same for (EVENT)?
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT
MONTH, YEAR) THAT ARE THE SAME.

BOX NSL6

routing

IF ANOTHER EVENT SELECTED AT NSL5 IS A REPEAT VISIT, GO TO NSL6 - RVLINKS.
ELSE GO TO BOX NSBEG.

NS81

yes/no

BOX NSEND

routing

YOU HAVE ENTERED ALL CHARGE/PAYMENT DATA FOR ALL EVENTS REPORTED.
NSTATEMENT

DO YOU HAVE ANY MSN, INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENTS THAT YOU HAVE NOT YET ENTERED?
IF INTTYPE = (C007), GO TO END.
IF INTTYPE = (C001, C004, C005), GO TO CPS.
IF INTTYPE = (C002, C006, C010) AND SEASON=WINTER AND 11TH ROUND INTERVIEW OR
SEASON=SUMMER, GO TO PXQ. ELSE, GO TO END.

Page 16 of 16