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pdf2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) CONTINUE
OM3-OMHRSPCH
OTHER MEDICAL EXPENSES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=ALL
Other: N/A
PLACEMENT
Administer after PMQ.
OMINTRO
OMHRSPCH
OMINTRO
OM3
routing
yes/no
Next I’m going to ask you about other medical expenses that [you/(SP)] may have had [between (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(01) YES
buy, replace, or pay for repairs of an amplifier for a telephone, or similar device to help [you/(SP)] hear or speak?
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[INCLUDE RELATED EXPENSES SUCH AS BATTERIES FOR A HEARING AID OR SPEAKING DEVICE]
(-9) Refused
(01) OM4 - EVENT_OMHRSP
(02) BOX OMA1
(03) DO NOT DISPLAY.
(-8) BOX OMA1
(-9) BOX OMA1
[DO NOT INCLUDE HEARING AID PURCHASES, REPAIRS, OR WARRENTIES AT THIS QUESTION.]
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair a hearing or speech device?
(01) continuous answer
(-8) Don't Know
(-9) Refused
EVENT_OMHRSP
OM4
roster
OMADD
OM4AA
code one
BOX OM1BB
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM4A - OMSATHMO
ELSE GO TO BOX OM1BB2.
OM4A
yes/no
On (EVENT DATE), did [you/(SP)] buy or repair the hearing or speech device at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
(01) YES
BELOW]?
(02) NO
(-8) Don't Know
[PROBE: This could include buying or repairing the hearing or speech device at a plan center; from an
(-9) Refused
audiologist, speech pathologist, or other provider that honors [your/(SP’s)] plan card; or through a place or
service that the plan referred [you/(SP)] to.]
BOX OM1BB2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA1.
BOX OMA1
routing
IF SP WAS STILL RENTING AT LEAST ONE ORTHOPEDIC ITEM AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS5INTR - ORTHINTRO.
ELSE GO TO OM5 - OMPRORTH.
OMS5INTR
no entry
The next questions are about orthopedic items [you were/(SP) was] renting as of (REFERENCE DATE).
OMSATHMO
ORTHINTRO
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE
OF INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
MM:
DD:
YYYY:
OM4AA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM4-EVENT_OMHRSP
(02) BOX OM1BB
(01) continuous answer
(-7) Empty
BOX OM1BB2
OMS5 - RENTSTIL
Page 1 of 15
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) BOX OM4
(-8) BOX OM4
(-9) BOX OM4
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) DO NOT DISPLAY.
(-8) OM9 - OMPRDIAB
(-9) OM9 - OMPRDIAB
(01) OM7 - EVENT_OMORTH
(02) OM7 - EVENT_OMORTH
(03) OM7 - EVENT_OMORTH
(04) OM6A - RENTPROB
(05) OM6A - RENTPROB
(06) OM6A - RENTPROB
(07) OM7 - EVENT_OMORTH
(91) OM6 - EVOSTEXT
OM6A - RENTPROB
At the time of the last interview, [you were/(SP) was] renting (ORTHOPEDIC ITEM). As of (today/DATE OF
DEATH/DATE OF INSTITUTIONALIZATION), (was/were/is/are) the (ORTHOPEDIC ITEM) being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OMS5
code one
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPRORTH
OM5
yes/no
SHOW CARD OM1
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, repair or rent (other) orthopedic
items, such as any of those listed on this card?
[Orthopedic items include crutches, canes, wheelchairs, walkers, corrective shoes or inserts, support stockings,
and braces or supports.]
ORTHTYPE
OM6
code one
What was the item?
(01) BRACES/SUPPORTS
(02) CANE
(03) CORRECTIVE SHOES/INSERTS
(04) CRUTCHES
(05) WALKER
(06) WHEELCHAIR/CART
(07) STOCKINGS
(91) OTHER
EVOSTEXT
OM6
verbatim text
OTHER (SPECIFY)
(01) continuous answer
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
Did [you/(SP)] buy or repair the (ORTHOPEDIC ITEM), or did [you/(SP)] rent (it/them)?
RENTPROB
OM6A
EVENT_OMORTH
OM7
OMADD
OM7AAA
BOX OM1CC
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
routing
(01) OM7 - EVENT_OMORTH
(02) OM7A - EVENT_OMORTHRENT
(03) DO NOT DISPLAY.
(-8) OM7 - EVENT_OMORTH
(-9) OM7 - EVENT_OMORTH
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE
OM7AAA-OMADD
(01) OM7-EVENT_OMORTH
(02) BOX OM1CC
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM7AA - OMSATHMO
ELSE GO TO BOX OM1EE1.
Page 2 of 15
2023 MCBS Community Questionnaire
Variable Name
OMSATHMO
MR Screen Name
OM7AA
OMQ-OTHER MEDICAL EXPENSES
Question Type
yes/no
Question Text/Description
On (EVENT DATE), did [you/(SP)] buy (or repair) the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[PROBE: This could include buying or repairing the (ORTHOPEDIC ITEM) at a plan center; at a place or store
that honors [your/(SP's)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
EVENT_OMORTHRE
OM7A
NT
yes/no
ENTER ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) AND (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (ORTHOPEDIC ITEM).
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
OM8- MOREORTH
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM7B - RENTSTIL
[Are you/Is (SP)/Was (SP)] still renting the (ORTHOPEDIC ITEM)?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM7B
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
(01) BOX OM1EE
(02) OM7C - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1EE1
(-9) BOX OM1EE1
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDMM
OM7C
date
EVENDDD
OM7C
date
(01) continuous answer
(-8) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(-9) Refused
RENTAL PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
RENTAL PERIOD.]
What was the last date the (ORTHOPEDIC ITEM) (were/was) rented?
EVENDYY
OM7C
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
RENTAL PERIOD.]
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM7C - EVENDDD
OM7C - EVENDYY
DD:
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM3A
YYYY:
BOX OM3A
routing
IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM7CC - RENT2BUY.
ELSE GO TO BOX OM1EE.
RENT2BUY
OM7CC
code one
You said [you/(SP)] stopped renting the (ORTHOPEDIC ITEM). Is this because [you/(SP)] no longer (have/has)
that item or because it was purchased through a rent-to-buy option?
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused
REN2BVB
OM7CCVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (ORTHOPEDIC ITEM).
RECORD VERBATIM.
(01) continuous answer
(01) BOX OM1EE
(02) BOX OM1EE
(03) OM7CCVB - REN2BVB
(-8) BOX OM1EE
(-9) BOX OM1EE
BOX OM1EE
OM7CC-OMADD
Page 3 of 15
2023 MCBS Community Questionnaire
OMQ-OTHER MEDICAL EXPENSES
Variable Name
MR Screen Name
Question Type
OMADD
OM7CC1
code one
BOX OM1EE
routing
OM7D
yes/no
BOX OM1EE1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM4.
BOX OM4
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS5 - RENTSTIL
ELSE GO TO OM8 - MOREORTH.
OM8
yes/no
In addition to the orthopedic item(s) you just told me about, did [you/(SP)] buy, repair, or rent any other
orthopedic items [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].?
OMSATHMO
MOREORTH
OMPRDIAB
OM9
yes/no
Question Text/Description
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
Code List
Routing
(01) ADD ANOTHER
(02) ALL DONE
(01) OM7A-EVENT_OMORTHRENT
(02) BOX OM1EE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1EE1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) OM6 - ORTHTYPE
(02) OM9 - OMPRDIAB
(03) OM9 - OMPRDIAB
(04) OM9 - OMPRDIAB
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM7D - OMSATHMO.
ELSE GO TO BOX OM1EE1.
Did [you/(SP)] rent the (ORTHOPEDIC ITEM) at [READ MANAGED CARE PLAN NAME(S) BELOW] or through
a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
[PROBE: This could include renting the (ORTHOPEDIC ITEM) at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP]] to.]
SHOW CARD OM2
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(01) YES
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(02) NO
buy diabetic equipment or supplies, such as those listed on this card?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Diabetic equipment or supplies include syringes, test paper, test strips, and blood monitoring kits.]
(-9) Refused
(01) OM10 - EVENT_OMDIAB
(02) OM11 - OMPRAMBL
(03) DO NOT DISPLAY.
(-8) OM11 - OMPRAMBL
(-9) OM11 - OMPRAMBL
[DO NOT INCLUDE INSULIN.]
EVENT_OMDIAB
OM10
roster
OMADD
OM10AA
code one
BOX OM1FF
routing
(01) continuous answer
(-8) Don't Know
SELECT OR ADD ALL DATES AT THIS ROSTER.
(-9) Refused
When did [you/(SP)] buy diabetic equipment or supplies? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE)
MM:
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) ADD ANOTHER
(02) ALL DONE
OM10AA-OMADD
(01) OM10-EVENT_OMDIAB
(02) BOX OM1FF
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM10A-OMSATHMO
ELSE GO TO BOX OM1FF2.
Page 4 of 15
2023 MCBS Community Questionnaire
Variable Name
OMSATHMO
MR Screen Name
OM10A
OMQ-OTHER MEDICAL EXPENSES
Question Type
yes/no
Question Text/Description
On (EVENT DATE), did [you/(SP)] buy the diabetic equipment or supplies at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[PROBE: This could include buying the diabetic equipment or supplies at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
BOX OM1FF2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM11 - OMPRAMBL.
Code List
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
OMPRAMBL
OM11
yes/no
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY (02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(03) INDICATED YES BY DATAPREP
use any ambulance or rescue squad service?
(-8) Don't Know
(-9) Refused
EVENT_OMAMBL
OM12
roster
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] use an ambulance? Please tell me all the dates [since (REFERENCE DATE/SURVEY
REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
OMADD
OM12AA
code one
BOX OM1GG
routing
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
Routing
BOX OM1FF2
(01) OM12 - EVENT_OMAMBL
(02) OM13 - OMPRPROS
(03) DO NOT DISPLAY.
(-8) OM13 - OMPRPROS
(-9) OM13 - OMPRPROS
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM12AA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM12-EVENT_OMAMBL
(02) BOX OM1GG
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM12A - OMSATHMO
Was the ambulance on (EVENT DATE) provided by or approved by [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO
OMPRPROS
(01) YES
(02) NO
[PROBE: This could mean that the ambulance was sent by the plan, or that [you/(SP)] or someone for [you/(SP)] (-8) Don't Know
contacted the plan for them to authorize or approve the use of the ambulance. This approval could have come (-9) Refused
after the use of the ambulance.]
OM12A
yes/no
BOX OM1GG2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM13 - OMPRPROS.
yes/no
SHOW CARD OM3
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(03) INDICATED YES BY DATAPREP
buy or pay for repairs of any prostheses, such as those on the card?
(-8) Don't Know
(-9) Refused
[Prostheses include artificial leg or arm, mastectomy prosthesis, and artificial or glass eye.]
OM13
BOX OM1GG2
(01) OM14 - EVENT_OMPROS
(02) BOX OMA4
(03) DO NOT DISPLAY.
(-8) BOX OMA4
(-9) BOX OMA4
Page 5 of 15
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
(01) continuous answer
(-8) Don't Know
SELECT OR ADD ALL DATES AT THIS ROSTER.
(-9) Refused
When did [you/(SP)] buy or repair the prosthesis? Please tell me all the dates [since (REFERENCE
DATE/SURVEY REFERENCE DATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)
MM:
and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
DD:
YYYY:
EVENT_OMPROS
OM14
roster
OMADD
OM14AA
code one
BOX OM1HH
routing
OM14A
yes/no
BOX OM1HH2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OMA4.
BOX OMA4
routing
IF SP WAS STILL RENTING OXYGEN-RELATED EQUIPMENT AT THE TIME OF THE PREVIOUS ROUND
INTERVIEW, GO TO OMS19INTR - OXGNINTRO.
ELSE GO TO OM19 - OMPROXGN.
OMS19INTR
no entry
The next questions are about oxygen-related equipment [you were/(SP) was] renting as of (REFERENCE
DATE).
OMSATHMO
OXGNINTRO
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
OMS19
code one
Routing
OM14AA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM14-EVENT_OMPROS
(02) BOX OM1HH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1HH2
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM14A-OMSATHMO
ELSE GO TO BOX OM1HH2.
On (EVENT DATE), did [you/(SP)] buy or repair the prosthesis at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
[PROBE: This could include buying or repairing the prosthesis at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
At the time of the last interview, [you were/(SP) was] renting oxygen-related equipment. As of [today/(DATE OF
DEATH)/(DATE OF INSTITUTIONALIZATION)/(ENDUTILD)] (is/was) the oxygen-related equipment being
rented?
RENTSTIL
Code List
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
OMS19 - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM9
(-8) BOX OM9
(-9) BOX OM9
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPROXGN
OM19
yes/no
(Other than what we already talked about,) [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any (other) expenses for oxygen
or supplies or oxygen-related equipment?
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM19A - OXGNTYPE
(02) BOX OMA11
(03) DO NOT DISPLAY.
(-8) BOX OMA11
(-9) BOX OMA11
OXGNTYPE
OM19A
code one
What was that?
(01) OXYGEN/SUPPLIES
(02) OXYGEN-RELATED EQUIPMENT
(01) OM20 - EVENT_OMOXGN
(02) OM19B - RENTPROB
Page 6 of 15
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did (you/(SP)] purchase the [(oxygen or supplies)/(oxygen-related equipment)]? Please tell me the dates
of each purchase [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
Did [you/(SP)] buy or repair the oxygen-related equipment, or did [you/(SP)] rent it?
RENTPROB
OM19B
EVENT_OMOXGN
OM20
roster
OMADD
OM20AAA
code one
BOX OM1II
routing
OMSATHMO
OM20AA
yes/no
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
EVENT_OMOXGNRE
OM20A
NT
routing
roster
(01) OM20 - EVENT_OMOXGN
(02) OM20A - EVENT_OMOXGNRENT
(03) OM20 - EVENT_OMOXGN
(-8) OM20 - EVENT_OMOXGN
(-9) OM20 - EVENT_OMOXGN
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM20AAA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM20-EVENT_OMOXGN
(02) BOX OM1II
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM7
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM20B - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1KK
(02) OM20C - EVENDMM
(03) BOX OM1KK1
(-8) BOX OM1KK1
(-9) BOX OM1KK1
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM20AA - OMSATHMO
ELSE GO TO BOX OM7.
On (EVENT DATE), did [you/(SP)] buy or repair the (OXYGEN ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[PROBE: This could include buying or repairing the (OXYGEN ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
BOX OM7
Routing
IF OM19B - RENTPROB = 3/BoughtAndRented, GO TO OM20A - EVENT_OMOXGNRENT.
ELSE GO TO BOX OM1KK1.
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the oxygen-related equipment.
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
[Are you/Is (SP)/Was (SP)] still renting the oxygen-related equipment?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM20B
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date the equipment was rented?
EVENDMM
OM20C
date
(01) continuous answer
(02) Don't Know
(03) Refused
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
MM:
RENTAL PERIOD.]
DD:
YYYY:
OM20C - EVENDDD
Page 7 of 15
2023 MCBS Community Questionnaire
OMQ-OTHER MEDICAL EXPENSES
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
EVENDDD
OM20C
date
EVENDYY
OM20C
date
(01) continuous answer
(02) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(03) Refused
RENTAL PERIOD.]
BOX OM8A
routing
IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM20CC - RENT2BUY.
ELSE GO TO BOX OM1KK.
RENT2BUY
OM20CC
code one
You said [you/(SP)] stopped renting the oxygen-related equipment. Is this because [you/(SP)] no longer
(have/has) the equipment or because it was purchased through a rent-to-buy option?
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused
REN2BVB
OM20CCVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE OXYGEN-RELATED EQUIPMENT.
RECORD VERBATIM.
(01) continuous answer
OMADD
OM20CC1
code one
BOX OM1KK
routing
OM20D1
yes/no
BOX OM1KK1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM9.
BOX OM9
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS19_IN - NAVIGATOR.
ELSE GO TO BOX OM10.
BOX OM10
routing
IF OM20D HAS NOT BEEN ASKED, GO TO OM20D - MOREOXGN.
ELSE GO TO BOX OMA11.
OM20D
yes/no
In addition to the [(oxygen or supplies)/(oxygen-related equipment)] that you just told me about, did [you/(SP)]
[(buy oxygen or supplies)/(have any expenses for oxygen-related equipment)]?
BOX OM11
routing
IF OM19A - OXYGTYPE = 1/Supplies, SET NEXT OXYGEN TYPE TO EQUIPMENT AND GO TO OM19B RENTPROB.
ELSE SET NEXT OXYGEN TYPE TO SUPPLIES AND GO TO OM20 - EVENT_OMOXGN.
Routing
What was the last date the equipment was rented?
(01) continuous answer
(02) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(03) Refused
RENTAL PERIOD.]
OM20C - EVENDYY
What was the last date the equipment was rented?
OMSATHMO
MOREOXGN
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
BOX OM8A
(01) BOX OM1KK
(02) BOX OM1KK
(03) OM20CCVB - REN2BVB
(04) BOX OM1KK
(05) BOX OM1KK
OM20CC1-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM20A-EVENT_OMOXGNRENT
(02) BOX OM1KK
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1KK1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX OM11
(02) BOX OMA11
(-8) BOX OMA11
(-9) BOX OMA11
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM20D1 - OMSATHMO.
ELSE GO TO BOX OM1KK1.
Did [you/(SP)] rent the oxygen equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or through a
service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
[PROBE: This could include renting the oxygen equipment at a plan center; at a place or store that honors
[your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
Page 8 of 15
2023 MCBS Community Questionnaire
Variable Name
KDNYINTRO
OMQ-OTHER MEDICAL EXPENSES
MR Screen Name
Question Type
Question Text/Description
BOXOMA11
routing
IF SP WAS RENTING AT LEAST ONE KIDNEY DIALYSIS EQUIPMENT AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS21INTR - KDNYINTRO.
ELSE GO TO OM21 - OMPRKDNY.
OMS21INTR
no entry
The next questions are about kidney dialysis equipment [you were/(SP) was] renting as of (REFERENCE
DATE).
Code List
Routing
OMS21 - RENTSTIL
At the time of the last interview, [you were/(SP) was] renting equipment for kidney dialysis. As of (today/DATE
OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD)], (is/was) the equipment being rented?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OMS21
code one
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1NN
(02) OM22C - EVENDMM
(03) BOX OM16
(-8) BOX OM16
(-9) BOX OM16
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPRKDNY
OM21
yes/no
(01) YES
(Other than what we already talked about), [(Since/since) (REFERENCE DATE/SURVEY REFERENCE
(02) NO
DATE/UTILDATE)/(Between/between) (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF
(03) INDICATED YES BY DATAPREP
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy any (other) kidney dialysis supplies
(-8) Don't Know
or buy, rent, or repair any related equipment?
(-9) Refused
KDNYTYPE
OM21A
code one
What was that?
(01) KIDNEY DIALYSIS SUPPLIES
(02) KIDNEY DIALYSIS EQUIPMENT
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] (purchase the kidney dialysis supplies)/(buy or repair kidney dialysis equipment)? Please
tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
Did [you/(SP)] buy or repair the dialysis equipment, or did [you/(SP)] rent it?
RENTPROB
OM21B
EVENT_OMKDNY
OM22
roster
OMADD
OM22AAA
code one
BOX OM1LL
routing
OMSATHMO
OM22AA
yes/no
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) OM21A - KDNYTYPE
(02) BOX OMA18
(03) DO NOT DISPLAY.
(-8) BOX OMA18
(-9) BOX OMA18
(01) OM22 - EVENT_OMKDNY
(02) OM21B - RENTPROB
(01) OM22 - EVENT_OMKDNY
(02) OM22A - EVENT_OMKDNYRENT
(03) DO NOT DISPLAY.
(-8) OM22 - EVENT_OMKDNY
(-9) OM22 - EVENT_OMKDNY
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM22AAA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM22-EVENT_OMKDNY
(02) BOX OM1LL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1NN1
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM22AA - OMSATHMO
ELSE GO TO BOX OM1NN1.
On (EVENT DATE), did [you/(SP)] buy (or repair) the (KIDNEY ITEM) at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
[PROBE: This could include buying (or repairing) the (KIDNEY ITEM) at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
Page 9 of 15
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
EVENT_OMKDNYRE
OM22A
NT
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
roster
SELECT OR ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the kidney dialysis equipment.
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
Code List
Routing
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM22B - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1NN
(02) OM22C - EVENDYY
(03) DO NOT DISPLAY.
(-8) BOX OM1NN1
(-9) BOX OM1NN1
[Are you/Is (SP)/Was (SP)] still renting the kidney dialysis equipment?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM22B
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date the equipment was rented?
(01) continuous answer
(-8) Don't Know
(-9) Refused
EVENDMM
OM22C
date
EVENDDD
OM22C
date
EVENDYY
OM22C
date
(01) continuous answer
(-8) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(-9) Refused
RENTAL PERIOD.]
BOX OM15A
routing
IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM22CC - RENT2BUY.
ELSE GO TO BOX OM1NN.
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
MM:
RENTAL PERIOD.]
DD:
YYYY:
OM22C - EVENDDD
What was the last date the equipment was rented?
(01) continuous answer
(-8) Don't Know
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
(-9) Refused
RENTAL PERIOD.]
OM22C - EVENDYY
What was the last date the equipment was rented?
RENT2BUY
OM22CC
code one
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
You said [you/(SP)] stopped renting the dialysis equipment. Is this because [you/(SP)] no longer (have/has) the
(91) OTHER
equipment or because it was purchased through a rent-to-buy option?
(-8) Don't Know
(-9) Refused
REN2BVB
OM22CCVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE DIALYSIS EQUIPMENT.
RECORD VERBATIM.
OMADD
OM22CC1
code one
BOX OM1NN
routing
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) continuous answer
(01) ADD ANOTHER
(02) ALL DONE
BOX OM15A
(01) BOX OM1NN
(02) BOX OM1NN
(03) OM22CCVB - REN2BVB
(-8) BOX OM1NN
(-9) BOX OM1NN
BOX OM1NN
OM22CC1-OMADD
(01) OM22A-EVENT_OMKDNYRENT
(02) BOX OM1NN
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM22D1 - OMSATHMO.
ELSE GO TO BOX OM1NN1.
Page 10 of 15
2023 MCBS Community Questionnaire
OMQ-OTHER MEDICAL EXPENSES
Variable Name
MR Screen Name
Question Type
OMSATHMO
OM22D1
yes/no
BOX OM1NN1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM16.
BOX OM16
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS21 - RENTSTIL
ELSE GO TO BOX OM17.
BOX OM17
routing
IF OM22D HAS NOT BEEN ASKED, GO TO OM22D - MOREKDNY.
ELSE GO TO BOX OMA18.
OM22D
yes/no
In addition to the [(kidney dialysis supplies)/(kidney dialysis equipment)] that you just told me about, did
[you/(SP)] [(obtain any kidney dialysis equipment)/(buy any kidney dialysis supplies)]?
BOX OM18
routing
IF OM21A - KDNYTYPE = 1/Supplies, SET NEXT KIDNEY TYPE TO EQUIPMENT AND GO TO OM21B RENTPROB.
ELSE SET NEXT KIDNEY TYPE TO SUPPLIES AND GO TO OM22 - EVENT_OMKDNY.
BOX OMA18
routing
IF SP WAS STILL RENTING AT LEAST ONE OTHER MEDICAL EQUIPMENT AT THE TIME OF THE
PREVIOUS ROUND INTERVIEW, GO TO OMS23INTR - OTHRINTRO.
ELSE GO TO OM23 - OMPROTHR.
OMS23INTR
no entry
The next questions are about other medical equipment [you were/(SP) was] renting as of (REFERENCE
DATE).
MOREKDNY
OTHRINTRO
Question Text/Description
Did [you/(SP)] rent the kidney dialysis equipment at [READ MANAGED CARE PLAN NAME(S) BELOW] or
through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
[PROBE: This could include renting the kidney dialysis equipment at a plan center; at a place or store that
honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
At the time of the last interview, [you were/(SP) was] renting (OTHER MEDICAL EXPENSE ITEM). As of
(today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION)/(ENDUTILD), (is/was) the (OTHER MEDICAL
EXPENSE ITEM) being rented?
RENTSTIL
OMS23
code one
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1NN1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX OM18
(02) BOX OMA18
(-8) BOX OMA18
(-9) BOX OMA18
OMS23 - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) BOX OM23
(-8) BOX OM23
(-9) BOX OM23
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
OMPROTHR
OM23
yes/no
SHOW CARD OM4
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
(01) YES
buy, rent, or repair any other medical equipment or buy any other medical supplies besides what we have talked
(02) NO
about?
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
[Other medical equipment and supplies include portable commodes or raised toilet seats, portable tub seats,
(-9) Refused
special chairs or cushions, hospital beds, ostomy supplies, incontenence supplies such as Depends, Serenity or
other brands of disposable undergarments, pads or briefs, bandages, dressings, tape supplies, pulmonary
equipment such as a Nebulizer or CPAP, and blood pressure equipment such as cuffs or monitors, etc.]
(01) OM24 - OTHRTYPE
(02) BOX OM24
(03) DO NOT DISPLAY.
(04) BOX OM24
(05) BOX OM24
Page 11 of 15
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
Code List
Routing
(01) OM24A - RENTPROB
(02) OM24A - RENTPROB
(03) OM24A - RENTPROB
(04) OM24A - RENTPROB
(05) BOX OM18B
(06) BOX OM18B
(07) BOX OM18B
(08) OM24A - RENTPROB
(09) OM26 - EVENT_OMOTHR
(91) OM24 - EVOSTEXT
OM24A - RENTPROB
OTHRTYPE
OM24
code one
What kind of equipment was the item?
(01) PORTABLE COMMODE OR RAISED TOILET
SEAT
(02) PORTABLE TUB SEAT
(03) SPECIAL CHAIR/CUSHION/MATTRESS
(04) HOSPITAL BED/BED SIDES
(05) OSTOMY SUPPLIES
(06) INCONTINENCE SUPPLIES (I.E. DEPENDS,
SERENITY DISPOSABLE DIAPERS OR PADS)
(07) BANDAGES, DRESSINGS, TAPE SUPPLIES
(08) PULMONARY EQUIPMENT
(09) BLOOD PRESSURE EQUIPMENT
(91) OTHER
EVOSTEXT
OM24
verbatim text
OTHER (SPECIFY)
(01) continuous answer
OM24A
code one
(01) BUY/REPAIR
(02) RENT
(03) BOUGHT/REPAIRED EQUIPMENT AND RENTED
[IF THE RESPONDENT RENTED AND BOUGHT THE ITEM THROUGH A RENT-TO-BUY PROGRAM WITHIN EQUIPMENT
THE SAME ROUND, SELECT "RENT."]
(-8) Don't Know
(-9) Refused
BOX OM18B
routing
IF NOT ADMINISTERING ST AND NOT ADMINISTERING NS, GO TO OM25 - GETNUM.
ELSE GO TO BOX OM1QQ1.
numeric
THIS ITEM AND NUMBER OF PURCHASES HAS BEEN ENTERED ALREADY FOR THIS ROUND. PLEASE
CORRECT THE NUMBER OF TIMES TO BE THE TOTAL NUMBER OF TIMES PURCHASED SINCE
(REFERENCE DATE/UTILDATE).
How many times [since (REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)] [[have you/has (SP)] bought or obtained/did (SP) buy
or obtain] (OTHER MEDICAL EXPENSE ITEM)?
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM)? Please tell me all the dates [since
(REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
Did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM), or did [you/(SP)] rent it?
RENTPROB
GETNUM
OM25
EVENT_OMOTHR
OM26
roster
OMADD
OM26AAA
code one
BOX OM1OO
routing
OMSATHMO
OM26AA
yes/no
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) OM26 - EVENT_OMOTHR
(02) OM26A - EVENT_OMOTHRRENT
(03) DO NOT DISPLAY.
(-8) OM26 - EVENT_OMOTHR
(-9) OM26 - EVENT_OMOTHR
BOX OM1QQ1
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
OM27AAA-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) OM26-EVENT_OMOTHR
(02) BOX OM1OO
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM21
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM26AA - OMSATHMO
ELSE GO TO BOX OM1QQ1.
On (EVENT DATE), did [you/(SP)] buy or repair the (OTHER MEDICAL EXPENSE ITEM) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
PLAN NAME(S) BELOW]?
[PROBE: This could include buying or repairing the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a
place or store that honors [your/(SP’s)] plan card; or through a place or store that the plan referred [you/(SP)] to.]
Page 12 of 15
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name
EVENT_OMOTHRRE
OM26A
NT
OMQ-OTHER MEDICAL EXPENSES
Question Type
Question Text/Description
roster
ADD ONLY ONE DATE AT THIS ROSTER.
Please tell me the first date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] that [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM).
[FOR EACH RENTAL THAT OCCURS ON A MONTHLY BASIS, ENTER ONLY ONE EVENT. DO NOT ENTER
A SEPARATE RENTAL EVENT FOR EACH MONTH.]
Code List
Routing
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM26A1 - RENTSTIL
(01) YES
(02) NO
(03) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) BOX OM1QQ
(02) OM26B - EVENDMM
(03) DO NOT DISPLAY.
(-8) BOX OM1QQ1
(-9) BOX OM1QQ1
(01) continuous answer
(-8) Don't Know
(-9) Refused
OM26B - EVENDDD
[Are you/Is (SP)] still renting the (OTHER MEDICAL EXPENSE ITEM)?
[IF THE RESPONDENT PURCHASED THE ITEM THROUGH A RENT-TO-BUY PROGRAM, SELECT "NO."]
RENTSTIL
OM26A1
yes/no
[IF THE ITEM IS STILL BEING RENTED AS OF THE DATE OF THE CURRENT INTERVIEW SELECT "YES"
AT THIS SCREEN.]
[FOR RECURRING RENTALS, SUCH AS MONTHLY RENTALS, SECLET "YES" AT THIS QUESTION IF THE
ITEM IS STILL BEING RENTED. DO NOT ENTER A NEW EVENT FOR EACH MONTH.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDMM
OM26B
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
RENTAL PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDDD
OM26B
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
RENTAL PERIOD.]
What was the last date [you/(SP)] rented the (OTHER MEDICAL EXPENSE ITEM)?
EVENDYY
OM26B
date
[IF RESPONDENT BOUGHT THE RENTAL, ENTER THE DATE OF PURCHASE AS THE LAST DATE OF THE
RENTAL PERIOD.]
MM:
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
routing
IF SP IS NOT DECEASED (SPAISTATUS = 1 OR 2), GO TO OM26BB - RENT2BUY.
ELSE GO TO BOX OM1QQ.
RENT2BUY
OM26BB
code one
You said [you/(SP)] stopped renting the (OTHER MEDICAL EXPENSE ITEM). Is this because [you/(SP)] no
longer (have/has) the item or because it was purchased through a rent-to-buy option?
(01) NO LONGER HAVE THE ITEM
(02) PURCHASED THROUGH RENT-TO-BUY
(91) OTHER
(-8) Don't Know
(-9) Refused
REN2BVB
OM26BBVB
verbatim text
BRIEFLY EXPLAIN WHY SP STOPPED RENTING THE (OTHER MEDICAL EXPENSE ITEM).
RECORD VERBATIM.
(01) continuous answer
OMADD
OM26BB1
code one
BOX OM1QQ
routing
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
BOX OM22A
YYYY:
BOX OM22A
HAVE ALL DATES BEEN ENTERED?
OM26B - EVENDYY
DD:
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX OM1QQ
(02) BOX OM1QQ
(03) OM26BBVB - REN2BVB
(-8) BOX OM1QQ
(-9) BOX OM1QQ
BOX OM1QQ
OM26BB1-OMADD
(01) OM26A-EVENT_OMOTHRRENT
(02) BOX OM1QQ
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO OM26C - OMSATHMO.
ELSE GO TO BOX OM1QQ1.
Page 13 of 15
2023 MCBS Community Questionnaire
OMQ-OTHER MEDICAL EXPENSES
Variable Name
MR Screen Name
Question Type
OMSATHMO
OM26C
yes/no
BOX OM1QQ1
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX OM23.
BOX OM23
routing
IF ASKING ABOUT A RENTAL ITEM FROM THE PREVIOUS ROUND, GO TO OMS23 - RENTSTIL
ELSE GO TO OM27 - MOREOTHR.
OM27
yes/no
(01) YES
In addition to the medical equipment you just told me about, did [you/(SP)] buy, rent, or repair any other medical
(02) NO
equipment [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
(-9) Refused
BOX OM24
routing
IF SP HAD AT LEAST ONE ALTERATION THAT WAS NOT COMPLETE AT THE TIME OF THE PREVIOUS
ROUND INTERVIEW, GO TO OMS28INTR - ALTRINTRO.
ELSE GO TO OM28 - OMPRALTR.
OMS28INTR
no entry
The next questions are about an alteration [you were/(SP) was] making as of (REFERENCE DATE).
MOREOTHR
ALTRINTRO
Question Text/Description
Did [you/(SP)] rent the (OTHER MEDICAL EXPENSE ITEM) at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
[PROBE: This could include renting the (OTHER MEDICAL EXPENSE ITEM) at a plan center; at a place or
store that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDMM
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDDD
OMS28
date
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
Last time [you/(SP)] had started to make an alteration (ALTERATION) that was not completed as of
(REFERENCE DATE/SURVEY REFERENCE DATE).
EVENDYY
OMS28
date
OMNOTDONE
OMS28
code one
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE)/between (REFERENCE
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/(ENDUTILD)] was this alteration completed?
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1QQ1
(01) OM24 - OTHRTYPE
(02) BOX OM24
(-8) BOX OM24
(-9) BOX OM24
OMS28 - EVENDMM
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
OMS28 - EVENDDD
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
OMS28 -EVENDYY
(01) continuous answer
(-7) Empty
(-8) Don't Know
(-9) Refused
OMS28 - OMNOTDONE
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
OM28 - OMPRALTR
Page 14 of 15
2023 MCBS Community Questionnaire
Variable Name
OMPRALTR
MR Screen Name
OM28
OMQ-OTHER MEDICAL EXPENSES
Question Type
yes/no
Question Text/Description
SHOW CARD OM5
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)]
make any alterations or modify the inside or outside of (your/his/her) home or car because of some illness or
injury? This card lists some examples.
[Alterations include ramps, handrails, elevator or incline chair, tub seats, tub handrails, and any car alterations.]
Code List
Routing
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM29 - ALTRTYPE
(02) BOX OM26
(03) DO NOT DISPLAY.
(-8) BOX OM26
(-9) BOX OM26
(01) OM30 - EVENDMM
(02) OM30 - EVENDMM
(03) OM30 - EVENDMM
(04) OM30 - EVENDMM
(05) OM30 - EVENDMM
(06) OM30 - EVENDMM
(91) OM29 - EVOSTEXT
OM30 - EVENDMM
ALTRTYPE
OM29
code one
What was the alteration?
(01) ELEVATOR OR INCLINE CHAIR
(02) HANDRAILS (OTHER THAN TUB)
(03) RAMPS
(04) TUB HANDRAILS
(05) TUB SEAT
(06) ANY CAR ALTERATION
(91) OTHER
EVOSTEXT
OM29
verbatim text
OTHER (SPECIFY)
(01) continuous answer
EVENDMM
OM30
date
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
(-9) Refused
was this alteration completed?
OM30 - EVENDDD
MM:
EVENDDD
OM30
date
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
(-9) Refused
was this alteration completed?
OM30 - EVENDDD
DD:
EVENDYY
OM30
date
(01) continuous answer
(-7) Empty
On what date [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]
(-9) Refused
was this alteration completed?
OM30 - OMNOTDONE
YYYY:
OMNOTDONE
OM30
OMADD
OM30B
MOREALTR
(01) ALTERATION NOT YET COMPLETED
(-7) Empty
code one
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) ADD ANOTHER
(02) ALL DONE
BOX OM25A
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM31 - MOREALTR.
OM31
yes/no
(01) YES
In addition to the alteration(s) you just told me about, did [you/(SP)] make any other alterations because of some
(02) NO
illness or injury [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between (REFERENCE
(-8) Don't Know
DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
(-9) Refused
BOX OM26
routing
GO TO STQ.
OM30B-OMADD
(01) OM30-EVBEGMM
(02) BOX OM25A
(01) OM29 - ALTRTYPE
(02) BOX OM26
(-8) BOX OM26
(-9) BOX OM26
Page 15 of 15
| File Type | application/pdf |
| File Title | Medicare Current Beneficiary Survey Section Specifications for OMQ |
| Subject | Medicare beneficiaries, MCBS community questionnaire, 2023, Other medical expenses utilization, OMQ |
| Author | NORC |
| File Modified | 2023-09-01 |
| File Created | 2023-08-18 |