CMS-P-0015A Expenditures

Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

Fac2024_Expenditures_EX

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

OMB: 0938-0568

Document [pdf]
Download: pdf | pdf
2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EXS2

EXPENDITURES SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF
SEASON= ALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX EXS1

routing

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

BOX EXS1A

routing

IF FIRST/NEXT PRELOAD BPER HAS PreloadBPRO.ANCLPOST = 0/No, DK or PreloadBPRO.ANYANCIL = DK,
GO TO EX15PRES1 - EX15PRCT.
ELSE GO TO EX20S1PRE - BASSMINT.
The next questions are about health-related services received by (SP) for which there was a separate charge, that
is, your (facility/home)'s ancillary services.

EX15PRCT

EX15PRES1

code one

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

BOX EXS2

routing

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

ANCLPOST

EX16S1

yes/no

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

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

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

ANYANCIL

EX17S1

yes/no

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

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

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

ANCILAMT

EX18S1

dollar

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

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

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

BASSMINT

EX20S1PRE

code one

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

(01) Continue

(01) BOX EX7BS1

BOX EX7BS1

routing

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

RECDBASP

EX20S1

yes/no

Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING
PERIOD ABOVE] billing period?

(00) NO
(01) YES

(00) BOX EX14S1
(01) EX21AAS1 - ADDSOP1

ADDSOP1

EX21AAS1

yes/no

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

(00) NO
(01) YES

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

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

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

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

EX21ABS1

code one

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

HMOOS1

EX21ABS1

verbatim

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACS1 - BASRATE

SOPOS1

EX21ABS1

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACS1 - BASRATE

Page 1 of 16

2024 MCBS Facility Instrument

Variable Name
BASRATE

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

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

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

(01) [Continuous answer.]

(01) BOX EX8S1

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

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

(01) [Continuous answer.]

(01) BOX EX9S1

(01) Continue

(01) BOX EX9AAS1

(01) Continue

(01) BOX EX10S1

(01) Continue

(01) BOX EX11S1

EX21ACS1

Grid

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

BOX EX7CS1

routing

IF MEDICARE IS IDENTIFIED AS A SOURCE OF PAYMENT FOR BASIC CARE AND THERE IS NO STAY IN A
HOSPITAL BETWEEN (BP START DATE - 60 DAYS) AND (BP END DATE + 60 DAYS) AND THIS WAS NOT
EXPLAINED THIS ROUND, GO TO EX21BS1 - VEXPTXTB.
ELSE GO TO BOX EX8S1.
Medicare has been reported as a payment source for basic care for (SP) for [READ BILLING PERIOD ABOVE], but
I have not recorded any preceding hospital stays for (him/her).

VEXPTXTB

EX21BS1

verbatim

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

BOX EX8S1

routing

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND (BASICPAY
<= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >= BASICAMT*0.7) AND
(BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX22S1 - BAS10PCT
WAS ASKED THIS BP ROUND AND (BASICPAY >= BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)), GO
TO BOX EX9S1.
ELSE GO TO EX22S1 - BAS10PCT.
There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP END DATE)
and the payments received. The total amount billed I have entered for this billing period is (TOTAL AMOUNT
BILLED FOR THIS BILLING PERIOD) and the total payments for the period are (SUM OF EX21 PAYMENTS).
Why is that?

BAS10PCT

EX22S1

code one

BAS10POS

EX22S1

verbatim

OTHER (SPECIFY)

BOX EX9S1

routing

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

PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

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

EX23A1S1

code one

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

BOX EX9AAS1

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED AND
FACILITY HAS NEVER CONFIRMED), GO TO EX23A2S1 - EX23A2S1C.
ELSE GO TO BOX EX10S1.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.

EX23A2S1C

EX23A2S1

code one

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

BOX EX10S1

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX24AS1 - EX24AS1C.
ELSE GO TO BOX EX11S1.
Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a source of payment.

EX24AS1C

EX24AS1

code one

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

BOX EX11S1

routing

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

Page 2 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EX12S1

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

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

(01) [Continuous answer.]

(01) BOX EX14S1

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

EX25S1

code one

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

CAREPRTB

BOX EX12S1

routing

EX26S1

yes/no

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING PERIOD,
GO TO EX26S1 - CAREPRTB.
ELSE GO TO BOX EX14S1.
Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is
this Medicare payment a Part B payment?
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

VBPETXTE

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

EX27S1

verbatim

BOX EX14S1

routing

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

RECDANCP

EX28S1

yes/no

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

(00) NO
(01) YES

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

ADDSOP2

EX29AAS1

yes/no

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

(00) NO
(01) YES

(00) EX29ACS1 - ANCRATE
(01) EX29ABS1 - PAYMPLN2
(01) EX29ACS1 - ANCRATE
(02) EX29ACS1 - ANCRATE
(03) EX29ACS1 - ANCRATE
(04) EX29ACS1 - ANCRATE
(05) EX29ACS1 - ANCRATE
(06) EX29ACS1 - ANCRATE
(07) EX29ACS1 - ANCRATE
(08) EX29ACS1 - ANCRATE
(09) EX29ABS1 - HMOOS2
(10) EX29ACS1 - ANCRATE
(91) EX29ABS1 - SOPOS2
(-8) EX29ACS1 - ANCRATE
(-9) EX29ACS1 - ANCRATE

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

PAYMPLN2

EX29ABS1

code all

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING PERIOD ABOVE]?
(05) PRIVATE INSURANCE
(06) PENSION
SELECT ALL THAT APPLY.
(07) MEDICARE
SEPARATE RESPONSES BY USING THE SPACEBAR.
(08) VA CONTRACT
(09) HMO CONTRACT
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

HMOOS2

EX29ABS1

verbatim

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACS1 - ANCRATE

SOPOS2

EX29ABS1

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACS1 - ANCRATE

ANCRATE

EX29ACS1

Grid

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

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

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

routing

IF BPER.ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= BPER.ANCILAMT*0.9) AND
(BPER.ANCILPAY <= BPER.ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND
(BPER.ANCILPAY >= BPER.ANCILAMT*0.7) AND (BPER.ANCILPAY <= BPER.ANCILAMT*1.1)) OR (A WRITEOFF WAS PREVIOUSLY REPORTED AND EX30S1 - ANC10PCT WAS ASKED THIS BP ROUND AND
(BPER.ANCILPAY >= BPER.ANCILAMT*0.7) AND (BPER.ANCILPAY <= BPER.ANCILAMT*1.1)), GO TO BOX
EX16S1.
ELSE GO TO EX30S1 - ANC10PCT.
(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

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

(01) [Continuous answer.]

(01) BOX EX16S1

BOX EX15S1

ANC10PCT

EX30S1

code one

ANC10POS

EX30S1

verbatim

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

Page 3 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX16S1

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

routing

Code List

Routing

(01) Continue

(01) BOX EX16AAS1

(01) Continue

(01) BOX EX17S1

(01) Continue

(01) BOX EX18S1

(01) Continue

(01) EX33BS1 - EXSBKCT

(01) Continue

(01) BOX EX20S1

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

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

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

Can you explain this to me?
RECORD VERBATIM BELOW.

(01) [Continuous answer.]

(01) BOX EX21AS1

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

EX31A1S1

code one

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

EX31A2S1C

BOX EX16AAS1

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED AND
FACILITY HAS NEVER CONFIRMED), GO TO EX31A2S1 - EX31A2S1C.
ELSE GO TO BOX EX17S1.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.

EX31A2S1C

EX31A2S1

code one

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

BOX EX17S1

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX32AS1 - EX32AS1C.
ELSE GO TO BOX EX18S1.
Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source of payment.

EX32AS1C

EX32AS1

code one

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

BOX EX18S1

routing

IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR
ANCILLARIES FOR THE CURRENT BILLING PERIOD BUT APPEARS IN THE PRECEDING PERIOD, GO TO
EX33S1 - EX33S1C.
ELSE GO TO EX33BS1 - EXSBKCT.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care. Earlier, I
recorded that (his/her) charges for ancillaries in a previous billing period were paid by Medicaid, and in this billing
period, Medicaid is no longer a payment source.

EX33S1C

EX33S1

code one

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

EXSBKCT

EX33BS1

code one

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

BOX EX20S1

routing

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

BOX EX21S1

routing

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

EX34S1

VEXPTXTG

EX35S1

verbatim

Page 4 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX21AS1

routing

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

EX35AS1

code one

(01) STILL PENDING
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] (02) DENIED
eligibility status was pending. Is it still pending or has [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] been (03) APPROVED
denied or approved?
(-8) Don't Know
(-9) Refused

BOX EXSEND

routing

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

BOX EXBEG

routing

GO TO EX1PRE - EX1PRECT.

Code List

Routing

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

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

EX1PRE

code one

[The first few questions are about billing and sources of payment when (he/she) first became a resident here on
(FAD/RAD).]
PRESS "1" TO CONTINUE.
The following questions are about (SP)'s basic care between (EX REFERENCE START DATE) and (EX
REFERENCE END DATE).

ANYBASIC

EX2

yes/no

EX2ANAME

EX2A

roster

VEXPTXTA

EX3

verbatim

Was there a charge for (her/his) room and board and basic care between (EX REFERENCE START DATE) and
(EX REFERENCE END DATE)? Please include any charges to (SP), (her/his) family, or a third party, such as
Medicaid, Medicare, or a legal guardian.
Please tell me the name of someone in (FACILITY) who could give me that information.
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
Why were there no charges?
IF ANSWER IS "MEDICAID PAID", BACK UP TO EX2 AND ENTER "1".

(01) Continue

(01) EX2 - ANYBASIC

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

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

(01) [Continuous answer.]

(01) EXEND - EXENDCNT

(01) [Continuous answer.]

(01) EXEND - EXENDCNT

RECORD VERBATIM.
BOX EX1A

ANCILSEP

EX4

routing

yes/no

GO TO EX4 - ANCILSEP.
Between (EX REFERENCE START DATE) and (EX REFERENCE END DATE), was (SP) billed separately for
health-related ancillary services? (That is, were there charges for ancillary services that were not included in the
basic rate?)

(00) NO
(01) YES

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

PRESS F1 FOR DEFINITION OF ANCILLARY SERVICES.
Through what date do you have complete billing records for the services provided to (SP)?

COMRECMM

EX5

date

(01) [Continuous answer.]

(01) EX5 - COMRECDD

COMRECDD

EX5

date

COMRECYY

EX5

date

DAY

(01) [Continuous answer.]

(01) EX5 - COMRECYY

YEAR

(01) [Continuous answer.]

(01) BOX EX2AA

BOX EX2AA

routing

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

BPLENCUR

EX6

code one

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

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

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

BPLNCROS

EX6
BOX EX2AA1

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX EX2AA1

routing

GO TO BOX EX2A.

BOX EX2A

routing

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

MONTH

Page 5 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) FEX2 - BILLINFO

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

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

(01) [Continuous answer.]

(01) EX8 - BPENDDATE

(01) [Continuous answer.]

(01) BOX EX3A2

(01) [Continuous answer.]

(01) BOX EX3

(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
(03) SP DECEASED
(04) SP ADMITTED AFTER BP START DATE
(05) SP DISCHARGED TO ANOTHER NH
(91) OTHER
(-8) Don't Know
(-9) Refused

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

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

EX7PCNT

EX7PRE

code one

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

BILLINFO

BPBEGDATE

FEX2

code one

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

BOX EX3A

routing

GO TO EX8 - BPBEGDATE.

EX8

Date

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

BPENDDATE

BILLDAYS

EX8

Date

BP END DATE[: (BILLENDDATE)]

BOX EX3A2

routing

GO TO EX9 - BILLDAYS.

EX9

Numeric

BOX EX3

routing

EX10CODE

EX10

Code one

EX10OS

EX10

Code one

Between (BP START DATE) and (BP END DATE), how many days was (SP) billed for care?
PRESS F1 FOR HELP ENTERING FLAT-RATE BILLING.
IF EX9 - BILLDAYS = 0, GO TO EX33B - EXABKCT.
ELSE IF (RHDAYS = DK) OR (EX9 - BILLDAYS = RHDAYS AND (BPDAYS = EX9 - BILLDAYS OR (RHDAYS <
BPDAYS))), GO TO EX11 - BRATRATE.
ELSE IF BPDAYS = RHDAYS AND RHDAYS > EX9 - BILLDAYS, GO TO EX10 - EX10CODE.
ELSE IF (BPDAYS > EX9 - BILLDAYS AND EX9 - BILLDAYS > RHDAYS) OR (BPDAYS > RHDAYS AND
RHDAYS > EX9 - BILLDAYS) OR (BPDAYS = EX9 - BILLDAYS AND EX9 - BILLDAYS > RHDAYS), GO TO EX10A
- EX10ACOD.
ELSE GO TO EX10 - EX10CODE.

Can you tell me why I have a discrepancy between the number of days in this billing period, that is, (DAYS IN
BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS BILLED)?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

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

EX10ACOD

EX10A

code all

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

EX10AOS

EX10A

verbatim

OTHER (SPECIFY)

BOX EX3B

routing

GO TO EX11 - BRATRATE
Between (BP START DATE) and (BP END DATE), what rates were billed for (SP)'s care? (I'll ask about billing for
ancillary services later.)

BRATRATE

EX11

Quantity Unit

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

(01) [Continuous answer.]

(01) BOX EX3B

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

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

(01) [Continuous answer.]

(01) BOX EX3B

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

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

What is the amount?

Page 6 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

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

BRATUNIT

EX11

Quantity Unit

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

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

BRATUNOS

EX11

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX11 - BRATDAYS

BRATDAYS

EX11

Numeric

How many days were billed at that rate?

(01) [Continuous answer.]

(01) BOX EX4

BOX EX4

routing

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

BOX EX5

routing

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

(01) Continue

(01) EX16 - ANCLPOST

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

EX15PRE

code one

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

ANCLPOST

EX16

yes/no

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

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

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

ANYANCIL

EX17

yes/no

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

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

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

ANCILAMT

EX18

dollar

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

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

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

BOX EX7B

routing

GO TO EX20 - RECDBASP

RECDBASP

EX20

yes/no

Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING
PERIOD ABOVE] billing period?

(00) NO
(01) YES

(00) BOX EX14
(01) EX21AA - ADDSOP1

ADDSOP1

EX21AA

yes/no

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

(00) NO
(01) YES

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

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

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

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

EX21AB

code all

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

HMOOS1

EX21AB

verbatim

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX21AC - BASRATE

SOPOS1

EX21AB

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX21AC - BASRATE

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

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

BASRATE

EX21AC

Grid

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

BOX EX7C

routing

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

Page 7 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) [Continuous answer.]

(01) BOX EX8

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

EX21B

Verbatim Text

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

BOX EX8

routing

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

BAS10PCT

EX22

code one

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

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

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

BAS10POS

EX22

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX EX9

routing

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

(01) Continue

(01) BOX EX9AA

(01) Continue

(01) BOX EX10

(01) Continue

(01) BOX EX11

BOX EX9

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

EX23A1

code one

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

BOX EX9AA

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED AND
FACILITY HAS NEVER CONFIRMED), GO TO EX23A2 - EX23A2C.
ELSE GO TO BOX EX10.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.

EX23A2C

EX23A2

code one

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

BOX EX10

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX24A - EX24AC.
ELSE GO TO BOX EX11.
Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a source of payment.

EX24AC

EX24A

code one

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

BOX EX11

routing

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

Page 8 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EX12

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

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

(01) [Continuous answer.]

(01) BOX EX14

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

EX25

code

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

CAREPRTB

BOX EX12

routing

EX26

yes/no

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING PERIOD,
GO TO EX26 - CAREPRTB.
ELSE GO TO BOX EX14.
Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is
this Medicare payment a Part B payment?
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

VBPETXTE

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

EX27

Verbatim Text

BOX EX14

routing

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

RECDANCP

EX28

yes/no

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

(00) NO
(01) YES

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

ADDSOP2

EX29AA

yes/no

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

(00) NO
(01) YES

(00) EX29AC - ANCRATE
(01) EX29AB - PAYMPLN2
(01) EX29AC - ANCRATE
(02) EX29AC - ANCRATE
(03) EX29AC - ANCRATE
(04) EX29AC - ANCRATE
(05) EX29AC - ANCRATE
(06) EX29AC - ANCRATE
(07) EX29AC - ANCRATE
(08) EX29AC - ANCRATE
(09) EX29AB - HMOOS2
(10) EX29AC - ANCRATE
(91) EX29AB - SOPOS2
(-8) EX29AC - ANCRATE
(-9) EX29AC - ANCRATE

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

PAYMPLN2

EX29AB

code all

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING PERIOD ABOVE]?
(05) PRIVATE INSURANCE
(06) PENSION
SELECT ALL THAT APPLY.
(07) MEDICARE
SEPARATE RESPONSES BY USING THE SPACEBAR.
(08) VA CONTRACT
(09) HMO CONTRACT
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

HMOOS2

EX29AB

Verbatim Text

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX29AC - ANCRATE

SOPOS2

EX29AB

Verbatim Text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX29AC - ANCRATE

Grid

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

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

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

routing

IF EX18 - ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= EX18 - ANCILAMT*0.9)
AND (BPER.ANCILPAY <= EX18 - ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND
(BPER.ANCILPAY >= EX18 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18 - ANCILAMT*1.1)) OR (A WRITEOFF WAS PREVIOUSLY REPORTED AND EX30 - ANC10PCT WAS ASKED THIS BP ROUND AND
(BPER.ANCILPAY >= EX18 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18 - ANCILAMT*1.1)), GO TO BOX
EX16.
ELSE GO TO EX30 - ANC10PCT.
(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

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

ANCRATE

EX29AC

BOX EX15

ANC10PCT

EX30

code one

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

Page 9 of 16

2024 MCBS Facility Instrument

EX-Expenditures

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

ANC10POS

EX30

verbatim text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX EX16

BOX EX16

routing

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

(01) Continue

(01) BOX EX16AA

(01) Continue

(01) BOX EX17

(01) Continue

(01) BOX EX18

(01) Continue

(01) EX33B - EXABKCT

(01) Continue

(01) BOX EX20

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

EX31A1

code one

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

BOX EX16AA

routing

IF (MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICARE CERTIFED AND
FACILITY HAS NEVER CONFIRMED), GO TO EX31A2 - EX31A2C.
ELSE GO TO BOX EX 17.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicare but I have identified Medicare as a payment source.

EX31A2C

EX31A2

code one

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

BOX EX17

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX32A - EX32AC.
ELSE GO TO BOX EX18.
Earlier, I recorded that (SP) was not a Medicaid recipient but I have identified Medicaid as a source of payment.

EX32AC

EX32A

code one

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

BOX EX18

routing

IF MEDICAID IS NOT IDENTIFIED AS PAYMENT SOURCE FOR ANCILLARIES FOR THE CURRENT BILLING
PERIOD BUT APPEARS IN THE PRECEDING PERIOD (INCLUDING IF THE BILLING PERIOD OCCURRED IN
THE PREVIOUS ROUND), GO TO EX33 - EX33C.
ELSE GO TO EX33B - EXABKCT.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care. Earlier, I
recorded that (his/her) charges for ancillaries in a previous billing period were paid by Medicaid, and in this billing
period, Medicaid is no longer a payment source.

EX33C

EX33

code one

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

EXABKCT

EX33B

code one

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

BOX EX20

routing

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

BOX EX21

routing

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

Page 10 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

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

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

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

(01) [Continuous answer.]

(01) BOX EX21A

USENOLTC

EX34

yes/no

VEXPTXTG

EX35

verbatim text

BOX EX21A

routing

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

EX35A

code one

(01) STILL PENDING
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] (02) DENIED
eligibility status was pending. Is it still pending or has [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] been (03) APPROVED
denied or approved?
(-8) Don't Know
(-9) Refused

BOX EX3AB2

routing

GO TO EX8B2 - BPBEGDATE.

BPBEGDATE

EX8B2

Date

BPENDDATE

EX8B2

Date

BOX EX3A2B2

routing

EX9B2

Numeric

Can you explain this to me?

ECAIDECO

BILLDAYS

BOX EX3B2

routing

EX10CODE

EX10B2

code all

EX10OS

EX10B2

Verbatim Text

RECORD VERBATIM BELOW.

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

EX10AB2

code all

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

(01) EX8B2 - BPENDDATE

(01) [Continuous answer.]

(01) BOX EX3A2B2

(01) [Continuous answer.]

(01) BOX EX3B2

(01) SP DISCHARGED TO COMMUNITY
(02) SP SENT TO HOSPITAL
(03) SP DECEASED
(04) SP ADMITTED AFTER BP START DATE
(05) SP DISCHARGED TO ANOTHER NH
(91) OTHER
(-8) Don't Know
(-9) Refused

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

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

Can you tell me why I have a discrepancy between the number of days in this billing period, that is, (DAYS IN
BILLING PERIOD) and the number of days for which (SP) was billed, that is, (DAYS BILLED)?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.

OTHER (SPECIFY)

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

EX10AOS

(01) [Continuous answer.]

GO TO EX9B2 - BILLDAYS.

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

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

EX10AB2

Verbatim Text

OTHER (SPECIFY)

BOX EX3BB2

routing

GO TO EX11B2 - BRATRATE.

(01) [Continuous answer.]

(01) BOX EX3BB2

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

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

(01) [Continuous answer.]

(01) BOX EX3BB2

Page 11 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

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

BRATRATE

EX11B2

Quantity Unit

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

Code List

Routing

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

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

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

What is the amount?

BRATUNIT

EX11B2

Quantity Unit

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

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

BRATUNOS

EX11B2

Quantity Unit

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX11B2 - BRATDAYS

BRATDAYS

EX11B2

Quantity Unit

How many days were billed at that rate?

(01) [Continuous answer.]

(01) BOX EX4B2

BOX EX4B2

routing

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

BOX EX5B2

routing

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

(01) Continue

(01) EX16B2 - ANCLPOST

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

EX15PREB2

code one

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

ANCLPOST

EX16B2

yes/no

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

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

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

ANYANCIL

EX17B2

Yes/No

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

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

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

ANCILAMT

EX18B2

dollar

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

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

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

BOX EX6B2

routing

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

BOX EX6BB2

routing

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

BOX EX7BB2

routing

GO TO EX20B2 - RECDBASP.

RECDBASP

EX20B2

yes/no

Have you received all of the payments for basic care you expect to receive for (SP) during the [READ BILLING
PERIOD ABOVE] billing period?

(00) NO
(01) YES

(00) BOX EX14B2
(01) EX21AAB2 - ADDSOP1

ADDSOP1

EX21AAB2

yes/no

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

(00) NO
(01) YES

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

Page 12 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

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

EX21ABB2

code all

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

Code List

Routing

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

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

HMOOS1

EX21ABB2

Verbatim Text

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACB2 - BASRATE

SOPOS1

EX21ABB2

Verbatim Text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX21ACB2 - BASRATE

BASRATE

EX21ACB2

Grid

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

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

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

BOX EX7CB2

routing

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

(01) [Continuous answer.]

(01) BOX EX8B2

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

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

(01) [Continuous answer.]

(01) BOX EX9B2

(01) Continue

(01) BOX EX9AAB2

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

EX21BB2

Verbatim Text

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

BOX EX8B2

BAS10PCT

EX22B2

routing

code one

IF BPER.BASICAMT = DK, RF OR BPER.BASICPAY = DK OR ((BASICPAY >= BASICAMT*0.9) AND (BASICPAY
<= BASICAMT*1.1)) OR (MEDICAID IS A SOURCE OF PAYMENT AND (BASICPAY >= BASICAMT*0.7) AND
(BASICPAY <= BASICAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX22B2 - BAS10PCT
WAS ASKED THIS ROUND AND (BASICPAY >= BASICAMT*0.7) AND (BASICPAY <= BASICAMT*1.1)), GO TO
BOX EX9B2.
ELSE GO TO EX22B2 - BAS10PCT.
There seems to be a difference between what (FACILITY) billed between (BP START DATE) and (BP END DATE)
and the payments received. The total amount billed I have entered for this billing period is (TOTAL AMOUNT
BILLED FOR THIS BILLING PERIOD) and the total payments for the period are (SUM OF EX21 PAYMENTS).
Why is that?
PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BAS10POS

EX22B2

BOX EX9B2

verbatim text

OTHER (SPECIFY)

routing

IF (MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE AND FACILITY IS NOT MEDICAID CERTIFIED AND
FACILITY HAS NEVER CONFIRMED), GO TO EX23A1B2 - EX23A1B2C.
ELSE GO TO BOX EX9AAB2.
I seem to have recorded some discrepant information. Earlier, I recorded that (FACILITY) is not certified by
Medicaid but I have identified Medicaid as a payment source.

EX23A1B2C

EX23A1B2

code one

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

Page 13 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

BOX EX9AAB2

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

routing

Code List

Routing

(01) Continue

(01) BOX 10B2

(01) Continue

(01) BOX EX11B2

(01) Continue

(01) BOX EX12B2

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

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

(01) [Continuous answer.]

(01) BOX EX14B2

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

EX23A2B2

code one

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

BOX EX10B2

routing

IF THIS IS THE FIRST TIME MEDICAID IS IDENTIFIED AS A PAYMENT SOURCE FOR AN SP WHOSE
MEDICAID STATUS IN THIS ROUND IS "NO" GO TO EX24AB2 - EX24AB2C.
ELSE GO TO BOX EX11B2.
Earlier, I recorded that (SP) was not a Medicaid recipient, but I have identified Medicaid as a source of payment.

EX24AB2C

EX24AB2

code one

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

BOX EX11B2

routing

IF MEDICAID IS NOT IDENTIFIED AS A PAYMENT SOURCE FOR THE CURRENT BILLING PERIOD BUT
APPEARS IN THE PRECEDING BILLING PERIOD, GO TO EX25B2 - EX25B2C.
ELSE GO TO BOX EX12B2.
It seems that I might have made a mistake in identifying the various sources of payment for (SP)'s care. Earlier, I
recorded that (his/her) basic charges from a previous billing period were paid by Medicaid, and in this billing period,
Medicaid is no longer a payment source.

EX25B2C

EX25B2

code one

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

CAREPRTB

BOX EX12B2

routing

EX26B2

yes/no

IF MEDICARE IS IDENTIFIED AS A PAYMENT SOURCE AND THE AMOUNT PAID BY MEDICARE
REPRESENTS LESS THAN 10 PERCENT OF THE TOTAL PAYMENTS RECEIVED FOR THE BILLING PERIOD,
GO TO EX26B2 - CAREPRTB.
ELSE GO TO BOX EX14B2.
Medicare's payment for this billing period represents less than 10 percent of the total payments for basic care. Is
this Medicare payment a Part B payment?
IF NECESSARY, BACK UP TO CORRECT PAYMENTS.

EX27B2

Verbatim Text

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

BOX EX14B2

routing

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

RECDANCP

EX28B2

yes/no

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

(00) NO
(01) YES

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

ADDSOP2

EX29AAB2

yes/no

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

(00) NO
(01) YES

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

VBPETXTE

Page 14 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

PAYMPLN2

EX29ABB2

code all

(01) MEDICAID
(02) PRIVATE PAY OR SP/FAMILY INCOME
(03) SOCIAL SECURITY
(04) SP/FAMILY INCOME
What Source(s) of Payment do you need to add for (SP)'s ancillary services for [READ BILLING PERIOD ABOVE]?
(05) PRIVATE INSURANCE
(06) PENSION
SELECT ALL THAT APPLY.
(07) MEDICARE
SEPARATE RESPONSES BY USING THE SPACEBAR.
(08) VA CONTRACT
(09) HMO CONTRACT
IF NO RESPONSES ARE AVAILABLE, BACK UP AND CORRECT YOUR RESPONSE.
(10) SUPPLEMENTAL SECURITY INCOME (SSI)
(91) OTHER
(-8) Don't Know
(-9) Refused

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

HMOOS2

EX29ABB2

Verbatim Text

HMO CONTRACT (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACB2 - ANCRATE

SOPOS2

EX29ABB2

Verbatim Text

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) EX29ACB2 - ANCRATE

ANCRATE

EX29ACB2

Grid

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

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

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

routing

IF EX18B2 - .ANCILAMT = DK, RF OR BPER.ANCILPAY = DK OR ((BPER.ANCILPAY >= EX18B2 ANCILAMT*0.9) AND (BPER.ANCILPAY <= EX18B2 - ANCILAMT*1.1)) OR (MEDICAID IS A SOURCE OF
PAYMENT AND (BPER.ANCILPAY >= EX18B2 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18B2 ANCILAMT*1.1)) OR (A WRITE-OFF WAS PREVIOUSLY REPORTED AND EX30B2 - ANC10PCT WAS ASKED
THIS BP ROUND AND (BPER.ANCILPAY >= EX18B2 - ANCILAMT*0.7) AND (BPER.ANCILPAY <= EX18B2 ANCILAMT*1.1)), GO TO BOX EX16B2.
ELSE GO TO EX30B2 - ANC10PCT.
(01) MEDICAID WRITE-OFF/ADJUSTMENT
(02) OTHER WRITE-OFF/ADJUSTMENT
(91) OTHER
(-8) Don't Know
(-9) Refused

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

(01) [Continuous answer.]

(01) BOX EX16B2

(01) Continue

(01) BOX EX16AAB2

(01) Continue

(01) BOX EX17B2

BOX EX15B2

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

ANC10PCT

EX30B2

code one

ANC10POS

EX30B2

Verbatim Text

OTHER (SPECIFY)

routing

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

PRESS F1 FOR DEFINITION OF "MEDICAID WRITE-OFF".

BOX EX16B2

Code List

Routing

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

EX31A1B2

code one

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

BOX EX16AAB2

routing

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

EX31A2B2C

EX31A2B2

code one

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

BOX EX17B2

routing

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

Page 15 of 16

2024 MCBS Facility Instrument

Variable Name

EX-Expenditures

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX EX18B2

(01) Continue

(01) EX33BB2 - EXBBKCT

(01) Continue

(01) BOX EX20B2

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

EX32AB2

code one

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

BOX EX18B2

routing

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

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

EX33B2

code one

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

EXBBKCT

THIS IS THE LAST SCREEN FOR THIS BILLING PERIOD .

EX33BB2

code one

BOX EX20B2

routing

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

BOX EX21B2

routing

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

USENOLTC

EX34B2

yes/no

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

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

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

VEXPTXTG

EX35B2

Verbatim Text

Can you explain this to me?
RECORD VERBATIM BELOW.

(01) [Continuous answer.]

(01) BOX EX21AB2

BOX EX21AB2

routing

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

ECAIDECO

EX35AB2

code one

(01) STILL PENDING
The last time I was here, I collected information that (SP)'s [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] (02) DENIED
eligibility status was pending. Is it still pending or has [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] been (03) APPROVED
denied or approved?
(-8) Don't Know
(-9) Refused

EXENDCNT

EXEND

code one

PRESS "1" TO CONTINUE.

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

(01) Continue

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

(01) BOX EXEND

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

routing

GO TO NAVIGATOR

Page 16 of 16


File Typeapplication/pdf
File TitleMedicare Current Beneficiary Survey Section Specifications for EX
SubjectMedicare beneficiaries, MCBS facility instrument, 2024, Expenditures, EX
AuthorNORC
File Modified2024-02-19
File Created2024-02-16

© 2024 OMB.report | Privacy Policy