Crosswalk

MCBS Community Additions

MCBS Revision to Current Clearance
Proposed Changes to Community Interviews and Effect on Burden

Community Interview Additions

Addition: Immunization Prevalence,
Location, and Cost-Sharing

Section

IMQ:
Winter Round

Effect on
Annual
Burden

Question Text

Shingles is an illness that results in a rash or blisters on the skin and is usually painful. There
are two vaccines that have been used to prevent shingles. The first was Zostavax®, which was
available in the U.S. from 2006 through 2020 and required one shot. The other is Shingrix®,
Increase of which has been available since 2017 and requires two shots.
2.0 minutes
[Have you/Has (SP)] ever had a vaccine for Shingles?

Response Options

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

IF THE RESPONDENT HAD ONE DOSE OF A SHINGLES VACCINE, SELECT YES.

Did [you/(SP)] get [you/their] Shingles vaccine since January 1, 2023?

Shingles is an illness that results in a rash or blisters on the skin and is usually painful. There
are two vaccines that have been used to prevent shingles. The first was Zostavax®, which was
available in the U.S. from 2006 through 2020 and required one shot. The other is Shingrix®,
which has been available since 2017 and requires two shots.
Since (LAST IM MONTH YEAR), [have you/has (SP)] had a vaccine for Shingles?

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

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

IF THE RESPONDENT HAD ONE DOSE OF A SHINGLES VACCINE, SELECT YES.

Where did [you/(SP)] go for [your/(SP)'s] Shingles vaccine?

(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED

Did [you/(SP)] pay some or all of the cost of the Shingles vaccine?

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

For what reason didn't [you/(SP)] get a Shingles vaccine?
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL REASON
FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND A
PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(-8) DON'T KNOW
(-9) REFUSED

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Response Options

[Have you/Has (SP)] EVER had a pneumonia shot?
This shot is usually given only once or twice in a person's lifetime and is different from the flu
shot. It is also called the pneumococcal vaccine. There are two types of pneumonia shots:
polysaccharide, also known as Pneumovax®23, and conjugate, also known as Prevnar®20 or
Vaxneuvance®.

Did [you/(SP)] get [your/their] pneumonia vaccine since January 1, 2023?

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

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

Since (LAST IM MONTH YEAR), [have you/has (SP)] EVER had a pneumonia shot?
This shot is usually given only once or twice in a person's lifetime and is different from the flu
shot. It is also called the pneumococcal vaccine. There are two types of pneumonia shots:
polysaccharide, also known as Pneumovax®23, and conjugate, also known as Prevnar®20 or
Vaxneuvance®.

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

Where did [you/(SP)] go for [your/(SP)'s] pneumonia shot?

(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED

Did [you/(SP)] pay some or all of the cost of the pneumonia shot?

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

For what reason didn't [you/(SP)] get a pneumonia shot?
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

Respiratory syncytial (sin-SISH-uhl) virus, or RSV, is a common respiratory virus that usually
causes mild, cold-like symptoms. Adults aged 60 years and older may receive a single dose of
RSV vaccine.
[Have you/Has (SP)] EVER had a vaccine for RSV?

(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL REASON
FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND A
PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(-8) DON'T KNOW
(-9) REFUSED

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

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Did [you/(SP)] get [your/their] RSV vaccine since January 1, 2023?

Respiratory syncytial (sin-SISH-uhl) virus, or RSV, is a common respiratory virus that usually
causes mild, cold-like symptoms. Adults aged 60 years and older may receive a single dose of
RSV vaccine.
Since (LAST IM MONTH YEAR), [have you/has (SP)] had a vaccine for RSV?

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

Where did [you/(SP)] go for [your/(SP)'s] RSV vaccine?

Did [you/(SP)] pay some or all of the cost of the RSV vaccine?

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

[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

KNQ:
Winter Round

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

(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED

For what reason didn't [you/(SP)] get an RSV vaccine?

Addition: Beneficiary Knowledge of IRA
Provisions

Response Options

Increase of As far as you know, is there a federal law in place that …Requires the federal government to
0.80 minutes negotiate the price of some prescription drugs for people with Medicare

(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL REASON
FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND A
PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(-8) DON'T KNOW
(-9) REFUSED

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

Places an annual limit on out-of-pocket prescription drug costs for people with Medicare

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

Caps the cost of each insulin product for people with Medicare at $35 per month

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

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Removes out-of-pocket costs for recommended vaccines covered under Medicare Part D
[IF NEEDED: Vaccines covered under Medicare Part D protect against Shingles, Respiratory
Syncytial Virus (RSV), Hepatitis A, Hepatitis B, Measles, Mumps, and Rubella (MMR), and
others, including vaccines recommended for international travel.]

Response Options

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

(01) YES
Allows Medicare Part D enrollees to spread their out-of-pocket prescription drug costs out over (02) NO
the year
(-8) Don't Know
(-9) Refused

Redesign of Income and Assets
Collection: Additions by Topic Area

Financial Investments

IAQ:
Summer Round

Net increase
of 4.0
minutes for
all IAQ
updates

[Do you/Does (SP)] [or (SP FIRSTNAME LASTNAME)/(SPOUSE FIRSTNAME
(01) YES
LASTNAME)] own any other financial investments? Examples include a business, a farm, real
(02) NO
estate [other than [your/(SP)’s] home, motorcycles, boats, and RV's?
(-8) DON'T KNOW
(-9) REFUSED
DO NOT INCLUDE BURIAL PLOTS.

You told me earlier that [you/(SP)] and [(SP FIRSTNAME LASTNAME)/(SPOUSE
FIRSTNAME LASTNAME)] have other financial investments, such as a business, a farm, real
estate [other than [your/(SP)’s] home], motorcycles, boats, and RV's. If these investments were
sold today and any debts on them were paid off, in total, about how much would they bring?
IF NEEDED: We don’t need an exact dollar amount.

(01) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

IF NEEDED: We know questions like these may be difficult to answer, but we need to know
this to understand how people manage financially as they age and what effect this might have on
their health.

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], in total, how
much income did [you/(SP)] and [(SP FIRSTNAME LASTNAME)/(SPOUSE FIRSTNAME
LASTNAME)] receive from these other investments before any federal or state taxes were taken
out?
IF NEEDED: We don’t need an exact dollar amount.
IF NEEDED: We know questions like these may be difficult to answer, but we need to know
this to understand how people manage financially as they age and what effect this might have on
their health.

(01) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

IF NO INCOME WAS RECEIVED FROM THESE OTHER INVESTMENTS, ENTER 0.

Over the past year, would you say that [your/[SP]'s] (family's) spending exceeded [your/[SP]'s]
(family's) income, that it was about the same as [your/[SP]'s] income, or that [you/[SP]] spent
less than [your/[SP]'s] income?
Financial Liquidity

[IF NEEDED: Spending should not include any investments [you have/(SP) has] made.)
IF DEBTS ARE BEING REPAID ON NET, TREAT THIS AS SPENDING
LESS THAN INCOME.

(01) SPENDING EXCEEDED INCOME
(02) SPENDING SAME AS INCOME
(03) SPENDING WAS LESS THAN INCOME
(-8) DON’T KNOW
(-9) REFUSED

The next few questions will now ask about any debt [you/(SP)] [or (SP FIRSTNAME
LASTNAME)/(SPOUSE FIRSTNAME LASTNAME)] may have.

Medical Debt and Credit Card Debt

Please think about any money [you/(SP)] currently owe or debt you have due to medical or
dental bills. This may include bills for your own medical or dental care or someone else’s care,
such as a child, spouse, or parent.
[Do you/Does (SP)] currently have...
Any medical or dental bills [you are/(SP) is] paying off over time directly to a provider?

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

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Any medical or dental bills [you have/(SP) has] put on a credit card, and [you are/(SP) is]
paying off over time?
Please include consumer and medical credit cards.

Response Options

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

(01) YES
Any debt [you owe/(SP) owes] to a bank, collection agency, or other lender that includes debt or (02) NO
loans used to pay medical or dental bills?
(-8) DON'T KNOW
(-9) REFUSED

Any debt [you owe/(SP) owes] to a family member or friend for money [you/(SP)] borrowed to
pay medical or dental bills?

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

Any other medical or dental bills that [you are/(SP) is] unable to pay?

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

(01) [continuous response]
You mentioned that [you have/(SP) has] medical or dental bills [you are/(SP) is] paying off over
(-8) DON’T KNOW
time directly to a provider. About how much [do you/does (SP)] currently owe?
(-9) REFUSED

SHOW CARD IA23
Please look at this card and tell me which is closest.

You mentioned that [you have/(SP) has] medical or dental bills [you have/(SP) has] put on a
credit card, and [you are/(SP) is] paying off over time. About how much [do you/does (SP)]
currently owe?

(01) LESS THAN $500
(02) $500 TO LESS THAN $2,500
(03) $2,500 TO LESS THAN $5,000
(04) $5,000 TO LESS THAN $25,000
(05) $25,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

(01) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

Please include any interest and fees accrued in the total balance.

SHOW CARD IA23
Please look at this card and tell me which is closest.

(01) LESS THAN $500
(02) $500 TO LESS THAN $2,500
(03) $2,500 TO LESS THAN $5,000
(04) $5,000 TO LESS THAN $25,000
(05) $25,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

You mentioned that [you have/(SP) has] debt [you owe/(SP) owes] to a bank, collection agency,
or other lender that includes debt or loans used to pay medical or dental bills. About how much (01) [continuous response]
[do you/does (SP)] currently owe?
(-8) DON’T KNOW
(-9) REFUSED
Please do not include any debt held on a credit card.

SHOW CARD IA23
Please look at this card and tell me which is closest.

(01) LESS THAN $500
(02) $500 TO LESS THAN $2,500
(03) $2,500 TO LESS THAN $5,000
(04) $5,000 TO LESS THAN $25,000
(05) $25,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

You mentioned that [you have/(SP) has] debt [you owe/(SP) owes] to a family member or friend (01) [continuous response]
for money borrowed to pay medical or dental bills. About how much [do you/does (SP)]
(-8) DON’T KNOW
currently owe?
(-9) REFUSED

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

SHOW CARD IA23
Please look at this card and tell me which is closest.

Response Options

(01) LESS THAN $500
(02) $500 TO LESS THAN $2,500
(03) $2,500 TO LESS THAN $5,000
(04) $5,000 TO LESS THAN $25,000
(05) $25,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

(01) [continuous response]
You mentioned that [you have/(SP) has] other medical or dental bills that [you/(SP)] are unable
(-8) DON’T KNOW
to pay. About how much [do you/does (SP)] currently owe?
(-9) REFUSED

SHOW CARD IA23
Please look at this card and tell me which is closest.

(01) LESS THAN $500
(02) $500 TO LESS THAN $2,500
(03) $2,500 TO LESS THAN $5,000
(04) $5,000 TO LESS THAN $25,000
(05) $25,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

(01) MY OWN CARE
Thinking about the medical or dental bills that led to [your/(SP'S)] medical debt, were these bills (02) SOMEONE ELSE'S CARE
for [your/(SP'S)] own care, someone else’s care, or both [your/(SP'S)] care and someone else’s (03) BOTH MY AND SOMEONE ELSE'S CARE
care?
(-8) DON'T KNOW
(-9) REFUSED

(01) DOCTOR VISITS OR LAB FEES OR
DIAGNOSTIC TESTS SUCH AS X-RAYS OR MRIS
Were any of the bills that caused [your/(SP's)] medical debt due to...
(02) EMERGENCY CARE OR AMBULANCE
SERVICES
DOCTOR VISITS OR LAB FEES OR DIAGNOSTIC TESTS SUCH AS X-RAYS OR MRIS (03) HOSPITALIZATION OR OUTPATIENT
EMERGENCY CARE OR AMBULANCE SERVICES
SURGERY
HOSPITALIZATION OR OUTPATIENT SURGERY
(04) PRESCRIPTION DRUGS
PRESCRIPTION DRUGS
(05) LONG TERM CARE SERVICES OR SUPPORT,
LONG TERM CARE SERVICES OR SUPPORT, EITHER IN HOME OR IN A NURSING EITHER IN HOME OR IN A NURSING HOME OR
HOME OR RESIDENTIAL FACILITY
RESIDENTIAL FACILITY
MEDICAL EQUIPMENT
(06) MEDICAL EQUIPMENT
DENTAL CARE
(07) DENTAL CARE
OR SOME OTHER EVENT?
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

Which of the following comes closer to describing the bills that contributed to [your/(SP's)]
medical debt?

(01) BILL FOR A ONE TIME OR SHORT-TERM
MEDICAL EXPENSE, SUCH AS A SINGLE
HOSPITAL STAY OR TREATMENT FOR AN
ACCIDENT
(02) BILLS THAT BUILD UP OVER TIME, SUCH AS
TREATMENT FOR CHRONIC ILLNESS LIKE
DIABETES OR CANCER
(-8) DON'T KNOW
(-9) REFUSED

Approximately how long ago did [this incident occur/the treatment that led to [your/(SP's)]
medical debt begin]?

(01) WITHIN THE LAST YEAR
(02) BETWEEN ONE AND TWO YEARS AGO
(03) BETWEEN THREE AND FOUR YEARS AGO
(04) FIVE YEARS AGO OR MORE
(-8) DON'T KNOW
(-9) REFUSED

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Response Options

Besides what you've already told me about, do [you/(SP)] [or (SP FIRSTNAME
LASTNAME)/(SPOUSE FIRSTNAME LASTNAME)] owe any money for credit card bills?
EXCLUDE CREDIT CARD BILLS THAT WERE PAID IN FULL OR REIMBURSED. DO (01) YES
NOT INCLUDE ANY AMOUNT CURRENTLY COUNTED TOWARDS MEDICAL DEBT (02) NO
BALANCE.
(-8) DON'T KNOW
(-9) REFUSED
[IF NEEDED: This item is asking specifically about money owed for credit card bills that
cannot be paid off by the due date on the statement. If the bills were paid off by the statement
due date, do not include those bills.]

What is the total amount of credit card debt [you/(SP)] [and (SP FIRSTNAME
LASTNAME)/(SPOUSE FIRSTNAME LASTNAME)] currently owe?
Please include any interest and fees accrued.
EXCLUDE CREDIT CARD DEBT FOR BUSINESS EXPENSES THAT WILL BE PAID
OR REIMBURSED. DO NOT INCLUDE ANY AMOUNT CURRENTLY COUNTED
TOWARDS MEDICAL DEBT BALANCE.

SHOW CARD IA24
Please look at this card and tell me which is closest.

(01) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

(01) LESS THAN $1,000
(02) $1,000 TO LESS THAN $5,000
(03) $5,000 TO LESS THAN $10,000
(04) $10,000 TO LESS THAN $25,000
(05) $25,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

The government has an energy assistance program which helps pay heating and cooling costs.
This assistance can be received directly by the household or it can be paid directly to the electric (01) YES
company, gas company, or fuel dealer.
(02) NO
(-8) DON'T KNOW
In [CURRENT YEAR - 1], did [you/this household/(SP's) household] receive assistance of this (-9) REFUSED
type from the federal, state, or local government?

Federal Assistance Program
Participation and Awareness

As you may know, the government has programs that help beneficiaries pay for the costs
associated with a Medicare drug plan and the purchase of prescription drugs. The help provided (01) YES
is referred to as a "low-income subsidy" or "extra help".
(02) NO
(-8) DON'T KNOW
Before today, were you aware that Medicare offers a low-income subsidy or extra help with
(-9) REFUSED
prescription drug coverage?

[Are you/Is (SP)] receiving this type of help to pay for [your/(SP's)] (CURRENT YEAR)
Medicare prescription drug coverage?

(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Beneficiaries who qualify for these programs receive help paying (-8) DON'T KNOW
for the Medicare drug plan's monthly premium, help paying any yearly deductible, help paying (-9) REFUSED
coinsurance and copayments for prescription drugs, and have no coverage gap.]

As you may know, the government has a set of programs, called Medicare Savings Programs
(MSP), that help beneficiaries pay for the costs associated with Medicare, such as Part A
(Hospital Insurance) or Part B (Medical Insurance) premiums, deductibles, coinsurance, and
copayments. Unlike additional insurance plans that require a monthly premium, Medicare
Savings Programs provide financial help at no cost to eligible beneficiaries who have limited
income and resources.Before today, were you aware that Medicare offers these programs?

Addition: Charity Care

HFQ:
Fall Round

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

(01) YES
Increase of Since (LAST HF MONTH YEAR) [have you/has (SP)] had any medical bills reduced through a (02) NO
0.10 minutes financial assistance program for people who have trouble paying?
(-8) DON'T KNOW
(-9) REFUSED

MCBS Community Deletions and Migrations

MCBS Revision to Current Clearance
Proposed Changes to Community Interviews and Effect on Burden

Community Interview Additions

Section

Migration to IMQ: Pneumonia and
Shingles Vaccine Prevalence

PVQ:
Winter Round

Effect on
Annual
Burden

Question Text

Shingles is an illness that results in a rash or blisters on the skin, and is usually painful. There
(01) YES
are two vaccines now available for shingles; Zostavax®, which requires 1 shot, and Shingrix®,
Decrease of
(02) NO
a new vaccine which requires 2 shots.
0.2 minutes
(-8) DON'T KNOW
(-9) REFUSED
[Have you/Has (SP)] had a vaccine for Shingles?

[Have you/Has (SP)] EVER had a pneumonia shot?
This shot is usually given only once or twice in a person's lifetime and is different from the flu
shot. It is also called the pneumococcal vaccine. There are two types of pneumonia shots:
polysaccharide, also known as Pneumovax®23, and conjugate, also known as Prevnar13®.

Migration to IAQ: MSP Program
Participation and Application

KNQ:
Winter Round

Response Options

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

We’re interested in learning about how Medicare beneficiaries navigate certain programs
available to help them pay for their health care costs. As you may know, the government has a
set of programs, called Medicare Savings Programs (MSP), that help beneficiaries pay for the
costs associated with Medicare, such as Part A (Hospital Insurance) or Part B (Medical
Insurance) premiums, deductibles, coinsurance, and copayments. Unlike additional insurance
plans that require a monthly premium, Medicare Savings Programs provide financial help at no
cost to eligible beneficiaries who have limited income and resources. We’re going to ask you a
few questions about these programs, and what [your/(SP)’s] experience, if any, has been with
(01) YES
them.
Net Decrease
(02) NO
of 0.1 minute
(-8) Don't Know
[Are you/Is (SP)] receiving any assistance from a Medicare Savings Program (MSP) to help pay
(-9) Refused
for [your/(SP)'s] (CURRENT YEAR) health care costs?
[EXPLAIN IF NECESSARY: Medicare Savings Programs pay for remaining costs (premiums,
deductibles, coinsurance, and copayments) not covered by Medicare. These programs are
different from additional insurance plans, such as Medicare Supplement Insurance (Medigap) or
private insurance plans, in that beneficiaries will not pay for this extra financial help. Instead,
beneficiaries must be eligible (i.e., have limited resources or income) and apply to receive this
financial assistance from an MSP.

Deletion: MSP Program Participation
and Application

KNQ:
Winter Round

Did [you/(SP)] apply to the [STATE] Medicare office for help with (CURRENT YEAR)
expenses?

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

As you may know, the government has programs that help beneficiaries pay for the costs
associated with a Medicare drug plan and the purchase of prescription drugs. The help provided
is referred to as a "low-income subsidy" or "extra help".
Migration to IAQ: LIS Program
Participation and Application

RXQ:
Summer Round

Net Decrease
[Are you/Is (SP)] receiving this type of help to pay for [your/his/her] (CURRENT YEAR)
of 0.1
Medicare prescription drug coverage?
minutes

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

[EXPLAIN IF NECESSARY: Beneficiaries who qualify for these programs receive help paying
for the Medicare drug plan's monthly premium, help paying any yearly deductible, help paying
coinsurance and copayments for prescription drugs, and have no coverage gap.]

Deletion: LIS Program Participation and RXQ:
Application
Summer Round

Did [you/(SP)] apply to the Social Security Administration for extra help with (CURRENT
YEAR) drug coverage?

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

Was [your/(SP's)] application for extra help accepted or denied?

(01) ACCEPTED
(02) DENIED
(03) STILL PENDING/NO DECISION YET
(-8) Don't Know
(-9) Refused

MCBS Community Deletions and Migrations

Community Interview Additions

Deletion: Income and Assets

Section

Effect on
Annual
Burden

Note: the
deletion of
22 items
from the IAQ
is included in
IAQ:
the net
Summer Round
increase to
respondent
burden in the
"additions"
tab

Question Text

Response Options

Did [you/(SP)] do any work for pay in the last week? By the last week, I mean the week
beginning on Sunday [MONTH, DAY OF SUNDAY PRIOR TO TODAY/MONTH, DAY OF
SUNDAY PRIOR TO THE SATURDAY BEFORE TODAY’S DATE] and ending [today/on
Saturday (MONTH, DAY OF SATURDAY PRIOR TO TODAY’S DATE)]?

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

Is this because [you were/(SP) was] retired or [you/(SP)] never worked?

(01) RETIRED
(02) NEVER WORKED
(03) NO, NEITHER OF THESE IS TRUE
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
[Do you/Does (SP)] have a job from which [you were/(he/she) was] absent last week because of (02) NO
illness, vacation, or some other reason?
(-8) DON'T KNOW
(-9) REFUSED

Last week, did [you/(SP)] have more than one job, including part-time, evening, or weekend
work?

How many hours did [you/(SP)] work last week?
ENTER NUMBER OF HOURS

You said [you were/(SP) was] absent from work last week. How many hours did [you/he/she]
work the last week [you were/(he/she) was] at work?
ENTER NUMBER OF HOURS

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

(1) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

(1) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

[Are you/Is (SP)/In (your/{SP}’s)] main job, [are you/is (he/she)] paid every week, every two
weeks, two times a month, or on some other schedule?

(1) EVERY WEEK
(2) EVERY TWO WEEKS
(3) TWO TIMES A MONTH
(4) ONCE A MONTH
(5) DAILY
(91) OTHER SPECIFY
(-8) DON’T KNOW
(-9) REFUSED

SPECIFY OTHER PAYMENT SCHEDULE

(1) [continuous response]

How much was [your/(SP)’s] last paycheck before taxes and any other deductions [for
(your/his/her) main job]?
IF NEEDED: We don’t need an exact dollar amount. An approximate amount is fine.

(1) ENTER PAYCHECK AMOUNT
(2) ENTER PAY PER HOUR
IF NEEDED: If it is easier, you can just tell me how much [you earn/(SP) earns] per hour or per (3) ENTER PAY PER DAY
day.
(-8) DON’T KNOW
(-9) REFUSED
IF NEEDED: We know questions like these may be difficult to answer, but we need to know
this to understand how people manage financially as they age and what effect this might have on
their health.

MCBS Community Deletions and Migrations

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Response Options

ENTER PAYCHECK AMOUNT
(1) [continuous response]
$

[Do you/Does (SP)] [or (SP FIRSTNAME LASTNAME)/(SPOUSE FIRSTNAME
LASTNAME)/(PARTNER FIRSTNAME LASTNAME)] expect to pay off the mortgage
within 5 years, 10 years, or longer?
IF NEEDED: Include any payments on a home equity loan or second mortgage.

(1) WITHIN 5 YEARS
(2) WITHIN 10 YEARS
(3) LONGER THAN 10 YEARS
(-8) DON’T KNOW
(-9) REFUSED

[Do you/Does (SP)] get payments by direct deposit, on a prepaid card, or by mail?

(1) MAIL
(2) DIRECT DEPOSIT
(3) PREPAID CARD
(-8) DON’T KNOW
(-9) REFUSED

What month and year did [you/(SP)] start receiving Social Security?
[ENTER MONTH AND YEAR]

(1) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

What month and year did [you/(SP)] start receiving Social Security?
[ENTER MONTH AND YEAR]

(1) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

(1) YES, SP HAS ASSET
[Do you/Does (SP)] [or (SP FIRSTNAME LASTNAME)/(SPOUSE FIRSTNAME
(2) YES, SPOUSE/PARTNER HAS ASSET
LASTNAME)/(PARTNER FIRSTNAME LASTNAME)] own a business, a farm, or any other (3) YES, SP AND SPOUSE/PARTNER HAVE ASSET
real estate [besides (your/{SP}’s) home], including land or rental properties?
JOINTLY
(4) NO ASSET OF THIS TYPE
[SELECT ALL THAT APPLY]
(-8) DON’T KNOW
(-9) REFUSED

(1) INSURANCE SETTLEMENT
(2) PENSION SETTLEMENT
(3) INHERITANCE (OR TRUST)
(4) GIFT
What was the largest lump sum [you/(SP)] [or (SP FIRSTNAME LASTNAME)/(SPOUSE
(5) LAWSUIT
FIRSTNAME LASTNAME)/(PARTNER FIRSTNAME LASTNAME)] received - was it from
(91) OTHER (SPECIFY)
an inheritance, a trust, an insurance settlement, a pension settlement, a gift, a lawsuit, or what?
(-8) DON'T KNOW
(-9) REFUSED
SHOWCARD IA35

OTHER (SPECIFY)

(1) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

About how much did [you/(SP)] [or (SP FIRSTNAME LASTNAME)/(SPOUSE FIRSTNAME
(01) YES
LASTNAME)/(PARTNER FIRSTNAME LASTNAME)] receive from the [insurance
(02) NO
settlement/pension settlement/inheritance or trust/gift/lawsuit/(OTHER)]?
(-8) DON'T KNOW
(-9) REFUSED
DO NOT PROBE.

Did it amount to less than $50,000, more than $50,000, or what?
DO NOT PROBE.

(1) LESS THAN $50K
(2) ABOUT $50K
(3) MORE THAN $50K
(-8) DON'T KNOW
(-9) REFUSED

MCBS Community Deletions and Migrations

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

Now, I would like to change topics and talk about automobiles [you own/(SP) owns] [or
(your/his/her) (husband/wife/partner) owns].
[Do you/Does (SP)] [or (your/his/her) (husband/wife/partner)] own any cars, trucks, or vans?
IF NEEDED: Do not include recreational vehicles, such as motorcycles, trailers, motor homes,
boats, or airplanes.

Altogether, what is their present value, that is, about how much would they bring if [you/(SP)]
sold them on today’s market?
ENTER DOLLAR AMOUNT

SHOW CARD IA36
Please look at this card and tell me which is closest.

Deletion: Outstanding Medical Bills

HFQ:
Fall Round

Response Options

(1) YES
(2) NO
(-8) DON’T KNOW
(-9) REFUSED

(1) [continuous response]
(-8) DON’T KNOW
(-9) REFUSED

(1) LESS THAN $2,500
(2) $2,500 TO LESS THAN $5,000
(3) $5,000 TO LESS THAN $7,500
(4) $7,500 TO LESS THAN $10,000
(5) $10,000 TO LESS THAN $20,000
(6) $20,000 OR MORE
(-8) DON’T KNOW
(-9) REFUSED

(01) YES
Net decrease
Since (LAST HF MONTH YEAR) [have you/has (SP)] had any medical bills reduced through a (02) NO
of 0.1
financial assistance program for people who have trouble paying?
(-8) DON'T KNOW
minutes
(-9) REFUSED