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

2024 MCBS Facility Instrument

Variable Name

MR Screen Name

IN-Health Insurance

Question Type

Question Text/Description

Code List

Routing

(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE
INTERVIEW)
(04) FINAL REFUSAL

(01) IN1PRE2 - IN1PR2CT
(02) INEND - INENDCT
(03) IN1PRE2 - IN1PR2CT
(04) INEND - INENDCT

(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL

(01) BOX IN3
(02) INEND - INENDCT
(03) INEND - INENDCT

HEALTH INSURANCE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
SEASON
If SAMPLE_TYPE= CFR, then SEASON=FALL
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX INBEG

routing

IF INDISP = 1/ConsentRequired OR INDISP = 4/InitialRefusal, GO TO INCONREF - CONREFFN.
ELSE GO TO IN1PRE2 - IN1PR2CT.

CONREFFN

INCONREF

code one

PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS FOR THIS SECTION.

IN1PR2CT

IN1PRE2

code one

BOX IN3

routing

ICAIDECO

IN1

yes/no

Has (SP) ever been covered by [READ NAME(S) FROM ABOVE]?

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

(00) IN13A - ICAREPTD
(01) IN5A-MCAIDHMO
(02) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD

ICAIDNOW

IN1A

yes/no

Is (SP) now covered by [READ NAME(S) FROM ABOVE]?

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

(00) IN18 - IGAPCOV
(01) IN5A-MCAIDHMO
(02) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

MCAIDHMO

IN5A

yes/no

(00) NO
Some states now use HMOs (health maintenance organizations) to provide some or all health care for Medicaid (01) YES
beneficiaries. (Is/Was) (SP) enrolled in a [READ NAME(S) FROM ABOVE] HMO?
(-8) Don't Know
(-9) Refused

BOX IN3A

routing

IF THIS IS A BASELINE INTERVIEW, GO TO IN6 - ICDCRCOV.
ELSE GO TO IN18 - IGAPCOV.

IN6

yes/no

Was (SP) covered by [READ NAME(S) FROM ABOVE] [on September 1, (CURRENT YEAR)?/when (he/she)
was admitted on (FAD/RAD)?]

The following questions are about (SP's) health insurance.

ICDCRCOV

IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.
IF THIS IS A BASELINE INTERVIEW GO TO IN1 - ICAIDECO.
ELSE IF THIS IS NOT A BASELINE INTERVIEW GO TO IN1A - ICAIDNOW.

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

(00) IN13A - ICAREPTD
(01) IN13A - ICAREPTD
(-8) IN13A - ICAREPTD
(-9) IN13A - ICAREPTD

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

(00) IN18 - IGAPCOV
(01) IN18 - IGAPCOV
(-8) IN18 - IGAPCOV
(-9) IN18 - IGAPCOV

(00) NO
On [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD], was (SP) covered by private health insurance that pays
(01) YES
for some or all charges for inpatient and outpatient hospital and physician services and/or supplements
(-8) Don't Know
Medicare (Medigap policy)?
(-9) Refused

(00) IN 20-ILTCCOV
(01) IN19-IGAPNAME
(-8) IN20-ILTCCOV
(-9) IN20-ILTCCOV

Our records show that (SP) is covered by Medicare. I'd like to ask some questions about (his/her) Medicare
coverage.
ICAREPTD

IN13A

yes/no

Was (SP) covered by Part D of Medicare on [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD]?
PRESS F1 FOR PART D DEFINITIONS.

IGAPCOV

IN18

yes/no

IGAPNAME

IN19

Text

(00) BOX IN3A
(01) BOX IN3A
(-8) BOX IN3A
(-9) BOX IN3A

What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

(01) Continuous Answer

(01) IN19 - IGAPNAM2

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2024 MCBS Facility Instrument

Variable Name

MR Screen Name

IN-Health Insurance

Question Type

Question Text/Description

Code List

Routing

(01) Continuous Answer

(01) IN19 - IGAPNAM3

(01) Continuous Answer

(01) IN19 - IGAPNAM4

(01) Continuous Answer

(01) IN19 - IGAPNAM5

(01) Continuous Answer

(01) IN20 - ILTCCOV

What is the name of the insurance company?
IGAPNAM2

IN19

Text

IGAPNAM3

IN19

Text

IGAPNAM4

IN19

Text

IGAPNAM5

IN19

Text

ILTCCOV

IN20

yes/no

ILTCNAME

IN21

Text

ILTCNAM2

IN21

Text

ILTCNAM3

IN21

Text

ILTCNAM4

IN21

Text

ILTCNAM5

IN21

Text

ICHACOV

IN22

Yes/No

Was (SP) covered by either TRICARE or CHAMPVA for hospital or physician care on [September 1, (CURRENT (00) NO
YEAR)/(FAD/RAD)/DOD]?
(01) YES
(-8) Don't Know
PRESS F1 FOR EXPLANATION OF TRICARE AND CHAMPVA.
(-9) Refused

(00) IN23 - IDVACOV
(01) IN23 - IDVACOV
(-8) IN23 - IDVACOV
(-9) IN23 - IDVACOV

IDVACOV

IN23

Yes/No

Was (SP) covered by any other Department of Veterans Affairs (VA) program or contract on [September 1,
(CURRENT YEAR)/(FAD/RAD)/DOD]?

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

(00) IN24 - IPUBCOV
(01) IN24 - IPUBCOV
(-8) IN24 - IPUBCOV
(-9) IN24 - IPUBCOV

IPUBCOV

IN24

Yes/No

(Besides [READ NAME(S) FROM ABOVE], was/Was) (SP) covered by any other public assistance health
insurance program on [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD]?

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

(00) BOX IN9
(01) IN25 - IPUBNAME
(-8) BOX IN9
(-9) BOX IN9

IPUBNAME

IN25

Text

What (is/was) the name of the public assistance health insurance program?

(01) Continuous Answer

(01) BOX IN9

BOX IN9

routing

IF SP ALIVE, AND A CFR, FFC, OR FCF AND IS A FALL ROUND, GO TO INBQ13A - IMARSTAT.
ELSE GO TO INEND - INENDCT.
(01) INEND - INENDCT
(02) INEND - INENDCT
(03) INEND - INENDCT
(04) INEND - INENDCT
(05) INEND - INENDCT
(-8) INEND - INENDCT
(-9) INEND - INENDCT
(01) BOX INEND

[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.
What is the name of the insurance company?
[PROBE: Any others?]
IF NO MORE INSURANCE COMPANY NAMES, PRESS ENTER TO CONTINUE.

(00) NO
On [September 1, (CURRENT YEAR)/(FAD/RAD)/DOD], was (SP) covered by private health insurance that pays (01) YES
for some or all charges for more than 100 days of nursing home care, that is, a long-term care policy?
(-8) Don't Know
(-9) Refused
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]
What is the name of the insurance company?
[PROBE: Any others?]

(00) IN22 - ICHACOV
(01) IN21 - ILTCNAME
(-8) IN22 - ICHACOV
(-9) IN22 - ICHACOV

(01) Continuous Answer

(01) IN21 - ILTCNAM2

(01) Continuous Answer

(01) IN21 - ILTCNAM3

(01) Continuous Answer

(01) IN21 - ILTCNAM4

(01) Continuous Answer

(01) IN21 - ILTCNAM5

(01) Continuous Answer

(01) IN22 - ICHACOV

IMARSTAT

INBQ13A

code one

Is (SP) currently married, widowed, divorced, separated, or never married?

(01)NEVER MARRIED
(02) MARRIED
(03) WIDOWED
(04) DIVORCED
(05) SEPARATED
(-8) Don't Know
(-9) Refused

INENDCT

INEND

code one

YOU HAVE COMPLETED THE HEALTH INSURANCE SECTION FOR THIS SP.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(01) CONTINUE

BOX INEND

routing

GO TO NAVIGATOR

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