Facility Prepare Interview Letter

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services

[Month], [Year]
Dear [Administrator]:
Thank you for your willingness to participate in the Medicare Current Beneficiary
Survey. One of our interviewers will be contacting your facility soon to complete your
interview.
On the back of this letter, you will find a summary of potential topics covered that will be
asked for the beneficiary in your facility selected for this survey. We hope this will help
to prepare you and/or your staff for your interview. Please note that it is likely the
interviewer may not cover all topics listed.
For the most recent public version of the questions you may be asked, you may visit:
cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Questionnaires
We sincerely thank you for your time and effort in providing us the information we
need to improve. Know that your participation is making a meaningful difference
in lives of Medicare beneficiaries across the country.
We look forward to speaking with you soon. In the meantime, if you have any
questions, please do not hesitate to contact NORC toll-free at 1-844-777-2151, or
by email at mcbs@norc.org.
Sincerely,

Marina Vornovitsky
Director, Medicare Current Beneficiary Survey
Centers for Medicare and Medicaid Services

Enclosure
OMB No. 0938-0568 | Expires 8/31/2025

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services

Interview Topic

Facility Questionnaire

Residence History

Description

Collects your facility’s contact information, structure type, eligibility,
classification, certification status of beds within your facility, and billing rates.

Establishes where your resident has resided within the last few months.

Background

Collects background and demographic information on your resident including
race, income, level of education, service in the Armed Forces, and family
composition.

Health Insurance

Collects information on your resident’s health insurance coverage including all
types of health insurance coverage your resident may have in addition to
Medicare such as, private insurance, long-term Care insurance, Dept. of
Veterans Affairs eligibility, and TRICARE or CHAMPVA.

Health Status

Collects information on your resident’s general health status and conditions, and
ability to perform various physical activities.

Use of Health Services

Collects information on the health care services delivered to your resident while
residing in your facility.

Expenditure

COVID-19
Beneficiary Supplement

COVID-19
Facility-level Supplement

Enclosure
OMB No. 0938-0568 | Expires 8/31/2025

Collects your facility’s billing periods and charges for your resident’s health
care to capture billing rate changes and your resident’s source of payments for
those charges.
Collects data on COVID-19 pandemic topics related to your resident’s
utilization of COVID-19 testing, COVID-19 medical care, and COVID-19
vaccine utilization.
Collects information on your facility regarding topics related to the COVID-19
pandemic’s impact on MCBS eligible facilities including availability of
telehealth services, COVID-19 prevention measures, and mental health and
social and recreational services offered inside and outside of your facility.