Crosswalk

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Addition

KNQ

Increase
of 1.3
minutes

-

-

Effect on
Annual
Burden

Increase
of 1.3
minutes

Question
Name

KN58 OEINTRO

Question text

Now I would like to ask you about comparisons [you/(SP)] may have made during the last
Medicare Open Enrollment Period, which is sometimes called the Annual Election Period
or Annual Coordinated Enrollment Period. The Open Enrollment Period runs each year
from mid-October to early-December.

Skip instructions

KN58A - RVWCOST

(01) CONTINUE
During the last open enrollment period, did [you/(SP)] review [your/his/her] Medicare
insurance coverage to see if there were going to be changes in [your/his/her] monthly
premium, deductibles, co-payments, or other out of pocket expenses?

KN58A RVWCOST

[EXPLAIN IF NECESSARY: The Open Enrollment Period – sometimes called the
Annual Election Period or Annual Coordinated Enrollment Period – runs each year from
mid-October to early-December.]

KN58B - RVWSRVC

(01) YES
(02) NO
(03) NOT APPLICABLE, JUST SIGNED UP FOR MEDICARE
(-8) DON'T KNOW
(-9) REFUSED
During the last open enrollment period, did [you/(SP)] review [your/his/her] Medicare
insurance coverage to see if the kinds of treatment, drugs, and services covered will meet
[your/his/her] health care needs?

KN58B RVWSRVC

[EXPLAIN IF NECESSARY: The Open Enrollment Period – sometimes called the
Annual Election Period or Annual Coordinated Enrollment Period – runs each year from
mid-October to early-December.]

KN58C - CMPRPLN

(01) YES
(02) NO
(03) NOT APPLICABLE, JUST SIGNED UP FOR MEDICARE
(-8) DON'T KNOW
(-9) REFUSED
As you know, Medicare beneficiaries can choose different types of Medicare insurance
plans. During the last open enrollment period, did [you/(SP)] compare [your/his/her]
Medicare insurance plan with other Medicare plans that were available?

KN58C CMPRPLN

[EXPLAIN IF NECESSARY: The Open Enrollment Period – sometimes called the
Annual Election Period or Annual Coordinated Enrollment Period – runs each year from
mid-October to early-December.]
(01) YES
(02) NO
(03) NOT APPLICABLE, JUST SIGNED UP FOR MEDICARE
(-8) DON'T KNOW
(-9) REFUSED

Page 1 of 7

If (01) YES, go to KN58D - CPLNTYPE
If (02) NO, go to KN59 - KCSUGGST
If (03) NOT APPLICABLE, JUST
SIGNED UP FOR MEDICARE, go to
KN59 - KCSUGGST
If (-8) DON'TKNOW, go to KN59 KCSUGGST
If (-9) REFUSED, go to KN59 KCSUGGST

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Effect on
Annual
Burden

Question
Name

Question text

Skip instructions

SHOWCARD KN10What types of Medicare plans did [you/(SP)] compare with
[your/his/her] Medicare insurance plan?
[EXPLAIN IF NECESSARY:
-Medicare Parts A and B, commonly referred to as “Original Medicare,” provide hospital
and medical insurance.
-Medicare Part C includes Medicare Advantage plans. These are plans offered to
Medicare beneficiaries by private companies (approved by Medicare) and provide
beneficiaries with their Part A and B benefits. Medical Advantage is an alternative to
Original Medicare.
-Part D covers prescription drugs -- this type of plan is also known as an MPDP.
KN58D Prescription drug plans are offered by private companies (approved by Medicare).
CPLNTYPE
- Medigap is a supplemental insurance plan sold by private companies for use with
Original Medicare. It cannot be used with Medicare Advantage. Medigap plans help pay
some of the health care costs that Original Medicare doesn't cover, like copayments,
coinsurance and deductibles.]

KN59 - KCSUGGST

(01) Medicare Parts A and B (Original Medicare)
(02) Medicare Part C, Medicare Advantage (MA) Plans
(03) Medicare Part D, Medicare Prescription Drug Plans (MPDPs)
(04) Medigap Plans
(-8) DON'T KNOW
(-9) REFUSED

Addition

USQ

Increase
of 0.4

-

-

Increase
of 0.4
minutes

PP58A DOCCARE

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need help from
[anyone in (US5A PROVIDER NAME)'s office/the doctors or other health professionals
at (US3A PROVIDER NAME)] to manage [your/his/her] care among these different
providers and services?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

If (01) YES, go to PP58B-GETHELP
If (02) NO, go to PP59-ONEDOC
If (-8) DON'T KNOW, go to PP59ONEDOC
If (-9) REFUSED, go to PP59-ONEDOC

SHOW CARD US5

PP58BGETHELP

Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get the help
[you/he/she] needed from [(US5A PROVIDER NAME)'s office/the doctors or other
health professionals at (US3A PROVIDER NAME)] to manage [your/his/her] care among
these different providers and services?
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED

Page 2 of 7

PP59-ONEDOC

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Effect on
Annual
Burden

Question
Name

Question text

Skip instructions

Many health care providers are beginning to participate in innovative health care
initiatives, programs, and payment models. Is (US5A PROVIDER NAME)/(US3A
PROVIDER NAME) associated with an innovative health care initiative such as an
accountable care organization or a patient centered medical home?

Addition

USQ

Increase
of 0.5
minutes

-

-

Increase
of 0.5
minutes

IF NEEDED: Innovative health care initiatives are programs that test ways to improve the
delivery of health care, improve the quality of health care, lower health care costs, and
US7 reduce health disparities.IF THE RESPONDENT DOESN'T KNOW WHAT
INNOVATE
INNOVATIVE HEALTH CARE INITATIVES ARE OR HAS NEVER HEARD OF
INNOVATIVE HEALTH CARE INITIATIVES, SELECT 'DON'T KNOW'.

BOX USD

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
The next few questions will help us to understand how (US5A PROVIDER NAME)/the
doctors or other health professionals at (US3A PROVIDER NAME) use(s) a computer
during [your/(SP)'s] office visit. Please answer the questions that follow based upon where
[you go/(SP) goes] for medical care most of the time.
Addition

USQ

Increase
of 2.7
minutes

-

-

Increase
of 2.7
minutes

EHR2COMPUSE

If (01) YES, go to US37K - EMEDREC
[Does (US5A PROVIDER NAME)/Do the providers at (US3A PROVIDER NAME)] use
If (02) NO, go to BOX EHR2
a computer during [your/(SP)'s] office visit?
If (-8) DON'T KNOW, go to BOX EHR2
If (-9) REFUSED, go to BOX EHR
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Is the examination room set up so that (US5A PROVIDER NAME)/the doctors or other
health professionals at (US3A PROVIDER NAME) can easily show [you/(SP)]
information on the computer screen?

EHR3 COMPSHW (01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

EHR4 COMPHLTH

[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] use the computer to show [you your/(SP) his/(SP) her] health
information during [your/his/her] visit, such as trends in blood pressure reading, height,
weight and body mass index, previous lab results, x-rays/images, immunizations or
medications?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Page 3 of 7

If (01) YES, go to EHR4-COMPHLTH
If (02) NO, go to BOX EHR2
If (-8) DON'T KNOW, go to BOX EHR2
If (-9) REFUSED, go to BOX EHR2

If (01) YES, go to EHR5-COMPREC
If (02) NO, go to BOX EHR2
If (-8) DON'T KNOW, go to BOX EHR2
If (-9) REFUSED, go to BOX EHR2

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Effect on
Annual
Burden

Question
Name

Question text

Skip instructions

[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] use the computer to show [you/(SP)] recommendations for
preventive health screenings or other medical services?
EHR5 COMPREC

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

BOX EHR2

[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] read back to [you/(SP)] information that [you have/(SP) has] given
during [your/(SP)'s] visit that is being put into [your/(SP)'s] medical record?
EHR6 COMPRD

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

EHR7-COMPINF

[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] send [you/(SP)] health information electronically, such as
information about [your/(SP)'s] medications, exercise plans, dietary advice, etc.?
EHR7 COMPINF

EHR8 COMPACC

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Does (US5A PROVIDER NAME)'s/Do the doctors or other health professionals at
(US3A PROVIDER NAME)]'s office give [you/(SP)] access through [your/(SP)'s] own
computer or smart phone to parts or all of [your/(SP)'s] electronic medical record (such as
a list of [your/(SP)'s] medications, lab results, x-ray reports, office notes) through a
“patient portal” or other electronic system?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Page 4 of 7

EHR8-COMPACC

BOX EHR3

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Effect on
Annual
Burden

Question
Name

Question text

Skip instructions

SHOW CARD US6
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A
PROVIDER NAME) use of the computer during [my/(SP)'s] visit is helpful to [me/(SP)].
EHR9 COMPHLP

(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) DON'T KNOW
(-9) REFUSED

EHR9-COMPDIST

SHOW CARD US6
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A
PROVIDER NAME) use of the computer during [my/(SP)'s] visit distracts him/her from
paying attention to [me/(SP)].
EHR9 (01) STRONGLY AGREE
COMPDIST
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused

EHR9-COMPATT

SHOW CARD US6
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A
PROVIDER NAME) use of the computer during [my/(SP)'s] visit distracts [me/(SP)] from
paying attention to the clinician.
EHR9 COMPATT

(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) DON'T KNOW
(-9) REFUSED

Page 5 of 7

EHR10-COMPTM

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Effect on
Annual
Burden

Question
Name

Question text

Skip instructions

SHOWCARD US8

EHR10 COMPTM

Deletion

Included in
above
calculation
for KNQ

KNQ

KN53DKNDOCREC

The amount of time during the visit that (US5A PROVIDER NAME)/the doctors or other
health professionals at (US3A PROVIDER NAME) spend(s) on the computer
seems:much more than it should be, somewhat more than it should be, about what it
should be, somewhat less than it should be, or no opnion?
BOX USEND
(01) Much more than it should be
(02) Somewhat more than it should be
(03) About what it should be
(04) Somewhat less than it should be
(05) Much less than it should be
(06) No opinion
Many health care providers are beginning to use electronic or computer-based medical
records instead of using paper-based records.
When [you/ (SP)] (visit/visits) (your/his/her) usual health care provider, does a doctor or
other health professional generally enter [your/ (SP's)] health information into a computer
while (you are/he is/she is) present?
[EXPLAIN IF NECESSARY: "Health Information" includes information such as
symptoms, vital signs, test results, or prescribed medicines.]

BOX KN8

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

Within the first 12 months of a beneficiary’s Medicare enrollment, Medicare pays for a
one-time “Welcome to Medicare” visit with their primary care provider to assess their
current health. After a beneficiary has been enrolled in Medicare for 12 months, Medicare
pays for “Annual Wellness” visits. These visits are yearly appointments with the
beneficiary’s primary care provider to update their personalized prevention plan.
Addition

PVQ

-

-

Increase of
0.8 minutes

Increase
of 0.8
minutes

PV8A Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has SP] had either a
WELLNESS
“Welcome to Medicare” or an “Annual Wellness” visit?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Page 6 of 7

PV9-BPTAKEN

MCBS Revision to Current Clearance
Proposed Changes to Community Interview and Effect on Burden
Winter
Fall
Community Interview
Summer
2020
2020
Change
Section
2020
(Addition/Deletion/Ch
Round
87 Round 88
Round 86
ange)

Addition

PVQ

-

-

Increase of
0.3 minutes

Effect on
Annual
Burden

Increase
of 0.3
minutes

Question
Name

Question text

[Have you/Has SP] ever had an exam for oral cancer in which the doctor or dentist pulls
on [your/his/her] tongue, sometimes with gauze wrapped around it, and feels under the
tongue and inside the cheeks?
PV10A BASKORAL (01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Skip instructions

If (01) YES, go to PV10C-OCCEXAM
If (02) NO, go to BOX PV19
If (-8) DON'T KNOW, go to BOX PV19
If (-9) REFUSED, go to BOX PV19

Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has SP] had an exam for oral
cancer in which the doctor or dentist pulls on [your/his/her] tongue, sometimes with gauze
wrapped around it, and feels under the tongue and inside the cheeks?
PV10B CASKORAL (01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PV19

When did [you/SP] have [your/his/her] most recent oral or mouth cancer exam?
Was it within the past year, between 1 and 3 years ago, or over 3 years ago?
PV10C (01) WITHIN THE PAST YEAR
OCCEXAM
(02) BETWEEN 1 AND 3 YEARS AGO
(03) OVER 3 YEARS AGO
(-8) DON'T KNOW
(-9) REFUSED

BOX PV19

[Have you/Has (SP)] lost all of [your/his/her] upper and lower natural (permanent) teeth?
Addition

HFQ

-

-

Increase of
0.2 minutes

Increase
of 0.2
minutes

DIS2A DISTEETH

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

Page 7 of 7

DIS3 - DISDECISION