CMS-P-0015A Access to Care

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ACQ-ACCESS TO CARE

Question Type

Question Text/Description

Code List

Routing

ACCESS TO CARE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007
SPALIVE=1
SEASON= WINTER
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after MPQ.

ACINT

ERVISIT

BOX AC1AA

routing

IF INTTYPE=7 AND VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE NE 1 AND (SP DID NOT HAVE ER
VISIT IN CURRENT ROUND AND AC6A NOT ALREADY ASKED), GO TO ACINTRO - ACINT.
ELSE IF (SP HAD AN ER VISIT IN THE CURRENT ROUND OR ANY OF THE 2 PREVIOUS ROUNDS) AND
(AC6A NOT ALREADY ASKED), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX AC1C.

ACINTRO

no entry

The next questions are about health care services [you/(SP)] may have used since [TODAY’S MONTH YEAR-12
MONTHS].

AC1

AC1 - ERVISIT

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

(01) AC6A - EWAITUNT
(02) BOX AC1C
(-8) BOX AC1C
(-9) BOX AC1C

yes/no

Since [TODAY’S MONTH YEAR-12 MONTHS], did [you/(SP)] go to a hospital emergency room?

(00) BOX AC1C.
(01) AC6A - EWAITHRS
(02) AC6A - EWAITMIN
(03) AC6A - EWAITHRS
(-8) BOX AC1C
(-9) BOX AC1C

EWAITUNT

AC6A

code one

(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
Think about the most recent time [you/(SP)] went to the hospital emergency room. How long did [you/(SP)] have
(02) MINUTES ONLY
to wait during (your/his/her) visit before (you/he/she) saw a doctor or some other medical person? Please include
(03) HOURS AND MINUTES
the time spent in the waiting room and exam room.
(-8) Don't Know
(-9) Refused

EWAITHRS

AC6A

numeric

Think about the most recent time [you/(SP)] went to the hospital emergency room. How long did [you/(SP)] have
to wait during (your/his/her) visit before (you/he/she) saw a doctor or some other medical person? Please include (01) continuous answer
the time spent in the waiting room and exam room.

If AC6A - EWAITUNT = 3/HoursAndMinutes, go to
AC6A - EWAITMIN.
Else go to BOX AC1C.

EWAITMIN

AC6A

numeric

Think about the most recent time [you/(SP)] went to the hospital emergency room. How long did [you/(SP)] have
to wait during (your/his/her) visit before (you/he/she) saw a doctor or some other medical person? Please include (01) continuous answer
the time spent in the waiting room and exam room.

BOX AC1C

routing

IF AC6A ASKED WHILE ADMINISTERING ER, GO TO BOX ER6.
ELSE IF INTTYPE=7 AND VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE NE 1 AND (SP DID NOT
HAVE OP VISIT IN CURRENT ROUND AND AC16A NOT ALREADY ASKED), GO TO AC8 - OPDVISIT.
ELSE IF (SP HAD AN OP VISIT IN THE CURRENT ROUND OR ANY OF THE 2 PREVIOUS ROUNDS) AND
(AC9-AC16A NOT ALREADY ASKED), GO TO AC9 - OPDREAS.
ELSE GO TO BOX AC1E.

yes/no

Since [TODAY’S MONTH YEAR-12 MONTHS], did [you/(SP)] go to a hospital clinic or outpatient department?
DO NOT INCLUDE HOSPITAL INPATIENT STAYS.

BOX AC1C

OPDVISIT

AC8

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

(01) AC9 - OPDREAS
(02) BOX AC1E
(-8) BOX AC1E
(-9) BOX AC1E

Page 1 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ACQ-ACCESS TO CARE

Question Type

Question Text/Description

Code List

[I have a few more questions about visits that [you/(SP)] had in the past.]

OPDREAS

AC9

code all

(01) MEDICAL CONDITION NAMED
(02) TESTS
Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department. What was the
(03) FOLLOW-UP
reason [you/(SP)] went to the hospital clinic or outpatient department?
(04) CHECKUP
[PROBE FOR THE MOST RECENT VISIT IF RESPONDENT MENTIONS MORE THAN ONE. IF NEEDED,
(05) REFERRAL
PROBE WITH ‘What did you have done during your most recent visit to the hospital clinic or outpatient
(06) SURGERY
department?’ SELECT ALL THAT APPLY.]
(07) PREVENTIVE SHOT
[PROBE: Any other reason?]
(08) TREATMENT SHOT
(09) TO GET OR REFILL PRESCRIPTION
THE MOST RECENT VISIT CAN BE OUTSIDE OF THE REFERENCE PERIOD USED IN OTHER SECTIONS (91) OTHER
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused

OPDOTHOS

AC9

verbatim text

OTHER (SPECIFY)

routing

IF (INTTYPE=7 AND VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE NE 1 AND SP DID NOT REPORT
OUTPATIENT DEPARTMENT VISIT AT OP4) AND (RESPONSE TO AC9 - OPDREAS INCLUDES
1/MedCondNamed OR 6/Surgery), GO TO AC12 - OPDAPPT.
ELSE IF INTTYPE=7 AND VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE NE 1 AND SP DID NOT
REPORT OUTPATIENT DEPARTMENT VISIT AT OP4) AND (RESPONSE TO AC9 - OPDREAS DOES NOT
INCLUDE 1/MedCondNamed AND DOES NOT INCLUDE 6/Surgery), GO TO AC10 - OPDSCOND.
ELSE GO TO AC12 - OPDAPPT.

BOX AC1D

OPDSCOND

OPDAPPT

OPDDRTEL

AC10

AC12

AC13

(01) BOX AC1D
(02) BOX AC1D
(03) BOX AC1D
(04) BOX AC1D
(05) BOX AC1D
(06) BOX AC1D
(07) BOX AC1D
(08) BOX AC1D
(09) BOX AC1D
(91) AC9 - OPDOTHOS
(-8) BOX AC1D
(-9) BOX AC1D

(01) continuous answer

BOX AC1D

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

AC12 - OPDAPPT

yes/no

Was that for a specific condition?

code one

(01) APPOINTMENT
Did [you/(SP)] have an appointment for this visit to the hospital clinic or outpatient department, or did (you/he/she) (02) WALKED IN
just walk in?
(-8) Don't Know
(-9) Refused

code one

We are interested in knowing how the appointment was made for the visit to the hospital clinic or outpatient
department you just told me about.
Did someone make this appointment during an earlier visit, or did [you/(SP)] contact the hospital clinic or
outpatient department to set up the appointment ?

How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?

Routing

(01) AC13 - OPDDRTEL
(02) AC16A - HWAITUNT
(-8) AC16A - HWAITUNT
(-9) AC16A - HWAITUNT

(01) SOMEONE MADE APPOINTMENT DURING
EARLIER VISIT
(02) SP CONTACTED OFFICE TO SET UP
APPOINTMENT
(03) DOCTOR'S OFFICE CONTACTED SP TO SET
UP APPOINTMENT
(-8) Don't Know
(-9) Refused

(01) AC14 - OPDAWUNT
(02) AC14 - OPDAWUNT
(03) AC14 - OPDAWUNT
(-8) AC16A - HWAITUNT
(-9) AC16A - HWAITUNT

(00) DID NOT HAVE TO WAIT
(01) DAYS
(02) WEEKS
(03) MONTHS
(-8) Don't Know
(-9) Refused

(00) AC16A - HWAITUNT
(01) AC14 - OPDAWDAY
(02) AC14 - OPDAWWKS
(03) AC14 - OPDAWMOS
(-8) AC16A - HWAITUNT
(-9) AC16A - HWAITUNT

OPDAWUNT

AC14

code one

OPDAWDAY

AC14

numeric

How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?

(01) continuous answer

AC16A - HWAITUNT

OPDAWWKS

AC14

numeric

How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?

(01) continuous answer

AC16A - HWAITUNT

OPDAWMOS

AC14

numeric

How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?

(01) continuous answer

AC16A - HWAITUNT

WE ARE ASKING HOW MUCH TIME PASSED BETWEEN THE FIRST CONTACT FOR SETTING THE
APPOINTMENT AND THE ACTUAL DATE OF THE APPOINTMENT

Page 2 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ACQ-ACCESS TO CARE

Question Type

Question Text/Description

Code List

(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
(02) MINUTES ONLY
How long did [you/(SP)] have to wait [beyond [your/(SP's)] appointment time] during (your/his/her) most recent
(03) HOURS AND MINUTES
visit before (you/he/she) saw a doctor or some other medical person? Please include the time spent in the waiting
(-8) Don't Know
room and exam room.
(-9) Refused
[Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department.]

HWAITUNT

AC16A

code one

[Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department.]
HWAITHRS

AC16A

numeric

How long did [you/(SP)] have to wait [beyond [your/(SP's)] appointment time] time during (your/his/her) most
(01) continuous answer
recent visit before (you/he/she) saw a doctor or some other medical person? Please include the time spent in the
waiting room and exam room.

Routing
(00) BOX AC1E
(01) AC16A - HWAITHRS
(02) AC16A - HWAITMIN
(03) AC16A - HWAITHRS
(-8) BOX AC1E
(-9) BOX AC1E

If AC16A - HWAITUNT = 3/HoursAndMinutes, go to
AC16A - HWAITMIN
Else go to BOX AC1E.

[Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department.]
HWAITMIN

AC16A

numeric

How long did [you/(SP)] have to wait [beyond [your/(SP's)] appointment time] during (your/his/her) most recent
(01) continuous answer
visit before (you/he/she) saw a doctor or some other medical person? Please include the time spent in the waiting
room and exam room.

BOX AC1E

IF AC9-AC16A ASKED WHILE ADMINISTERING OP, GO TO BOX OP7.

BOX AC1E

routing

ELSE IF BENEFICIARY IS IN THE SECOND ROUND BASELINE INTERVIEW (INTTYPE=7) AND IS NONNEWLY ELIGIBLE (VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE NE 1) AND [(SP DID NOT REPORT A
MEDICAL PROVIDER VISIT OR REPORTED ONLY MEDICAL PROVIDER VISITS THAT WERE ALSO SD
EVENTS (THE EVNT LOOP CONTAINS NO ENTRIES WHERE EVNTTYPE=MP AND
EVNTRNDC=CURROUND)) OR REPORTED ONLY MEDICAL PROVIDER VISITS THAT ARE FLAGGED AS
ERRORS OR DELETIONS (THE ONLY ENTRIES IN THE EVNT LOOP WHERE EVNTTYPE=MP AND
EVNTRNDC=CURROUND ARE FLAGGED WITH EVERRFLG=1 OR EVNTDFLG=1) AND (AC20-AC28A1
NOT ALREADY ASKED), GO TO AC19-MDVISIT.
ELSE IF (SP HAD AN MP VISIT IN THE CURRENT ROUND OR ANY OF THE 2 PREVIOUS ROUNDS) AND
(AC20-AC28A1 NOT ALREADY ASKED), GO TO AC20 - DRSPCLTY
ELSE GO TO BOX AC1G.

MDVISIT

AC19

yes/no

Next, I want to ask about [your/(SP)’s] visits to doctors since [TODAY’S MONTH YEAR-12 MONTHS]. [Have
you/Has (SP)] seen a medical doctor since [TODAY’S MONTH YEAR-12 MONTHS]? Please do not include a
doctor seen at home, at an emergency room or outpatient department, or while an inpatient at a hospital.
[IF NECESSARY, SAY, ‘Please look at show card AC1 for examples of types of medical doctors.’]

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

(01) AC20 - DRSPCLTY
(02) BOX AC1G
(-8) BOX AC1G
(-9) BOX AC1G

Page 3 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ACQ-ACCESS TO CARE

Question Type

Question Text/Description

Code List

(01) AC21 - MDREAS
(02) AC21 - MDREAS
(03) AC21 - MDREAS
(04) AC21 - MDREAS
(05) AC21 - MDREAS
(06) AC21 - MDREAS
(07) AC21 - MDREAS
(08) AC21 - MDREAS
(09) AC21 - MDREAS
(10) AC21 - MDREAS
(11) AC21 - MDREAS
(12) AC21 - MDREAS
(13) AC21 - MDREAS
(14) AC21 - MDREAS
(15) AC21 - MDREAS
(16) AC21 - MDREAS
(17) AC21 - MDREAS
(18) AC21 - MDREAS
(19) AC21 - MDREAS
(20) AC21 - MDREAS
(21) AC21 - MDREAS
(22) AC21 - MDREAS
(23) AC21 - MDREAS
(24) AC21 - MDREAS
(25) AC21 - MDREAS
(26) AC21 - MDREAS
(27) AC21 - MDREAS
(28) AC21 - MDREAS
(29) AC21 - MDREAS
(30) AC21 - MDREAS
(31) AC21 - MDREAS
(32) AC21 - MDREAS
(33) AC21 - MDREAS
(34) AC21 - MDREAS
(35) AC21 - MDREAS
(36) AC21 - MDREAS
(37) AC21 - MDREAS
(38) AC21 - MDREAS
(39) AC21 - MDREAS
(40) AC21 - MDREAS
(41) AC21 - MDREAS
(42) AC21 - MDREAS
(43) AC21 - MDREAS
(91) AC20 - MDSPCLOS
(-8) AC21 - MDREAS
(-9) AC21 - MDREAS

(01) continuous answer

AC21 - MDREAS

(01) MEDICAL CONDITION NAMED
(02) TESTS
(03) FOLLOW-UP
(04) CHECKUP
(05) REFERRAL
(06) SURGERY
(07) PREVENTIVE SHOT
(08) TREATMENT SHOT
(09) TO GET OR REFILL PRESCRIPTION
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX AC1F
(02) BOX AC1F
(03) BOX AC1F
(04) BOX AC1F
(05) BOX AC1F
(06) BOX AC1F
(07) BOX AC1F
(08) BOX AC1F
(09) BOX AC1F
(91) AC21 - MDOTHOS
(-8) BOX AC1F
(-9) BOX AC1F

(01) continuous answer

BOX AC1F

DRSPCLTY

AC20

code one

(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
(03) CARDIOLOGY (HEART)
(04) DERMATOLOGY (SKIN)
(05) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(06) FAMILY PRACTICE
(07) GASTROENTEROLOGY
(08) GENERAL PRACTICE
(09) GENERAL SURGERY
(10) GERIATRICS (ELDERLY)
(11) GYNECOLOGY - OBSTETRICS
(12) HEMATOLOGY (BLOOD)
(13) HOSPITAL RESIDENCE
(14) INTERNAL MEDICINE (INTERNIST)
(15) NEPHROLOGY (KIDNEYS)
(16) NEUROLOGY
(17) NUCLEAR MEDICINE
SHOW CARD AC1
(18) ONCOLOGY (TUMORS, CANCER)
(19) OPHTHALMOLOGY (EYES)
[I have a few more questions about visits that [you/(SP)] had in the past.]
(20) ORTHOPEDICS
(21) OSTEOPATHY (DO)
Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a hospital. (22) OTORHINOLARYNGOLOGY (EAR, NOSE,
What was the doctor’s specialty?
THROAT)
(23) PAIN MANAGEMENT SPECIALIST
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC'
(24) PATHOLOGY
SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE (25) PHYS MED/REHAB
GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE (26) PHYSICIAN’S ASSISTANT
RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER
(27) PLASTIC SURGERY
DR SPECIALTY'.]
(28) PODIATRIST
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(32) RADIOLOGY
(33) RHEUMATOLOGY (ARTHRITIS)
(34) THORACIC SURGERY (CHEST)
(35) UROLOGY
(36) VASCULAR SURGEON/SPECIALIST
(37) AUDIOLOGIST
(38) CHIROPRACTOR
(39) DENTIST
(40) OPTOMETRIST
(41) PHYSICAL THERAPIST
(42) PSYCHOLOGIST
(43) NURSE PRACTITIONER
(91) OTHER DR SPECIALTY
(-8) Don't Know
(-9) Refused

MDSPCLOS

AC20

verbatim text

OTHER DR SPECIALTY (SPECIFY)

What was the reason [you/(SP)] saw the doctor?
MDREAS

AC21

code all

[PROBE: ‘What did you have done during the visit?’ IF RESPONDENT DOES NOT UNDERSTAND WHAT IS
BEING ASKED. PROBE: ‘Any other reason?’ TO OBTAIN ALL REASONS.]
CHECK ALL THAT APPLY.

MDOTHOS

AC21

verbatim text

OTHER (SPECIFY)

Routing

Page 4 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX AC1F

ACQ-ACCESS TO CARE

Question Type

routing

Question Text/Description

Code List

Routing

Was that for a specific condition?

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

AC24 - MDAPPT

Did [you/(SP)] have an appointment for this visit with the doctor, or did (you/he/she) just walk in?

(01) APPOINTMENT
(02) WALKED IN
(-8) Don't Know
(-9) Refused

(01) AC25 - MDDRTEL
(02) AC28A1 - DWAITUNT
(-8) AC28A1 - DWAITUNT
(-9) AC28A1 - DWAITUNT

(01) SOMEONE MADE APPOINTMENT DURING
EARLIER VISIT
(02) SP CONTACTED OFFICE TO SET UP
APPOINTMENT
(03) DOCTOR'S OFFICE CONTACTED SP TO SET
UP APPOINTMENT
(04) STANDING APPOINTMENT
(-8) Don't Know
(-9) Refused

(01) AC26 - MDAWUNT
(02) AC26 - MDAWUNT
(03) AC26 - MDAWUNT
(04) AC28A1 - DWAITUNT
(-8) AC28A1 - DWAITUNT
(-9) AC28A1 - DWAITUNT

IF THE BENEFICIARY IS IN THE SECOND ROUND BASELINE INTERVIEW (INTTYPE=7) AND IS NONNEWLY ELIGIBLE (VIEW_MCBSCOMM_PRELOAD.NEWLY_ELIGIBLE NE 1) AND [((SP DID NOT REPORT
A MEDICAL PROVIDER VISIT OR REPORTED ONLY MEDICAL PROVIDER VISITS THAT WERE ALSO SD
EVENTS ((THE EVNT LOOP CONTAINS NO ENTRIES WHERE EVNTTYPE=MP AND
EVNTRNDC=CURROUND)) OR REPORTED ONLY MEDICAL PROVIDER VISITS THAT ARE FLAGGED AS
ERRORS OR DELETIONS (THE ONLY ENTRIES IN THE EVNT LOOP WHERE EVNTTYPE=MP AND
EVNTRNDC=CURROUND ARE FLAGGED WITH EVERRFLG=1 OR EVNTDFLG=1)) AND (RESPONSE TO
AC21- MDREAS DOES NOT INCLUDE 1/MedCondNamed AND DOES NOT INCLUDE 6/Surgery), GO TO
AC22 - MDSCOND.
ELSE GO TO AC24 - MDAPPT.

MDSCOND

MDAPPT

MDDRTEL

AC22

AC24

AC25

yes/no

code one

code one

We are interested in knowing how the appointment was made for the visit to the doctor’s office you just told me
about.
Did someone make this appointment during an earlier visit, or did [you/(SP)] contact the doctor’s office to set up
the appointment?

MDAWUNT

AC26

code one

(00) DID NOT HAVE TO WAIT
How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days, weeks,
(01) DAYS
or months?
(02) WEEKS
(03) MONTHS
WE ARE ASKING HOW MUCH TIME PASSED BETWEEN THE FIRST CONTACT FOR SETTING THE
(-8) Don't Know
APPOINTMENT AND THE ACTUAL DATE OF THE APPOINTMENT
(-9) Refused

MDAWDAY

AC26

numeric

How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days, weeks,
(01) continuous answer
or months?

AC28A1 - DWAITUNT

MDAWWKS

AC26

numeric

How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days, weeks,
(01) continuous answer
or months?

AC28A1 - DWAITUNT

MDAWMOS

AC26

numeric

How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days, weeks,
(01) continuous answer
or months?

AC28A1 - DWAITUNT

code one

[Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a
hospital.] How long did [you/(SP)] have to wait [beyond [your/(SP's)] appointment time] during (your/his/her) most
recent visit before (you/he/she) saw a doctor or some other medical person? Please include the time spent in the
waiting room and exam room.

numeric

[Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a
hospital.] How long did [you/(SP)] have to wait [beyond [your/(SP's)] appointment time] during (your/his/her) most
(01) continuous answer
recent visit before (you/he/she) saw a doctor or some other medical person? Please include the time spent in the
waiting room and exam room.

If AC28A1 - DWAITUNT = 3/HoursAndMinutes, go to
AC28A1 - DWAITMIN
Else go to BOX AC1G.

AC28A1

numeric

[Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a
hospital.] How long did [you/(SP)] have to wait [beyond [your/(SP's)] appointment time] during (your/his/her) most
(01) continuous answer
recent visit before (you/he/she) saw a doctor or some other medical person? Please include the time spent in the
waiting room and exam room.

BOX AC1G

BOX AC1G

routing

IF AC20-AC28A1 ASKED WHILE ADMINISTERING MP, GO TO MP18 - MPHPRAC.
ELSE IF SP HAS A CURRENT MEDICARE MANAGED CARE PLAN, GO TO AC33 - MHREFDIF.
ELSE GO TO BOX AC3.

DWAITUNT

DWAITHRS

DWAITMIN

AC28A1

AC28A1

(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) Don't Know
(-9) Refused

(00) AC28A1 - DWAITUNT
(01) AC26 - MDAWDAY
(02) AC26 - MDAWWKS
(03) AC26 - MDAWMOS
(-8) AC28A1 - DWAITUNT
(-9) AC28A1 - DWAITUNT

(00) BOX AC1G
(01) AC28A1 - DWAITHRS
(02) AC28A1 - DWAITMIN
(03) AC28A1 - DWAITHRS
(-8) BOX AC1G
(-9) BOX AC1G

Page 5 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ACQ-ACCESS TO CARE

Question Type

Question Text/Description

The following questions are about health care that [you/(SP)] received through (CURRENT MEDICARE
MANAGED CARE PLAN NAME).
MHREFDIF

AC33

code one

While a member of (CURRENT MEDICARE MANAGED CARE PLAN NAME), [have you/has (SP)] had difficulty
in obtaining referrals for the services of a specialist or other medical person within (CURRENT MEDICARE
MANAGED CARE PLAN NAME) that [you/(SP)] thought were necessary?
[IF NECESSARY, SAY: ‘The referral must have been for services provided by a specialist or medical provider
who is associated with your Medicare Managed Care plan, not a specialist or medical provider who is "outside" of
the plan.’]

MPSPCLTY

AC34A

code one

SHOW CARD AC1
What kind of specialist or medical person was this?
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC'
SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE
GENERIC WORD IS SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE
RESPONSE CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER
DR SPECIALTY'.]

MHSPCLOS

AC34A

verbatim text

OTHER (SPECIFY)

Code List

Routing

(01) YES
(02) NO
(03) N/A, HAVEN'T TRIED TO OBTAIN REFERRAL
(-8) Don't Know
(-9) Refused

(01) AC34A - MPSPCLTY
(02) AC36 - MHREFPAY
(03) AC36 - MHREFPAY
(-8) AC36 - MHREFPAY
(-9) AC36 - MHREFPAY

(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
(03) CARDIOLOGY (HEART)
(04) DERMATOLOGY (SKIN)
(05) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(06) FAMILY PRACTICE
(07) GASTROENTEROLOGY
(08) GENERAL PRACTICE
(09) GENERAL SURGERY
(10) GERIATRICS (ELDERLY)
(11) GYNECOLOGY - OBSTETRICS
(12) HEMATOLOGY (BLOOD)
(13) HOSPITAL RESIDENCE
(14) INTERNAL MEDICINE (INTERNIST)
(15) NEPHROLOGY (KIDNEYS)
(16) NEUROLOGY
(17) NUCLEAR MEDICINE
(18) ONCOLOGY (TUMORS, CANCER)
(19) OPHTHALMOLOGY (EYES)
(20) ORTHOPEDICS
(21) OSTEOPATHY (DO)
(22) OTORHINOLARYNGOLOGY (EAR, NOSE,
THROAT)
(23) PAIN MANAGEMENT SPECIALIST
(24) PATHOLOGY
(25) PHYS MED/REHAB
(26) PHYSICIAN’S ASSISTANT
(27) PLASTIC SURGERY
(28) PODIATRIST
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(32) RADIOLOGY
(33) RHEUMATOLOGY (ARTHRITIS)
(34) THORACIC SURGERY (CHEST)
(35) UROLOGY
(36) VASCULAR SURGEON/SPECIALIST
(37) AUDIOLOGIST
(38) CHIROPRACTOR
(39) DENTIST
(40) OPTOMETRIST
(41) PHYSICAL THERAPIST
(42) PSYCHOLOGIST
(43) NURSE PRACTITIONER
(91) OTHER DR SPECIALTY
(-8) Don't Know
(-9) Refused

(01) AC35 - MHDIFCLT
(02) AC35 - MHDIFCLT
(03) AC35 - MHDIFCLT
(04) AC35 - MHDIFCLT
(05) AC35 - MHDIFCLT
(07) AC35 - MHDIFCLT
(08) AC35 - MHDIFCLT
(09) AC35 - MHDIFCLT
(10) AC35 - MHDIFCLT
(11) AC35 - MHDIFCLT
(12) AC35 - MHDIFCLT
(13) AC35 - MHDIFCLT
(14) AC35 - MHDIFCLT
(15) AC35 - MHDIFCLT
(16) AC35 - MHDIFCLT
(17) AC35 - MHDIFCLT
(18) AC35 - MHDIFCLT
(19) AC35 - MHDIFCLT
(20) AC35 - MHDIFCLT
(21) AC35 - MHDIFCLT
(22) AC35 - MHDIFCLT
(23) AC35 - MHDIFCLT
(24) AC35 - MHDIFCLT
(25) AC35 - MHDIFCLT
(26) AC35 - MHDIFCLT
(27) AC35 - MHDIFCLT
(28) AC35 - MHDIFCLT
(29) AC35 - MHDIFCLT
(30) AC35 - MHDIFCLT
(31) AC35 - MHDIFCLT
(32) AC35 - MHDIFCLT
(33) AC35 - MHDIFCLT
(34) AC35 - MHDIFCLT
(35) AC35 - MHDIFCLT
(36) AC35 - MHDIFCLT
(37) AC35 - MHDIFCLT
(38) AC35 - MHDIFCLT
(39) AC35 - MHDIFCLT
(40) AC35 - MHDIFCLT
(41) AC35 - MHDIFCLT
(42) AC35 - MHDIFCLT
(43) AC35 - MHDIFCLT
(91) AC34A - MHSPCLOS
(-8) AC35 - MHDIFCLT
(-9) AC35 - MHDIFCLT

(01) continuous answer

AC35 - MHDIFCLT

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2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

ACQ-ACCESS TO CARE

Question Type

Question Text/Description

What kind of difficulty did [you/(SP)] have?

Code List

Routing

(01) PLAN WOULDN’T AUTHORIZE SERVICE
(02) THE WAIT FOR APPOINTMENT WAS TOO
LONG
(03) PROVIDER’S LOCATION WAS NOT
CONVENIENT
(04) DOCTOR/PLAN WOULDN'T GIVE SP
REFERRAL TO SEE PROVIDER SP WANTED TO
SEE
(05) SP DIDN'T LIKE/NOT CONFIDENT IN PROVIDER
PLAN REFERRED SP TO
(06) PROVIDER’S OFFICE HOURS WERE NOT
CONVENIENT
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) AC36 - MHREFPAY
(02) AC36 - MHREFPAY
(03) AC36 - MHREFPAY
(04) AC36 - MHREFPAY
(05) AC36 - MHREFPAY
(06) AC36 - MHREFPAY
(91) AC35 - MHOTHOS
(-8) AC36 - MHREFPAY
(-9) AC36 - MHREFPAY

MHDIFCLT

AC35

code all

MHOTHOS

AC35

verbatim text

OTHER (SPECIFY)

(01) continuous answer

AC36 - MHREFPAY

AC36

code one

Has (CURRENT MEDICARE MANAGED CARE PLAN NAME) ever refused to pay for emergency treatment that
[you/(SP)] felt was necessary?
[‘EMERGENCY TREATMENT’ REFERS TO URGENTLY NEEDED MEDICAL CARE THAT IS REQUIRED
WHEN THE BENEFICIARY IS OUTSIDE OF THE PLAN'S SERVICE AREA OR WHEN THE CARE IS
REQUIRED DURING A TIME THAT IS OUTSIDE THE PLAN'S NORMAL OPERATING HOURS.]

(01) YES
(02) NO
(03) N/A, HAVEN'T NEEDED EMERGENCY
TREATMENT
(-8) Don't Know
(-9) Refused

BOX AC3

BOX AC3

routing

IF 11TH ROUND INTERVIEW AND (INTTYPE IN C001) AND (MREFDATE) IS AFTER (JANUARY 1
(CURRENT YEAR)) GO TO STQ.
ELSE GO TO PMQ.

MHREFPAY

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

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