Missouri Medicaid Survey--We Need Your Help
The Missouri Budget Project is working with more than 20 organization to gather information about what is happening to Missourians who are losing their health care coverage because of cuts to Medicaid. Please take a few moments to fill out the survey.
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I understand that this survey is being conducted to help track the effects of changes in the Missouri Medicaid program. You have permission to release my information as follows:
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You may use this information for your oganization's statistical tracking purposes only
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You may share this information with other organizations who are tracking the effects of the cuts
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Please let us know whether we can use your name for follow-up:
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You may use my name and I am willing to be contacted by other organizations for further information and follow up
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You may use my name and I am willing to be contacted by the media
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Please do not use my name and I do not wish to be contacted for follow up
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4/5/2007
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Name
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Street Address
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City
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Zip Code
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County
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Phone Number
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Second Phone Number
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E-mail address
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Age
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Gender
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Race / Ethnicity
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Caucasian / White
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African American
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Asian
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Hispanic
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Other:
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Average Monthly Household Income
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Number of People in Household
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One
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Two
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Three
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Four
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Five
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Six or more
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Please check all that apply to you
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I depend on Missouri Medicaid for my health coverage
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Children in my household depend on Missouri Medicaid
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Other close family member(s) depend on Missouri Medicaid
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I am dual eligible (have both Medicaid and Medicare)
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I applied for but was denied Medicaid
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Have the Missouri Medicaid changes affected you?
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How did you find out about the changes to your or your family's Medicaid coverage?
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Letter from Missouri Department of Social Services
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Letter from my local county Family Support Division Office (DFS office)
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Media (TV, Radio or Newspaper)
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Doctor or healthcare service provider
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Other:
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Which of the following describes your situation (check all that apply)
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I am a parent and I have lost coverage because I now make too much money to qualify
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I am temporarily or permanently disabled and lost General Relief Medicaid coverage
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I have lost coverage because of the elimination of MC+ for parents
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I have lost my Medical Assistance for Disabled Workers (MAWD) coverage because I am disabled and still work
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I am elderly and my income is over $678 per month
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I am disabled and my income is over $678 per month
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I cannot afford the office visit or pharmacy co-pay
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My child/children no longer receive coverage because I cannot afford the monthly premium
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What goods or services have you or your family lost (check all that apply)
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I have lost dental services (including dentures)
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I no longer receive mental health services
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I cannot afford or have access to my prescription drugs
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I have lost podiatry (foot) services
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I have lost orthopedic services
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I have lost hearing aid services
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I cannot get batteries or accessories for my wheelchair
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I need but cannot get a cane, crutches or a walker
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I cannot get eyeglasses
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I cannot get a hearing aid
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Please check all that apply to you
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I have lost day rehabilitation services
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I have lost occupational, speech or physical therapy
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I have an artificial limb but canot get it fitted or adjusted or receive therapy to use it
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I will lose a personal care attendant
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Other services I need but are no longer covered by Medicaid
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Which of the following describes your situation (check all the apply)
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My child/children still receive MC+ coverage but I must now pay a premium
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My doctor no longer takes me as a patient
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My dentist no longer takes me as a patient
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I have to be on the waiting list to get medical care
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I have to be on a waiting list to get dental care
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I wil no longer have access to transportation to get health care
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I will have to remove my relative from a residential care facility
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I had a preauthorization for a procedure, equipment or examination but I was scheduled after August 31 so had to be cancelled
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Other:
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How do you plan on getting access to healthcare? (check all that apply)
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I am planning on going to my local hospital emergency room
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I am planning on going to another community's hospital emergency room
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I am planning on going to a local free clinic
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I am planning on going to the community health center
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I am planning on going to my county health department
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I will quit my job to keep Medicaid coverage
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I will go inot a residential care facility to get coverage
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I will cut back on food to pay for my medicine or helath care
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I will cut back on utility use or housing expenses to pay for my medicine or health care
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I do not know what I am going to do
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Other:
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Please feel free to tell us more about yourself and how Missouri Medicaid cuts are affecting you or your family.
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