Questionnaire for Medicaid Waiver Recipients and Medicare/Medicaid Beneficiaries




Completing this questionnaire is voluntary. No information is being collected that will reveal your identity or anything about you. Please answer the questions to the best of your ability. It is fine to leave something blank, but please answer as many as you can. If you need assistance, it is fine for family members and caregivers to help you complete the questionnaire or complete it for you. Family members and caregivers filling out the questionnaire for you should base their response on YOUR experience.


Responses received on or before Monday, February 20 will help inform a proposal the State of Ohio is submitting to the Centers for Medicare & Medicaid Services for the development of a more coordinated system of care for individuals who are eligible for both Medicare and Medicaid services in Ohio. The State of Ohio will continue to accept responses after February 20 to help inform the next phase of our work.


Thank you for taking the time to complete this questionnaire.