Application for Presumptive Eligibility

Use this form to find out if you qualify for presumptive eligibility for MO HealthNet at a qualified hospital or clinic. Presumptive Eligibility offers you and your family immediate access to health care while you apply and wait to learn if you qualify for regular MO HealthNet coverage.

To find out if you qualify for regular MO HealthNet, you must complete the Single Streamlined application (IM-1SSL):

Online at mydss.mo.gov;

By telephone at 1-855-373-9994; or

Mail, fax, or drop off a completed IM-1SSL at any Family Support Division Office.

If you need help:

Ask your healthcare provider to assist you;

Call our Contact Center at 1-855-373-9994.

TDD Voice Access: 1-800-735-2466

En Español: Llame a nuestro centro de ayuda gratis al 1-855-373-9994.

Who can qualify for presumptive eligibility for MO HealthNet?	You can qualify for presumptive eligibility for MO HealthNet if you meet all of these rules: Your income is below the monthly limit; You do not already have MO HealthNet, except for Uninsured Women's Health Services or Extended Women's Health Services; You have not had presumptive eligibility for MO HealthNet in the past 12 months. Or, if you are pregnant, you have not had Temporary (TEMP) MO HealthNet during this pregnancy. You are in one of the groups that qualifies for presumptive eligibility for MO HealthNet: Children under age 19; Parents and caretaker relatives of children under age 19; Pregnant women; People under age 26 who were in foster care at age 18; Women in treatment for breast and cervical cancer.

Provider Name: Provider Number: Phone number:

1 Tell us about yourself

We ask for this information so we can contact you about this application.

Legal Name (first, middle, last)

Home address (leave blank if you don’t have one)

City	State	ZIP code	County

Mailing address (if different from home address)

Phone number (if you have one)	Email address (if you have one)

2	Tell us about your family List yourself and the members of your family who live with you based on the below household categories: Tax filers include: Anyone required to file income taxes. This may include you, your spouse, or the person claiming you on their taxes Tax Dependents include: Everyone who will be claimed on the tax filers’ taxes as a dependent. Non tax filers include: person needing coverage, children of the person needing coverage, spouse, parents (including step-parents) and siblings under 19.
Legal Name (first, middle, last)	Date of birth (XX/XX/ XXXX)	Relationship to you	Applying for presumptive eligibility for MO HealthNet? (Yes or No)	Already has MO HealthNet? (Yes or No)	Resident of Missouri? (Yes or No)	Race (optional)	Social Security Number (optional)
Answer for family members who are applying. If a person is not applying, you do not have to answer these questions for that person.
(Same person as step 1)	(Self)

Questions? Ask your hospital representative or call us at 1-855-373-9994. The call is free.

TDD Voice: 1-800-735-2466. You can call Monday through Friday 8 a.m.- 5 p.m.

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Other questions

3	Answer these questions for yourself and your family members listed in Section 2. Your answers will make it

easier to find out if you and any family members qualify.

Is anyone pregnant?  Yes  No If yes, who?

How many babies does she expect? What is the estimated due date? _

Is everyone who is applying for MO HealthNet Presumptive Eligibility a U.S. citizen? (If applicant is pregnant, no response is required for this question.)  Yes  No

If no, list the following information for applicants who are not U.S. Citizens: Name, Immigration status, and date of entry:

Is anyone who is applying for MO HealthNet Presumptive Eligibility a parent or caretaker relative?  Yes  No

If yes, who is the parent or caretaker relative?

If yes, is any child in their care and control under age 18 or a full time student under age 19?  Yes  No

Was anyone who is applying for MO HealthNet Presumptive Eligibility in foster care 30 days prior to their 18 birthday?  Yes  No

If yes, who?

Is anyone who is applying for MO HealthNet presumptive eligibility being treated for	 Yes  No breast or cervical cancer?

If yes, who?

4 Tell us about your family’s income

Write the total income before taxes are taken out for all family members listed in Section 2.

 Job income For example, wages, salaries, and self-employment income.

Amount $

How often? (check one) Weekly	Biweekly	Semi-monthly

Monthly	Yearly

Do you pay for certain things that can be deducted on a Federal income tax return? Please enter the monthly amount below. (Example: Alimony paid, student loan interest paid, and other expenses allowed by the IRS to calculate adjusted gross income.)

Name of Deduction:	Amount $	Name of Deduction:	Amount $

Name of Deduction:	Amount $	Name of Deduction:	Amount $

 Other income - For example: unemployment checks, alimony, or disability payments from the Social Security

Administration (SSDI). (Do not include Supplemental Security Income (SSI), any child support you receive, veteran’s benefits, gifts,

American Indian/Alaskan Payments or educational assistance.)

Amount $

How often? (check one) Weekly	Biweekly	Semi-monthly

Monthly	Yearly

5	Sign this form here By signing, you are swearing that everything you wrote on this form is true as far as you know. We will keep your information secure and private.
Your signature:	Date:

Questions? Ask your hospital representative or call us at 1-855-373-9994. The call is free.

TDD Voice: 1-800-735-2466. You can call Monday through Friday 8 a.m. – 5 p.m.

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6 If you qualify for presumptive eligibility for MO HealthNet, what happens next?

You will get a letter from the hospital or clinic saying you were approved.

You can start using your MO HealthNet Presumptive Eligibility coverage right away for services such as doctor visits, hospital care, and prescription drugs. You can go to any health care provider who accepts MO HealthNet, starting the day you are approved.

Use the letter provided by the hospital or clinic until your MO HealthNet card arrives. The card should arrive within five business (5) days. If you lose the letter, call us at 1-855-373-9994 for a replacement.

If the letter says you qualify for presumptive eligibility for MO HealthNet because you are pregnant, you can get care at outpatient clinics or other places in the community. MO HealthNet Presumptive Eligibility will not cover the cost if you are admitted to a hospital.

If you do not fill out and send the MO HealthNet Single Streamlined application (IM-1SSL) to see if you qualify for regular MO HealthNet, your presumptive eligibility for MO HealthNet coverage will end on the last day of the month after the month you are approved.

 For example, if you qualified for presumptive eligibility for MO HealthNet in January, it will end on the last day of February.

To see if you qualify for regular MO HealthNet, visit us online at mydss.mo.gov and submit an application, call 1-855-373-9994 to apply, or mail, fax, or drop off a completed IM-1SSL at any Family Support Division Office. The hospital representative can also give you an application.

7 If you do not qualify for presumptive eligibility for MO HealthNet, what happens next?

You will receive a copy of the QE Presumptive Eligibility Determination from the hospital or clinic saying you were not approved. You cannot appeal the hospital or clinic’s decision. BUT, you can still apply for regular MO HealthNet coverage using the MO HealthNet Single Streamlined application (IM-1SSL):

Online at mydss.mo.gov;

By telephone at 1-855-373-9994; or

Mail, fax, or drop off a completed IM-1SSL at any Family Support Division Office.

Questions? Ask your hospital representative or call us at 1-855-373-9994. The call is free.

TDD Voice: 1-800-735-2466. You can call Monday through Friday 8 a.m. – 5 p.m.

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