MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MO HEALTHNET ANNUAL REVIEW
FROM	FAMILY SUPPORT DIVISION	TELEPHONE NUMBER - -	DATE December 27, 2013
OFFICE ADDRESS (STREET)
CITY, STATE, ZIP CODE
TO	NAME
ADDRESS (STREET)
CITY, STATE, ZIP CODE ,
RE	CASE NAME	CASE DCN
Dear
We are required to do an annual review of MO HealthNet eligibility. In order to determine your family’s continued eligibility, we are asking you to complete all sections in the white areas of the attached form. Race and ethnic group information is only for statistical use and is optional. The Social Security Number is required only for persons applying for MO HealthNet coverage.
Please read each item carefully before you answer it. The answers you give will be used to determine continued eligibility for MO HealthNet coverage. If you need any assistance in completing the form, or have any questions, please contact the Family Support Division Information Center at 1-855-373-4636.
After you have completed the form, please sign on the line indicated “parent/guardian” and return in the attached envelope by .
Please include proof of your income such as paycheck stubs for the last 30 days, employer statement, or if you are self-employed, include a copy of your latest tax return. At your request, these documents will be returned to you.
Failure to return the review form may result in MO HealthNet coverage being closed.
Family Support Division
855-373-4636
MO 886-2811 (11-2013)	IM-1U (E 11-2013)

For children to be eligible for MO HealthNet coverage, your family Modified Adjusted Gross Income must be below the amounts indicated, based on your family size.
Maximum Monthly Income Per Family Size**
Family Size	2	3	4	5
NO-COST	$1,939	$2,442	$2,944	$3,447
Monthly Premium	$2,392	$3,011	$3,631	$4,251
*You will be notified of Premium amounts when approved. The monthly premium includes all eligible children in the household. Coverage does not begin until the premium payment is received by the Premium Collections Unit.

For parents to be eligible for MO HealthNet coverage, the family’s Modified Adjusted Gross Income must be below the following amounts, based on family size:
Maximum Monthly Income Per Family Size**
Family Size	2	3	4	5
MONTHLY INCOME	$241	$301	$353	$400
**Family size includes parents and children. Income amounts change annually in April.

Please keep this page. It contains important information.

MO 886-2811 (11-2013)	IM-1U (11-2013)

MISSOURI MO HEALTHNET REVIEW
COMPLETE IN INK	FOR OFFICE USE ONLY
NAME (FIRST, MIDDLE, LAST)	DATE RECEIVED
ADDRESS (HOUSE NO., STREET OR RURAL ROUTE, P.O. BOX NO.) CITY, STATE, ZIP CODE	COUNTY	DCN
HOME PHONE NUMBER	WORK PHONE NUMBER	MESSAGE PHONE NUMBER	ELIGIBILITY SPECIALIST/SUPV/LOAD / /
INSTRUCTIONS: Please answer each question completely. Attach an additional sheet if more space is needed in any section.
A. HOUSEHOLD INFORMATION (LIST ALL CHILDREN, PARENTS/GUARDIANS AND STEPPARENTS WHO LIVE IN YOUR HOME, YOURSELF FIRST.)
NAME (FIRST, MIDDLE, LAST) (MAIDEN)	RACE*/ SEX	HISPANIC Y/N	RELATIONSHIP TO PERSON #1	BIRTHDATE	PLACE OF BIRTH	SOCIAL SECURITY NUMBER
1.	SELF
2.
3.
4.
5.
6.
*(1 -- White 2 -- Black/African American 4 -- American Indian/Alaska Native 5 -- Asian 6. -- Native Hawaiian/Pacific Islander)
1.	Do you wish to start coverage for any of the above persons who are not currently covered by MO HealthNet? YES NO
If yes, who?
2.	Are both parents of all the children in the home? YES NO If NO, complete section D.
3.	Are all of the persons requesting MO HealthNet U.S. citizens? YES NO If NO, list the following information for persons applying
applying for or receiving MO HealthNet who are not U.S. citizens: Name, immigration status, registration number, and date of entry:
4.	Is anyone in your household pregnant? YES NO If YES, who?	Expected due date
B. INCOME (Please attach verification; i.e. paycheck stubs, note from employer, federal income tax return, award letter, etc.)
1.	Are you employed? YES NO If YES, name of employer
How much are you paid before taxes or deductions?	Weekly Every two weeks Twice monthly Monthly
2.	Is anyone else in your home employed? YES NO	If YES, who?
Name of employer
How much are they paid before taxes or deductions?	Weekly Every two weeks Twice monthly Monthly
3.	Does anyone in your home operate their own business or are they otherwise self-employed? YES NO
If YES, who?	Describe what type of self-employment (baby-sitting, farm income, other) and amount
earned:	Weekly Every two weeks Twice monthly Monthly
4.	If you pay for certain things that can be deducted on a federal tax return, list them below:
Alimony Paid	$	How Often
Student Loan interest	$	How Often
Other Deductions	$	How Often	Type:
5.	To make it easier to determine my eligibility, I agree to allow the Family Support Division to use income data, including information
from tax returns for the period of time marked below. The Family Support Division will send me a notice, let me make any changes, and I can opt out at any time.
5 years 4 years 3 years 2 years 1 year Do not use information from tax returns to renew my coverage.
MO 886-211 (11-2013) IM-1U (11-2013)	IM-1U (7-06)/E 11-2013

6.	Does anyone in your home receive other income such as alimony, Unemployment Compensation benefits, sick benefits, interest income, Social Security benefits, or other unearned income? YES NO If YES, complete the following:
PERSON RECEIVING	WHO PROVIDES THE MONEY?	AMOUNT RECEIVED	HOW OFTEN RECEIVED?
C. HEALTH INSURANCE
1.	Does anyone in your home have medical, hospital insurance or Medicare? YES NO If YES, list policies below.
PERSONS INSURED	NAME OF COMPANY AND POLICY NUMBER	TYPE OF COVERAGE
Doctor Hospital If limited coverage explain:
Doctor Hospital If limited coverage explain:
2.	Has anyone in your home lost or dropped health insurance within the past six months? YES NO If yes, provide name(s),
date and reason coverage ended.
3.	Is health insurance available for any member of your family through an employer or other group membership? YES NO
If YES, name of employer or group:
Is the insurance available for: Self Spouse Children How much is the premium for the children?	per
4.	Do any of your children have a medical condition that left untreated would result in death or serious physical injury of the child?
YES NO If YES, provide name(s) of child(ren)
5.	Is a third party responsible to pay for any of your medical care? YES NO If yes, who?
6.	Please refer to the income guidelines sent with the application. If income and family size fall into the premium group, submit 2
quotes from private insurance companies of what they would charge for medical coverage for all of your children.
1. $	per mo. Company	2. $	per mo. Company
D. ABSENT PARENT INFORMATION (Complete this section if a parent of any of the children is absent from the home.)
NAME (FIRST, MIDDLE, LAST) (MAIDEN)	RACE/SEX	SOCIAL SECURITY NUMBER	BIRTHDATE	PARENT OF WHICH CHILD?	LAST KNOWN ADDRESS
1.	Do you have any new information about an absent parent(s)? YES NO If YES, please give details.
2.	Do you have a good reason for not cooperating in obtaining support for medical care? YES NO If YES, please explain
E. PLEASE READ CAREFULLY AND SIGN BELOW.
I/We agree to provide Social Security Numbers of all persons applying for MO HealthNet as required by law. The Social Security Number is used to determine eligibility and verify information.
I/We agree to be evaluated for the Health Insurance Premium Payment Program (HIPP) if I or members of the household are employed or lost employment in the last 30 days and the employer or former employer offers group health insurance.
I/We agree that statements and information provided may be verified.
I/We will report any changes in circumstances within TEN DAYS of when they happen.
I/We know it is against the law to obtain or attempt to obtain benefits to which I am/we are not entitled. Any false claim, statement, or concealment of any material fact whatever, in whole or in part, may subject me/us to criminal and/or civil prosecution. I/we agree that by being determined eligible for MO HealthNet for a child who is deprived of parental support, I/we have assigned all rights to medical support to the State of Missouri, and that I/we must cooperate in establishing paternity and obtaining medical support, unless I/we have good cause. Failure to cooperate does not affect a child’s eligibility for MO HealthNet.
I/We understand that acceptance of MO HealthNet constitutes an assignment of rights to the Department of Social Services, MO HealthNet Division for payment for medical care from a third party.
I/We agree medical information about me and/or my family can be released if needed for treatment, payment of medical expenses, health care operations, and/or to administer this program.
If I am/we are found to be eligible for MO HealthNet I/we know the state of Missouri will pay for covered services on my/our behalf and agree the state may file a claim against my/our estate to recover any assistance received.
My/our signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete, to the best of my/our knowledge. I/we authorize insurers or employers to release any information on myself or my/our dependent(s) needed to determine eligibility for the HIPP program.
SIGNATURE /AFFIDAVIT DATE	SIGNATURE OF SPOUSE /AFFIDAVIT DATE
MO 886-211 (11-2013)	IM-1U (11-2013)

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