MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

NOTICE OF CASE ACTION FOR ADULT MEDICAID AND CASH ASSISTANCE

FROM	OFFICE	TELEPHONE NUMBER - -	DATE December 27, 2013
ADDRESS (STREET, CITY, STATE, ZIP CODE)
TO	NAME	RE	CASE NAME
ADDRESS (STREET)	CASE NUMBER
CITY	STATE	ZIP CODE
The following action was taken on your case:
Your application has been rejected.
Your cash grant has been closed effective .
Your new grant amount will be $ , beginning .
Your MO HealthNet benefits have not changed.
MO HealthNet coverage has ended for .
The last day of MO HealthNet coverage is .
Other:
The action was taken because:
If you do not agree with this decision, you have the right to request a hearing within 90 days from the date of this letter.
If you request a hearing, you may present your information, or your attorney or another person who knows your situation may represent you. You can have witnesses on your behalf, and you can question witnesses who appear at the request of the Family Support Division. To ask about free legal services, call - - .
You must report any changes in your situation to the Family Support Division. The law has penalties for a person who receives benefits because s/he did not tell us all the facts, or because s/he did not report a change. If you seek medical coverage under another health insurance plan, such as a group plan offered by your employer, you may need a Certificate of Creditable Coverage showing when you were covered by MO HealthNet. The certificate may help prove you have met part or all of an exclusionary period for pre-existing conditions. You may request a certificate within 24 months of losing MO HealthNet benefits. You may request a certificate by calling the MO HealthNet Division, Recipient Services at 1-800-392-2161.
NAME	TITLE
Enclosure: Information Leaflet No.
MO 886-0707 (01-2014)	RETAIN CURRENT FORM	IM-33 (01-2014)