MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION NOTICE OF CASE ACTION
FROM	FSD TEAM MEMBER	TELEPHONE NUMBER - -	DATE 05/28/2015
FSD OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) ,
TO	NAME	RE	HEAD OF HOUSEHOLD NAME
ADDRESS (STREET)	CASE NUMBER
CITY STATE ZIP CODE
WE HAVE TAKEN THE FOLLOWING ACTION(S) ON YOUR CASE:
Your MO HealthNet application dated has been rejected.
Your MO HealthNet review was completed and there are no changes to your benefits.
MO HealthNet benefits have been discontinued for the following person(s):
.
The last day of MO HealthNet coverage is:	.
MO HealthNet benefits have changed to effective
for the following persons: .
You are now required to pay a monthly premium to continue coverage for the following person(s):
.
You will receive an invoice informing you of the premium amount and the date payment is due.
The reason for this decision is:
that your countable income of	exceeds the maximum of	for your household size
of	.	(RSMo 208.991.2(2))
you did not return the first (1st) quarterly report form. (42 U.S.C. 1396r–6)
your family no longer resides in Missouri. (RSMo 208.990)
you no longer have an eligible child living in the home, because the last such child either has left your
household or has exceeded the MO HealthNet for Families age requirement. (RSMo 208.151)
we received your	Transitional MO HealthNet report. Your current income of	exceeds
the limit of	to continue receiving coverage under this program. (42 U.S.C. 1396r–6)
Other:
Eligibility for health coverage has changed to Transitional MO HealthNet for the individuals listed above because of
earnings from employment. There has been no change in your healthcare benefits for these individuals.
Coverage will continue through	.	If you meet certain requirements, you may be
eligible for an additional six months. coverage.
Your MO HealthNet for Families healthcare benefits have been reinstated effective
The reason for this action is
Due to the closing of your MO HealthNet for Families case an ex parte review was completed. The following changes
in coverage were made:
If you disagree 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 the information yourself or you may be represented by your own attorney or by other persons who know your situation. You have the right to present witnesses on your own behalf and to question witnesses who appear at the request of the Family Support Division.
For the possibility of free legal services, call	- -
You must report any change in situation within 10 days to the FSD Information Center at (855) 373-4636) or a FSD Resource Center. The law provides penalties for any persons who receive benefits to which they are not entitled through misrepresenting the facts or not reporting full information about their situation.
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 medical 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.
Enclosure: Information Leaflet No. IM-4.
IM-33MAGI 06/2015