MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION NOTICE OF CASE ACTION
FROM	FSD TEAM MEMBER	TELEPHONE NUMBER - -	DATE 11/03/2014
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 ON YOUR MO HEALTHNET FOR FAMILIES(MHF) CASE:
Your application for MO HealthNet for Families has been rejected because.
MO HealthNet for Families (healthcare benefits) have been discontinued for the following persons:
.
The last day of MO HealthNet coverage is:	.
The reason for this decision is:
that your countable income of	exceeds the maximum of	for your household size
of	.	(RSMO 208.151.3)
you did not return the first (1st) quarterly report form. (42 U.S.C. 1396r–6)
your family no longer resides in Missouri. (13 CSR 40-2.310)
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. (42 U.S.C. 1396r–6)
we received your	Transitional MO HealthNet report. Your current income of	Exceeds
the limit of	to continue receiving coverage under this program. (13CSR 40-2.310, 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 in 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	- -
If your situation changes, you must report these changes to the local county office. 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 MC+ healthcare. 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 MC+ healthcare benefits. You may request a certificate by calling the Division of Medical Services, Recipient Services at 1-800-392-2161.
Enclosure: Information Leaflet No. IM-4.
IM-33MHF 10/2014