MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MO HEALTHNET UNDUE HARDSHIP WAIVER LETTER
FROM	ELIGIBILITY SPECIALIST	TELEPHONE NUMBER - -	DATE 10/03/2013
COUNTY OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) ,
TO	NAME	CASE NAME
ADDRESS (STREET)	CASE NUMBER
CITY, STATE ZIP CODE	TELEPHONE NUMBER - -
Your MO HealthNet vendor case will be:
Closed per Section	RSMo 208.010.7 & 42 U.S.C. 1396p(c)
Denied per Section	RSMo 208.010.7 & 42 U.S.C. 1396p(c)
due to the imposition of the penalty for transfer of assets.
The penalty will begin	and last until	.
If you are a nursing home or institutionalized hospice patient, this means that MO HealthNet will not pay for your stay at the NH or services you receive as an institutionalized hospice recipient. If you are applying for or receiving MO HealthNet under one of the other “waivered” categories, this means you are not eligible for Medicaid, and your case will be denied or closed. You will receive a separate computer generated notice to this effect. If you feel that the denial/closure/penalty of your case will result in undue hardship to you (not to your spouse or anyone else), you may apply for an Undue Hardship Waiver to exclude the asset/transfer(s) that is making you ineligible or penalized. However, there are very strict guidelines for this to be considered. For transferred assets, you must take “legal action and equitable remedies to recover the asset” before undue hardship can be considered. If you would like to pursue applying for the Undue Hardship Waiver, contact me using the information at the end of this letter, within 10 calendar days of the date on this notice.
The due date is	.
I will mail/give you a form to complete. You must return the completed form to me with other information, including proof of the legal action taken, etc. I will let you know if other information is needed, perhaps including documentation from your physician. Your application for Undue Hardship will be forwarded to MO HealthNet Program and Policy (MHN P&P) to review for approval or denial. If MHN P&P denies your waiver application, you will be sent another notice outlining the action taken. At that time, you may further make an appeal to be heard by an Administrative Hearing Officer. You may request a hearing by contacting the FSD Information Center toll free at 1-855-FSD-INFO (1-855-373-4636), going to any FSD office, or mailing a request to any FSD office or to the address at the top of this letter. For questions and/or to request the Undue Hardship Waiver information, contact the Family Support Division Information Center at (855) 373-4636 and ask to have an eligibility specialist call you back.