MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

ADVERSE ACTION NOTICE

FROM	Address (Street, City, State, Zip Code) , MO	DATE December 27, 2013
TO	NAME	CASE NAME
ADDRESS (STREET OR P.O. BOX NO.)	CASE NUMBER
CITY STATE ZIP
BASED ON THE INFORMATION WE HAVE ABOUT YOUR ELIGIBILITY WE MUST:
discontinue your	grant effective for the month of
reduce your	grant to	effective for the month of
The reason for this decision is that
discontinue MO HealthNet for
The last day of MO HealthNet coverage is
(MONTH)	(DAY)	(YEAR)
The reason for this decision is that
other:
The reason for this decision is that
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.
If you agree with this decision, you do not have to request a hearing. If you do not request a hearing, we will discontinue or reduce your assistance following the date indicated above. If you believe this decision is wrong or if you have
information that you believe will prove you need to continue to receive your present amount of assistance, you have
until	to request a hearing.
(DAY OF WEEK) (MONTH) (DAY) (YEAR)
If you wish to have a hearing, you may request it by mail, by telephone, or in person. To request a hearing
by telephone, call - -	To request a hearing by mail, you may fill out and return the information on page 2.
If you request a hearing by the date above, your benefits may continue pending the results of the hearing. If the hearing decision shows that the plan to reduce your benefits or close your case was correct, your household will be responsible for repaying the amount of benefits you were not entitled to receive while your hearing was pending. If you elect to discontinue receiving benefits while your hearing is pending and the hearing decision is ruled in your favor, lost benefits will be restored to you.
If you request a hearing, we will schedule it for you and notify you of the time of the hearing. At the hearing, you may present your information yourself or you may be represented by your own attorney or by other persons who know your situation. If you do not have an attorney, or cannot afford one, and live in an area served by a legal aid or legal services office, you may be eligible for this service.
For the possibility of free legal services call:	- -	. 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.
SIGNATURE	TITLE	TELEPHONE - -
ENCLOSURE: INFORMATION LEAFLET(S) NO. IM-4
MO 886-0747 (01-2014)	IM-80 (01-2014)

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IF YOU WANT A FAIR HEARING, FILL OUT THIS FORM AND MAIL IT TO:
NAME OF PERSON REQUESTING HEARING	ADDRESS
TELEPHONE NUMBER WHERE YOU CAN BE REACHED	YOUR SIGNATURE	TODAY’S DATE
USE THIS SPACE TO TELL US WHY YOU WANT A FAIR HEARING
FOR OFFICE USE ONLY
CASE NO.	CASEWORKER	LOAD NO.	DATE NOTICE SENT December 27, 2013	DATE REQUEST RECEIVED
MO 886-0747 (01-2014)	IM-80 (01-2014)