MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

MO HEALTHNET FOR FAMILIES ADVERSE ACTION NOTICE

FROM	Address (Street, City, State, Zip Code) , MO	DATE November 3, 2014
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 MO HEALTHNET FOR
FAMILIES COVERAGE FOR: discontinue MO HealthNet for Families coverage for:
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 will change to Transitional MO HealthNet for the individual(s) listed above because of earnings from employment.
There is no change in healthcare coverage for these individuals. Coverage will continue through	.
If certain requirements are met, you may be eligible for six (6) months additional coverage. (13 CSR 40-2.375, RSMo 208.145)
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.
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 855-373-4636.	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.
FSD Team Member:	TITLE	TELEPHONE - -
ENCLOSURE: INFORMATION LEAFLET(S) NO. IM-4
MO 886-0747 (10-2014)	IM-80 TMH(10-2014)

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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 November 3, 2014	DATE REQUEST RECEIVED
MO 886-0747 (01-2014)	IM-80 (01-2014)