Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: NEW FORM FOR MO HEALTHNET FOR FAMILIES (MAGI) ONGOING COVERAGE SIGNATURE REQUEST (IM-1SSL)
FORM REVISION #
IM-1SSL Ongoing Coverage Signature Request
The purpose of this memorandum is to introduce a new form, the IM-1SSL Ongoing Coverage Signature Request. This form is to be used for completing an ex parte review for MAGI eligibility when a new case is established for the participant due to moving out of the existing MAGI household.
Example: Ms. A is receiving MO HealthNet for Pregnant Women (MPW) under her mother’s case and when the birth of the baby is reported it is learned that the birth mother is no longer living in the existing MAGI household. A new case should be established and a signature should be obtained by sending the IM-1SSL Ongoing Coverage Signature Request with an IM-31A.
Note: In this example, Family Support Division (FSD) would observe the pending adverse action period on the case on which the participant is being removed. Once the new case is established, after the observation of the adverse action period, FSD will not take a negative action if the IM-1SSL Ongoing Coverage Signature Request form is not returned, however, FSD will attempt another contact as well as send a new IM-31A with the form.
When requesting a signature, the following statement should be used on the IM31A:
Please complete the enclosed IM-1SSL Ongoing Coverage Signature Request Form. You either receive(d) coverage on someone else’s case or you don’t currently have your own case with FSD. FSD has information that indicates you may be eligible to continue coverage on your own MO HealthNet case, but we’d like your permission to open a case for you. Review your Rights and Responsibilities and complete section 1 with your additional household members.
Please call 855-373-4636 with any questions.
Thank you for your cooperation!
- Review this memorandum with appropriate staff.
- Implement the manual follow up process for tracking the IM-31A and the signature request form.