Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: EMERGENCY MO HEALTHNET FOR INELIGIBLE ALIENS (EMCIA) FORMS UPDATE
FORM REVISION #
Updates have been made to forms used for EMCIA determinations.
The Emergency MO HealthNet for Ineligible Aliens (IM-365) form was updated to add MO HealthNet Adult Expansion Group (AEG), update contact information for the Medical Review Team (MRT) Processing Center, allow additional dates of service (up to 6), and change to PDF format.
The Emergency MO HealthNet for Ineligible Aliens Determination (IM-365D) was created to document the MRT physician’s determination of qualified coverage dates for EMCIA emergency medical conditions as outlined in Section 1903(v) of the Social Security Act.
These forms are available for staff use in the FSD Intranet Income Maintenance (IM) Forms Manual.
- Review this memorandum with appropriate staff.
- Use the forms with the revision date of 10/2021.
- Discard any forms with older revision dates.