Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: UPDATE TO MO HEALTHNET (MHN) APPLICATION AND RELATED MHN FORMS
FORM REVISION #
| IM-1ADP | IM-1SSL (SPANISH) |
| IM-1ADP (SPANISH) | IM-1SSL (LARGE PRINT) |
| IM-1OSR | IM-1SSL (DARI) |
| IM-1SSL | IM-1SSL (PASHTO) |
DISCUSSION:
Revisions to the Application for Health Coverage & Help Paying Costs (IM-1SSL) requested through a state plan amendment (SPA) have been approved by the Centers for Medicare and Medicaid Services (CMS).
The revised IM-1SSL allows participants to apply for MHN coverage and provide information so that applications can be processed by Family Support Division (FSD) quickly, and often without requiring additional contact or information from the participant.
Application improvements include:
- Clarifying instructions.
- Adding demographic questions to capture more accurate reporting data.
- Improving ease of reading and understanding of eligibility questions.
- Removing questions that do not impact eligibility.
- Adding questions regarding MO HealthNet Adult Expansion Group eligibility.
- Updating Rights & Responsibilities.
- Adding a new Appendix A (optional) form to capture prior quarter income information.
- Aligning the Appendix C (optional) form with the Family Support Division Appointing an Authorized Representative (IM-6AR) form.
The revised IM-1SSL is available in English, Spanish, Dari, Pashto, and large print.
Other forms are used with the IM-1SSL and were revised to match formatting and other changes made to the IM-1SSL:
- Ongoing Coverage Signature Request (IM-1OSR) was revised and has a new form number. This was previously form number, IM-1SSL Ongoing.
- MO HealthNet Add a Person (IM-1ADP) was revised and renamed. As the IM-1SSL only has room for two household members, this form is used to include additional people on an initial IM-1SSL application. The IM-1ADP may also be used to request to add a new household member to an active MO HealthNet case. IM-1ADP (Spanish) was also revised.
All revised forms have a 9/2023 revision date. All other versions of these forms are now obsolete. FSD will accept obsolete forms until 12/31/23.
Forms are available in the public forms manual and the internal forms manual.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Immediately begin using forms with the 9/2023 revision date.
- Order new IM-1SSL (English and Spanish) from the e-store.
- Access and print necessary forms from the public forms manual and the internal forms manual.
- Remove and recycle obsolete forms.
- Share with community partners.
KE/cj