Category: IM Memo

IM-91 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) UPDATED IM-160 AND IM-161 FORMS WITH IM-160 INSTRUCTIONS AND MANUAL UPDATE

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) UPDATED IM-160 AND IM-161 FORMS WITH IM-160 INSTRUCTIONS AND MANUAL UPDATE

MANUAL REVISIONS:

1145.015.00

FORM REVISION #

IM-160
IM-160 INSTRUCTIONS
IM-161

 

DISCUSSION:

The Advance Notice of Your Administrative Disqualification Hearing (IM-160) and Waiver of Administrative Hearing Disqualification Consent Agreement (IM-161) forms have been converted into fillable PDF forms. The instructions for the IM-160 and policy regarding Disqualification Penalties have been updated to clarify language.

The revised forms are currently available in the IM Forms Manual.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Destroy all previous paper versions of the IM-160 and IM-161 and immediately begin using the updated versions.

 

KE/mm

IM-90 INTRODUCING NEW MEDICAL REVIEW TEAM PACKET (IM-61MRT), UPDATING DISABILITY DETERMINATION FORMS, AND OBSOLETING THE MO HEALTHNET AGED, BLIND, AND DISABLED APPLICATION APPENDICES

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  INTRODUCING NEW MEDICAL REVIEW TEAM PACKET (IM-61MRT), UPDATING DISABILITY DETERMINATION FORMS, AND OBSOLETING THE MO HEALTHNET AGED, BLIND, AND DISABLED APPLICATION APPENDICES

FORM REVISION #
IM-61MRT
IM-61B
IM-61D

 

DISCUSSION:

Introducing IM-61MRT

A new forms packet has been created for MO HealthNet for the Aged, Blind, and Disabled (MHABD) disability determinations. The Medical Review Team Packet to Determine Disability (IM-61MRT) contains many of the forms that are necessary for Family Support Division staff to request medical records, schedule evaluations, and make a disability determination during the Medical Review Team (MRT) process.

The IM-61MRT packet includes:

  • Disability History (IM-61B)
  • Work History (IM-61C)
  • Provider History (IM-61D)
  • Authorization for Disclosure of Consumer Medical/Health Information (MO 650-2616)

Updating Disability Determination Forms

Two of the forms used during the MRT process were updated for clarity and to improve the disability determination process.

The IM-61B has been renamed Disability History (previously Disability Questionnaire) for consistency with other forms used for disability determinations.

The IM-61D has been renamed Provider History (previously Hospitals, Medical Facilities and Physicians Seen within the Past Year). The form requests information for any medical providers the participant has seen in the last five (5) years. This change is to gather a more thorough medical history for the MRT process.

Obsolete MHABD Application Appendices

The MHABD application appendices are now obsolete. Any unused forms in offices should be destroyed.

The forms that were included in the appendices can be accessed individually in the Department of Social Services (DSS) Manuals Forms Manual:

  • Disability History (IM-61B)
  • Work History (IM-61C)
  • Provider History (IM-61D)
  • Authorization for Disclosure of Consumer Medical/Health Information (MO 650-2616)
  • Declaration and Assessment of Assets (IM-78)
  • Appointing an Authorized Representative (IM-6AR)
  • Authorization for Release of Medical/Health Information Nursing facilities, In-Home Nursing Care Providers, and Other Providers of Medical Services (IM-6NF)

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/cj

IM-89 2021 POVERTY INCOME GUIDELINES FOR FAMILY MO HEALTHNET (MAGI) PROGRAMS EXTENDED

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  2021 POVERTY INCOME GUIDELINES FOR FAMILY MO HEALTHNET (MAGI) PROGRAMS EXTENDED

MANUAL REVISION #
Appendix A

 

DISCUSSION:

The MAGI income guidelines in Appendix A which posted April 1, 2021 have been extended through March 31, 2022. The updated Appendix A can be found in the Family MO HealthNet (MAGI) Manual.

 

NECESSARY ACTION:

Review this memorandum with appropriate staff.

 

KE/bl

IM-88 INTERNAL USE ONLY FORMS REMOVED FROM PUBLIC DEPARTMENT OF SOCIAL SERVICES (DSS) FORMS MANUAL AND MOVED TO THE INCOME MAINTENANCE (IM) FORMS MANUAL

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  INTERNAL USE ONLY FORMS REMOVED FROM PUBLIC DEPARTMENT OF SOCIAL SERVICES (DSS) FORMS MANUAL AND MOVED TO THE INCOME MAINTENANCE (IM) FORMS MANUAL

 

DISCUSSION:

The DSS Manuals Forms Manual (public site) is intended to be used primarily by the public. The purpose is to assist participants and community partners who help participants with applying for and maintaining assistance from the Family Support Division (FSD).

The DSS Manuals Forms Manual (public site) has been updated to remove forms that are for internal use only. This includes many forms that staff complete and send to participants, as well as forms that are for field processing only and should not be accessible to participants.

The forms listed below are now available to staff only in the FSD Intranet Forms Manual (internal site).

 

Internal Use Only forms removed from the DSS Manuals Forms Manual:

BCC-1

BCCT Temporary Medicaid Authorization

CARS-3

Demand Letter for Overissuance

CARS-3

Out State Demand Letter (OTSTAT)

CARS-3-AE

Agency Error

CARS-3-IHE

Inadvertent Household Error (SPV-N)

CARS-3-IHE-H

Inadvertent Household Error Suspected Program Violation (SPV-Y)

CTYINFO

County Information Template (IM Forms)

FA-351

Child Care Provider Health and Safety Information

FA-352

Child Care Invoicing And Payment Information

FA-402

Letter for FA-402’s Returned After 90 Days

FA-700

Confidentiality Agreement

FA-701

FAMIS User Request

FA-702

Request for Access to FAMIS Information

FA-703

Access or Revocation of Profile to a FAMIS User Granted by Central Security Administrator

FSD/DBH

Coversheet

FSD/WIU

Tracking Sheet

IM-115

Request for Food Stamp Household Report

IM-14

Request for Interpretation of Policy

IM-145 OTH

Change Report Form

IM-16

Communication Transmittal

IM-16 Log

Child Support TA Sanction Request

IM-204

Returned Check Register

IM-206

Check Transmittal

IM-210 MHN

Report of MHN Quality Control Review

IM-29

MAGI

IM-29

Medicaid Eligibility Authorization

IM-29 OPE

Out-of-Pocket Expenses

IM-29 SPDN

Notification of Spend Down Coverage

IM-30A

MA Spend Down Worksheet

IM-30B

Surplus Computation Worksheet

IM-31

Appointment Letter

IM-311Q

QC Referral For Contact/Sanction

IM-31A

Request for Information

IM-31A

Request for Information Electronic

IM-31A

Request for Information – Spanish

IM-31A SHMB

Request for Information Show Me Healthy Babies

IM-31M

Notification of Missed Interview

IM-31Q

Notice Of Contact Requested

IM-31SPDN

Spend Down Notification

IM-32DIV

Temporary Assistance Diversion Approval Notice

IM-32MAGI

Approval Notice

IM-32MAWD

Notice of Case Action

IM-32SMHB

Action Notice – SMHB

IM-32SPDN

Notice of Approval for Medical Assistance Spend Down

IM-33

Notice of Case Action

IM-33A

Notice of Temporary Assistance/Food Stamp Case Action

IM-33MAGI

MAGI Notice of Case Action

IM-33MAGI

MAGI Notice of Case Action – Spanish

IM-33MHF

MO HealthNet for Families Notice of Action

IM-33TMH-R

Transitional MO HealthNet Quarterly Report

IM-360A

Extension or Closing Summary

IM-363

Notice of Temporary Assistance Extension for Hardship Action

IM-365

EMCIA Cover Sheet

IM-39

Request For Employment Security Information – Outside State Of Missouri

IM-39A

Request For Public Assistance Information – Outside The State Of Missouri

IM-41TA

TANF Months Used

IM-54

Referral for Services

IM-54A

Home and Community Based Services Referral/Assessment

IM-58

Transitional MO HealthNet Suspension Notice

IM-61

Social Information Summary

IM-62

Notice of Eligibility for Nursing Facility/Other Vendor

IM-62 PEME

Notice Of Post Eligibility Medical Expense Reduction In Surplus

IM-62 PEME-NFA

PEME Facility Notification – Approval

IM-62 PEME-NFD

PEME Facility Notification – Denial

IM-63 HWD

MO HealthNet Undue Hardship Waiver Decision

IM-63 HWN

MO HealthNet Undue Hardship Waiver Letter

IM-63 HWR

MO HealthNet Undue Hardship Waiver Request

IM-66 MAN

Medical Appointment Notification

IM-66 MAR

Medical Appointment Notification – Authorized Representative

IM-66 MRN

Medical Appointment Reschedule Notification

IM-66 MRR

Medical Appointment Reschedule Notification – Authorized Representative

IM-6EBT

Authorization for Release of Information

IM-76

Social Security Referral Request

IM-80

Adverse Action Notice

IM-80PRE

Pre-Closing Notice

IM-80SPDN

Non-spend down to spend down Adverse Action Notice

IM-80TMH

Adverse Action Notice

IM-82A

Notice of Vendor Termination

IM-89

Agency Representative Food Stamp Hearing Control Log

IM-90

Withdrawal of Request for Hearing

IM-90A

Agency Action Rescinded

IM-90B

Agency Action Withdrawn Participant Notification

IM-94A

Family Child Care Provider Notice of Registration (Appr/Rej)

IM-94B

Parental Notice of Family Child Care Provider Registration (Appr/Rej)

Menu

Adds Menu Items for IM Forms to MS Word

MO 580-2421

Family Care Safety Registration  – Child Care And Elder-Care Worker Registration

MRT Checklist

MRT Checklist

PE-1

SSL Application

PE-2

Worksheet

PE-3

PE Auth

PE-3

TEMP SMHB

WRKRINFO

Worker Information Template
 

SSI/SSDI Transition Letter

 

SSI/SSDI Transition Letter – Spanish
 

Signature Request Letter
 

Internal Inspections Report/Field Office
 

IRS Notice Log
 

Research and Evaluation Request
 

Standard Visitor Log
 

DHSS Referral Letter
 

DHSS Referral Letter-Spend Down
 

Application for Other Benefits letter
 

MO HealthNet Spend Down Discussion Checklist
 

Temporary Assistance Diversion Transmittal Form

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Update saved links.

 

KE/cj

IM-87 APPLICATION FOR HEALTH COVERAGE & HELP PAYING COSTS (IM-1SSL) UPDATED

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  APPLICATION FOR HEALTH COVERAGE & HELP PAYING COSTS (IM-1SSL) UPDATED

FORM REVISION #
IM-1SSL

 

DISCUSSION:

The IM-1SSL has been updated to add new options for applicants to submit their application to Family Support Division.

Mail to: Family Support Division
615 E. 13th St.
Kansas City, MO 64106

Email to: FSD.Documents@dss.mo.gov

Fax to: (573) 526-9400

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Order forms from the E-store or print from Department of Social Services Forms manual.
  • Use the form with the Kansas City submission address (see page 8) and discard any forms with the Joplin address.

 

KE/cj

IM-86 INTRODUCING MO HEALTHNET (MHN) INFORMATIONAL NOTICE (IM-34 AEG) FOR USE WITH MHN APPLICATION PROCESSING

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  INTRODUCING MO HEALTHNET (MHN) INFORMATIONAL NOTICE (IM-34 AEG) FOR USE WITH MHN APPLICATION PROCESSING

FORM REVISION #
IM-34 AEG

 

DISCUSSION:

The MHN Informational Notice (IM-34 AEG) is a new form Family Support Division (FSD) will send to applicants who may potentially be eligible for MHN Adult Expansion Group (AEG). The IM-34 AEG advises participants that they were rejected for MO HealthNet for Families, but they will still be evaluated for AEG when FSD begins processing AEG applications.

When a determination will reject an adult applicant, but must be authorized to approve benefits for a pregnant individual or a child (age 0-18 years old), staff must fill out this form, send a copy to the participant, and a copy to the electronic file.

EXAMPLE:  Carla applies for MHN for herself and her husband, George. Carla reports that she is pregnant and there are no other children in the home. The eligibility system determines that Carla is eligible for MO HealthNet for Pregnant Women and George is ineligible as there is no eligible child in the home. However, George may be eligible for AEG.

    • Approve MPW for Carla and reject MHF for George.
    • Complete the IM-34 AEG, send to Carla, and save a copy in Carla’s electronic file.
    • Add notes to Carla’s person page that the case was authorized to approve a pregnant individual and an IM-34 AEG was sent for George.

The IM-34 AEG was added to the IM Forms Manual for staff to access.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/cj

IM-85 AVAILABLE RESOURCES FOR OLD AGE ASSISTANCE (OAA) AND PERMANENT AND TOTAL DISABILITY (PTD) CALCULATED USING CONSUMER PRICE INDEX-URBAN

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  AVAILABLE RESOURCES FOR OLD AGE ASSISTANCE (OAA) AND PERMANENT AND TOTAL DISABILITY (PTD) CALCULATED USING CONSUMER PRICE INDEX-URBAN

MANUAL REVISION #
1030.000.00

 

DISCUSSION:

Dated 7/1/2021, IM-70 Annual Mo HealthNet for Aged, Blind, and Disabled (MHABD) Asset Limit Increase shows the Individual Asset Limit increased to $5,035 and Couple Asset Limit increased to $10,070. These figures were calculated using the Consumer Price Index-Urban (CPI-U). CPI-U is the measure of the average change over time in the prices paid by urban consumers for a market basket of consumer goods and services. Manual Section 1030.000.00 has been updated to reflect the changes in the assets as well as a definition of CPI-U.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/mc

IM-84 MILEAGE REIMBURSEMENT RATE INCREASE FOR ALL INCOME MAINTANENCE (IM) PROGRAMS

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  MILEAGE REIMBURSEMENT RATE INCREASE FOR ALL INCOME MAINTANENCE (IM) PROGRAMS

MANUAL REVISION #
APPENDIX J

 

DISCUSSION:

The state mileage rate used to calculate expenses for all IM programs increased from $.43 per mile to $.49 per mile effective 07/01/2021. Use the rate of $.49 per mile when calculating mileage expenses.

Eligibility system updates were completed on 07/21/2021 to reflect the rate increase. Appendix J of the MO HealthNet for the Aged, Blind and Disabled manual has been updated to reflect the change.

Note: Final approval for the increased rate was received after July benefits were created. Affected cases have been adjusted to reflect this change for July 2021 and notices will be generated.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/nw

IM-83 APPLICATIONS SIGNED BY A RELATIVE REQUESTING MO HEALTHNET FOR THE AGED, BLIND, AND DISABLED (MHABD) BENEFITS

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  APPLICATIONS SIGNED BY A RELATIVE REQUESTING MO HEALTHNET FOR THE AGED, BLIND, AND DISABLED (MHABD) BENEFITS

MANUAL REVISION #
0105.010.00

 

DISCUSSION:

Section 0105.010.00 SIGNING THE APPLICATION of the General Information Manual was updated to specify that a relative is a person aged 18 years or older who is related to the applicant biologically, by marriage, or by adoption.

This is consistent with Family MO HealthNet (MAGI) Manual, 1802.020.00 SIGNING THE APPLICATION.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/cj

IM-82 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) IM-210 FORM AND INSTRUCTIONS REVISED

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) IM-210 FORM AND INSTRUCTIONS REVISED

FORM REVISION #
Report of SNAP Quality Control Review (IM-210)
Instructions for Completing the IM-210

 

DISCUSSION:

The Report of SNAP Quality Control Review form (IM-210) and Instructions have been updated. The updated form revises Food Stamps to SNAP, job title terms and time frames. The revised form is currently available in the IM Forms Manual.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Destroy all previous paper versions of the IM-210 and immediately begin using this version.

 

KE/mm