Category: MoHealthNet Home

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

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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-80 MANUAL SECTIONS REVISED TO ONLY INCLUDE THE ESTATE RECOVERY INFORMATION NECESSARY FOR THE ADMINISTRATION OF MO HEALTHNET FOR THE AGED, BLIND, AND DISABLED (MHABD) PROGRAMS

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  MANUAL SECTIONS REVISED TO ONLY INCLUDE THE ESTATE RECOVERY INFORMATION NECESSARY FOR THE ADMINISTRATION OF MO HEALTHNET FOR THE AGED, BLIND, AND DISABLED (MHABD) PROGRAMS

MANUAL REVISION #

0880.005.00
1025.015.04.01

 

DISCUSSION:

Revisions have been made to the Estate Recovery section in 0880.005.00 of the MHABD Manual, and the December 1973 Eligibility Requirements Manual section 1025.015.04.01 on Special Needs Trusts, Supplemental Needs Trusts, and Pooled Trusts.

These sections have been updated to remove the descriptive stipulations surrounding when the MO HealthNet Division (MHD) Cost Recovery Unit will or will not file an estate recovery claim against the estate of an MHABD recipient or former recipient. This information is not necessary or required in order for Family Support Division (FSD) staff to determine eligibility for MHABD programs. Estate Recovery section 0880.005.00, has also been revised to include the current email address for the MHD Cost Recovery Unit, as listed below.

As a reminder, staff are prohibited from providing any financial planning advice to participants, authorized representatives, attorneys, or legal guardians. Estate recovery is a legal matter that is managed and overseen exclusively by the MHD Cost Recovery Unit. Participants and/or representatives must be directed to contact MHD directly for assistance, and information regarding estate recovery regulations, processes, and procedures:

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/vm

IM-78 OBSOLETE FORMS REMOVED FROM DEPARTMENT OF SOCIAL SERVICES (DSS) FORMS MANUAL AND INCOME MAINTENANCE (IM) FORMS MANUAL

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  OBSOLETE FORMS REMOVED FROM DEPARTMENT OF SOCIAL SERVICES (DSS) FORMS MANUAL AND INCOME MAINTENANCE (IM) FORMS MANUAL

 

DISCUSSION:

The DSS Manuals IM Forms Manual (public site) and FSD Intranet IM Forms Manual (internal site) have both been updated to remove forms that are obsolete and no longer to be used by Family Support Division (FSD) staff.

Obsolete forms that were removed:

DOI-1 

Referral for Investigation

IM-1

Application for Benefits

IM-2

Application for Benefits

IM-2

Mod Adult Adult Supplement – Spanish

IM-209

Case Reading Form

IM-23

Client Services Postcard

IM-2C

Expenses of Producing Income – Spanish

IM-2U

Eligibility Recording Form

IM-30C

Explanation of Financial Eligibility

IM-30IBCA

Income Maintenance Budget (IBCA)

IM-31A MC+

MC+ Request for Information

IM-32MC

MC+ Approval Notice (Non-premium groups)

IM-32MPW

MC+ for Pregnant Women Approval Notice

IM-32PRM

MC+ Approval Notice (Premium Group)

IM-32QMB

Notice of Approval

IM-32SLMB

Notice of Approval

IM-33A

Notice of Temporary Assistance/Food Stamp Case Action

IM-33MAF

MAF Notice of Case Action

IM-33MC

MC+ Notice of Denial

IM-33MCC

MC+ Notice of Action

IM-34

Change of Status Summary

IM-35

Identification Data Form

IM-36

Vital Statistics Form

IM-37

Insurance Form

IM-38

IM-2 Recording Worksheet

IM-3A

Reinvestigation Notice

IM-4 MA

Information about your Medical Assistance

IM-42

Inter-county Transfer

IM-42A

County Transfer Letter

IM-80MC

MC+ Advance Action Notice

PC-1

Presumptive Eligibility Determination

PC-2

MO HealthNet for Kids Presumptive Eligibility Determination

SPNDDOWN

Spend Down Calculation Document
 

Audit Document Request Form
 

Flow Chart for Pregnant Women Applications
 

Affidavit of Disaster Loss
 

Case Manager Performance Plan
 

Case Worker Performance Plan
 

Program Improvement Plan

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Discontinue use of any forms shown.
  • Discard any unused forms shown if paper copies are being stored.

 

KE/cj

IM-77 COMMON LAW MARRIAGE UPDATE FOR ALL INCOME MAINTENANCE PROGRAMS

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  COMMON LAW MARRIAGE UPDATE FOR ALL INCOME MAINTENANCE PROGRAMS

MANUAL REVISION #
1100.010.00
1105.015.04.15
0205.025.00
1805.030.10.07
1013.000.00

 

DISCUSSION:

If a common law marriage was established in another state, each partner is considered a spouse in Missouri. Common law marriages cannot be initiated in Missouri.

EXAMPLE: Edward and Ana state they are common law spouses. Their marriage began in Kansas, where common law marriages can be established. Consider them spouses for eligibility purposes.

The following manual sections have been updated or created to reflect this information:

Child Care will continue to follow Temporary Assistance policy for specified relatives. Refer to 2010.010.00 Relationship of the Applicant to the Child for more information.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Send questions regarding common law marriages through normal supervisory channels.

 

KE/ers

IM-76 TAX CREDIT CHANGES RESULTING FROM THE AMERICAN RESCUE PLAN ACT (ARPA) OF 2021

Posted on

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  TAX CREDIT CHANGES RESULTING FROM THE AMERICAN RESCUE PLAN ACT (ARPA) OF 2021

 

DISCUSSION:

The ARPA modified the provisions of several commonly used tax credits. Most of the changes are in effect only for 2021. The following tax credits are refundable, meaning the credit amount can be paid directly to the tax filer if his/her tax liability is $0.

 

Child Tax Credit (CTC) Earned Income Credit (EIC) Child and Dependent Care Credit
A credit increase to $3600 for qualifying children ages 0-5; $3000 for children ages 6 through 17. The minimum age to qualify for the EIC is lowered to 19 and the maximum age is removed. The maximum amount of this credit increased to $6000 for one child and $16,000 for two or more children.
One-half of the estimated CTC amount is payable to parents in advance monthly payments starting in July 2021; the other half will be issued as part of 2021 tax refunds. The maximum income for an earner without children is increased to $9820.  
Tax filers will be able to opt out of the advance monthly payments. Some married filers may be treated as unmarried filers in certain circumstances.  

 

Do not count advance monthly payments or lump sum refunds of a refundable tax credit as income or a resource for Income Maintenance programs. For programs that consider resources, count tax credit funds remaining after 12 months as a resource.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

KE/ers