MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION
 NOTICE OF CASE ACTION 
FROM 	Eligibility Specialist Telephone Number Date
                        	     	
	County Office Address (Street, City, State, Zip Code) 
                                	
TO 	Name 
         	RE 	Case Name 
     	
	Address (Street) 
     		Case Number 
     	
	City State Zip Code 
                           			
Your application for ________________________________________________________________has been approved. 

 Your Medicaid coverage will begin        .

 You are eligible to purchase Medicaid coverage. Your coverage cannot begin until       because your income exceeds the maximum allowed to receive coverage prior to this date or without paying a premium. 

Your premium is based upon your monthly income of $      . 

You selected       as your beginning month of coverage. 

You must pay a premium of $      for each month of coverage from the month selected forward. You will be billed for this coverage. You will be billed each month in advance, example billed in September for October coverage.

 Other:      

If you do not agree with this decision, you have the right to ask for a hearing within 90 days of the date of this letter. To request a hearing, call the local Family Support Division office                       . If you request a hearing, you may present your information yourself or may ask anyone else to assist you.  You have the right to present witnesses in your behalf and to question witnesses who appear at the request of the Family Support Division. To see if you can get free legal services call                    . Read and keep the enclosed leaflet(s) for important information about your benefits. It is very important that you inform us immediately when your employment status changes, if your income or assets change and when you move or change your address. If your situation changes it is your responsibility under the law to report these changes at once to your local county office. The law provides penalties for any persons who receive benefits to which they are not entitled through misrepresenting the facts or not reporting full information about their situation. 	
SIGNATURE 
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Enclosure: Information Leaflet No.      	

IM-32 TWHA (08/07)