MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION NOTICE OF CASE ACTION
FROM	FSD OFFICE Family Support Division	TELEPHONE NUMBER 855-373-4636	DATE 1/30/2024
FSD OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) PO BOX 2700, Jefferson City, MO 65102
TO	NAME	RE	HEAD OF HOUSEHOLD NAME
ADDRESS (MAILING)	DCN
CITY, STATE, ZIP CODE
WE HAVE TAKEN THE FOLLOWING ACTION ON YOUR CASE:
Your MO HealthNet application dated has been rejected.
Your MO HealthNet case was reviewed and there are no changes to your benefits.
MO HealthNet benefits have been discontinued for the following person(s):
.
The last day of MO HealthNet coverage is:	.
MO HealthNet benefits have changed to effective
for the following persons: .
You are now required to pay a monthly premium to continue coverage for the following person:
.
You will receive an invoice informing you of the premium amount and the date payment is due.
The reason for this decision is:
Your countable income of	exceeds the maximum of	for your household size
of	.	(RSMo 208.151)
You did not return the first (1st) quarterly report form. (42 U.S.C. 1396r–6)
Your family no longer resides in Missouri. (13 CSR 40-2.040)
You no longer have an eligible child living in the home, because the last such child has either left your household, exceeds the MO HealthNet for Families age requirement or is 18 and does not meet the educational requirements for MO HealthNet for Families. (RSMo 208.151, 42 U.S.C 1396r-6)
We received your	Transitional MO HealthNet report. Your current income of	exceeds
the limit of	to continue receiving coverage under this program. (42 U.S.C. 1396r–6)
Other:
Transitional MO HealthNet
Eligibility for health coverage has changed to Transitional MO HealthNet for the individuals listed above because of
earnings from employment. There has been no change in your healthcare benefits for these individuals.
Coverage will continue through	.	If you meet certain requirements, you may be
eligible for an additional six months. coverage.
Your MO HealthNet for Families healthcare benefits have been reinstated effective
The reason for this action is MO HealthNet benefits had previously been terminated for _ _____ Your ongoing coverage is being reviewed and you will receive an additional notice on the outcome of that review.
Due to the closing of your MO HealthNet for Families case a pre-closing review was completed. The following changes in coverage were made:
Report Changes
You must report any changes within 10 days that might affect your health coverage, such as: Date pregnancy ends You lose or gain any health insurance You are found eligible for or start receiving Medicare You move Your income or employment changes Your household changes (Such as if someone in your household marries or divorces, becomes pregnant, or has a child.) To report changes, go online at mydss.mo.gov or call FSD at 855-373-4636.
If you think we are wrong
You have the right to ask for a hearing within 90 days of this Action Notice, if you think the department made a mistake about your benefit determination. A hearing is a meeting between you, a staff member from Family Support Division (FSD), and a hearing officer. At the hearing, you can explain why you think we made a mistake. If you request a hearing, you will continue receiving your current benefits while you wait for the hearing decision, and you may be responsible for repaying these benefits if the hearing decision is not in your favor. You can ask for a hearing: By phone: Call the FSD Information center at 855-373-4636 By fax: Send your request to 573-526-4554 By mail: Mail your request to the address at the top of this letter. By email: Email your request to IMHearing.FSD@dss.mo.gov In person: Visit your local FSD Resource Center to speak to the FSD team member. For written requests, describe the error that was made and include your DCN number. To prepare for your hearing, you can: Bring someone with you to the hearing, like a friend, relative, or lawyer (but you can also come by yourself) Bring documents or witnesses to show us where you think we made a mistake Request free legal services by contacting Legal Aid at Enter Legal Aid Phone Number for Region. Once you ask for a hearing, you will receive a notice in the mail with your hearing date.
Certificate of Creditable Coverage
If you seek medical coverage under another health insurance plan, such as a group plan offered by your employer, you may need a Certificate of Creditable Coverage showing when you were covered by MO HealthNet. The certificate may help prove you have met part or all of an exclusionary period for pre-existing medical conditions You may request a certificate within 24 months of losing MO HealthNet benefits. You may request a certificate by calling the MO HealthNet Division, Participant Services at 800-392-2161.
Enclosure: .