MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MO HEALTHNET UNDUE HARDSHIP WAIVER NOTICE
FROM	Family Support Division	TELEPHONE NUMBER 855-373-4636	DATE 1/30/2024
OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) PO BOX 2700, Jefferson City, MO 65102
TO	NAME	CASE NAME
ADDRESS (MAILING)	DCN
CITY, STATE ZIP CODE	TELEPHONE NUMBER - -
Due to the imposition of the penalty for transfer of assets, your MO HealthNet vendor case will be:
Closed per RSMo 208.010.7 & 42 U.S.C. 1396p(c)
Rejected per RSMo 208.010.7 & 42 U.S.C. 1396p(c)
The penalty will begin	and last until	.
If you are a nursing home or institutionalized hospice patient, this means that MO HealthNet will not pay for your stay at the nursing home or services you receive as an institutionalized hospice recipient. If you are applying for or receiving MO HealthNet under one of the other “waivered” categories, this may mean you are not eligible for Medicaid, or that your case will be closed. You will receive a separate Action Notice with your eligibility decision and your hearing rights. If the rejection, closure, or penalty of your case will result in undue hardship to you (not to your spouse or anyone else), you may apply for an Undue Hardship Waiver to exclude the asset(s) or transfer(s) that is making you ineligible or penalized. However, there are very strict guidelines for this to be considered. For transferred assets, you must take “legal action and equitable remedies to recover the asset” before undue hardship can be considered. If you would like to pursue applying for the Undue Hardship Waiver, contact Family Support Division using the information at the end of this letter, within 10 calendar days of the date on this notice.
The due date is
You must complete and return the Undue Hardship Waiver Request form to Family Support Division (FSD) , provide any other information that supports your claim, including proof of the legal action taken, etc. FSD will let you know if other information is needed, including documentation from your physician. Once the request is received, FSD will review the Undue Hardship Waiver Request. If FSD denies your waiver application, you will be sent another Action Notice. At that time, you may further make an appeal to be heard by an Administrative Hearing Officer. For questions and/or to request the Undue Hardship Waiver information, contact the Family Support Division at 855-373-4636.