MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

TRANSITIONAL MO HEALTHNET SUSPENSION NOTICE

FROM	Address (Street, City, State, Zip Code) , MO	DATE July 9, 2019
TO	HEAD OF HOUSEHOLD NAME
ADDRESS (STREET OR P.O. BOX NO.)	HEAD OF HOIUSEHOLD DCN
CITY STATE ZIP
Transitional MO HealthNet benefits for will suspend effective
because you did not return your completed Transitional MO HealthNet Quarterly Report Form and /or verification. This is required under section 1925 (B) of the Social Security Act. Your case will remain suspended until you submit this completed form. If you need help completing the form or obtaining requested verification, contact the Family Support Division Information Center at 855-FSD-INFO (855- 373-4636). Your MO HealthNet COVERAGE will start again the month following the month you submitted the completed form if it is determined you are otherwise eligible. Your Transitional MO HealthNet is limited to a maximum of twelve (12) months. If you submit your quarterly reports and remain eligible, your Transitional MO HealthNet benefits can only extend through . If you agree with the above decision, nothing further needs to be done. If you disagree with this decision to suspend your MO HealthNet benefits you have the right to request a hearing within 90 days from the date of this notice. If you wish to have a hearing you may advise us of this by mail, telephone, or in person. We will then schedule a time and date for your hearing and notify you by mail. If you request a hearing you may present your information yourself or you may be represented by your attorney or anyone else who has knowledge of your situation. If you do not have an attorney, or cannot afford one, and live in an area by a legal aid or legal services office, you may be eligible for this service. For the possibility of free legal services call: You have the right to present witnesses on your own behalf and to question witnesses who appear at the request of the Family Support Division.
ENCLOSURE: INFORMATION LEAFLET(S) NO. IM-4 Hearing Rights
MO 886-0747 (10-2014)	IM-58 (07-2019)