Missouri Department of Social Services Children’s Division INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC) FINANCIAL/MEDICAL PLAN
IDENTIFYING INFORMATION--(MUST BE COMPLETED)
Child’s Name:	DOB:	SSN:	DCN:
Name of Proposed Resource:	Address:
Relationship to Child:
PART 1--FINANCIAL PLAN FOR THE CHILD’S CARE
SECTION I
1. The child listed above is in alternative care. Yes No
2. Child is Title IV-E eligible: Yes No Please attach copy of FACES Title IVE/FFP Information screen
SECTION II
Mark Only one(1) box:
MO Children’s Division will provide foster care payments once the placement resource is licensed/certified as a foster parent in the receiving state. (Receiving state MUST provide proof of licensure before payment will begin.)
This is a relative resource that is expected to apply for TANF and Medicaid in the receiving state. MO CD will provide reimbursement if receiving state denies child for TANF related Medicaid. A written statement stating why child is not eligible must be provided by the receiving state to MO CD before MO CD will provide reimbursement.
This is a relative resource has agreed in writing to provide for this child without additional assistance. (Attach written statement from resource)
This is a placement with a parent. The parent is expected to provide/support this child financially and medically. (This can include applying for TANF and Medicaid benefits in the receiving state.)
This Child is SSI eligible and the resource provider may be made payee of benefits. $ Amount of SSI
ADOPTIVE PLACEMENT ONLY:
This is an adoptive placement; and If this box is checked then Mark Only one(1) box below:
The resource is expected to support the child.
The resource is expected to apply for assistance in the receiving state through TANF and Medicaid to provide for the child.
Adoption subsidy is planned and the amount will be determined prior to the date of placement. The appropriate ICAMA forms will be completed and submitted prior to finalization.
PART II—MEDICAL PLAN FOR THE CHILD
This child is Title IV-E eligible and is eligible to receive Medicaid through the receiving state. The receiving state will arrange for Medicaid coverage based on the Title IV-E eligibility.
This child is Medicaid eligible as a recipient of SSI.
This child is NOT Title IV-E eligible. Resource is expected to apply for TANF Medicaid in the receiving state. MO CD will provide reimbursement if receiving state denies child for TANF related Medicaid. A written statement stating why child is not eligible must be provided by the receiving state to MO CD before MO CD will provide reimbursement.
This placement resource has agreed in writing to provide for and meet the medical needs of the child. (Attach copy.)
This placement is with a parent. The parent is financially responsible for meeting the medical needs of the child.
The Missouri Children’s Division shall continue to have financial responsibility for support and maintenance of this child during the period of placement as set forth in Article V (a) of RSMo 210.620. In the event that disruption occurs, the Missouri Children’s Division will arrange and pay for transportation back to the state of Missouri. This financial/medical plan will remain in effect for the duration of the child’s placement in the receiving state or until termination of the placement is approved, consistent with the provisions of the Interstate Compact on the Placement of Children.
Worker’s Name:	Title:
Phone Number:	E-mail Address:
Worker’s Signature:	Date:

PLEASE SUBMIT IN TRIPLICATE (3 Copies)