The Missouri Department of Social Services Family Support Division's MO 886 2811 form is an essential document for families participating in the MC+ program, tasked with conducting an annual review to ascertain continued eligibility for healthcare coverage. This comprehensive form requests detailed information, including household composition, income, and health insurance status, essential for determining eligibility under the specified income thresholds. Requiring completion predominantly in the white sections, it ensures a thorough collection of data regarding each household member seeking coverage while emphasizing the necessity of providing accurate and current income verification, such as recent paycheck stubs or tax returns. The form uniquely balances the need for comprehensive data collection with privacy considerations, leaving certain items like race and ethnicity as optional for statistical purposes only, and underscores the importance of the Social Security Number for applicants. With implicit mandatory clauses, it warns of the risk of MC+ coverage cancellation should the form not be returned promptly, including the requisite documentation. The form also doubles as a consent to verify the provided information and obtain necessary medical data to support the program's administrative purposes, making it a critical step in maintaining healthcare benefits for eligible families in Missouri.
| Question | Answer |
|---|---|
| Form Name | Form Mo 886 2811 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | mo healthnet review form online, IM-1U, mo support review, SUPV |
MISSOURI DEPARTMENT OF SOCIAL SERVICES
FAMILY SUPPORT DIVISION
MC+ ANNUAL REVIEW
FROM |
ELIGIBILITY SPECIALIST |
TELEPHONE NUMBER |
DATE |
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COUNTY OFFICE ADDRESS (STREET) |
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CITY, STATE, ZIP CODE |
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TO |
NAME |
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ADDRESS (STREET) |
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CITY, STATE, ZIP CODE |
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RE |
CASE NAME |
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Dear
We are required to do an annual review of MC+ healthcare eligibility. In order to determine your family’s continued eligibility, we are asking you to complete all sections in the white areas of the attached form. Race and ethnic group information is only for statistical use and is optional. The Social Security Number is required only for persons applying for MC+ coverage.
Please read each item carefully before you answer it. The answers you give will be used to determine continued eligibility for MC+ healthcare coverage. If you need any assistance in completing the form, or have any questions, please contact your MC+ Service Representative.
After you have completed the form, please sign on the line indicated “parent/guardian” and return, in the attached envelope by ___________________ .
Please include proof of your income such as paycheck stubs for the last 30 days, employer statement, or copies of your latest tax return, if
Failure to return this form may result in MC+ coverage being canceled.
Sincerely,
______________________________
Eligibility Specialist
Phone Number _____ - _____ - _____
MO |
For children to be eligible for MC+ healthcare coverage, your family income must be below the amounts indicated, based on your family size.
Maximum Monthly Income Per Family Size**
What You Pay |
2 |
3 |
4 |
5 |
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$1,650 |
$2,075 |
$2,500 |
$2,925 |
Monthly Premium
$3,300
$4,150
$5,001
$5,850
*You will be notified of Premium amounts when approved. The monthly premium includes all eligible children in the household. Coverage does not begin until the premium payment is received by the Premium Collections Unit.
For parents to be eligible for MC+ health
coverage, the family’s income (after allowable
child care, child support income disregard, and work expense deductions) must be below the following amounts, based on family size:
Maximum Monthly Income Per Family Size**
Family Size |
2 |
3 |
4 |
5 |
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MONTHLY INCOME |
$234 |
$292 |
$342 |
$388 |
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**Family size includes parents and children. Income amounts change annually in April.
Please keep this page. It contains important information.
MO |
MISSOURI MC+ REVIEW
COMPLETE IN INK |
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FOR OFFICE USE ONLY |
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NAME (FIRST, MIDDLE, LAST) |
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DATE RECEIVED |
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ADDRESS (HOUSE NO., STREET OR RURAL ROUTE, P.O. BOX NO.) CITY, STATE, ZIP CODE |
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COUNTY |
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HOME PHONE NUMBER |
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WORK PHONE NUMBER |
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MESSAGE PHONE NUMBER |
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ELIGIBILITY SPECIALIST/SUPV/LOAD |
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INSTRUCTIONS: Please answer each question completely. Attach an additional sheet if more space is needed in any section. |
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A. HOUSEHOLD INFORMATION |
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(LIST ALL CHILDREN, PARENTS/GUARDIANS AND STEPPARENTS |
WHO LIVE IN YOUR HOME, |
YOURSELF |
FIRST.) |
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NAME |
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RACE*/ |
HISPANIC |
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RELATIONSHIP |
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PLACE OF |
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SOCIAL SECURITY |
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BIRTHDATE |
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(FIRST, MIDDLE, LAST) |
(MAIDEN) |
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SEX |
Y/N |
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BIRTH |
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NUMBER |
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PERSON #1 |
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1. |
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SELF |
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5. |
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6. |
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*(1 — White 2 — Black/African American |
4 — American Indian/Alaskan Native |
5 — Asian |
6 — Native Hawaiian/Pacific Islander) |
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1. |
Do you wish to start coverage for any of the above persons who are not currently covered by MC+? |
YES |
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NO |
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If yes, who? |
__________________________________________________________________________________________________ |
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2. |
Are both parents of all the children in the home? |
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YES |
NO |
If NO, complete section D. |
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3. |
Are all of the persons requesting MC+ U.S. citizens? |
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YES |
NO |
If NO, list the following information for persons applying |
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or receiving MC+ who are not U.S. citizens: Name, immigration status and registration number, date of entry: |
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____________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________ |
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4. |
Is anyone in your household pregnant? |
YES |
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NO |
If YES, who? ___________________ |
Expected due date __________ |
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5. |
Is your net worth (net worth is the value of everything you own minus any debt.): |
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less than $50,000 |
$50,000 - $100,000 |
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$100,000 - $150,000 |
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$150,000 - $200,000 |
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$200,000 - $250,000 |
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above $250,000 |
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Please list your assets (bank accounts, stocks/bonds, vehicles, home, real and personal property, etc.) |
__________________________ |
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____________________________________________________________________________________________________________ |
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B. INCOME (Please attach verification; i.e. paycheck stubs, note from employer, federal income tax return, award letter, etc.) |
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1. |
Are you employed? |
YES |
NO |
If YES, name of employer |
__________________________________________________ |
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How much are you paid before taxes or deductions? _____________ |
Weekly |
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Every two weeks |
Twice monthly |
Monthly |
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2. |
Is anyone else in your home employed? |
YES |
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NO |
If YES, who? |
____________________________________________ |
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Name of employer |
______________________________________________________________________________________________ |
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How much are they paid before taxes or deductions? _____________ |
Weekly |
Every two weeks |
Twice monthly |
Monthly |
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3. |
Does anyone in your home operate their own business or are they otherwise |
YES |
NO |
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If YES, who? _______________________________ |
Describe what type of |
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earned: ________________________________ |
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Weekly |
Every two weeks |
Monthly |
Yearly |
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4. |
Childcare costs may be an allowable income deduction for working families. Do you pay someone to care for your child? |
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YES |
NO |
If YES, list names of child(ren) cared for: ________________________________________________________ |
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How much do you pay for child care? _____________ |
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Weekly |
Every two weeks |
Twice monthly |
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Monthly |
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MO |
5. Does anyone in your home receive other income such as child support, alimony, Unemployment Compensation benefits, sick benefits,
interest income, Social Security benefits, or other unearned income? |
YES |
NO |
If YES, complete the following: |
PERSON RECEIVING
WHO PROVIDES THE MONEY?
AMOUNT RECEIVED
HOW OFTEN RECEIVED?
C. HEALTH INSURANCE
1. Does anyone in your home have medical, hospital insurance, or Medicare? |
YES |
NO |
If yes, list policies below. |
PERSONS INSURED |
NAME OF COMPANY AND POLICY NUMBER |
TYPE OF COVERAGE |
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Doctor |
Hospital If limited coverage explain: |
Doctor
Hospital If limited coverage explain:
2. |
Has anyone in your home lost or dropped health insurance within the past six months? |
YES |
NO |
If yes, provide name(s), |
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date and reason coverage ended. ________________________________________________________________________________ |
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3. |
Is health insurance available for any member of your family through an employer or other group membership? |
YES |
NO |
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If yes, name of employer or group: ________________________________________________________________________________ |
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Is the insurance available for: |
Self |
Spouse |
Children |
How much is the premium for the children? $ _______ per _______ |
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4. |
Do any of your children have a medical condition that left untreated would result in the death or serious physical injury of the child? |
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YES |
NO |
If yes, provide name(s) of child(ren) ____________________________________________________________ |
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5. |
Is a third party responsible to pay for any of your medical care? |
YES |
NO |
If yes, who? _____________________________ |
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6. |
Please refer to the income guidelines sent with the application. If income and family size fall in the premium group, submit 2 quotes from |
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private insurance companies of what they would charge for medical coverage for all of your children. |
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A. $ ________ per mo. Company ________________________ |
2. B. $ ________ per mo. Company ________________________ |
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D. ABSENT PARENT INFORMATION (Complete this section if a parent of any of the children is absent from the home.)
NAME |
RACE/SEX |
SOCIAL SECURITY |
PARENT OF |
(FIRST, MIDDLE, LAST) |
BIRTHDATE |
LAST KNOWN ADDRESS |
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(MAIDEN) |
NUMBER |
WHICH CHILD? |
1. Do you have any new information about an absent parent(s)?
YES
NO If YES, please give details.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2. Do you have a good reason for not cooperating in obtaining support for medical care?
YES
NO If YES, please explain.
____________________________________________________________________________________________________________
E. PLEASE READ CAREFULLY AND SIGN BELOW
•I/we agree I/we must provide Social Security Numbers of all persons applying for MC+ as required by law. The Social Security Number is used to determine eligibility and verify information.
•I/we agree I/we must be evaluated for the Health Insurance Premium Payment Program (HIPP) if I/we or members of the household are employed or lost employment in the last 30 days and the employer or former employer offers group health insurance.
•I/we agree my/our statements and information provided may be verified.
•I/we will report any changes in circumstances within TEN DAYS of when they happen.
•I/we know it is against the law to obtain or attempt to obtain benefits to which I am/we are not entitled. Any false claim, statement, or concealment of any material fact whatever, in whole or in part, may subject me/us to criminal and/or civil prosecution.
•I/we agree by applying for (and being determined eligible for) MC+ for a child who is deprived of parental support, I/we have assigned all rights to medical support to the State of Missouri, and that I/we must cooperate in establishing paternity and obtaining medical support, unless I/we have good cause.
•I/we agree that medical information about me and/or my family can be released if needed to administer this program.
•Provided I am/we are found to be eligible for MC+ I/we know the State of Missouri will pay for covered services on my/our behalf and agree the state may collect payments from any third party (i.e., insurance, estate, etc.) for services paid by the state.
•I/we authorize insurers or employers to release any information on myself or my dependent(s) needed to determine eligibility for the HIPP Program.
My/our signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete to the best of my/our knowledge. I/we authorize insurers or employers to release any information on myself or my dependent(s) needed to determine eligibility for the HIPP program.
SIGNATURE/AFFIDAVIT |
DATE |
SIGNATURE OF SPOUSE/AFFIDAVIT |
DATE |
MO |