Fill in a Valid Mo 886 3846 Form Open Document Now

Fill in a Valid Mo 886 3846 Form

The MO 886 3846 form serves as the official application for Missouri HealthNet (Medicaid) and is part of the suite of documents facilitated by the Missouri Department of Social Services, Family Support Division. It is designed to collect detailed information about applicants seeking Medicaid coverage, encompassing personal, household, income, and property details to determine eligibility. For individuals and families navigating the complexities of health insurance coverage, properly completing and submitting this document is a pivotal step.

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Applying for healthcare coverage can be a meticulous task, especially for those navigating the intricacies of Medicaid in Missouri through the MO 886-3846 form. Administered by the Missouri Department of Social Services' Family Support Division, this form serves as a gateway for residents seeking to avail themselves of MO HealthNet (Medicaid) benefits. It is designed to capture a comprehensive snapshot of an applicant's demographic, household, and financial information, thereby assessing eligibility for health care coverage. Essential details demanded by this form include basic personal information, household composition, financial resources, income, property details, citizenship status, and more. Furthermore, it also offers avenues for applicants over 65, those with disabilities, visual impairments, or those requiring in-home nursing or assistance with Medicare premiums and co-insurance costs. For individuals facing language barriers, the form promises support in various languages and provides contact numbers for TTY users and those needing information about Rehabilitation Services for the Blind. Completing this application is the first step towards obtaining much-needed health care services for many Missourians, underscoring the importance of accurate and thorough responses. The form also delineates instructions for appointing a representative, suggesting that applicants might need assistance navigating the process. Thus, the MO 886-3846 form symbolizes more than just a bureaucratic requirement; it is a crucial lifeline for individuals and families in pursuit of health security.

Example - Mo 886 3846 Form

MissOuri departMent Of sOcial services faMily suppOrt divisiOn

appLICaTIoN foR mo hEaLThNET (mEdICaId)

Need help with your application?

Call us at 1-855-373-4636. If you need help in a language other than English, tell the customer service representative the language you need. TTY users can call: 1-800-735-2966. If you are blind or visually impaired and would like information regarding Rehabilitation Services for the Blind, please call 1- 800-592-6004.

¿Necesita ayuda con su aplicación?

Llámenos al 1-855-373-4636. Si necesita ayuda en una lengua que no sea el inglés, dígale al representante de servicio al cliente la lengua que usted necesite. Los usuarios de teléfonos de texto pueden llamar al: 1-800-735-2966. Si usted es ciego o tiene una discapacidad visual y desearía informacion sobre los Servicios de Rehabilitación para Invidentes, por favor llame al 1-800-592-6004.

MO 886-3846 (7-15)

page 1 Of 7

pERmaNENT      iM-1Ma (07/15)

 

 

 

 

foR offICE uSE oNLY

 

MissOuri departMent Of sOcial services

date applied

 

 

faMily suppOrt divisiOn

 

 

 

appLICaTIoN foR mo hEaLThNET (mEdICaId)

 

SECTIoN 1: Your Basic Information

 

dcn #1

dcn #2

 

 

 

applicant full legal naMe (first, Middle, last)

 

Maiden naMe (if any)

 

HOMe address (HOuse nuMber, street Or rural rOute, pO bOx, HOMeless)

city, state, zip cOde

 

Mailing address (if different frOM HOMe address)

city, state, zip cOde

 

priMary pHOne nuMber

 

cell    Home    Work

alternate pHOne nuMber

cell    Home    Work

 

 

 

Other: ________________

 

Other: ________________

e-Mail address

 

 

 

 

 

preferred MetHOd Of cOntact

 

 

 

 

call

*text 

e-mail 

Mail      *Texting is not available in all locations.

 

sOcial security nuMber

date Of birtH

place Of birtH

 

 

 

race* (OptiOnal)

sex

 

M 

f

Hispanic (OptiOnal)

yes 

nO

* 1. caucasian 

2. black/african aMerican 

3. aMerican indian/alaska native 

4. asian 

5. native HaWaiian/pacific islander

i, the above named applicant, apply for MO Healthnet under the laws of the state of Missouri. check any of these that apply to you or your spouse if your spouse wants coverage.

i/We are over age 65.

i/We are disabled and get social security disability or ssi.

i/We are disabled and do not get social security disability or ssi.

If you check this box, also fill out appendix a to help determine if you meet the disability requirements.

i/We are blind or visually impaired.

If you check this box, also fill out section 8 of this application to see if you qualify for Blind programs.

i/We live in a nursing home or similar facility.

If you check this box, please list:

facility naMe

facility address

i/We are age 63 and over and need in-home nursing care.

If you check this box, also fill out appendix B if you’re married, and one of you either lives in a nursing home or needs skilled nursing care at your home.

i/We need help paying for Medicare premiums and co-insurance costs.

i/We work and pay income taxes, and want coverage under the ticket to Work program.

If you check this box, this may let you qualify for mo healthNet by paying a premium.

i/We need help with medical bills from the last 3 months.

i/We have a conservator, guardian, attorney-in-fact, or another person to represent us.

If you check this box, fill out appendix C to name an authorized representative, or provide conservator, guardian, or power of attorney documents. Then fill out the representative’s contact information on page 7.

all applicants must fill out sections 2 through 7

MO 886-3846 (7-15)

page 2 Of 7

pERmaNENT      iM-1Ma (07/15)

SECTIoN 2: Your household

below, list your spouse first, then anyone who lives with you, or would be if you weren’t in a nursing home.

naMe

 

(first, Middle, last)

(Maiden)

Hispanic

race*

 

y/n

sex

(optional)

(optional)

 

 

 

 

relatiOnsHip

TO yOu

(spouse, son, sister, friend)

date Of birtH

cHeck (✓)

sOcial

if tHey’re security nuMber

applying

(if applying)

place Of birtH

(if applying)

* 1. caucasian 

2. black/african aMerican 

3. aMerican indian/alaska native

4. asian

5. native HaWaiian/pacific islander

 

 

are yOu Married and live WitH yOur spOuse, Or lived WitH yOur spOuse WHen yOu entered a nursing HOMe? 

 

yes   

nO

 

 

 

 

if yes, we need your spouse’s income and resource information, but your spouse doesn’t have to apply for coverage.

 

 

 

 

enter tHe date yOu gOt Married

 

 

 

 

 

 

 

SECTIoN 3: money available To You

 

 

 

 

 

 

 

are yOu Or yOur spOuse a party tO a trust? 

 

 

 

yes   

nO

 

 

 

 

if yes, we must review the entire trust. you must provide it and fill out below:

naMe and date Of trust

WHat is yOur Or yOur spOuse’s rOle in tHe trust?

i/We have the following resources (include trust assets you can access): check (✓) all that apply.

CaSh aNd SECuRITIES

 

owNER

aCCouNT #(S)

BaNk/LoCaTIoN

 

vaLuE

 

checking accounts/Joint checking accounts

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

savings accounts/Joint savings accounts,

 

 

 

 

 

 

 

 

$

 

 

christmas club savings, certificates of deposit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

credit union accounts

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pre-paid card (other than ebt)

 

 

 

 

 

 

 

 

 

$

 

 

Example: card of Social Security income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

patient accounts at a nursing home or other

 

 

 

 

 

 

 

 

$

 

 

institution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cash on hand

 

 

 

 

N/a

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stocks, bonds, iras, retirement plans, other

 

 

 

 

 

 

 

 

$

 

 

investments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

annuities (We will need the whole contract)

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notes or mortgages owed to you

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pRE-paId BuRIaL pLaN

 

 

 

 

 

 

 

 

 

 

 

 

i/We OWn 1 Or MOre pre-paid burial plans

 

 

 

 

 

 

 

 

 

 

 

 

yes    nO

 

 

 

 

 

 

 

 

 

 

 

 

if yes, fill out below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NamE of INSuREd

 

fuNERaL homE

 

poLICY/CoNTRaCT #

 

CaSh SuRRENdER

REvoCaBLE oR

 

 

 

 

 

 

 

 

vaLuE

 

REfuNdaBLE?

 

 

 

 

 

 

 

 

 

 

 

 

yes 

nO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes 

nO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes     

nO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO 886-3846 (7-15)

page 3 Of 7

pERmaNENT      iM-1Ma (07/15)

SECTIoN 4: Your Income and Expenses

i/We receive income from the following. check (✓) all that apply.

uNEaRNEd INComE

who gETS IT?

whERE IS IT fRom?

amouNT pER moNTh

social security

 

n/a

$

claim number:

 

 

 

 

 

 

 

 

supplemental security income (ssi)

 

n/a

$

 

 

 

 

 

 

trusts and annuities

 

 

$

 

 

 

 

 

 

 

non-va pensions, retirement, and disability

 

 

$

 

 

 

 

 

 

 

interest or dividends

 

 

$

 

 

 

 

 

 

 

unemployment compensation

 

 

$

 

 

 

 

 

 

 

Worker’s compensation

 

 

$

 

 

 

 

 

 

 

Military branch retirement pension

 

 

$

 

 

 

 

 

 

 

Worker’s compensation

 

 

$

 

 

 

 

 

 

 

Money from friends or family

 

 

$

 

 

 

 

 

 

 

va payments (check all that apply)

 

n/a

$

va pension

 

 

$

disability compensation

 

 

$

dic compensation

 

 

$

aid & attendance

 

 

$

Homebound allowance

 

 

$

Medical reimbursement

 

 

$

 

 

 

 

Other (explain where the money comes from and the amount)

 

 

EaRNEd INComE

EmpLoYER

INComE BEfoRE TaxES

how ofTEN aRE You paId

ThISamouNT?(ChECk oNE)

i am employed

 

 

 

Weekly

every 2 Weeks

 

 

 

tWice a MOntH

MOntHly

 

 

 

 

 

 

 

 

 

 

My spouse is employed

 

 

 

Weekly

every 2 Weeks

 

 

 

tWice a MOntH

MOntHly

 

 

 

 

 

 

 

 

 

 

____________________ is employed

 

 

 

Weekly

every 2 Weeks

 

 

 

tWice a MOntH

MOntHly

 

 

 

 

 

 

 

 

 

SELf-EmpLoYmENT

who IS

TYpE of BuSINESS

moNThLY INComE afTER

SELf-EmpLoYEd?

TaxES &ExpENSES

 

 

 

someone in my house or i am self-

 

 

 

$

 

employed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

fILL ouT ThIS SECTIoN oNLY If You’RE maRRIEd aNd LIvINg IN a NuRSINg homE

 

 

My spouse and i pay these costs

 

 

 

 

 

TYpE of CoST

amouNT

 

how ofTEN do You paY foR IT?

utilities (not including phone)

$

 

 

 

 

 

 

 

 

 

 

Mortgage

$

 

 

 

 

 

 

 

 

 

 

rent

$

 

 

 

 

 

 

 

 

 

 

real estate taxes

$

 

 

 

 

 

 

 

 

 

 

Homeowner’s insurance

$

 

 

 

 

 

 

 

 

 

 

condo fees

$

 

 

 

 

 

 

 

 

 

 

phone

$

 

 

 

 

MO 886-3846 (7-15)

page 4 Of 7

pERmaNENT      iM-1Ma (07/15)

fILL ouT ThIS SECTIoN If You paY aNY ChILd SuppoRT oR aLImoNY paYmENTS

CaSE NumBER

amouNT pER moNTh

whaT STaTE doES ThE oRdER ComE fRom?

$

$

$

SECTIoN 5: Your Citizenship and Residency

1.i/We are residents Of MissOuri and plan tO stay in MissOuri

yes  nO

2.all applicants are u.s. citizens

yes 

nO      if no, fill out the following:

NamE of NoN-CITIzEN appLICaNT

ImmIgRaTIoN STaTuS

REgISTRaTIoN NumBER

daTE of ENTRY

3. i/We agree tO apply fOr OtHer benefits i/We May be able tO get (rsdi, ssi, va, etc)

yes 

nO      if no, you may not be able to get MO Healthnet.

SECTIoN 6: Your personal property

TRaNSfER of pRopERTY oR moNEY

Has anyOne in yOur HOMe sOld Or given aWay MOney, veHicles, Or prOperty WitHin tHe last five years?

yes    nO      if yes, fill out below:

MOney/veHicle/prOperty sOld Or given

dates sOld Or given

 

 

persOn it Was sOld Or given tO

reasOn

 

 

value Of MOney/veHicle/prOperty

aMOunt received

$

$

 

 

vEhICLES

list cars, trucks, vans, motorcycles, recreational vehicles, and others. 

i/We don’t own a vehicle.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

makE/modEL

YEaR

 

owNER

 

vaLuE

amouNT owEd

 

how IS IT uSEd?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REaL ESTaTE pRopERTY

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We OWn Or are buying real estate.

 

 

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, provide a copy of the deed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER ThE addRESS oR LoCaTIoN

 

 

owNER

 

 

vaLuE

 

amouNT

 

how IS IT uSEd?

 

 

 

 

 

(home, rental,

(for mobile homes, see personal property below)

 

 

 

 

 

owEd

 

 

 

 

 

 

 

 

 

acreage, other)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pERSoNaL pRopERTY

i/We own the following types of personal property (include trust assets that you have access to). check (✓) all that apply.

TYpE of pRopERTY

how maNY?

dESCRIpTIoN

 

vaLuE

amouNT You owE

Mobile Home

 

 

$

 

$

check here if this is your home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

farm machinery (include tractors)

 

 

$

 

$

 

 

 

 

 

 

farm livestock

 

 

$

 

$

 

 

 

 

 

 

farm grain or produce in storage

 

 

$

 

$

 

 

 

 

 

 

business equipment

 

 

$

 

$

 

 

 

 

 

 

trailer (utility, boat, etc.)

 

 

$

 

$

 

 

 

 

 

 

boat

 

 

$

 

$

 

 

 

 

 

 

MO 886-3846 (7-15)

page 5 Of 7

pERmaNENT      iM-1Ma (07/15)

aircraft

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

property claims in probate court

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (explain)

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTIoN 7: Your Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have life insurance

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, fill out below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pERSoN INSuREd

 

INSuRaNCE CompaNY

 

poLICY NumBER

 

CaSh vaLuE

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have Medicare

 

 

 

 

 

 

 

 

 

 

 

yes   

nO     

 

 

 

 

 

 

 

 

 

 

 

if yes, list the names of the people who have Medicare:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have lOng-terM care insurance

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, fill out below:

 

 

 

 

 

 

 

 

 

 

 

 

NamE of pERSoN wITh LoNg-TERm CaRE INSuRaNCE

 

INSuRaNCE CompaNY

poLICY NumBER

pREmIum (per month)

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have OtHer HealtH insurance

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, fill out below:

 

 

 

 

 

 

 

 

 

 

 

 

pERSoN INSuREd

 

INSuRaNCE CompaNY

 

TYpE of CovERagE

poLICY NumBER

pREmIum (per month)

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

if yOu can get casH payMents and Have an accOunt, dO yOu Want tHe casH tO gO directly intO yOur accOunt?

 

 

 

 

 

yes, i Want direct depOsit    nO, i dO nOt Want direct depOsit.

 

 

 

 

 

only fill out this section (Section 8) if you want Blind pension or Supplemental aid to the Blind.

SECTIoN 8: Blind pension and Supplemental aid to the Blind

1.

do you have a sighted spouse or parent?

yes

nO

2.

do you ask or beg for money?

yes

nO

3.

Have you applied or do you agree to apply for supplemental security income (ssi) as a condition of eligibility?

yes

nO

4.

Have you had eye surgery within the last five years?

yes

nO

5.

if you are younger than 75, are you willing to have medical treatment or an operation to correct your blindness?

yes

nO

6.

Would you be willing to do job training or work at a job for which you are suited?

yes

nO

7.

do you have an eye doctor (either an opthalmologist or an optometrist)?

yes

nO

 

if yes, fill out below:

 

 

facility and dOctOr naMe

address (HOuse nuMber, street Or rural rOute, pO bOx)

city, state, zip cOde

 

 

date Of last eye exaM

date Of next appOintMent

 

 

MO 886-3846 (7-15)

page 6 Of 7

pERmaNENT      iM-1Ma (07/15)

RIghTS aNd RESpoNSIBILITIES: pLEaSE REad CaREfuLLY aNd SIgN BELow

i/We understand that it is against the law to obtain or attempt to obtain benefits to which i/we are not entitled. any false claim, statement or concealment of any material fact whatever, in whole or in part, may subject me to criminal and/or civil prosecution.

i/We authorize the director of family support division or his/her appointee to investigate and verify these circumstances and statements.

i/We understand if i/we disagree with the decision concerning our eligibility, i/we may request a fair hearing by contacting the local family support office. this request must be received within 90 days of the eligibility decision.

i/We understand that i/we must report any changes in circumstances within ten days of when they happen.

i/We understand that i/we must provide social security numbers (ssn) of all persons applying for MO Healthnet. the ssn is used to determine eligibility and verify information (section 1137 of the social security act).

i/We understand that i/we are entitled to fair and equal treatment regardless of race, color, religion, national origin, sex, ancestry, age, sexual orientation, veteran status, or disability.

i/We understand that the state of Missouri may file a claim against my/our estate to recover any assistance received. this does not apply to Qualified Medicare beneficiary and specified low income Medicare beneficiary programs.

i/We understand that i/we must provide complete information regarding any health or accident insurance benefit available to any household member and i/we must report within 30 days any accident for which medical care is received.

i/We hereby authorize all providers of medical benefits who render services or merchandise to me/us under MO Healthnet to release all records regarding such services or merchandise to the department of social services and its representatives.

i/We understand that application for and acceptance of MO Healthnet constitutes an assignment of rights to the department of social services, MO Healthnet division for payment for medical care from a third party.

provided i/we are found to be eligible for assistance, i/we wish payments by the MO Healthnet division and/or the title xviii medical insurance program to be made directly to physicians and medical suppliers on any future covered unpaid bills for medical and other health services furnished me/us while eligible for MO Healthnet.

If signing electronically: by entering my name, i have agreed to submit this application by electronic means. i understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

by signing this application on paper or electronically, you are giving us permission to deliver, or cause to be delivered, phone calls to you regarding your case from an automated dialing system at the primary phone number you provided on page 2. you do not have to consent to this as part of your application. if you want to opt out of getting these calls, check here:

SIgN hERE

my/our signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete.

signature Of applicant

date

signature Of spOuse

date

signature On beHalf Of applicant

date

if yOu are signing On tHe applicant’s beHalf, please identify yOur relatiOnsHip tO tHe applicant:

guardian or conservator

pOa/attorney-in-fact

estate representative

authorized representative (complete form iM-6ar in appendix c)

family member

attorney representing applicant (please provide entry of appearance)

 

 

please print your name and contact information below.

 

representative naMe (first, Middle, last)

 

 

 

 

 

representative Mailing address

 

city, state, zip cOde

 

 

 

MO 886-3846 (7-15)

page 7 Of 7

pERmaNENT      iM-1Ma (07/15)

File Attributes

Fact # Fact Name Description
1 Form Identification The form MO 886-3846, revised July 2015, is for applying for MO HealthNet (Medicaid) in Missouri.
2 Assistance Availability Applicants can receive help with their application by calling 1-855-373-4636. Assistance is available in languages other than English and for the deaf or hard-of-hearing and blind or visually impaired individuals.
3 Application Section The form includes sections for basic information, household details, financial resources, income and expenses, citizenship and residency, and personal property.
4 Governing Law The application for MO HealthNet is governed by the laws of the State of Missouri.
5 Eligibility Requirements Eligibility conditions mentioned in the form include age, disability, blindness, living in a nursing facility, needing in-home nursing care, needing help with Medicare premiums and copayments, participating in the Ticket to Work program, having medical bills from the last three months, and representation by another party.
6 Household Member Information Applicants must list all household members, indicating their relationship to the applicant, their demographic information, and if they are applying for coverage as well.
7 Financial Information Required The application requires detailed information about available money, trusts, resources such as bank accounts, securities, and pre-paid burial plans, along with income from various sources and expenses.
8 Personal and Real Property Disclosure Applicants must disclose ownership of vehicles, real estate, and personal property, including farmland and machinery, business equipment, and more.
9 Citizenship and Residency Confirmation Applicants must declare their residency in Missouri and citizenship status, and agree to apply for any other benefits they may be eligible for, such as SSDI, SSI, and VA benefits.

How to Write Mo 886 3846

Filling out the MO 886-3846 form can be a pathway to receiving benefits under the Missouri Department of Social Services, aimed at providing medical assistance through the Family Support Division. This form is essential for applying for MO HealthNet (Medicaid) and requires attention to detail to ensure all the necessary information is provided accurately. Below are the steps to guide you through the process of completing this form effectively.

  1. Start with Section 1: Your Basic Information. Enter your full legal name including your maiden name if applicable. Provide your home address, city, state, and zip code. If your mailing address differs from your home address, include this information as well.
  2. Provide your primary and alternate phone numbers, marking whether it's a cell, home, or work number. Indicate your preferred method of contact (call, text, email, mail) and include your email address if email is preferred.
  3. Enter your Social Security Number, date of birth, place of birth, race (optional), sex, and if you are Hispanic or not (optional).
  4. Check any boxes that apply to you or your spouse regarding age, disability, living in a nursing home, needing help with Medicare premiums, etc. Fill out any additional sections (Appendix A, B, C) as indicated for your specific circumstances.
  5. Move to Section 2: Your Household. List your spouse first, then anyone else who lives with you, including their relationship to you, date of birth, and other details as requested. Indicate whether you are married and live with your spouse.
  6. In Section 3: Money Available To You, answer questions about trusts and list all resources including checking accounts, savings, and any cash securities. Be thorough in detailing pre-paid burial plans if applicable.
  7. For Section 4: Your Income and Expenses, check all types of income you or anyone in your household receives. Include employer details, income before taxes, and how often you're paid. If self-employed, indicate the type of business and monthly income after taxes. If married and living in a nursing home, list your combined monthly costs.
  8. If applicable, fill out the child support or alimony payments section with the case number, amount per month, and the state the order comes from.
  9. Address your citizenship, residency, and agreement to apply for other benefits in Section 5. Provide details for all applicants, including non-citizen information if applicable.
  10. In Section 6: Your Personal Property, disclose any transfers of money, vehicles, or property in the last five years. List vehicles owned, real estate property, and personal property including farm machinery, livestock, and business equipment.

Once you've completed all sections accurately, review your application to ensure all the information is correct and complete. After you're satisfied with your application, submit it as directed by the Missouri Department of Social Services for processing. Remember, providing detailed and accurate information is crucial for a timely and favorable review of your application. With these steps, navigating the form should be more manageable, moving you one step closer to the support you're seeking.

What You Should Know About This Form

What is the purpose of the MO 886-3846 form?

The MO 886-3846 form serves as an application for MO HealthNet (Medicaid) in the state of Missouri. It is designed for individuals seeking health coverage through Medicaid, offering comprehensive instructions on how to apply for benefits. The form gathers essential personal information, health status, household details, financial information, and more to assess eligibility for health care support under MO HealthNet.

Who needs to complete the MO 886-3846 form?

The form must be completed by anyone residing in Missouri who wishes to apply for MO HealthNet (Medicaid). This includes individuals over the age of 65, those who are disabled, blind or visually impaired, residents in nursing homes or similar facilities, those needing in-home nursing care, individuals seeking assistance with Medicare premiums and co-insurance costs, participants in the Ticket to Work program, anyone needing help with medical bills from the last three months, and individuals who have a designated representative, such as a conservator, guardian, or attorney-in-fact. Applicants should provide detailed information about every household member, as the information can affect the eligibility and coverage.

What documents are required to complete this application?

To successfully complete the MO 886-3846 application, several types of documentation may be required, including:

  • Proof of income – such as pay stubs, tax returns, or letters from Social Security
  • Documentation of resources – including bank statements, property deeds, or vehicle registrations
  • Proof of residency – such as a utility bill or lease agreement in the applicant’s name
  • Citizenship or immigration status documents
  • Any other documentation pertaining to special circumstances mentioned in the application, such as trust documents, medical bills, or proof of disability

How and where can one submit the MO 886-3846 form?

The MO 886-3846 form can be submitted through various means to accommodate different preferences and needs:

  1. In Person: Applicants can submit the form at their local Family Support Division office. This method allows for immediate receipt confirmation and the opportunity to ask any questions.
  2. By Mail: The completed form can be mailed to the Family Support Division. It is advisable to keep a copy of the application for personal records.
  3. Online: While the MO 886-3846 form itself may not be directly submitted online, Missouri allows for online applications through its official portal for those who prefer a digital submission.
  4. By Phone: Individuals can also call the provided customer service numbers to get assistance with the application process over the phone or to request further information on how to submit their application.

Assistance in languages other than English is available, and TTY users can call a dedicated number for service. It’s important to ensure all sections of the form are completed accurately to avoid delays in the processing of the application.

Common mistakes

Filling out forms can sometimes feel overwhelming, especially when they're as important as the application for MO HealthNet (Medicaid) in Missouri. While it’s crucial to provide accurate and complete information, mistakes can happen. Here are nine common errors people make on the MO 886-3846 form that you should avoid:

  1. Not providing full legal names: Applicants sometimes forget to include their full legal name, including any middle names or maiden names if applicable. This can cause delays in processing the application.

  2. Incomplete address details: It’s important to include your complete home address. If you use a P.O. box, make sure to also provide your physical address to ensure all communications reach you.

  3. Skipping phone and email information: The form asks for both a primary phone number and an email address. Failing to provide these can hinder the Missouri Department of Social Services' ability to contact you for additional information or to clarify your application details.

  4. Misunderstanding household composition: Some applicants get confused about who to include in their household. Remember to list your spouse first, then anyone who lives with you, or would live with you if not for residing in a nursing home.

  5. Forgetting to discuss assets: The form requires detailed information about your financial situation, including bank accounts, real estate, and vehicles. Leaving out assets or not fully disclosing them can affect your eligibility.

  6. Unclear income information: Not accurately reporting income from all sources, including jobs, social security, or other benefits, can lead to issues with your application. It's essential to include income before taxes and how often you receive it.

  7. Omitting information on other benefits: Applicants sometimes forget to indicate whether they are applying for other benefits like Social Security, SSI, or VA benefits. This section is crucial for determining your full eligibility for MO HealthNet.

  8. Neglecting citizenship or residency questions: Every applicant must fill out their citizenship status and residency intentions. If this part is skipped or filled out incorrectly, it may result in application denial.

  9. Not appointing an authorized representative, if needed: If you have a conservator, guardian, or someone who has a power of attorney, you must fill out Appendix C. This step is often overlooked and can be vital for those who need assistance managing their health benefits.

Avoiding these mistakes can streamline the process, ensuring your MO HealthNet application is processed efficiently and accurately. Always double-check your information before submitting to ensure everything is complete and correct.

Documents used along the form

Applying for MO HealthNet (Medicaid) involves a thorough review process, which requires not only the primary application but also additional forms and documents. These supplementary materials help in providing a comprehensive overview of an applicant's situation for the authorities. Understanding the commonly used forms and documents alongside the MO 886-3864 form can streamline the process for applicants.

  • IM-1SSL: This Statement of Support Legal (IM-1SSL) form is used to declare income from alimony, child support, or other family support sources. It's vital for establishing financial eligibility.
  • IM-4EMA: The Emergency Medical Authorization (IM-4EMA) form must be completed for cases that qualify for urgent or emergency medical assistance under Medicaid, ensuring timely care in urgent situations.
  • IM-1MA: This Medical Assistance application form is required for individuals applying for various Medicaid programs, serving as a detailed record of personal, financial, and health information.
  • IM-50: The Authorization to Disclose Information (IM-50) form allows the Medicaid program to obtain medical records and other personal information necessary for eligibility determination.
  • PA-1: The Presumptive Eligibility Application (PA-1) form is used by qualified providers to determine short-term Medicaid eligibility for certain groups like pregnant women or children, allowing immediate access to healthcare services.
  • IM-2AR: The Annual Renewal form (IM-2AR) is crucial for existing Medicaid recipients, ensuring that beneficiaries reconfirm their eligibility each year to continue receiving benefits.
  • Appendix C: Often attached with the MO 886-3846 form, Appendix C specifically addresses the designation of an authorized representative, who can act on behalf of the applicant in Medicaid matters.
  • IM-4MED: The Medical Report form (IM-4MED), which may be necessary for individuals claiming Medicaid eligibility based on disability, illness, or age-related conditions, providing comprehensive medical information from a healthcare professional.

These documents are instrumental in ensuring that the application for MO HealthNet is accurately processed, reflecting the applicant's current needs and circumstances. Ensuring these forms are correctly filled out and submitted with the necessary information can greatly enhance the efficiency of the eligibility determination process, ultimately providing vital healthcare coverage to those in need.

Similar forms

The MO 886 3846 form, which is the application for MO HealthNet (Medicaid) in Missouri, shares similarities with several key documents used in different states for similar purposes. These documents facilitate the application process for health coverage assistance through Medicaid or similar state-specific programs. Understanding these forms can provide insights into the broader landscape of health coverage applications in the United States.

The Form 1040 for Health Coverage Exemption is one such document that parallels the MO 886 3846 form in certain aspects. Both forms require detailed personal information, including income levels, household size, and specific eligibility criteria for health coverage exemptions or assistance. The Form 1040 specifically caters to individuals seeking exemptions from the Affordable Care Act's (ACA) mandatory health coverage, while the MO 886 3846 form focuses on applying for Medicaid benefits. However, they similarly assess an individual's financial situation to determine eligibility for health coverage support or exemptions.

CalFresh Application Form, California's version of the Supplemental Nutrition Assistance Program (SNAP) application form, also bears resemblance to the MO 886 3846 form. Despite different primary objectives—CalFresh focuses on food assistance while MO HealthNet addresses healthcare coverage—both applications require detailed household information, financial status, and special conditions like disabilities that might affect eligibility. Each form serves as a gateway to state-provided assistance, aiming to evaluate the applicant's needs based on similar socioeconomic factors.

Application for Benefits (Texas Health and Human Services) is another example of a document with similarities to Missouri's MO 886 3846 form. This comprehensive application is designed for a variety of assistance programs in Texas, including Medicaid, SNAP, and TANF (Temporary Assistance for Needy Families). Like the MO 886 3846 form, it collects detailed personal, household, and financial information to determine eligibility across multiple assistance programs. Both forms play a crucial role in facilitating access to necessary services for residents in their respective states, emphasizing the importance of accurate and complete application submissions for potential beneficiaries.

Dos and Don'ts

When completing the MO 886-3846 form for MO HealthNet (Medicaid) application, it's important to follow certain guidelines to ensure your application is processed correctly and efficiently. Here are ten things you should do and ten things you shouldn't do:

Things You Should Do:

  • Read the instructions carefully before filling out the form to ensure you understand what is required.
  • Provide complete and accurate information for every section to avoid delays in processing your application.
  • If you're unsure about a question, seek clarification by calling the customer service number provided in the form.
  • Use black ink and write legibly if filling out the form by hand to make sure all information is readable.
  • Include information for all household members as required in Section 2 of the form.
  • List all sources of income and expenses accurately in Section 4 to ensure eligibility is correctly assessed.
  • If applicable, make sure to check the appropriate boxes regarding disability, nursing home residence, or the need for in-home nursing care.
  • Sign and date the form in the designated area to certify that the information provided is accurate.
  • Provide copies of necessary documents, such as proof of income or identification, as requested in the form instructions.
  • After completing the form, review all sections to confirm that no information has been missed.

Things You Shouldn't Do:

  • Avoid leaving sections blank; if a section doesn't apply, indicate with “N/A” (not applicable).
  • Don't provide false or misleading information as this could result in denial of benefits or legal action.
  • Forget to list all household members and their information, as incomplete household information can affect eligibility.
  • Avoid using erasable ink or pencil, which can smudge or be altered, potentially causing issues with your application.
  • Don't omit any financial details, including all forms of income and resources, which are critical for determining eligibility.
  • Assume eligibility without providing all requested information regarding other benefits, disabilities, or healthcare needs.
  • Don't neglect to check the box and fill out additional appendices if you or your spouse are disabled, blind, or need special care.
  • Avoid forgetting to sign and date the application, as an unsigned application will not be processed.
  • Don't send original documents unless specifically requested; always provide copies.
  • Wait to submit the application if you're missing some information. It's better to submit as much as you can and provide additional information later.

Misconceptions

When it comes to understanding the complexities of Medicaid applications, specifically the Missouri MO 886-3846 form for MO HealthNet (Medicaid), there are several common misconceptions. Let's clarify some of these to ensure families seeking assistance receive the correct information.

  • It's only for the elderly: While it's true MO HealthNet provides for those over 65, it also extends to other groups, including disabled individuals, those in need of nursing home care, and low-income families, among others.

  • You can’t apply if you're not a U.S. citizen: Non-U.S. citizens can apply for MO HealthNet. The form asks for your immigration status and registration number to accommodate diverse applicants.

  • Text messaging is available for communication: Although the form suggests text as a preferred method of contact, it notes that texting is not available in all areas. It's important to have alternative communication preferences.

  • Applying for others is not permitted: Actually, you can apply on behalf of others, such as your spouse or children. The form includes sections for adding other household members, and if necessary, designating an authorized representative.

  • It's strictly for medical coverage: While MO HealthNet is primarily health coverage, it also offers assistance with Medicare premiums, co-insurance costs, and even provides some support for in-home nursing care, which goes beyond simple medical insurance.

  • Income disqualifies you: MO HealthNet considers various factors, not just income. Assets, household size, and specific needs all play a part in eligibility, allowing a broader range of individuals to qualify than might be expected.

  • The application process is entirely in English: Assistance is available in multiple languages, ensuring non-English speakers can apply and receive support in their preferred language.

  • You must be employed to apply: Employment is not a prerequisite for application. The form caters to those who are unemployed, self-employed, retired, or disabled, recognizing the diverse situations of applicants.

  • Only traditional families are eligible: MO HealthNet applications accommodate various household compositions, including non-traditional families, reflecting the diverse nature of modern households.

  • It's a lengthy and complicated form: While comprehensive, the form is structured to guide applicants through each step. It breaks down the process into manageable sections, each focusing on different aspects of the applicant's life and needs.

Tackling these misconceptions head-on can not only demystify the application process but also encourage more eligible families and individuals to seek the assistance they need. Understanding the MO 886-3846 form is the first step toward accessing vital health care coverage and benefits.

Key takeaways

When filling out the MO 886-3846 application for MO HealthNet (Medicaid), it is important to consider the following key takeaways to ensure a complete and accurate submission:

  • Gather all required information before starting: This includes your full legal name, social security number, birth date, home and mailing addresses, contact information, and financial details.
  • The form allows you to specify a preferred method of contact, including calls, texts (where available), email, or mail, ensuring the communication is convenient for you.
  • If applying based on disability, age, living in a nursing home, or requiring in-home nursing care, make sure to complete the relevant sections or appendices to adequately support your application.
  • Include detailed information about all household members, including related financial and personal information, as this can affect eligibility and the type of coverage you may receive.
  • Being honest and accurate about your income, including both earned and unearned income, is crucial as it impacts eligibility and the benefits available to you and your household.
  • If you or your spouse have any resources in a trust, you must provide comprehensive details about the trust, including your role and the resources included in the trust.
  • Disclose any real estate, vehicles, and personal property, as ownership and values can influence your eligibility for MO HealthNet.
  • Understanding your rights and responsibilities, including the agreement to apply for other potential benefits (e.g., RSDI, SSI, VA), is pivotal for compliance and ensuring you receive all possible assistance.

Completing the MO 886-3846 form accurately and providing all the necessary documentation can streamline the review process and improve your chances of receiving MO HealthNet benefits.

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