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.
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
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)
priMary pHOne nuMber
cell Home Work
alternate pHOne nuMber
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
page 2 Of 7
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
(optional)
relatiOnsHip
TO yOu
(spouse, son, sister, friend)
cHeck (✓)
sOcial
if tHey’re security nuMber
applying
(if applying)
are yOu Married and live WitH yOur spOuse, Or lived WitH yOur spOuse WHen yOu entered a nursing HOMe?
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?
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
REfuNdaBLE?
page 3 Of 7
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)
trusts and annuities
non-va pensions, retirement, and disability
interest or dividends
unemployment compensation
Worker’s compensation
Military branch retirement pension
Money from friends or family
va payments (check all that apply)
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
____________________ is employed
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
page 4 Of 7
fILL ouT ThIS SECTIoN If You paY aNY ChILd SuppoRT oR aLImoNY paYmENTS
CaSE NumBER
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
2.all applicants are u.s. citizens
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)
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
amouNT owEd
how IS IT uSEd?
REaL ESTaTE pRopERTY
i/We OWn Or are buying real estate.
nO if yes, provide a copy of the deed
ENTER ThE addRESS oR LoCaTIoN
(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
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
page 5 Of 7
aircraft
property claims in probate court
Other (explain)
SECTIoN 7: Your Insurance
i/We Have life insurance
nO if yes, fill out below:
pERSoN INSuREd
INSuRaNCE CompaNY
poLICY NumBER
CaSh vaLuE
i/We Have Medicare
if yes, list the names of the people who have Medicare:
i/We Have lOng-terM care insurance
NamE of pERSoN wITh LoNg-TERm CaRE INSuRaNCE
pREmIum (per month)
i/We Have OtHer HealtH insurance
TYpE of CovERagE
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?
2.
do you ask or beg for money?
3.
Have you applied or do you agree to apply for supplemental security income (ssi) as a condition of eligibility?
4.
Have you had eye surgery within the last five years?
5.
if you are younger than 75, are you willing to have medical treatment or an operation to correct your blindness?
6.
Would you be willing to do job training or work at a job for which you are suited?
7.
do you have an eye doctor (either an opthalmologist or an optometrist)?
if yes, fill out below:
facility and dOctOr naMe
address (HOuse nuMber, street Or rural rOute, pO bOx)
date Of last eye exaM
date Of next appOintMent
page 6 Of 7
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
signature On beHalf Of applicant
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
page 7 Of 7
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.
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.
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.
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.
To successfully complete the MO 886-3846 application, several types of documentation may be required, including:
The MO 886-3846 form can be submitted through various means to accommodate different preferences and needs:
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.
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:
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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:
Things You Shouldn't Do:
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.
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:
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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