Homepage Fill Out Your Mo 886 3846 Form
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The MO 886 3846 form serves as a critical application for Missouri's HealthNet, designed to help residents access Medicaid services. This application encompasses several essential sections that gather detailed information about the applicant's personal, household, and financial circumstances. Fundamental data required includes the applicant’s full legal name, address, and contact information, as well as pertinent demographic details such as Social Security number and date of birth. The form also prompts applicants to indicate specific eligibility criteria, such as age, disability status, or living arrangements, ensuring that those who need assistance can clearly identify their situation. Furthermore, it collects crucial information regarding household composition and income sources, which are examined to determine the applicant's financial eligibility for Medicaid benefits. Particular emphasis is placed on ensuring that applicants can convey any additional needs for assistance, such as language interpretation services or special accommodations for disabilities. The structure of the form allows for a thorough assessment, enabling the Family Support Division to make well-informed decisions regarding eligibility for government healthcare support.

Mo 886 3846 Example

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)

Form Characteristics

Fact Name Description
Purpose The MO 886-3846 form is used to apply for MO HealthNet, which is Missouri's Medicaid program.
Governing Law This form operates under Missouri state law regarding Medicaid eligibility and benefits.
Eligibility Applicants must meet specific criteria, such as age, disability status, and income limits.
Assistance Contact If you need help with the application, call 1-855-373-4636 for support in English or other languages.
Sections Required All applicants must complete Sections 1 through 7 of the form to ensure complete processing.
Application Language For non-English speakers, assistance is available; simply inform the representative of your language needs.
Additional Resources Contacts for specialized assistance, such as for those who are blind or visually impaired, are provided.
Document Verification Certain sections require the submission of additional documents to verify information, such as income and property ownership.

Guidelines on Utilizing Mo 886 3846

Completing the MO 886 3846 form is an important step in securing necessary health coverage through MO HealthNet. As you navigate this process, take your time and ensure that all information is accurate and complete to avoid delays. If you encounter any challenges while filling out this form, assistance is available through customer service at the designated phone numbers.

  1. Gather Necessary Documents: Collect all required identification and financial documents, including your Social Security number, proof of income, and any relevant tax information.
  2. Complete Your Basic Information: Fill in your full legal name, home address, contact number, and email address. Be sure to list your date of birth and Social Security number accurately.
  3. Indicate Your Eligibility: Check any boxes that apply to you or your spouse, such as age, disability status, or need for in-home nursing care.
  4. List Household Members: Provide details about everyone living in your household, starting with your spouse. This includes their names, relationships, date of birth, and Social Security numbers if they are applying.
  5. Outline Financial Resources: Document all available resources, such as bank accounts, investments, and any ownership of personal property. Check the appropriate boxes for each resource type.
  6. Detail Your Income: Identify all sources of income, whether earned or unearned. Record the amount you receive monthly from each source.
  7. Answer Residency and Citizenship Questions: Confirm your residency in Missouri and your citizenship status. If you are not a U.S. citizen, provide the required immigration details.
  8. State Any Transfers of Property: If applicable, list any money, vehicles, or property transferred in the last five years. Include details such as sale dates and amounts received.
  9. Review and Sign: Carefully review your completed form for accuracy. Ensure all sections are filled out, and then sign and date the form.
  10. Submit the Form: Once completed, submit your form through the method indicated in the instructions, making sure it reaches the correct department.

What You Should Know About This Form

What is the MO 886-3846 form?

The MO 886-3846 form is an application for MO HealthNet, which is Missouri's Medicaid program. This form allows individuals and families to apply for health coverage that assists with medical costs. It collects essential information about the applicant's financial situation, household members, and health needs to determine eligibility for benefits under the program.

Who should fill out the MO 886-3846 form?

Any individual or family seeking financial assistance with medical expenses in Missouri should fill out this form. This includes those who are disabled, elderly, or in need of long-term care. It is suitable for people living in nursing homes, those needing in-home nursing care, or those requiring help with medical bills from previous months.

What information do I need to provide on the form?

Applicants are required to provide personal details such as full name, address, date of birth, and Social Security number. Additionally, information regarding household members, financial resources, and monthly income must be included. Specific questions may ask about any previous transfers of money or property, ongoing income sources, and residency status in Missouri.

How can I submit the MO 886-3846 form?

The completed form can typically be submitted by mailing it to the appropriate Family Support Division office in Missouri. It’s important to check the most current guidelines or contact customer service for assistance with submission methods. If needed, online submission options may also be available, depending on the resources provided by the state.

What should I do if I need help filling out the form?

If you need assistance with the application process, you can call the customer service number at 1-855-373-4636. They offer help in multiple languages. If you are hearing impaired, you can reach out via TTY at 1-800-735-2966. Additionally, consider asking a trusted family member or a social service professional for support to ensure that you provide accurate information.

What happens after I submit the MO 886-3846 form?

Once the form is submitted, the Family Support Division will review your application to determine your eligibility for MO HealthNet benefits. You may receive additional correspondence if further information or documentation is required. Typically, applicants will be notified of their eligibility status within a few weeks after submitting the form.

Common mistakes

Filling out the MO 886-3846 form can be a straightforward process, but many applicants make common mistakes that can lead to delays or complications in their application. One significant mistake is failing to provide complete and accurate personal information. Missing or incorrect details—such as name, address, or Social Security number—can result in the application being rejected or sent back for corrections. Always double-check this information before submission.

Another frequent error occurs in Section 2, where the household members' details are listed. Individuals often neglect to include all members of their household or inaccurately state their relationships. This omission can affect eligibility assessments, so it's crucial to ensure everyone who lives in the household is accounted for correctly.

Many applicants mistakenly skip sections or fail to follow through with all required portions of the form. It's vital to fill out all sections, from household information to income sources. Incomplete applications can lead to unnecessary delays, as additional information might be requested after submission.

Providing inaccurate financial information is also a common pitfall. In Section 3, where resources and income need to be outlined, incorrectly stating the amount or failing to disclose all income sources can jeopardize the application. Ensure that all assets and income streams, including trust funds and assistance programs, are accurately represented.

Some applicants overlook the importance of checking applicable boxes thoroughly. In Section 1, there are several eligibility categories. If someone mistakenly leaves out a checkmark or indicates the wrong qualifiers, it could lead to misinterpretation of the application requirements. Careful attention to these details can prevent misunderstandings regarding coverage eligibility.

Moreover, failing to provide necessary documentation can hinder the process. For example, if an applicant has a conservator or guardian, they must include corresponding documents in Appendix C. The absence of any required supportive documentation can cause delays or rejection of the application.

Many individuals also forget to include a preferred contact method in Section 1. This detail helps ensure timely communication with the family support division. Whether you prefer to be contacted by phone, text, or email, clearly indicating this can facilitate smoother interactions throughout the application process.

Lastly, neglecting to review the completed form before submission is a critical oversight. Many individuals submit their applications without a final check, which can lead to unnoticed errors or omissions. Take a moment to go back through each section to confirm that everything is accurate and complete. This extra step can help in successfully securing the benefits without unnecessary hassle.

Documents used along the form

The MO 886 3846 form is an important document for those applying for Missouri Medicaid, known as MO HealthNet. Alongside this form, there are several other documents that may be required to complete your application process or offer additional information. Here’s a brief overview of commonly used forms that accompany the MO 886 3846 form.

  • Appendix A - Disability Determination: This appendix is required if an applicant is applying based on a disability and does not receive Social Security Disability or SSI. It helps assess whether the applicant meets the state's disability criteria.
  • Appendix B - Nursing Home Care Information: This document is essential for married applicants where one spouse is living in a nursing home and needs skilled care. It provides details about the relationship and financial status of both spouses.
  • Appendix C - Authorized Representative: If an applicant has someone else managing their application, this form identifies that representative. It may include details about conservators, guardians, or attorneys-in-fact.
  • Social Security Verification Letter: This letter confirms the applicant's benefits received from Social Security, which is important for fulfilling income verification requirements.
  • Income Verification Documents: Various forms such as pay stubs, bank statements, and tax returns to substantiate income claims may be needed. These documents will support the information provided in the MO 886 3846 form.
  • Proof of Citizenship or Immigration Status: Applicants must provide documentation that verifies their citizenship or immigration status, ensuring compliance with federal regulations.
  • Financial Account Statements: These are needed to report assets and can include savings, checking, and investment accounts. Providing these statements helps establish the applicant's financial situation.

Understanding these additional forms and documents can streamline the application process for MO HealthNet. Gathering the necessary paperwork ahead of time helps ensure a more efficient review and can lead to quicker access to essential health services.

Similar forms

The MO 886 3846 form, used for applying for Medicaid in Missouri, shares similarities with the following documents:

  • Form 1040: This is the standard individual income tax return form, which collects basic identification information and confirms financial eligibility for various programs.
  • W-2 Form: Issued by employers, this form details an employee's annual wages and taxes withheld, allowing for a clear assessment of income.
  • Social Security Administration Application: This application collects personal information and determines eligibility for social security benefits, similar to how the MO 886 3846 assesses needs.
  • SNAP Application: This application processes state benefits for the Supplemental Nutrition Assistance Program, requiring household income and member details akin to the Medicaid application.
  • Medicare Application: This form gathers personal and financial information to determine eligibility for Medicare benefits, paralleling the process seen in the MO 886 3846.
  • Temporary Assistance Application: This document determines eligibility for financial assistance, requiring similar personal details and income assessments as found in the MO 886 3846.
  • VA Benefits Application: Veterans utilize this to apply for various benefits. It similarly collects information regarding income and personal circumstances.
  • Child Support Application: This form assesses income level and custody situations to establish child support needs, resembling the financial inquiries in the MO 886 3846.
  • Housing Assistance Application: This application determines eligibility for subsidized housing, requiring information about income and household composition, just like the MO 886 3846.
  • Powers of Attorney Document: While serving a different purpose, this document often contains personal information and the identities of individuals involved, similar to the information collected in the MO 886 3846.

Dos and Don'ts

When filling out the MO 886-3846 form for MO HealthNet, it's essential to navigate the process carefully. Errors or omissions can delay your application or affect your eligibility. Here are nine important dos and don’ts:

  • Do read the instructions thoroughly before starting the form.
  • Do provide accurate and complete information for each section.
  • Do double-check your personal information, such as your name, address, and Social Security number.
  • Do make sure to answer all questions, especially regarding income and household members.
  • Do keep copies of the completed form and any supporting documents for your records.
  • Don't leave any sections blank. If a question does not apply, indicate that with "N/A."
  • Don't rush through the application. Take your time to minimize mistakes.
  • Don't forget to sign and date the form; an unsigned application cannot be processed.
  • Don't hesitate to seek assistance if needed. Call customer service or reach out for help in your preferred language.

By following these guidelines, you can enhance your chances of a smooth application process. Remember, attention to detail is crucial! Don't overlook small details; they can lead to significant implications for your health coverage.

Misconceptions

Understanding the MO 886 3846 form for Missouri's Medicaid program is crucial for those seeking health coverage. However, several misconceptions often arise about this application. Below are some common myths and the truths that debunk them.

  • Only elderly individuals qualify for MO HealthNet coverage. This is not true. While there are options for seniors, individuals of all ages can apply, especially those with disabilities or low income.
  • You cannot apply if you earn any income. Many believe that any income disqualifies them. However, MO HealthNet takes one’s income into account and provides coverage based on income levels, which means working individuals can still qualify.
  • The application is only available in English. This misconception can create barriers. In fact, the application process offers assistance in multiple languages by simply informing the customer service representative of the need.
  • You cannot have assets and still qualify for assistance. Some people think having any assets disqualifies them from Medicaid. In reality, there are resource limits, but certain assets are excluded, and planning can help maintain eligibility.
  • All applicants need to provide extensive documentation. While some documentation is required, the specifics can vary based on individual circumstances. The form itself outlines which sections must be completed, often minimizing the burden.
  • Once you apply, you can’t change your application. Applicants sometimes fear that their submitted information is set in stone. However, modifications can be made if circumstances change, and there is a process for updating your information as needed.

By addressing these misconceptions, individuals can feel more empowered to navigate the application process and secure the health coverage they need.

Key takeaways

  • The MO 886 3846 form is used to apply for MO HealthNet (Medicaid) in Missouri. It assists applicants in receiving necessary health care benefits.

  • Initially, individuals must provide their basic information, including name, address, and contact details. Accurate completion of these sections is essential for the application process.

  • There are sections tailored for households, meaning applicants need to provide details not only about themselves but also about family members who live with them.

  • Applicants must disclose any income they or their spouse receive. This includes both earned and unearned income sources, such as social security and pensions.

  • Relevant expenses should also be included in the application. Expenses like rent, mortgages, and monthly utility bills are critical for assessing financial eligibility.

  • Citizenship and residency status are also vital components in the application. Applicants must confirm that they reside in Missouri and are either U.S. citizens or have proper immigration status.

  • For those with special circumstances, such as being blind or living in a nursing home, additional sections must be filled out to confirm eligibility for specific programs.

  • It is essential to provide accurate details regarding any assets, including bank accounts, vehicles, and trusts. These can affect eligibility and benefit levels.

  • If assistance is needed during the application process, a customer service line is available. A representative can help understand questions related to filling out the form.