The Indiana 53421 form is the Application for the Healthy Indiana Plan, designed to provide health coverage for uninsured adults aged 19 to 64. Completing this application is essential for those seeking access to necessary medical care and services. To begin the process of securing health coverage, please fill out the form by clicking the button below.
The Indiana 53421 form, officially known as the Application for the Healthy Indiana Plan, serves as a crucial document for adults seeking health coverage under this state program. This application is specifically designed for uninsured individuals aged 19 to 64, ensuring they have access to essential healthcare services. When filling out the form, applicants will need to provide personal details, including their Social Security Number, which is mandatory for processing. The form guides users through selecting a health plan, detailing household members, and reporting income and expenses. Additionally, it includes health screening questions to determine eligibility for enhanced services. It’s important to note that this application is not intended for children or pregnant women; separate applications are available for those groups. Clear instructions are provided throughout the form, emphasizing the importance of accuracy and completeness in the application process. By following the outlined steps, applicants can efficiently navigate their way toward obtaining health coverage that meets their needs.
Application for Healthy Indiana Plan
State Form 53421 (R6 / 8-11) HIP 2515
*This agency is requesting the disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
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Instructions: Please fill out your application as completely as you can, and don't forget to sign your name on page 4 question 13.
This application form is not for children and pregnant women. To obtain an application for children and pregnant women contact 1-877-GET HIP9 (1-877-438-4479) and ask for a Hoosier Healthwise application.
1. Health Plan Selection
If your application is approved, you will be enrolled in one of our health plans. If you have made your selection, please mark the box next to your chosen plan.
Anthem Blue Cross Blue Shield
MHS
MDwise
Provider directories are available on the health plan websites. If you have given us your e-mail address, we will send an
electronic copy to you . Do you need a paper copy instead?
Yes
No
If you have any questions about how to choose your health plan or would like the provider directory before being assigned to a health plan, please call 1-877-GET-HIP9(1-877-438-4479).
2. Tell us about adult members of your family living in your household. Place a applying for HIP.
Date of Birth
Social Security
Marital
Sex
Relationship
U.S.
Place a
Name (First, MI, Last)
Status
Race
to
Citizen?
(mm/dd/yyyy)
Number *
M/D/S
M/F
Applicant 1
Yes / No
applying
Adult / Applicant 1
Self
Adult / Applicant 2
3.How many total members are in your household? _____
4.Tell us your address and telephone number.
Home address (number and street)
City
State
ZIP code
County
Mailing address (if different)
Home telephone number
Alternate telephone number
Email Address
Completed by Enrollment Center:
Date of application:(mm, dd, yyyy)________________ Center's Code: ______________ Interviewer: ________________________________________
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5.Tell us about children living in your home.
Applicant 1 is
Applicant 2 is a
U.S. Citizen?
a caregiver of
caregiver of
this child
Yes/No
Child 1
Child 1 Relation to Applicant 1:
Child 1 Relation to
Applicant 2:
Child 2
Child 2 Relation to Applicant 1:
Child 2 Relation to
Child 3
Child 3 Relation to Applicant 1:
Child 3 Relation to
Child 4
Child 4 Relation to Applicant 1:
Child 4 Relation to
6.Do all of the applicants live in Indiana?
7. Does either of the applicants pay someone to care for a dependant child or a disabled/elderly adult so that a household
member can work, look for a job or go to school?
If yes, does the person for whom the expense is being paid live in the household?
If no, go on to the next item. If yes, enter out-of-pocket expenses only, not expenses that are paid by a non-household member, or child care assistance agency.
Applicant Number
Name of person being cared for
How often paid
Amount paid
Name of care provider
Address of provider (number and street, city, state, and ZIP code)
8.Complete this section for each applicant who is not a citizen of the United States.
1.
Lawful Permanent Resident
3. Granted Political Asylum
5. Parolee
7. Undocumented
2.
Refugee
4. Cuban/Haitian Entrant
6. Amerasian
8. Other (specify) __________
Document Number
Immigration Status
(number from above)
Status Date
(mm/dd/yy)
Country of origin
Date of entry into the U.S.
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9.For each applicant please provide the following information.
Place a if
Applicant has
Covered by
Date applicant last
Why was health insurance lost? Please write one
Blind or
Pregnant
access to health
health insurance
had health insurance
of these reasons below; Loss of employment,
Disabled
insurance at
now including
including Medicare
Could not afford, Coverage limit reached,
employer
Medicare
Company ended coverage, Non-custodial parent
(check one for
dropped insurance, Divorce, Cobra expired, Other
each applicant)
Applicant 2
10.Tell us how much total work income the applicant(s) earn.
Start date (mm/dd/yy)
End date (mm/dd/yy)
Amount of gross pay per period ($)
How often paid?
Weekly
Bi-weekly
Monthly
Twice a month
Other: _______________
Hours worked per week
Is person self-employed?
Do hours vary?
Name of employer and telephone number
11.Tell us if you or family members receive other income from the types listed here. If your family has no income, initial here: _______.
A) SSI
F) Military Allotment
K) Interest Payments
O) Child Support
B) Social Security
G) Unemployment
L) Educational Income
P) Employment
C) Veteran's Benefits
H) Alimony
M) Cash from Friends,
income from
D) Railroad Retirement
I) Sick Benefits
Relatives, etc.
children
E) Pension
J) Strike Benefits
N) Worker's
Q) Other:____________
Compensation
Who receives the payments?
(applicant number or child number)
What type of payments?
(Use letter code from above.)
How Often are Payments
Received?
When did Payments Begin?
Amount of the
Payments ($)
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12. Health Screening Questions
(These questions must be answered in order for your application to be considered complete.)
To the best of your ability, please answer either “Yes” or “No” to the following questions by checking the appropriate answer. This information is being collected to determine whether you will be eligible for the Enhanced Services Plan. This plan will provide a high degree of coordinated medical care for persons with specialized health care needs. If you are otherwise found to be eligible for HIP, you cannot be denied coverage based on a medical condition. Answering “Yes” to any of the following questions will not prevent you from obtaining health coverage.
For each question below, check only one answer for each applicant.
a. In the last three years have you been diagnosed or actively treated for an internal
Cancer? This includes but is not limited to cancers of the: brain; head or neck; throat;
esophagus; larynx; lung; breast; stomach; intestines; colon; pancreas; liver or biliary
tract; ovary; prostate; testicles; bladder; bone; or blood.
b. Have you ever been the recipient of an organ transplant including heart, lung, liver,
kidney or bone marrow?
c. Are you currently on a transplant waiting list for one of the above organs or been advised
that you will require such a transplant within the next 12 months?
d. Have you ever been diagnosed with or otherwise told by a medical professional that you
have HIV, AIDS or the virus that causes AIDS?
e. Do you take or have you ever taken medication for HIV, AIDS, or the virus that causes
AIDS?
f. Have you ever been diagnosed with aplastic anemia?
g. Do you require frequent blood transfusions due to a medical condition?
h. Have you ever been diagnosed with or are you being actively treated for hemophilia, or
other rare bloodstream diseases including Von Willebrand's disease, or congenital factor
VIII disorder?
All information collected will be treated as confidential pursuant to 470 IAC 1-2-7, 470 IAC 1-3-1, 42 CFR 431 Subpart F and 45 CFR 164 Subpart E.
13.Signature Required Please read carefully, then sign and date below.
I certify under penalty of perjury, that all the information I have provided is complete and correct to the best of my knowledge and belief.
Applicant 1 signature: ______________________________________ Date: (mm/dd/yy): _________________
Applicant 2 signature: ______________________________________ Date: (mm/dd/yy): _________________
Signature of witness if signed with “X”: ____________________________________________________________
14.Do you want to register to vote ?
Your answer will not affect your eligibility for health coverage.
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Information to Get You Started
Enclosed is your application for the Healthy Indiana Plan, a health coverage program for uninsured adults age 19 through 64. The steps to follow in applying for HIP are explained below.
Step 1: Complete and sign the application.
Answer ALL questions truthfully and completely to the best of your knowledge, including the Health Screening Questions. Use only black or blue pen.
Gather and copy any of the documents listed below as proof of the information on your application.
Sending these papers with your application will help us process it faster. Write your name and Social Security Number on all copies of documents that you send with your application.
To provide
Send for each person applying …
proof of…
Identity
Valid driver’s license or state or student photo ID card. If you have someone acting on your
behalf, that person will need to provide proof of his or her identity also.
US citizenship
Legal birth certificate, Certificate of Naturalization, Certificate of Citizenship, U.S. passport if it
was issued with no restrictions.
Money
Wages: Pay stubs, paychecks, statement from employer(s) for the most current month;
received by
Employment termination: A statement from last employer giving dates of employment and
applicant,
reason for termination.
spouse, and
Self-employment: Last year’s signed tax return or personally kept self-employment records.
dependent
Child Support, Social Security, VA, SSI, Workers’ Compensation, disability, sick pay,
children in the
home
unemployment, or other benefits: court order, award letter or other proof of payment from
the source of the income.
Loans, gifts, or contributions: Promissory note; loan agreement; or statement from person
providing the money that includes the person’s name, address, phone number, signature, and
date.
Guardianship
If someone has legal authority to act on your behalf, provide a copy of the Power of Attorney,
or Power of
Guardianship Order, Court Order, or similar documents.
Attorney
Immigration
If you are not a US citizen, a copy of your alien registration card, permanent resident card, or
other documentation from the Bureau for Citizenship and Immigration Services (formerly the
INS).
Step 2: Return the application to us. If you choose to send by fax, be sure to fax both sides of the application pages and any additional documents. You can return your completed application and other documents to us by:
Mailing them to the Document Center at: FSSA Document Center / PO Box 1630 / Marion, IN 46952; or
Faxing them to the Document Center at 1-800-403-0864; or
Dropping them off at a local FSSA DFR office. To find a local office, please go to our Web site at www.in.gov/fssa/dfr or call toll free 1-800-403-0864.
Step 3: Cooperate with requests for more information or interviews. We will contact you by telephone or mail if we need additional information or documentation to complete your application. Please respond quickly to requests for additional information so that we can process your application.
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IMPORTANT INFORMATION ABOUT THE HEALTHY INDIANA PLAN
Keep this information for your records. Do not send it in with your application.
Benefits under the Plan
HIP provides health insurance coverage to eligible adults. Enrolled members keep their HIP benefits for 12 continuous months even if income or family size changes. Members must live in Indiana and have no other access to health insurance coverage. Benefits are provided through private health insurance companies and also the State’s Enhanced Services Plan (ESP) for members who have complex medical needs. You can choose your health plan on the first page of the application, or you can call the HIP Line at 1-877-GET-HIP-9 (1-877-438-4479) to get further information about the plan and to register your choice. If you don’t select a health plan, one will be chosen for you. Members with complex health care needs will be assigned to the ESP so that enhanced disease management services and specialized networks can be accessed. An applicant’s health condition has no bearing on the HIP eligibility decision. If FSSA determines that the ESP is not the appropriate health plan, the member’s coverage will be transferred. Benefits will not lapse when the plan is changed from ESP to another HIP health plan.
HIP members have a POWER account of $1100 that will be used to pay for their initial health care expenses. The State will contribute to the account and members pay a small percentage of their income (2% - 5%) according to a sliding scale based on family income. When an application is approved, the new member is notified in writing of the amount of the POWER payment.
Your POWER account payment will stay the same during your 12-month enrollment period unless you report a change and specifically ask that your payment be recalculated. During the 12-month enrollment period, you can request 1 recalculation only for changes in your income. This limitation does not apply to changes in your family size. You must make your POWER account contribution each month.
Failure to pay may result in termination from the program, and once terminated due to failure to pay, a person cannot come back to the program for 1-year.
For Additional Information about the Healthy Indiana Plan, call us at
1(877) GET-HIP 9 (1-877-438-4479) Toll Free
Your Rights and Responsibilities as a HIP Applicant and Member
1.Once your signed application is received, federal rules allow 45 days for a decision to be made on your eligibility. We will send you a written Notice explaining whether or not you qualify for HIP. You may appeal and have a fair hearing if you disagree with any decision on your eligibility or if your application is not processed in 45 days.
2.Information you give on the application is kept confidential under state and federal law.
3.A Social Security number (SSN) must be given for each applicant who can legally have a number. An applicant who does not have a number must apply for one. Your SSN will be used to check information kept by the Social Security Administration, the Internal Revenue Service, Workforce Development and other state and federal agencies. We ask for the SSNs of family members not applying for HIP for identification purposes; however you are not required to provide the number.
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4.Eligibility for benefits is considered without any regard to race, color, sex, age, disability or national origin. We ask about your racial-ethnic heritage to comply with the Federal Civil Right Law; however you are not required to provide this information. If you choose not to provide this information we will indicate an ethnicity/race category for you for data collection purposes.
5.Certain information given on your application, such as your income must be verified. If you cannot get the necessary papers, you will need to sign a release form so that we can get them for you.
6.You must provide accurate information. A person who gives false information or misrepresents the truth is committing a crime and can be prosecuted under federal law or state law, or both. The value of benefits received by a person who was not entitled to receive them is subject to recovery by the State.
7.IF YOU MOVE, please tell us your new address so that important mail about your application and membership will reach you without delay. Also, you must tell us if you get health insurance from another source such as Medicare, or if your employer offers health insurance coverage.
8.The immigration status of non-citizens who are applying for HIP is subject to verification by the Bureau of Citizenship and Immigration Services (CIS). Undocumented immigrants and lawful permanent residents who have not yet lived in the U.S. for 5 years are not eligible for full HIP benefits. HIP does not report undocumented immigrants to the CIS.
9.Your rights to payments for medical care are assigned to the State of Indiana if you are found eligible for HIP. This includes rights to medical support and payment for any medical care that you have on behalf of yourself or your children receiving Hoosier Healthwise/Medicaid.
10.If you believe that you have been discriminated against and wish to file a complaint, you may do so by contacting the Department of Health and Human Services, Regional Manager, Region V, Office for Civil Rights, 233 N. Michigan Ave., Suite 240, Chicago, Illinois, 60601. You may call the Regional Office at (800) 368-1019 or, for TDD Call, (800) 537-7697.
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Completing the Indiana 53421 form is an essential step in applying for the Healthy Indiana Plan. After filling out the form, you will need to submit it along with any required documentation to ensure a smooth application process.
After completing the form, gather any necessary documentation to support your application. This includes proof of identity, citizenship, and income. Once everything is ready, submit your application by mail, fax, or in person at a local office. Promptly respond to any requests for additional information to keep your application moving forward.
The Indiana 53421 form is the application for the Healthy Indiana Plan (HIP). This program provides health coverage for uninsured adults aged 19 through 64. The form collects essential information to determine eligibility and enroll applicants in a health plan. It is important to note that this form is not intended for children or pregnant women; separate applications exist for those groups.
You will need to provide various personal details on the form, including:
Make sure to answer all questions truthfully and completely. Missing information can delay processing.
You can submit the completed form in several ways:
Choose the method that is most convenient for you, but ensure you keep a copy of your submission for your records.
Once your application is submitted, it will be reviewed for completeness. If additional information is needed, you will be contacted by phone or mail. It’s crucial to respond promptly to any requests for more information to avoid delays in processing your application. If approved, you will be enrolled in one of the health plans available under HIP.
While there is no specific deadline mentioned for submitting the form, it is advisable to apply as soon as you determine you need health coverage. Timely submission ensures that you can receive benefits without unnecessary delays. If you have questions about your eligibility or the application process, reach out to the provided contact number, 1-877-GET-HIP9 (1-877-438-4479).
Incomplete Information: One of the most common mistakes is not filling out all required fields. Each section of the form needs to be completed to avoid delays in processing.
Missing Signatures: Applicants often forget to sign the form. Remember, a signature is required on page 4, question 13, to validate the application.
Incorrect Social Security Number: Providing an incorrect Social Security Number can lead to rejection of the application. Ensure that this number is accurate, as it is mandatory for processing.
Choosing the Wrong Health Plan: Applicants may neglect to mark their chosen health plan. It is essential to select a plan to ensure proper enrollment.
Omitting Household Members: Failing to include all adult members living in the household can lead to discrepancies in eligibility. Every adult must be listed, along with their details.
Inaccurate Income Reporting: Misreporting income can affect eligibility. It's crucial to provide precise figures and details about all sources of income.
Neglecting Health Screening Questions: Skipping these questions can render the application incomplete. Each question must be answered to determine eligibility for enhanced services.
Failing to Include Supporting Documents: Not attaching necessary documentation can slow down the application process. Proof of identity, income, and other relevant documents should be included.
The Indiana 53421 form, known as the Application for Healthy Indiana Plan, is essential for individuals seeking health coverage under this program. Several other forms and documents are often used in conjunction with this application to ensure a comprehensive submission. Below is a list of these documents, each serving a specific purpose in the application process.
Understanding these forms and documents is crucial for a successful application process. Each plays a vital role in demonstrating eligibility and ensuring that applicants receive the appropriate health coverage under the Healthy Indiana Plan.
The Indiana 53421 form is similar to the Medicaid application form, which is used to determine eligibility for Medicaid benefits. Both forms require detailed personal information, including income, household composition, and medical history. The Medicaid application also mandates the disclosure of Social Security numbers and may ask for additional documentation to verify the information provided. Just like the Indiana 53421, the Medicaid application is crucial for individuals seeking health coverage through government assistance programs, ensuring that applicants meet the necessary criteria for enrollment.
Another document that shares similarities with the Indiana 53421 form is the Supplemental Nutrition Assistance Program (SNAP) application. This form is designed to assess eligibility for food assistance. Both applications require personal details, income information, and household composition. Furthermore, they both emphasize the need for accurate reporting of all members living in the household. The SNAP application also requires the disclosure of Social Security numbers, similar to the Indiana 53421 form, to help verify the identity and eligibility of applicants.
The Temporary Assistance for Needy Families (TANF) application is yet another form that aligns closely with the Indiana 53421. TANF provides financial assistance to families in need, and its application process involves providing information about household income, expenses, and family structure. Both forms require applicants to disclose their Social Security numbers and other identifying information. The goal of both applications is to determine eligibility for assistance programs that support low-income families.
The Health Insurance Marketplace application also has parallels with the Indiana 53421 form. This application is used to enroll individuals in health insurance plans under the Affordable Care Act. Both forms gather information about household members, income, and existing health coverage. They also require the disclosure of Social Security numbers to verify identities and eligibility. The Health Insurance Marketplace application aims to help individuals access affordable health coverage, much like the Healthy Indiana Plan does.
The Medicare Savings Program application can be compared to the Indiana 53421 form as well. This application helps low-income individuals pay for Medicare premiums and other out-of-pocket costs. Both forms require detailed personal and financial information, including Social Security numbers. They aim to assist individuals in obtaining necessary health coverage by evaluating their eligibility based on income and household size.
Similar to the Indiana 53421, the Women, Infants, and Children (WIC) program application serves a specific demographic. It is designed to provide nutritional assistance to pregnant women, new mothers, and young children. Both applications require information about household composition, income, and health status. The WIC application also requests Social Security numbers to ensure accurate identification and eligibility determination, similar to the requirements of the Indiana 53421 form.
The Low-Income Home Energy Assistance Program (LIHEAP) application is another document that shares similarities with the Indiana 53421. LIHEAP helps low-income households with their energy bills. Both forms require information about household income, size, and expenses. They also mandate the disclosure of Social Security numbers to verify the identity of applicants. The goal of both applications is to provide assistance to those who need it most, ensuring they can access essential services.
The Child Care Assistance Program application is akin to the Indiana 53421 form, as it helps families afford child care services. Both forms require detailed information about household income and family structure. They also ask for Social Security numbers to confirm the identities of applicants. The Child Care Assistance Program application aims to support working families by easing the financial burden of child care, much like the Healthy Indiana Plan aims to alleviate health care costs.
Lastly, the Unemployment Benefits application is similar to the Indiana 53421 form in that it seeks to provide assistance to individuals in need. This application requires information about employment history, household income, and personal identification, including Social Security numbers. Both forms serve the purpose of evaluating eligibility for assistance, ensuring that those who are struggling can receive the support they require during difficult times.
When filling out the Indiana 53421 form, there are several important guidelines to keep in mind. Here’s a list of what you should and shouldn’t do:
Following these guidelines will help ensure that your application is processed smoothly and efficiently.
Here are ten common misconceptions about the Indiana 53421 form, along with clarifications to help you understand the application process better.
This form is specifically for uninsured adults aged 19 through 64. For children and pregnant women, a different application called Hoosier Healthwise is required.
Providing a Social Security Number is mandatory. The application cannot be processed without it.
You can indicate a preference for a health plan on the form, but you do not need to choose one before applying. If approved, you will be assigned to a plan.
While the form requires detailed information, it is designed to be straightforward. Completing it accurately will help speed up the processing time.
Even if you have lost health insurance, you can still apply. The form asks for details about any previous coverage to assess eligibility.
Proof of income is necessary. You must include documentation such as pay stubs or tax returns to support your application.
Assistance is available. You can contact the enrollment center or local FSSA office for guidance on completing the application.
Answering "Yes" to health screening questions does not automatically disqualify you. It helps determine eligibility for enhanced services.
You can submit the form by mail, fax, or in person at a local FSSA office. Choose the method that works best for you.
Registering to vote is optional and does not affect your eligibility for health coverage. You can choose to register or decline.
Here are some key takeaways about filling out and using the Indiana 53421 form:
Understanding these points can help streamline the application process and ensure you receive the necessary health coverage.