Medicaid Application
Content
INFORMATION TO GET YOU STARTED HEALTH COVERAGE
A. Our web site is the Easiest and Fastest way to get help! If you can, use our web site www.in.gov/fssa/apply to request Health Coverage. B. If you are completing this form… Please use a pen with black ink or dark blue ink Please print in capital letters like
First Name MI Last Name
*DFRIMAE0100CXBRO6*
Suffix
E-mail address: Home Address: EXAMPLE: 1234 N. MAIN ST. NW APARTMENT 34
Number and Street Apartment/Lot Number
C. Additional Important Information The information that you give us is kept private under state and federal law. It will not be released except as permitted or required by law or with your consent. Health Coverage benefits can begin no earlier than three months prior to the month of application. Therefore, you should file your application as soon as possible.
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Page 1 of 2
www.in.gov/fssa/apply
DFRIMAE0100CXBRO6
INFORMATION TO GET YOU STARTED HEALTH COVERAGE
D. You may send these items with your request for faster processing For each person, proof of… Identity Social Security Number US citizenship Immigration status Income/money received Resources * Life or burial insurance * Medical expense and health insurance Guardianship or Power of Attorney
*DFRIMAE0200CXBRO5*
Examples of what you can fax or mail copies of … Valid driver’s license or student ID SSN for each applicant or proof of application for a Social Security Number Birth certificate, hospital or baptism certificate, other accepted proof of birth For non-US citizen, alien registration card, permanent resident card, etc Current pay stub, employer statement of employment termination, selfemployment records, social security, VA, etc. Current statements for bank accounts, stocks, bonds, trusts; vehicle registration, property tax statements, etc. Policy, insurance card, statement of value from company If disabled or age 65 or over – statement from medical provider, insurance company, or bills/receipts for out of pocket medical expenses, or receipt for health insurance premiums. Proof of past medical expenses are not required for Medicaid eligibility, but may be used to meet Medicaid spend down. Power of Attorney, Guardianship Order
*Information about resources (assets) are not required for most categories of health coverage unless you are aged, blind, disabled or receiving Medicare. If you send these items to us by fax, we receive them sooner than if mailed. If you send these items by mail, please send copies and not originals. We are required by Federal law to assist you in obtaining verifications. Please contact us if you need assistance. If you have questions about completing this form, call 1-800-403-0864 - Monday through Friday - between 8:00 AM and 4:30 PM Si tiene preguntas sobre como completer este formulario llamar al 1-800-403-0864 - Lunes a Viernes - entre 8:00 AM y 4:30 PM E. YOUR NEXT STEP Complete and sign your Application for Assistance and send to us. By Fax:
If you choose to send by fax, be sure to fax both sides of the application pages and any additional documents.
1-800-403-0864
By Mail:
FSSA Document Center PO Box 1810 Marion, IN 46952
In Person: To a FSSA local county office… See www.in.gov/fssa/apply for locations Page 2 of 2 www.in.gov/fssa/apply
DFRIMAE0200CXBRO5
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0100CXBRO3*
INSTRUCTIONS: Please fill out your application as completely as you can. It will help if you can answer all of the questions. Please do not forget to sign your application on Page 1 Section 5. 1. If you are completing this application on behalf of someone else and you do not live in their household, please provide your name below and contact information in section 32. If you are completing this application on behalf of someone else and you do live in their household, please provide your information in Section 20:
First Name MI Last Name Suffix
2. Information for person needing assistance: (additional individuals may be added in Section 20)
Check the Help This Person Needs: Health Coverage Not Applying Yes No If Health Coverage is checked and you are not eligible for full benefits, do you want to be considered for Family Planning Services only? If Not Applying is checked, completion of the Social Security Number is optional. First Name MI Last Name Suffix
a p p l i c a t i o n
Date of Birth (mm-dd-yyyy) Social Security Number
t e s t
Gender: M F
Marital Status:
Single
Married
Divorced
Separated
Widowed Apartment/Lot Number
3. Home Address:
Number and Street
1 2 3
City County:
t e s t
State
l a f a y e t t e
I N
Zip Code
4 7 9 0 5
Telephone Number:
How many people live at this address including you?
1
OFFICIAL USE ONLY
4. Mailing Address (if different than home address):
City
State
Zip Code
5. Signature Required
I certify under penalty of perjury, all information I have given on this application, any attachments and information provided during the eligibility determination process is complete and correct to the best of my knowledge and belief, including the citizenship or immigration status of each applicant.
Signature
Date (mm-dd-yyyy):
Signature of witness if signed with “X”
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0200CXBRO2*
6. Ethnicity/Race
Ethnicity: Are you Hispanic or Latino? White Yes No Asian Race: (select all that apply) Black or African American
American Indian or Alaskan Native If American Indian or Alaska Native, please answer the questions below: Are you a member of a federally recognized tribe? If yes, enter tribe name Yes No
Native Hawaiian or Pacific Islander
Have you received a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? If no, are you eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Yes Yes
No No
7. Citizenship/Immigration Information
Are you a U.S. citizen or U.S. national? If no , select your immigration status: Lawful Permanent Resident Refugee Other Date of Status: (mm-dd-yyyy) Date of entry into the U.S. (mm-dd-yyyy) Document Type First Name Name as it appears on the document: Date of birth as it appears on the document(mm-dd-yyyy): Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? Yes No MI Last Name Country of origin Document Number Granted Political Asylum Cuban/Haitian Entrant Parolee Amerasian Undocumented Yes No
8. Additional Information For Person Needing Assistance
Do you live with at least one child under the age of 18, and are you the main person taking care of this child? Are you Pregnant? Yes No If yes, how many babies are expected during this pregnancy? Pregnancy due date (mm-dd-yyyy): No Yes Are you disabled? No Yes No Are you incarcerated? Yes Yes No No Yes No
Pregnancy begin date (mm-dd-yyyy): Are you blind? Yes
Are you living in a nursing facility?
Are you pending for or receiving a Medicaid Waiver? Yes No
Are you living in a Residential Care Facility or Room and Board Facility?
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0300CXBRO1*
Were you in foster care at age 18?
Yes
No
If Yes, what State was responsible for your foster care?
If you are determined eligible for Presumptive Eligibility (PE), please enter your Presumptive Eligibility Identification Number (PE RID):
9. Tax Filing Information
Are you required to file a Federal Income Tax Return? Yes No Yes No Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.) If yes, Please answer questions a-c a. Will you file jointly with a spouse? If yes, does the spouse live in your household? First Name Name of spouse: b. Will you claim any dependents on your tax return? If yes, do the dependents live in your household? Yes Yes No No If no, skip to question c Yes No Yes No MI Last Name
If yes how many dependents live in your household? List name(s) of dependents who live in your household: First Name Dependent 1 Name First Name Dependent 2 Name First Name Dependent 3 Name First Name Dependent 4 Name First Name Dependent 5 Name First Name Dependent 6 Name c. Will you be claimed as a dependent on someone’s tax return? First Name If yes, please list the name of the tax filer: How are you related to the tax filer?
If no, how many dependents live outside your household?
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
Yes
No MI Last Name
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0400CXBRO0*
10. Current Employment:
Name of employer Name of employer
Employer Address
Employer Address
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Monthly Bi-weekly Twice a month
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Bi-weekly Monthly Twice a month
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0500CXBRO9*
11. Other Income: check all that apply, and enter the monthly amount.
Note: Child support, veteran's payments, and Supplemental Security Income (SSI) is not counted for many categories of assistance, and you would not need to include unless you are aged, blind, disabled or receiving Medicare. None Unemployment Pensions/Retirement Social Security Benefits Supplemental Security Income (SSI) Child Support Alimony received Canceled Debts Educational Income $ $ $ Net farming/fishing Net rental/royalty Court Awards Jury Duty Investment Income Capital Gains Veterans Payments $ $ $ $ $ $ $
$ $ $ $ $ $
Cash Support $ (Money from someone other than your parent or spouse)
Portion of Educational Income used for general living expenses Other income $ Type:
12. American Indian/Alaska Native Tribal Income: check all that apply, and enter the monthly amount.
If you are American Indian or Alaska Native and a member of a federally recognized tribe, certain money received may not be counted for Medicaid or the Children's Health Insurance Program (CHIP). Select any income reported on your application that includes money from the following sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (Including reservations and former reservations) • Money from selling things that have cultural significance • Money from Scholarship, Award or Fellowship Grant Net farming/fishing Net rental/royalty Self-employment Educational Income Other income $ $ $ $ $ Type:
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0600CXBRO8*
13. Deductions: check all that apply, and give the amount and how often amount is deducted.
If you pay for certain things that can be deducted on a federal income tax return, please indicate them below. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment in the Current Employment section. Alimony paid $ How Often?
Student loan interest
$
How Often?
Other deductions
$
How Often?
Type:
14. Annual Income
What is your expected annual income for the current year? $
15. Resources
If you are Aged, Blind, Disabled or receiving Medicare, indicate if you have any of the following: Cash: Real Estate: Annuity Account: Yes Yes Yes No No No Vehicles: Checking Account: Other: Yes Yes Yes No No No Savings Account: Life Insurance: Yes Yes No No
16. Health Coverage Information
Are you enrolled in health coverage now? If yes, check the type of coverage Medicare Part A Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Is this a retiree health plan? Other Name of health insurance: Policy number: Is this a limited-benefit plan (like a school accident policy)? Yes No Yes Yes No No Medicare Part B TRICARE VA health care programs Peace Corps Yes No
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0700CXBRO7*
Have you lost health insurance coverage in the past 3 months? When did coverage end (mm-dd-yyyy)?
Yes
No
Please indicate why coverage was lost by putting a beside the reason(s). Loss of employment Could not afford Coverage limit reached Company ended coverage Non-custodial parent dropped insurance Divorce/Death of parent
Insurance premium more than 5% of income for child's coverage Child has special health care needs
Cost of family insurance coverage more than 9.5% of income Other
17. Health Plan Selection: (Please answer this question if anyone is applying for health coverage.)
We will check your eligibility for all of our health coverage categories. Children under age 19, low-income families, and pregnant women who are approved for Hoosier Healthwise 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 for Hoosier Healthwise 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 questions about how to choose your health plan or would like the provider directory before being assigned to a health plan, please call the Hoosier Healthwise Helpline at 1-800-889-9949. Applicants approved for Medicaid under the aged, blind, or disabled categories will not be enrolled in one of the above health plans. You will receive information about our traditional health plan with your Hoosier Health Card.
18. Is anyone listed on this application offered health coverage from a job?
If Yes, complete Section 31, Health Coverage from Jobs Is this a state employee benefit plan? Yes No
Yes
No
Select Yes even if the coverage is from someone else's job, such as a parent or spouse.
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0800CXBRO6*
19. Contact Information
Work Telephone: Alternate Telephone:
Yes No Do you want to receive automated calls from our agency? (Examples of calls you may receive are appointment reminders or due dates for requested documents)
E-mail address:
Note: Applicants that are aged, blind, disabled may be required to have an interview. What is your preference for your application interview appointment? By telephone At an office
Please indicate if you need the following interpreter services for your application interview appointment: Language interpreter Language
Sign Language interpreter
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0900CXBRO5*
20. Provide the following information for all other persons who live at the home address in Section 3 and all persons included on your tax return. If you file taxes, we need to know about everyone on your tax return: • Person listed in Section 2 does not need to be listed again. • Include person(s) living in an institution who need assistance. • If Not Applying is checked, completion of the Social Security Number is optional.
Check the Help This Person Needs: Health Coverage Not Applying
If Health Coverage is checked and this person is not eligible for full benefits, does he/she want to be considered for Family Planning Services only? Yes No If Not Applying is checked, completion of the Social Security Number is optional. First Name MI Last Name Suffix
Date of Birth (mm-dd-yyyy)
Social Security Number
Gender: M F
Marital Status:
Single
Married
Divorced Yes No
Separated
Widowed
Does this person live at the same address as you? If no, list their address: City
State
Zip Code
Relationship to person needing assistance listed in Section 2: Ethnicity: Is this person Hispanic or Latino? White Yes No Asian
Race: (select all that apply)
Black or African American
American Indian or Alaskan Native If American Indian or Alaska Native, please answer the questions below: Is this person member of a federally recognized tribe? If yes, enter tribe name Yes No
Native Hawaiian or Pacific Islander
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Yes Yes
No No
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1000CXBRO2*
21. Citizenship/Immigration Information
Is this person a U.S. citizen or U.S. national? If no, select this person's immigration status: Lawful Permanent Resident Refugee Other Date of Status: (mm-dd-yyyy) Date of entry into the U.S. (mm-dd-yyyy) Document Type Document Number First Name Name as it appears on the document: Date of birth as it appears on the document (mm-dd-yyyy): Is this person, or his/her spouse or parent a veteran or an active-duty member of the U.S. military? Yes No MI Last Name Country of origin Granted Political Asylum Cuban/Haitian Entrant Parolee Amerasian Undocumented Yes No
22. Additional Information For Person Needing Assistance
Does this person live with at least one child under the age of 18, and is he/she the main person taking care of this child? Is this person Pregnant? Pregnancy begin date (mm-dd-yyyy): Is this person blind? Yes No Yes No Yes No Yes Yes No No No Yes No If yes, how many babies are expected during this pregnancy? Yes No
Pregnancy due date (mm-dd-yyyy): Is this person disabled? Yes No
Is this person incarcerated?
Is this person living in a nursing facility?
Is this person living in a Residential Care Facility or Room and Board Facility? Is this person pending for or receiving a Medicaid Waiver? Was this person in foster care at age 18? Yes
If Yes, what State was responsible for this person's foster care?
If this person is determined eligible for Presumptive Eligibility (PE), please enter his/her Presumptive Eligibility Identification Number (PE RID):
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1100CXBRO1*
23. Tax Filing Information
Is this person required to file a Federal Income Tax Return? Yes No Yes No Does this person plan to file a federal income tax return NEXT YEAR? (He/she can still apply for health insurance even if he/she doesn’t file a federal income tax return.) If yes, Please answer questions a-c If no, skip to question c Yes No Yes No MI Last Name
a. Will this person file jointly with a spouse?
If yes, does his/her spouse live in the same household? First Name Name of spouse:
b. Will this person claim any dependents on his/her tax return? If yes, do the dependents live in this person's household?
Yes Yes
No No
If yes, how many dependents live in this person's household? List name(s) of dependents who live in this person's household: First Name Dependent 1 Name First Name Dependent 2 Name First Name Dependent 3 Name First Name Dependent 4 Name First Name Dependent 5 Name First Name Dependent 6 Name
If no, how many dependents live outside this person's household?
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
c. Will this person be claimed as a dependent on someone’s tax return? First Name If yes, please list the name of the tax filer: How is this person related to the tax filer?
Yes
No MI Last Name
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1200CXBRO0*
24. Current Employment:
Name of employer Name of employer
Employer Address
Employer Address
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Monthly Bi-weekly Twice a month
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Bi-weekly Monthly Twice a month
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1300CXBRO9*
25. Other Income: check all that apply, and enter the monthly amount.
Note: Child support, veteran's payments, and Supplemental Security Income (SSI) is not counted for many categories of assistance, and you would not need to include unless you are aged, blind, disabled or receiving Medicare. None Unemployment Pensions/Retirement Social Security Benefits Supplemental Security Income (SSI) Child Support Alimony received Canceled Debts Educational Income $ $ $ Net farming/fishing Net rental/royalty Court Awards Jury Duty Investment Income Capital Gains Veterans Payments $ $ $ $ $ $ $
$ $ $ $ $ $
Cash Support $ (Money from someone other than your parent or spouse)
Portion of Educational Income used for general living expenses Other income $ Type:
26. American Indian/Alaska Native Tribal Income: check all that apply, and enter the monthly amount.
If you are American Indian or Alaska Native and a member of a federally recognized tribe, certain money received may not be counted for Medicaid or the Children's Health Insurance Program (CHIP). Select any income reported on your application that includes money from the following sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (Including reservations and former reservations) • Money from selling things that have cultural significance • Money from Scholarship, Award or Fellowship Grant Net farming/fishing Net rental/royalty Self-employment Educational Income Other income $ $ $ $ $ Type:
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1400CXBRO8*
27. Deductions: check all that apply, and give the amount and how often amount is deducted.
If you pay for certain things that can be deducted on a federal income tax return, please indicate them below. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment in the Current Employment section. Alimony paid $ How Often?
Student loan interest
$
How Often?
Other deductions
$
How Often?
Type:
28. Annual Income
What is your expected annual income for the current year? $
29. Resources
If you are Aged, Blind, Disabled or receiving Medicare, indicate if you have any of the following: Cash: Real Estate: Annuity Account: Yes Yes Yes No No No Vehicles: Checking Account: Other: Yes Yes Yes No No No Savings Account: Life Insurance: Yes Yes No No
30. Health Coverage Information
Are you enrolled in health coverage now? If yes, check the type of coverage Medicare Part A Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Is this a retiree health plan? Other Name of health insurance: Policy number: Is this a limited-benefit plan (like a school accident policy)? Yes No Yes Yes No No Medicare Part B TRICARE VA health care programs Peace Corps Yes No
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1500CXBRO7*
Have you lost health insurance coverage in the past 3 months? When did coverage end (mm-dd-yyyy)?
Yes
No
Please indicate why coverage was lost by putting a beside the reason(s). Loss of employment Could not afford Coverage limit reached Company ended coverage Non-custodial parent dropped insurance Divorce/Death of parent
Insurance premium more than 5% of income for child's coverage Child has special health care needs
Cost of family insurance coverage more than 9.5% of income Other
If more than two (2) people live at your address or more than two (2) people are included on your tax return, please provide information on page 19.
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1600CXBRO6*
31. Health Coverage from Jobs
You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job. Tell us about the job that offers coverage. EMPLOYEE Information First Name MI Last Name
Employee Social Security number
EMPLOYER Information Employer name
Employer Identification number (EIN)
Employer telephone number
Employer address:
City
State
Zip Code
Who can we contact about employee health coverage at this job? First Name MI Last Name
Telephone number (if different from above)
Email address:
Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue) No (Stop here and go to Section 32 in the application)
If you're in a waiting or probationary period, when can you enroll in coverage? List the names of anyone else who is eligible for coverage from this job. First Name Name 1 First Name Name 2 First Name Name 3 MI Last Name MI Last Name MI (mm-dd-yyyy) Last Name
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1700CXBRO5*
Tell us about the health plan offered by this employer. Does the employer offer a health plan that meets the minimum value standard*? Yes No
For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
What change will the employer make for the new plan year (if known)? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See previous question ) a. How much will the employee have to pay in premiums for that plan? b. How often? Weekly Every 2 weeks $ Quarterly Yearly
Twice a month
Date of change (mm-dd-yyyy)
* An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
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Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1800CXBRO4*
32. If you are completing this application on behalf of someone else, please provide your contact information below:
Street Address
City
State
Zip Code
Telephone number: Do you live with the person(s) needing assistance? Yes No
If no, what is your relationship to the person(s) needing assistance?
NOTE: If you are a representative for the person(s) needing assistance, the applicant must complete and sign the enclosed Authorized Representative form. 33. Do you want to register to vote? 34. For Certified Navigators Only
Complete this section if you are a certified Navigator filling out this application for somebody else. First Name MI Last Name Suffix Yes No
Your answer will not affect your eligibility for health coverage.
Navigator Individual ID number Organization name
Navigator Organization ID number
Page 18 of 18
APPLICATION DOCUMENT COVER SHEET
State Form 53678 (R2 / 1-11) / DFR 1011
*DFRASAE0100CXBRO7*
Instructions
Please fill out and sub it t!is for "!en #ou send co$ies of docu ents t!at "e !a%e as&ed #ou to $ro%ide' A list of the do !me"ts to #ro$ide is i" the Information to Get You Started i"str! tio"s i" l!ded %ith &o!r a##li atio"' (he" &o! ha$e filled o!t this form) #la e it o" to# of the o#ies of &o!r do !me"ts a"d mail or fa* it a"d &o!r o#ies to+ Mailin( Address) FSSA Do !me"t ,e"ter -. /o* 1810 0ario") 1"dia"a 26952 *a+ Nu ber) 1-800-203-0862
3o fill o!t the form) #lease om#lete the Do !me"ts 1" l!ded se tio" 4elo% !si"5 a 4l!e or 4la 6 i"6 #e"' -la e a" , i" the 4o* "e*t to ea h do !me"t that &o! are se"di"5 !s' 7*am#le+ , 8tilit& /ill 1f a do !me"t that &o! are se"di"5 !s is "ot listed) the" #la e a" , i" the 4o* "e*t to 9.ther(s): a"d %rite the "ame of the do !me"t(s) o" the li"e #ro$ided' -lease se"d o#ies of the do !me"ts i"stead of ori5i"als' (rite &o!r "ame a"d So ial Se !rit& ;!m4er o" ea h item &o! fa* or mail' 3his form sho!ld 4e !sed to #ro$ide i"formatio" for &o!r ho!sehold o"l&' <o! ma& o#& this form 4efore filli"5 it o!t a"d sa$e it to !se later if &o! a""ot se"d i" all of the re=!ested do !me"ts "o%' If #ou !a%e -uestions. $lease call us toll/free at 01/233/435/32647 bet"een 8)33 AM and 4)33 PM Monda# t!rou(! *rida#' Identity Money Recei ed !con"t# Resources !con"t# Child Care / Child Support $%penses
> Dri$er:s ?i e"se > State -hoto 1D ,ard > St!de"t -hoto 1D
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> Disa4ilit& -a&me"ts > 7m#lo&er Stateme"t > 7m#lo&er Stateme"t of
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DFRASAE0100CXBRO7
AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE
State Form 55366 (R / 10-13) / DFR 2123HC
*DFRAZAE0100CXBRO9*
If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do. You can select more than one representative and choose the same or different functions. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.
Section 1
Section 2
Name of Representative (Please print clearly):
Check association with applicant/recipient. Please select ONE (1).
Attorney Institution of Residence Eligibility Assistance Company Waiver Case Manager Friend Other (Specify) Family
Mailing Address (number and street, city, state, and ZIP code):
SELECT THE FUNCTION(S) THE AUTHORIZED REPRESENTATIVE WILL DO:
FUNCTION FUNCTION DESCRIPTION HEALTH COVERAGE
• Sign application and be interviewed. • Provide all required proof of information necessary to determine eligibility for benefits. APPLY • Receive the Notice of the application decision. Apply • Speak on applicant’s behalf at a hearing if the application decision is appealed. • Report changes. • Attend periodic redeterminations. ONGOING • Receive the appointment notices and any redetermination mail-in forms. Ongoing NOTE: Do not check this function if the representative will not continue to act on recipient’s behalf after the application decision is made. In agreeing to be the authorized representative, I understand that I am expected to be knowledgeable of the applicant’s/recipient’s circumstances and that this authorization can be revoked by the applicant/recipient at any time. Signature: Date (mm/dd/yyyy): Telephone ((###) ###-####):
Section 3
I authorize this representative to act for me in taking care of the functions and program eligibility process which I have checked above. (If applicant/recipient is medically incapable to sign authorization, provide medical documentation.) I understand that I am responsible for the information anyone acting as my authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from being my authorized representative, it is my responsibility to contact the Division of Family Resources. Applicant/Recipient Name Applicant/Recipient Signature Date (mm/dd/yyyy):
Case Number (Optional):
DFRAZAE0100CXBRO9
NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES
State Form 55367 (8-13)/DFR 0009M
*DFRNHAE0100CXBRO1*
Client Name:
Case Number:
HEALTH COVERAGE - Medicaid; Hoosier Healthwise; the Healthy Indiana Plan (HIP)
Please read this form about the rights and responsibilities for Health Coverage (Medicaid, Hoosier Healthwise, and the Healthy Indiana Plan) for which you have applied for or are being redetermined. When we refer to "you", we mean all persons applying for and receiving benefits in your household. Ask a worker or call toll free at 1-800-403-0864. If you have any questions. 1. You have the right to apply for benefits at any time during normal office hours. The date you submit your application determines the date your benefits begin if you are eligible. You have the opportunity to submit the application online, by mail, fax, over the telephone, or inperson. You can also apply for health coverage through the Federally Facilitated Marketplace. Don't delay in filing your application. You may appoint someone to apply for benefits on your behalf. A decision must be made on your application within the following time frames: forty-five (45) days for all categories of Health Coverage, except Medicaid under the Disability category which is ninety (90) days. You have the right to review information you provide that is entered into the on-line eligibility system. You will need to answer all questions that are required to determine eligibility. All personal information you give is confidential and will only be used to determine your eligibility for benefits. Eligibility for benefits is determined without any regard to race, color, creed, sex, age, disability, national origin, or political belief. Information is requested about your racial-ethnic heritage to comply with the Federal Civil Rights Law. However, you do not have to provide this information. If you choose not to give us this information, we will indicate a race/ethnicity classification for you for data collection purposes. A Social Security number (SSN) must be given for each applicant who can legally have a number. If you don't have an SSN you must apply for one. This requirement does not apply to certain immigrants who cannot legally have a number and therefore can be eligible for emergency services only under Medicaid/Hoosier Healthwise. Your SSN will be used to check the records of other State and Federal agencies such as the Social Security Administration, Bureau of Motor Vehicles, Internal Revenue Service, Department of Homeland Security, Department of Workforce Development, and other states' public assistance records. Any information we receive about you from these sources is kept strictly confidential, and used only to determine your eligibility for benefits. We may ask for the Social Security numbers of family members who are not applying; however, you do not have to provide these numbers as a condition of eligibility. Determination of eligibility will not be delayed, denied, or discontinued due to waiting on a Social Security number to be issued. If you are an immigrant, you must provide the document showing your immigration status if we are unable to verify the information electronically. A person who does not provide immigration documents or has no documentation can only be eligible for health coverage for medical emergencies. The immigration status of lawful immigrants who are applying for or receiving benefits is subject to verification by the U.S. Citizenship and Immigration Services (USCIS). You will need to verify certain information you provide, if not able to be done so electronically, based on the requirements of the programs you have chosen or may be eligible for. If you have tried to get the documentation, but are unable to do so, you can sign a release of information and the worker will assist in obtaining the information. Any release of information form that you sign must have the name of the person, agency, or organization that the worker will be contacting.
2. 3. 4. 5. 6.
7.
8.
9.
10. Certain persons must be included in the application and/or have their income, resources, needs and/or expenses counted in determining eligibility for benefits. For this reason you must report everyone who lives with you. 11. You are required to report changes in your circumstances to the Division of Family Resources. The changes that you must report include your new address if you move, increases or decreases in your household's income, resources, or any change in your family circumstances that may affect your eligibility for benefits. You must report changes within ten (10) days of the date on which you are aware of the change. Also, there are certain circumstances in which resources are not counted and income of parents is exempt and therefore changes do not have to be reported. You will be given a form describing your reporting requirements. 12. If you move, please tell us your new address so that important mail about your application and health plan membership will reach you without delay. Also, you must tell us if you or your child(ren) becomes covered under other health insurance such as Medicare or employer-sponsored health insurance. 13. You are required to provide complete and correct information to the best of your knowledge. A person who receives benefits by intentionally giving false information or by failing to report information may be criminally prosecuted under State and Federal law.
14. You have the right to receive a written notice about any action taken on your application or on the benefits you receive. 15. You may request a fair hearing in writing if you disagree with any action taken on your case, including the late processing of your application. Your case may be presented at the hearing by any person you choose. 16. In accordance with Federal Law and United States Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. 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,
Page 1 of 3
DFRNHAE0100CXBRO1
NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES
State Form 55367 (8-13)/DFR 0009M
*DFRNHAE0200CXBRO0*
Region V, Office for Civil Rights, 233 N. Michigan Ave,, Suite 240, Chicago, Illinois 60601. You may call them at (800) 368-1019 or for TDD calls, (800) 537-7697. 17. The category you qualify for will be chosen for you. Some categories provide limited coverage. You will be approved for the most benefits you are eligible to receive based upon the information you have provided. However, if you want your eligibility determined under a different category, you have the right to choose your category. 18. You must file for any benefits which you may be eligible for, such as Social Security or pensions, or disability benefits. 19. Benefits paid on your behalf after you become fifty-five (55) years of age become a preferred claim against your estate. This claim has priority over all claims except prior recorded claims and taxes. 20. You may be required to pay back health coverage benefits that have been paid on your behalf, including capitation fees paid to a health plan or provider, if you had been incorrectly determined eligible whether by agency or client error or through providing fraudulent information. 21. We will not report undocumented immigrants to the United States Citizenship and Immigration Service. Applying for health coverage benefits will not affect your immigration status or chances of becoming a permanent resident or U.S. citizen. 22. Your rights to payments for medical care are assigned to the State of Indiana if you are found eligible for benefits. This includes rights to medical support and payment for medical care that you have on behalf of yourself and your dependents who are approved for benefits under this application. However, the assignment does not include Medicare payments. You must tell us about health insurance that you have. You must tell us about any legal or administrative actions you take to get payment for medical care, such as a personal injury settlement. The establishment of paternity is an important service for Medicaid/Hoosier Healthwise members that benefits children who do not have legal fathers. We encourage you to contact your local child support office in your County Prosecutor's office when your children are enrolled in Medicaid/Hoosier Healthwise. Except for children enrolled in Package C, there is no cost for this service or other child support services. 23. For children who are enrolled under Hoosier Healthwise Package C, there is a cap on the amount of cost-sharing that you will have to pay. This amount is 5% of your annual income before taxes. It is your responsibility to keep track of the amount of premiums and co-payments you pay. If you reach the cap, you will need to contact the Division of Family Resources and provide your receipts so that you will no longer have to make payments. If your children are approved for Package C, the approval notice you receive will tell you the cost-share cap. 24. American Indians and Alaskan Natives who are members of a federally recognized tribe are exempt from some premiums, copayments and other cost sharing requirements. You will need to provide your tribal identification in order to receive this exemption. 25. Certain income received by American Indians and Alaskan Natives who are members of a federally recognized tribe is exempt. The exempt income includes: distributions from Alaska Native Corporations and Settlement Trusts, distributions from any property held in trust located within a former Federal reservation or under the supervision of the Secretary of the Interior, distributions and payments from rents, leases, royalties, rights of way, or natural resource extraction and harvest, distributions from real property ownership interests or usage rights to items that have unique religious, spiritual, or cultural significance, and student financial assistance provided under the Bureau of Indiana Affairs educational programs. 26. Preventative health care services are available for children under age twenty-one (21). You may request assistance with appointment scheduling and arranging transportation for the Health Watch services by contacting a worker.
27. If you are applying for Medicaid long term care services (Medicaid facility or waiver services), you are specifically required by federal law to provide all information about annuities which you or your spouse own. For annuities purchased on or after November 1, 2009, the State of Indiana will become a preferred remainder beneficiary under the annuity for the total amount of medical assistance paid on your behalf. 28. If you are eligible for the Medicare Savings Program, it will take at least 3-4 months for the Social Security Administration to stop withholding the Part B premium from your check. However, you will receive a refund for the full amount of premiums that we owe you.
29. Family Planning Services are available under Indiana's Medicaid program. Men and Women who do not qualify for full coverage Medicaid can qualify for these services if they meet the income requirements. If you are enrolled in Hoosier Healthwise for pregnancy, we will determine your eligibility for Family Planning Services when your pregnancy ends. 30. If you are found eligible for the Children's Health Insurance Plan (CHIP) or the Healthy Indiana Plan (HIP) and are required to make premiums or contributions to a POWER Account, you must make such payments in order to become and remain eligible. 31. If you have a CHIP or HIP appeal which allows benefits to be maintained during the administrative appeal process, you must continue to pay your premium or POWER Account contribution in order to maintain coverage. If the Administrative Law Judge (ALJ) rules in your favor by deciding your CHIP or HIP benefits should not have been discontinued or denied, your coverage will be restored back to the date of discontinuance or denial. You will be responsible for paying the amount of premiums or contributions to the POWER Account back to the date of discontinuance or denial. Plan on saving money to pay back your premiums or contributions to your POWER Account back to the date of discontinuance or denial. 32. We will use electronic sources to verify income, citizenship, alien status, and other eligibility factors whenever possible; if certain eligibility factors cannot be verified electronically, you may be asked to provide paper documentation.
Page 2 of 3
DFRNHAE0200CXBRO0
NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES
State Form 55367 (8-13)/DFR 0009M
*DFRNHAE0300CXBRO9*
33. If you are not eligible for Medicaid/Hoosier Healthwise/Healthy Indiana Plan, you may be eligible for other health insurance coverage through the health insurance marketplace. If your application is denied or discontinued (for non-procedural reasons), your application will be submitted to the health insurance marketplace for a determination of other insurance affordability programs. If your family income is under 400% of the federal poverty level, you may be eligible for Advance Premium Tax Credits (APTC) or Cost Sharing Reduction (CSR) through the marketplace. 34. Beginning in 2014, most individuals will be required to have health insurance coverage. Such coverage may be obtained through employer-sponsored health insurance, qualified health plans through the marketplace, or through Medicaid/Hoosier Healthwise/Healthy Indiana Plan. 35. The Affordable Care Act (ACA) mandates the use of the Modified Adjusted Gross Income (MAGI) financial methodology when determining Medicaid income eligibility for most parents and other caretakers, children, pregnant women, and adults aged 19-64 who are not blind, disabled, or in need of long term care services. 36. The Indiana Application for Health Coverage meets the requirements of an alternative single, streamlined application for all insurance affordability programs. 37. Redeterminations will be completed every 12 months to determine if you still meet the eligibility requirements. We will first attempt to complete your annual redetermination using available electronic data sources and will automatically continue your enrollment for another 12 months if found eligible. If we are unable to do this, you will receive a pre-populated reenrollment form in the mail that must be completed and returned.
Page 3 of 3
DFRNHAE0300CXBRO9
A. Our web site is the Easiest and Fastest way to get help! If you can, use our web site www.in.gov/fssa/apply to request Health Coverage. B. If you are completing this form… Please use a pen with black ink or dark blue ink Please print in capital letters like
First Name MI Last Name
*DFRIMAE0100CXBRO6*
Suffix
E-mail address: Home Address: EXAMPLE: 1234 N. MAIN ST. NW APARTMENT 34
Number and Street Apartment/Lot Number
C. Additional Important Information The information that you give us is kept private under state and federal law. It will not be released except as permitted or required by law or with your consent. Health Coverage benefits can begin no earlier than three months prior to the month of application. Therefore, you should file your application as soon as possible.
Go to the next page
Page 1 of 2
www.in.gov/fssa/apply
DFRIMAE0100CXBRO6
INFORMATION TO GET YOU STARTED HEALTH COVERAGE
D. You may send these items with your request for faster processing For each person, proof of… Identity Social Security Number US citizenship Immigration status Income/money received Resources * Life or burial insurance * Medical expense and health insurance Guardianship or Power of Attorney
*DFRIMAE0200CXBRO5*
Examples of what you can fax or mail copies of … Valid driver’s license or student ID SSN for each applicant or proof of application for a Social Security Number Birth certificate, hospital or baptism certificate, other accepted proof of birth For non-US citizen, alien registration card, permanent resident card, etc Current pay stub, employer statement of employment termination, selfemployment records, social security, VA, etc. Current statements for bank accounts, stocks, bonds, trusts; vehicle registration, property tax statements, etc. Policy, insurance card, statement of value from company If disabled or age 65 or over – statement from medical provider, insurance company, or bills/receipts for out of pocket medical expenses, or receipt for health insurance premiums. Proof of past medical expenses are not required for Medicaid eligibility, but may be used to meet Medicaid spend down. Power of Attorney, Guardianship Order
*Information about resources (assets) are not required for most categories of health coverage unless you are aged, blind, disabled or receiving Medicare. If you send these items to us by fax, we receive them sooner than if mailed. If you send these items by mail, please send copies and not originals. We are required by Federal law to assist you in obtaining verifications. Please contact us if you need assistance. If you have questions about completing this form, call 1-800-403-0864 - Monday through Friday - between 8:00 AM and 4:30 PM Si tiene preguntas sobre como completer este formulario llamar al 1-800-403-0864 - Lunes a Viernes - entre 8:00 AM y 4:30 PM E. YOUR NEXT STEP Complete and sign your Application for Assistance and send to us. By Fax:
If you choose to send by fax, be sure to fax both sides of the application pages and any additional documents.
1-800-403-0864
By Mail:
FSSA Document Center PO Box 1810 Marion, IN 46952
In Person: To a FSSA local county office… See www.in.gov/fssa/apply for locations Page 2 of 2 www.in.gov/fssa/apply
DFRIMAE0200CXBRO5
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0100CXBRO3*
INSTRUCTIONS: Please fill out your application as completely as you can. It will help if you can answer all of the questions. Please do not forget to sign your application on Page 1 Section 5. 1. If you are completing this application on behalf of someone else and you do not live in their household, please provide your name below and contact information in section 32. If you are completing this application on behalf of someone else and you do live in their household, please provide your information in Section 20:
First Name MI Last Name Suffix
2. Information for person needing assistance: (additional individuals may be added in Section 20)
Check the Help This Person Needs: Health Coverage Not Applying Yes No If Health Coverage is checked and you are not eligible for full benefits, do you want to be considered for Family Planning Services only? If Not Applying is checked, completion of the Social Security Number is optional. First Name MI Last Name Suffix
a p p l i c a t i o n
Date of Birth (mm-dd-yyyy) Social Security Number
t e s t
Gender: M F
Marital Status:
Single
Married
Divorced
Separated
Widowed Apartment/Lot Number
3. Home Address:
Number and Street
1 2 3
City County:
t e s t
State
l a f a y e t t e
I N
Zip Code
4 7 9 0 5
Telephone Number:
How many people live at this address including you?
1
OFFICIAL USE ONLY
4. Mailing Address (if different than home address):
City
State
Zip Code
5. Signature Required
I certify under penalty of perjury, all information I have given on this application, any attachments and information provided during the eligibility determination process is complete and correct to the best of my knowledge and belief, including the citizenship or immigration status of each applicant.
Signature
Date (mm-dd-yyyy):
Signature of witness if signed with “X”
Go to the next page Page 1 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0200CXBRO2*
6. Ethnicity/Race
Ethnicity: Are you Hispanic or Latino? White Yes No Asian Race: (select all that apply) Black or African American
American Indian or Alaskan Native If American Indian or Alaska Native, please answer the questions below: Are you a member of a federally recognized tribe? If yes, enter tribe name Yes No
Native Hawaiian or Pacific Islander
Have you received a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? If no, are you eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Yes Yes
No No
7. Citizenship/Immigration Information
Are you a U.S. citizen or U.S. national? If no , select your immigration status: Lawful Permanent Resident Refugee Other Date of Status: (mm-dd-yyyy) Date of entry into the U.S. (mm-dd-yyyy) Document Type First Name Name as it appears on the document: Date of birth as it appears on the document(mm-dd-yyyy): Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? Yes No MI Last Name Country of origin Document Number Granted Political Asylum Cuban/Haitian Entrant Parolee Amerasian Undocumented Yes No
8. Additional Information For Person Needing Assistance
Do you live with at least one child under the age of 18, and are you the main person taking care of this child? Are you Pregnant? Yes No If yes, how many babies are expected during this pregnancy? Pregnancy due date (mm-dd-yyyy): No Yes Are you disabled? No Yes No Are you incarcerated? Yes Yes No No Yes No
Pregnancy begin date (mm-dd-yyyy): Are you blind? Yes
Are you living in a nursing facility?
Are you pending for or receiving a Medicaid Waiver? Yes No
Are you living in a Residential Care Facility or Room and Board Facility?
Go to the next page Page 2 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0300CXBRO1*
Were you in foster care at age 18?
Yes
No
If Yes, what State was responsible for your foster care?
If you are determined eligible for Presumptive Eligibility (PE), please enter your Presumptive Eligibility Identification Number (PE RID):
9. Tax Filing Information
Are you required to file a Federal Income Tax Return? Yes No Yes No Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.) If yes, Please answer questions a-c a. Will you file jointly with a spouse? If yes, does the spouse live in your household? First Name Name of spouse: b. Will you claim any dependents on your tax return? If yes, do the dependents live in your household? Yes Yes No No If no, skip to question c Yes No Yes No MI Last Name
If yes how many dependents live in your household? List name(s) of dependents who live in your household: First Name Dependent 1 Name First Name Dependent 2 Name First Name Dependent 3 Name First Name Dependent 4 Name First Name Dependent 5 Name First Name Dependent 6 Name c. Will you be claimed as a dependent on someone’s tax return? First Name If yes, please list the name of the tax filer: How are you related to the tax filer?
If no, how many dependents live outside your household?
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
Yes
No MI Last Name
Go to the next page Page 3 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0400CXBRO0*
10. Current Employment:
Name of employer Name of employer
Employer Address
Employer Address
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Monthly Bi-weekly Twice a month
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Bi-weekly Monthly Twice a month
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
Go to the next page Page 4 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0500CXBRO9*
11. Other Income: check all that apply, and enter the monthly amount.
Note: Child support, veteran's payments, and Supplemental Security Income (SSI) is not counted for many categories of assistance, and you would not need to include unless you are aged, blind, disabled or receiving Medicare. None Unemployment Pensions/Retirement Social Security Benefits Supplemental Security Income (SSI) Child Support Alimony received Canceled Debts Educational Income $ $ $ Net farming/fishing Net rental/royalty Court Awards Jury Duty Investment Income Capital Gains Veterans Payments $ $ $ $ $ $ $
$ $ $ $ $ $
Cash Support $ (Money from someone other than your parent or spouse)
Portion of Educational Income used for general living expenses Other income $ Type:
12. American Indian/Alaska Native Tribal Income: check all that apply, and enter the monthly amount.
If you are American Indian or Alaska Native and a member of a federally recognized tribe, certain money received may not be counted for Medicaid or the Children's Health Insurance Program (CHIP). Select any income reported on your application that includes money from the following sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (Including reservations and former reservations) • Money from selling things that have cultural significance • Money from Scholarship, Award or Fellowship Grant Net farming/fishing Net rental/royalty Self-employment Educational Income Other income $ $ $ $ $ Type:
Go to the next page Page 5 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0600CXBRO8*
13. Deductions: check all that apply, and give the amount and how often amount is deducted.
If you pay for certain things that can be deducted on a federal income tax return, please indicate them below. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment in the Current Employment section. Alimony paid $ How Often?
Student loan interest
$
How Often?
Other deductions
$
How Often?
Type:
14. Annual Income
What is your expected annual income for the current year? $
15. Resources
If you are Aged, Blind, Disabled or receiving Medicare, indicate if you have any of the following: Cash: Real Estate: Annuity Account: Yes Yes Yes No No No Vehicles: Checking Account: Other: Yes Yes Yes No No No Savings Account: Life Insurance: Yes Yes No No
16. Health Coverage Information
Are you enrolled in health coverage now? If yes, check the type of coverage Medicare Part A Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Is this a retiree health plan? Other Name of health insurance: Policy number: Is this a limited-benefit plan (like a school accident policy)? Yes No Yes Yes No No Medicare Part B TRICARE VA health care programs Peace Corps Yes No
Go to the next page Page 6 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0700CXBRO7*
Have you lost health insurance coverage in the past 3 months? When did coverage end (mm-dd-yyyy)?
Yes
No
Please indicate why coverage was lost by putting a beside the reason(s). Loss of employment Could not afford Coverage limit reached Company ended coverage Non-custodial parent dropped insurance Divorce/Death of parent
Insurance premium more than 5% of income for child's coverage Child has special health care needs
Cost of family insurance coverage more than 9.5% of income Other
17. Health Plan Selection: (Please answer this question if anyone is applying for health coverage.)
We will check your eligibility for all of our health coverage categories. Children under age 19, low-income families, and pregnant women who are approved for Hoosier Healthwise 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 for Hoosier Healthwise 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 questions about how to choose your health plan or would like the provider directory before being assigned to a health plan, please call the Hoosier Healthwise Helpline at 1-800-889-9949. Applicants approved for Medicaid under the aged, blind, or disabled categories will not be enrolled in one of the above health plans. You will receive information about our traditional health plan with your Hoosier Health Card.
18. Is anyone listed on this application offered health coverage from a job?
If Yes, complete Section 31, Health Coverage from Jobs Is this a state employee benefit plan? Yes No
Yes
No
Select Yes even if the coverage is from someone else's job, such as a parent or spouse.
Go to the next page Page 7 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0800CXBRO6*
19. Contact Information
Work Telephone: Alternate Telephone:
Yes No Do you want to receive automated calls from our agency? (Examples of calls you may receive are appointment reminders or due dates for requested documents)
E-mail address:
Note: Applicants that are aged, blind, disabled may be required to have an interview. What is your preference for your application interview appointment? By telephone At an office
Please indicate if you need the following interpreter services for your application interview appointment: Language interpreter Language
Sign Language interpreter
Go to the next page Page 8 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE0900CXBRO5*
20. Provide the following information for all other persons who live at the home address in Section 3 and all persons included on your tax return. If you file taxes, we need to know about everyone on your tax return: • Person listed in Section 2 does not need to be listed again. • Include person(s) living in an institution who need assistance. • If Not Applying is checked, completion of the Social Security Number is optional.
Check the Help This Person Needs: Health Coverage Not Applying
If Health Coverage is checked and this person is not eligible for full benefits, does he/she want to be considered for Family Planning Services only? Yes No If Not Applying is checked, completion of the Social Security Number is optional. First Name MI Last Name Suffix
Date of Birth (mm-dd-yyyy)
Social Security Number
Gender: M F
Marital Status:
Single
Married
Divorced Yes No
Separated
Widowed
Does this person live at the same address as you? If no, list their address: City
State
Zip Code
Relationship to person needing assistance listed in Section 2: Ethnicity: Is this person Hispanic or Latino? White Yes No Asian
Race: (select all that apply)
Black or African American
American Indian or Alaskan Native If American Indian or Alaska Native, please answer the questions below: Is this person member of a federally recognized tribe? If yes, enter tribe name Yes No
Native Hawaiian or Pacific Islander
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Yes Yes
No No
Go to the next page Page 9 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1000CXBRO2*
21. Citizenship/Immigration Information
Is this person a U.S. citizen or U.S. national? If no, select this person's immigration status: Lawful Permanent Resident Refugee Other Date of Status: (mm-dd-yyyy) Date of entry into the U.S. (mm-dd-yyyy) Document Type Document Number First Name Name as it appears on the document: Date of birth as it appears on the document (mm-dd-yyyy): Is this person, or his/her spouse or parent a veteran or an active-duty member of the U.S. military? Yes No MI Last Name Country of origin Granted Political Asylum Cuban/Haitian Entrant Parolee Amerasian Undocumented Yes No
22. Additional Information For Person Needing Assistance
Does this person live with at least one child under the age of 18, and is he/she the main person taking care of this child? Is this person Pregnant? Pregnancy begin date (mm-dd-yyyy): Is this person blind? Yes No Yes No Yes No Yes Yes No No No Yes No If yes, how many babies are expected during this pregnancy? Yes No
Pregnancy due date (mm-dd-yyyy): Is this person disabled? Yes No
Is this person incarcerated?
Is this person living in a nursing facility?
Is this person living in a Residential Care Facility or Room and Board Facility? Is this person pending for or receiving a Medicaid Waiver? Was this person in foster care at age 18? Yes
If Yes, what State was responsible for this person's foster care?
If this person is determined eligible for Presumptive Eligibility (PE), please enter his/her Presumptive Eligibility Identification Number (PE RID):
Go to the next page Page 10 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1100CXBRO1*
23. Tax Filing Information
Is this person required to file a Federal Income Tax Return? Yes No Yes No Does this person plan to file a federal income tax return NEXT YEAR? (He/she can still apply for health insurance even if he/she doesn’t file a federal income tax return.) If yes, Please answer questions a-c If no, skip to question c Yes No Yes No MI Last Name
a. Will this person file jointly with a spouse?
If yes, does his/her spouse live in the same household? First Name Name of spouse:
b. Will this person claim any dependents on his/her tax return? If yes, do the dependents live in this person's household?
Yes Yes
No No
If yes, how many dependents live in this person's household? List name(s) of dependents who live in this person's household: First Name Dependent 1 Name First Name Dependent 2 Name First Name Dependent 3 Name First Name Dependent 4 Name First Name Dependent 5 Name First Name Dependent 6 Name
If no, how many dependents live outside this person's household?
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
MI
Last Name
c. Will this person be claimed as a dependent on someone’s tax return? First Name If yes, please list the name of the tax filer: How is this person related to the tax filer?
Yes
No MI Last Name
Go to the next page Page 11 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1200CXBRO0*
24. Current Employment:
Name of employer Name of employer
Employer Address
Employer Address
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
City State Telephone number Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy) Zip Code
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Monthly Bi-weekly Twice a month
Amount of gross pay per period $ How often paid? Weekly Other: Hours worked per week Do hours vary? Are you self-employed? If yes, type of work Yes Yes No No Bi-weekly Monthly Twice a month
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
How much net income (profits once business expenses are paid) will you get from this self-employment this month? $
Go to the next page Page 12 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1300CXBRO9*
25. Other Income: check all that apply, and enter the monthly amount.
Note: Child support, veteran's payments, and Supplemental Security Income (SSI) is not counted for many categories of assistance, and you would not need to include unless you are aged, blind, disabled or receiving Medicare. None Unemployment Pensions/Retirement Social Security Benefits Supplemental Security Income (SSI) Child Support Alimony received Canceled Debts Educational Income $ $ $ Net farming/fishing Net rental/royalty Court Awards Jury Duty Investment Income Capital Gains Veterans Payments $ $ $ $ $ $ $
$ $ $ $ $ $
Cash Support $ (Money from someone other than your parent or spouse)
Portion of Educational Income used for general living expenses Other income $ Type:
26. American Indian/Alaska Native Tribal Income: check all that apply, and enter the monthly amount.
If you are American Indian or Alaska Native and a member of a federally recognized tribe, certain money received may not be counted for Medicaid or the Children's Health Insurance Program (CHIP). Select any income reported on your application that includes money from the following sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (Including reservations and former reservations) • Money from selling things that have cultural significance • Money from Scholarship, Award or Fellowship Grant Net farming/fishing Net rental/royalty Self-employment Educational Income Other income $ $ $ $ $ Type:
Go to the next page Page 13 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1400CXBRO8*
27. Deductions: check all that apply, and give the amount and how often amount is deducted.
If you pay for certain things that can be deducted on a federal income tax return, please indicate them below. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment in the Current Employment section. Alimony paid $ How Often?
Student loan interest
$
How Often?
Other deductions
$
How Often?
Type:
28. Annual Income
What is your expected annual income for the current year? $
29. Resources
If you are Aged, Blind, Disabled or receiving Medicare, indicate if you have any of the following: Cash: Real Estate: Annuity Account: Yes Yes Yes No No No Vehicles: Checking Account: Other: Yes Yes Yes No No No Savings Account: Life Insurance: Yes Yes No No
30. Health Coverage Information
Are you enrolled in health coverage now? If yes, check the type of coverage Medicare Part A Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Is this a retiree health plan? Other Name of health insurance: Policy number: Is this a limited-benefit plan (like a school accident policy)? Yes No Yes Yes No No Medicare Part B TRICARE VA health care programs Peace Corps Yes No
Go to the next page Page 14 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1500CXBRO7*
Have you lost health insurance coverage in the past 3 months? When did coverage end (mm-dd-yyyy)?
Yes
No
Please indicate why coverage was lost by putting a beside the reason(s). Loss of employment Could not afford Coverage limit reached Company ended coverage Non-custodial parent dropped insurance Divorce/Death of parent
Insurance premium more than 5% of income for child's coverage Child has special health care needs
Cost of family insurance coverage more than 9.5% of income Other
If more than two (2) people live at your address or more than two (2) people are included on your tax return, please provide information on page 19.
Go to the next page Page 15 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1600CXBRO6*
31. Health Coverage from Jobs
You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job. Tell us about the job that offers coverage. EMPLOYEE Information First Name MI Last Name
Employee Social Security number
EMPLOYER Information Employer name
Employer Identification number (EIN)
Employer telephone number
Employer address:
City
State
Zip Code
Who can we contact about employee health coverage at this job? First Name MI Last Name
Telephone number (if different from above)
Email address:
Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue) No (Stop here and go to Section 32 in the application)
If you're in a waiting or probationary period, when can you enroll in coverage? List the names of anyone else who is eligible for coverage from this job. First Name Name 1 First Name Name 2 First Name Name 3 MI Last Name MI Last Name MI (mm-dd-yyyy) Last Name
Go to the next page Page 16 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1700CXBRO5*
Tell us about the health plan offered by this employer. Does the employer offer a health plan that meets the minimum value standard*? Yes No
For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
What change will the employer make for the new plan year (if known)? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See previous question ) a. How much will the employee have to pay in premiums for that plan? b. How often? Weekly Every 2 weeks $ Quarterly Yearly
Twice a month
Date of change (mm-dd-yyyy)
* An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Go to the next page Page 17 of 18
Indiana Application for Health Coverage
State Form 55390 (9-13)
*DFRAMAE1800CXBRO4*
32. If you are completing this application on behalf of someone else, please provide your contact information below:
Street Address
City
State
Zip Code
Telephone number: Do you live with the person(s) needing assistance? Yes No
If no, what is your relationship to the person(s) needing assistance?
NOTE: If you are a representative for the person(s) needing assistance, the applicant must complete and sign the enclosed Authorized Representative form. 33. Do you want to register to vote? 34. For Certified Navigators Only
Complete this section if you are a certified Navigator filling out this application for somebody else. First Name MI Last Name Suffix Yes No
Your answer will not affect your eligibility for health coverage.
Navigator Individual ID number Organization name
Navigator Organization ID number
Page 18 of 18
APPLICATION DOCUMENT COVER SHEET
State Form 53678 (R2 / 1-11) / DFR 1011
*DFRASAE0100CXBRO7*
Instructions
Please fill out and sub it t!is for "!en #ou send co$ies of docu ents t!at "e !a%e as&ed #ou to $ro%ide' A list of the do !me"ts to #ro$ide is i" the Information to Get You Started i"str! tio"s i" l!ded %ith &o!r a##li atio"' (he" &o! ha$e filled o!t this form) #la e it o" to# of the o#ies of &o!r do !me"ts a"d mail or fa* it a"d &o!r o#ies to+ Mailin( Address) FSSA Do !me"t ,e"ter -. /o* 1810 0ario") 1"dia"a 26952 *a+ Nu ber) 1-800-203-0862
3o fill o!t the form) #lease om#lete the Do !me"ts 1" l!ded se tio" 4elo% !si"5 a 4l!e or 4la 6 i"6 #e"' -la e a" , i" the 4o* "e*t to ea h do !me"t that &o! are se"di"5 !s' 7*am#le+ , 8tilit& /ill 1f a do !me"t that &o! are se"di"5 !s is "ot listed) the" #la e a" , i" the 4o* "e*t to 9.ther(s): a"d %rite the "ame of the do !me"t(s) o" the li"e #ro$ided' -lease se"d o#ies of the do !me"ts i"stead of ori5i"als' (rite &o!r "ame a"d So ial Se !rit& ;!m4er o" ea h item &o! fa* or mail' 3his form sho!ld 4e !sed to #ro$ide i"formatio" for &o!r ho!sehold o"l&' <o! ma& o#& this form 4efore filli"5 it o!t a"d sa$e it to !se later if &o! a""ot se"d i" all of the re=!ested do !me"ts "o%' If #ou !a%e -uestions. $lease call us toll/free at 01/233/435/32647 bet"een 8)33 AM and 4)33 PM Monda# t!rou(! *rida#' Identity Money Recei ed !con"t# Resources !con"t# Child Care / Child Support $%penses
> Dri$er:s ?i e"se > State -hoto 1D ,ard > St!de"t -hoto 1D
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DFRASAE0100CXBRO7
AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE
State Form 55366 (R / 10-13) / DFR 2123HC
*DFRAZAE0100CXBRO9*
If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to select the function(s) that the representative is being authorized to do. You can select more than one representative and choose the same or different functions. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.
Section 1
Section 2
Name of Representative (Please print clearly):
Check association with applicant/recipient. Please select ONE (1).
Attorney Institution of Residence Eligibility Assistance Company Waiver Case Manager Friend Other (Specify) Family
Mailing Address (number and street, city, state, and ZIP code):
SELECT THE FUNCTION(S) THE AUTHORIZED REPRESENTATIVE WILL DO:
FUNCTION FUNCTION DESCRIPTION HEALTH COVERAGE
• Sign application and be interviewed. • Provide all required proof of information necessary to determine eligibility for benefits. APPLY • Receive the Notice of the application decision. Apply • Speak on applicant’s behalf at a hearing if the application decision is appealed. • Report changes. • Attend periodic redeterminations. ONGOING • Receive the appointment notices and any redetermination mail-in forms. Ongoing NOTE: Do not check this function if the representative will not continue to act on recipient’s behalf after the application decision is made. In agreeing to be the authorized representative, I understand that I am expected to be knowledgeable of the applicant’s/recipient’s circumstances and that this authorization can be revoked by the applicant/recipient at any time. Signature: Date (mm/dd/yyyy): Telephone ((###) ###-####):
Section 3
I authorize this representative to act for me in taking care of the functions and program eligibility process which I have checked above. (If applicant/recipient is medically incapable to sign authorization, provide medical documentation.) I understand that I am responsible for the information anyone acting as my authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from being my authorized representative, it is my responsibility to contact the Division of Family Resources. Applicant/Recipient Name Applicant/Recipient Signature Date (mm/dd/yyyy):
Case Number (Optional):
DFRAZAE0100CXBRO9
NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES
State Form 55367 (8-13)/DFR 0009M
*DFRNHAE0100CXBRO1*
Client Name:
Case Number:
HEALTH COVERAGE - Medicaid; Hoosier Healthwise; the Healthy Indiana Plan (HIP)
Please read this form about the rights and responsibilities for Health Coverage (Medicaid, Hoosier Healthwise, and the Healthy Indiana Plan) for which you have applied for or are being redetermined. When we refer to "you", we mean all persons applying for and receiving benefits in your household. Ask a worker or call toll free at 1-800-403-0864. If you have any questions. 1. You have the right to apply for benefits at any time during normal office hours. The date you submit your application determines the date your benefits begin if you are eligible. You have the opportunity to submit the application online, by mail, fax, over the telephone, or inperson. You can also apply for health coverage through the Federally Facilitated Marketplace. Don't delay in filing your application. You may appoint someone to apply for benefits on your behalf. A decision must be made on your application within the following time frames: forty-five (45) days for all categories of Health Coverage, except Medicaid under the Disability category which is ninety (90) days. You have the right to review information you provide that is entered into the on-line eligibility system. You will need to answer all questions that are required to determine eligibility. All personal information you give is confidential and will only be used to determine your eligibility for benefits. Eligibility for benefits is determined without any regard to race, color, creed, sex, age, disability, national origin, or political belief. Information is requested about your racial-ethnic heritage to comply with the Federal Civil Rights Law. However, you do not have to provide this information. If you choose not to give us this information, we will indicate a race/ethnicity classification for you for data collection purposes. A Social Security number (SSN) must be given for each applicant who can legally have a number. If you don't have an SSN you must apply for one. This requirement does not apply to certain immigrants who cannot legally have a number and therefore can be eligible for emergency services only under Medicaid/Hoosier Healthwise. Your SSN will be used to check the records of other State and Federal agencies such as the Social Security Administration, Bureau of Motor Vehicles, Internal Revenue Service, Department of Homeland Security, Department of Workforce Development, and other states' public assistance records. Any information we receive about you from these sources is kept strictly confidential, and used only to determine your eligibility for benefits. We may ask for the Social Security numbers of family members who are not applying; however, you do not have to provide these numbers as a condition of eligibility. Determination of eligibility will not be delayed, denied, or discontinued due to waiting on a Social Security number to be issued. If you are an immigrant, you must provide the document showing your immigration status if we are unable to verify the information electronically. A person who does not provide immigration documents or has no documentation can only be eligible for health coverage for medical emergencies. The immigration status of lawful immigrants who are applying for or receiving benefits is subject to verification by the U.S. Citizenship and Immigration Services (USCIS). You will need to verify certain information you provide, if not able to be done so electronically, based on the requirements of the programs you have chosen or may be eligible for. If you have tried to get the documentation, but are unable to do so, you can sign a release of information and the worker will assist in obtaining the information. Any release of information form that you sign must have the name of the person, agency, or organization that the worker will be contacting.
2. 3. 4. 5. 6.
7.
8.
9.
10. Certain persons must be included in the application and/or have their income, resources, needs and/or expenses counted in determining eligibility for benefits. For this reason you must report everyone who lives with you. 11. You are required to report changes in your circumstances to the Division of Family Resources. The changes that you must report include your new address if you move, increases or decreases in your household's income, resources, or any change in your family circumstances that may affect your eligibility for benefits. You must report changes within ten (10) days of the date on which you are aware of the change. Also, there are certain circumstances in which resources are not counted and income of parents is exempt and therefore changes do not have to be reported. You will be given a form describing your reporting requirements. 12. If you move, please tell us your new address so that important mail about your application and health plan membership will reach you without delay. Also, you must tell us if you or your child(ren) becomes covered under other health insurance such as Medicare or employer-sponsored health insurance. 13. You are required to provide complete and correct information to the best of your knowledge. A person who receives benefits by intentionally giving false information or by failing to report information may be criminally prosecuted under State and Federal law.
14. You have the right to receive a written notice about any action taken on your application or on the benefits you receive. 15. You may request a fair hearing in writing if you disagree with any action taken on your case, including the late processing of your application. Your case may be presented at the hearing by any person you choose. 16. In accordance with Federal Law and United States Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. 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,
Page 1 of 3
DFRNHAE0100CXBRO1
NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES
State Form 55367 (8-13)/DFR 0009M
*DFRNHAE0200CXBRO0*
Region V, Office for Civil Rights, 233 N. Michigan Ave,, Suite 240, Chicago, Illinois 60601. You may call them at (800) 368-1019 or for TDD calls, (800) 537-7697. 17. The category you qualify for will be chosen for you. Some categories provide limited coverage. You will be approved for the most benefits you are eligible to receive based upon the information you have provided. However, if you want your eligibility determined under a different category, you have the right to choose your category. 18. You must file for any benefits which you may be eligible for, such as Social Security or pensions, or disability benefits. 19. Benefits paid on your behalf after you become fifty-five (55) years of age become a preferred claim against your estate. This claim has priority over all claims except prior recorded claims and taxes. 20. You may be required to pay back health coverage benefits that have been paid on your behalf, including capitation fees paid to a health plan or provider, if you had been incorrectly determined eligible whether by agency or client error or through providing fraudulent information. 21. We will not report undocumented immigrants to the United States Citizenship and Immigration Service. Applying for health coverage benefits will not affect your immigration status or chances of becoming a permanent resident or U.S. citizen. 22. Your rights to payments for medical care are assigned to the State of Indiana if you are found eligible for benefits. This includes rights to medical support and payment for medical care that you have on behalf of yourself and your dependents who are approved for benefits under this application. However, the assignment does not include Medicare payments. You must tell us about health insurance that you have. You must tell us about any legal or administrative actions you take to get payment for medical care, such as a personal injury settlement. The establishment of paternity is an important service for Medicaid/Hoosier Healthwise members that benefits children who do not have legal fathers. We encourage you to contact your local child support office in your County Prosecutor's office when your children are enrolled in Medicaid/Hoosier Healthwise. Except for children enrolled in Package C, there is no cost for this service or other child support services. 23. For children who are enrolled under Hoosier Healthwise Package C, there is a cap on the amount of cost-sharing that you will have to pay. This amount is 5% of your annual income before taxes. It is your responsibility to keep track of the amount of premiums and co-payments you pay. If you reach the cap, you will need to contact the Division of Family Resources and provide your receipts so that you will no longer have to make payments. If your children are approved for Package C, the approval notice you receive will tell you the cost-share cap. 24. American Indians and Alaskan Natives who are members of a federally recognized tribe are exempt from some premiums, copayments and other cost sharing requirements. You will need to provide your tribal identification in order to receive this exemption. 25. Certain income received by American Indians and Alaskan Natives who are members of a federally recognized tribe is exempt. The exempt income includes: distributions from Alaska Native Corporations and Settlement Trusts, distributions from any property held in trust located within a former Federal reservation or under the supervision of the Secretary of the Interior, distributions and payments from rents, leases, royalties, rights of way, or natural resource extraction and harvest, distributions from real property ownership interests or usage rights to items that have unique religious, spiritual, or cultural significance, and student financial assistance provided under the Bureau of Indiana Affairs educational programs. 26. Preventative health care services are available for children under age twenty-one (21). You may request assistance with appointment scheduling and arranging transportation for the Health Watch services by contacting a worker.
27. If you are applying for Medicaid long term care services (Medicaid facility or waiver services), you are specifically required by federal law to provide all information about annuities which you or your spouse own. For annuities purchased on or after November 1, 2009, the State of Indiana will become a preferred remainder beneficiary under the annuity for the total amount of medical assistance paid on your behalf. 28. If you are eligible for the Medicare Savings Program, it will take at least 3-4 months for the Social Security Administration to stop withholding the Part B premium from your check. However, you will receive a refund for the full amount of premiums that we owe you.
29. Family Planning Services are available under Indiana's Medicaid program. Men and Women who do not qualify for full coverage Medicaid can qualify for these services if they meet the income requirements. If you are enrolled in Hoosier Healthwise for pregnancy, we will determine your eligibility for Family Planning Services when your pregnancy ends. 30. If you are found eligible for the Children's Health Insurance Plan (CHIP) or the Healthy Indiana Plan (HIP) and are required to make premiums or contributions to a POWER Account, you must make such payments in order to become and remain eligible. 31. If you have a CHIP or HIP appeal which allows benefits to be maintained during the administrative appeal process, you must continue to pay your premium or POWER Account contribution in order to maintain coverage. If the Administrative Law Judge (ALJ) rules in your favor by deciding your CHIP or HIP benefits should not have been discontinued or denied, your coverage will be restored back to the date of discontinuance or denial. You will be responsible for paying the amount of premiums or contributions to the POWER Account back to the date of discontinuance or denial. Plan on saving money to pay back your premiums or contributions to your POWER Account back to the date of discontinuance or denial. 32. We will use electronic sources to verify income, citizenship, alien status, and other eligibility factors whenever possible; if certain eligibility factors cannot be verified electronically, you may be asked to provide paper documentation.
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DFRNHAE0200CXBRO0
NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES
State Form 55367 (8-13)/DFR 0009M
*DFRNHAE0300CXBRO9*
33. If you are not eligible for Medicaid/Hoosier Healthwise/Healthy Indiana Plan, you may be eligible for other health insurance coverage through the health insurance marketplace. If your application is denied or discontinued (for non-procedural reasons), your application will be submitted to the health insurance marketplace for a determination of other insurance affordability programs. If your family income is under 400% of the federal poverty level, you may be eligible for Advance Premium Tax Credits (APTC) or Cost Sharing Reduction (CSR) through the marketplace. 34. Beginning in 2014, most individuals will be required to have health insurance coverage. Such coverage may be obtained through employer-sponsored health insurance, qualified health plans through the marketplace, or through Medicaid/Hoosier Healthwise/Healthy Indiana Plan. 35. The Affordable Care Act (ACA) mandates the use of the Modified Adjusted Gross Income (MAGI) financial methodology when determining Medicaid income eligibility for most parents and other caretakers, children, pregnant women, and adults aged 19-64 who are not blind, disabled, or in need of long term care services. 36. The Indiana Application for Health Coverage meets the requirements of an alternative single, streamlined application for all insurance affordability programs. 37. Redeterminations will be completed every 12 months to determine if you still meet the eligibility requirements. We will first attempt to complete your annual redetermination using available electronic data sources and will automatically continue your enrollment for another 12 months if found eligible. If we are unable to do this, you will receive a pre-populated reenrollment form in the mail that must be completed and returned.
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DFRNHAE0300CXBRO9
