medicaid application

INFORMATION TO GET YOU STARTED HEALTH COVERAGE

of 2 www.in.gov/fssa/apply

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 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

*DFRIMAE0100CXBRO6*

DFRIMAE0100CXBRO6

INFORMATION TO GET YOU STARTED HEALTH COVERAGE

of 2 www.in.gov/fssa/apply

D. You may send these items with your request for faster processing

For each person, proof of…

Examples of what you can fax or mail copies of … Identity Valid driver’s license or student ID Social Security Number SSN for each applicant or proof of application for a Social Security Number US citizenship Birth certificate, hospital or baptism certificate, other accepted proof of birth Immigration status For non-US citizen, alien registration card, permanent resident card, etc Income/money received Current pay stub, employer statement of employment termination, self-

employment records, social security, VA, etc. Resources * Current statements for bank accounts, stocks, bonds, trusts; vehicle

registration, property tax statements, etc. Life or burial insurance * Policy, insurance card, statement of value from company Medical expense and health insurance

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.

Guardianship or Power of Attorney

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: 1-800-403-0864 If you choose to send by fax, be sure to fax both sides of the application pages and any additional documents.

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

*DFRIMAE0200CXBRO5*

DFRIMAE0200CXBRO5

http://www.in.gov/fssa/apply

Go to the next page

Indiana Application for Health Coverage State Form 55390 (9-13)

2. Information for person needing assistance: (additional individuals may be added in Section 20)

First Name Last NameMI

Social Security NumberDate of Birth (mm-dd-yyyy)

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.

Not Applying Health CoverageCheck the Help This Person Needs:

M F

Gender:

Suffix

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 Last NameMI Suffix

Single Married Divorced Separated WidowedMarital Status:

If Not Applying is checked, completion of the Social Security Number is optional.

If Health Coverage is checked and you are not eligible for full benefits, do you want to be considered for Family Planning Services only? Yes No

3. Home Address: Number and Street Apartment/Lot Number

City State Zip Code

County:

How many people live at this address including you?

Telephone Number:

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

Signature of witness if signed with “X”

Date (mm-dd-yyyy):

a p p l i c a t i o n

I N 4 7 9 0 5

1

l a f a y e t t e

t e s t

1 2 3 t e s t

*DFRAMAE0100CXBRO3*

Page 1 of 18

Go to the next page


Are you a U.S. citizen or U.S. national? Yes No

Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? Yes No

Document Number

Date of Status: (mm-dd-yyyy) Country of origin

Date of entry into the U.S. (mm-dd-yyyy)

Document Type

If no , select your immigration status:

Lawful Permanent Resident Granted Political Asylum Parolee Undocumented

Other

Name as it appears on the document:

Date of birth as it appears on the document(mm-dd-yyyy):

Do you live with at least one child under the age of 18, and are you the main person taking care of this child? Yes No8. Additional Information For Person Needing Assistance

Are you disabled?Are you blind? Yes No Yes No

Yes NoAre you Pregnant? If yes, how many babies are expected during this pregnancy?

Are you living in a nursing facility? Yes No

Are you living in a Residential Care Facility or Room and Board Facility? Yes No

Are you pending for or receiving a Medicaid Waiver? Yes No

Pregnancy begin date (mm-dd-yyyy): Pregnancy due date (mm-dd-yyyy):

Are you incarcerated? Yes No

Cuban/Haitian Entrant Refugee Amerasian


Are you Hispanic or Latino? Yes NoEthnicity:

Race: (select all that apply) White Black or African American Asian

American Indian or Alaskan Native Native Hawaiian or Pacific Islander

Yes NoAre you a member of a federally recognized tribe?

If yes, enter tribe name

Yes NoHave 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 No

If American Indian or Alaska Native, please answer the questions below:

6. Ethnicity/Race

7. Citizenship/Immigration Information

*DFRAMAE0200CXBRO2*

Page 2 of 18

Go to the next page


Yes Noc. Will you be claimed as a dependent on someone’s tax return?

If yes, please list the name of the tax filer:

How are you related to the tax filer?

List name(s) of dependents who live in your household:

Dependent 1 Name

Yes Nob. Will you claim any dependents on your tax return?

If yes how many dependents live in your household?

Yes NoIf yes, do the dependents live in your household?

If no, how many dependents live outside your household?

Yes Noa. Will you file jointly with a spouse?

Name of spouse:

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.)

Yes NoIf yes, does the spouse live in your household?

9. Tax Filing Information

Are you required to file a Federal Income Tax Return? Yes No Yes No

If yes, Please answer questions a-c If no, skip to question c

Yes NoWere you in foster care at age 18? 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):



Dependent 2 Name


Dependent 3 Name


Dependent 4 Name


Dependent 5 Name


Dependent 6 Name



*DFRAMAE0300CXBRO1*

Page 3 of 18

Go to the next page


10. Current Employment:

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Amount of gross pay per period $

Hours worked per week

How often paid?

Are you self-employed? Yes No

Do hours vary? Yes No





How often paid?



Name of employer Name of employer

Employer Address Employer Address

Telephone number Telephone number

If yes, type of work If yes, type of work

How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$


$

Bi-weekly Weekly Monthly Twice a month

Other:


Other:

City City

State Zip Code State Zip Code

*DFRAMAE0400CXBRO0*

Page 4 of 18

Go to the next page


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

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).

Child Support $

11. Other Income: check all that apply, and enter the monthly amount.

None

Unemployment

Pensions/Retirement

$

Social Security Benefits

$

Supplemental Security Income (SSI) $

Net farming/fishing $

Net rental/royalty $

Other income $ Type:

$

Alimony received $

Canceled Debts $

Court Awards $

Jury Duty $

Investment Income $

Capital Gains $

Veterans Payments $

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.

Cash Support $

$ Educational Income

Portion of Educational Income used for general living expenses $

12. American Indian/Alaska Native Tribal Income: check all that apply, and enter the monthly amount.



Self-employment $

Educational Income $


(Money from someone other than your parent or spouse)

*DFRAMAE0500CXBRO9*

Page 5 of 18

Go to the next page


What is your expected annual income for the current year?

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 $

Student loan interest $

Other deductions $

Type:

How Often?

How Often?

How Often?

14. Annual Income

Cash: Yes No Vehicles: Yes No Savings Account: Yes No

Real Estate: Yes No Checking Account: Yes No Life Insurance: Yes No

Annuity Account: Yes No Other: Yes No

If you are Aged, Blind, Disabled or receiving Medicare, indicate if you have any of the following:15. Resources

Is this a retiree health plan? Yes No

No YesIs this COBRA coverage?

Policy number:

Name of health insurance:

Employer insurance

Peace Corps VA health care programs TRICARE Medicare Part B Medicare Part A

Are you enrolled in health coverage now?

16. Health Coverage Information Yes No

If yes, check the type of coverage

$

No YesIs this a limited-benefit plan (like a school accident policy)?

Policy number:


Other

*DFRAMAE0600CXBRO8*

Page 6 of 18

Go to the next page


Have you lost health insurance coverage in the past 3 months? Yes No

When did coverage end (mm-dd-yyyy)?

Please indicate why coverage was lost by putting a beside the reason(s).

Loss of employment Coverage limit reached Non-custodial parent dropped insurance Divorce/Death of parent

Could not afford Company ended coverage Insurance premium more than 5% of income for child's coverage

Cost of family insurance coverage more than 9.5% of income Child has special health care needs

Other

17. Health Plan Selection: (Please answer this question if anyone is applying for health coverage.)

MDwise MHS Anthem Blue Cross Blue Shield

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.

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.

Do you need a paper copy instead?

If you have made your selection, please mark the box next to your chosen plan.

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.

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.

18. Is anyone listed on this application offered health coverage from a job?

Yes NoIs this a state employee benefit plan?

Select Yes even if the coverage is from someone else's job, such as a parent or spouse.

If Yes, complete Section 31, Health Coverage from Jobs

Yes No

*DFRAMAE0700CXBRO7*

Page 7 of 18

Go to the next page


Alternate Telephone: Work Telephone:

E-mail address:

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)

Yes No

What is your preference for your application interview appointment? At an office By telephone

Please indicate if you need the following interpreter services for your application interview appointment:

Language interpreter

Language

Sign Language interpreter

Note: Applicants that are aged, blind, disabled may be required to have an interview.

19. Contact Information

*DFRAMAE0800CXBRO6*

Page 8 of 18

Go to the next page



Is this person Hispanic or Latino?

Social Security NumberDate of Birth (mm-dd-yyyy)

Not Applying Health CoverageCheck the Help This Person Needs:

M F

Gender:

Yes No

Suffix

Ethnicity:

Race: (select all that apply)

American Indian or Alaskan Native Native Hawaiian or Pacific Islander

White Black or African American Asian

Single Married Divorced Separated WidowedMarital Status:

Yes No 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?

Does this person live at the same address as you? Yes No

If no, list their address:

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.

Yes NoIs this person member of a federally recognized tribe?

If yes, enter tribe name

Yes NoHas 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 No

If American Indian or Alaska Native, please answer the questions below:

Relationship to person needing assistance listed in Section 2:

If Not Applying is checked, completion of the Social Security Number is optional.

City State Zip Code

*DFRAMAE0900CXBRO5*

Page 9 of 18

Go to the next page


Is this person a U.S. citizen or U.S. national? Yes No

Is this person, or his/her spouse or parent a veteran or an active-duty member of the U.S. military? Yes No

Document Number

Date of Status: (mm-dd-yyyy) Country of origin

Date of entry into the U.S. (mm-dd-yyyy)

Document Type

If no, select this person's immigration status:

Lawful Permanent Resident Granted Political Asylum Parolee Undocumented

Other

Date of birth as it appears on the document (mm-dd-yyyy):

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? Yes No22. Additional Information For Person Needing Assistance

Is this person disabled?Is this person blind? Yes No Yes No

Yes NoIs this person Pregnant? If yes, how many babies are expected during this pregnancy?

Is this person living in a nursing facility? Yes No

Is this person living in a Residential Care Facility or Room and Board Facility? Yes No

Is this person pending for or receiving a Medicaid Waiver? Yes No

Pregnancy begin date (mm-dd-yyyy): Pregnancy due date (mm-dd-yyyy):

Is this person incarcerated? Yes No

21. Citizenship/Immigration Information

Cuban/Haitian Entrant Refugee Amerasian

Yes NoWas this person in foster care at age 18? 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):

Name as it appears on the document:


*DFRAMAE1000CXBRO2*

Page 10 of 18

Go to the next page


Yes Noc. Will this person be claimed as a dependent on someone’s tax return?

How is this person related to the tax filer?

List name(s) of dependents who live in this person's household:

Yes Nob. Will this person claim any dependents on his/her tax return?

If yes, how many dependents live in this person's household?

Yes NoIf yes, do the dependents live in this person's household?

If no, how many dependents live outside this person's household?

Yes Noa. Will this person file jointly with a spouse?

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.)

Yes NoIf yes, does his/her spouse live in the same household?

23. Tax Filing Information

Is this person required to file a Federal Income Tax Return? Yes No Yes No

If yes, Please answer questions a-c If no, skip to question c

Name of spouse:


Dependent 1 Name


Dependent 2 Name


Dependent 3 Name


Dependent 4 Name


Dependent 5 Name


Dependent 6 Name


If yes, please list the name of the tax filer:


*DFRAMAE1100CXBRO1*

Page 11 of 18

Go to the next page


24. Current Employment:





How often paid?







How often paid?



Name of employer Name of employer

Employer Address Employer Address

Telephone number Telephone number

If yes, type of work If yes, type of work


$


$


Other:


Other:

City City

State Zip Code State Zip Code

*DFRAMAE1200CXBRO0*

Page 12 of 18

Go to the next page


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

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).

Child Support $

25. Other Income: check all that apply, and enter the monthly amount.

None

Unemployment

Pensions/Retirement

$

Social Security Benefits

$

Supplemental Security Income (SSI) $




$

Alimony received $

Canceled Debts $

Court Awards $

Jury Duty $

Investment Income $

Capital Gains $

Veterans Payments $

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.

Cash Support $

$ Educational Income

Portion of Educational Income used for general living expenses $

26. American Indian/Alaska Native Tribal Income: check all that apply, and enter the monthly amount.



Self-employment $

Educational Income $


(Money from someone other than your parent or spouse)

*DFRAMAE1300CXBRO9*

Page 13 of 18

Go to the next page


What is your expected annual income for the current year?

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 $

Student loan interest $

Other deductions $

Type:

How Often?

How Often?

How Often?

28. Annual Income

Cash: Yes No Vehicles: Yes No Savings Account: Yes No

Real Estate: Yes No Checking Account: Yes No Life Insurance: Yes No

Annuity Account: Yes No Other: Yes No

If you are Aged, Blind, Disabled or receiving Medicare, indicate if you have any of the following:29. Resources

Is this a retiree health plan? Yes No

No YesIs this COBRA coverage?

Policy number:


Employer insurance

Peace Corps VA health care programs TRICARE Medicare Part B Medicare Part A

Are you enrolled in health coverage now?

30. Health Coverage Information Yes No

If yes, check the type of coverage

$

No YesIs this a limited-benefit plan (like a school accident policy)?

Policy number:


Other

*DFRAMAE1400CXBRO8*

Page 14 of 18

Go to the next page


Have you lost health insurance coverage in the past 3 months? Yes No

When did coverage end (mm-dd-yyyy)?

Please indicate why coverage was lost by putting a beside the reason(s).

Loss of employment Coverage limit reached Non-custodial parent dropped insurance Divorce/Death of parent

Could not afford Company ended coverage Insurance premium more than 5% of income for child's coverage

Cost of family insurance coverage more than 9.5% of income Child has special health care needs

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.

*DFRAMAE1500CXBRO7*

Page 15 of 18

Go to the next page


31. Health Coverage from JobsYou 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

Employee Social Security number

EMPLOYER Information

Employer name

Employer Identification number (EIN)

Employer address:

City State Zip Code

Who can we contact about employee health coverage at this job?

Employer telephone number

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)

If you're in a waiting or probationary period, when can you enroll in coverage? (mm-dd-yyyy)

List the names of anyone else who is eligible for coverage from this job.

Name 1


Name 2


Name 3


No (Stop here and go to Section 32 in the application)



*DFRAMAE1600CXBRO6*

Page 16 of 18

Go to the next page


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? Every 2 weeks Weekly 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 thatmeets 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? Every 2 weeks Weekly Twice a month Quarterly Yearly

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)

*DFRAMAE1700CXBRO5*

Page 17 of 18


Telephone number:

Do you live with the person(s) needing assistance? Yes No

Zip CodeStateCity

Street Address

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.

32. If you are completing this application on behalf of someone else, please provide your contact information below:

33. Do you want to register to vote? No Yes Your answer will not affect your eligibility for health coverage.

34. For Certified Navigators OnlyComplete this section if you are a certified Navigator filling out this application for somebody else.

Navigator Individual ID number

First Name Last NameMI Suffix

Organization name

Navigator Organization ID number

*DFRAMAE1800CXBRO4*

Page 18 of 18

APPLICATION DOCUMENT COVER SHEET State Form 53678 (R2 / 1-11) / DFR 1011

Instructions Please fill out and submit this form when you send copies of documents that we have asked you to provide. A list of the documents to provide is in the Information to Get You Started instructions included with your application. When you have filled out this form, place it on top of the copies of your documents and mail or fax it and your copies to:

Mailing Address:FSSA Document Center

PO Box 1810Marion, Indiana 46952

Fax Number: 1-800-403-0864

To fill out the form, please complete the Documents Included section below using a blue or black ink pen. Place an X in the box next to each document that you are sending us. Example: X Utility Bill If a document that you are sending us is not listed, then place an X in the box next to ‘Other(s)’ and write the name of the document(s) on

the line provided. Please send copies of the documents instead of originals. Write your name and Social Security Number on each item you fax or mail. This form should be used to provide information for your household only. You may copy this form before filling it out and save it to use later if you cannot send in all of the requested documents now. If you have questions, please call us toll-free at (1-800-403-0864) between 8:00 AM and 4:30 PM Monday through Friday.

Identity

□ Driver’s License

□ State Photo ID Card

□ Student Photo ID

Social Security Number□ Social Security Card

□ Proof of Application for Social Security Card

US Citizenship / Immigration Status□ Alien Registration Card

□ Baptismal Certificate

□ Birth Certificate

□ Bureau for Citizenship & Immigration Svcs. Document

□ Hospital Birth Certificate

□ Passport

□ Permanent Resident Card

Money Received / Income

□ Child Support – Proof of Payment Received

□ Copy of Paychecks

Money Received (con’t)

□ Disability Payments

□ Employer Statement

□ Employer Statement of Termination

□ Pay Stubs

□ Pension Statements / Stubs

□ Railroad Retirement Benefits

□ Self Employment Records

□ Sick Benefits

□ Social Security / SSI Award Letter

□ Statement of Loan, Gift or Contribution

□ Unemployment Benefits

□ Veteran’s Benefits

□ Worker’s Compensation

Resources□ Annuity Contract

□ Bank/ Credit Union Statement

□ Real Estate, Oil, Gas or Mineral Rights Deed/Document

□ Statement of Vehicle Value from Licensed dealer

Resources (con’t)

□ Stock / Bond Statement or Certificate

□ Trust Statement

□ Vehicle Registration

Insurance□ Insurance Card

□ Life / Burial / Health Insurance Policy

□ Statement from Insurance Provider

Expenses

□ Cancelled Rent Check

□ Homeowner’s Insurance Statement

□ Lease Agreement

□ Proof of Energy Assistance Received

□ Proof of Public Housing Assistance

□ Property Tax Statement

□ Rent Receipt

□ Landlord or Mortgage Lender Statement

□ Utility Bill

Child Care / Child Support Expenses□ County Clerk Record for

Child Support

□ Proof of Child Support You Pay

□ Receipt / Copy of Check for Child Care that You Pay

□ Statement from Child Care Provider

Medical

□ Medical Bill / Receipt

□ Medical Statement

□ Medical Statement of Pregnancy / Due Date

□ Prescription Receipt or Printout

Legal□ Divorce Decree

□ Guardianship Order

□ Marriage Certificate

□ Paternity record

□ Power of Attorney

Other Documents□ Other(s): _____________________________________________________________________________________________________________________

*DFRASAE0100CXBRO7*

DFRASAE0100CXBRO7

AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE State Form 55366 (R / 10-13) / DFR 2123HC

Section 1 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 2Name of Representative (Please print clearly):

Check association with applicant/recipient. Please select ONE (1).

Attorney Eligibility Assistance Company Friend Family

Institution of Residence Waiver Case ManagerMailing Address (number and street, city, state, and ZIP code):

FUNCTION FUNCTION DESCRIPTION

ApplyAPPLY

Ongoing

Signature: Date (mm/dd/yyyy): Telephone ((###) ###-####):

SELECT THE FUNCTION(S) THE AUTHORIZED REPRESENTATIVE WILL DO:

HEALTH COVERAGE • Sign application and be interviewed. • Provide all required proof of information necessary to determine eligibility for benefits. • Receive the Notice of the application decision. • Speak on applicant’s behalf at a hearing if the application decision is appealed. • Report changes. • Attend periodic redeterminations. • Receive the appointment notices and any redetermination mail-in forms. NOTE: Do not check this function if the representative will not continue to act on recipient’s behalf after the application decision is made.

ONGOING

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.

Other (Specify)

Section 3

Applicant/Recipient Name Applicant/Recipient Signature

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.

Date (mm/dd/yyyy):

Case Number (Optional):

*DFRAZAE0100CXBRO9*

DFRAZAE0100CXBRO9

NOTICE REGARDING RIGHTS & RESPONSIBILITIES FOR HEALTH COVERAGE DIVISION OF FAMILY RESOURCES State Form 55367 (8-13)/DFR 0009M

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.

Page 1 of 3

Client Name: Case Number:

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 in-person. You can also apply for health coverage through the Federally Facilitated Marketplace. Don't delay in filing your application.

2. You may appoint someone to apply for benefits on your behalf.

3. 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.

4. You have the right to review information you provide that is entered into the on-line eligibility system.

5. 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.

6. 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.

7. 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.

8. 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).

9. 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.

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,

*DFRNHAE0100CXBRO1*

DFRNHAE0100CXBRO1


Page 2 of 3

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.

*DFRNHAE0200CXBRO0*

DFRNHAE0200CXBRO0


Page 3 of 3

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.

*DFRNHAE0300CXBRO9*

DFRNHAE0300CXBRO9

medicaid application

Documents

health coverage page

proof of application

health insurance premiums

categories of health

health coverage benefits

insurance card

insurance company

dfrimae0100cxbro6 information