Indiana Form 53421 – Fill Out and Use This PDF

The Indiana 53421 form, known officially as the Application for Healthy Indiana Plan, serves as a vital document for individuals seeking health coverage under the Healthy Indiana Plan (HIP). This form is specifically designed for uninsured adults between the ages of 19 and 64, and it requires comprehensive information, including personal details, household composition, income verification, and health screening questions to evaluate eligibility. For those ready to secure health coverage, complete the Indiana 53421 form by clicking the button below.

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Indiana Form 53421 PDF Details

The Indiana 53421 form, officially titled "Application for Healthy Indiana Plan," serves as a vital entry point for uninsured adults ages 19 through 64 seeking health coverage under the Healthy Indiana Plan (HIP). Through meticulous sections asking for personal, household, and financial details, this form aims to scrutinize eligibility and facilitate the enrollment process into a health plan that best fits the applicant's needs. Key sections detail plan selection, providing options among Anthem Blue Cross Blue Shield, MHS, and MDwise, and urge applicants to meticulously report household compositions, including adult members and children, affirm residency, and disclose any dependent care expenses which could influence eligibility. Moreover, considerations for non-citizens highlight the inclusive nature of the application process, bespeaking the plan’s aim to cater to a wide demographic. The necessity for thoroughness extends to disclosing income sources, whether from employment, support payments, or other benefits, showcasing the form's comprehensive approach to understanding an applicant's financial landscape. Additionally, addressing health screening questions underscores the program's effort to cater to those with specialized health care needs, affirming its commitment to providing tailored health solutions. Instructions for submission and the emphasis on confidentiality and accuracy further underscore the form's role in the deliberate and delicate process of securing health insurance coverage in Indiana.

Question	Answer
Form Name	Indiana Form 53421
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	healthy families application south bend indiana, indiana application healthy plan, how to indiana application healthy plan, how to indiana form application healthy plan

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Application for Healthy Indiana Plan

State Form 53421 (R6 / 8-11) HIP 2515

*This agency is requesting the disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Reset Form

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Instructions: Please fill out your application as completely as you can, and don't forget to sign your name on page 4 question 13.

This application form is not for children and pregnant women. To obtain an application for children and pregnant women contact 1-877-GET HIP9 (1-877-438-4479) and ask for a Hoosier Healthwise application.

1. Health Plan Selection

If your application is approved, you will be enrolled in one of our health plans. If you have made your selection, please mark the box next to your chosen plan.

Anthem Blue Cross Blue Shield

MHS

MDwise

Provider directories are available on the health plan websites. If you have given us your e-mail address, we will send an

electronic copy to you . Do you need a paper copy instead?

Yes

If you have any questions about how to choose your health plan or would like the provider directory before being assigned to a health plan, please call 1-877-GET-HIP9(1-877-438-4479).

2. Tell us about adult members of your family living in your household. Place a applying for HIP.

	Date of Birth	Social Security	Marital		Sex	Relationship	U.S.	Place a
Name (First, MI, Last)	Date of Birth	Social Security	Status	Race	Sex	to	Citizen?	Place a
	(mm/dd/yyyy)	Number *	M/D/S		M/F	Applicant 1	Yes / No	applying
Adult / Applicant 1						Self

Adult / Applicant 2

3.How many total members are in your household? _____

4.Tell us your address and telephone number.

Home address (number and street)	City	State	ZIP code	County

Mailing address (if different)	City	State	ZIP code	County

Home telephone number	Alternate telephone number

Email Address


Completed by Enrollment Center:

Date of application:(mm, dd, yyyy)________________ Center's Code: ______________ Interviewer: ________________________________________

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Application for Healthy Indiana Plan

State Form 53421 (R6 / 8-11) HIP 2515

5.Tell us about children living in your home.

	Date of Birth	Social Security	Applicant 1 is	Applicant 2 is a		Sex	U.S. Citizen?
	Date of Birth	Social Security	a caregiver of	caregiver of		Sex	U.S. Citizen?
Name (First, MI, Last)	(mm/dd/yyyy)	Number *	a caregiver of	caregiver of	Race	M/F	Yes / No
Name (First, MI, Last)	(mm/dd/yyyy)	Number *	this child	this child	Race	M/F	Yes / No
			this child	this child
			Yes/No	Yes/No
Child 1

Child 1 Relation to Applicant 1:			Child 1 Relation to	Applicant 2:

Child 2

Child 2 Relation to Applicant 1:			Child 2 Relation to	Applicant 2:

Child 3

Child 3 Relation to Applicant 1:			Child 3 Relation to	Applicant 2:

Child 4

Child 4 Relation to Applicant 1:			Child 4 Relation to	Applicant 2:

6.Do all of the applicants live in Indiana?

Yes

7. Does either of the applicants pay someone to care for a dependant child or a disabled/elderly adult so that a household

member can work, look for a job or go to school?

Yes

If yes, does the person for whom the expense is being paid live in the household?

Yes

If no, go on to the next item. If yes, enter out-of-pocket expenses only, not expenses that are paid by a non-household member, or child care assistance agency.

Applicant Number

Name of person being cared for

How often paid

Amount paid

Name of care provider

Address of provider (number and street, city, state, and ZIP code)

8.Complete this section for each applicant who is not a citizen of the United States.

1.	Lawful Permanent Resident	3. Granted Political Asylum	5. Parolee	7. Undocumented
2.	Refugee	4. Cuban/Haitian Entrant	6. Amerasian	8. Other (specify) __________

Applicant Number

Document Number

Immigration Status

(number from above)

Status Date

(mm/dd/yy)

Country of origin

Date of entry into the U.S.

(mm/dd/yy)

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Application for Healthy Indiana Plan

State Form 53421 (R6 / 8-11) HIP 2515

9.For each applicant please provide the following information.

	Place a if	Place a if	Applicant has		Covered by		Date applicant last	Why was health insurance lost? Please write one
	Blind or	Pregnant	access to health		health insurance		had health insurance	of these reasons below; Loss of employment,
	Disabled		insurance at		now including		including Medicare	Could not afford, Coverage limit reached,
			employer		Medicare		(mm/dd/yy)	Company ended coverage, Non-custodial parent
			(check one for		(check one for			dropped insurance, Divorce, Cobra expired, Other
			each applicant)		each applicant)

Applicant 1			Yes	No	Yes	No

Applicant 2			Yes	No	Yes	No

10.Tell us how much total work income the applicant(s) earn.

Applicant 1	Applicant 2

Start date (mm/dd/yy)	Start date (mm/dd/yy)

End date (mm/dd/yy)	End date (mm/dd/yy)

Amount of gross pay per period ($)	Amount of gross pay per period ($)

How often paid?	Weekly		Bi-weekly	Monthly	How often paid?	Weekly		Bi-weekly	Monthly
	Twice a month		Other: _______________			Twice a month		Other: _______________

Hours worked per week					Hours worked per week

Is person self-employed?		Yes		No	Is person self-employed?		Yes	No

Do hours vary?		Yes		No	Do hours vary?		Yes	No

Name of employer and telephone number					Name of employer and telephone number

11.Tell us if you or family members receive other income from the types listed here. If your family has no income, initial here: _______.

A) SSI	F) Military Allotment	K) Interest Payments	O) Child Support
B) Social Security	G) Unemployment	L) Educational Income	P) Employment
C) Veteran's Benefits	H) Alimony	M) Cash from Friends,	income from
D) Railroad Retirement	I) Sick Benefits	Relatives, etc.	children
E) Pension	J) Strike Benefits	N) Worker's	Q) Other:____________
		Compensation

Who receives the payments?

(applicant number or child number)

What type of payments?

(Use letter code from above.)

How Often are Payments

Received?

When did Payments Begin?

Amount of the

Payments ($)

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Application for Healthy Indiana Plan

State Form 53421 (R6 / 8-11) HIP 2515

12. Health Screening Questions

(These questions must be answered in order for your application to be considered complete.)

To the best of your ability, please answer either “Yes” or “No” to the following questions by checking the appropriate answer. This information is being collected to determine whether you will be eligible for the Enhanced Services Plan. This plan will provide a high degree of coordinated medical care for persons with specialized health care needs. If you are otherwise found to be eligible for HIP, you cannot be denied coverage based on a medical condition. Answering “Yes” to any of the following questions will not prevent you from obtaining health coverage.

For each question below, check only one answer for each applicant.	Applicant 1		Applicant 2
a. In the last three years have you been diagnosed or actively treated for an internal
Cancer? This includes but is not limited to cancers of the: brain; head or neck; throat;	Yes	No	Yes	No
esophagus; larynx; lung; breast; stomach; intestines; colon; pancreas; liver or biliary	Yes	No	Yes	No

tract; ovary; prostate; testicles; bladder; bone; or blood.

b. Have you ever been the recipient of an organ transplant including heart, lung, liver,	Yes	No	Yes	No
kidney or bone marrow?	Yes	No	Yes	No
kidney or bone marrow?
c. Are you currently on a transplant waiting list for one of the above organs or been advised	Yes	No	Yes	No
that you will require such a transplant within the next 12 months?	Yes	No	Yes	No

d. Have you ever been diagnosed with or otherwise told by a medical professional that you	Yes	No	Yes	No
have HIV, AIDS or the virus that causes AIDS?	Yes	No	Yes	No
have HIV, AIDS or the virus that causes AIDS?
e. Do you take or have you ever taken medication for HIV, AIDS, or the virus that causes	Yes	No	Yes	No
AIDS?	Yes	No	Yes	No
AIDS?
f. Have you ever been diagnosed with aplastic anemia?	Yes	No	Yes	No
	Yes	No	Yes	No

g. Do you require frequent blood transfusions due to a medical condition?	Yes	No	Yes	No
	Yes	No	Yes	No

h. Have you ever been diagnosed with or are you being actively treated for hemophilia, or
other rare bloodstream diseases including Von Willebrand's disease, or congenital factor	Yes	No	Yes	No
VIII disorder?

All information collected will be treated as confidential pursuant to 470 IAC 1-2-7, 470 IAC 1-3-1, 42 CFR 431 Subpart F and 45 CFR 164 Subpart E.

13.Signature Required Please read carefully, then sign and date below.

I certify under penalty of perjury, that all the information I have provided is complete and correct to the best of my knowledge and belief.

Applicant 1 signature: ______________________________________ Date: (mm/dd/yy): _________________

Applicant 2 signature: ______________________________________ Date: (mm/dd/yy): _________________

Signature of witness if signed with “X”: ____________________________________________________________

14.Do you want to register to vote ?

Yes

No	Your answer will not affect your eligibility for health coverage.

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Information to Get You Started

Enclosed is your application for the Healthy Indiana Plan, a health coverage program for uninsured adults age 19 through 64. The steps to follow in applying for HIP are explained below.

Step 1: Complete and sign the application.

Answer ALL questions truthfully and completely to the best of your knowledge, including the Health Screening Questions. Use only black or blue pen.

Gather and copy any of the documents listed below as proof of the information on your application.

Sending these papers with your application will help us process it faster. Write your name and Social Security Number on all copies of documents that you send with your application.

	To provide	Send for each person applying …
	proof of…	Send for each person applying …
	Identity	Valid driver’s license or state or student photo ID card. If you have someone acting on your
		behalf, that person will need to provide proof of his or her identity also.

	US citizenship	Legal birth certificate, Certificate of Naturalization, Certificate of Citizenship, U.S. passport if it
		was issued with no restrictions.

	Money	Wages: Pay stubs, paychecks, statement from employer(s) for the most current month;
	received by	Employment termination: A statement from last employer giving dates of employment and
	applicant,	reason for termination.
	spouse, and	Self-employment: Last year’s signed tax return or personally kept self-employment records.
	dependent
	dependent	Child Support, Social Security, VA, SSI, Workers’ Compensation, disability, sick pay,
	children in the
	home	unemployment, or other benefits: court order, award letter or other proof of payment from
		the source of the income.
		Loans, gifts, or contributions: Promissory note; loan agreement; or statement from person
		providing the money that includes the person’s name, address, phone number, signature, and
		date.

	Guardianship	If someone has legal authority to act on your behalf, provide a copy of the Power of Attorney,
	or Power of	Guardianship Order, Court Order, or similar documents.
	Attorney

	Immigration	If you are not a US citizen, a copy of your alien registration card, permanent resident card, or
	Status	other documentation from the Bureau for Citizenship and Immigration Services (formerly the
		INS).

Step 2: Return the application to us. If you choose to send by fax, be sure to fax both sides of the application pages and any additional documents. You can return your completed application and other documents to us by:

Mailing them to the Document Center at: FSSA Document Center / PO Box 1630 / Marion, IN 46952; or

Faxing them to the Document Center at 1-800-403-0864; or

Dropping them off at a local FSSA DFR office. To find a local office, please go to our Web site at www.in.gov/fssa/dfr or call toll free 1-800-403-0864.

Step 3: Cooperate with requests for more information or interviews. We will contact you by telephone or mail if we need additional information or documentation to complete your application. Please respond quickly to requests for additional information so that we can process your application.

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IMPORTANT INFORMATION ABOUT THE HEALTHY INDIANA PLAN

Keep this information for your records. Do not send it in with your application.

Benefits under the Plan

HIP provides health insurance coverage to eligible adults. Enrolled members keep their HIP benefits for 12 continuous months even if income or family size changes. Members must live in Indiana and have no other access to health insurance coverage. Benefits are provided through private health insurance companies and also the State’s Enhanced Services Plan (ESP) for members who have complex medical needs. You can choose your health plan on the first page of the application, or you can call the HIP Line at 1-877-GET-HIP-9 (1-877-438-4479) to get further information about the plan and to register your choice. If you don’t select a health plan, one will be chosen for you. Members with complex health care needs will be assigned to the ESP so that enhanced disease management services and specialized networks can be accessed. An applicant’s health condition has no bearing on the HIP eligibility decision. If FSSA determines that the ESP is not the appropriate health plan, the member’s coverage will be transferred. Benefits will not lapse when the plan is changed from ESP to another HIP health plan.

HIP members have a POWER account of $1100 that will be used to pay for their initial health care expenses. The State will contribute to the account and members pay a small percentage of their income (2% - 5%) according to a sliding scale based on family income. When an application is approved, the new member is notified in writing of the amount of the POWER payment.

Your POWER account payment will stay the same during your 12-month enrollment period unless you report a change and specifically ask that your payment be recalculated. During the 12-month enrollment period, you can request 1 recalculation only for changes in your income. This limitation does not apply to changes in your family size. You must make your POWER account contribution each month.

Failure to pay may result in termination from the program, and once terminated due to failure to pay, a person cannot come back to the program for 1-year.

For Additional Information about the Healthy Indiana Plan, call us at

1(877) GET-HIP 9 (1-877-438-4479) Toll Free

Your Rights and Responsibilities as a HIP Applicant and Member

1.Once your signed application is received, federal rules allow 45 days for a decision to be made on your eligibility. We will send you a written Notice explaining whether or not you qualify for HIP. You may appeal and have a fair hearing if you disagree with any decision on your eligibility or if your application is not processed in 45 days.

2.Information you give on the application is kept confidential under state and federal law.

3.A Social Security number (SSN) must be given for each applicant who can legally have a number. An applicant who does not have a number must apply for one. Your SSN will be used to check information kept by the Social Security Administration, the Internal Revenue Service, Workforce Development and other state and federal agencies. We ask for the SSNs of family members not applying for HIP for identification purposes; however you are not required to provide the number.

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4.Eligibility for benefits is considered without any regard to race, color, sex, age, disability or national origin. We ask about your racial-ethnic heritage to comply with the Federal Civil Right Law; however you are not required to provide this information. If you choose not to provide this information we will indicate an ethnicity/race category for you for data collection purposes.

5.Certain information given on your application, such as your income must be verified. If you cannot get the necessary papers, you will need to sign a release form so that we can get them for you.

6.You must provide accurate information. A person who gives false information or misrepresents the truth is committing a crime and can be prosecuted under federal law or state law, or both. The value of benefits received by a person who was not entitled to receive them is subject to recovery by the State.

7.IF YOU MOVE, please tell us your new address so that important mail about your application and membership will reach you without delay. Also, you must tell us if you get health insurance from another source such as Medicare, or if your employer offers health insurance coverage.

8.The immigration status of non-citizens who are applying for HIP is subject to verification by the Bureau of Citizenship and Immigration Services (CIS). Undocumented immigrants and lawful permanent residents who have not yet lived in the U.S. for 5 years are not eligible for full HIP benefits. HIP does not report undocumented immigrants to the CIS.

9.Your rights to payments for medical care are assigned to the State of Indiana if you are found eligible for HIP. This includes rights to medical support and payment for any medical care that you have on behalf of yourself or your children receiving Hoosier Healthwise/Medicaid.

10.If you believe that you have been discriminated against and wish to file a complaint, you may do so by contacting the Department of Health and Human Services, Regional Manager, Region V, Office for Civil Rights, 233 N. Michigan Ave., Suite 240, Chicago, Illinois, 60601. You may call the Regional Office at (800) 368-1019 or, for TDD Call, (800) 537-7697.

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how to indiana form healthy plan spaces to complete

Include the asked particulars in the Mailing address if different, City, State, ZIP code, County, Home telephone number, Alternate telephone number, Email Address, Completed by Enrollment Center, Date of applicationmm dd yyyy, and DFRIHFE segment.

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The application will ask for more information with the intention to effortlessly complete the area Child, Child Relation to Applicant, Child, Child Relation to Applicant, Child, Child Relation to Applicant, Child, Child Relation to Applicant, Child Relation to Applicant, Child Relation to Applicant, Child Relation to Applicant, Child Relation to Applicant, Do all of the applicants live in, Does either of the applicants pay, and If yes does the person for whom.

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As part of section Applicant Number, Name of person being cared for, How often paid, Amount paid, Name of care provider, Address of provider number and, Complete this section for each, Applicant Number, Document Number, Immigration Status number from, Status Date mmddyy, Country of origin, Date of entry into the US mmddyy, and DFRIHFE, identify the rights and obligations.

Filling in how to indiana form healthy plan part 4

Complete the form by taking a look at these particular fields: Applicant has access to health, Covered by health insurance now, Yes No Yes No, Yes No Yes No, Applicant, Applicant, Tell us how much total work, Applicant, Applicant, Start date mmddyy, End date mmddyy, Start date mmddyy, End date mmddyy, Amount of gross pay per period, and Amount of gross pay per period.

how to indiana form healthy plan Applicant has access to health, Covered by health insurance now, Yes No Yes No, Yes No Yes No, Applicant, Applicant, Tell us how much total work, Applicant, Applicant, Start date mmddyy, End date mmddyy, Start date mmddyy, End date mmddyy, Amount of gross pay per period, and Amount of gross pay per period fields to insert

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Indiana Form 53421 – Fill Out and Use This PDF

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