State Form 43202 – Fill Out and Use This PDF

APPLICATION FOR HOOSIER HEALTHWISE

FOR CHILDREN AND PREGNANT WOMEN

STATE FORM 43202 (R8 / 8-12) / FI 2030	*DFRHHEE01*

1.Tell us about the members of your family living in your household. Put your name first, and list only children, spouses, and parents. Place a  in the last column if that person is applying for health coverage.

	Name (First, MI, Last)	Date of	Social Security Number Marital Race	Sex	Relationship	Citizen of U.S.?  if
		Birth
			Status		to You	Yes / No	applying
		mm/dd/yyyy
			*			*

Self

* See #6 and #8 of Rights and Responsibilities.

2.Tell us your address and telephone number.

Do you want to receive automated calls from our agency?  Yes  No

(Examples of calls you may receive are appointment reminders or due dates for requested documents.)

3. 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 above, 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.

4.Do the applicants live in Indiana?  Yes  No

5.Does any applicant have a court-appointed legal guardian?  Yes  No If yes, who? ______________________

6.Are any of the applicants pregnant?  Yes  No

Completed by Enrollment Center: Date of application (month,day,year) : __________ Center’s Code:______ Interviewer: ______________________

Completed by DFR: Date received (month,day,year): ______________ Case Number: ___________________________

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APPLICATION FOR HOOSIER HEALTHWISE

FOR CHILDREN AND PREGNANT WOMEN

STATE FORM 43202 (R8 / 8-12) / FI 2030	*DFRHHEE02*

10.Are any applicants covered by health insurance now?  Yes  No If yes, who? ______________________________

11.Did any applicants who do not have health insurance lose their coverage in the past 3 months?  Yes  No

If yes, who: ___________________________________________ When did coverage end?____________________

Please tell us why coverage was lost by putting a  beside the reason(s).

 Loss of employment

 Coverage limit reached

 Non-custodial parent dropped insurance

 Divorce

12. Tell us how much work income you and other members of your family make.

Name of person working _________________________________		Name of person working _______________________________
Start Date: _________________ End Date: ________________		Start Date: ________________ End Date: ________________
How often Paid?Weekly Bi/weekly Monthly Twice a Month		How often Paid?Weekly Bi/weekly Monthly Twice a Month
Amount of Gross Pay Per Pay Period: $__________________		Amount of Gross Pay Per Period: $__________________
Hours worked a week: ____	Do hours vary?  Yes  No	Hours worked a week: ____	Do hours vary?  Yes  No
Is person self-employed?	 Yes  No	Is person self-employed?	 Yes  No
Employer name and phone number		Employer name and phone number

13.Tell us if you or any family members receive other income from the types listed here. If your family has no income, initial here _______. (For child support, put the child as the person receiving it)

1.	SSI	6.	Military Allotment			11. Interest Payments
2.	Social Security	7.	Unemployment			12.		Educational Income
3.	Veteran’s Benefits	8.	Support (alimony or child support)			13. Cash from Friends, Relatives, etc.
4.	Railroad Retirement	9.	Sick Benefits			14.		Worker’s Compensation
5.	Pension	10.	Strike Benefits			15.		Other? Please specify ______________
	Name of the Person Receiving the			What Type	How Often are			When did Payments	Amount of the
	Payments			(from above)	Payments Received			Begin	Payments

14.Was the household income in the prior 3 months the same as it is now?  Yes  No If no, please explain:

_______________________________________________________________________________________

15.Please read the following statement and sign your application below.

I certify under penalty of perjury, that all of the information I have provided is complete and correct to the best of my knowledge and belief and that I have received the notice entitled “Important Information about Hoosier Healthwise” and understand what it states.

Your Signature: ____________________________________________________________Date: _______________

Signature of witness if signed with “X”:_______________________________________________________________________

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APPLICATION FOR HOOSIER HEALTHWISE

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IMPORTANT INFORMATION ABOUT HOOSIER HEALTHWISE

I. The Benefits of Hoosier Healthwise and How your Eligibility will be Determined

There are 4 Benefit Packages as explained below. We will determine your eligibility for the most benefits possible based on your situation and family income. If you are applying for Hoosier Healthwise for your children, we will first check eligibility for the premium-free plans. If your income is more than the premium-free plans allow, we will check eligibility for Package C.

Package A - Standard Plan

Provides comprehensive health care coverage to eligible adults and children. There are no premiums.

Package B - Pregnancy Coverage

Provides coverage for pre-natal care, treatment of conditions that may complicate the pregnancy, delivery, and 60 days of after-pregnancy care. There are no premiums.

Package C – Children’s Health Plan

Provides comprehensive health care coverage for children under age 19. There is a premium based on family income and the number of children covered. When children are approved for the Children’s Health Plan, we send a notice that tells the amount of the premium which must be paid before coverage starts.

Package E – Emergency Services Only

Provides coverage for treatment of serious medical emergencies. This plan is for certain immigrants who do not meet the necessary immigration status requirements for full coverage under the other benefit packages.

II.Your Rights and Responsibilities as a Hoosier Healthwise Applicant and Member

1.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 Rights 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.

2.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.

3.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 must be repaid to the Hoosier Healthwise program.

4.Information you give is kept confidential under state and federal law.

5.IF YOU MOVE, please tell us your new address so that important mail about your application and membership will reach you without delay. Also, tell us if you or your child(ren) become covered under other health insurance or if you have a change in your income.

6.A Social Security number must be given for each applicant. An applicant who does not have a number must apply for one. This requirement does not apply to certain immigrants who cannot have a number and therefore are eligible only for the limited benefits under Package E. The number you provide 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 Social Security numbers of family members who are not applying for health coverage for themselves, however, it is not required that you provide them.

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APPLICATION FOR HOOSIER HEALTHWISE

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7.We will send you a notice telling you the decision on your application. You may request a fair hearing if you disagree with any decision about your eligibility, or if your application is not processed within forty (45) days.

8.The immigration status of non-citizens who are applying for health coverage is subject to verification by the United States Citizenship and Immigration Services (USCIS). However, the Hoosier Healthwise Program does not report undocumented immigrants to the USCIS.

9.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.

10.FOR MEMBERS ENTITLED UNDER 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. The Package C approval notice will tell you what your annual cap is. If you reach the cap, you will need to contact your Division of Family Resources office and provide receipts so that you will no longer have to make payments.

11.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 them at (800) 368-1019 or for TDD calls, (800) 537-7697.

12.Effective January 1, 2013, Family Planning Services will be 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.

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