Form Preview Example

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE01*

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

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

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

Marital Status:

Single

Married

Divorced

3. Home Address:

Number and Street

	Gender:
	M	F
	M	F

Separated	Widowed

Apartment/Lot Number

City

State

Zip Code

County:

Telephone Number:

How many people live at this address including you?

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

DFRAMAE01

Indiana Application for Health Coverage

State Form 55390 (9-13)

6. Ethnicity/Race

Ethnicity:

Are you Hispanic or Latino?

Yes

*DFRAMAE02*

Race: (select all that apply)


White	Black or African American		Asian
American Indian or Alaskan Native		Native Hawaiian or Pacific Islander

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

Are you a member of a federally recognized tribe?

Yes

If yes, enter tribe name

Have you received a service from the Indian Health Service, a tribal health program, or urban Indian health program,

Yes

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

Yes

programs, or through a referral from one of these programs?

7. Citizenship/Immigration Information

Are you a U.S. citizen or U.S. national?

If no , select your immigration status:

Yes

Lawful Permanent Resident

Refugee

Granted Political Asylum

Cuban/Haitian Entrant

Parolee

Amerasian

Undocumented

Other

Date of Status: (mm-dd-yyyy)

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

Country of origin

Document

Number

Document Type

First Name

MI Last 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

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

If yes, how many babies are expected during this pregnancy?

Yes

Pregnancy begin date (mm-dd-yyyy):

Pregnancy due date (mm-dd-yyyy):

Are you blind?

Yes

Are you disabled?

Yes

Are you incarcerated?

Are you living in a nursing facility?

Yes

Are you pending for or receiving a Medicaid Waiver?

Are you living in a Residential Care Facility or Room and Board Facility?

Yes

Go to the next page

DFRAMAE02

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE03*

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

Do you plan to file a federal income tax return NEXT YEAR?

Yes

(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

If no, skip to question c

a. Will you file jointly with a spouse?

Yes

If yes, does the spouse live in your household?

Yes

First Name

MI Last Name

Name of spouse:

b. Will you claim any dependents on your tax return?

Yes

If yes, do the dependents live in your household?

Yes

If yes how many dependents live in your household?

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

If no, how many dependents live outside your household?

MI Last Name

Dependent 1 Name

First Name

Last Name

Dependent 2 Name

First Name

Last Name

Dependent 3 Name

First Name

Last Name

Dependent 4 Name

First Name

Last Name

Dependent 5 Name

First Name

Last Name

Dependent 6 Name

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

Yes

First Name

Last Name

If yes, please list the

name of the tax filer:

How are you related to the tax filer?

Go to the next page

DFRAMAE03

Indiana Application for Health Coverage

State Form 55390 (9-13)

10. Current Employment:

*DFRAMAE04*

Name of employer

Employer Address

City

State

Zip Code

Telephone number

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Amount of gross pay per period $

How often paid?

Weekly

Monthly

Bi-weekly

Twice a month

Other:

Hours worked per week

Do hours vary?

Yes

Are you self-employed?

Yes

If yes, type of work

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

Name of employer

Employer Address

City

State

Zip Code

Telephone number

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Amount of gross pay per period $

How often paid?

Weekly

Bi-weekly

Monthly

Twice a month

Other:

Hours worked per week

Do hours vary?

Yes

Are you self-employed?

Yes

If yes, type of work

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

Go to the next page

DFRAMAE04

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE05*

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
Benefits
Supplemental Security	$


Income (SSI)
Income (SSI)	$
Child Support


Alimony received	$



Canceled Debts	$



Educational Income	$




Portion of Educational Income used for general living expenses		$

			Net farming/fishing						$
			Net rental/royalty						$
			Net rental/royalty						$
			Court Awards						$
			Court Awards						$
			Jury Duty						$
			Jury Duty						$
			Investment Income						$
			Investment Income						$
			Capital Gains						$
			Capital Gains						$
			Veterans Payments						$
			Veterans Payments						$
			Cash Support						$
			Cash Support
			(Money from someone
			(Money from someone
			other than your parent
			or spouse)

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

DFRAMAE05

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE06*

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				$
	Student loan interest				$
	Other deductions				$
	Other deductions				$

	Type:

How Often?

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:

Yes

Vehicles:

Yes

Savings Account:

Yes

Real Estate:

Yes

Checking Account:

Yes

Life Insurance:

Yes

Annuity Account:

Yes

Other:

Yes

16. Health Coverage Information

Are you enrolled in health coverage now?

Yes

If yes, check the type of coverage

Medicare Part A

Medicare Part B

TRICARE

VA health care programs

Employer insurance

Name of health insurance:

Policy number:

Is this COBRA coverage?

Yes

Is this a retiree health plan?

Yes

Peace Corps

Other

Name of health insurance:

Policy number:

Is this a limited-benefit plan (like a school accident policy)?

Yes

Go to the next page

DFRAMAE06

Indiana Application for Health Coverage

State Form 55390 (9-13)

Have you lost health insurance coverage in the past 3 months?

Yes

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

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

*DFRAMAE07*

Loss of employment	Coverage limit reached
Could not afford	Company ended coverage

Cost of family insurance coverage more than 9.5% of income

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

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

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?

Yes

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

Is this a state employee benefit plan?

Yes

Go to the next page

DFRAMAE07

Indiana Application for Health Coverage

State Form 55390 (9-13)

19. Contact Information

*DFRAMAE08*

Work Telephone:

Alternate Telephone:

Do you want to receive automated calls from our agency?

Yes

(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

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

Language interpreter

Language

At an office

Sign Language interpreter

Go to the next page

DFRAMAE08

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE09*

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

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

First Name

Last Name

Suffix

Date of Birth (mm-dd-yyyy)

Social Security Number

Gender:

Marital Status:

Single

Married

Divorced

Separated

Widowed

Does this person live at the same address as you?

Yes

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?

Yes

Race: (select all that apply)

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

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

Is this person member of a federally recognized tribe?

Yes

If yes, enter tribe name

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 No

Go to the next page

DFRAMAE09

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE10*

21. Citizenship/Immigration Information

Is this person a U.S. citizen or U.S. national?

Yes

If no, select this person's immigration status:

Lawful Permanent Resident

Granted Political Asylum

Parolee

Undocumented

Refugee

Cuban/Haitian Entrant

Amerasian

Other

Date of Status:

(mm-dd-yyyy)

Country of origin

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

Document Type

Document Number

First Name

MI Last 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

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?				Yes	No

Is this person Pregnant?	Yes	No	If yes, how many babies are expected during this pregnancy?
Is this person Pregnant?	Yes	No	If yes, how many babies are expected during this pregnancy?

Pregnancy begin date (mm-dd-yyyy):


Is this person blind?	Yes		No
Is this person incarcerated?		Yes		No
Is this person incarcerated?		Yes		No
Is this person living in a nursing facility?					Yes
Is this person living in a nursing facility?					Yes

Pregnancy due date (mm-dd-yyyy):

Is this person disabled?

Yes

Is this person living in a Residential Care Facility or Room and Board Facility?

Yes

Is this person pending for or receiving a Medicaid Waiver?

Yes

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

DFRAMAE10

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE11*

23. Tax Filing Information

Is this person required to file a Federal Income Tax Return?

Yes

Does this person plan to file a federal income tax return NEXT YEAR?

Yes

(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

a. Will this person file jointly with a spouse?

Yes

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

First Name

MI Last Name

Name of spouse:

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

Yes

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

Yes

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

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

MI Last Name

First Name

Last Name

Dependent 2 Name

First Name

Last Name

Dependent 3 Name

First Name

Last Name

Dependent 4 Name

First Name

Last Name

Dependent 5 Name

First Name

Last Name

Dependent 6 Name

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

Yes

First Name

Last Name

If yes, please list the

name of the tax filer:

How is this person related to the tax filer?

Go to the next page

DFRAMAE11

Indiana Application for Health Coverage

State Form 55390 (9-13)

24. Current Employment:

*DFRAMAE12*

Name of employer

Employer Address

City

State

Zip Code

Telephone number

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Amount of gross pay per period $

How often paid?

Weekly

Monthly

Bi-weekly

Twice a month

Other:

Hours worked per week

Do hours vary?

Yes

Are you self-employed?

Yes

If yes, type of work

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

Name of employer

Employer Address

City

State

Zip Code

Telephone number

Start Date (mm-dd-yyyy)

End Date (mm-dd-yyyy)

Amount of gross pay per period $

How often paid?

Weekly

Bi-weekly

Monthly

Twice a month

Other:

Hours worked per week

Do hours vary?

Yes

Are you self-employed?

Yes

If yes, type of work

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

Go to the next page

DFRAMAE12

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE13*

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

None
Unemployment	$


Pensions/Retirement	$



Social Security	$



Benefits
Benefits
Supplemental Security	$


Income (SSI)
Income (SSI)	$
Child Support


Alimony received	$



Canceled Debts	$



Educational Income	$




Portion of Educational Income used for general living expenses		$

			Net farming/fishing						$
			Net rental/royalty						$
			Net rental/royalty						$
			Court Awards						$
			Court Awards						$
			Jury Duty						$
			Jury Duty						$
			Investment Income						$
			Investment Income						$
			Capital Gains						$
			Capital Gains						$
			Veterans Payments						$
			Veterans Payments						$
			Cash Support						$
			Cash Support
			(Money from someone
			(Money from someone
			other than your parent
			or spouse)

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

•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

DFRAMAE13

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE14*

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				$
	Student loan interest				$
	Other deductions				$
	Other deductions				$

	Type:

How Often?

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:

Yes

Vehicles:

Yes

Savings Account:

Yes

Real Estate:

Yes

Checking Account:

Yes

Life Insurance:

Yes

Annuity Account:

Yes

Other:

Yes

30. Health Coverage Information

Are you enrolled in health coverage now?

Yes

If yes, check the type of coverage

Medicare Part A

Medicare Part B

TRICARE

VA health care programs

Employer insurance

Name of health insurance:

Policy number:

Is this COBRA coverage?

Yes

Is this a retiree health plan?

Yes

Peace Corps

Other

Name of health insurance:

Policy number:

Is this a limited-benefit plan (like a school accident policy)?

Yes

Go to the next page

DFRAMAE14

Indiana Application for Health Coverage

State Form 55390 (9-13)

Have you lost health insurance coverage in the past 3 months?

Yes

*DFRAMAE15*

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.

Go to the next page

DFRAMAE15

Indiana Application for Health Coverage

State Form 55390 (9-13)

31. Health Coverage from Jobs

*DFRAMAE16*

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.

(mm-dd-yyyy)

First Name

Last Name

Name 1

First Name

Last Name

Name 2

First Name

Last Name

Name 3

Go to the next page

DFRAMAE16

Indiana Application for Health Coverage

State Form 55390 (9-13)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that meets the minimum value standard*?

*DFRAMAE17*

Yes

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

What change will the employer make for the new plan year (if known)?

Employer won't offer health coverage

Quarterly

Yearly

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

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)

Go to the next page

DFRAMAE17

Indiana Application for Health Coverage

State Form 55390 (9-13)

*DFRAMAE18*

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?

Yes

Your answer will not affect your eligibility for health coverage.

34.

For Certified Navigators Only

Complete this section if you are a certified Navigator filling out this application for somebody else.

First Name

Last Name

Suffix

Navigator Individual ID number

Organization name

Navigator Organization ID number

DFRAMAE18

Question	Answer
Form Name	State Form 55390
Form Length	18 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 30 sec
Other names	where to fax indiana form 55390, state form 55390 r7 8 17, in application for health coverage form 55390, indiana state form 55390

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