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Indiana 53421 PDF Form

The Indiana 53421 form, formally known as the Application for Healthy Indiana Plan, is a critical document for residents seeking health coverage under this specific initiative. It mandates the disclosure of an applicant's Social Security Number as part of a comprehensive application process, designed to evaluate eligibility for the state's health plan tailored for uninsured adults between 19 and 64 years of age. This form not only inquires about personal identifiers and household composition but also dives into detailed financial, health, and residency information to ensure applicants meet the stringent requirements set by the Healthy Indiana Plan.

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Table of Contents

Embarking on the journey to obtain health coverage under the Healthy Indiana Plan (HIP) requires a comprehensive understanding of the State Form 53421, an essential document for adults living in Indiana seeking health insurance. This form, crucial for those aged 19 through 64 who are uninsured, demands meticulous attention as it encompasses various vital sections that applicants must complete accurately. These sections include personal information, health plan selection, household details, income, and a detailed health screening. It's important to note that this form is not applicable to children and pregnant women, who are directed to seek coverage through a different application process. The form also mandates the provision of one's Social Security Number, as per state law, underlining its importance in the application process. From choosing a health plan from options like Anthem Blue Cross Blue Shield, MHS, and MDwise, to providing details about every adult member and child in the household, and from disclosing income information to answering health screening questions aimed at determining eligibility for more comprehensive plans, the form serves as an integral link between applicants and their potential health coverage. Additionally, it prompts applicants to consider their voting registration status, highlighting the broader societal engagement encouraged alongside the pursuit of health coverage. Adherence to instructions and prompt responses to follow-up requests play a pivotal role in the processing time and eventual determination of eligibility, making the thorough completion of this form a critical step for all applicants.

Example - Indiana 53421 Form

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.

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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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File Information

Fact Name	Description
Purpose of the Form	The Indiana 53421 form is an application for the Healthy Indiana Plan (HIP), a health coverage program for uninsured adults aged 19 through 64.
Mandatory Social Security Number Disclosure	Disclosure of the applicant's Social Security Number is mandatory for processing the form, in accordance with IC 4-1-8-1.
Special Instructions	Applicants must complete the application as fully as possible and sign it on page 4, question 13. This form is not intended for children and pregnant women, who have a separate application process.
Governing Laws	The form is governed by Indiana Code and specifically mentions IC 4-1-8-1 for Social Security Number disclosure requirements. The confidentiality of information collected is protected under 470 IAC 1-2-7, 470 IAC 1-3-1, 42 CFR 431 Subpart F, and 45 CFR 164 Subpart E.

How to Fill Out Indiana 53421

Once you receive the Indiana 53421 form, which is the application for the Healthy Indiana Plan (HIP), it's important to fill it out carefully to ensure your application is processed smoothly. This plan is aimed at providing health coverage for uninsured adults between the ages of 19 and 64. Completing this application is your first step towards accessing comprehensive health care services. Here’s a step-by-step guide to help you fill out the form correctly.

First, read the instructions on the cover page to understand the overall application process.
Select your preferred health plan by marking the box next to the plan's name (Anthem Blue Cross Blue Shield, MHS, or MDwise) in section 1.
For section 2, provide details about adult members of your household, including their name, date of birth, Social Security Number, marital status, sex, relationship to applicant, race, and whether they are a U.S. citizen.
In section 3, indicate the total number of members in your household.
Enter your home and mailing addresses, telephone numbers, and email address in section 4.
Section 5 asks for information about children in your home. Fill in details such as their name, date of birth, Social Security Number, sex, and U.S. citizenship status, and specify which applicant they are related to.
Confirm residency in Indiana in section 6 by answering yes or no.
Detail any dependent care expenses in section 7, including the amount paid and the provider's information.
For non-U.S. citizens, complete section 8 with relevant immigration status details.
In section 9, provide information regarding each applicant's access to health insurance and their medical history as requested.
Report work income and other types of income received by the applicant, spouse, and dependent children in sections 10 and 11.
Answer health screening questions in section 12 honestly to determine eligibility for the Enhanced Services Plan.
Sign and date the application in section 13, certifying that all provided information is accurate. If applicable, have a witness sign as well.
Lastly, in section 14, indicate whether you want to register to vote.

After completing the application, gather any required documents as listed on the form. These documents may include proof of identity, U.S. citizenship, income, guardianship, and immigration status for non-citizens. Mail or fax the completed form and documents to the addresses provided, or drop them off at a local FSSA DFR office. Keep an eye out for any correspondence from the health plan, as they may reach out if additional information is needed to process your application. Timely cooperation with these requests will help ensure that you receive the health coverage you need.

Things to Know About Indiana 53421

What is the Indiana 53421 form used for?

The Indiana 53421 form is an application for the Healthy Indiana Plan (HIP), which is a health coverage program for uninsured adults aged 19 through 64. This application is crucial for individuals seeking to enroll in the program, as it collects essential information regarding applicants' health plans, household members, income, and other pertinent details required for eligibility assessment. Children and pregnant women have separate application processes and are not covered by this form.

How do I choose a health plan on the Indiana 53421 form?

On the Indiana 53421 form, applicants are asked to select a health plan from the options provided if their application is approved. The form lists several health plans, including Anthem Blue Cross Blue Shield, MHS, and MDwise. Applicants should mark the box next to their chosen plan. For those who need additional information before making a choice or who want a provider directory, the application advises calling 1-877-GET-HIP9 (1-877-438-4479). If an email address is provided, an electronic copy of the provider directory can be sent, but applicants can also request a paper copy.

What documents are needed to accompany the Indiana 53421 form?

When applying for the Healthy Indiana Plan using the Indiana 53421 form, applicants are encouraged to provide several types of documents to support their application. These include proof of identity, U.S. citizenship or immigration status, income from various sources (such as wages, self-employment, or benefits like child support or unemployment), and, if applicable, guardianship or power of attorney documents. Attaching these documents to the application helps expedite the processing time by providing the necessary evidence for the information stated in the application.

How do I submit the Indiana 53421 form?

After completing the Indiana 53421 form, applicants have several options for submission. They can mail the completed application and any accompanying documents to the FSSA Document Center at PO Box 1630, Marion, IN 46952. Alternatively, the application and documents can be faxed to 1-800-403-0864, ensuring that both sides of each page are sent. Another option is to drop off the application and documents at a local FSSA DFR office. Locations of local offices can be found on the official website or by calling 1-800-403-0864. Applicants are reminded to cooperate with any requests for additional information or interviews to complete the application process efficiently.

Common mistakes

Filling out state forms can sometimes feel like navigating through a labyrinth. The Indiana 53421 form, which is the application for the Healthy Indiana Plan, is no exception. Here are ten common mistakes people often make when completing this form:

Not providing a complete social security number as required. This is a mandatory field for processing the form.
Missing the signature on page 4, question 13, which is essential to verify the information provided and complete the application process.
Choosing a health plan without consulting the available provider directories, which may lead to being enrolled in a plan that does not meet the individual's needs or preferences.
Failing to accurately provide information about all adult household members. This can affect eligibility and the determination of the appropriate health plan.
Omitting details of any children living in the home, including their relationship to the applicants, which is crucial for a complete household assessment.
Incorrectly answering the residency question, which can lead to eligibility issues since the program is for Indiana residents only.
Overlooking the section on dependent care expenses, which can help in qualifying for additional benefits or subsidies.
Not detailing income sources correctly or completely, affecting the evaluation of financial eligibility.
Skipping health screening questions, which are important for identifying eligibility for Enhanced Services Plans catering to specialized healthcare needs.
Forgetting to check the desire to register to vote at the end of the form, missing an opportunity to engage in the voting process.

To avoid these mistakes:

Review each section of the form carefully.
Use the supporting documentation list as a guide to prepare what is needed in advance.
Take advantage of help lines or online resources if there are uncertainties on how to complete the application.

In conclusion, taking time to understand the requirements and available support, and double-checking information before submission, can significantly streamline the application process for the Healthy Indiana Plan.

Documents used along the form

Applying for healthcare coverage through the Healthy Indiana Plan (HIP) necessitates completing the Indiana 53421 form. While this document is critical, applicants may need to submit additional forms or documents to provide comprehensive information about their identity, financial status, and eligibility. Understanding these supplementary documents can ensure a smooth application process.

Proof of Identity: A valid driver's license, state ID, or student photo ID. This verifies the applicant's identity.
Proof of U.S. Citizenship: A legal birth certificate, Certificate of Naturalization, Certificate of Citizenship, or U.S. passport. This document is mandatory for verifying citizenship status.
Proof of Indiana Residency: Utility bills, rent receipts, or a lease agreement. These documents confirm that the applicant lives in Indiana.
Proof of Income: Pay stubs, employer statements, or tax returns. These are needed to verify income levels for eligibility purposes.
Proof of Self-Employment Income: Signed tax returns or self-employment records to validate income for those who are self-employed.
Proof of Other Income: Court orders, award letters, or statements from the source of income such as child support, Social Security, or unemployment benefits.
Power of Attorney or Guardianship Documents: Legal documentation showing that someone has the authority to act on behalf of the applicant.
Immigration Status Documents: Alien registration card, permanent resident card, or documentation from the Bureau for Citizenship and Immigration Services for non-U.S. citizens.
Proof of Dependent Care Expenses: Receipts or contracts showing the cost of care for dependent children or disabled adults, which may affect eligibility.

Together, the Indiana 53421 form and these accompanying documents form a vital packet of information for those applying to the Healthy Indiana Plan. Ensuring all the required documents are complete and accurate can help expedite the application process, leading to quicker coverage decisions for applicants. Assistance with gathering and completing these documents is available through local offices and the HIP helpline, ensuring that all Indiana residents have access to the support they need to navigate the application process.

Similar forms

The Indiana 53421 form, an application for the Healthy Indiana Plan (HIP), is similar to other forms used to apply for health insurance programs, specifically those that cater to individuals and families with moderate to low incomes. Like these forms, the Indiana 53421 requires applicants to provide detailed personal information, including Social Security numbers, household composition, employment and income details, health coverage history, and a signature attesting to the truthfulness and completeness of the information provided. This form is vital for assessing eligibility and enrolling in the HIP program, aimed at uninsured adults aged 19 through 64.

Another document the Indiana 53421 form closely resembles is the application for Medicaid. Both applications gather comprehensive information on financial status, household size, and identity verification to assess eligibility for health coverage. They require similar supporting documents, such as proof of income, U.S. citizenship or legal residency, and identification. While Medicaid caters to a broader audience, including low-income individuals, families, pregnant women, the elderly, and people with disabilities, the HIP is more specifically targeted towards uninsured adults in Indiana. Nevertheless, the depth of information and type of data collected by both applications are parallel, aiming to ensure that applicants receive the appropriate level of health care assistance.

Moreover, the form parallels applications for state-specific health assistance programs, such as California's Medi-Cal or New York's Medicaid program, in its structure and requirements. These state-level applications, like the Indiana 53421 form, demand detailed personal, financial, and health information to determine eligibility. They all emphasize the importance of disclosing accurate information under penalty of perjury, including income verification, household membership, and immigration status where applicable. Each form serves as a gateway to accessing essential health services, tailoring its requirements to the state's specific health coverage programs for underserved populations.

Dos and Don'ts

Filling out state forms can sometimes feel like navigating through a maze. Here are essential guidelines one should follow when completing the Indiana 53421 form, specifically designed for applications to the Healthy Indiana Plan (HIP). Ensuring accuracy and completeness in your application can pave the way for a smoother processing experience. Here's a breakdown of what you should and shouldn't do:

Do:

Use only blue or black ink when filling out the application. This ensures that the information is legible and can be scanned or copied without issues.
Answer all questions to the best of your knowledge. Completeness is key to avoiding delays in processing your application.
Sign and date the form on page 4, question 13. Your signature certifies that the information you've provided is accurate and complete.
Provide your Social Security Number. Disclosure is mandatory as the form cannot be processed without it, in accordance with IC 4-1-8-1.
Include documents for proof as specified in the instructions. Attaching the necessary documentation can expedite the review process.
Ensure that your application includes information about all adult members of your household as requested.
Fill out the health screening questions fully. These are crucial for determining eligibility for certain services within the plan.

Don't:

Leave any sections blank. If a section doesn't apply to you, write "N/A" or "None" to indicate this. Incomplete applications may lead to processing delays.
Forget to check the box next to your chosen health plan under the "Health Plan Selection" section if you have a preference.
Use pencil or colors other than blue or black ink. These cannot be scanned and may cause your application to be returned.
Provide false information. Falsification of any details can have serious legal implications and might result in denial of your application.
Ignore the signature requirement. An unsigned application is considered incomplete and will not be processed.
Omit the date of application at the "Completed by Enrollment Center" section. The date is important for tracking the processing timeline of your application.
Forget to mention if you wish to receive a paper copy of the health plan provider directory. Indicating your preference ensures that you receive the information in your preferred format.

By carefully following these guidelines, applicants can ensure their submission is complete and clear, leading to a smoother and more efficient processing of their Healthy Indiana Plan application.

Misconceptions

When people hear about the Indiana 53421 form, also known as the Application for Healthy Indiana Plan, several misconceptions often cloud their understanding of the application process and its requirements. Clearing up these misunderstands is crucial to ensure that eligible individuals feel confident and informed when applying for health coverage.

Misconception 1: The form is only for individuals without any health conditions.

This belief is incorrect. The Healthy Indiana Plan (HIP) is designed to provide coverage to a wide range of individuals, including those with pre-existing conditions. The section of the form titled "Health Screening Questions" is meant to identify whether applicants qualify for the Enhanced Services Plan, which offers coordinated medical care for individuals with specialized healthcare needs, not to disqualify them based on their health status.

Misconception 2: Children and pregnant women can apply using the Indiana 53421 form.

Contrary to this belief, the form explicitly states that it is not intended for children and pregnant women. Those needing coverage for these groups should request a Hoosier Healthwise application by contacting 1-877-GET HIP9 (1-877-438-4479), ensuring they are directed towards the correct application process suited to their specific needs.

Misconception 3: If you don't have a Social Security Number, you can't apply.

While the form does require the disclosure of your Social Security Number and states that the form cannot be processed without it, this requirement primarily applies to U.S. citizens and those with eligible immigration status who have a Social Security Number. Individuals without a Social Security Number due to their immigration status should not be discouraged, as they might still be eligible under different criteria or programs and are encouraged to inquire further for assistance.

Misconception 4: You must choose a health plan on the application form or you won't be enrolled.

This is not true. Applicants are asked to select a health plan if they have a preference, but if no selection is made, one will be assigned upon approval of their application. The main goal is to ensure all approved applicants receive health coverage, regardless of whether they select a plan themselves or have one assigned to them, guaranteeing no eligible individual is left without coverage simply because they did not choose a plan.

Understanding these key points about the Application for Healthy Indiana Plan can demystify the process and encourage more eligible individuals to apply confidently, knowing exactly what is required of them and what they can expect.

Key takeaways

When seeking health coverage under Indiana's Healthy Indiana Plan (HIP), understanding the application process is crucial. The State Form 53421 is designed for uninsured adults between 19 and 64 who need to navigate the specifics of HIP enrollment successfully. Delving into the form provides insightful highlights to ensure a smooth application journey:

The disclosure of your Social Security Number (SSN) is mandatory due to state law IC 4-1-8-1; the application can't proceed without it.
Remember to completely fill out the application and sign it on the fourth page, specifically at question number 13, as this is critical for the process to move forward.
It's important to note that this application is not suitable for children and pregnant women, who must seek a different form for Hoosier Healthwise through the specified contact number.
Choosing your health plan is part of the application process. If accepted, you'll be enrolled in one, but you can make your selection known if you have a preference among the options listed like Anthem Blue Cross Blue Shield, MHS, or MDwise.
Applicants must provide detailed information about all adult household members, including their relationship to the applicant, which is crucial for demographic and eligibility considerations.
Accuracy in reporting your household size, address, contact info, and details about children in the household is essential for a comprehensive application.
Questions about residency, dependent care expenses, and immigration status are included to assess eligibility and ensure that the applicants meet the Indiana residency requirement.
Applicants need to disclose any health insurance coverage details and income information to help determine the appropriate program options and eligibility.
Answering health screening questions truthfully is required to complete your application, aiming to identify individuals who might be eligible for the Enhanced Services Plan.
If you're not a U.S. citizen, you must include your immigration status and details to verify eligibility for the HIP program.
Submission of the completed form can be done through mail, fax, or by dropping it of at a local FSSA DFR office. Timely cooperation with any requests for further information or interviews is also critical.
Voting registration is offered as part of the form, emphasizing that choosing to register or not won't affect the health coverage application.

Thoroughly understanding each requirement and accurately completing the form ensures a smoother application process for the Healthy Indiana Plan (HIP), paving the way for eligible individuals to receive necessary health coverage.

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Indiana Department of Unemployment - It's mandatory to disclose Social Security Numbers as part of the application process, in compliance with Indiana Code.