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Fill in Your Indiana 53421 Form

The Indiana 53421 form is the application for the Healthy Indiana Plan, designed to provide health coverage for uninsured adults aged 19 to 64. This form requires detailed information about applicants, including personal details, household composition, and income sources. To get started on your application, fill out the form by clicking the button below.

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Table of Contents

Similar forms

The Indiana 53421 form, which is the application for the Healthy Indiana Plan, shares similarities with the Medicaid application form. Both documents serve the purpose of determining eligibility for health coverage. They require personal information, including income, household composition, and citizenship status. Each form also asks for signatures to confirm the accuracy of the provided information, ensuring that applicants understand the importance of truthful disclosures for their eligibility determination.

Another document similar to the Indiana 53421 form is the Supplemental Nutrition Assistance Program (SNAP) application. This form is designed to assess an individual's eligibility for food assistance. Like the Indiana 53421, it collects information about household members, income, and expenses. Both applications emphasize the need for complete and accurate information, as this directly impacts the benefits that individuals may receive.

The Temporary Assistance for Needy Families (TANF) application is also comparable to the Indiana 53421 form. TANF provides financial assistance to families in need, and its application process includes gathering personal and financial details. Both forms require applicants to disclose information about their household composition and any income sources. Additionally, they both necessitate signatures to validate the information provided.

To facilitate property transfers, it’s helpful to understand the components of a proper bill of sale, such as the comprehensive elements necessary for a Missouri Bill of Sale template, which you can find here.

The Health Insurance Marketplace application bears similarities to the Indiana 53421 form as well. This document helps individuals and families apply for health insurance coverage through the federal or state marketplace. It requires similar personal and financial information, such as income and household size. Both applications aim to connect applicants with health coverage options based on their eligibility.

The Medicare application form is another document that aligns with the Indiana 53421 form. Medicare serves seniors and certain disabled individuals, and its application collects information regarding age, disability status, and income. Like the Indiana form, it requires applicants to provide accurate information to determine eligibility for coverage. Both forms also include sections for signatures to affirm the truthfulness of the information submitted.

The Children’s Health Insurance Program (CHIP) application is similar in purpose to the Indiana 53421 form, as it aims to provide health coverage for children in families with limited income. This application gathers information about household income and the number of children in the home. Both forms focus on ensuring that applicants meet specific criteria to receive health benefits, and they require signatures to confirm the accuracy of the information provided.

The WIC (Women, Infants, and Children) application is another document that resembles the Indiana 53421 form. WIC provides nutritional assistance to low-income pregnant women, new mothers, and young children. The application requires information about household size, income, and nutritional needs. Like the Indiana form, it emphasizes the importance of accurate disclosures and includes a signature section to verify the information given.

The Unemployment Insurance application also shares commonalities with the Indiana 53421 form. This document is used by individuals seeking financial assistance during periods of unemployment. Both forms require detailed personal information, including employment history and income. They both aim to assess eligibility for benefits based on the information provided, and signatures are required to validate the accuracy of the claims made in the application.

The Social Security Disability Insurance (SSDI) application is similar to the Indiana 53421 form in that it assesses eligibility for benefits based on disability status. This application requires detailed medical and financial information, similar to the health-related inquiries found in the Indiana form. Both documents seek to ensure that applicants meet specific criteria for receiving assistance, and both require signatures to affirm the truthfulness of the information submitted.

Lastly, the Veteran Affairs benefits application shares similarities with the Indiana 53421 form. This application is designed for veterans seeking health care and other benefits. It collects personal and service-related information to determine eligibility. Like the Indiana form, it emphasizes the importance of accurate information and includes a signature section to confirm the validity of the claims made by the applicant.

FAQ

What is the Indiana 53421 form?

The Indiana 53421 form is the application for the Healthy Indiana Plan (HIP), a health coverage program designed for uninsured adults aged 19 through 64. This form collects essential information about applicants to determine their eligibility for health coverage under this program.

Who should fill out the Indiana 53421 form?

This application is specifically for adults. If you are applying for coverage for children or pregnant women, you will need to contact 1-877-GET HIP9 (1-877-438-4479) to obtain the appropriate application for Hoosier Healthwise.

What information do I need to provide on the form?

When completing the form, you will need to provide personal details such as your name, date of birth, Social Security number, address, and contact information. Additionally, you will need to disclose information about your household members, income, and any existing health insurance coverage. It’s crucial to answer all questions truthfully and completely.

Is my Social Security number mandatory?

Yes, providing your Social Security number is mandatory. The Indiana Family and Social Services Administration requires this information to process your application. Without it, your application cannot be completed.

How do I submit the Indiana 53421 form?

You can submit the completed form in several ways. You can mail it to the FSSA Document Center at PO Box 1630, Marion, IN 46952, or fax it to 1-800-403-0864. Alternatively, you can drop it off at a local FSSA DFR office. Be sure to check the website or call for the nearest office location.

What happens after I submit my application?

Once your application is submitted, the FSSA may contact you for additional information or documentation. It is essential to respond promptly to any requests to avoid delays in processing your application. You will be notified of your eligibility status after your application has been reviewed.

Can I choose my health plan?

If your application is approved, you will be enrolled in one of the available health plans. You can indicate your preferred plan on the application. The options include Anthem Blue Cross Blue Shield, MHS, and MDwise. If you need assistance in making a selection, you can call 1-877-GET-HIP9 for help.

What if I have more questions about the application process?

If you have additional questions or need further assistance, you can call the same number, 1-877-GET-HIP9. They can provide guidance on completing your application and address any concerns you may have about the Healthy Indiana Plan.

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Common mistakes

Filling out the Indiana 53421 form can be straightforward, but many people make common mistakes that can delay the process. One frequent error is failing to provide a Social Security Number. This number is mandatory, and without it, the application cannot be processed. Always double-check that this information is included before submitting the form.

Another mistake occurs when applicants overlook the signature requirement. It’s essential to sign your name on page 4, question 13. Without a signature, the application will be incomplete. This simple step is often forgotten but is crucial for the processing of your application.

Some individuals also neglect to mark their health plan selection. If you have a preferred health plan, be sure to check the appropriate box. Not indicating a choice can lead to automatic enrollment in a plan you may not want. Always take a moment to review this section carefully.

Providing inaccurate information about household members is another common error. Ensure that you list all adult members living in your household, including their relationship to you. Missing or incorrect details can lead to complications in determining eligibility.

People often forget to answer the health screening questions completely. These questions are vital for assessing eligibility for enhanced services. Ensure you answer each question with either “Yes” or “No.” Incomplete answers can delay the review process.

Additionally, some applicants fail to specify their income correctly. Be thorough when reporting work income and other financial details. Misreporting or omitting income can affect your eligibility and the benefits you receive.

Another mistake is not providing the correct documentation to support the information in the application. For instance, if you claim certain types of income, be prepared to submit proof. Failing to include necessary documents can lead to delays or denials.

Some applicants mistakenly assume that all questions are optional. Each question is important and contributes to the overall assessment of your application. Take the time to answer all questions to the best of your ability.

Lastly, many individuals do not keep a copy of their completed application. It’s wise to make a copy for your records before submitting the form. This can help you track your application status and provide reference in case of any issues.

By avoiding these common mistakes, you can help ensure that your Indiana 53421 form is processed smoothly and efficiently.

Indiana 53421 Preview

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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