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Blank Indiana 53421 Form

The Indiana 53421 form is the official application for the Healthy Indiana Plan, designed for uninsured adults aged 19 to 64. This form requires detailed personal information, including Social Security numbers, to process applications for health coverage. It is important to complete the form accurately and submit it promptly to ensure eligibility for the program.

Outline

The Indiana 53421 form, officially known as the Application for Healthy Indiana Plan, serves as a crucial document for adults seeking health coverage under the state's program. This application is specifically designed for individuals aged 19 to 64 who are uninsured and need assistance. It requires detailed information about the applicant and their household members, including personal identification, income details, and health-related questions. Notably, the form mandates the disclosure of the applicant's Social Security Number, which is essential for processing the application. Additionally, applicants must select a health plan from available options, such as Anthem Blue Cross Blue Shield, MHS, or MDwise. It is important to note that this form is not applicable for children or pregnant women, who must use a different application process. Completing the Indiana 53421 form accurately and thoroughly is vital, as it directly impacts eligibility for health benefits and services. Furthermore, applicants are encouraged to gather necessary documentation to expedite the review process, ensuring they receive the support they need in a timely manner.

Sample - 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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Form Information

Fact Name	Description
Form Purpose	The Indiana 53421 form is an application for the Healthy Indiana Plan, designed for uninsured adults aged 19 through 64.
Mandatory Disclosure	Applicants must disclose their Social Security Number as it is required for processing the application, per Indiana Code IC 4-1-8-1.
Eligibility Restrictions	This application is specifically for adults; children and pregnant women must use a different application, available by calling 1-877-GET HIP9.
Health Plan Enrollment	If approved, applicants will be enrolled in one of the available health plans, such as Anthem Blue Cross Blue Shield, MHS, or MDwise.
Confidentiality Assurance	All information collected through this form is treated as confidential, in accordance with 470 IAC 1-2-7 and other relevant regulations.

Detailed Guide for Filling Out Indiana 53421

Filling out the Indiana 53421 form is an essential step toward applying for the Healthy Indiana Plan. After completing the form, you will need to submit it along with any required documentation to ensure a smooth application process.

Begin by entering your personal information in the designated sections, including your full name, date of birth, and Social Security Number. Remember, providing your Social Security Number is mandatory.
Indicate your health plan selection by marking the box next to your chosen plan: Anthem Blue Cross Blue Shield, MHS, or MDwise.
List all adult members of your household, providing their names, dates of birth, Social Security Numbers, marital status, sex, relationship to you, race, and U.S. citizenship status.
Count the total number of members in your household and write that number in the space provided.
Fill in your home address, including the city, state, ZIP code, and county. If your mailing address differs, include that as well.
Provide your home and alternate telephone numbers, along with your email address.
List any children living in your home, including their names, dates of birth, Social Security Numbers, sex, race, and U.S. citizenship status.
Answer whether all applicants live in Indiana and whether any applicant pays for care for a dependent child or disabled/elderly adult.
If applicable, complete the section regarding immigration status for any applicants who are not U.S. citizens.
Provide information about any health insurance coverage lost by each applicant, including reasons for loss and dates of coverage.
Detail the total work income for each applicant, including start and end dates of employment, gross pay, and hours worked per week.
Indicate any additional income sources and provide the necessary details, including the type of payment and amount received.
Answer the health screening questions truthfully for each applicant, checking "Yes" or "No" as appropriate.
Sign and date the application, ensuring all signatures are completed where required.
Decide if you want to register to vote and indicate your choice.

Obtain Answers on Indiana 53421

What is the Indiana 53421 form?

The Indiana 53421 form, also known as the Application for Healthy Indiana Plan, is a document used by adults aged 19 to 64 to apply for health coverage under the Healthy Indiana Plan (HIP). This program is designed for uninsured individuals and aims to provide access to essential health services.
Who is eligible to apply using this form?

This application is specifically for adults. It is important to note that it does not cover children or pregnant women. If you need an application for children or pregnant women, you can contact 1-877-GET-HIP9 (1-877-438-4479) for a Hoosier Healthwise application.
What information do I need to provide on the form?

You will need to provide personal details such as your name, date of birth, Social Security number, and contact information. Additionally, you must list all adult members living in your household, their relationships to you, and their Social Security numbers. Income details, health insurance status, and any caregiving expenses should also be included.
What happens if I do not include my Social Security number?

Providing your Social Security number is mandatory for processing the application. If you do not include it, your application cannot be processed, and you may not receive the health coverage you are seeking.
How do I choose a health plan?

Upon approval of your application, you will be enrolled in one of the available health plans. You can select a plan by marking the appropriate box on the form. The options include Anthem Blue Cross Blue Shield, MHS, and MDwise. If you need assistance in choosing a plan or want to view the provider directory, you can call 1-877-GET-HIP9 (1-877-438-4479).
What are the health screening questions for?

The health screening questions are designed to gather information about any medical conditions you or your applicants may have. This information helps determine eligibility for the Enhanced Services Plan, which offers coordinated medical care for individuals with specialized health care needs. Answering these questions will not affect your eligibility for health coverage.
How do I submit the completed form?

You can submit the completed Indiana 53421 form by mailing it to the FSSA Document Center at PO Box 1630, Marion, IN 46952, faxing it to 1-800-403-0864, or dropping it off at a local FSSA DFR office. Ensure that you include any required documentation to expedite the processing of your application.
What should I do if I receive a request for more information?

If you are contacted for additional information or documentation, respond promptly. This will help ensure your application is processed without unnecessary delays. Cooperation with these requests is crucial for a smooth application process.

Common mistakes

Filling out the Indiana 53421 form can be a straightforward process, but many make common mistakes that can delay their application. One frequent error is leaving out essential information. Applicants sometimes skip sections or forget to fill in required fields, such as the Social Security Number. This number is mandatory for processing the application. Without it, the application cannot move forward.

Another common mistake is not signing the application. The form clearly states that the applicant must sign their name on page 4, question 13. If this step is overlooked, it can lead to significant delays. Remember, a signature confirms that the information provided is accurate and complete. Always double-check that you have signed where required before submitting the form.

Inaccurate information is also a significant issue. Some applicants provide incorrect dates of birth or Social Security Numbers, which can lead to confusion during the review process. It is crucial to verify that all personal details are correct. Even small errors can result in the application being returned or rejected, causing unnecessary stress.

Lastly, many applicants fail to include necessary documentation. The form asks for proof of identity and income, among other things. Not providing these documents can slow down the application process. Gather all required paperwork before submitting the application to ensure everything is complete. Taking these steps can help avoid common pitfalls and make the application process smoother.

Documents used along the form

The Indiana 53421 form, officially known as the Application for Healthy Indiana Plan, is essential for individuals seeking health coverage under this program. To ensure a smooth application process, several additional forms and documents are commonly utilized alongside the Indiana 53421. Below is a list of these forms, each accompanied by a brief description.

Hoosier Healthwise Application: This form is specifically for children and pregnant women who are seeking health coverage. It provides a pathway for families to access necessary medical services for their dependents.
Power of Attorney: This document grants someone the legal authority to act on behalf of another person. It may be required if an applicant needs assistance in completing their application or managing their healthcare decisions.
Proof of Identity Documents: Valid identification, such as a driver’s license or state-issued ID, is necessary to verify the identity of the applicant. This helps to ensure that the application is processed accurately.
Proof of Citizenship Documents: Applicants must provide documentation confirming their U.S. citizenship, such as a birth certificate or passport. This is crucial for eligibility verification.
Income Verification Documents: Pay stubs, tax returns, or statements from employers are needed to demonstrate income levels. This information is vital for determining eligibility for the Healthy Indiana Plan.
Medical Records: In some cases, medical records may be required to provide a complete picture of an applicant's health needs. This assists in evaluating eligibility for specific health plans.
Immigration Status Documentation: Non-citizens must submit documents like an alien registration card or permanent resident card to confirm their immigration status. This is essential for processing their application.
Child Support Documentation: If applicable, proof of child support payments may be necessary. This documentation helps to clarify the financial situation of the household.
Social Security Number Disclosure: While the Indiana 53421 form requests the disclosure of Social Security Numbers, additional forms may also require this information for identity verification and eligibility assessment.

Each of these forms and documents plays a critical role in the application process for the Healthy Indiana Plan. By gathering and submitting the necessary paperwork, applicants can ensure a more efficient review of their eligibility for health coverage.

Similar forms

The Indiana 53421 form, used for applying to the Healthy Indiana Plan, shares similarities with several other documents related to health care applications and benefits. Here’s a list of nine similar forms:

Medicaid Application Form: Like the Indiana 53421, this form collects personal and financial information to determine eligibility for Medicaid, a state and federal program that provides health coverage for low-income individuals.
Medicare Enrollment Form: This form is used to enroll in Medicare, the federal health insurance program for people aged 65 and older, and requires similar personal and financial details.
Children’s Health Insurance Program (CHIP) Application: This document is for families seeking health coverage for their children. It gathers information about household income and residency, much like the Indiana 53421.
Food Assistance Program Application: This form is used to apply for food assistance benefits. It requires information about household members and income, similar to the health plan application.
Supplemental Security Income (SSI) Application: This application collects detailed information about income, resources, and living arrangements to determine eligibility for SSI benefits, paralleling the data collection in the Indiana 53421.
Temporary Assistance for Needy Families (TANF) Application: This form requests personal and financial information to assess eligibility for cash assistance, reflecting the same thoroughness as the health plan application.
Veterans Affairs Health Care Application: This document is for veterans seeking health care benefits. It requires personal and service-related information, similar to the Indiana 53421.
Marketplace Health Insurance Application: Used for applying for health insurance through the Health Insurance Marketplace, this form collects income and household information akin to the Indiana 53421.
State Health Benefits Application: This application is for state-sponsored health benefits programs and requires similar demographic and financial information to determine eligibility.

Dos and Don'ts

When filling out the Indiana 53421 form, it's important to be careful and thorough. Here are some helpful tips on what to do and what to avoid:

Do read the instructions carefully before starting the application.
Do provide your Social Security Number as it is mandatory for processing.
Do answer all questions truthfully and completely to the best of your knowledge.
Do sign your name on page 4, question 13, to ensure your application is valid.

Don't forget to include all adult members living in your household on the application.
Don't leave any questions unanswered; incomplete applications may delay processing.
Don't use any ink color other than black or blue when filling out the form.
Don't submit the application without gathering necessary supporting documents.

Misconceptions

Misconception 1: The Indiana 53421 form is for children and pregnant women.

This form is specifically designed for adults aged 19 to 64. Families seeking coverage for children or pregnant women must use a different application, known as the Hoosier Healthwise application.

Misconception 2: You can submit the form without providing a Social Security Number.

Providing a Social Security Number is mandatory for processing the application. Without it, the application cannot be completed.

Misconception 3: You must choose a health plan before submitting the application.

While applicants are encouraged to select a health plan, it is not a requirement for submitting the application. Enrollment in a health plan occurs after approval of the application.

Misconception 4: All applicants must be U.S. citizens to qualify for the Healthy Indiana Plan.

While U.S. citizenship is a requirement for some applicants, the form also accommodates lawful permanent residents and other specific immigration statuses.

Misconception 5: The information provided on the form is not confidential.

All information collected through the Indiana 53421 form is treated as confidential, ensuring privacy in accordance with federal and state regulations.

Misconception 6: You cannot apply if you have health insurance.

Individuals who currently have health insurance can still apply. The application includes questions about previous coverage and loss of insurance, which may help determine eligibility for the program.

Misconception 7: The application process is the same for everyone.

The application process may vary based on individual circumstances, such as income, household size, and specific health needs. Applicants are encouraged to provide complete and accurate information to ensure proper processing.

Misconception 8: You cannot change your health plan after enrollment.

Once enrolled, individuals may have options to change their health plan based on specific circumstances. It is advisable to contact customer service for guidance on making changes.

Key takeaways

Here are some key takeaways regarding the Indiana 53421 form:

The Indiana 53421 form is used to apply for the Healthy Indiana Plan, which provides health coverage for uninsured adults aged 19 to 64.
It is important to fill out the application completely and sign it on page 4, question 13.
Applicants must provide their Social Security Number, as it is mandatory for processing the application.
This form is not intended for children or pregnant women. Separate applications are available for those groups.
Applicants should indicate their preferred health plan by marking the appropriate box. Options include Anthem Blue Cross Blue Shield, MHS, and MDwise.
Provide accurate information about all adult members in the household, including their Social Security numbers and other personal details.
Applicants must disclose any income sources, including wages, child support, and other benefits, to determine eligibility.
Health screening questions must be answered honestly, as they help assess eligibility for enhanced services.
Once completed, the application can be submitted by mail, fax, or in person at a local FSSA office.