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Fill Out Your Indiana 53421 Form

The Indiana 53421 form, also known as the Application for Healthy Indiana Plan, is designed for adults seeking health coverage under the HIP program. This form serves as a crucial step in obtaining necessary health benefits, ensuring coverage for individuals aged 19 to 64 who are uninsured. If you are ready to apply, click the button below to start filling out the form.

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Article Structure

The Indiana 53421 form, officially titled the Application for Healthy Indiana Plan (HIP), serves as a crucial tool for uninsured adults in Indiana who are seeking access to healthcare coverage. This application is specifically designed for individuals who are 19 years and older, excluding children and pregnant women, who have separate application processes. Applicants must accurately fill out the form, which requires personal details such as name, date of birth, and Social Security Number—a mandatory disclosure for processing the application. The form also facilitates health plan selection, where applicants can indicate their preferred health plan from options including Anthem Blue Cross Blue Shield, MHS, and MDwise. Importantly, the application requires information about household members, income details, and prior health coverage status to determine eligibility for the Health Indiana Plan’s range of services. Additionally, the form mandates responses to several health screening questions aimed at assessing applicants’ specific healthcare needs. This thorough collection of information ensures that applicants receive appropriate health coverage tailored to their circumstances. Finally, applicants are reminded to provide necessary signatures and required documentation to expedite the processing of their applications, further emphasizing the importance of accuracy and completeness in this essential health initiative.

Indiana 53421 Example

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.

Reset Form

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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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Get Indiana 53421 PDF Form

Form Characteristics

Fact Name	Details
Form Title	Application for Healthy Indiana Plan State Form 53421
Governing Law	Indiana Code IC 4-1-8-1 mandates disclosure of Social Security numbers in applications.
Eligibility	This application is specifically for adults aged 19 to 64. It does not cover children or pregnant women.
Email Communication	Applicants can receive electronic copies of their application or documents if they provide an email address.
Health Plan Enrollment	If approved, applicants will be enrolled in a selected health plan, which includes options like Anthem Blue Cross Blue Shield and MHS.
Caregiver Expenses	The form allows applicants to report caregiver expenses for dependent children or disabled/elderly adults.
Signature Requirement	A signature is mandatory for the application to be considered complete, affirming the truthfulness of the information provided.

Guidelines on Utilizing Indiana 53421

Filling out the Indiana form 53421 is an important step towards obtaining health coverage through the Healthy Indiana Plan. It’s crucial to provide accurate and complete information to ensure a smooth application process. After submitting the form, you may need to respond to any requests for additional information or documentation that may arise during the review of your application.

Gather necessary documents: Collect proof of identity, citizenship, and any income sources. This includes documents like a valid driver’s license, birth certificate, pay stubs, or tax returns.
Use blue or black pen: Gently fill out the application form, making sure to write clearly and legibly throughout.
Complete each section: Accurately fill in the details for health plan selection, family members residing in your household, and any relevant income details for each applicant.
Answer health screening questions: Carefully respond to the health screening section, checking either “Yes” or “No” for each applicant’s status regarding health conditions.
Check residency and care expenses: Indicate whether all applicants live in Indiana and provide details about any payments made for child care or care for dependent adults.
Sign your name: On page 4, don’t forget to sign and date the application. Your signature certifies that the information provided is accurate.
Initial if no income: If applicable, initial the space confirming that your family has no income.
Prepare mailing materials: Place the filled-out application and any photocopied documents into an envelope for mailing, or prepare it for faxing if preferred.
Return the application: Send your completed application to the FSSA Document Center via mailing, faxing, or deliver it in person at a local office.

Following these steps will help promote an efficient review process for your Healthy Indiana Plan application, placing you one step closer to securing health care coverage.

What You Should Know About This Form

What is the purpose of the Indiana 53421 form?

The Indiana 53421 form, officially titled "Application for Healthy Indiana Plan," is designed for uninsured adults, aged 19 through 64, to apply for health coverage under the Healthy Indiana Plan (HIP). The form requires applicants to provide personal details, including household composition, income information, and any health-related conditions that may affect eligibility. Proper completion of this form allows individuals to receive necessary health coverage if they qualify based on the provided information.

Who should complete the Indiana 53421 form?

The form is intended for adults who do not have health insurance. It is not applicable for children or pregnant women. Those interested in health coverage for children or pregnant women should contact the Indiana Family and Social Services Administration (FSSA) to request a different application specific to those groups, namely the Hoosier Healthwise application. The form must be filled out by individuals who are seeking health coverage for themselves, including necessary demographic and financial information.

What information is required on the Indiana 53421 form?

Applicants must provide several details to complete the Indiana 53421 form. Key information includes personal identification such as name, date of birth, and Social Security number. Additionally, applicants need to identify all adults and children living in the household, their relationship to the applicant, and their citizenship status. Financial information such as income levels, employer information, and any other benefits received should also be reported. The application includes questions related to medical history, which help determine eligibility for specific health coverage plans under HIP.

What happens after submitting the Indiana 53421 form?

Once the form is submitted via mail, fax, or in person, the information will be reviewed by the FSSA. It is important for applicants to respond promptly to any requests for additional information or documentation that may arise during the processing of their application. If the application is approved, individuals will be enrolled in one of the available health plans, and they will receive further details regarding their coverage options and benefits.

Common mistakes

Filling out the Indiana 53421 form, or Application for Healthy Indiana Plan, can be straightforward if you avoid common mistakes. One typical error is not providing a Social Security Number. The form explicitly states that disclosing your Social Security Number is mandatory. Failing to include it will result in your application not being processed.

Another frequent mistake is neglecting to mark your health plan selection. If you skip marking a box next to your chosen plan, it causes delays in enrollment. Furthermore, not signing the application can halt the entire process. Ensure that you sign your name on page 4, question 13, as this step is crucial.

People often make errors regarding household information. It's essential to provide accurate data for all adult members living in your household. Missing or incorrect information about family members can lead to further complications. Each family member’s relationship to the applicant must also be clear to avoid confusion.

A common oversight occurs when applicants misinterpret the health screening questions. Inaccurately answering these questions, or failing to provide clear answers, may affect eligibility for the Enhanced Services Plan. Review these questions carefully before submitting your form.

Some applicants incorrectly state their living arrangements. If any applicants do not reside in Indiana, you must answer “No” to the question about Indiana residency. Providing incorrect residency information can lead to outright disqualification from the program.

Income reporting is another area where mistakes happen. Ensure that you clearly indicate total earnings without neglecting any sources of income. Omitting income details can lead to significant errors in evaluating eligibility and might stall the application.

Finally, not including required supporting documents is a frequent misstep. When submitting the form, include any requested proof of identity, income, or immigration status. A missing document can delay processing and may result in a need for resubmission.

Documents used along the form

The Indiana 53421 form, known as the Application for Healthy Indiana Plan, serves as a crucial document for individuals seeking health coverage in Indiana. Along with the Indiana 53421 form, several other forms and documents may be necessary to ensure a comprehensive application process. Here’s an overview of some commonly associated documents.

Hoosier Healthwise Application - This application is intended for children and pregnant women who are seeking health coverage under Indiana's Medicaid program. It ensures that families can access necessary healthcare services for their dependents.
Proof of Identity Documents - Applicants must submit documents to confirm their identity, such as a driver’s license, state ID, or passport. These documents help verify the applicant's identity and eligibility for the program.
Income Verification Documents - Pay stubs or tax returns may be necessary to establish the household income level. This information is crucial in determining eligibility for the Healthy Indiana Plan.
Immigration Status Documentation - Non-citizens must provide proof of their immigration status, such as an alien registration card or permanent resident card. This documentation helps determine eligibility for specific health coverage options.
Guardianship Documents - If someone is applying on behalf of another individual, a Power of Attorney or similar legal document must be provided. This ensures that the representative has the authority to complete the application process.

Gathering and submitting these documents along with the Indiana 53421 form can streamline the application process. Being thorough and organized will significantly enhance the likelihood of timely approval for health coverage.

Similar forms

Medicaid Application (Form 2021): Similar to the Indiana 53421 form, the Medicaid Application collects personal data, income, and household member information for individuals seeking health insurance assistance from the state. It also requires disclosure of Social Security numbers and citizenship status.
Application for Food Assistance (Form 1330): This form requests detailed information about applicants' household income, expenses, and family members. Like the Indiana 53421, it ensures that applicants meet certain eligibility criteria for government aid.
Temporary Assistance for Needy Families (TANF) Application: Also requiring personal information and social security numbers, this application helps determine eligibility for financial assistance programs for low-income families, paralleling aspects of the Indiana 53421 form.
Supplemental Nutrition Assistance Program (SNAP) Application: Similar in its function to the Indiana 53421, this form collects information on family size, income, and expenses to determine eligibility for food assistance.
Indiana Works Health Coverage Application: This application, much like the Indiana 53421, is designed to enroll low-income adults in health insurance. It collects similar data on gross income and household composition.
Low-Income Home Energy Assistance Program (LIHEAP) Application: Like the Indiana 53421 form, the LIHEAP application requires applicants to provide income details and household information to determine eligibility for energy assistance.
Child Care Assistance Application: This document requests information about household income and children’s ages, making it similar in structure to the Indiana 53421. Both assessments focus on determining eligibility based on family circumstances.
Hoosier Healthwise Application: This form is specifically for children and pregnant women, contrasting with the Indiana 53421. However, both forms share a similar approach in gathering household details and social security information.
Indiana State Department of Health Immunization Records Request Form: While focused on health documentation, this request also requires similar personal data from individuals, such as names and dates of birth.
Emergency Assistance Application: This form assists individuals facing crises and requests financial information comparable to those required in the Indiana 53421. It assesses eligibility based on immediate and critical needs.

Dos and Don'ts

When filling out the Indiana 53421 form, here are some essential dos and don’ts to keep in mind:

Do read the instructions carefully before starting.
Do provide your Social Security Number, as it is mandatory for processing.
Do fill out the application as completely as possible.
Do ensure you sign the application on page 4 at question 13.
Do mark your health plan selection clearly if applicable.
Don’t forget to provide accurate birth dates and Social Security numbers for all applicants.
Don’t leave any questions unanswered; all questions must be addressed.
Don’t submit the application without including necessary documents, as this may delay processing.
Don’t ignore requests for additional information from the agency after submission.

Misconceptions

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

This form is specifically designed for adults aged 19 to 64. For children and pregnant women, a different application called the Hoosier Healthwise application must be requested by contacting 1-877-GET HIP9 (1-877-438-4479).

Misconception 2: All health plan selections are available to applicants on the Indiana 53421 form.

While applicants can indicate their preferred health plan, not all plans may be available in every situation. Upon approval of the application, each applicant will be enrolled in one of the health plans based on eligibility criteria and availability.

Misconception 3: Providing a Social Security Number is optional on the Indiana 53421 form.

In fact, the disclosure of a Social Security Number is mandatory for processing. This requirement is in accordance with specific state laws. Not providing this information will result in the inability to process the application.

Misconception 4: Completing the health screening questions is not essential for application approval.

The health screening questions are crucial. They determine whether the applicant qualifies for the Enhanced Services Plan, which offers coordinated medical care for those with specialized health care needs. All health screening questions must be answered to consider the application complete.

Key takeaways

Ensure you fill out the Indiana 53421 form completely. Missing information can delay processing.
Sign your application on page 4, question 13. An unsigned application cannot be processed.
This application is for individuals aged 19 to 64 only. Children and pregnant women need a different application.
Choose your health plan carefully. If approved, you'll be enrolled in one of the selected plans, like Anthem or MDwise.
Provide accurate Social Security Numbers for all applicants. This is mandatory for processing the application.
List all household members, including their relationship to you, in the appropriate sections of the form.
Answer all health screening questions honestly. Your answers will aid in determining eligibility for the Enhanced Services Plan.
Attach any required documentation to support your application, such as proof of identity and income. This can speed up processing.
Return your completed form through the designated methods: fax, mail, or drop-off at a local office. Each method has specific instructions to follow.

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