FSSA Home
• OMPP Home
• Healthy Indiana Plan (HIP)
• Hoosier Healthwise
• Children's Health Insurance Program (CHIP)
• Care Select
• Medicaid Select
• MEDWorks
• Medicaid Waivers
• Provider Information
• Other Programs
• Prenatal Care
• Medicare Assistance
  • Help With Medicare Costs
  • Help With Medicare Costs (Español)
  • Hoosier Rx
  • State Health Insurance Assistance Program (SHIP)
  • Long Term Care Insurance Program
• Hospital Care for the Indigent
  • Original Policy
  • Important Notices Regarding HCI Changes
  • Notice of Privacy Practice
• Indiana Chronic Disease Management Program
• Indiana Medicaid
• Rx for Indiana
• Data & Statistics
• Contact Us

Question #1

Tell us about the members of your family - Please provide the names and other basic demographic information about your family. Be sure to indicate everyone in your family who is applying for health coverage.

Part of this section asks whether the child is a citizen of the U.S. - If the answer is NO, then some type of proof of immigration status will be needed. For example, an immigration document or document number like an alien registration number. If the answer is YES, proof is needed. Remember, it does not matter whether the person filling out the application or either of the child's parents are a U.S. citizen, the application refers only to the children who need health care. The Hoosier Healthwise program does not report undocumented immigrants to the INS.

Question #2

Tell us your address and telephone number - Put the address, phone number(s) and county of the person who is applying on behalf of the children.

Question #3

Does the applicant live in Indiana? - "Applicant" refers to the person applying for health care.

Question #4

Does any applicant have a court - appointed legal guardian - "Applicant" refers to the person applying for health care.

Question #5

Are any of the applicants pregnant - If anyone who is applying for health care is pregnant, then it will be important to have the name of a licensed health care professional who can verify that the applicant is pregnant or something signed by a licensed health care professional verifying the pregnancy and the date it began.

Question #6

Are any of the applicants blind or disabled? - "Applicant" refers to the person applying for health care.

Questions #7

Are any of the applicants covered by health insurance now? - Even if one or all of the children have private health insurance, they may still be eligible for Hoosier Healthwise. If the box for private insurance is checked YES -- then proof of the insurance, like an insurance card, will be needed. Also, the following information will be helpful:

1. the name, address, and phone number of the insurance company;
2. the name of the person who has the policy;
3. the policy number;
4. the names of the people covered under the policy; and
5. the type of coverage, such as "hospitalization".

Question #8

Did any applicants who do not have health insurance lose coverage in the past 3 months? - This information is needed for determining eligibility through Package C - Children's Health Plan.

Question #9

Work income you and other members of your family make - Please list each family member who is employed. (Attach a separate sheet if you don't have enough room on the form). Question #9 asks about income earned at work. If the family can include proof of their last month's income with the application, that will help us to determine eligibility faster. Proof must be a document from the company, person, or organization that pays the income, such as:

• Pay stubs or a signed statement from your employer.
• Last year's income tax return if someone in the household is self-employed.

When family income is calculated, we look at your gross employment pay (pay earned before taxes). Then we subtract $90. If money is spent on child care or care for an incapacitated adult living in the household, then even more money is subtracted to figure your family's income (see question 12)

Question #10

Income from other sources - Which should be answered in the boxes just below the list. Some type of documentation showing what kind of "other income" is helpful to include with the application. An award letter showing the current amount of pension or benefit or a statement of child support payments from a non-custodial parent are examples of acceptable documentation. Remember, if you can't get proof of income or if you are not sure about what to send, it's fine to submit the application without them.

Question #11

Was the household income in the prior 3 months the same as it is now? - If your family's household income for the current month is the same as in the prior three months, then proof of what was earned in income for this month is all that you need to get retroactive coverage for the last months. However, if your family's income this month is different from the last three months, then proof of income for each of the last three months may be needed to get retroactive coverage.

Question #12

Expenses paid to care for children or incapacitated adults living in the household - This is for money spent on things like childcare or adult daycare. This information is collected because if you pay for childcare out of your income, Hoosier Healthwise will subtract up to $200 per month per child for childcare expenses for children under two years old and up to $175 per month per child for children two years and older. The final number, after subtractions, is what is used against the income table to see if a child is eligible for Hoosier Healthwise.

Question #13

Does anyone living in the household pay support payments? - In special situations, your or your spouse's support payments are used in determining an applicant's eligibility.

Question #14

Assignment of Rights - This says that if a child who receives health coverage through Hoosier Healthwise is later found to have been eligible for health care through an absent parent, then the state can try to recover some of its costs from either the absent parent or the absent parent's health insurance company.

Question #15

Signature - By signing the application and initialing the first paragraph, you are promising that all of the information on the application is correct to the best of your knowledge. If it is later found that you filled out the application and intentionally lied just to become eligible, then you are breaking the law. By initialing the second paragraph you are agreeing to pay the premiums and co-payments if your children are found eligible for Package C - Children's Health Program. Agreeing to pay the premiums and co-payments is an eligibility factor for Package C. If you do not initial this paragraph, no attempt will be made to determine your children's eligibility for Package C if they do not qualify for Package A, B, or D.

• Child Carefinder
• Forms
• Apply for Services
• Hoosier Healthwise Enrollment Centers

More Online Services »

1. Apply for Medicaid.
2. Know how much Hoosier Healthwise costs.
3. Find a Medicaid doctor.
4. Find a Medicaid dentist.
5. Obtain Hoosier Rx coverage.
6. Apply for CHIP
7. Quit smoking.
8. Report suspected fraud or abuse.