Application For Hoosier Healthwise Page 3
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4APPLICATION FOR HOOSIER HEALTHWISE
*DFRIGAE01*
FOR CHILDREN AND PREGNANT WOMEN
Keep this page
IMPORTANT INFORMATION ABOUT HOOSIER HEALTHWISE
I. The Benefits of Hoosier Healthwise and How your Eligibility will be Determined
There are 4 Benefit Packages as explained below. We will determine your eligibility for the most benefits possible based on
your situation and family income. If you are applying for Hoosier Healthwise for your children, we will first check eligibility
for the premium-free plans. If your income is more than the premium-free plans allow, we will check eligibility for Package C.
Package A - Standard Plan
Provides comprehensive health care coverage to eligible adults and children. There are no premiums.
Package B - Pregnancy Coverage
Provides coverage for pre-natal care, treatment of conditions that may complicate the pregnancy, delivery,
and 60 days of after-pregnancy care. There are no premiums.
Package C – Children’s Health Plan
Provides comprehensive health care coverage for children under age 19. There is a premium based on family income
and the number of children covered. When children are approved for the Children’s Health Plan, we send a notice that
tells the amount of the premium which must be paid before coverage starts.
Package E – Emergency Services Only
Provides coverage for treatment of serious medical emergencies. This plan is for certain immigrants who do not meet
the necessary immigration status requirements for full coverage under the other benefit packages.
II. Your Rights and Responsibilities as a Hoosier Healthwise Applicant and Member
1. 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 Rights 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.
2. 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.
3. 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 must be repaid to the Hoosier Healthwise program.
4. Information you give is kept confidential under state and federal law.
5. IF YOU MOVE, please tell us your new address so that important mail about your application and membership
will reach you without delay. Also, tell us if you or your child(ren) become covered under other health insurance or if
you have a change in your income.
6. A Social Security number must be given for each applicant. An applicant who does not have a number must
apply for one. This requirement does not apply to certain immigrants who cannot have a number and therefore are
eligible only for the limited benefits under Package E. The number you provide 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 Social Security numbers of family members who are not applying for
health coverage for themselves, however, it is not required that you provide them.
DFRIGAE01
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