Application For Hoosier Healthwise Page 4
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4APPLICATION FOR HOOSIER HEALTHWISE
*DFRIGAE02*
FOR CHILDREN AND PREGNANT WOMEN
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7. We will send you a notice telling you the decision on your application. You may request a fair hearing if you
disagree with any decision about your eligibility, or if your application is not processed within forty (45) days.
8. The immigration status of non-citizens who are applying for health coverage is subject to verification by the United
States Citizenship and Immigration Services (USCIS). However, the Hoosier Healthwise Program does not report
undocumented immigrants to the USCIS.
9. Your rights to payments for medical care are assigned to the State of Indiana if you are found eligible for benefits.
This includes rights to medical support and payment for medical care that you have on behalf of yourself and your
dependents who are approved for benefits under this application. However, the assignment does not include
Medicare payments.
You must tell us about health insurance that you have. You must tell us about any legal or administrative
actions you take to get payment for medical care, such as a personal injury settlement.
The establishment of paternity is an important service for Medicaid/Hoosier Healthwise members that benefits
children who do not have legal fathers. We encourage you to contact your local child support office in your
County Prosecutor’s office when your children are enrolled in Medicaid/Hoosier Healthwise. Except for children
enrolled in Package C, there is no cost for this service or other child support services.
10. FOR MEMBERS ENTITLED UNDER PACKAGE C, there is a cap on the amount of cost-sharing that you will
have to pay. This amount is 5% of your annual income before taxes. The Package C approval notice will tell you
what your annual cap is. If you reach the cap, you will need to contact your Division of Family Resources office
and provide receipts so that you will no longer have to make payments.
11. 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 them at (800) 368-1019 or for TDD
calls, (800) 537-7697.
12. Effective January 1, 2013, Family Planning Services will be available under Indiana’s Medicaid program.
Men and women who do not qualify for full coverage Medicaid can qualify for these services if they meet the
income requirements. If you are enrolled in Hoosier Healthwise for pregnancy, we will determine your eligibility
for Family Planning Services when your pregnancy ends.
DFRIGAE02
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