7/27/2019 Healthy Indiana Plan

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HIPDISCONTINUATIONOTICE

Yourhealth overage enefi tper iod nder he Healthyndiana lanwil l endeffective ECEMBER1-,2013 eqause: 'EFFECTIVEANUARY,2OL4,DUE OTHEAVAILABILITYFNE WFEDERALROGRAMSOHELP AYFORHEALTHNSURANCETHENCOME TANDARDOR HEHEALTHYNDIANA LAN HIP)HASBEENLOWEREDO100%OFTHEFEDERALOVERTY-EVELFPL).THASBEEN ETERMINEDHROUGHSPECIALUTORENEWALPROCESSHAT OURNCOME XCEEDSROGRAMLIGIBILITYTANDARDS.YOUR IPBENEFITSILL NDDECEMBERI ,2013.YOUWILLRECEIVEN OFFICIALOTICENDECEMBEREGARDINGHEDISCONTINUANCEFYOUR IPBENEFITS.Youroptions:

1. l f youwil l no onger e covered y HlP, ou maywant o consider pplyingor health overagethrough he ederal ealth nsurance arketplacer through he pr ivatemarket.Based n yourincome, ou maybe el igibleor other nsuranceffordabi l i ty rograms fferedby he federalgovernment. hese nclude dvance remium axCredit APTC)nd Cost-Shar ingeduction(CSR). o do a pre-screeningor oneof theseprograms,o f ind nformation n how o apply ortheseprograms, r to estimate hat he costof health lansmightbe or you,vis i twww.healthcare.govr cal l ol l ree1-800-318-2596.Below sa chart hatmayassist ou n estimatinghow uchan ndividualmaypay or healthcare overage'throughhe marketplace. oumaywant o vis i t he federalwebsite isted bove, and i l l out a federal ppl icationo determine hatyourcostswil l be.

: .' Incomelnd iv idua l )Min imumPremium

Contr ibutionAnnua l Do l l a rAmount Annua l Pe rcen t o fIncome Annua l Do l l a rAmounL

$ 6 8 9 . 4 0 - $ 1 , 4 4 7 . ' 7 45 0 - 2 0 0 % s 1 7 , 2 3 5 - $ 2 2 , 9 8 0$ 2 8 72 5 - $ 3 4 4 ' 7 8 . 0 5 - 9 . 5 % s 2 , 3 7 2 . 3 6 - $ 3 , 2 1 4 . 6 5s 0 - 3 0 0 %

7/27/2019 Healthy Indiana Plan

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FSSADocumen CenterP.o. ox408Marion, IN 46952,,vlfigF. '

l f you needhelp n applyingor health overagehrough he marketplacer needmoreinformation bout he costs, ou maywant o contact cert i f ied ndianaNavigator. n IndianaNavigators rained o helpyoucomplete health overage ppl ication ndprqvidenformationon how muchyoucansaveby purchasingeal th overagehrough he federalmarketplace. ormore nformation nd a l ist ing f Navigatorsnyourcommunity, lease efer o:http://www. n.gov/heathca ereform

2. " l f your ncome as ecently ecreasedorou hinkybUmaysti l lbe el igible ndwant o be --- .- 'reconsideredor HIPbenefi tsn 2014, oumustcomplete notherHIPapplication r ior o. November 0,2013. f youarecondit ional lypproved,ou mustmake our PowerAccount' payment eforeDecember ,,2013,n order o continueo receive enefi ts i thoutaninterru t ion.

Example f MaximumMonthlyIncome,Standardo Reapplyor.HlP -Household f 1Srooo Householdf 2s1358 Household f 351710 Household f 452062,'ryYoucan ind hisnew HIPapplication t htto://www.in.gov/ fssa/hip/2332.htm.ryou maycal l -977-

. ,{*qqlg wi th questions rto havean appl ication ai led o you.A ' l t / ', / \ L / , /\ \ . /\ : . l f rU care or ch i ld ren t tndpr app 1R v r r r mr \ / n r a l i f r r n r Hnnc ior f . lo r l th r r r ico Tho H^^"1^ ,l f f iu care or chi ldren nderage18youmayquali fyor HoosieS ealthwise. heHoosieralthwise rogram oversow-incomeamil ies ndoffersaddit ional enefi ts uchasdental .andvision arewith no monthly ayment equired. he ncome imit s based n amily ize. orexample,$3 yonthly income imit or a familyofthree s5310.Formore nformation bouthow o apply or HoosieiHebit6wise, hichal6b over5 hi ldren nd lEgnant women; is i t thewebsiteat www.in.gov/f sse/dfr.4. Indianaesidents nder he ageof 65 who arebl indor disabledmaybe el igibleo receive ealthcoveragender ndiana's edicaid rogram. personwho sdetermined y he State o bedisabled aybg el igibleor Medicaidifncome ndasset uidel ines remet.Visit he website twww.in.eov/fssa/dfro f indout how o apply or Medicaid.

l f youdon'thaveaccesso the nternet oucancontact our ocal f f iceof the Divis ion f Fami lyResourcesor assistace.

lf you haveany questions bout his notice,please ontactFSSA t 100-403-0864.//