405 IAC 8-2-5 - "Complete applicant file" defined
Authority: IC 12-10-16-5
Affected: IC 12-10-16
Sec. 5.
(a)
"Complete applicant file" means an enrollment form for the Indiana prescription
drug program that includes the following information about the applicant and
applicant's spouse, if applicable:
(1)
Name.
(2) Address of
domicile.
(3) Date of
birth.
(4) Social Security
number.
(5) Medicare Health
Insurance Claim Number (HICN).
(6)
Marital status.
(7)
Signature.
(8) Proof of low-income
subsidy determination by the Social Security Administration. Proof includes
either a letter of determination from the Social Security Administration or
electronic confirmation provided by the Centers for Medicare and Medicaid
Services.
(9) Proof that the
applicant's income is below one hundred fifty percent (150%) of the federal
poverty limit applicable to the individual's family size.
(10) Proof of enrollment in a Medicare
prescription drug plan. Acceptable proof should be electronic confirmation
provided by the Centers for Medicare and Medicaid Services or a Medicare Part D
plan member identification number.
(b) Applicants may provide information to the
office by mail, facsimile, or telephone or over the Internet.
Notes
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