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HIPDISCONTINUATION NOTICE

Yourhealthcoverage Indiana benefitperiodunderthe Healthy Planwill end effective DECEMBER 31-, . 2 0 1 3b e q a u s e : ' EFFECTIVE JANUARY I,2OL4,DUE TO THEAVAILABILITY OFNEWFEDERAL PROGRAMS TO HELP PAYFOR HEALTH INSURANCETHE (HIP) INCOME STANDARD FOR THEHEALTHY INDIANA PLAN HASBEEN (FPL). LOWERED TO 100%OFTHEFEDERAL POVERTY I-EVEL tT HASBEEN DETERMINED THROUGH A SPECIAL AUTORENEWALPROCESS THAT YOUR INCOME EXCEEDS PROGRAM ELIGIBILITY STANDARDS. YOUR H I PB E N E F I T S W ILL E N DD E C E M B E 3R I , 2 0 1 3 . Y O UW I L L RECEIV AE NOFFICIA N L O T I CIE N DECEMBE RR EGARDIN G Y O U R OC FE H I PB E N E F I T S . T H ED I S C O N T I N U A N Youroptions: you maywant to consider 1. lf you will no longerbe covered by HlP, applying for healthcoverage throughthe federalhealthinsurance marketplace or throughthe privatemarket. Based on your you programs income, affordability may be eligible for other insurance offeredby the federal government. TaxCredit(APTC) Advance Premium Theseinclude and Cost-Sharing Reduction (CSR). To do a pre-screening for one of theseprograms, to find information on how to applyfor theseprograms, what the costof healthplansmightbe for you,visit or to estimate www.healthcare.gov or calltoll free 1-800-318-2596. you in estimatinghow Belowis a chartthatmayassist muchan individual may payfor health Youmaywant to visitthe federalwebsitelistedabove carecoverage'through the marketplace. , andfill out a federalapplication what your costswill be. to determine :. ' M i n i m u mP r e m i u m Contribution
Annual Percent Income of Annual Dollar AmounL $689.40-$1,447.'74 8.05-9.5%

(lndividual) Income
Annual Dollar Amount

150-200%

s17,235-$22,980 o $ 2 8, 7 2 5 - $ 3 4 , 4'7

2s0-300%

s2,372.36-$3,214.65

P.o. Box408 atL*iIF oatff{ei- Marion, IN 46952
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menr Center s-H*Yl'? FSSADocu

lf you needhelpin applying for healthcoverage throughthe marketplace or needmore information you may want to contact aboutthe costs, a certified Indiana Navigator. An Indiana Navigator is trainedto helpyou complete a healthcoverage application andprqvideinformation on how muchyou cansaveby purchasing healthcoverage throughthe federalmarketplace. For moreinformation your please and a listing of Navigators in community, referto: http://ww w.in.gov/hea lthca rereform " 2. lf your incomehasrecently you thinkybUmay stillbe eligible decreasedor and want to be ---.-' reconsidered for HIPbenefits in 2014,you mustcomplete anotherHIPapplication priorto . November 30, 2013. lf you are conditionally you must makeyour Power approved, Account ' payment beforeDecember 1,,2013, in orderto continue to receive benefits withoutan ption. interru

Example of MaximumMonthlyIncome,Standard to Reapply for.HlP, Household of 1 Householo df 2 s1358 Household of 3 51710 Household of 4 52062

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Youcanfind this new HIPapplication at htto://www.in.gov/fssa/hip/2332.htm. Or you may call I-977questions with orto have an application you. mailed to . ,{*qqlg

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lffiu l f f r U care c a r e for f o r children c h i l d r e n under t t n d p r age a p p 18 1 R you v r r rI may m r \ / qualify n r r a l i f r rfor f n r HoosieS Hnncior f .lorlthrrrico T ho H ^^"1^, Healthwise. The Hoosier program althwise covers low-income families and offersadditional benefits suchas dental . andvisioncarewith no monthlypaymentrequired. Theincomelimit is based on familysize. For example, is 5310.Formore information about $3 yonthly incomelimit for a familyofthree how to applyfor HoosieiHebit6wise, whichal6bcover5 children andllEgnant women;visitthe websiteat www.in.gov/fsse/dfr.

4. Indiana residents underthe ageof 65 who are blindor disabled may be eligible to receive health coverage underIndiana's program. Medicaid A person who is determined by the Stateto be disabled may bg eligible for Medicaidif guidelines income and asset are met. Visitthe website at www.in.eov/fssa/dfr to find out how to applyfor Medicaid. lf you don't haveaccess to the internetyou cancontact your localofficeof the Division of Family Resources for assista nce.

lf you haveany questions about this notice,please contactFSSA at 1€00-403-0864. //

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