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. (1) Name.
2. (2) Address of domicile.
3. (3) Date of birth.
4. (4) Social Security number.
5. (5) Medicare Health Insurance Claim Number (HICN).
6. (6) Marital status.
7. (7) Signature.
8. (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. (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. (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.

(Office of the Secretary of Family and Social Services; 405 IAC 8-2-5; filed Mar 29, 2006, 2:19 p.m.: 29 IR 2527; readopted filed Jun 18, 2012, 11:19 a.m.: 20120718-IR-405120201RFA; readopted filed Apr 9, 2018, 9:12 a.m.: 20180509-IR-405180110RFA; readopted filed Oct 16, 2024, 11:20 a.m.: 20241113-IR-405230817RFA)