PE Member Application

Indiana Resident

The applicant declares whether or not they are a resident of Indiana and plans to continue living in Indiana.

Final verification of state residency will be required by DFR for final determination of Medicaid benefits.

Incarcerated

Incarceration includes a county jail or any type of prison or correctional facility.

Home detention does NOT apply as incarceration.

"Yes" is pre-populated in this field when submitting a PE Application using the PE Application for Inmate button on the Eligibility Verification Request page.

DOC Facility

DOC Facility is a mandatory field that the user must populate if the Incarcerated question is answered "Yes"

The user should select the applicable DOC Facility from the list. If the applicable DOC Facility is not in the list of selections, the user should choose "Facility Not Listed".

Date of Incarceration

If known, the Date of Incarceration should be entered in MMDDYYYY format.

Number of People in Family

Family size is based on the tax household.  If you do not file taxes, the household includes the child, the child’s parents (biological, adopted, and step), and the child’s siblings (biological, adopted, and step).

US Citizen?

If the applicant is a U.S. Citizen, please select yes. If the applicant is not a U.S. Citizen, please select no.

If no is selected, please select a status from the Alien Status dropdown that is displayed. This is required if the applicant is not a U.S. Citizen.

Family Income

Income includes income from applicant, spouse, and parents of applicant if applicant is under 18 and living at home.  For children and dependents, if the children/dependents are not required to file taxes, then their income is not counted.  Income includes:

• *Wages/Salaries
• *Tips
• *Self-employment
• *Dividends
• *Interest
• *Social Security; Disability and Retirement
• *Unemployment Compensation
• *Sick benefits
• *Retirement benefits or Pensions
• *Rental income
• Do not count: Supplemental Security Income (SSI); child support and/or alimony; Veteran’s Benefits; Cash contributions; American Indiana/Alaska Native Tribal Income
• Deduct from income the following: alimony paid, student loan interest, other allowable IRS deductions

Pending Indiana Application for Health Coverage?

If the applicant has recently submitted an application with the Division of Family Resources (DFR) that is still pending a determination, please select yes.

Health Insurance Coverage?

If the applicant has health insurance coverage administered through a private carrier, please select yes.

Medicare?

If the applicant has Medicare Coverage, please select yes.

In Foster Care on 18th birthday?

If the applicant was in foster care on 18th birthday, please select yes.

Do you live with at least one child under 18 years of age and are you the main caretaker?

If the applicant is the parent or caretaker living in the same household of at least one child under 18 years of age, and is the primary caretaker, please select yes.