Quick Screener

Disclaimer: Data & Privacy Notice

The information you enter into this screening tool is not stored or shared. Your responses are used only to generate your screening results and are not accessible after your session ends. We collect only anonymous, aggregate data to track total usage and improve the tool over time.

Preliminary Screening

HIP Work Requirements are activities you must complete to get health coverage through HIP.
For more information, please visit: www.myfssa.in.gov
Let’s determine if they apply to you.

Are you between 19 and 64 years old and receiving Medicaid through HIP (Healthy Indiana Plan)?

Applicant Information

Who are you completing this survey for?

Age

General Exception and Exclusion Screening

Some HIP expansion adults do not need to complete Work Requirements for a particular month if they meet one of the following exceptions and exclusions for at least one day of that month. Select all that apply.

Pregnant, or it has been 12 months or less since your pregnancy endedIncludes any stage of pregnancy.

Under age 26 who aged out of foster careYou are between the ages of 18 and 25, were in foster care and had Medicaid coverage on your 18th birthday.

Member of a recognized Native American tribe

Parent, caretaker, or guardian of children 13 or youngerYou are the parent, primary caregiver, or guardian for a child living in your home.

Parent, caretaker, or guardian of an individual with disabilitiesYou are the parent, primary caregiver, or guardian for a person with a disability who lives in your household.

Individual complying with work requirements under the SNAP or TANF programs

Veterans with a total disability ratingYou served in the U.S. military and have a disability related to your service.

Currently in jail or prison, or were released in the last 90 daysYou are currently in a jail, prison, or other correctional facility, or you were recently released.

Enrolled in Medicare A/BYou are enrolled in Medicare that covers inpatient hospital services or Medicare that covers physician and outpatient services

Health-Related Exclusion Questions

Select all conditions that apply. Any of these health conditions may exclude you from work activity requirements.

Are you medically frail or have special medical needs, including: blindness or disability, substance use disorder, other significant physical, intellectual, or developmental disabilities?Person who is medically frail or has special medical needs.

Are you participating in a drug addiction or alcohol treatment program?Currently enrolled in a substance abuse treatment program (not including AA or NA).

Work and HIP Work Requirements Activities

Enter all hours of HIP Work activities. This includes employment (full time, part time, and gig work), volunteering (unpaid work for a nonprofit like a community or religious organization) and job training (programs offered by WorkOne and similar training providers).

Monthly hours of paid employment

Monthly hours of volunteer service

Monthly Hours of Job Training

Are you enrolled at least half-time in an educational program?Includes higher education institutions (like a college or university) and career and technical education programs (like trade schools)

Are you receiving unemployment insurance?

Income Information

Enter your monthly gross income from all sources. This includes wages or salary from an employer, earnings from self-employment or freelance work, and unearned income such as child support, alimony, gifts, or pension payments.

Monthly gross earned income ($)

Monthly self-employment income ($)

Monthly unearned income ($)

Review Your Answers

Review of your screening answers
Screening Question	Response

Disclaimer: Data & Privacy Notice

Preliminary Screening

Applicant Information

General Exception and Exclusion Screening

Health-Related Exclusion Questions

Work and HIP Work Requirements Activities

Income Information

Review Your Answers

Status

You must meet at least one of the following HIP Work Requirements:

Hours

Income

Activities

Your Exclusion Reasons:

Detailed Results