INDIANAPOLIS | Low-income Hoosiers can begin filling out applications for the cigarette tax-funded health insurance program state lawmakers created last spring.

The state estimates the Healthy Indiana Plan will provide health care for up to 130,000 uninsured adults earning less than double the federal poverty rate -- $19,600 for a single person or $40,000 for a family of four. To be eligible, applicants must have gone without access to insurance for at least six months.

On Monday, the Indiana Family and Social Services Administration posted a five-page application for the plan online at Hip.in.gov. Applications also are available at local FSSA offices or by mail by calling (877) 438-4479.

The state will begin accepting applications for the program Dec. 17, with insurance coverage scheduled to begin in January.

Participants, who will be enrolled on a first-come basis, must pay into the plan up to 5 percent of their income based on a sliding scale that begins at 2 percent for individuals who earn $9,800 or less.

Enrollees each will gain access to at least $500 in annual preventive care, such as mammograms and prostate exams, and receive a $1,100 health savings account to cover doctor visits and other medical expenses. Those who exhaust those accounts can tap up to $300,000 in additional annual insurance coverage.

The health plan, Gov. Mitch Daniels' signature legislative accomplishment for the year, will be bankrolled primarily by a 44-cent cigarette tax hike that took effect in July.