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New Application Form (2010) Used for Medicaid, Child Health Plus and Family Health Plus in New York State

Views: 27781
Posted: 17 Jun, 2010
by Valerie Bogart (New York Legal Assistance Group)
Updated: 03 Mar, 2014
by David Silva (New York Legal Assistance Group)

In April 2010, the New York State Department of Health introduced a new 6-page application form to be used for Medicaid, Family Health Plus, and Child Health Plus.   The new form is called the  Access NY Application for public health insurance benefits, also known as form DOH-4220.  

As of January 1, 2014, the DOH-4220 application should not be used for Medicaid applicants in the MAGI category.  All MAGI applicants should go through the NYS Health Benefits Exchange to apply for Medicaid.

As of June 11, 2010, all local districts in New York State are required to accept the revised DOH-4220.  They must accept it for all applications for Medicaid (including for coverage of long-term care services) and Medicare Savings Program. 

  • Now, the new DOH-4220 - Access NY Health Care  application can be used for  all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home  (with the addition of the Supplement A form, described below). It can also still be used for Family Health Plus and Child Health Plus. 

  • Before, Medicaid applicants seeking long-term care at home or in nursing homes had to use the 16-page green LDSS-2921 - Common Application form.  This 16-page monstrosity (which you may recognize from its green print) has remained substantially the same for years.  It is still used to apply for Public Assistance, Food Stamps, and several other public benefits.  Until now, this was the only application that could be used for those Medicaid applicants who require community-based long-term care or nursing home care.  Because it contained many questions that only applied to Food Stamps and  the other benefits, this was a frustrating application to use.  As of June 11, 2010, there is no longer any reason to use the LDSS-2921 to apply for public health coverage in New York State!  So say goodbye to the "green monster..." 

According to the guidance accompanying the new form, "[t]he Access NY Health Care application was revised to support recent changes in policy which eliminate the resource test for non-SSI-Related Medicaid and Family Health Plus (FHPlus) applicants and the requirement for a personal interview for individuals applying for Medicaid and FHPlus coverage."  See DOH 10 OHIP/ADM-5 at 2.

Applicants who only want a Medicare Savings Program (MSP) may continue to use the MSP-only application (and this is recommended).  Districts must also continue to accept the LDSS-2921, although it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance.

Must Complete Supplement A (DOH-4495A) - For Age 65+, Disabled, or Blind Medicaid Applicants Seeking Home Care or other Long-Term Care Services in the Community or in a Nursing Home

In addition to the revised DOH-4220, there is a new Supplement A  to the application that must be completed for those who are:

(a) disabled, aged or blind (aka DAB), and

(b) in need of long-term care services (including home care). 

This supplement collects information about the applicant's current resources (for those seeking coverage of community-based LTC), and past resources (for nursing home coverage).  If a disabled, aged, or blind applicant does not seek coverage of long-term care, then they do not need to submit the supplement.

If someone is in one of the other Medicaid categories (Singles/Childless Couples [S/CC], Low-Income Families [LIF], or ADC-related), then they do not need to complete the Supplement A, even if they require coverage of short-term home care or nursing home.  However, if such a person is in a nursing home in permanent absence status, then they must apply for the DAB category by using the Supplement.    See this article for more about these different Medicaid categories, and these charts of the different rules for counting income and resources for the different categories.

There are several other online resources relating to the new application:

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.


Also read
document Income and Resource Limits for New York State Public Health Insurance Programs
document When Documentation of Resources and Income is Required for Medicaid Applications & Renewals - and When is "Attestation" Enough?
document Where to Apply for Medicaid and Medicaid Home Care in New York City
document Family Health Plus Overview
document Child Health Plus in New York: A Program Primer
document Elimination of resource test for adults in Family Health Plus and many adults in Medicaid
document Nursing Home Medicaid Coverage - Basic Financial Eligibility Rules about Income, Resources, and Spousal Protections
document Medicare Savings Programs (MSP) in New York
document Medicaid Resource and Income Disregards
document Financial maintenance requirements at application and renewal
document Delays in Processing of Medicaid Applications - What are Your Rights and Lawsuits Challenging Delays
document Medicaid in 2014: Understanding MAGI & the Marketplace

Also listed in
folder Medicare Savings Program
folder Family Health Plus
folder Medicaid -> Applying For and Keeping Medicaid

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