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NYS Medicaid Application Form (updated 2021) for Age 65+ or Disabled or Blind - New Supp A NYC 2021

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Posted: 17 Jun, 2010
by Valerie Bogart (New York Legal Assistance Group)
Updated: 06 Feb, 2024
by Rachel Holtzman (New York Legal Assistance Group)

Since 2010, the New York State Department of Health Medicaid application form is called the  Access NY Application or Health Insurance Application or form DOH-4220. Download the most recent version of the form at this link. (As of 02-06-24, the form was last updated in January 2023.) 

  • For those age 65+ or who are disabled or blind, a second form is also required - Supplement A - As of Jan. 2021 the same Supplement A form is used statewide - DOH-5178A (English). NYC applicants should no longer use DOH-4220.
  • See more information here about Jan. 2021 changes for NYC applicants regarding Supplement A. 

  • This supplement collects information about the applicant's current resources and past resources (for nursing home coverage).   

All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled) (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program for Working People with Disabilities.  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.

The 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). 


There are different version of the statewide DOH-4220 Medicaid Application form, which applicants use to apply for non-MAGI Medicaid. The Medical Assistance Program (MAP) accepts the DOH-4220 form versions dated: 1/23, 8/21, and 3/15. However, if an applicant is using one of the two older version of the DOH-4220 form (dated 8/21 or 3/15), the applicant must also submit the OHIP-0112 and DOH-5130. Meanwhile, it is important that Medicaid providers use only one version of the form per applicant; it is not permitted for providers to submit an application for an applicant that contains pages from different version of the DOH-4220.




Check here for updates and  changes


Spanish (Espanol)

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


Attached files
item 2024-01-23 Submission of the DOH-4220 Application's Appropriate Pages.pdf (125 kb) Download

Also read
item Income and Resource Limits for New York State Public Health Insurance Programs
item When Documentation of Resources and Income is Required for Medicaid Applications & Renewals - and When is "Attestation" Enough?
item Where to Apply for Medicaid and Medicaid Home Care in New York City
item Child Health Plus in New York: A Program Primer
item Nursing Home Medicaid Coverage - Basic Financial Eligibility Rules about Income, Resources, and Spousal Protections
item Medicare Savings Programs (MSP) in New York
item Medicaid Resource and Income Disregards
item Financial maintenance requirements at application and renewal
item Delays in Processing of Medicaid Applications - What are Your Rights and Lawsuits Challenging Delays
item Medicaid & MSP: Must apply for Social Security and Enroll in Medicare
item "MAGI" Medicaid Eligibility under the Affordable Care Act - Rules for Most People Under age 65 Without Medicare
item Know Your Rights: NYLAG Webinars on Medicare and Medicaid -

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

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