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Medicaid
MAP-2161 and MAP 2161a Spousal / Parental Refusal Form (2023) (ENGLISH) Download
MAP-2161 (2023-03) + MAP-2161a (2023-11) Combined ENGLISH.pdf
Applicants for Medicaid in New York City can use this "APPLICANT/RECIPIENT DECLARATION CONCERNING THE LEGALLY
RESPONSIBLE RELATIVE’S INCOME/RESOURCES" forms to indicate the refusal of their legally responsible relative to make available their income or resources for the cost of necessary medical care and services, i.e. "spousal/parental refusal." Since 2018, includes language to request accommodation of disability in reading notice. Instructions explain whi h form to use - MAP-2161 or 2161a - don't need both. Both attached in same PDF. Other languages availaable of MAP-2161 at https://www.nyc.gov/site/hra/help/health-assistance.page
20 Mar, 2024 329 kb Downloads: 65768
NYS Medicaid Income and Resource Levels for Past Years - 2001 - 2023 Download
2001_to_2023_NYS_income__resource_level_charts.pdf
Income and Resource levels for Medicaid and other public health programs in NYS for 2001 - 2023. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.
11 Mar, 2024 3.52 mb Downloads: 299974
Medicaid income and resource levels - 2023 (06-06-23) Download
HRA chart March 1 2024.pdf
NYC HRA MAPDR-01 (updated4-5-2023) -- 2023 NYS Income and Resource Standards revised. Note these now use 2023 Federal Poverty Levels so should be the FINAL figures for 2023.
01 Mar, 2024 304 kb Downloads: 441665
2023-12-28 Contact Information Update for the Medical Assistance Program's Third-Party Health Insurance Unit Download
2023-12-28 Contact Information Update for the Medical Assistance.pdf
06 Feb, 2024 136 kb Downloads: 123
Supplemental Needs Trusts Outline for Advocates - Including Impact on Various Benefits of Transfers of Lump Sums into SNT's UPdated 6/2023 Download
SNT Outline 2023-06.pdf
Training Outline for Advocates on Supplemental Needs Trusts (SNTs) (individual and pooled), and the effect of SNTs on various public benefit programs (updated 6/30/2023). Updated sections include Temporary/Public cash assistance, SNAP, ABLE accounts, Public Housing and Section 8, changes in procedures for submitting pooled trusts in NYC. Also heads up about 2023 increases in Medicaid income and asset limits and update about the 30-month community based lookback).
01 Jul, 2023 1.3 mb Downloads: 215187
MAPDR-05 (08/04/2022) List of Managed Care & Managed Long Term Care Plans in NYC Download
2022-08-04 MAPDR-05 Medicaid Managed Care Plans NYC.pdf
This includes a list of all managed care organizations participating in the following types of Medicaid managed care, including ID and code numbers, contact information, and service areas:
* Medicaid Managed Care
* Health and Recovery Plan Managed Care Plans (HARP)
* Managed Long Term Care (MLTC)
* Medicaid Advantage Plus (for dual eligibles, includes MLTC)
* HIV Special Needs Plans (SNP)
* Programs of All-inclusive Care for the Elderly (PACE)
* Fully Integrated Dual Advantage (FIDA) IDD

Updated August 4, 2022 (current on HRA site as of 5/31/23)
31 May, 2023 129 kb Downloads: 60879
MAP-909E DAB Renewal Form Redacted (2022-01-04) Download
MAP-909e DAB Renewal (2022-01-04) Redacted Sample with 2023 ACT NOW insert.pdf
HRA Medicaid Renewal Form being sent in 2023 to Disabled, Aged, & Blind (DAB) recipients in the "unwinding" of the Public Health Emergency. Note that the packet contains
(1) a 2-page Renewal Notification letter with the deadline to return the renewal, which is always the 10th of the 2nd month after the notification,
(2) "ACT NOW" alert intended to alert consumers that this renewal MUST be returned, unlike those sent during the Public Health Emergency (MAP-3185 - 2023-01-19),
(3) Renewal form has a new section in Part 6 RESOURCES requiring authorization for HRA to verify resources using data matching (page 6 of the PDF);
(4) Renewal form must be signed by both applicant and spouse (p. 9 of PDF)
(5) Financial Maintenance form - not new - only required if housing costs are more than 70% gross monthly income (p. 10 of PDF);
(6) NEW: Authorization for Verification of Resources - Recipient and Spouse each must sign this and send back with renewal!
(MAP-3179 and 3179a) (pp. 11-13 of PDF)
(7) Renewal instructions (pp. 14-16 of PDF)
31 May, 2023 2.17 mb Downloads: 11169
Using an SNT to Eliminate the Medicaid spend-down - Fact Sheet (May 2023) Download
SNT Short 2023-05 FINAL.pdf
How to get Medicaid despite having "excess income" - Using a Supplemental Needs Trust to Eliminate the Spend-down for Persons who are Elderly (65+), Blind or Disabled. Written by New York Legal Assistance Group Evelyn Frank Legal Resources Program, updated May 2023 with new procedures in NYC for submitting disability forms, and with 2023 figures.
23 May, 2023 476 kb Downloads: 160089
HRA MAP 259d Nursing Home Discharge Alert - for Community Budgeting & Related Forms with various forms updated as of 3-24-2023 Download
MAP-259d-e-f-g-t Discharge Alert and Related Nursing Home Forms as of 2023-03-24 (259f -259t+ 648p).pdf
NYC MICSA Medicaid Alerts from 2015 and 2020 with nursing home forms updated as of 3/23/23 including "Discharge Alert" 259d that nursing home physician must sign to certify that resident has a reasonable expectation to return home, which entitles resident to community budgeting (non-chronic care) - so they keep entire community Medicaid allowance rather than only $50/month. Form replaces 1159. PDF includes - Form 259f Notice of Discharge revised 2020 (now includes check-off that resident advised of Special Income Standard for those discharged from NH to MLTC) ; Form 259e (Change/Cancellation of Discharge Plan), 259g (Respite Alert), 259t (updated 5/2020) -- PDF has updated forms as of 3/24/2023 from NYC MARC website.
25 Mar, 2023 3.04 mb Downloads: 74039
MAP-648 P SUBMISSION OF REQUEST FROM RESIDENTIAL HEALTH CARE FACILITIES (RHCF)(05/05/2022) Download
MAP-648p Submission of request from RHCF-NH 2022-05-05.pdf
Transmittal form for Nursing Home to submit to HRA: new Medicaid application, request to convert coverage from community Medicaid, upgrade coverage, or notify HRA that transfer penalty period expired. (updated 5/5/2022)
25 Mar, 2023 69 kb Downloads: 10263
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