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Medicaid
Medicaid Household Size Chart for Aged, Blind and Disabled Individuals ("SSI-Related") Download
HOUSEHOLD SIZE FOR SSI RELATED CHART 2023 (using 2022 FPL).pdf
Updated 2023 using the 2022 FPLs. We hope to update it again when DOH adopts the 2023 FPLS.
22 Jan, 2023 140 kb Downloads: 50530
MAP-751W Consumer/Provider Request to Change Information on File (3-25-21)(fill-able) Download
MAP-751W Request to Change Information (3-25-21) (fill-able)(with 3-4-22 memo where to submit).pdf
NYC HRA Form to notify HRA of corrections or changes, e.g. close case, combine case, add/remove individual, notify of death, change in immigration status, upgrade eligibility, request MSP evaluation, budgeting changes, pooled trust budgeting and add/remove third party health insurance. Per attached 3/2022 memo may be faxed to (917) 639-0837 or mailed. Note that a change in demographic information (such as name, address, phone number) should be reported in a different form: MAP-751K. The MAP-751W is also posted at https://www1.nyc.gov/site/hra/help/health-assistance.page in other languages.
24 Oct, 2022 376 kb Downloads: 8174
Disabled Adult Child Medicaid Extensions/Continuations Download
DAC -Pickle- 1619B Chart (OCRed).pdf
This chart discusses the Medicaid Extensions/Continuations for certain special cases of SSI recipients once their SSI has been terminated. Specifically, it compares the eligibility criteria, resource/income levels, residential program requirements, spendown/NAMI contributions, reinstatement, and Medicare Buy-IN eligibility for the following groups:
A. 1619B
B. Pickle
C. DAC
22 Mar, 2022 103 kb Downloads: 7929
2021-10-28 DARB Online Payment Option for Medicaid Excess Income Consumers Download
2021-10-28 DARB Online Payment Option for Medicaid Excess Income Consumers.pdf
2021-10-28 DARB Online Payment Option for Medicaid Excess Income Consumers - provides instructions for Online Credit Card payment to the Division of Accounts Receivable and Billing (DARB) to participate in the Medicaid Pay-In Program. Link to NYC CityPay website (https://a836-citypay.nyc.gov/) is provided. Medical bills cannot be submitted through this website.
16 Nov, 2021 124 kb Downloads: 2927
2021-08-30 Updated Fax & E-maikl Submissions to HRA Medicaid and HCSP Download
2021-08-30 Fax-e-Mail submissions to MAP - Home Care Services Preogram.pdf
updates earlier fax lists - allowing submission of applications and other documents by fax during COVID-19 emergency, and adds some email addresses for inquiries
04 Sep, 2021 152 kb Downloads: 6138
Nassau County Physician's Request for Personal Care Aide and Orders to the Service Agency (07-2020) Download
Physician's Order Nassau County Form 517 - (2020).pdf
Form for doctor to complete to request Medicaid personal care services and CDPAP from the Nassau County DSS. Revised July 2020.
26 Aug, 2021 1.46 mb Downloads: 10822
CASA Directory Updated 9-09-2020 (Home Care Services Program (HCSP) Download
2020-09 NYC Home Care Services Program -CASA directory.pdf
CASA field offices have been consolidated. There is one CASA office per borough. Includes announcement of new email address for HCSP inquiries
04 Aug, 2021 309 kb Downloads: 6762
Contact List of CASA Offices - Home Care Services Program (HCSP) Download
2020-09 NYC Home Care Services Program -CASA directory.pdf
Includes announcement of new e-mail address for inquiries about HCSP cases (7-2021)
04 Aug, 2021 309 kb Downloads: 35440
MAP-751K Consumer Request to Change Information on File (3-15-21)(fill-able) Download
MAP-751K (3-15-2021)(English)(fill-able).pdf
NYC HRA Form to use to notify HRA of change in name, address, mailing address, date of birth, SSN, and to request mail in different languages or formats for disability (Updated 3-15-21). The MAP-751K is also posted at https://www1.nyc.gov/site/hra/help/health-assistance.page in other languages. Upon completion, it can be faxed to HRA using 917-639-0837. (Updated 2-18-2021) NOTE: The 751k is no longer used to request a change in budgeting. For that, use new form MAP-751W posted at the same webpage as above for the 751K.
16 May, 2021 89 kb Downloads: 9109
2020-06-22 NYS Medicaid Program Modifications COVID-19 Emergency Download
2020-06-22 NYS Medicaid program Modifications COVID-19 Emergency.pdf
23 Jun, 2020 253 kb Downloads: 2251
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