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Medicaid
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: 76270
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: 11219
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: 52018
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: 9063
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: 3757
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: 6992
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: 11402
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: 7146
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: 36644
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: 2561
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