New York Health Access - Files

Medicaid

	MAP-259H Consumer Intent to Return/Not Return Home MAP-259H Intent to Return Home 2008-06-20.pdf This form is used when a client enters a residential facility and makes a determination that he/she will either return or not return home.
	13 Apr, 2015 236 kb Downloads: 4170

	Agreement to Participate in the Medicaid Pay-In Program MAP-931B Agreement to Participate in Pay-In Program searchable pdf.pdf This is the form in both English & Spanish agreeing to participate in the Medicaid Pay-In Program
	13 Apr, 2015 86 kb Downloads: 2838

	Optional Pay-In Program for Individuals with Excess Income MAP-931A Optional Pay-In Program searchable pdf.pdf This explains the Excess Income Program for clients whose incomes exceeds the Medical Assistance income limits
	13 Apr, 2015 142 kb Downloads: 2600

	Notice of Acceptance of your Medical Assistance Application/Recertification MAP-259p_redacted.pdf This is a redacted MAP-259p form to act as a guide for purposes of Medical Assistance application/recertification
	13 Apr, 2015 334 kb Downloads: 3347

	Notice of Renewal of your Public Health Insurance Coverage MAP 2088v_redacted.pdf This is a redacted notice of renewal of public health insurance coverage to act as a guide to help clients fill out their renewals.
	13 Apr, 2015 882 kb Downloads: 4333

	Formerly Incarcerated Individuals Reactivation Transmittal map-3103 Formerly Incarcerated Individuals Reactivation Transmittal.pdf This form was uploaded by NYC HRA on 2/20/15 to help formerly incarcerated individuals reactivate their medicaid account once they have been released.
	13 Apr, 2015 111 kb Downloads: 2687

	Notice of Permanent Placement Medicaid Managed Care MAP-2159i Notice of Permanent Placement Medicaid Managed Care.pdf NYC HRA uploaded this form on 4/3/15 to be used for clients requiring permanent placement under Medicaid's managed care plan.
	13 Apr, 2015 36 kb Downloads: 6107

	MAGI Consumers Long Term Eligibility Rules 2014-10-24 MAGI Consumers Long Term Eligibility Rules.pdf long term eligibility rules for individuals who are eligible for Medicaid under a Modified Adjusted Gross Income (MAGI) eligibility group
	09 Apr, 2015 74 kb Downloads: 5118

	8 Helpful hints for accurate completion of the medical request for home care (M11Q) 2014-12-09 8 Helpful HInts re Completion M11q.pdf 8 helpful hints for accurate completion of the medical request for home care (M11Q)
	09 Apr, 2015 61 kb Downloads: 4576

	Consumers Whose Active Medicaid Coverage on the NYSOH (Marketplace) Must be Transitioned to WMS 2015-01-05 Consumers transitioned from NYSOH to WMS update (HIV SNP).pdf Consumers who wish to enroll in an HIV SNP must also have their coverage transitioned to WMS.
	09 Apr, 2015 53 kb Downloads: 3837

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