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MAP-259H Consumer Intent to Return/Not Return Home Download
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 Download
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 Download
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 Download
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 Download
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 Download
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 Download
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 Download
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) Download
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 Download
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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