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Financial Eligibility
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: 68047
Fact Sheet & Form for Keeping SSI for 90 Days in Temporary Hospital or Nursing Home Placement Download
SSI Temporary Institutional Stay Fact Sheet and Form 2024-03 (3-11-14 VB).pdf
This fact sheet explains requirements for maintaining SSI (Supplemental Security Income) for up to 90 days during a temporary hospital or nursing home stay. The PDF also includes a new official form (2023) for requesting continuation of SSI benefits, which must be filed with the Social Security Administration within strict timelines. Note that if SSI benefits are terminated, Medicaid will also be terminated, after "Stenson" notices are mailed giving the recipient an opportunity to recertify for Medicaid without SSI. See http://www.wnylc.com/health/entry/85/
11 Mar, 2024 312 kb Downloads: 13845
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: 217773
Future Expansion of Medicaid Buy-In For Working People with Disabilities (MBI-WPD) coming in 2025 Download
Expansion of MBI-WPD in NYS Budget 2023-24.pdf
The 2023-24 NYS Budget enacted a significant expansion of the MBI-WPD program. Once it is implemented in 2025, the asset limits will go up to $300,000 and the income limits will increase by almost 10 times the current limits for the program. At income levels above the current limits there will be a new premium charged on a sliding scale. This document describes the changes and some concerns for how it ican be implemented in the most favorable way for consumers.
30 Jun, 2023 114 kb Downloads: 2485
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: 15743
SSA Emergency Message EM-21014 Exempting Supplemental Hardship Fund Payments to Nazi Victims (2021) Download
EM 21014 SSA.pdf
PolicyNet/Instructions Updates/EM-21014: Supplemental Hardship Fund Payments to Jewish Nazi Victims (ssa.gov) - EM 21014 was released in February 2021 with a retention date of February 2022, meaning it has not been available on the SSA website since that date. Nevertheless, the policy remains in effect. See more about the policy here http://health.wnylc.com/health/entry/65/#Hardship%20March%202021
26 Mar, 2023 380 kb Downloads: 992
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
2023-01-25 Medicaid Program Modifications COVID-19 Emergency ENDING Download
2023-01-25 COVID-19 Program Modifications.pdf
Medicaid program COVID-19 easements
29 Jan, 2023 82 kb Downloads: 14047
APPENDIX from NYLAG webinar 1/18/23 on Medicaid Increased Income Limits 2023 (Updated 1/27/23) Download
Medicaid NYLAG CLE Appendix final.revised3 UPDATED.pdf
APPENDIX distributed at webinar of Jan. 18, 2023 - UPDATED after webinar with UPDATED HRA Chart of Medicaid Income Levels and UPDATED HRA form MAP-3190 (1/10/23). See further updates of that chart posted at http://health.wnylc.com/health/entry/15/. (Will be updated soon when NYS DOH issues a GIS implemented the 2023 FPL levels. Meanwhile, the 2023 Medicaid levels announced to date were based on the 2022 FPLs.
28 Jan, 2023 3.16 mb Downloads: 2759
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