NY Health Access About Us   |   Contact Us Empire Justice Center Legal Aid Society NYLAG WNYLC
New York City Government
12-22-22 HRA Medicaid Alert - Eligibility increases starting Jan. 2023 & REVISED MAP-3190 Form to Request Re-budgeting Download
2022-12-27 Non-MAGI Eligibility Increases 2023- with REVISED map-3190 (1-10-23).pdf
HRA Medicaid Alert announcing the increases in income and asset eligibility for Age 65+, Disabled & Blind recipients starting Jan. 2023. NYLAG has swapped in HRA's iupdated form MAP-3190 form (rev. 1-10-23) that will be mailed to everyone with a spend-down starting Jan. 30, 2023. The form can be completed and returned to HRA to request a decreease in the spend-down. See more at http://www.wnylc.com/health/news/90/#II.%20Timing
28 Jan, 2023 827 kb Downloads: 1063
Medicaid income and resource levels - 2023 (1-25-23) Download
HRA MAPDR-01 2023 Income-Resource Levels (1-25-2023).pdf
NYC HRA MAPDR-01 (updated 1-25-2023) -- 2023 NYS Income and Resource Standards revised. NOte these use 2022 Federal Poverty Levels. Will be updated again once NYS DOH issues levels based on 2023 FPL
25 Jan, 2023 294 kb Downloads: 432191
NYS Medicaid Income and Resource Levels for Past Years - 2001 - 2022 Download
2001_to_2022_NYS_income__resource_level_charts.pdf
Income and Resource levels for Medicaid and other public health programs in NYS for 2001 - 2022. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.
21 Jan, 2023 3.78 mb Downloads: 297985
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: 5120
NYC Medicaid Alert 6-30-2022 - Change in Submissions to HRA for Disability Determination for Pooled Trusts & MBI-WPD (revises 5/31/22 Alert) Download
2022-6-30 MA Alert Disability Determination by New York State Medicaid.pdf
Eff. June 1, 2022, submissions to HRA to approve a Pooled Trust or MBI-WPD no longer need to include the disability forms (DOH-5141, DOH-5143, Authorization MAO-751e, AIDS report form MAP 252F. Instead, once the pooled trust is filed with HRA, HRA will route it to NYS DOH Disabilitiy Review Team, which will then request MAP 3177 Disability Determination Request from the consumer. Unclear if other documentation will be required but likely - stay tuned look for updates at http://www.wnylc.com/health/entry/44/ (This revises the Alert issued May 31, 2022
01 Jul, 2022 148 kb Downloads: 1257
2022-0-5-13 New York Independent Assessor Download
2022-05-13 New York Independent Assessor.pdf
Beginning May 16, 2022, any adult 18 and older seeking fee for service (FFS) Personal Care Services (PCS) and/or Consumer Directed Personal Care Services (CDPAS) for the first time or seeking initial MLTC plan eligibility must be referred to the New York Independent Assessor (NYIA) for their Community Health Assessment (CHA) and Clinical Appointment (CA). This change does not include the Immediate Needs process at this time. NYIA will conduct independent assessments, provide independent practitioner orders, and perform independent reviews of high needs cases for PCS and CDPAS. The NYIA will also take over the work currently done by the Conflict Free Evaluation and Enrollment Center (CFEEC) to assess individuals for MLTC plan eligibility.
23 May, 2022 93 kb Downloads: 585
DOH-5130 Form Download
DOH form 5130_updated 9-2021.pdf
Per MICSA Alert dated 03-24-2022, if an older version than the revised DOH 4220 form - Access NY Health Care Application (updated as of 9-2021) is submitted, DOH 5130 (and OHIP-0112) has to be submitted.
31 Mar, 2022 23 kb Downloads: 470
Revised DOH-4220, Access NY Health Care Application (updated 8-2021) Download
DOH form 4220_updated 8-2021.pdf
This is the statewide DOH-4220 Medicaid Application form used to apply for non-MAGI Medicaid (updated 8/2021 but HRA just announced this change in an Alert dated 03-24-2022).
31 Mar, 2022 619 kb Downloads: 434
MICSA Alert re Revised DOH-4220, Access NY Health Care Application Download
2022-03-24 Revised DOH-4220 Access NY Health Care Application.pdf
The statewide DOH-4220 Medicaid Application form used to apply for non-MAGI Medicaid has been updated (dated 8/2021 but HRA just announced this change in this alert). If an applicant submits an older version of the form, the agency will continue to accept it and not require the applicant to complete the newer application form. However, copies of the OHIP-0112 and DOH-5130 would need to be sent with the older application. It has reminder that as of March 1, 2022, the DOH-5178A will be the only Supplement A accepted with the DOH-4220 application.
31 Mar, 2022 136 kb Downloads: 497
2022-02-04 Changes to the LDSS-3183 Provider or MLTC Plan and Recipient Letter Download
2022-02-04 Changes to LDSS-3183 Provider or MLTC Plan & Recipient Letter.pdf
A Medicaid Recipient who submits medical bills from a Provider to meet the spenddown will receive an OHIP-3183 “Provider/Recipient Letter” indicating which medical expenses are the responsibility of the Recipient (and which the Provider should not bill to Medicaid). When the Recipient is enrolled with a Managed Long Term Care Plan (MLTC), the Recipient and the MLTC will receive an OHIP-0128 “MLTC/Recipient Letter” indicating the amount that the Recipient owes to the MLTC (after deducting the medical expenses/bills from the spenddown). These forms replace the LDSS-3183 form.
17 Feb, 2022 810 kb Downloads: 986
← Prev Next
1 2 3 4 5 6 7 8 9 10


This site provides general information only. This is not legal advice. You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelpny.org. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law. However, we do not guarantee the accuracy of this information. To report a dead link or other website-related problem, please e-mail us.