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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: 66194
CASA Contact List Download
CASA List (HCSP-3037 English) 12-4-2023.pdf
HRA contacts for the New York City Home Care Services Program CASA offices (updated 12/2023)
18 Mar, 2024 74 kb Downloads: 70635
NYS Medicaid Income and Resource Levels for Past Years - 2001 - 2023 Download
2001_to_2023_NYS_income__resource_level_charts.pdf
Income and Resource levels for Medicaid and other public health programs in NYS for 2001 - 2023. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.
11 Mar, 2024 3.52 mb Downloads: 300417
Medicaid income and resource levels - 2023 (06-06-23) Download
HRA chart March 1 2024.pdf
NYC HRA MAPDR-01 (updated4-5-2023) -- 2023 NYS Income and Resource Standards revised. Note these now use 2023 Federal Poverty Levels so should be the FINAL figures for 2023.
01 Mar, 2024 304 kb Downloads: 443523
HRA MICSA Alert 2015-03-10 Download
2015-03-10 CORRECTED UPDATE Transition coverage from NYSOH to WMS with copy of 2014-06 Original Alert + Transmittal form.pdf
Consumers who have their Medicaid coverage through the New York State of Health (the Marketplace) and who require certain services, must have their case transitioned to WMS (and administered by HRA) in order to receive those services. Amends and references an earlier Alert of June 2014, which is attached to this copy along with the Transmittal form annexted to the June 2014 Alert.
31 Oct, 2023 505 kb Downloads: 5424
NYC HRA Medicaid Alert NY Independent Assessor & Changes to Personal Care (PCS) Assessment Process (5/31/23) Download
2023-05-31 NYIA and Changes to Personal Care Assessment Process.pdf
Explains what consumers seeking Medicaid CDPAP or personal care (PCS) should do in 2 situations: (1) Those who contacted NYIA directly, rather than applying for Immediate Need services and who are not in a Mainstream Medicaid managed care plan (known as "Fee for service (FFS) consumers") - If the NYIA notice says they are not eligible to enroll in MLTC and refers them to the LDSS - they should fax a copy of their NYIA decision notice to the CASA Central Intake unit (718) 636-7784. Case will be assigned to a CASA to use the notice to retrieve the NYIA assessments and then proceed to assess whether eligible for PCS or CDPAPt. But.. if they are a dual eligible and not in a hospice program, or in OPWDD, TBI or NHTD waiver - they are probably only eligible for 8 hours/WEEK of Housekeeping services from CASA. T

(2) If you applied to HRA for Immediate Need services - PCS or CDPAP via eFax (917) 639-0665 - you should not have to contact the HRA Home Care Services Program/CASA after the NYIA assessessments -- because NYIA should notify CASA of the outcome of the assessments directly and they should contact you about next steps to decide if you are eligible for services and if so - what is your plan of care.
03 Jun, 2023 132 kb Downloads: 1062
MAPDR-05 (08/04/2022) List of Managed Care & Managed Long Term Care Plans in NYC Download
2022-08-04 MAPDR-05 Medicaid Managed Care Plans NYC.pdf
This includes a list of all managed care organizations participating in the following types of Medicaid managed care, including ID and code numbers, contact information, and service areas:
* Medicaid Managed Care
* Health and Recovery Plan Managed Care Plans (HARP)
* Managed Long Term Care (MLTC)
* Medicaid Advantage Plus (for dual eligibles, includes MLTC)
* HIV Special Needs Plans (SNP)
* Programs of All-inclusive Care for the Elderly (PACE)
* Fully Integrated Dual Advantage (FIDA) IDD

Updated August 4, 2022 (current on HRA site as of 5/31/23)
31 May, 2023 129 kb Downloads: 61068
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: 12160
Stenson - Sample Notice of Discontinuance for Failure to Return Stenson Renewal Download
Disco notice after Stenson packet not received - 2023 Redacted.pdf
Sample notice of intent to discontinue Medicaid, where former SSI recipient failed to return a renewal package to renew Medicaid as a separate stand-alone benefit from SSI. Redacted.
27 Mar, 2023 2.25 mb Downloads: 748
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: 10420
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