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Applying For and Keeping Medicaid
Form M-11q - Medical Request for Home Care (12-9-014) Download
HCSP-M11q (12-9-2014)Fill-in-able.2.pdf
This is the form used by the New York City Human Resources Administration for doctors to request personal care services through Medicaid for people who are excluded or exempt from Managed Long Term Care. This means it is for people in the OPWDD, TBI or NHTDW waivers, who require only Housekeeping services of up to 8 hours/week or who are under age 21. The form was updated 12/2014. This is a fillable version. THe original PDF can be downloaded at http://www.nyc.gov/html/hra/downloads/pdf/services/micsa/m_11q.pdf.
21 May, 2015 137 kb Downloads: 52031
NYLAG Evelyn Frank Program "Appendix" of documents on MLTC and FIDA for CLE 4/20/15 Download
Appendix Final.pdf
NYLAG Evelyn Frank Program "Appendix" of documents on MLTC and FIDA for CLE 4/20/15 - includes helpful lists of plans, forms, and a Troubleshooting guide.
27 Apr, 2015 2.24 mb Downloads: 19263
Troubleshooting Problems Enrolling in MLTC Plans - Tips for Avoiding Delays and Medicaid Spend-down Problems Download
Troubleshooting - 4-16-15 pp.pdf
Fact sheet written by New York Legal Assistance Group Evelyn Frank Legal Resources Problem addressing common problems encountered by those trying to enroll in MLTC plans, especially where they have a spend-down OR are trying to leave a nursing home. Learn how to avoid delays in enrollment. Includes helpful forms, focused on NYC but can be adapted statewide (updated April 15, 2015)
16 Apr, 2015 2.11 mb Downloads: 27573
HSCP-3047b MLTC Nursing Home Eligibility Determination Cover Sheet Download
HCSP-3047b 1-26-2015.pdf
This is the cover sheet to used for MLTC NHED
13 Apr, 2015 55 kb Downloads: 5689
HCSP-3047a MLTC/PRU Download
HCSP-3047a MLTC-PRU 1-26-15.pdf
This is the MLTC Provider Relations Unit cover sheet to be used
13 Apr, 2015 47 kb Downloads: 3757
MAP-58u List of Medicaid Offices Download
MAP-58u Where To Apply.pdf
This is a list of Medicaid Offices throughout NYC's 5 boroughs, along with a list of MICSA/MAP sites with certified application counselotrs
13 Apr, 2015 377 kb Downloads: 5145
Spousal Refusal Form - Suffolk County Download
Spousal Refusal Form - suffolk county.doc
This is the spousal refusal form for Suffolk County residents
13 Apr, 2015 25 kb Downloads: 14716
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: 3656
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: 3362
Notice of Acceptance of your Medical Assistance Application/Recertification Download
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: 4208
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