NYS EPIC Application (DOH-5080)(May 2015) Fill-able version. This version was supposed to be phased out in 2020, replaced by a new version posted on EPIC website https://www.health.ny.gov/forms/doh-5080.pdf. However, DOH indicated it will accept the 2015 version. An April 29th letter signed by Donna Frescatore, of the NYS Dept of Health Office of Health Insurance Programs: "We understand your concerns regarding COVID-19 and ensuring that seniors get access to needed medications. As such, we will continue to accept the prior version of the
EPIC application until after the emergency period and will also work closely with seniors to obtain the information needed so the EPIC program staff can facilitate their applications for the Extra Help program."

Training materials written and updated by various staff at the Evelyn Frank Legal Resources program since 2005. This outline is updated for the 2019 enrollment period (which begins 10/15/18 and ends 12/7/18) and covers the basic design of the Medicare Part D prescription drug benefit, the Extra Help subsidy for low income beneficiaries, how Part D works with other types of drug coverage including EPIC and Medicaid, and how to get Extra Help by using the Medicare Savings Program.

PowerPoint presented with Webinar Presentation, recorded on April 13, 2016, by Evelyn Frank Legal Resources Program.
View recording at https://www.youtube.com/watch?v=u76iY5ycUjI&feature=youtu.be

EPIC renewal form for 2013

Letter to EPIC members describing the changes for 2013

Sample of Claims History Obtained from EPIC to show Amount of Expenses Paid by EPIC - Can be used to Meet Spend-down.

This document is in WORD so that it can be adapted easily to an individual case. Use this to submit the EPIC Claims History along with the Medicaid application. Bills paid by EPIC can be used to meet the spend-down. http://nyhealth.gov/health_care/medicaid/excess_income.htm#past_bills which states:

"Bills paid by EPIC or ADAP in the three months before the month in which you applied for Medicaid may be used to meet your excess income."

Adapts the official NYS Office of Court Administration HIPAA form -- http://www.health.state.ny.us/forms/doh-2557.pdf for EPIC

This letter was sent in late September 2010 to new EPIC members and those currently exempt from joining Part D (union/retiree coverage, MA plan without drug coverage, and no Medicare Part A or B). In bold type the letter states that EPIC members who are exempt from Part D are not affected by this policy change.