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NYC Medicaid Application Changes!! Revised Medicaid App AND New "Supplement A" form required in All Applications and Must be Signed by Spouse

28 Mar, 2022

Two changes in Medicaid applications:

  1. Statewide DOH-4220 Medicaid Application form has been updated (dated 8/2021 but HRA just announced this change in NYC Medicaid Alert 3/24/22).  If an applicant submits an older version of the DOH-4220, the agency will continue to accept it, and not require the applicant to complete the newer application. In these situations, copies of the OHIP-0112 and DOH-5130 would need to be sent with the older application.

  2. Since March 1, 2022 all NYC Medicaid applications must have the new  Supplement A (DOH 5178A) that replaces the fold form (DOH 4495A). Only DOH 5178A will be accepted as of March 1, 2022.   The new form must be signed by the SPOUSE in all cases, even if using spousal refusal.  See more below on this. 

The 12/2021 HRA alert  announcing the new Supplement A is 2021-12-28 Usage of DOH 5178A Medicaid Application Supplement and DOH 4495A 

The 2020-12-22  HRA Alert is Asset Verification System Expanded to all DAB/SSI Related Submissions --Why this electronic system is expanding is explained below.  

Besides requiring a different Supplement A form, here are the other big changes:


Use DOH-5178A  - the same form that has been used outside of NYC.   DO NOT USE Form DOH-4495A, which has been used in NYC until now.   

The form and the entire Medicaid application can also  be found in various languages at https://www.health.ny.gov/health_care/medicaid/ Click on the dropdown for General Medicaid FAQs, then on the dropdown for "What Do I Need to Apply For Medicaid?"   Beware that this website still has the old 4495A Supp A form posted, along with the new 5178A form.   Here are links to translations of the new 5178A form:  

2.   SUPPLEMENT A  is now required for ALL Applications for people Age 65+, Disabled or Blind - not just those seeking home care or other community-based long term care.

  • Supplement A is NOW  required even for applicants who are not seeking community-based long term care services such as MLTC, the Assisted Living Program, or personal care or CDPAP services for those not required to enroll in MLTC plans such as "immediate need" services.  However, it is not required for applicants for the Medicare Saving Programs only. 

  • WHAT HAPPENS TO "ATTESTATION?"    Since a 2004 ADM,  applicants for community Medicaid who are not seeking community-based long term care services may "attest" to the amount of their resources, rather than document the amount of the resources.  This is still true - they do not have to document that their resources are under the Medicaid limit. See this article.   But, until now in NYC, they also were not required to complete and submit Supplement A.   Now they are.  This is a big change.

    • COVID ALERT - ATTESTATION of RESOURCES -- and INCOME -- MAY BE USED FOR ALL APPLICANTS -- As long as the Public Health Emergency is ongoing, "attestation" of resources is allowed for ALL Medicad applications, including those seeking community-based long term Care.  See info posted here.   The PHE was just extended on Jan. 7, 2021 eff. Jan. 21, 2021.  The extensions are for 3 months so it ends April 21, 2021.   Updates will be posted here

      • Note that attestation is not allowed even during the COVID emergency for citizenship and identity.   See the link above for details on the rules. 

  • SILVER LINING - The plus side of always requiring a Supplement A is that this should prevent the longstanding problem of people being blocked from enrolling in an MLTC plan because their "Medicaid eligibility code" does not entitle them to community-based long term care.  Under the 2004 rules, one must PROVE and not just attest to the amount of resources to be able to enroll in MLTC or obtain other long-term care services. See this article.   A Supplement A has always been required to qualify for those services.  The lack of a Supplement A has always been Number 1 in identifying and troubleshooting barriers to MLTC enrollment. See Troubleshooting Problems Enrolling in MLTC Plans - Tips for Solving Medicaid Spend-down Problems and Barriers that Block Enrollment

3.    SPOUSES MUST SIGN the new SUPPLEMENT A, even if using SPOUSAL REFUSAL or even if NOT APPLYING.  

  • The SPOUSE of a married applicant MUST sign the new Supplement A.   This is required even if the spouse is not applying, or even if the applicant is using spousal refusal.   This is why NYC is switching to the new form - it has a space for the spouse to sign.


  • Since this is a change, HRA administrators told NYLAG and other advocates at a meeting on January 7, 2021 that they will not DENY applications using the old Supplement A.   

    • If a married applicant uses the old Supplement A, HRA will "defer" the application and ask for the new form to be submitted signed by the spouse and the applicant. 

    • If a single applicant uses the old Supplement A, HRA says it will accept it, at least for now.   This is because the old and new forms are only different in that the new one has a signature line for the spouse.  

    • In HRA Medicaid Alert dated 12-28-21, the old form (DOH 4495A) will be accepted provided it is accompanied by DOH 5148 or DOH 5149.  

    • However, as of March 1, 2022, only the DOH-5178A will be accepted.


Since 2017, the State has required local Medicaid programs to implement an electronic Asset Verification System (AVS) that verifies accounts held in banking institutions or real property owned by the applicant.  See 17ADM-02 - Asset Verification System  with attachments here.  NYC HRA has implemented this gradually - first in Nursing Homes in 2018  and then in hospital applications in 2019.  NYC is now implementing it in community applications.  

NYLAG suspects that HRA has been under pressure to expand AVS for years, but that the impending new LOOKBACK for community-based long term care is lighting a fire.  See information here about the new lookback, which will eventually be 30 months, that is scheduled to begin April 1, 2021.  AVS will be of some help in the lookback, as HRA will have access to bank account and real property information, so submission of those records will hopefully not be required.  (Of course applicants and their representatives still should review them as any large withdrawals or payments must be explained to show they are not transfers of assets, or to show that deposits do not reflect unreported income or accounts).   AVS does not include investment accounts, annuities, or IRA's, however.  

Where Can You Find Other HRA Medicaid Alerts?

Unfortunately, HRA does not post these for the general public.  Organizations registered as "authorized submitters" of Medicaid applications - also known as "C-REP" submitters -  receive emails alerting them to these alerts that are posted on the  MAP Authorized Resource Center (MARC) - NYC.gov.  For your organization to become an authorized submitter its employees  need to sign up for attend trainings on Medicaid eligibility and applications.  See information on the MARC website.

NYLAG re-posts Medicaid Alerts of general interest on this website -- in this article Medicaid Alerts & Other Protocols published by the NYC HRA Medical Insurance and Community Services Administration (MICSA)  and in applicable articles.  

Information about the new Supplement A requirements is also posted in this article -  Applying for Medicaid Personal Care or CDPAP Services in New York City - 2021 Changes.

 Sign up here to receive periodic e-mail updates from the Evelyn Frank Legal Resources Program (select TOPIC:  Elder Law (Medicaid, long-term care) and any other topics you are interested in.  See past e-lerts here

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; Asset Verification System Supplement A Medicaid application DOH-5178A attestation; : DOH-4495A

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