New Application Form (2010) Used for Medicaid, Child Health Plus and Family Health Plus in New York State

In April 2010, the New York State Department of Health introduced a new 6-page application form to be used for Medicaid, Family Health Plus, and Child Health Plus.   The new form is called the  Access NY Application for public health insurance benefits, also known as form DOH-4220.  

As of June 11, 2010, all local districts in New York State are required to accept the revised DOH-4220.  They must accept it for all applications for Medicaid (including for coverage of long-term care services) and Medicare Savings Program. 

• Before, an earlier version of the Access NY application could be used only for Family Health Plus and Child Health Plus, and a limited group of people applying for Medicaid --  those applicants who were permitted to "attest" to their resources, rather than provide proof.  Because of this limitation, the old Access NY application could not be used for those needing Medicaid community-based long-term care (i.e., home care) or nursing home care. 

• Now, the new DOH-4220 - Access NY Health Care  application can be used for  all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home  (with the addition of the Supplement A form, described below). It can also still be used for Family Health Plus and Child Health Plus. 

• Before, Medicaid applicants seeking long-term care at home or in nursing homes had to use the 16-page green LDSS-2921 - Common Application form.  This 16-page monstrosity (which you may recognize from its green print) has remained substantially the same for years.  It is still used to apply for Public Assistance, Food Stamps, and several other public benefits.  Until now, this was the only application that could be used for those Medicaid applicants who require community-based long-term care or nursing home care.  Because it contained many questions that only applied to Food Stamps and  the other benefits, this was a frustrating application to use.  As of June 11, 2010, there is no longer any reason to use the LDSS-2921 to apply for public health coverage in New York State!  So say goodbye to the "green monster..." 

According to the guidance accompanying the new form, "[t]he Access NY Health Care application was revised to support recent changes in policy which eliminate the resource test for non-SSI-Related Medicaid and Family Health Plus (FHPlus) applicants and the requirement for a personal interview for individuals applying for Medicaid and FHPlus coverage."  See DOH 10 OHIP/ADM-5 at 2.

Applicants who only want a Medicare Savings Program (MSP) may continue to use the MSP-only application (and this is recommended).  Districts must also continue to accept the LDSS-2921, although it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance.

Must Complete Supplement A (DOH-4495A) - For Age 65+, Disabled, or Blind Medicaid Applicants Seeking Home Care or other Long-Term Care Services in the Community or in a Nursing Home

In addition to the revised DOH-4220, there is a new Supplement A  to the application that must be completed for those who are:

(a) disabled, aged or blind (aka DAB), and

(b) in need of long-term care services (including home care). 

This supplement collects information about the applicant's current resources (for those seeking coverage of community-based LTC), and past resources (for nursing home coverage).  If a disabled, aged, or blind applicant does not seek coverage of long-term care, then they do not need to submit the supplement.

If someone is in one of the other Medicaid categories (Singles/Childless Couples [S/CC], Low-Income Families [LIF], or ADC-related), then they do not need to complete the Supplement A, even if they require coverage of short-term home care or nursing home.  However, if such a person is in a nursing home in permanent absence status, then they must apply for the DAB category by using the Supplement.    See this article for more about these different Medicaid categories, and these charts of the different rules for counting income and resources for the different categories.

There are several other online resources relating to the new application:

• Application (DOH-4220)
• Instructions (DOH-4220i)
• Documentation Checklist (DOH-4220b)
• Fact Sheet (DOH-4220c) in English and Spanish
• Access NY Supplement A (DOH-4495A)

The new version of the Application and other documents are available in Spanish.