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"Coverage Determination Notice" - Official Template for NYS MAP Plans using Integrated Appeal process Download
ICDN_NY_MAP - Coverage Determination Notice 11.15.19.docx
Official template for NYS Medicaid Advantage Plus plans to deny an initial request for prior approval for a service or for an increase in a service. See article at http://www.wnylc.com/health/entry/225/. This form is from a zipped file of MAP notice templates posted at https://www.cms.gov/files/zip/nyiagintegratedbenenotices.zip.
01 Apr, 2021 64 kb Downloads: 33
"Appeal Decision Notice" for NYS Medicaid Advantage Plus plans (MAP) Download
AppealDenial_NY_MAP FINAL 11.15.19.docx
State template for final decisions after the internal plan appeal in the new integrated appeal procedure that began in 2020 for MAP plans. See article at http://www.wnylc.com/health/entry/225/. This form is from a zipped file of MAP notice templates posted at https://www.cms.gov/files/zip/nyiagintegratedbenenotices.zip.
01 Apr, 2021 81 kb Downloads: 45
MAP-751W Consumer/Provider Request to Change Information on File (3-25-21) Download
MAP-751W Request to Change Information (3-25-21).pdf
NYC HRA Form to use to notify HRA of corrections or changes such as to close case, combine case, add/remove individual, notify of death, change in immigration status, upgrade eligibility, request MSP evaluation, budgeting changes, pooled trust budgeting and add/remove third party health insurance. Note that a change in demographic information (such as name, address, phone number) should be reported in a different form: MAP-751K. The MAP-751W is also posted at https://www1.nyc.gov/site/hra/help/health-assistance.page in other languages.
31 Mar, 2021 297 kb Downloads: 313
MAP-751k (Spanish)(3-15-2021) Download
MAP-751K (3-15-2021)(Spanish).pdf
NYC HRA Form to use to notify HRA of change in name, address, mailing address, date of birth, SSN, and to request mail in different languages or formats for disability (Updated 3-15-2021) NOTE: The 751k is no longer used to request a change in budgeting. Instead use new form MAP-751W available at https://www1.nyc.gov/site/hra/help/health-assistance.page in various languages.
31 Mar, 2021 75 kb Downloads: 119
MAP-751K Consumer Request to Change Information on File (3-15-21) Download
MAP-751K (3-15-2021)(English).pdf
NYC HRA Form to use to notify HRA of change in name, address, mailing address, date of birth, SSN, and to request mail in different languages or formats for disability (Updated 3-15-21). The MAP-751K is also posted at https://www1.nyc.gov/site/hra/help/health-assistance.page in other languages. Upon completion, it can be faxed to HRA using 917-639-0837. (Updated 2-18-2021) NOTE: The 751k is no longer used to request a change in budgeting. For that, use new form MAP-751W posted at the same webpage as above for the 751K.
31 Mar, 2021 74 kb Downloads: 4820
Most downloaded
Medicaid income and resource levels - 2021 Download
2021-01-12 HRA Medicaid Chart.pdf
NYC HRA Form MAPDR-01
2021 NYS Income and Resource Standards and Federal Poverty Levels (FPL)
Dated 1-12-2021
17 Jan, 2021 2.37 mb Downloads: 417669
NYS Medicaid Income and Resource Levels for Past Years - 2001 - 2020 Download
2001_to_2020_NYS_income__resource_level_charts.pdf
Income and Resource levels for Medicaid and other public health programs in NYS for 2001 - 2020. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.
10 Jan, 2021 2.65 mb Downloads: 292918
Medicaid Eligibility in 2014 Download
Understanding MAGI & the Marketplace.pdf
Training provides framework for understanding the changes to Medicaid effective 2014, including: new categories, new income levels, new budgeting and new benefits.
15 Nov, 2013 1.56 mb Downloads: 269462
Supplemental Needs Trusts Outline for Advocates - Including Impact on Various Benefits of Transfers of Lump Sums into SNT's Download
NYLAG SNT Outline 1-13-19 FINAL.pdf
Training Outline for Advocates on Supplemental Needs Trusts (SNTs) (including individual and pooled), and the affect of SNTs on various public benefit programs. (updated 1-9-2019). Update includes new section on Veteran's Pension benefits, expanded information on Temporary/Public cash assistance and HASA, 2018 changes in the SSA POMS regarding expenses SNT's may pay; ABLE accounts as alternative to SNTs and updated section on Public Housing and Section 8 and SNTs.
13 Jan, 2019 1.47 mb Downloads: 204934
Directory of MICSA (NYC Medicaid) Contacts - August 2013 Download
MICSA Directory (08-06-13).pdf
NYC Medicaid office moved from 330 West 34th Street to 785 Atlantic Avenue, Brooklyn NY 11238 in May 2013. Contact numbers at that office listed in this document.
15 Aug, 2013 3.07 mb Downloads: 202452

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