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Medicaid
NY HRA HCSP MLTC Cover Sheet ("Conversion" Form) -- HCSP 3047a (1/26/2015) replaces HCSP-3022 (9/26/2013) Download
HCSP-3047a MLTC-PRU 1-26-15_150415121649.pdf
"Conversion" Form used in NYC by MLTC, PACE and Medicaid Advantage Plus plans to ask HRA Medicaid program to convert the Medicaid eligibility codes and allow them to enroll an individual who has been determined eligible for Medicaid into MLTC plan. Most commonly needed for people with a spend-down. They may have been found eligible for Medicaid but Medicaid is not activated until spend-down is met OR until HRA has processed this "conversion" to activate Medicaid even if spend-down is not met. Also see MLTC Frequently Asked Questions HCSP Quick Reference- REVISED 11-13-2013.pdf posted on this site
15 Apr, 2015 58 kb Downloads: 2928
MAP 649F Undercare Download
MAP 649F UnderCare Transmittal.pdf
Undercare Renewal/Follow-up Transmittal
13 Apr, 2015 79 kb Downloads: 378
HSCP-3046 Home Care Services Program Cover Sheet Download
HCSP-3046 1-26-2015.pdf
This is the cover sheet to be used for Home Care Services Program
13 Apr, 2015 38 kb Downloads: 542
HCSP 3047 MLTC Cover Sheet Download
HCSP 3047 1-26-2015.pdf
This is the cover sheet to be used for MLTC cases
13 Apr, 2015 44 kb Downloads: 555
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: 1421
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: 547
HCSP 3026 ALP Medicaid Cover Sheet Download
HCSP-3026 HCSP Cover Sheet for ALP-MLTC 1-26-2015.pdf
This is the cover sheet for HRA-ALP Medicaid Cover Sheet
13 Apr, 2015 44 kb Downloads: 528
Notice of Admission/Discharge for the Assisted Living Program Download
HCSP 3027 1-26-2015.pdf
This form is to be mailed to Home Care Services Program once a client is admitted or discharged from Assisted Living Programs
13 Apr, 2015 44 kb Downloads: 680
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: 1056
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: 1794
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