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NYS Medicaid Income and Resource Levels for Past Years - 2001 - 2021 Download
Income and Resource levels for Medicaid and other public health programs in NYS for 2001 - 2021. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.
10 Mar, 2022 3.26 mb Downloads: 297038
Form DOH-5143 - Medical Disability Form - replaces LDSS-486T (08-2018) Download
DOH-5143 Replaces 486T Medical Report for Determination of Disability (08-2018) - FILLABLE.pdf
Form to be signed by treating physician to certify disability as required for approval of Supplemental Needs Trusts, or for Medicaid based on disability where the Social Security Administration has not determined disability. Replaces Form 486T. See HRA MICSA Alert Dec. 20, 2021, available at http://www.wnylc.com/health/fdownload/799/
22 Dec, 2021 50 kb Downloads: 1635
DOH Model 30-Day Notice of Intent to Disenroll from MLTC Plan for Long Term Nursing Home Stay Download
Plan Intent to disenroll Batch Process_07.01.21_Final.pdf
Notice sent by MLTC plans to members of intent to disenroll because of a Long Term Nursing Home Stay - a stay of more than 3 months, where the member has been approved for Nursing Home Medicaid. Notice sent 30 days prior to disenrolllment. A second notice is sent by NY Medicaid Choice 10 days prior to disenrollment, posted with more info in this article http://www.wnylc.com/health/entry/199/
20 Oct, 2021 83 kb Downloads: 480
"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: 738
"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: 762
Sample Notice to MLTC Members Explaining new Lock-In Rule that Starts Dec. 1, 2020 Download
Lock in notice 2020-10 redacted.pdf
Sample Notice sent to MLTC Members in October 2020 Explaining new Lock-In Rule that Starts Dec. 1, 2020. This notice is from VNS Choice, but each plan would be sending their own versiono n their letterhead, using State-approved language.
29 Oct, 2020 1.95 mb Downloads: 1222
MLTC Member Handbook Amendment - New "Lock-in" Download
MLTC Partial Lock In Member Handbook.pdf
Language that Plans must add to their MLTC Member Handbooks to explain the new Lock-in that begins Dec 1, 2020 for people enrolling in a plan after that date, whether a first-time enrollee or changing plans on or after that date
29 Oct, 2020 18 kb Downloads: 1118
NYSDOH Dear Administrator Letter to Nursing Homes 6-11-2020 re Disenrollment from MLTC of Nursing Home Residents Download
DAL Updated NHBL 6.11.20.pdf
NYSDOH Dear Administrator Letter (DAL) to Nursing Homes 6/11/2020 revising the one issued 1-21-2020 (posted at http://www.wnylc.com/health/download/718). DAL advising them that residents who are members of MLTC plans will be disenrolled after 3 months in NY. The letter should eventually be posted with other DAL letters here - https://www.health.ny.gov/professionals/nursing_home_administrator/letters.htm#dal. See discussion in this article http://www.wnylc.com/health/entry/199/
28 Jun, 2020 181 kb Downloads: 1374
EPIC Application (DOH-5080)(May 2015) Fill-able version Download
EPIC Application 2015-05 fill-able.pdf
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."
01 May, 2020 173 kb Downloads: 3091
NYS DOH Covid19 Guidance: Medicaid Eligibility & Enrollment Download
DOH COVID-19 Medicaid Eligibility Guidance.pdf
Guidance to local Departments of Social Services regarding streamlining Medicaid applications and enrollment, and suspending discontinuance actions during the pandemic emergency
29 Mar, 2020 1.93 mb Downloads: 2863
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