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Nassau County Physician's Request for Personal Care Aide and Orders to the Service Agency (May-2016) Download
Physician's Nassau Request for Personal Care Aide Form 517 (Rev. 05-16).pdf
Form for doctor to complete to request Medicaid personal care services and CDPAP from the Nassau County DSS. Revised May 2016.
02 Jan, 2018 218 kb Downloads: 3279
Form to Designate Representative to Request Managed Care/MLTC Appeal or Hearing Download
AUTHORIZATION – Medicaid Managed Care Requests.pdf
Form designed by NYLAG EFLRP for a managed care or MLTC member to designate a family member, attorney or care manager, provider, and/or the ICAN Ombudsprogram to request a plan appeal, fair hearing, or a change in services from a managed care or MLTC plan. This new form is necessary because of changes starting in March 2018. At that time, one must first request an internal plan appeal before requesting a fair hearing. The request must be signed by the plan member unless a representative was previously designated. Signing this form in advance could prevent harmful delays in obtaining a client signature when requesting an appeal- especially if Aid Continuing is needed. See more at http://www.wnylc.com/health/news/80/
27 Dec, 2017 54 kb Downloads: 178
NYS DOH Model Managed Care/MLTC PLAN APPEAL DECISION Reducing Services - Effective March 1, 2018 Download
Final FAD With AC 11-20-17.pdf
The "Final Adverse Determination" template that NYS DOH has provided to Medicaid managed care and MLTC plans for Plan Internal Appeal Decisions affirming a proposed reduction of services. This notice must be used after March 1, 2018, when embers must first request an internal appeal and wait until that is decided before they may request a fair hearing. See more here http://www.wnylc.com/health/news/80/. This "Final Adverse Determination" will advise the member of the right to request a fair hearing with aid continuing.
26 Dec, 2017 679 kb Downloads: 64
NYS DOH Model Managed Care/MLTC Notice Reducing Services - Effective March 1, 2018 Download
Final IAD With AC 11-20-17.pdf
The notice template that NYS DOH has provided to Medicaid managed care and MLTC plans for reducing services after March 1, 2018, on which date members must first request an internal appeal and wait until that is decided before they may request a fair hearing. See more here http://www.wnylc.com/health/news/80/. A sample of a completed notice is posted at http://www.wnylc.com/health/download/644/ - this is an unofficial sample using hypothetical facts, created by NYLAG for illustration.
22 Dec, 2017 738 kb Downloads: 100
Sample of Model Notice of Reduction for Managed Care/MLTC Plans Reducing Services - After 3/1/18 Download
Final IAD With AC 11-20-17 Reduction Sample UNOFFICIAL (NYLAG).pdf
This is an unofficial sample of the model notice template that NYS DOH has given to Managed care and MLTC plans, to use after March 1, 2018. This is the notice for reducing services such as personal care. This sample was created by NYLAG on hypothetical facts. It is not an official sample. The official template is posted at http://www.wnylc.com/health/download/643/.
22 Dec, 2017 691 kb Downloads: 70
MAP-751K Consumer Request to Change Information on File Download
MAP-751K - Consumer request to change info on file.pdf
NYC HRA Form to use any time notifying HRA of change or requesting a change in budgeting. Use for requesting Special Income Disregard for Housing, Spousal Impoverishment budgeting, Pooled Trust budgeting, etc.
04 Dec, 2017 495 kb Downloads: 146
NYLAG Fact Sheet on Applying for Medicaid and Home Care if "Immediate Need" for Personal Care or Consumer-Directed Services Download
Fact Sheet Immediate Need (10-17).pdf
Fact Sheet includes key forms
08 Nov, 2017 558 kb Downloads: 408
State DOH Letter to Former Guildnet Members in LI, estchester 9-29-17 - May ask to Restore Hours Download
2017.10.16 DOH letter Guildnet redacted updated.pdf
Letter from State DOH to people who were in Guildnet MLTC plan in Nassau, Suffolk and Westchester counties and moved to another plan after Mar. 20, 2017. They must call NY Medicaid Choice before Dec. 29, 2017 to ask for their hours to be restored to the amount Guildnet had authorized, if the new plan reduced their hours.
16 Oct, 2017 81 kb Downloads: 252
HRA CDPAP FI List - 6.2017 Download
2017-06-07 HRA CDPAP FI list.pdf
10 Oct, 2017 562 kb Downloads: 431
Letter from North Shore LIJ MLTC Plan to members, dated 9/22/17, that plan closing 12/31/17 Download
North Shore LIJ - Letter to members closing redacted.pdf
Letter from North Shore LIJ MLTC Plan to members, dated 9/22/17, that plan closing 12/31/17. Informs member that unless chooses and enrolls in a different plan before 11/10/17, will be auto-assigned to Centers Plan for Health Living effective 1/1/18.
09 Oct, 2017 2.04 mb Downloads: 1214
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