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NYS Medicaid Income and Resource Levels for Past Years - 2001 - 2019 Download
2001_to_2019_NYS_income__resource_level_charts.pdf
Income and Resource levels for Medicaid and other public health programs in NYS for 2001 - 2019. Includes Medicare Savings Programs, Family Health Plus, Child Health Plus, Spousal Impoverishment levels, MBI-WPD, etc.
19 May, 2020 3.71 mb Downloads: 287280
NYC HRA Medicaid Alert April 16, 2020 Download
2020-04-16 Fax Submissions to MICSA & HCSP.pdf
HRA Alert with fax numbers for authorized submitters and providers to fax applications and other requests to various HRA Medicaid units - during the COVID-19 epidemic. The fax number posted at https://www1.nyc.gov/site/hra/locations/medicaid-locations.page for the PUBLIC to fax applications is not on this list - it is 917-639-0732
17 Apr, 2020 172 kb Downloads: 221
HRA Medicaid alert 2020-04-06 Authorized Client Representatives - COVID-19 Application Submissions by E-fax Download
2020-04-06 MICSA Alert c-rep applicaitons e-fax.pdf
Establishes new e-Fax number for "C-Rep" Authorized client Representatives for Medicaid applications not submitted electronically by EDITS. e-Fax 917-639-0731.

Requests ONE application be submitted per fax, with cover page listing all documents attached. Says not for MLTC application submissions (unclear what this means)
13 Apr, 2020 129 kb Downloads: 152
Medicaid income and resource levels - 2020 Download
2020 HRA chart medicaid 2019-12-31.pdf
NYC HRA Form MAPDR-01
2020 NYS Income and Resource Standards and Federal Poverty Levels (FPL)
Dated 12-31-2019
26 Feb, 2020 232 kb Downloads: 408813
Sample NYC Stenson Notice (revised 2015) with Renewal form (revised 2013) Download
MAP-909 (English) Stenson Notice (1-15-2015) with 3074 form (10-16-2013).pdf
Notice used in NYC to advise a former SSI recipient of the procedure to have continuing Medicaid eligibility determined, with Renewal form to be completed and returned (MAP 909 and MAP 3074)
15 Jan, 2020 2.02 mb Downloads: 5369
MAPDR-21 - Medicaid Managed Care Exemptions and Exclusions Download
MAPDR-21 Medicaid Managed Care Exemptions and Exclusions 9-28-2015.pdf
This documents lists which categories of beneficiaries are exempt or excluded from the requirement of joining a mainstream medicaid managed care plan. Rev'd 9/28/15
03 Jan, 2020 71 kb Downloads: 10437
MAP-751K Consumer Request to Change Information on File Download
MAP-751K - Consumer request to change info on file (2018-05-14) English.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. (5/14/2018)
09 Nov, 2019 45 kb Downloads: 3068
Consumer Directed Personal Assistance Application - NYC HRA Home Care Services Program Download
M-13d - CDPAP Application (2018-04) Fill-able.pdf
From M13d, rev. 4/2018, which a NYC consumer or person directing his/her care must complete and have approved by the CASA in order to enroll in the Consumer Directed Personal Assistance Program (CDPAP). Made fill-in-able by NYLAG EFLRP.
22 Oct, 2019 151 kb Downloads: 3761
NYC HRA Explanation of Medicaid Pay-In Program for Spend-down updated 2019-03-22 (Bengali) Download
MAP-931a (Bengali) Optional Pay-in Program for Individuals with Surplus Income 2019-03-22.pdf
NYC HRA Explanation of Medicaid Pay-In Program for Spend-down updated 2019-03-22 (Bengali) to include State fact sheet on pooled trusts also available at http//health.ny.gov/health_care/Medicaid/index.htm#trusts. Note that the NYS Bar Association Elder Law Section has asked DOH to revise the pooled trust fact sheet to make it more clear. Other languages now posted on this site
24 Aug, 2019 145 kb Downloads: 566
MAP-931A Explanation of Medicaid Pay-In Program (English) (updated 2013-03-22) Download
MAP-931a (English) 2019-03-22.pdf
NYC HRA Explanation of Medicaid Pay-In Program for Spend-down updated 2019-03-22 (English) to include State fact sheet on pooled trusts also available at http//health.ny.gov/health_care/Medicaid/index.htm#trusts. Note that the NYS Bar Association Elder Law Section has asked DOH to revise the pooled trust fact sheet to make it more clear. Other languages now posted on this site
24 Aug, 2019 59 kb Downloads: 8458
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