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NYC HRA MICSA Form MAP-3069b Request for Agency Conference Download
MAP-3069b 2014-05-01 Request for Agency Conference (Non-Edits and Edits combined).pdf
Form renamed in 2014 - formerly known as Request for Reconsideration. 2 versions of form are in this PDF - One is "Non-EDITs" and one is "EDITS."
25 Sep, 2015 73 kb Downloads: 2111
June 10, 2014 HRA MICSA Alert - Submission of Medicaid Application Reconsideration and Reapplication Requests Download
2014-06-10 Submission Application Reconsideration and Reapp Requests.pdf
Notifies outside submitters of changes to HRA’s process for submitting case reconsideration and reapplication requests. Both processes are being standardized across the Medical Insurance and Community Service Administration’s (MICSA’s) Divisions, with the exception of the Nursing Home Division. The reconsideration process is also being renamed as a
Request for an Agency Conference. MICSA’s Reconsideration Request form (MAP-3069b) has been renamed to “Request for an Agency Conference.” It replaces forms MAP-751, MAP-751a, MAP-751h and MAP-751j which
were previously used by various MICSA divisions to accept requests for case reconsiderations.
25 Sep, 2015 60 kb Downloads: 2624
MICSA - Renewal Status File Download
HRA Presentation to MLTC Plans - Renewal Status File.pdf
Presentation from NYC Human Resources Administration to managed care plans on the NYC process for helping managed care plans work with their members to renew Medicaid coverage. Describes renewal timeline in general, as well as special weekly data file (RS) sent to plans to help them identify members who need follow-up. May 14, 2012.
27 Jul, 2015 171 kb Downloads: 1478
NYC HRA MICSA Alert - Renewal Status Information for Medicaid Recipients (9/21/2012) Download
NYC HRA Medicaid Alert - Renewal Status Information for Medicaid Consumers 9-21-12.pdf
reminder that renewal status information is available for Medicaid clients through HRA’s Medicaid Helpline (888-692-6116). This status is available through an Interactive Voice Response System (IVRS) and is updated daily. By entering a client’s social security number and date of birth into IVRS, the caller can obtain information on the status of a client’s renewal:

Whether or not HRA has received a renewal from the client,
Status of HRA’s processing of the renewal and
The eligibility decision if the renewal has been processed.

The system is being upgraded and will, in the next few months, also allow the option of using case number to receive information.
27 Jul, 2015 56 kb Downloads: 3466
MAP-648P NH MA Transmittal 6-2015.pdf
Transmittal form used by HRA Medicaid where the Nursing Home provides HRA with streamlined information about the applicant and the applicant's request for Nursing Home Medicaid coverage.
18 Jun, 2015 147 kb Downloads: 5996
Policy Change for the Start Date of the Transfer of Assets Look Back Period Download
2015-06-02 Policy Change for the Start Date of the Transfer of Assets Look Back Period.pdf
Effectively immediately, the review of assets is limited to the 60-month period immediately preceding the month of institutionalization and application for Medicaid.

For Medicaid recipients who are institutionalized for long-term nursing home care or receiving more than 29 days of rehabilitation services, the look-back period consists of the 60 months preceding the month of institutionalization.
02 Jun, 2015 308 kb Downloads: 1918
Form M-11q - Medical Request for Home Care (12-9-014) Download
HCSP-M11q (12-9-2014)Fill-in-able.2.pdf
This is the form used by the New York City Human Resources Administration for doctors to request personal care services through Medicaid for people who are excluded or exempt from Managed Long Term Care. This means it is for people in the OPWDD, TBI or NHTDW waivers, who require only Housekeeping services of up to 8 hours/week or who are under age 21. The form was updated 12/2014. This is a fillable version. THe original PDF can be downloaded at http://www.nyc.gov/html/hra/downloads/pdf/services/micsa/m_11q.pdf.
21 May, 2015 137 kb Downloads: 41952
Newborn Processing Update Download
2015-05-06 Newborn Processing Update.pdf
Update advised that all newborns born in 2015 submitted via the NYS automated system have been determined processed either automatically or manually
06 May, 2015 191 kb Downloads: 2172
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: 4500
MAP 649F Undercare Download
MAP 649F UnderCare Transmittal.pdf
Undercare Renewal/Follow-up Transmittal
13 Apr, 2015 79 kb Downloads: 1243
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