NYS Medicaid Application Form (updated 2021) for Age 65+ or Disabled or Blind - New Supp A NYC 2021

Since 2010, the New York State Department of Health Medicaid application form is called the  Access NY Application or Health Insurance Application or form DOH-4220. Download the most recent version of the form at this link. (As of 02-06-24, the form was last updated in January 2023.) 

All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled) (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program for Working People with Disabilities.  Districts must also continue to accept the LDSS-2921, although it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance.

The DOH-4220 - Access NY Health Care  application can be used for  all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home (with the addition of the Supplement A form, described below). 

YOU CAN USE ONE OF THREE VERSIONS OF THE DOH-4220:

There are different version of the statewide DOH-4220 Medicaid Application form, which applicants use to apply for non-MAGI Medicaid. The Medical Assistance Program (MAP) accepts the DOH-4220 form versions dated: 1/23, 8/21, and 3/15. However, if an applicant is using one of the two older version of the DOH-4220 form (dated 8/21 or 3/15), the applicant must also submit the OHIP-0112 and DOH-5130. Meanwhile, it is important that Medicaid providers use only one version of the form per applicant; it is not permitted for providers to submit an application for an applicant that contains pages from different version of the DOH-4220.

DO NOT USE THE DOH-4220 FOR:

WHAT IF THE APPLICANT CANNOT SIGN THE APPLICATION?

DOH APPLICATION - WHERE TO FIND ONLINE

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This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG



Article ID: 119
Last updated: 06 Feb, 2024
Revision: 4
Child Health Plus -> NYS Medicaid Application Form (updated 2021) for Age 65+ or Disabled or Blind - New Supp A NYC 2021
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