New Application Form (2010, updated 3/2015) Used for Medicaid, Child Health Plus and Family Health Plus in New York State

Since  2010, the New York State Department of Health has used a uniform 6-page application form to be used for Medicaid -- called the  Access NY Application or form DOH-4220.  Download the form at this link - scroll down to Application for Non-MAGI.   As of October 2016, the form was last updated in March 2015. 

As of January 1, 2014, the DOH-4220 application should not be used for Medicaid applicants in the MAGI category.  All MAGI applicants should go through the NYS Health Benefits Exchange to apply for Medicaid.

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 fr Working People with Disabilities

According to the guidance accompanying the new form, "[t]he Access NY Health Care application was revised to support recent changes in policy which eliminate the resource test for non-SSI-Related Medicaid and Family Health Plus (FHPlus) applicants and the requirement for a personal interview for individuals applying for Medicaid and FHPlus coverage."  See DOH 10 OHIP/ADM-5 at 2.

Applicants who only want a Medicare Savings Program (MSP) may continue to use the MSP-only application (and this is recommended).  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.

Must Complete Supplement A (DOH-4495A) - For Age 65+, Disabled, or Blind Medicaid Applicants Seeking Home Care or other Long-Term Care Services in the Community or in a Nursing Home

In addition to the revised DOH-4220, there is a new Supplement to the application that must be completed for those who are:

(a) disabled, aged or blind (aka DAB), and

(b) in need of long-term care services (including home care). 

This supplement collects information about the applicant's current resources (for those seeking coverage of community-based LTC), and past resources (for nursing home coverage).  If a disabled, aged, or blind applicant does not seek coverage of long-term care, then they do not need to submit the supplement.

If someone is in one of the other Medicaid categories (Singles/Childless Couples [S/CC], Low-Income Families [LIF], or ADC-related), then they do not need to complete the Supplement A, even if they require coverage of short-term home care or nursing home.  However, if such a person is in a nursing home in permanent absence status, then they must apply for the DAB category by using the Supplement.    See this article for more about these different Medicaid categories, and these charts of the different rules for counting income and resources for the different categories.

There are several other online resources relating to the new application  - check here for changes



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


Article ID: 119
Last updated: 17 Oct, 2016
Revision: 4
Child Health Plus -> New Application Form (2010, updated 3/2015) Used for Medicaid, Child Health Plus and Family Health Plus in New York State