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.) 

• For those age 65+ or who are disabled or blind, a second form is also required - Supplement A - As of Jan. 2021 the same Supplement A form is used statewide - DOH-5178A (English). NYC applicants should no longer use DOH-4220.

• See more information here about Jan. 2021 changes for NYC applicants regarding Supplement A. 

• This supplement collects information about the applicant's current resources and past resources (for nursing home coverage).   

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:

• Medicaid applicants in the MAGI category (generally those under age 65 or, if younger and disabled,  are not receiving Medicare).  All MAGI applicants should go through the NYS of Health Exchange to apply for Medicaid.  They can contact a Navigator  or Community Health Advocates for assistance.    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.

• Applicants who only want ONLY a Medicare Savings Program (MSP) and not Medicaid too.  They should use the MSP-only application . 

WHAT IF THE APPLICANT CANNOT SIGN THE APPLICATION?

• Spouse or "authorized representative" can sign.   On page 1 Section A of the Application there is space to authorize a representative to apply and renew Medicaid,  discuss the case, and receive notices and other correespondence.  If this section is not completed on the application, a representative can be authorized later using Form DOH-5247, which is an Attachment to  DOH GIS 17 MA/017: Introduction to Form DOH-5247 - Medicaid Authorized Representative Designation/Change Request.    The form is available in several languages at this link.  

• If  neither spouse or authorized representative cans sign the application, use Form DOH-5147, “Submission of Application on Behalf of Applicant”  (Attachment 1 to 17ADM-02 - Asset Verification System) 

DOH APPLICATION - WHERE TO FIND ONLINE

Check here for updates and  changes

English

• Instructions (PDF, 249KB)
• Application (PDF, 11KB)
• Documents Needed When You Apply for Health Insurance (PDF, 163KB)
• Fact Sheet (PDF, 95KB)
• Supplement A   (PDF, 147KB, 2pg.)
• Instructions and Application in One File (PDF, 933KB)

Spanish (Espanol)

• Instrucciones (PDF, 985KB)
• Applicación (PDF, 207KB
• Documentos Necesarios Para Solicitar Seguro médico (PDF, 151KB)
• Hoja de Hechos (PDF, 125KB)
• Suplemento A (PDF, 147KB)

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