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UPDATED: JANUARY 2012

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OTHER ELIGIBILITY REQUIREMENTS APPLICATION, CERTIFICATION AND RENEWAL

NEW APPLICATION

Description: An application for Medicaid, Family Health Plus, Child Health Plus, the Family Planning Benefit Program, Medicare Savings Program, the Medicaid Cancer Treatment Program: Breast, Cervical, Colorectal, and Prostate Cancer Treatment Programs, and/or Medicaid Buy-In Program for Working People With Disabilities (MBI-WPD) is a written, dated form prescribed by the State. The applicant, his/her authorized representative or, when the applicant is incompetent or incapacitated, by someone acting on behalf of the A/R must sign it.

Policy: An applicant requesting Medicaid, Family Health Plus, the Family Planning Benefit Program, Medicare Savings Program, Medicaid Cancer Treatment Program: Breast, Cervical, Colorectal and Prostate Cancer Treatment Programs and/or Medicaid Buy-In Program for Working People With Disabilities may make application by dropping off an application to an LDSS or by mailing the application to the local district, facilitated enroller or other designated entity.

NOTE: Access NY Health Care applications and Supplement A can be printed from the internet at:

http://www.health.state.ny.us/nysdoh/fhplus/application.htm.

However, such applications may not be completed or submitted online.

Applicants may request assistance in understanding the Medicaid program or completing an application.

As of June 11, 2010, ALL applicants applying for Medicaid only, including applicants seeking coverage of long-term care services or nursing home care will make application for benefits on the Access NY Health Care application (DOH-4220). However, if an LDSS receives the LDSS-2921 application for a Medicaid-only applicant, they must accept the application and cannot require that the DOH-4220 or the DOH-4495A also be completed. The LDSS-2921 should continue to be used when an individual is applying for Medicaid and another program, such as Temporary Assistance, Child Care Assistance and/or Food Stamps. Individuals who are applying for the Family Planning Benefit Program (FPBP) should use the DOH-4282, Family Planning Benefit Program Application Form. The DOH-4286 (Instructions for the Family Planning Benefit Program Application) provides guidance for completing the DOH-4282. These forms may be accessed on the DOH website, at the LDSS, or at FPBP providers. Individuals who are applying for the Medicare Savings Program (MSP) should use the DOH-4328.

(MRG)