Since 2010, the New York State Department of Health Medicaid application form is called the Access NY Application or form DOH-4220. Download the form at this link (As of January 2021, the form was last updated in March 2015).
- 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 fr 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.j (with the addition of the Supplement A form, described below).
DO NOT USE THE DOH-4220 FOR:
WHAT IF THE APPLICANT CANNOT SIGN THE APPLICATION?
DOH APPLICATION – WHERE TO FIND ONLINE
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.