The Access NY Supplement A form (also known as DOH-4495A or doh 4495a ny) is an addendum to the main Access NY Health Care application. New York State requires this form when you apply for Medicaid programs that cover long-term care services. These include nursing home care, home care, adult day care, and community-based programs for people with disabilities.
You must submit the Supplement A along with your main NY Medicaid application if you are applying for any of the following programs:
You do not need this form if you are applying only for standard Medicaid or SNAP benefits. This supplement applies specifically to individuals with chronic illness, physical disability, or cognitive impairment who require ongoing care support.
Before you begin, gather the following documents and information:
The 60-month look-back period for asset transfers is one of the most important parts of this form. Any gifts or property transfers within five years of applying may affect your Medicaid eligibility date.
Submit the completed form to your local Department of Social Services (DSS) office. Acceptable submission methods include mail, in-person delivery, and online through the NY State of Health portal. Always keep a copy of your signed form and all supporting documents for your records.
For individuals who need additional documentation, review the long-term care application form for related program requirements.
| Question | Answer |
|---|---|
| Form Name | Access Ny Supplement A Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | access ny, access ny supplement a, doh 4495a spanish version, supplement a form medicaid |