Form Doh 5178A – Fill Out and Use This PDF

Supplement A

(Supplement to Access NY Health Care Application DOH-4220)

This Supplement must be completed if anyone who is applying is:

•Age 65 or older

•Certiied blind or certiied disabled (of any age)

•Not certiied disabled but chronically ill

•Institutionalized and applying for coverage of nursing home care. This includes care in a hospital that is equivalent to nursing home care.

Note: If you are applying for the Medicare Savings Program (MSP) only, this Supplement does not need to be completed.

INSTRUCTIONS:

•Sections A through E must be completed and this Supplement must be signed.

•If you or anyone in your household is applying for coverage of nursing home care, you must also complete sections F through G.

A. Applicant and Spouse Information

1. Applicant(s) this Supplement is being completed for:

			Marital	Social Security			If Deceased, List
Legal Last Name	Legal First Name	MI	Status	Number	Date of Birth		Date of Death
					/	/	/	/
					/	/	/	/
Is a person named above:
• Chronically ill?							Yes	No

(Examples of chronically ill would be unable to work for at least 12 months because of an illness or injury, or having an illness or disabling impairment that has lasted or is expected to last for 12 months.)

•	Certiied Blind by the Commission for the Blind and Visually Handicapped?	Yes	No
	(If yes, send proof.)
•	Interested in applying for the MBI-WPD program if disabled and working?	Yes	No

The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) program offers Medicaid coverage to people who are disabled, working, and at least 16 years old but not yet 65 years old. The program allows higher income levels than the regular Medicaid program so working people with disabilities can earn more and keep their Medicaid coverage.

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If an applicant is living in a long-term care facility/nursing home, adult home, or assisted living facility, provide the following information.

Name of Applicant who is in Facility	Name of Facility	Date Admitted		Telephone Number
		/	/	(	)	-
Street Address	City	State		Zip Code
Applicant’s Previous Address	City	State		Zip Code

If the above previous address was also a facility or adult home, list the address prior to admission below.

Applicant’s Second Previous Address		City				State	Zip Code
2. Applicant’s Spouse: (if not listed above)
Legal Last Name				Legal First Name			MI
Maiden Name or Other Name Known By:				Social Security Number			Date of Birth
							/	/
Street Address (if in a facility, list spouse’s address prior to being admitted to facility)
City						State	Zip Code
Is the applicant’s spouse living in a long-term care facility/nursing home?								Yes	No
If yes, provide the following information:
Name of Facility				Date Admitted			Telephone Number
				/	/		(	)	-
Street Address		City				State	Zip Code
Is the applicant’s spouse deceased?	Yes	No	If yes, what is the date of death? ____ / ____ / ____

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B. What Care and Services are you Applying for? (check the box that applies)

You are applying for Medicaid coverage but not coverage of community-based long-term care services. You may attest to the amount of your resources. You are not required to submit documentation of your resources at this time. If a computer match shows something different than what you reported, you may be asked to submit proof at a later date.

This coverage does not include nursing home care, home care or any of the community-based long-term care services listed below.*

You are applying for coverage of community-based long-term care services. Documentation of the current amount of your resources is required. However, you only need to submit documentation for certain resources at this time. See “Documentation Requirements” below for a list of these resources.

Note: Some examples of home and community-based programs that provide waiver and other services are Traumatic Brain Injury Program and Nursing Home Transition and Diversion Program.

You are institutionalized and applying for coverage of nursing home care. Documentation of your resources for the past 60 months is required. However, you only need to submit documentation for certain resources at this time. See “Documentation Requirements” below for a list of these resources.

*You may be eligible for short-term rehabilitation services. Short-term rehabilitation services include one commencement/admission in a 12-month period of up to 29 consecutive days of nursing home care and/or certiied home health care.

DOCUMENTATION REQUIREMENTS

If you are requesting coverage for community-based long-term care services or nursing home care, provide documentation for the time period indicated above for all of the following resources, if applicable.

• Life insurance policy;	• Burial agreement or fund;
• Securities, stocks, bonds, and mutual funds;	• Trust document and accounts.
• Annuities;

You do not need to send proof of any other resources at this time. This is because other resources may be veriied through computer matches. If the resources you report do not match our records or cannot be veriied through our records, we may ask you to submit proof of those other resources at a later date.

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C. Resources/Assets

INSTRUCTIONS FOR SECTIONS 1 THROUGH 8:

•List all resources currently owned by you and/or your spouse/parent(s), including custodial accounts.

•Check the “NONE” box if you and/or your spouse/parent(s) do not own any of those resources.

•If applying for coverage of nursing home care, also list any accounts CLOSED in the past 60 months; include the balance at closing and provide an explanation of where the balance was transferred to or how it was spent. On a separate sheet of paper, provide an explanation of each transaction of $2,000 or more.

Note: Medicaid retains the right to review all transactions made during the transfer look-back period.

1. Checking/Savings/Credit Union Accounts/Certiicates of Deposits (CDs):							NONE
			Current		Closed Accounts
			Account			Balance
Bank Name	Account Number	Name of Owner(s)	Balance	Date Closed		at Closing
			$	/	/	$
			$	/	/	$
			$	/	/	$
			$	/	/	$
			$	/	/	$
			$	/	/	$
			$	/	/	$
			$	/	/	$
			$	/	/	$

2. Retirement Accounts (Deferred Compensation, IRA and/or Keogh):										NONE
					Current		Closed Accounts
					Account				Balance
Institution Name	Account Number	Name of Owner(s)	Pay Out		Balance	Date Closed			at Closing
			Yes	No	$	/	/	$
			Yes	No	$	/	/	$
			Yes	No	$	/	/	$
			Yes	No	$	/	/	$

3. Annuities, Stocks, Bonds, Mutual Funds:									NONE
						Closed Accounts
Institution/Company				Current	Date Closed			Value
Name	Account Number	Name of Owner(s)	Date Purchased	Value	or Sold			at Closing
				$	/	/	$
				$	/	/	$
				$	/	/	$
				$	/	/	$
				$	/	/	$
				$	/	/	$
				$	/	/	$

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4. Life Insurance Policies:

NONE

Cancelled Policies

Current

Current

Date

Cash Out

Insurance Company

Policy Number

Name of Owner(s)

Cash Value

Face Value

Cancelled

Value

$

$

/

/

$

$

$

/

/

$

$

$

/

/

$

$

$

/

/

$

$

$

/

/

$

5. Burial Assets/Burial Contracts: (Include copies):

NONE

a. Do you and/or your spouse have a pre-paid funeral agreement for you or anyone else in your family?

Yes

No

b. Do you and/or your spouse have a burial space or plot for you or anyone else in your family?

Yes

No

c. Do you and/or your spouse have money in a bank account set aside for a burial fund?

Yes

No

If yes, in what account(s) is your and/or your spouse’s burial fund?

Bank Name and Account Number

Name of Owner(s)

Value

$

$

$

d. Do you have life insurance to be used as your burial fund?

Yes

No

If yes, what is your policy number(s)?

If yes, is the full cash value to be used for your burial expenses?

Yes

No

e. Does your spouse have life insurance to be used as a burial fund?

Yes

No

If yes, what is the policy number(s)?

If yes, is the full cash value to be used for burial expenses?

Yes

No

6.Trust Accounts: If you and/or your spouse created or are the beneiciary of a trust,

submit a copy of the trust, including the current schedule of trust assets.

NONE

Name of Trust

Grantor

Trustee(s)

Assets

Beneiciary

Income

$

$

$

$

$

$

$

$

7. Vehicle(s): List all cars, trucks and vans. List all recreational vehicles, including campers,

snowmobiles, boats and motorcycles.

NONE

Name of Owner(s)

Year/Make/Model

Fair Market Value

Amount Owed

In use?

Date Sold

$

Yes

No

/

/

$

Yes

No

/

/

$

Yes

No

/

/

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8. List Any Other Resources:

Resource Type	Name of Owner(s)	Value
		$
		$
		$
		$
		$
		$

D. Homestead

1.	Do you and/or your spouse own or have a legal interest in your home, including a life estate?				Yes	No
2.	If you are in a medical facility and own your home, do you intend to return to your home?				Yes	No
	If no, is anyone living in the home?				Yes	No
	Who is living in the home?
	How is this person related to you and/or your spouse?
	If you and/or your spouse’s child (of any age) is living in the home, is the child disabled?				Yes	No
	Note: If there is a legal impediment that prevents you from selling this property, the property
	is not counted in determining Medicaid eligibility. Send proof of legal impediment.

3.Equity Value in Home:

If you own your home, what is the equity value in your home? $

Note: Equity value is the fair market value less any outstanding liens, mortgages, etc.

E.Real Property (other than your home)

Do you and/or your spouse own or have a legal interest in any other real property? (Check any that apply)					Yes	No
Rental Property	Vacation Property	Time Share	Vacant Land	Other Property Rights
				(In or outside of New York State)

If yes, provide the following information:

Name and Address of Owner(s)	Address of Property	Type of Ownership (Check one)			Equity value
		Individual	Joint tenancy	Life estate	$
		Individual	Joint tenancy	Life estate	$
		Individual	Joint tenancy	Life estate	$
		Individual	Joint tenancy	Life estate	$

STOP HERE unless you or anyone in your household is institutionalized and applying for coverage of nursing home care. However, Section I of this document MUST be signed.

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F. Asset Transfers

1. Transfers
a. In the last 60 months, did you, your spouse, or someone on your behalf transfer, change			Yes	No
ownership in, give away, or sell any assets, including your home or other real property?
b. In the last 60 months, have you or your spouse created or transferred any assets			Yes	No
into or out of a trust?
If you answered yes to either of the questions above, explain the transfer(s) below.
Attach additional sheets of paper, if needed.
Description of Asset (including income)	Date of Transfer	Transferred to Whom	Amount of Transfer
			$
			$
			$
			$

c. Are you in the process of selling property?						Yes		No
d. In the last 60 months, did you, your spouse or someone on your behalf, change the deed or the						Yes		No
ownership of any real property, including creating a life estate?
If yes, when?
e. If you purchased a life estate in another person’s home, did you live in the home for at least one						Yes		No
year after you purchased the life estate?
f. In the last 60 months, did you, your spouse, or someone on your behalf purchase a mortgage, loan,						Yes		No
or promissory note?
If yes, when?
g. In the last 60 months, did you, your spouse, or someone on your behalf purchase or change						Yes		No
an annuity?
If yes, when?
2. Have you, your spouse, or someone acting on your behalf given a deposit to any health care or						Yes		No
residential facility, such as a nursing home, assisted living facility, continuing care retirement
community or life care community?

If yes, send copy of agreement.

G. Tax Returns

Did you and/or your spouse ile U.S. income tax returns in the last four years?

Yes

No

If yes, send complete copies of these returns including all schedules and attachments.

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H. Important Information

Liens on Real Property

Upon receipt of Medicaid, a lien may be iled and a recovery may be made against your real property under certain circumstances if you are in a medical institution and not expected to return home. Medicaid paid on your behalf may be recovered from persons who had legal responsibility for your support at the time medical services were obtained. Medicaid may also recover the cost of services and premiums incorrectly paid.

Transfer of Assets

Federal and State laws provide that an individual may be found ineligible for nursing facility services for a period of time if an individual or an individual’s spouse transfers an asset for less than fair market value within the look-back period. The look-back period is the 60 months immediately prior to the date an individual is both institutionalized and has applied for Medicaid.

Annuities

As a condition of Medicaid coverage for nursing facility services, applicants are required to disclose a description of any interest the individual or the individual’s spouse has in an annuity. This disclosure is required regardless of whether the annuity is irrevocable or a countable resource.

In addition to the purchase of an annuity, certain transactions made to an annuity by the applicant or the applicant’s spouse within the look-back period, may be treated as a transfer unless:

•The State is named the remainder beneiciary in the irst position for at least the amount of Medicaid paid on behalf of the annuitant; or

•The State is named in the second position after a community spouse or minor or disabled child, or in the irst position if such spouse or representative of such child disposes of any such remainder for less than fair market value.

If documentation is not submitted verifying that the State has been named remainder beneiciary, you may be ineligible for coverage of nursing facility services.

If the annuity is a countable resource at the time of application, you/your spouse are not required to name the State as remainder beneiciary.

I. Certiication and Authorization

I certify under penalty of perjury, that the information on this form is correct and complete to the best of my knowledge. I understand that I must report any changes in this information within 10 days of the change.

If eligibility depends on the amount of my and my spouse’s resources, by signing this application we authorize veriication of our resources with inancial institutions for the purpose of determining eligibility. Both spouses must sign below. This authorization will end if my application for Medicaid is denied, or I am no longer eligible for Medicaid, or I/we revoke this authorization in a written statement to my local Department of Social Services.

X		X
SIGNATURE OF APPLICANT/REPRESENTATIVE		DATE SIGNED
X		X
SIGNATURE OF APPLICANT’S SPOUSE		DATE SIGNED

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