Medicaid Ny Application Form – Fill Out and Use This PDF

INSTRUCTIONS

CONFIDENTIALITY STATEMENTAll of the information you provide on this application will remain confidential. The only people who will see this information are the Assistors and the State or local agencies and health plans who need to know this information in order to determine if you (the applicant) and your family members are eligible. The person helping you with this application cannot discuss the information with anyone, except a supervisor or the State or local agencies or health plans which need this information.

PURPOSE OF THIS APPLICATION Complete this application if you want health insurance to cover medical expenses. This application can be used to apply for Medicaid, the Family Planning Benefit Program, or for assistance paying your health insurance premiums. You can apply for yourself and/or immediate family members living with you.

IF YOU NEED HELP COMPLETING THIS APPLICATION DUE TO A DISABILITY, CALL YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. THEY WILL MAKE EVERY EFFORT TO PROVIDE REASONABLE ACCOMMODATIONS TO ADDRESS YOUR NEEDS.

PLEASE READ the entire application booklet before you begin to fill out the application. This application, along with Supplement A, must be filled out completely if you are 65 years old or older, certified blind, certified disabled or institutionalized, and/or if you are applying for coverage of nursing home care. Supplement A includes questions about your resources, such as money in the bank or property you own. This application is also used when applying through a provider, for individuals who are pregnant or under 19. If the application is for a pregnant person or child under 19, only Sections A thorough G, I, and J must be completed.

Any other Medicaid applicants must apply through NY State of Health. You can contact NY State of Health by visiting their website at https://nystateofhealth.ny.gov/, or by phone at 1-855-355-5777.

Whenever you see the words SEND PROOF on the application refer to the “Documents Needed When You Apply for Health Insurance” section for a listing of acceptable

supporting documents, pages 4-6.

HOW TO GET HELPWhen applying for public health insurance, you DO NOT need to visit your local department of social services or an Assistor for an interview, but you MAY come in or contact an Assistor for help filling out this application. You can get a list of Assistors where you got this application, or by calling 1-800-698-4543. You may also call the Medicaid help line at 1–800–541–2831. ALL HELP IS FREE.

(1-877-898-5849 TTY line for the hearing impaired)

After you have completed this application please mail/return to the local department of social services in the county in which you reside. https://www.health.ny.gov/health_care/medicaid/ldss.htm

SECTION A Applicant’s Information

We need to be able to contact the people applying for health insurance. The home address is where the people applying for health insurance live. The mailing address, if different, is where you want us to send health insurance cards and notices about your case. You can also tell us if you want someone else to get information about your case and/or to be able to discuss your case.

SECTION B Family Information

Please include information for everyone who lives with you even if they are not applying for health insurance. It is important that you list everyone who lives with you so that we can make a correct eligibility decision. Include legal name before marriage, if this applies to the person. Also include city, state and country of birth. If a person was born outside of the United States, just write the country of birth.

Is this person pregnant? If so, when is the baby due to be born? This information helps us determine the size of your family. A pregnant person counts as two people.

Relationship to the person on Line 1. Explain how each person is related to the person listed on Line 1 (for example, spouse, child, step-child, sibling, grandchild, etc.)

Public Health Coverage. If you or anyone who lives with you is already enrolled or was previously enrolled in Medicaid, the Family Planning Benefit Program, or any other form of public assistance such as the Supplemental Nutrition Assistance Program (SNAP), we need to know which program. Also, tell us the identification number on the New York State Benefit Identification Card.

Social Security Number. A Social Security Number should be provided for all persons applying, if the person has one. If the person does not have a Social Security Number, leave this box blank.

Citizenship and Immigration Status. This information is needed only for those people applying for health insurance. To be eligible for health insurance, persons age 19 and over must be U.S. citizens or be lawfully present. If we are unable to verify your U.S. Citizenship and identity electronically through federal databases, we will need to see documentation of U.S. citizenship and identity. Please contact your local department of social services or call 1-800-698-4543 to find out where you can bring these documents. Please note that if you are on Medicare, or receiving Social Security Disability but are not yet eligible for Medicare, it is not necessary to document citizenship or identity.

Race/Ethnic Group. This information is optional and it will help us make sure that all people have access to the programs. If you fill out this information, use the code shown on the application that best describes each person’s race or ethnic background. You may pick more than one.

SECTION C Family Income (Money Received)

In this section, list all types of income (money received) and the amounts received by the people you listed in Section B.

Please tell us how much you make before taxes are taken out.

If there is no money coming into your home, explain how you are paying for your living expenses, such as food and housing.

We need to know if you have changed jobs or if you are a student.

We also need to know if you pay another person or place, such as a day care center, to take care of your children or disabled spouse or parent while you are working or going to school. If you do, we need to know how much you pay.

We may be able to deduct some of the amount that you pay for these costs from the amount we count as your income.

SECTION D Health Insurance

It is important to tell us whether anyone applying is covered or could be covered by someone else’s health insurance. For some applicants, we can deduct the amount that you pay for health insurance from the amount we count as your income; or we may be able to pay the cost of your health insurance premium if we determine it is cost effective. We may be able to help pay for health insurance premiums if you have or can get insurance through your job. We will need to gather more information about the insurance and will mail an insurance questionnaire to you.

SECTION E Housing Expenses

Write in your monthly cost of housing. This includes your rent, monthly mortgage payment or other housing payment. If you have a mortgage payment, include property taxes in the mortgage amount you tell us. If you share your housing expenses or your rent is subsidized, please only tell us how much YOU pay toward your rent or mortgage. If you pay for your water, tell us how much you pay and how often.

SECTION F Blind, Disabled, Chronically Ill or Nursing Home Care

These questions help us determine which program is best for each applicant, and what services may be needed. A person with a disability, serious illness or high medical bills may be able to get more health services. You may have a disability if your daily activities are limited because of an illness or condition that has lasted or is expected to last for at least 12 months. If you are blind, disabled, chronically ill or need nursing home care, you will need to complete Supplement A. If neither you nor anyone applying is blind, disabled, chronically ill or in a nursing home, go to Section G.

SECTION G Additional Health Questions

If you have paid or unpaid medical bills from the past three months, Medicaid may be able to pay for these costs. Let us know who these bills are for and in which months the bills were incurred. Include copies of the medical bills with this application. Note: This three-month period begins when the local department of social services receives your application or when you meet with an Assistor to apply. You will need to tell us what your income was for any past months in which you have medical bills so that we can see if you are eligible during that time. We also ask about where you lived in the past three months, because this may affect our ability to pay for past bills. We ask about any pending lawsuits or health issues caused by someone else so we know if someone else should pay for any portion of your medical care costs.

If you are turning 65 within the next three months or you are 65 years of age or older, you may be entitled to additional medical benefits through the Medicare program. You are required to apply for Medicare as a condition of eligibility for Medicaid. Medicare is a federal health insurance program for people who are 65 or older and for certain

people with disabilities regardless of income. When a person has both Medicare and Medicaid, Medicare pays first and Medicaid pays second. You are required to apply for Medicare if:

You have Chronic Renal Failure (End Stage Renal Disease/ESRD) or Amyotrophic Lateral Sclerosis (ALS); OR

You are turning 65 in the next three months or are already age 65 or older AND your income is at or below 120% of the federal poverty level (based on the family size for a single individual or married couple), or is at the Medicaid standard. If so, then the Medicaid program can pay your premium or reimburse your Medicare premiums. If the Medicaid program can pay or

reimburse your premiums, you will be required to apply for Medicare as a condition of Medicaid eligibility. Only citizens and lawful permanent residents who have lived in the U.S. continuously for five years must apply for Medicare. Many immigrants and non-citizens are not required to apply for Medicare.

SECTION H Parent or Spouse Not Living in the Family or Deceased

If any applicants have an absent spouse or parent, you must complete this section so we can see if medical support is available to you or your child.

If you are pregnant, you do not have to answer these questions until 60 days after the birth of your child. All other people who are applying and are age 21 or over must be willing to provide information about a parent of an applying minor or a spouse living outside the home to be eligible for health insurance, unless there is good cause. An example of “good cause” is fear of physical or emotional harm to you or a family member. Question 2 refers to the PARENT of any applying child under age 21. Question 3 refers to the SPOUSE of anyone applying.

If the applying parent is not willing to provide this information, the applying child may still be eligible for Medicaid.

SECTION I Health Plan Selection

What is a Health Plan? If you are found eligible for Medicaid, you may be required to get your health care coverage through a Managed Care health plan. A Managed Care health plan will provide your care by working with a network of doctors, clinics, hospitals and pharmacies to provide its members with high quality health care. When you join a plan, you choose one doctor (Primary Care Provider or PCP) from that plan to take care of your regular health and medical needs. If you want to keep the doctor you have, you need to pick a plan that works with your doctor. Managed Care health plans focus on preventive care so that small problems do not become big ones. If you need a specialist, your PCP can refer you to one in your plan’s network.

Who Must Choose a Health Plan? MOST people who are eligible for Medicaid MUST choose a health plan to get most of their Medicaid benefits. Keep reading to find out how to get more information on this.

How Do I Know What Health Plan to Choose and If I Can Enroll?

For Medicaid, if you want to find out more about how managed care plans work, if you have to join, and how to choose a plan, call Medicaid CHOICE at 1-800-505-5678, or call or visit your local department of social services. Ask for a Managed Care Education Packet. Information about health plans is also on the NYS Department of Health website at www.health.ny.gov. You can also enroll by phone, by calling 1-800-505-5678.

NOTE: If you or a family member are found eligible for Medicaid, and are an American Indian/ Alaska Native you are not required to join a health plan. You will still be enrolled in the health plan you choose, unless you check the box on the application that says you don’t want to be enrolled, or tell us you do not want to be enrolled by calling or writing to your local department of social services.

SECTION J

Signature

Please read the paragraph in this section carefully and read the Terms, Rights and Responsibilities section. You must then sign and date the application. Remember to send the application to the local department of social services in the county in which you reside.

You need to provide proof of Identity, U.S. Citizenship and/or Immigration Status and Date of Birth.

You can provide ONE of the following documents to prove both U.S. Citizenship, Identity and your Date of Birth:

☐U.S. passport/card

☐Certificate of Naturalization (DHS Forms N-550 or N-570)

☐Certificate of U.S Citizenship (DHS Forms N-560 or N-561)

☐NYS Enhanced Driver’s License (EDL).

☐Native American Tribal Document issued by a Federally Recognized Tribe

When none of the above documents are available, ONE document from the U.S. Citizenship list and

ONE from the Identity list may be used to prove your citizenship and /or identity.

This list is not all-inclusive. If you do not have one of these documents, please refer to the “How to

Get Help” section of the instructions.

Documents with * next to it also show date of birth

U.S. Citizenship (Provide One)

☐U.S. Birth Certificate*

☐Certification of Birth issued by Department of State (Forms FS-545 or DS-1350)*

☐Report of Birth Abroad (FS-240)

☐U.S. National ID card (Form I-197 or I-179)

☐Religious/School Records*

☐Military record of service showing U.S. place of birth

☐Final adoption decree

☐Evidence of qualifying for U.S. citizenship under the Child Citizenship Act of 2000

AND

Identity (Provide One)

☐State Driver’s license or ID card with photo*

☐ID card issued by a federal, state, or local government agency

☐U.S. Military card or draft record or U.S Coast Guard Merchant Mariner Card

☐School ID card with a photo (may also show date of birth)

☐Certificate of Degree of Indian blood or other American Indian/Alaska Native tribal document with photo

☐Verified School, Nursery or Daycare records (for children under 18) (may also show date of birth)

☐Clinic, Doctor or Hospital records (for children under 18)*

If you do not have one of the documents that show your date of birth, you must also submit one of the following items:

☐Marriage certificate

☐NYS Benefit Identification Card

If you are not a U.S. Citizen

The list below contains some of the most common United States Citizenship and Immigration

Services (USCIS) forms used to show your immigration status.

This list is not all-inclusive. If you do not have one of these documents, please refer to the “How to

Get Help” section of the instructions.

We need to see ONE of the following documents to prove Immigration Status, Identity and your Date of Birth. You must prove all three.

Documents with * next to it also show date of birth

Immigration Status/Identity

PROOF OF CURRENT INCOME, OR INCOME YOU MIGHT GET IN THE FUTURE SUCH AS UNEMPLOYMENT BENEFITS OR A LAWSUIT: You must provide a letter, written statement, or copy of check or stubs, from the employer, person or agency providing the income. YOU DO NOT NEED TO SHOW US ALL OF THESE DOCUMENTS, only the ones that apply to you and the people living with you.

One proof for each type of income you have is required. Provide the most recent proof of income before taxes and any other deductions. The proof must be dated, include the employee’s name and show gross income for the pay period. The proof must be for the last four weeks, whether you get paid weekly, bi-weekly, or monthly. It is important that these be current.

☐I-551 Permanent Resident Card (“Green Card”)*

☐I-688B or I-766 Employment Authorization Card*

Immigration Status, but require an additional Identity document

☐I-94 Arrival/Departure Record*

☐USCIS Form I-797 Notice of Action

DOB/Identity, but require an additional immigration status document

☐Visa

☐U.S. Passport

Home Address: This address must match the home address that you write in Section A of the application. The proof must be dated within 6 months of when you signed the application.

☐Lease/ letter/ rent receipt with your home address from landlord

☐Utility Bill (gas, electric, phone, cable, fuel or water)

☐Property tax records or mortgage statement

☐Driver’s license (if issued in the past 6 months)

☐Government ID card with address

☐Postmarked envelope or post card (cannot use if sent to a P.O. Box)

Wages and Salary

☐Paycheck stubs

☐Letter from employer on company letterhead, signed and dated

☐Business/payroll records

Self-Employment

☐Currentsignedanddatedincometaxreturn andallSchedules

☐Records of earnings and expenses/ business records

Unemployment Benefits

☐Award letter/certificate

☐Monthly benefit statement from NYS Department of Labor

☐Printout of recipient’s account information from the NYS Department of Labor’s website (www.labor.ny.gov)

☐Copy of Direct Payment Card with printout

☐Correspondence from the NYS Department of Labor

Private Pensions/Annuities

☐Statement from pension/annuity

Social Security

☐Award letter/certificate

☐Annual benefit statement

☐Correspondence from Social Security Administration

Workers’ Compensation

☐Award letter

☐Check stub

Child Support/Alimony

☐Letter from person providing support

☐Letter from court

☐Child support/alimony check stub

☐Copy of NY EPPICard with printout

☐Copy of child support account information from www.childsupport.ny.gov

☐Copy of bank statement showing direct deposit

Veterans’ Benefits

☐Award letter

☐Benefit check stub

☐Correspondence from Veterans Affairs

Military Pay

☐Award letter

☐Check stub

Income from Rent or Room/Board

☐Letter from roomer, boarder, tenant

☐Check stub

Interest/Dividends/Royalties

☐Recent statement from bank, credit union or financial institution

☐Letter from broker

☐Letter from agent

☐1099 or tax return (if no other documentation is available)

If you pay to have care for your children or an adult in your family while you work, provide one of the following:

☐Written statement from day care center or other child/adult care provider

☐Canceled checks or receipts that show your payments

If you or your spouse are required to pay court ordered support you must provide the following:

☐Court Order

Proof of health insurance, provide all that apply:

☐Proof of current insurance (Insurance policy, Certificate of Insurance or Insurance Card)

☐Health Insurance Termination Letter

☐Medicare Card (Red, White and Blue Card)

☐Confirmation of Medicare Application

☐Medicare Award or Denial Letter

If you have medical bills in the last three months, provide all the following (if applicable):

For determination of eligibility for medical expenses from the past three months:

☐Proof of income for the month(s) in which the expense was incurred

☐Proof of residency/home address for the month(s) in which the expense was incurred, if different from the address listed in Section A of this application

☐Medical bills for last three months, whether or not you paid them

Resources (only if you are age 65 or older, certified blind or disabled and have no children under age 21 living with you):

☐Bank account statements: checking, savings, retirement (IRA and Keogh)

☐Stocks, bonds, certificates statements

☐Copy of Life Insurance policy

☐Copy of burial trust or fund burial plot deed or funeral agreement

☐Deed for real estate other than residence

Proof of Student Status for college students if employed:

☐Copy of schedule

☐Statement from college or university

☐Other correspondence from college showing student status

Legal First Name

Middle Initial

Legal Last Name

OPTIONAL: If there is another person you would like to receive your Medicaid notices, please provide this person’s contact information. I want this contact person to:

Apply for and/or renew Medicaid for me

Discuss my Medicaid application or case, if needed Get notices and correspondence

Name	State
Street	Apt.#	Zip Code
City	Phone #	Home	Cell
		Work	Other

SECTION B Family Information

If you live in the family, start with yourself. If you do not, start with any adults who live in the family. List the full legal names of the persons applying for or already receiving Medicaid and list the ID Number from their Benefit Card or health plan ID card. You must provide information for family members including: parents, step-parents, and spouses. You may provide information for other family members (for example, a dependent child under the age of 21). Listing other family members may allow us to give you a higher eligibility level. Applicants who are pregnant or under age 19 may be eligible for insurance regardless of immigration status. New York State ensures your right to access State benefits and/or services regardless of your sex, gender identity, or expression. If you would like to provide us with how you or your household members currently identify, please also select gender identity.

SECTION C

Family Income

Write the types of money and the amount received by everyone listed in Section B and SENDPROOF

Name of Person

Type of Income/Source

How Much? (before taxes)

How Often? (weekly, monthly)

Other:	Temporary (cash) Assistance, Supplemental Security Income (SSI) payments, student grants, or loans.					If none, check here:
Name of Person			Type of Income/Source		How Much? (before taxes)