for Children, Adults and

Families

HealthInsuranceAPPLICATION

­­­DOH-4220-I­­3/15­­­Page­2­

CONFIDENTIALITY STATEMENT­All­of­the­information­you­provide­on­this­application­will­remain­confidential.­The­only­people­who­will­see­this­information­are­the­Facilitated­Enrollers­and­the­State­or­local­agencies­and­health­plans­who­need­to­know­this­information­in­order­to­determine­ if­ you­ (the­ applicant)­ and­ your­ household­ members­ are­ eligible.­ The­ person­ helping­ you­ with­ this­ application­ cannot­ discuss­ the­information­with­anyone,­except­a­supervisor­or­the­State­or­local­agencies­or­health­plans­which­need­this­information.­

We­need­to­be­able­to­contact­the­people­applying­for­health­insurance.­The­home­address­is­where­the­people­applying­for­health­insurance­live.­The­mailing­address,­if­different,­is­where­you­want­us­to­send­health­insurance­cards­and­notices­about­your­case.­You­can­also­tell­us­if­you­want­someone­else­to­get­information­about­your­case­and/or­to­be­able­to­discuss­your­case.

INSTRUCTIONS

PLEASE READ the entire application booklet before you begin to fill out the application. If you are applying ONLY for children or if you are a pregnant woman applying alone, you must complete only Sections A through G and Sections I and J. Other applicants must complete all sections.

If you are 65 years old or older, certified blind, certified disabled, or institutionalized and applying for coverage of nursing home care, you must also complete Supplement A. The supplement includes questions about your resources, such as money in the bank or property you own.

Whenever you see the words on the application refer to the “Documentation Needed When You Apply for Health Insurance” section for a listing of acceptable supporting documents.

HOW TO GET HELP When applying for public health insurance, you DO NOT need to visit your local department of social services or a Facilitated Enroller for an interview, but you MAY come in or contact a Facilitated Enroller for help filling out this application. You can get a list of Facilitated Enrollers where you got this application, or by calling 1-800-698-4543. ALL HELP IS FREE. (1-877-898-5849 TTY line for the hearing impaired)

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.

Please­include­information­for­everyone­who­lives­with­you­even­if­they­are­not­applying­for­health­insurance.­It­is­important­that­you­list­everyone­who­lives­with­you­so­that­we­can­make­a­correct­eligibility­decision.­Include­maiden­name­(legal­name­before­marriage),­if­this­applies­to­the­person.­Also­include­City,­State­and­Country­of­birth.­If­a­person­was­born­outside­of­the­United­States,­just­write­the­country­of­birth.­We­also­need,­­for­each­person­applying,­his/her­mother’s­full­maiden­name­­(first­and­last­name).­This­information­may­be­used­to­obtain­proof­of­the­applicant’s­birth­date­under­certain­circumstances.

­ ­ Is this person pregnant?­If­so,­when­is­her­baby­due­to­be­born?­This­information­helps­us­determine­the­size­of­your­family.­A­pregnant­woman­counts­as­two­people.

­ ­ Relationship to the person on Line 1.­Explain­how­­each­person­is­related­to­the­person­listed­on­Line­1­­(for­example,­spouse,­child,­step-child,­brother,­sister,­­niece,­nephew,­etc.)

­ ­ Public Health Coverage.­If­you­or­anyone­who­lives­with­you­­is­already­enrolled­or­was­previously­enrolled­in­Medicaid,­the­Family­Planning­Benefit­Program,­or­any­other­form­of­public­assistance­such­as­Food­Stamps,­we­need­to­know.­­Also,­tell­us­the­identification­number­on­the­New­York­State­Benefit­Identification­Card.

­ ­ Social Security Number.­A­Social­Security­Number­should­­be­provided­for­all­persons­applying,­if­the­person­has­one.­­If­the­person­does­not­have­a­Social­Security­Number,­leave­this­box­blank.

­ ­ Citizenship and Immigration Status.­This­information­is­needed­only­for­those­people­applying­for­health­insurance.­Pregnant­women­do­not­have­to­complete­this­question.­­To­be­eligible­for­health­insurance,­other­persons­age­19­and­over­must­be­U.S.­citizens­or­be­in­an­eligible­immigration­category.­We­need­to­see­either­original­documentation­of­U.S.­citizenship­and­identity,­or­copies­of­these­documents.­Please­contact­your­local­department­of­social­services­or­­call­1-800-698-4543­to­find­out­where­you­can­bring­these­documents.­Please­note­that­if­you­are­on­Medicare,­or­receiving­Social­Security­Disability­but­are­not­yet­eligible­­for­Medicare,­it­is­not­necessary­to­document­citizenship­­or­identity.­

SEND PROOF

SECTION A Applicant’s Information

SECTION B Household Information

­ ­ In­this­section,­list­all­types­of­income­(money­received)­and­the­amounts­received­by­the­people­you­listed­in­Section­B.

­ ­Please­tell­us­how­much­you­make­before­taxes­are­taken­out.

­ ­ If­there­is­no­money­coming­into­your­home,­explain­how­you­are­paying­for­your­living­expenses,­such­as­food­and­housing.

­ ­We­need­to­know­if­you­have­changed­jobs­or­if­you­are­­a­student.

­ ­We­also­need­to­know­if­you­pay­another­person­or­place,­such­as­a­day­care­center,­to­take­care­of­your­children­or­disabled­spouse­or­parent­while­you­are­working­or­going­to­school.­If­you­do,­we­need­to­know­how­much­you­pay.­We­may­be­able­to­deduct­some­of­the­amount­that­you­pay­for­these­costs­from­the­amount­we­count­as­your­income.

PUBLIC CHARGE INFORMATION

The­United­States­Citizenship­and­Immigration­Services­(USCIS)­has­stated­that­enrollment­in­Medicaid,­or­the­Family­Planning­Benefit­Program­CANNOT­affect­a­person’s­ability­to­get­a­green­card,­become­a­citizen,­sponsor­a­family­member,­or­travel­in­and­out­of­the­country.­This­is­not­true­if­Medicaid­pays­for­long-term­care­in­a­place­such­as­a­nursing­home­or­psychiatric­hospital.

Write­in­your­monthly­cost­of­housing.­This­includes­your­rent,­monthly­mortgage­payment­or­other­housing­payment.­If­you­have­a­mortgage­payment,­include­property­taxes­in­the­amount­you­tell­us.­If­you­share­your­housing­expenses­or­your­rent­is­subsidized,­please­only­tell­us­how­much­YOU­pay­toward­your­rent­or­mortgage.­If­you­pay­for­your­water,­tell­us­how­much­you­pay­and­how­often.

If­you­have­paid­or­unpaid­medical­bills­from­the­past­three­months,­Medicaid­may­be­able­to­pay­for­these­costs.­Let­us­know­who­these­bills­are­for­and­in­which­months.­Include­copies­of­the­medical­bills­with­this­application.­Note:­This­three-month­period­begins­when­the­local­department­of­social­services­receives­your­application­or­when­you­meet­with­a­Facilitated­Enroller.­You­will­need­to­tell­us­what­your­income­was­for­any­past­months­in­which­you­have­medical­bills­so­that­we­can­see­if­you­are­eligible­during­that­time.­We­also­ask­about­where­you­lived­in­the­past­three­months,­because­this­may­affect­our­ability­to­pay­for­past­bills.­We­ask­about­any­pending­lawsuits­or­health­issues­caused­by­someone­else­so­we­know­if­someone­else­should­pay­for­any­portion­of­your­medical­care­costs.­

These­questions­help­us­determine­which­program­is­best­for­each­applicant,­and­what­services­may­be­needed.­A­person­with­a­disability,­serious­illness­or­high­medical­bills­may­be­able­to­get­more­health­services.­You­may­have­a­disability­if­your­daily­activities­are­limited­because­of­an­illness­or­condition­that­has­lasted­or­is­expected­to­last­for­at­least­12­months.­If­you­are­blind,­disabled,­chronically­ill­or­need­nursing­home­care,­you­will­need­to­complete­Supplement­A.­If­neither­you­nor­anyone­applying­is­blind,­disabled,­chronically­ill­or­in­a­nursing­home,­go­to­Section­G.

It­is­important­to­tell­us­whether­anyone­applying­is­covered­or­could­be­covered­by­someone­else’s­health­insurance.­This­information­may­affect­their­eligibility­for­coverage;­for­some­applicants,­we­can­deduct­the­amount­that­you­pay­for­health­insurance­from­the­amount­we­count­as­your­income;­or­we­may­be­able­to­pay­the­cost­of­your­health­insurance­premium­if­we­­determine­it­is­cost­effective.­We­may­be­able­to­help­pay­for­health­insurance­premiums­if­you­have­or­can­get­insurance­through­your­job.­We­will­need­to­gather­more­information­about­the­insurance­and­will­mail­an­insurance­questionnaire­to­you.

The State will not report any information on this application to the USCIS.

­ ­ Race/Ethnic Group. This­information­is­optional­and­it­will­help­us­make­sure­that­all­people­have­access­to­the­programs.­If­you­fill­out­this­information,­use­the­code­shown­on­the­application­that­best­describes­each­person’s­race­or­ethnic­background.­You­may­pick­more­than­one.

­­­DOH-4220-I­­3/15­­­Page­3­

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

SECTION C Household Income (Money Received)

SECTION G Additional Health Questions

SECTION D Health Insurance

SECTION E Housing Expenses

What is a Health Plan?­Applying­for­programs­through­Access­NY­Health­Care­may­mean­you­get­your­health­care­coverage­through­a­Managed­Care­plan.­When­you­join­a­plan,­you­choose­one­doctor­(Primary­Care­Provider­or­PCP)­from­that­plan­to­take­care­of­your­regular­needs.­If­you­want­to­keep­the­doctor­you­have,­you­need­to­pick­the­plan­that­works­with­your­doctor.­Managed­Care­health­plans­focus­on­preventive­care­so­small­problems­do­not­become­big­ones.­If­you­need­a­specialist,­your­PCP­will­refer­you­to­one.­

Please­read­the­paragraph­in­this­section­carefully­and­read­the­Terms, Rights and Responsibilities­section.­You­must­then­sign­and­date­the­application.­

­ 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.

­ Pregnant women do not have to answer these questions until 60 days after the birth of their child.­All­other­people­who­are­applying­and­are­age­21­or­over­must­be­willing­to­provide­information­about­a­parent­of­an­applying­minor­or­a­spouse­living­outside­the­home­to­be­eligible­for­health­insurance,­unless­there­is­good­cause.­An­example­of­“good­cause”­is­fear­of­physical­or­emotional­harm­to­you­or­a­family­member.­Question­2­refers­to­the­PARENT of­any­applying­child­under­age­21.­Question­3­refers­to­the­SPOUSE­of­anyone­applying.

­ ­If­the­parents­are­not­willing­to­provide­this­information,­the­applying­child­may­still­be­eligible­for­Medicaid.

Who Must Choose a Health Plan?­MOST­people­who­are­eligible­for­Medicaid­MUST choose­a­health­plan­to­get­most­of­their­Medicaid­benefits.­Keep­reading­to­find­out­how­to­get­more­information­­on­this.

How Do I Know What Health Plan to Choose and If I Can Enroll?­­For­Medicaid,­if­you­want­to­find­out­more­about­how­managed­care­plans­work,­if­you­have­to­join,­and­how­to­choose­a­plan,­call­Medicaid CHOICE­at­1-800-505-5678,­or­call­or­visit­your­local­department­of­social­services.­Ask­for­a­Managed­Care­Education­Packet.­Information­about­health­plans­is­also­on­the­NYSDOH­website­at­www.nyhealth.gov.­You­can­also­enroll­by­phone,­­by­calling­1-800-505-5678.

NOTE: If­you­or­a­family­member­are­found­eligible­for­Medicaid,­and­are­in­a­county­that­does­not­require­people­on­Medicaid­to­join­a­health­plan,­you­will­still­be­enrolled­in­the­health­plan­you­choose­if­it­provides­Medicaid,­unless­you­check­the­box­on­the­application­that­says­you­don’t­want­to­be­enrolled,­or­tell­us­you­do­not­want­­to­be­enrolled­by­calling­or­writing­to­your­local­department­of­social­services.

­­­DOH-4220-I­­3/15­­­Page­4­

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A

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igra

tion

stat

us.

SEC

TIO

N B

Hou

seho

ld In

form

atio

n

ACC

ESS

NY

HEA

LTH

CA

RE M

edic

aid

Prin

t cle

arly

in b

lue

or b

lack

ink.

An

inco

mpl

ete

appl

icat

ion

cann

ot b

e pr

oces

sed

and

will

resu

lt in

a d

elay

of a

dec

isio

n on

you

r app

licat

ion.

Lega

l Fir

st, M

iddl

e, L

ast N

ame

Date

of

Birt

h

Is th

is

pers

on

appl

ying

fo

r hea

lth

insu

ranc

e?

Is th

is

pers

on

preg

nant

?

Is th

is

pers

on th

e

pare

nt o

f an

app

lyin

g ch

ild?

Wha

t is t

he

rela

tions

hip

to th

e pe

rson

in

Box

1?

If th

is p

erso

n ha

s or h

ad

publ

ic h

ealth

cove

rage

in

the

past

, che

ck

the

box

that

app

lies.

Soci

al

Secu

rity

N

umbe

r (if

you

ha

ve o

ne)

*Rac

e/

Ethn

ic

Grou

p

03

­­

04 05 06 07

­­Yes

­­No

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e­­F

emal

e

­­Yes

­­No

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icai

d

­­Fam

ily­H

ealth

­Plu

s

ID­N

umbe

r­fro

m­ ­

Bene

fit­C

ard/

Plan

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d,­

if­kn

own:

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.­Citi

zen

­­Im

mig

rant

/non

-citi

zen

Ente

r­the

­dat

e­yo

u­re

ceiv

ed­­

your

­imm

igra

tion­

stat

us­

____

__/_

____

_/__

____

Mon

th­­­

­­­Da

y­­­­

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r

­­Non

-imm

igra

nt­(V

isa­

hold

er)

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e­of

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abov

eTh

is­P

erso

n’s­

Mot

her’s

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l­Mai

den­

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e

Full­

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den­

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e­(p

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birt

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me­

befo

re­th

ey­w

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ried)

City

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irth

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e­of

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hCo

untr

y­of

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h

­­Yes

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Wha

t­is­

the­

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e­Da

te?

/­­­­­

­­­­/­

­

This

­Per

son’

s­M

othe

r’s­F

ull­M

aide

n­N

ame

­­Yes

­­No

­­Mal

e­­F

emal

e

­­Yes

­­No

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icai

d

­­Fam

ily­H

ealth

­Plu

s

ID­N

umbe

r­fro

m­ ­

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fit­C

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Plan

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d,­

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own:

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zen

­­Im

mig

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zen

Ente

r­the

­dat

e­yo

u­re

ceiv

ed­­

your

­imm

igra

tion­

stat

us­

____

__/_

____

_/__

____

Mon

th­­­

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y­­­­

­­­­­­

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r

­­Non

-imm

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Mai

den­

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erso

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ried)

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untr

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othe

r’s­F

ull­M

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n­N

ame

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d

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zen

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mig

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Ente

r­the

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e­yo

u­re

ceiv

ed­­

your

­imm

igra

tion­

stat

us­

____

__/_

____

_/__

____

Mon

th­­­

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y­­­­

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r

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igra

nt­(V

isa­

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abov

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Full­

Mai

den­

Nam

e­(p

erso

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birt

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me­

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mar

ried)

City

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untr

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son’

s­M

othe

r’s­F

ull­M

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ame

­­Yes

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fit­C

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mig

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us­

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th­­­

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y­­­­

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othe

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­­Yes

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d

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Plan

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mig

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Ente

r­the

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igra

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us­

____

__/_

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th­­­

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y­­­­

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igra

nt­(V

isa­

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er)

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e­of

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abov

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Full­

Mai

den­

Nam

e­(p

erso

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birt

h­na

me­

befo

re­th

ey­w

ere­

mar

ried)

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untr

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/­­­­­

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Is­a

nyon

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r­hou

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?­­­Y

es­­­

­­­­­­

­­­­­N

o­­­­

­­­­­­

­­­­­­

­­If­y

es,­n

ame:

­

SEND

PRO

OF

Plea

se m

ark

one

box

that

in

dica

tes y

our c

urre

nt

Citiz

ensh

ip o

r Im

mig

ratio

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atus

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ot n

eede

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r pr

egna

nt w

omen

*Rac

e/Et

hnic

Gro

up C

odes

(opt

iona

l):­A

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an,­B

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r­Afr

ican

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eric

an,­I

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ive­

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lask

an­N

ativ

e,­P

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ive­

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aiia

n­or

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er­P

acifi

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ande

r,­W

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now

n.­P

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ispa

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ino-

H

Refe

r to

the

“Doc

umen

ts N

eede

d W

hen

You

Appl

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r Hea

lth In

sura

nce”

in th

e in

stru

ctio

ns o

n pa

ges 1

-3, “

Docu

men

tatio

n Ch

eckl

ist f

or H

ealth

Insu

ranc

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or a

list

of d

ocum

ents

that

pro

ve Id

entit

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itize

nshi

p or

Imm

igra

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us.

SEND

PRO

OF

SEND

PRO

OF

­­Yes

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Wha

t­is­

the­

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e­Da

te?

/­­­­­

­­­­/­

­

­­Yes

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t­is­

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­­­­/­

­

­­Yes

­­No

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t­is­

the­

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e­Da

te?

/­­­­­

­­­­/­

­

­­Yes

­­No

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t­is­

the­

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e­Da

te?

/­­­­­

­­­­/­

­

­­­DOH-4220-I­­3/15­­­Page­9­

SEC

TIO

N B

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son

Type

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ame

How

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wee

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mon

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)

Earn

ings

from

Wor

k:­In

clud

es­w

ages

,­sal

arie

s,­co

mm

issi

ons,­

tips,­

over

time,

­sel

f-em

ploy

men

t.­­­I

f­you

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udes

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ecur

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enefi

ts,­d

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ility

­pay

men

ts,­u

nem

ploy

men

t­pay

men

ts,­i

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est­a

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ends

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­­Che

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if­no

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arne

d­in

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e:­­

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Cont

ribu

tions

: Mon

ey­fr

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lativ

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nds,­

room

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or­b

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mon

ey­th

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e­gi

ves­

you­

each

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p­m

eet­l

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if­no

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ribut

ions

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mpo

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ecur

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ans.­

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ere­

if­no

ne:­­

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’s/ad

ult’s

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e:H

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2.­­­I

f­the

re­is

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inco

me­

liste

d­ab

ove,

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expl

ain­

how

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ng:­

(For

exa

mpl

e: li

ving

with

frie

nd o

r re

lati

ve)

1.­D

o­yo

u­or

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lyin

g­ad

ult­i

n­Se

ctio

n­B­

have

­no­

inco

me?

­­­­N

o­­

­­Yes

­­­W

ho?­

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

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3.­­H

ave­

you­

or­a

nyon

e­w

ho­is

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lyin

g­ch

ange

d­jo

bs­o

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pped

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ame­

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mpl

oyer

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re­y

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­­­N

o­­­Y

es­­­

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If­ye

s:­­­

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e­­­­

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e­­

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ergr

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­­­­­

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duat

e­­­

Stud

ent’s

­Nam

e:

5.­D

o­yo

u­ha

ve­to

­pay

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hild

care

­(or­f

or­ca

re­o

f­a­d

isab

led­

adul

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er­to

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k­or

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6.­If

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nnin

g­Be

nefit

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gram

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rest

ed­in

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g­co

vera

ge­fo

r­Fam

ily­P

lann

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ices

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es­­

­­­DOH-4220-I­­3/15­­­Page­10­

SEC

TIO

N C

H

ouse

hold

Inco

me

Wri

te th

e ty

pes o

f mon

ey a

nd th

e am

ount

rece

ived

by

ever

yone

list

ed in

Sec

tion

B an

d SE

ND P

ROOF

1.­­D

oes­

anyo

ne­w

ho­is

­app

lyin

g­ha

ve­M

edic

are?

­­­­­­

­­­­­­

­­­N

o­­­­

­­­­­­

­­­­Y

es­­­

­­­­­­

­­­­­­I

f yes

, inc

lude

a co

py o

f you

r car

d (r

ed, w

hite

and

blu

e ca

rd),

for e

ach

Med

icar

e be

nefic

iary

. Co

mpl

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the

rest

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his a

pplic

atio

n an

d co

mpl

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Supp

lem

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.

­ 2.­­­D

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y­ha

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­com

mer

cial

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lth­in

sura

nce,

­incl

udin

g­lo

ng­te

rm­ca

re­in

sura

nce?

­­­­

­­No­

­­­­­Y

es­­­

If ye

s, y

ou m

ust s

end

a co

py o

f the

fron

t and

bac

k of

th

e in

sura

nce

card

with

this

app

licat

ion.

­N

ame­

of­In

sure

d­(p

rimar

y)­_

____

____

____

____

____

____

____

____

___­

­­Per

sons

­Cov

ered

­___

____

____

____

____

____

____

____

__­­­

Cost

­of­P

olic

y­­_

____

____

___­

­­

End­

date

­of­c

over

age,

­if­e

ndin

g­so

on­_

____

_/__

____

_/__

____

_

Not

e:­If

­you

­are

­app

lyin

g­fo

r­the

­Med

icar

e­Sa

ving

s­Pr

ogra

m­o

nly­

(MSP

),­go

­to­S

ectio

n­G.

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NOT

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d­to

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plet

e­Su

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men

t­A.

­ 3.­­D

oes­

your

­curr

ent­j

ob­o

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­insu

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e m

ay b

e ab

le to

hel

p pa

y fo

r it.­

­­No­

­­­Y

es­­­

­­­­­­

If­ye

s,­a­

“Req

uest

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nfor

mat

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Empl

oyer

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ealth

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ranc

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rm­w

ill­b

e­se

nt­to

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.

You

and

your

fam

ily m

ay st

ill b

e el

igib

le e

ven

if yo

u ha

ve o

ther

hea

lth in

sura

nce.

SEND

PRO

OF

SEND

PRO

OF

SEND

PRO

OF

Mon

th­­­

­­­­­­

Day­

­­­­­­

­­­­­­

­Yea

r

1.­­M

onth

ly­h

ousi

ng­p

aym

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as re

nt o

r mor

tgag

e, in

clud

ing

prop

erty

taxe

s­(ju

st­y

our­s

hare

).­­­$

____

____

____

____

___

2.­If

­you

­pay

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ater

­sep

arat

ely­

how

­muc

h­do

­you

­pay

?­­$

____

____

____

____

­­­­

­­­­H

ow­o

ften­

do­y

ou­p

ay?­

­­­­­

­­eve

ry­m

onth

­­­­­­

­­­2

­tim

es­a

­yea

r­­­­­

­­­q

uart

erly

­(4­ti

mes

­a­y

ear)

­­­­­­

­­­o

nce­

a­ye

ar­

3.­D

o­yo

u­re

ceiv

e­fr

ee­h

ousi

ng­a

s­pa

rt­o

f­you

r­pay

?­­­­

­­­­­N

o­­­­

­­­­

­­Yes

1.­­­A

re­y

ou,­o

r­any

one­

who

­live

s­w

ith­y

ou,­a

nd­is

­app

lyin

g,­in

­a­re

side

ntia

l­tre

atm

ent­f

acili

ty­o

r­rec

eivi

ng­n

ursi

ng h

ome

care

­in­a

­hos

pita

l,­nu

rsin

g­ho

me­

or­o

ther

­med

ical

­inst

itutio

n?­

­­No­

­­­Y

es­

If­ye

s,­fin

ish­

com

plet

ing­

this

­app

licat

ion­

AND­

com

plet

e­Su

pple

men

t­A.

­ 2.­­­­A

re­y

ou­o

r­any

one­

who

­live

s­w

ith­y

ou­b

lind,

­dis

able

d­or

­chro

nica

lly­il

l?­

­­No­

­­­Y

es­­

If­ye

s,­fin

ish­

com

plet

ing­

this

­app

licat

ion­

AND­

com

plet

e­Su

pple

men

t­A.­

Not

e:­­I

f­you

­are

­app

lyin

g­fo

r­the

­Med

icar

e­Sa

ving

s­Pr

ogra

m­o

nly­

(MSP

),­go

­to­S

ectio

n­G.

­You

­do­

not­n

eed­

to­co

mpl

ete­

Supp

lem

ent­A

.

If no

one

app

lyin

g is

Blin

d, D

isab

led,

Chr

onic

ally

Ill o

r in

a N

ursi

ng H

ome

pl

ease

go

to S

ectio

n G.

STO

P

­­­DOH-4220-I­­3/15­­­Page­11­

SEC

TIO

N E

H

ousi

ng E

xpen

ses

SEC

TIO

N D

H

ealt

h In

sura

nce

SEC

TIO

N F

B

lind,

Dis

able

d, C

hron

ical

ly Il

l or N

ursi

ng H

ome

Care

Th

ese

ques

tions

hel

p us

det

erm

ine

whi

ch p

rogr

am is

bes

t for

the

appl

ican

ts.

1.­­D

oes­

anyo

ne­a

pply

ing­

have

­pai

d­or

­unp

aid­

med

ical

­or­p

resc

riptio

n­bi

lls­fo

r­thi

s­m

onth

­or­t

he­th

ree­

mon

ths­

befo

re­th

is­m

onth

?­M

edic

aid­

may

­be­

able

­to­p

ay­th

ese­

bills

­or­r

eim

burs

e­yo

u.­

­­­N

o­­­

­­Yes

­If­

yes:

Nam

e:­­_

____

____

____

____

____

____

____

____

____

____

____

____

__­­­

­­­In

­whi

ch­m

onth

(s)­o

f­the

­pre

viou

s­th

ree­

mon

ths­

do­y

ou­h

ave­

med

ical

­bill

s?­_

____

____

____

____

____

____

____

____

of

inco

me

for a

ny m

onth

in th

e th

ree-

mon

th p

erio

d fo

r whi

ch y

ou h

ave

bills

. If y

ou h

ave

paid

med

ical

bill

s for

whi

ch y

ou a

re s

eeki

ng re

imbu

rsem

ent,

you

mus

t sen

d co

pies

and

pro

of o

f pay

men

t.­­­

2.­­D

o­yo

u,­o

r­any

one­

appl

ying

,­hav

e­an

y­un

paid

­med

ical

­or­p

resc

riptio

n­bi

lls­o

lder

­than

­the­

prev

ious

­thre

e­m

onth

s?­­

­­­N

o­­

­­­Ye

s

3.­­H

ave­

you,

­or­a

nyon

e­w

ho­li

ves­

with

­you

­and

­is­a

pply

ing,

­mov

ed­in

to­th

is­co

unty

­from

­ano

ther

­sta

te­o

r­New

­Yor

k­St

ate­

coun

ty­w

ithin

­the­

past

­thre

e­m

onth

s?­

­­­N

o­­

­­­Ye

s­­ ­

If­ye

s,­w

ho?­

____

____

____

____

____

____

____

____

____

____

____

____

____

____

_­­­­

­Whi

ch­s

tate

?­__

____

____

____

____

____

____

____

____

____

__­­­

­Whi

ch­co

unty

?­__

____

____

____

____

____

____

____

____

4.­D

oes­

anyo

ne­w

ho­is

­app

lyin

g­ha

ve­a

­pen

ding

­law

suit­

due­

to­a

n­in

jury

?­­­­

­­­N

o­­

­­­Ye

s­­

If­ye

s,­w

ho:­­

____

____

____

____

____

____

____

____

____

____

____

____

____

____

__

5.­­­D

oes­

anyo

ne­a

pply

ing­

have

­a­W

orke

rs’­C

ompe

nsat

ion­

case

­or­a

n­in

jury

,­illn

ess,­

or­d

isab

ility

­that

­was

­caus

ed­b

y­so

meo

ne­e

lse­

(that

­coul

d­be

­cove

red­

by­in

sura

nce)

?­­­

­­­N

o­­

­­Yes

­

If­ye

s,­w

ho?­

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___­

­

1.­­­I

s­th

e­sp

ouse

­or­p

aren

t­of­a

nyon

e­ap

plyi

ng­d

ecea

sed?

­­­­N

o­­

­­Yes

­

If­ye

s,­na

me­

of­a

pplic

ant­w

ith­d

ecea

sed­

pare

nt­o

r­spo

use­

:­­__

____

____

____

____

____

____

____

____

____

____

­(If­s

pous

e­or

­par

ent­i

s­de

ceas

ed­g

o­to

­que

stio

n­3.

)

2.­­D

oes­

a­pa

rent

­of­a

ny­a

pply

ing­

child

­live

­out

side

­the­

hom

e?­(I

f­no,

­ski

p­to

­que

stio

n­3)

­­­­N

o­­­Y

es

SEND

PRO

OF

Child

’s N

ame:

­N

ame

of p

aren

t liv

ing

outs

ide

the

hom

e

Date

­of­B

irth­

(if­k

now

n):­­

____

__/_

____

_/__

____

Curr

ent o

r las

t kno

wn

addr

ess:

Stre

et:­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­C

ity/S

tate

:

SSN

­(if­k

now

n):

Child

’s N

ame:

­N

ame

of p

aren

t liv

ing

outs

ide

the

hom

e

Date

­of­B

irth­

(if­k

now

n):­­

____

__/_

____

_/__

____

Curr

ent o

r las

t kno

wn

addr

ess:

Stre

et:­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­C

ity/S

tate

:

SSN

­(if­k

now

n):

3.­­­I

s­an

yone

­app

lyin

g­st

ill­m

arrie

d­to

­som

eone

­who

­live

s­ou

tsid

e­th

e­ho

me?

­­­­N

o­­­

­­Yes

­If­

yes,­

nam

e­of

­per

son­

appl

ying

­who

­is­s

till­m

arrie

d:­­_

____

____

____

____

____

____

____

____

____

____

___­

If­yo

u­fe

ar­p

hysi

cal­o

r­em

otio

nal­h

arm

­if­y

ou­p

rovi

de­in

form

atio

n­ab

out­a

­spo

use­

who

­doe

s­no

t­liv

e­in

­the­

hom

e,­ch

eck­

this

­box

­­­

Lega

l nam

e of

spou

se li

ving

out

side

of t

he h

ome:

­D

ate

of B

irth

(if k

now

n):

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­_

____

_/__

____

/___

___

Curr

ent o

r las

t kno

wn

addr

ess:

Stre

et:­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­­

­­­­­C

ity/S

tate

:

SSN

­(if­k

now

n):

If­yo

u­fe

ar­p

hysi

cal­o

r­em

otio

nal­h

arm

­if­y

ou­p

rovi

de­in

form

atio

n­ab

out­a

­par

ent­w

ho­d

oes­

not­l

ive­

in­th

e­ho

me,

­chec

k­th

is­b

ox

­

­­­DOH-4220-I­­3/15­­­Page­12­

SEC

TIO

N G

A

ddit

iona

l Hea

lth

Que

stio

ns

SEC

TIO

N H

Pa

rent

or S

pous

e N

ot L

ivin

g

in th

e H

ouse

hold

or D

ecea

sed

Fam

ilies

­who

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lyin

g­fo

r­the

ir­ch

ildre

n­an

d­pr

egna

nt­w

omen

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ired­

to­fi

ll­ou

t­thi

s­sec

tion.

­­All­

othe

r­peo

ple­

who

­are

­app

lyin

g­an

d­ar

e­ag

e­21

­or­o

ver­

mus

t­be­

will

ing­

to­p

rovi

de­in

form

atio

n­ab

out­a

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ent­o

f­an­

appl

ying

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or­o

r­a­sp

ouse

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ng­o

utsi

de­th

e­ho

me­

to­b

e­el

igib

le­fo

r­hea

lth­in

sura

nce,

­unl

ess­t

here

­is­

good

­caus

e.­­C

hild

ren­

may

­still

­be­

elig

ible

­eve

n­if­

a­pa

rent

­is­n

ot­w

illin

g­to

­pro

vide

­this

­info

rmat

ion.

­­If­y

ou­fe

ar­p

hysi

cal­o

r­em

otio

nal­h

arm

­as­a

­resu

lt­of

­pro

vidi

ng­

info

rmat

ion­

abou

t­a­p

aren

t­or­s

pous

e­no

t­liv

ing­

in­th

e­ho

me,

­you

­may

­be­

excu

sed­

from

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vidi

ng­th

is­in

form

atio

n.­T

his­i

s­cal

led­

Good

Cau

se.­Y

ou­m

ay­b

e­as

ked­

to­

show

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­hav

e­a­

good

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on­fo

r­you

r­fea

rs.

IMPO

RTAN

T: M

ost­p

eopl

e­w

ith­M

edic

aid­

mus

t­cho

ose­

a­he

alth

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n;­if

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oose

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ealth

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n­yo

u­m

ay­b

e­au

tom

atic

ally

­enr

olle

d­in

­one

­unl

ess­

it­is

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erm

ined

­you

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mpt

.­ If­

you­

need

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rmat

ion­

abou

t­wha

t­­pl

ans­

are­

avai

labl

e­in

­you

r­cou

nty,­

wha

t­pla

ns­y

our­d

octo

r­is­

in­a

nd­if

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­hav

e­to

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,­ple

ase­

call­

New

Yor

k M

edic

aid

CHOI

CE­a

t­1-8

00-5

05-5

678.

­You

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also

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or­v

isit­

your

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l­Dep

artm

ent­o

f­Soc

ial­S

ervi

ces.­

­If­y

ou­­

alre

ady­

know

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t­pla

n­yo

u­w

ant,­

use­

this

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tion­

for­y

our­p

lan­

choi

ce.

NOT

E:­If

­you

­or­f

amily

­mem

bers

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­foun

d­el

igib

le­fo

r­Med

icai

d,­y

ou­w

ill­b

e­en

rolle

d­in

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heal

th­p

lan­

you­

choo

se­if

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rovi

des­

Med

icai

d.­If

­you

­live

­in­a

­coun

ty­th

at­d

oes­

not­r

equi

re­p

eopl

e­on

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icai

d­to

­join

­a­h

ealth

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n,­­­

you­

can­

tell­

us­y

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o­no

t­wan

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artm

ent­o

f­Soc

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ervi

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or­b

y­ch

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ng­th

is­b

ox­­

If yo

u ar

e in

rece

ipt o

f Med

icar

e,

sk

ip th

is s

ectio

n.

Lega

l Las

t N

ame

Lega

l Fir

st N

ame

Date

of B

irth

Soci

al S

ecur

ity #

Nam

e of

Hea

lth P

lan

Yo

u ar

e En

rolli

ng in

Pref

erre

d Do

ctor

or

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lth C

ente

r (op

tiona

l)

Chec

k Bo

x if

Your

Cur

rent

Pro

vide

rOB

/GYN

(opt

iona

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­­­­­­

­­­­­­

­­­­­­

­­­­­­

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­­­­­­

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­­­

I­agr

ee­to

­hav

e­th

e­in

form

atio

n­on

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licat

ion­

and­

on­th

e­an

nual

­rene

wal

­sha

red­

only

­am

ong­

Med

icai

d,­th

e­he

alth

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ns­in

dica

ted­

in­S

ectio

n­I,­

the­

loca

l­soc

ial­s

ervi

ces­

dist

rict,­

and­

the­

faci

litat

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nrol

lmen

t­or

gani

zatio

n­pr

ovid

ing­

the­

appl

icat

ion­

assi

stan

ce.­I

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o­co

nsen

t­to­

shar

ing­

this

­info

rmat

ion­

with

­any

­sch

ool-b

ased

­hea

lth­ce

nter

­that

­pro

vide

s­se

rvic

es­to

­the­

appl

ican

t(s).­

I­und

erst

and­

this

­info

rmat

ion­

is­b

eing

­sh

ared

­for­t

he­p

urpo

se­o

f­det

erm

inin

g­th

e­el

igib

ility

­of­t

hose

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vidu

als­

appl

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edic

aid,

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o­ev

alua

te­th

e­su

cces

s­of

­thes

e­pr

ogra

ms.­

Each

­app

lyin

g­ad

ult­m

ust­s

ign­

this

­app

licat

ion­

in­th

e­sp

ace­

belo

w.­­

I hav

e re

ad a

nd u

nder

stan

d th

e Te

rms,

Rig

hts a

nd R

espo

nsib

ilitie

s inc

lude

d in

this

app

licat

ion

book

let o

n th

e ne

xt p

age.

­I­ce

rtify

­und

er­p

enal

ty­o

f­per

jury

­that

­eve

ryth

ing­

on­th

is­a

pplic

atio

n­is

­the­

trut

h­as

­­be

st­I­

know

.

Date

Si

gnat

ure

of a

dult

appl

ican

t or

aut

horiz

ed r

epre

sent

ativ

e fo

r th

e ap

plic

ant

Date

Si

gnat

ure

of a

dult

appl

ican

t or

aut

horiz

ed r

epre

sent

ativ

e fo

r th

e ap

plic

ant

STO

P

­­­DOH-4220-I­­3/15­­­Page­13­

SEC

TIO

N I

H

ealt

h Pl

an S

elec

tion

SEC

TIO

N J

S

igna

ture

TERMS, RIGHTS AND RESPONSIBILITIES

By­completing­and­signing­this­application,­I­am­applying­for­Medicaid.­I­understand­that­this­application,­notices­and­other­supporting­information­will­be­sent­to­the­program(s)­for­which­­I­want­to­apply.­I­agree­to­the­release­of­personal­and­financial­information­from­this­application­and­any­other­information­needed­to­determine­eligibility­for­these­programs.­I­understand­that­I­­may­be­asked­for­more­information.­I­agree­to­immediately­report­­any­changes­to­the­information­on­this­application.

•­­ ­I­understand­that­I­must­provide­the­information­needed­to­­prove­my­eligibility­for­each­program.­If­I­have­been­unable­to­­get­the­information­for­Medicaid,­I­will­tell­the­social­services­­district.­The­social­services­district­may­be­able­to­help­in­getting­­the­information.

•­­ ­If­I­am­applying­at­a­place­other­than­a­local­department­of­social­services,­and­my­children­are­not­found­eligible­for­Medicaid­­using­this­application,­I­can­contact­the­local­department­of­social­services­to­see­if­my­children­are­eligible­for­Medicaid­on­some­­other­basis.

•­ ­I­understand­that­workers­from­the­programs­for­which­family­members­or­I­have­applied­may­check­the­information­given­by­me­for­this­application.­The­agencies­that­run­these­programs­will­keep­this­information­confidential­according­to­42­U.S.C.­1396a­(a)­(7)­and­42­CFR­431.300-431.307,­and­any­federal­and­state­laws­and­regulations.

•­­ ­I­understand­that­Medicaid,­will­not­pay­medical­expenses­that­insurance­or­another­person­is­supposed­to­pay,­and­that­if­I­am­applying­for­Medicaid,­I­am­giving­to­the­agency­all­of­my­rights­to­pursue­and­receive­medical­support­from­a­spouse­or­parents­of­persons­under­21­years­old­and­my­right­to­pursue­and­receive­third­party­payments­for­the­entire­time­I­am­in­receipt­of­benefits.

•­­ ­I­will­file­any­claims­for­health­or­accident­insurance­benefits­or­any­other­resources­to­which­I­am­entitled.­I­understand­that­I­­have­the­right­to­claim­good­cause­not­to­cooperate­in­using­health­insurance­if­its­use­could­cause­harm­to­my­health­or­safety­or­to­the­health­and­safety­of­someone­I­am­legally­responsible­for.

•­­ ­I­understand­that­my­eligibility­for­Medicaid­will­not­be­affected­by­my­race,­color,­or­national­origin.­I­also­understand­that­depending­on­the­requirements­of­the­program,­my­age,­sex,­disability­or­citizenship­status­may­be­a­factor­in­whether­or­not­I­am­eligible.

•­­ ­I­understand­that­if­my­child­is­on­Medicaid,­he­or­she­can­get­comprehensive­primary­and­preventive­care,­including­all­necessary­treatment­through­the­Child/Teen­Health­Program.­I­can­get­more­information­on­this­program­from­the­local­department­­of­social­services.

•­­ ­I­understand­that­anyone­who­knowingly­lies­or­hides­the­truth­in­order­to­receive­services­under­these­programs­is­committing­a­crime­and­subject­to­federal­and­state­penalties­and­may­have­to­­repay­the­amount­of­benefits­received­and­pay­civil­penalties.­­The­New­York­State­Department­of­Tax­and­Finance­has­the­right­­to­review­income­information­on­this­form.

SOCIAL SECURITY NUMBER

SSNs­are­required­for­all­applicants,­unless­the­person­is­pregnant­or­a­non-qualified­alien.­SSNs­are­not­required­for­members­of­my­household­who­are­not­applying­for­benefits­unless­the­person­is­my­spouse­and­my­eligibility­depends­on­the­amount­of­resources­owned­by­my­spouse.­I­understand­that­this­is­required­by­Federal­Law­at­42­U.S.C.­1320b-7­(a)­and­by­Medicaid­regulations­at­42­CFR­435.910.­SSNs­are­used­in­many­ways,­both­within­department­of­social­­services­(DSS)­and­between­the­DSS­and­federal,­state,­and­local­agencies,­both­in­New­York­and­other­jurisdictions.­Some­uses­of­SSNs­are:­to­check­identity,­to­identify­and­verify­earned­and­unearned­income,­to­see­if­non-custodial­parents­can­get­health­insurance­coverage­for­applicants,­to­see­if­applicants­can­get­medical­support,­­to­see­if­applicants­can­get­money­or­other­help,­and­to­verify­­resources­with­financial­institutions­for­applicants­and­their­­non-applying­spouse.­SSNs­may­also­be­used­for­identification­of­­the­recipient­within­and­between­central­governmental­Medicaid­­agencies­to­insure­proper­services­are­made­available­to­the­recipient.­Also,­if­I­apply­for­other­programs­in­this­joint­application,­those­programs­will­have­access­to­my­SSN­and­could­use­it­in­the­­administration­of­the­program.

FOR MEDICAID APPLICANTS ONLY

•­­ ­Release­of­Educational­Records­I­give­permission­to­the­local­department­of­social­services­and­New­York­State­to­obtain­any­information­regarding­the­educational­records­of­my­child(ren),­herein­named,­necessary­for­claiming­Medicaid­reimbursements­for­health-related­educational­services,­and­to­provide­the­appropriate­federal­government­agency­access­to­this­information­for­the­sole­purpose­of­audit.

•­­ ­Early­Intervention­Program­If­my­child­is­evaluated­for­or­participates­in­the­New­York­State­Early­Intervention­Program,­I­give­permission­to­the­local­­department­of­social­services­and­New­York­State­to­share­my­child’s­Medicaid­eligibility­information­with­my­county­Early­­Intervention­Program­for­the­purpose­of­billing­Medicaid.

•­­ ­Reimbursement­of­Medical­Expenses­I­understand­that­I­have­a­right­as­part­of­my­Medicaid­application,­or­later,­to­request­reimbursement­of­expenses­I­paid­for­covered­medical­care,­services­and­supplies­received­during­the­three­month­period­prior­to­the­month­of­my­application.­After­the­­date­of­my­application,­reimbursement­of­covered­medical­care,­services­and­supplies­will­only­be­available­if­obtained­from­­Medicaid­enrolled­providers.

MEDICAID MANAGED CARE

I­have­read­how­to­find­out­whether­my­county­requires­Medicaid­­enrollees­to­join­a­health­plan,­and­how­to­find­out­what­health­plans­are­available­to­me­in­Medicaid­managed­care.­I/we­also­understand­that­if­I/we­are­found­eligible­for­Medicaid­and­I/we­are­in­a­county­that­requires­Medicaid­enrollees­to­be­in­a­managed­care­health­plan,­I/we­will­be­enrolled­in­the­health­plan­I/we­chose­unless­that­health­plan­does­not­participate­in­Medicaid­managed­care.

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If­I/we­are­in­a­county­that­does­not­require­enrollees­to­be­in­a­­Medicaid­managed­care­health­plan,­I/we­will­still­be­enrolled­in­the­health­plan­I/we­chose­unless­I/we­notify­my­local­social­services­­department­in­writing,­or­I/we­check­the­box­in­Section­I,­that­I/we­do­not­want­to­be­in­that­plan.

I­have­read­how­to­find­out­the­rights­and­benefits­that­I­will­have­as­­a­member­of­a­managed­care­health­plan­and­the­benefit­limitations­of­managed­care­membership.­I­understand­that­in­Medicaid­managed­care,­I­must­choose­a­Primary­Care­Provider­(PCP)­and­that­I­will­have­a­choice­from­at­least­three­PCPs­in­my­health­plan.­I­understand­that­once­I­enroll­in­a­health­plan,­I­will­have­to­use­my­PCP­and­other­providers­in­my­health­plan­except­in­a­few­special­circumstances.

­­­­­I­understand­that­if­a­child­is­born­to­me­while­I­am­a­member­of­a­Medicaid­managed­care­health­plan,­my­child­will­be­enrolled­in­the­same­health­plan­that­I­am­in.­I­understand­that­if­a­child­is­born­­to­me­while­I­am­a­member­of­a­Medicaid­managed­care,­my­child­will­be­enrolled­in­the­same­health­plan­that­I­am­in.­­­­

•­­ ­Release­of­Medical­Information­I­consent­to­the­release­of­any­medical­information­about­me­and­any­members­of­my­family­for­whom­I­can­give­consent:­

­ •­­­By­my­PCP,­any­other­health­care­provider­or­the­New­York­State­Department­of­Health­(NYSDOH)­to­my­health­plan­and­any­health­care­providers­involved­in­caring­for­me­or­my­family,­­as­reasonably­necessary­for­my­health­plan­or­my­providers­to­­carry­out­treatment,­payment,­or­health­care­operations.­This­­may­include­pharmacy­and­other­medical­claims­information­needed­to­help­manage­my­care;­

­ •­­­­By­my­health­plan­and­any­health­care­providers­to­NYSDOH­and­other­authorized­federal,­state,­and­local­agencies­for­purposes­of­administration­of­the­Medicaid­programs;­and

­ •­­­By­my­health­plan­to­other­persons­or­organizations,­as­­reasonably­necessary­for­my­health­plan­to­carry­out­treatment,­payment,­or­health­care­operations.­

I­also­agree­that­the­information­released­for­treatment,­payment­and­health­care­operations­may­include­HIV,­mental­health­or­alcohol­and­substance­abuse­information­about­me­and­members­of­my­family­to­the­extent­permitted­by­law,­until­I­revoke­this­consent.­

If­more­than­one­adult­in­the­family­is­joining­a­Medicaid­health­plan,­the­signature­of­each­adult­applying­is­necessary­for­consent­to­release­information.

TERMS, RIGHTS AND RESPONSIBILITIES

FOR OFFICE USE ONLY

To be completed by the person assisting with the application

Signature­of­Person­Who­Obtained­Eligibility­Information:

X

Employed­By:­(check­one)­­­

­ ­­Health­Plan­­­­­­­­ ­­Social­Services­District­­­­­­­­­ ­­Provider­Agency­­­­­­­­ ­­Qualified­Entities

­Employer­Name:

To be used by the local Social Services District

Eligibility­Determined­By: Date: Eligibility­Approved­By: Date:

Center­Office: Application­Date: Unit­ID: Worker­ID:

Case­Name: District: Case­Type: Case­#:

Effective­Date: MA­Disposition­Reason­Code:

­ ­­Denial­Code­­­­ ­­Withdrawal

Proxy:­

­ ­­Yes­­­­­­­­­­­­­­­­­ ­­No

Registry­#: Ver:

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