NYS Medicaid Application Form and "Supplement A" for Age 65+ or Disabled or Blind

Since 2010, the New York State Department of Health Medicaid application form is called the  Access NY Application or Health Insurance Application or form DOH-4220 - available at this link. (As of 2-06-25 the form was last updated in January 2023.)  See GIS 23 MA/17 - Revised DOH-4220: Access NY Health Care Application (PDF)  and attached form.  

Links to the form in various languages can be found at this  State Dept. of Health webpage https://www.health.ny.gov/health_care/medicaid/how_do_i_apply.htm  (SCROLL DOWN to "Medicaid Application for Non-MAGI Eligibility Group (DOH-4220)" 

• Second form is also required - Supplement A - for those age 65+ or who are disabled or blind.  As of Jan. 2021 the same Supplement A form is used statewide - DOH-5178A (English). The DOH 4495A form is obsolete. Links to the form in various languages can be found at this  State Dept. of Health webpage https://www.health.ny.gov/health_care/medicaid/how_do_i_apply.htm  - SCROLL DOWN. 

• 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 both in the community and in a Nursing Home, Medicare Savings Program, the Medicaid Buy-In Program for Working People with Disabilities.   But it must be submitted with the Supplement A form.

The state revised the  DOH-4220 Medicaid Application form in January 2023 - see GIS 23 MA/17 - Revised DOH-4220: Access NY Health Care Application (PDF) .  That directive instructed local Medicaid offices that if an applicant is using an older version of the DOH-4220 form (dated 8/2021), the applicant must also submit the OHIP-0112 and DOH-5130.  

DO NOT USE THE DOH-4220 FOR:

• Medicaid applicants in the MAGI category (generally those under age 65 or, if younger and disabled,  are not receiving Medicare).  All MAGI applicants should go through the NYS of Health Exchange to apply for Medicaid.  They can contact a Navigator  or Community Health Advocates for assistance.    See this article for more about these different Medicaid categories.

• Applicants who only want ONLY a Medicare Savings Program (MSP) and not Medicaid too.  They should use the MSP-only application . 

WHAT IF THE APPLICANT CANNOT SIGN THE APPLICATION - or wants to appoint someone as their "Authorized Representative" to discuss their case? 

• Spouse or "authorized representative" can sign.   On page 1 Section A of the Application there is space to authorize a representative to apply and renew Medicaid,  discuss the case, and receive notices and other correspondence.  If this section is not completed on the application, a representative can be authorized later using Form DOH-5247, which is an Attachment to  DOH GIS 17 MA/017: Introduction to Form DOH-5247 - Medicaid Authorized Representative Designation/Change Request.    The form is available in several languages at this link.  

• If  neither spouse or authorized representative cans sign the application, use Form DOH-5147, “Submission of Application on Behalf of Applicant”  (Attachment 1 to 17ADM-02 - Asset Verification System) 

DOH APPLICATION - WHERE TO FIND ONLINE

Check   https://www.health.ny.gov/health_care/medicaid/how_do_i_apply.htm 

• Warning - The top of the State webpage above says "You may apply for Medicaid in the following ways" - listing FOUR options - the NYS of Health Exchange, managed care plans, calling the Medicaid helpline  and 4th - at your local Department of Social Services.  THIS IS MISLEADING for those who are age 65+, disabled or blind.  Their ONLY Option is the 4th option - to apply at their local Dept. of Social Services. 

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.