GUIDE TO COMPLETE YOUR
MEDICAID RENEWAL
Medical Assistance Program/OMR
ASSISTANCE WITH YOUR MEDICAID RENEWAL / FREE INTERPRETATION SERVICES
This booklet will help you complete your Renewal. We have included an English and a translated version.
Return only one. For help with your Renewal, call the HRA Medicaid Helpline at 1-888-692-6116 or
contact one of the Managed Care Plans listed on Page 4 of this booklet. Hearing impaired consumers
may call 711 or 1-718-636- 7783 with a Text Telephone (TTY) device (not a standard phone).
Free interpretation services are available over the phone or in any Medicaid office.
Remainder of page left blank intentionally
OMR Booklet (English) 12/21/2023 1
MAIL RENEWAL CHANGES
You may continue to call the HRA Medicaid Helpline at 1-888-692-6116 if you have any questions
about your Renewal Form. You can also contact one of the Managed Care Plans listed on Page
4 of the enclosed Guide to Complete your Medicaid Renewal Forms for assistance.
This is the only Renewal Application that will be automatically sent to you. Please keep it in a safe
place until you are ready to return it to us. We must receive your reply through the mail by the date
printed on Page 1 of the Application, or your coverage may end.
You can still pre-screen for additional benefits at the Access NYC site. It can be accessed by going
to http://access.nyc.gov/ and selecting Social Services from the menu located at the bottom of the
page. The site is safe, secure and easy to use.
Note:
•
You do not need to send proof of US citizenship at this time. You also do not need to send proof
of income unless the Renewal Form instructs you to do so.
➢ If you would like, you may send either or both now to help ensure that we have your
most accurate information.
➢ If you decide not to send proof now, we may write you to request that you do so at a later
date. The “Documentation Guide” on Pages 5 and 6 of this booklet show you the types of
proofs that we accept.
•
If you tell us that you are a US citizen, we will attempt to verify citizenship using a computer match. If
we are unable to do so, we will write to you to let you know that and request that
you send us proof.
•
We will also attempt to verify your income using a computer match. If the match results are
different than your self-reported information, the match results may be used when determining
your eligibility.
➢ If you decide not to send proof now, we may write you to request that you do so at a later
date.The “Documentation Guide” on Pages 5 and 6 of this booklet show you the types of
proofs that we accept.
•
If you recently moved from New York City to another county within New York State, but have not
yet had a public health insurance case opened where you now live, you should complete and
return this Renewal Form to us. We will assist you in transferring your coverage.
OMR Booklet (English) 12/21/2023 2
MEDICAID PARTICIPATING
MANAGED CARE PLANS
TELEPHONE
NUMBER
Bronx
Brooklyn
Manhattan
Queens
Staten Island
AFFINITY HEALTH PLAN
866-247-5678
⚫
⚫
⚫
⚫
⚫
EMBLEM HEALTH (formerly GROUP HEALTH
INSURANCE/HIP HEALTH PLAN OF GREATER
NY- GHI/HIP)
800-447-8255
⚫
⚫
⚫
⚫
⚫
HEALTHFIRST PHSP, INC.
866-463-6743
⚫
⚫
⚫
⚫
⚫
HEALTHPLUS AN AMERIGROUP COMPANY
800-950-7679
⚫
⚫
⚫
⚫
⚫
METRO-PLUS (METROPOLITAN HEALTH PLUS)
800-303-9626
⚫
⚫
⚫
⚫
⚫
NY STATE CATHOLIC HEALTHPLAN/FIDELIS
888-343-3547
⚫
⚫
⚫
⚫
⚫
UNITED HEALTHCARE COMMUNITY PLAN
(formerly AMERICHOICE BY UNITED/
AMERCHOICE OF NY INC.)
800-493-4647
⚫
⚫
⚫
⚫
⚫
WELLCARE OF NY, INC.
800-308-2571
800-215-1531
⚫
⚫
⚫
⚫
MEDICAID RENEWAL SITE
785 Atlantic Ave.
Brooklyn, NY 11238
888-692-6116
OMR Booklet (English) 12/21/2023 3
DOCUMENTATION GUIDE TO CONTINUE YOUR HEALTH CARE COVERAGE
Here is a list of proofs the Medical Assistance Programs accepts. Please use this guide with the Instructions
on the cover of the Renewal Notification Booklet to determine what documents you may need to provide in
order to continue health care coverage.
INCOME:
Wages and Salary/Employment
•
Current paycheck/stub(s) or payroll records
•
Detailed written statement from employer
•
W-2 (MBI-WPD consumers only)
•
Income tax return
(MBI-WPD consumers only)
Self Employment
•
Signed income tax return
•
Records of earnings and expenses
Work Income Type of Proof
• If salary stays the same --------------------------------------→
Copy of last pay stub or letter from employer.
•
If salary changes from pay period to pay period -------→
Copies pay stubs covering last 4
weeks or letter from employer.
•
If any part of your salary/income is paid in cash
and your employer will not provide written proof -----→
Answer “Yes” to the first question at the
bottom of the INCOME section of Page 2 of
Renewal Booklet
•
If self-employed
------------------------------------------------
→
Copy of most recent tax return and letter
(signed by you) of current income If income has
changed, explain why.
•
If receiving unemployment benefits
----------------------
→ Send copy of unemployment insurance award
letter or internet Printout from the NYS
Department of Labor:
https://ui.labor.state.ny.us/UBC/home.do
Unemployment Benefits
Social Security
Military Pay
Award Letter/certificate
Award Letter/certificate
Award Letter
Benefit statement or printout
Benefit Check
Check Stub
Letter from NYS Department
of Labor
Letter from Social Security
Administration
Child Support/Alimony
Worker’s Compensation
Income from Rent or
Room/Board
Letter from person providing
support or letter from court
Award Letter
Letter from roomer,
boarder, tenant
Child support/alimony check
stub
Check Stub
Check stub
Interest/Dividends/Royalties
Veteran’s Benefits
Private Pensions/Annuities
Letter from bank or credit
union
Award Letter
Statement from
pension/annuity
Letter from broker
Benefit check stub
Letter from agent
Letter from Veterans’
Administration
OMR Booklet (English) 12/21/2023 4
CITIZENSHIP: (If you are declaring to be a US citizen, you do not need to send proof
at this time. If documents are needed, you will receive a letter requesting them.)
•
US Passport • Certificate of U.S. Citizenship
• Certificate of Naturalization
•
U. S. Birth Certificate and one of the following identity proofs: (1) Driver’s license with
photograph, or other identifying information (2) School identification card with photograph, (3)
U.S. military card or draft record, (4) ID card issued by Federal, State or local government with
the same information included on a driver’s license.
IMMIGRATION STATUS: The following are documents issued by United States Citizenship &
Immigration Services (USCIS)
•
I-551 Permanent Resident Card
(Green Card)
•
I-94 Arrival/Departure Record
•
I-688B or 1-766 Employment Authorization Card
•
I-797 (Notice Of Action) or other official correspondence
to and from USCIS, ICE or EIOR
CHILDCARE/DEPENDENT CARE: Documents must include the amount you pay and how often
•
Letter from day care center or other child/adult care provider
•
Canceled checks or receipts that prove payment of care services
PREGNANCY:
•
Statement from doctor/medical professional with expected date of delivery
PRIVATE HEALTH INSURANCE: Documents must include the amount you pay
•
Insurance policy
• Certificate of insurance • Insurance card • Other proof of
private insurance
WE ACCEPT PHOTOCOPIES OF ALL DOCUMENTS OTHER THAN THOSE REQUIRED TO
PROVE YOUR CITIZENSHIP OR IDENTITY
OMR Booklet (English) 12/21/2023 5
DOCUMENTATION GUIDE TO CONTINUE YOUR HEALTH CARE COVERAGE cont’d
TERMS, RIGHTS AND RESPONSIBILITIES
By completing and signing this form, I am applying to renew Medicaid and/or Family Planning
Benefit Program coverage.
I understand that I must provide the information needed to prove my eligibility for each program.
I agree to immediately report any changes to the information on this form. If I am unable to get
the information, I will tell the social services district. The social services district may be able to
help in getting the information.
I understand that workers from the programs for which family members or I are renewing may
check the information given by me on this form. The agencies that run these programs will
keep this information confidential according to 42 U.S.C. 1396a (a) (7) and 42 CFR 431.300-
431.307, and any federal and state laws and regulations.
I understand that Medicaid and/or Family Planning Benefit Program coverage will not pay
medical expenses that insurance or another person is supposed to pay, and that I am giving
to the agency all of my rights to pursue and receive medical support from a spouse or parents
of persons under 21 years old and my right to pursue and receive third party payments for the
entire time I am in receipt of benefits.
I will file any claims for health or accident insurance benefits or any other resources to which I
am entitled. I understand that I have the right to claim good cause not to cooperate in using
health insurance if its use could cause harm to my health or safety or to the health and safety
of someone I am legally responsible for.
I understand that my eligibility for these programs will not be affected by my race, color, or
national origin. I also understand that depending on the requirements of these individual
programs, my age, disability or citizenship status may be a factor in whether or not I am eligible.
I understand that if my child is on Medicaid, they can get comprehensive primary and preventive
care, including all necessary treatment through the Child/Teen Health Program.
I understand that anyone who knowingly lies or hides the truth in order to receive services
under these programs is committing a crime and subject to federal and state penalties and
may have to repay the amount of benefits received and pay civil penalties. The New York
State Department of Tax and Finance has the right to review income information on this form.
CERTIFICATION OF CITIZENSHIP/IMMIGRATION STATUS I certify under penalty of
perjury, by signing my name on this form, that I, and/or any person for whom I am signing is
a U.S. citizen or national of the United States or has satisfactory immigration status. The term
“satisfactory immigration status” means an immigration status that does not make the person
ineligible for benefits. Important Information: The United States Citizenship and Immigration
Services (USCIS) has said that enrollment in Medicaid CANNOT affect a person’s ability to get
a green card, become a citizen, sponsor a family member or travel in and out of the country
(except if Medicaid pays for long term care in a place like a nursing home or psychiatric hospital).
The State will not report any information on this application to the USCIS.
OMR Booklet (English) 12/21/2023 6
SOCIAL SECURITY NUMBER All applicants must provide a social security number or proof
that they have applied for one or tried to apply for one. The only exceptions are pregnant
individuals, undocumented immigrants and temporary non-immigrants applying for the
treatment of an emergency medical condition, and certain battered immigrants. SSNs are
not required for members of my household who are not applying for benefits. I understand
that this is required by Federal Law at 42 U.S.C. 1320b-7 (a) and by Medicaid regulations at
42 CFR 435.910. SSNs are used in many ways, both within Department of Social Services
(DSS) and between the DSS and federal, state, and local agencies, both in New York and other
jurisdictions. Some uses of SSNs are: to check identity, to identify and verify earned and
unearned income, to see if non custodial parents can get health insurance coverage for
applicants, to see if applicants can get medical support, and to see if applicants can get money
or other help. SSNs may also be used for identification of the recipient within and between
central governmental Medicaid agencies to insure proper services are made available to the
recipient.
RELEASE OF MEDICAL INFORMATION I consent to the release of any medical information
about me and any members of my family for whom I can give consent: by my Primary Care
Provider, any other health care provider or the New York State Department of Health (SDOH)
to my health plan and any health care providers involved in caring for me or my family, as
reasonably necessary for my health plan or my providers to carry out treatment, payment, or
health care operations; by my health plan and any health care providers to SDOH and other
authorized federal, state, and local agencies for purposes of administration of the Medicaid;
and, by my health plan to other persons or organizations, as reasonably necessary for my
health plan to carry out treatment, payment, or health care operations. I also agree that the
information released may include HIV, mental health or alcohol and substance abuse
information about me and members of my family, to the extent permitted by law. If more than
one adult in the family is joining a Medicaid health plan, the signature of each adult applying
is necessary for consent to release information.
MEDICAID MANAGED CARE If I am adding a family member to a Medicaid case and I live in
a county that requires Medicaid recipients to join a health plan, I understand that this family
member will be enrolled in the same health plan as my family, unless they are exempt or
excluded.
RELEASE OF EDUCATIONAL RECORDS I give permission to the Local Department of Social
Services and New York State to obtain any information regarding the educational records of
my child(ren), herein named, necessary for claiming Medicaid reimbursements for health-
related educational services, and to provide the appropriate federal government agency
access to this information for the sole purpose of audit.
EARLY INTERVENTION PROGRAM If my child is evaluated for or participates in the New
York State Early Intervention Program, I give permission to the local Department of Social
Services and New York State to share my child's Medicaid eligibility information with my county
Early Intervention Program for the purpose of billing Medicaid. I consent to sharing this
information with any school-based health center that provides services to the applicant(s).
OMR Booklet (English) 12/21/2023 7
PRIVACY NOTICE
MAP-2020c (E) 12/21/2023
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. REVIEW IT CAREFULLY.
The New York Medicaid program must tell you how we use, share, and protect your
health
information. The New York Medicaid program includes regular Medicaid and
Medicaid Managed Care.
The program is administered by the New York State
Department of Health and the Local Departments
of Social Services.
Your Health Information is Private.
We are required to keep your information private, share your information only when we
need to, and follow
the privacy practices in this notice. We must make special efforts to
protect the names of people who get
HIV/AIDS or drug and alcohol services.
What Health Information Does the New York Medicaid Program Have?
When you applied for Medicaid, you may have provided us with information about your
health. When your
doctors, clinics, hospitals, managed care plans and other health care
providers send in claims for payment,
we also get information about your health, treatments,
and medications.
How Does the New York Medicaid Program Use and Share Your Health Information?
We must share your health information when:
•
You or your representative requests your health information.
•
Government agencies request the information as allowed by law such as audits.
•
The law requires us to share your information.
In your Medicaid application, you gave the New York Medicaid Program the right to use and
share your health
information to pay for your health care and operate the program. For
example, we use and share your
information to:
•
Pay your doctor, hospital, and/or health care provider bills.
•
Make sure you receive quality health care and that all the rules
and laws have been followed.
We may review your health information:
•
To determine whether you received the correct medical procedure or health
care equipment.
•
Contact you about important changes in your health benefits.
•
Make sure you are enrolled in the right health program.
MAP-2020c (E) 12/21/2023 Page 1 of 3
•
Collect payment from other insurance companies.
•
To determine eligibility in Medicare Part D or other insurance
programs that might be more
economical to you.
We may also use and share your health information under limited circumstances to:
•
Study health care. We may look at the health information of many consumers to find
ways to provide better
health care.
•
Prevent or respond to serious health or safety problems for you or your
community as allowed by
federal and state law.
Your written authorization is required for other uses and disclosures:
•
Psychotherapy notes
•
Uses and disclosures of Protected Health Information for marketing purposes,
including subsidized
treatment communications
•
Disclosures that constitute a sale of your Protected Health Information.
We must have your written permission to use or share your health information for any purpose
not mentioned in
this notice unless we are required to do so by the laws that apply to us.
What Are Your Rights?
You or your representatives have the right to:
•
Get a paper copy of this notice.
•
See or get a copy of your health information. If your request is denied, you have the
right to review the
denial.
•
Ask to change your health information. We will look at all requests, but cannot change
bills sent by your
doctor, clinic, hospital or other health care provider.
•
Ask to limit how we use and share your information. We will look at all requests, but do
not have to agree to
what you ask except where required by law to make such a
disclosure.
•
Ask us to contact you regarding your health care information in different ways (for
example, you can ask us
to send your mail to a different address).
•
Ask for special forms that you sign permitting us to share your health information with
whomever you
choose. You can take back your permission at any time, as long as the
information has not already been
shared.
•
Get a list of those who received your health information. This list will not include health
information
requested by you or your representative, information used to operate the New
York Medicaid Program or
information given out for law enforcement purposes.
•
Be notified upon a breach of any of your unsecured Protected Health Information.
MAP-2020c (E) 12/21/2023 Page 2 of 3
See the New York City Human Resources Administration web site for an electronic copy of
this notice
(https://www1.nyc.gov/assets/hra/downloads/pdf/services/micsa/privacy_notice.pdf).
You may also visit the New
York State Department of Health web site to see an alternate
version
(https://www.health.ny.gov/health_care/medicaid/program/hipaa/notepriveng.htm).
*You will not be penalized for filing a complaint. If we change the information in this
notice, we will post
the amended version on our website at:
(https://www1.nyc.gov/assets/hra/downloads/pdf/services/micsa/privacy_notice.pdf)
Do you have a medical or mental health condition or disability? Does this condition
make it hard for you
to understand this notice or to do what this notice is asking? Does this
condition make it hard for you to get
other services at HRA? We can help you. Call us at
888-692-6116. You can also ask for help when you visit
an HRA office. You have a right to
ask for this kind of help under the law.
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