WGIUPD GENERAL INFORMATION SYSTEM 11/01/07 DIVISION: Office of Health Insurance Programs PAGE 1 GIS 07 MA/022
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1 WGIUPD GENERAL INFORMATION SYSTEM 11/01/07 DIVISION: Office of Health Insurance Programs PAGE 1 GIS 07 MA/022 TO: Local District Commissioners, Medicaid Directors FROM: Linda LeClair, Director, Bureau of Medicaid/FHP Enrollment, Division of Coverage and Enrollment SUBJECT: Forms and Notices EFFECTIVE DATE: Immediately CONTACT PERSON: Local District Liaison: Upstate (518) New York City (212) The purpose of this GIS is to inform social services districts and users of the Department of Health (DOH) intranet that additional forms have been added to the DOH, Office of Health Insurance Programs website: Please see the attachment for a listing of all forms and notices which are available on the intranet. As forms/notices become available on the intranet, they will no longer be available for ordering through the warehouse. Districts must reproduce Action Taken Notices as legal size and two-sided (not two-paged) notices. It is particularly important that these notices be two-sided to ensure the recipient is properly identified when the notice is received by the Office of Temporary and Disability Assistance for fair hearing purposes. Both the English and Spanish Action Taken Notices should be printed on legal size paper (8½ inches x 14 inches). At this time, the Spanish version of some documents is not available, on the intranet. As they become available you will be notified. 06 OMM/ADM-5: Deficit Reduction Act of 2005 Long-Term Care Medicaid Eligibility Changes provided you with copies of the following notices and stated that districts should reproduce and use these documents until further notice. These documents are now updated and available on the intranet. All copies of the previous documents should be destroyed. DOH-4319: Long-Term Care Change In Need Resource Checklist LDSS-4144: Notice of Decision on Your Medical Assistance Application, Limited Coverage (Transfer of Assets Penalty) LDSS-4145: Notice of Decision on Your Request for Coverage of Nursing Facility Service, Limited Coverage (Transfer of Assets Penalty) LDSS-4294: Explanation of the Effect of Transfer of Asset(s) on Medical Assistance Eligibility OHIP-0001: Notice of Decision on Your Request For Undue Hardship Transfer of Asset(s) Penalty If you have any concerns or questions, please contact your local district liaison.
2 FORM NUMBER DOH-4272 DOH-4272S DOH-4282 DOH-4282S DOH-4283 DOH-4283S DOH-4284 DOH-4284S DOH-4286 DOH-4286S DOH-4287 DOH-4287S DOH-4289 DOH-4289S DOH-4290 DOH-4290S DOH-4312 DOH-4313 DOH-4314 DOH-4315 DOH-4315S DOH-4319 DOH-4319S DOH-4320 DOH-4320S DOH-4321 DOH-4321S DOH-4328 DOH-4328S DOH-4418 DOH-4418S LDSS-0486 LDSS-0486T LDSS-0639 LDSS-0654 LDSS-0901 LDSS-0939 LDSS-0939S LDSS-1151 FORM TITLE Notice of Acceptance For Family Health Plus Notice of Acceptance For Family Health Plus Family Planning Benefit Program Application Family Planning Benefit Program Application Notice of Decision on Your Family Planning Application (Acceptance) Notice of Decision on Your Family Planning Application (Acceptance) Applicant Release Agreement English Applicant Release Agreement Family Planning Benefit Program Application (Instructions) Family Planning Benefit Program Application (Instructions) Continuing Your Medicaid/Family Health Plus Continuing Your Medicaid/Family Health Plus Notice of Decision on Your Medical Assistance Application (Family Planning Acceptance) Notice of Decision on Your Medical Assistance Application (Family Planning Acceptance) Notice of Decision on Your Medical Assistance Application Medicaid/Family Health Plus Denial/Family Planning Benefit Program Declination Notice of Decision on Your Medical Assistance Application Medicaid/Family Health Plus Denial/Family Planning Benefit Program Declination Notice of Decision To Approve Or Deny Enrollment In The Care At Home I And II Waiver Program Notice of Decision To Approve Or Deny Enrollment In The Care At Home I And II Waiver Program Program Program (NYC-ONLY) Program (NYC-ONLY) Long-Term Care Change In Need Resource Checklist Long-Term Care Change In Need Resource Checklist Authorization For Short-Term Rehabilitative Nursing Home Care Authorization For Short-Term Rehabilitative Nursing Home Care Notice of Acceptance of Your Medical Assistance Application (Community Coverage Without Long-Term Care) Notice of Acceptance of Your Medical Assistance Application (Community Coverage Without Long-Term Care) Medicare Savings Program Application Medicare Savings Program Application Idenity, Citizenship and/or Immigration Status for the Medical Assistance Program Idenity, Citizenship and/or Immigration Status for the Medical Assistance Program Medical Report for Determination of Disability Medical Report for Determination of Disability Disability Review Team Certificate Transmittal Sheet Disability Forms Authorization for Medical Examination and Payment Request MA Questionnaire - Responsible Relative MA Questionnaire - Responsible Relative Disability Interview Page 1
3 LDSS LDSS-1348 LDSS-2284 LDSS-2353 LDSS-2400 LDSS-2831A LDSS-3139 LDSS-3183 LDSS-3286 LDSS-3377 LDSS-3451 LDSS-3457 LDSS-3477 LDSS-3478 LDSS-3622 LDSS-3622S LDSS-3623 LDSS-3623S LDSS-3817 LDSS-3818 LDSS-3827 LDSS-3827S LDSS-3868 LDSS-3868S LDSS-3869 LDSS-3869S LDSS-3955 LDSS-3973 LDSS-3973S LDSS-4021 LDSS-4021S LDSS-4022 LDSS-4022S LDSS-4023 LDSS-4023S LDSS-4038 LDSS-4038S LDSS-4040 LDSS-4040S LDSS-4141 LDSS-4141S LDSS-4144 LDSS-4144S LDSS-4145 Disability Interview Continuation Sheet Authorization - Voucher for Medical, Travel and Incidental Expenses SDX Change Form Eye-Exam Clearance - Blind Applicant for MA Request for Child/Teen Health Program Services Temporary Medicaid Authorization (3-Part) Home Assessment Abstract Provider/Recipient Letter (Financial Obligation of Recipient Toward Medical Expenses) Information Concerning Medical Assistance for SSI Beneficiaries (Spanish on Reverse) Mandatory Eye Exam Report CBVH Medical Eye Report Budget Worksheet - MA - SSI Related Budgeting and Monthly Deeming Worksheet Principal Provider Data Input Form Restriction/Exception Data Input Form Notice of Decision on Your Medical Assistance Application Notice of Decision on Your Medical Assistance Application Notice of Intent to Discontinue/Change Medical Assistance Notice of Intent to Discontinue/Change Medical Assistance Mental Residual Functional Capacity Assessment Psychiatric Review Technique Burial Fund Acknowledgement Burial Fund Acknowledgement Notice of Medical Assistance Review Notice of Medical Assistance Review Notice of Decision on Reimbursement of Medical Bills by MA Program Notice of Decision on Reimbursement of Medical Bills by MA Program Certification of Treatment of Emergency Medical Condition Notice of Decision on Your MA Application (Excess Income/Resources) Notice of Decision on Your MA Application (Excess Income/Resources) Notice of Intent to Change the Contribution Toward Chronic Care Costs Notice of Intent to Change the Contribution Toward Chronic Care Costs Notice of Intent to Establish a Liability Toward Chronic Care Notice of Intent to Establish a Liability Toward Chronic Care Notice of Intent to Discontinue for Failure to Comply With Recertification Procedures Notice of Intent to Discontinue for Failure to Comply With Recertification Procedures Explanation of the Excess Income Program Explanation of the Excess Income Program Notice of Decision on Eligibility for the Medicare Buy-In Program (Active MA Only Recipients) Notice of Decision on Eligibility for the Medicare Buy-In Program (Active MA Only Recipients) Notice of Medical Assistance Disability Determination Notice of Medical Assistance Disability Determination Notice of Decision On Your Medical Assistance Application, Limited Coverage (Transfer of Assets Penalty) Notice of Decision On Your Medical Assistance Application, Limited Coverage (Transfer of Assets Penalty) Notice of Decision on Your Medical Assistance Application for Nursing Facility Services, Limited Coverage (Transfer of Assets Penalty) Page 2
4 LDSS-4145S LDSS-4146 LDSS-4146S LDSS-4147 LDSS-4147S LDSS-4150 LDSS-4198 LDSS-4294 LDSS-4294S LDSS-4306 LDSS-4306S LDSS-4307 LDSS-4307S LDSS-4321 LDSS-4321S LDSS-4329 LDSS-4329S LDSS-4345 LDSS-4346 LDSS-4362 LDSS-4368 LDSS-4368S LDSS-4369 LDSS-4384 LDSS-4411 LDSS-4454EL LDSS-4466 LDSS-4489 LDSS-4489S LDSS-4528 LDSS-4528S LDSS-4544 LDSS-4544S LDSS-4545 LDSS-4545S LDSS-4546 LDSS-4546S LDSS-4547 LDSS-4547S Notice of Decision on Your Medical Assistance Application for Nursing Facility Services, Limited Coverage (Transfer of Assets Penalty) Notice of Decision of MA Application (Transfer of Resources) Notice of Decision of MA Application (Transfer of Resources) Notice of Intent to Discontinue/Change MA Coverage (Transfer of Assets) Notice of Intent to Discontinue/Change MA Coverage (Transfer of Assets) Medical Presumptive Eligibility for Pregnant Women Screening Checklist Third Party Data Sheet Explanation of the Effect of Transfer of Asset(s) on Medical Assistance Eligibility Explanation of the Effect of Transfer of Asset(s) on Medical Assistance Eligibility Notice of Acceptance for Medical Assistance with Limited Coverage (Spousal Refusal Community Cases) Notice of Acceptance for Medical Assistance with Limited Coverage (Spousal Refusal Community Cases) Notice of Action on Application/Benefit for Medical Assistance Payment of the COBRA Continuation Coverage Premium Notice of Action on Application/Benefit for Medical Assistance Payment of the COBRA Continuation Coverage Premium Explanation of the Excess Resources Program Explanation of the Excess Resources Program Notice of Action on Application/Benefit for Medical Assistance Payment of Health Insurance Premiums Under the AIDS Health Insurance Program Notice of Action on Application/Benefit for Medical Assistance Payment of Health Insurance Premiums Under the AIDS Health Insurance Program Budget Worksheet - MA Legally Responsible Relative (LRR) Income Contribution Budget Worksheet - MA Institutionalized Spouse Budget Worksheet Pediatric Patient Review Instrument for Care at Home Waiver Program Notice of Intent to Change Your Medical Assistance Coverage (SSI Recipient) Notice of Intent to Change Your Medical Assistance Coverage (SSI Recipient) Bank Inquiry & Clearance Report Medicaid/FHP Only Third Party Health Insurance Recertification for Medical Assistance (Chronic Care) LDSS Quarterly Estate and Casualty Recovery Report Notice of Intent to Impose a Lien on Real Property (Institutionalized Individual) Notice of Decision on Your Medical Assistance Application (Community Coverage) Notice of Decision on Your Medical Assistance Application (Community Coverage) Notice of Change in Limited Coverage Period for An Institutionalized Person Notice of Change in Limited Coverage Period for An Institutionalized Person Notice of Credit Due to Uncovered Expenses (Pay-In Program) Notice of Credit Due to Uncovered Expenses (Pay-In Program) Notice of Refund Due to Uncovered Expenses (Pay-In Program) Notice of Refund Due to Uncovered Expenses (Pay-In Program) Notice of Credit Due to Review of Medical Assistance Claims (Pay-In Program) Notice of Credit Due to Review of Medical Assistance Claims (Pay-In Program) Notice of Refund Due to Review of Medical Assistance Claims (Pay-In Program) Notice of Refund Due to Review of Medical Assistance Claims (Pay-In Program) Page 3
5 LDSS-4548 LDSS-4578 LDSS-4578S LDSS-4750 LDSS-4750S LDSS-4807 OHIP-0001 Optional Pay-In Program for Individuals with Excess Income Notice of Intent to Change Medical Assistance to Transitional Medical Assistance Coverage Notice of Intent to Change Medical Assistance to Transitional Medical Assistance Coverage Important Notice Concerning Your Contribution Toward Chronic Care Important Notice Concerning Your Contribution Toward Chronic Care Health Care Programs for New Yorkers (English and Spanish) Notice of Decision on your Request for Undue Hardship (Transfer of Assets Penalty) OHIP-0001S OHIP-0002 OHIP-0002S OHIP-0002(NYC) OHIP-0002(NYC)S OHIP-0003 OHIP-0003S OHIP-0003(NYC) Notice of Decision on your Request for Undue Hardship (Transfer of Assets Penalty) Premiums Premiums Premiums (NYC) Premiums (NYC) (NYC) OHIP-0003(NYC)(S) (NYC) Page 4
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