Supplement A

DOH - 5178A 8/15 (page 1 of 8) NYS DOH

Supplement A

(Supplement to Access NY Health Care Application DOH-4220)

This Supplement must be completed if anyone who is applying is:

• Age 65 or older

• Certiﬁed blind or certiﬁed disabled (of any age)

• Not certiﬁed disabled but chronically ill

• Institutionalized and applying for coverage of nursing home care.

This includes care in a hospital that is equivalent to nursing home care.

Note: If you are applying for the Medicare Savings Program (MSP) only, this Supplement does not need to be completed.

INSTRUCTIONS:

• Sections A through E must be completed and this Supplement must be signed.

• If you or anyone in your household is applying for coverage of nursing home care, you must

also complete sections F through G.

A. Applicant and Spouse Information

Is a person named above:

• Chronically ill?

Yes No

(Examples of chronically ill would be unable to work for at least 12 months because

of an illness or injury, or having an illness or disabling impairment that has lasted or

is expected to last for 12 months.)

• Certiﬁed Blind by the Commission for the Blind and Visually Handicapped? Yes No

(If yes, send proof.)

• Interested in applying for the MBI-WPD program if disabled and working? Yes No

The Medicaid Buy-In for Working People with Disabilities (MBI-WPD)

program offers Medicaid coverage to people who are disabled, working, and

at least 16 years old but not yet 65 years old. The program allows higher

income levels than the regular Medicaid program so working people with

disabilities can earn more and keep their Medicaid coverage.

1. Applicant(s) this Supplement is being completed for:

Legal Last Name Legal First Name MI

Marital

Status

Social Security

Number Date of Birth

If Deceased, List

Date of Death

/ / / /

DOH - 5178A 8/15 (page 2 of 8) NYS DOH

If an applicant is living in a long-term care facility/nursing home, adult home, or assisted living facility,

provide the following information.

Name of Applicant who is in Facility Name of Facility Date Admitted

/ /

Telephone Number

( ) -

Street Address City State Zip Code

Applicant’s Previous Address City State Zip Code

If the above previous address was also a facility or adult home, list the address prior to admission below.

Applicant’s Second Previous Address City State Zip Code

2. Applicant’s Spouse: (if not listed above)

Legal Last Name Legal First Name MI

Maiden Name or Other Name Known By: Social Security Number Date of Birth

/ /

Street Address (if in a facility, list spouse’s address prior to being admitted to facility)

City State Zip Code

Is the applicant’s spouse living in a long-term care facility/nursing home?

Yes No

If yes, provide the following information:

Name of Facility Date Admitted

/ /

Telephone Number

( ) -

Street Address City State Zip Code

Is the applicant’s spouse deceased?

Yes No If yes, what is the date of death? ____ / ____ / ____

DOH - 5178A 8/15 (page 3 of 8) NYS DOH

B. What Care and Services are you Applying for? (check the box that applies)

You are applying for Medicaid coverage but not coverage of community-based long-term care services. You

may attest to the amount of your resources. You are not required to submit documentation of your resources

at this time. If a computer match shows something different than what you reported, you may be asked to

submit proof at a later date.

This coverage does not include nursing home care, home care or any of the community-based long-term care

services listed below.*

You are applying for coverage of community-based long-term care services. Documentation of the current

amount of your resources is required. However, you only need to submit documentation for certain resources

at this time. See “Documentation Requirements” below for a list of these resources.

This coverage includes the following services:*

• Adult day health care

• Limited licensed home care

• Private duty nursing

• Hospice in the community

• Hospice residence program

• Assisted living program

• Consumer directed personal assistance program

DOCUMENTATION REQUIREMENTS

If you are requesting coverage for community-based long-term care services or nursing home care, provide

documentation for the time period indicated above for all of the following resources, if applicable.

• Life insurance policy; • Burial agreement or fund;

• Securities, stocks, bonds, and mutual funds; • Trust document and accounts.

• Annuities;

You do not need to send proof of any other resources at this time. This is because other resources may

be veriﬁed through computer matches. If the resources you report do not match our records or cannot be

veriﬁed through our records, we may ask you to submit proof of those other resources at a later date.

• Certiﬁed Home Health Agency services

• Residential treatment facility care

• Personal emergency response services

• Personal care services

• Managed long-term care in the community

• Waiver and other services provided through a

home and community-based waiver program

Note: Some examples of home and community-based programs that provide waiver and other services are

Traumatic Brain Injury Program and Nursing Home Transition and Diversion Program.

You are institutionalized and applying for coverage of nursing home care. Documentation of your resources

for the past 60 months is required. However, you only need to submit documentation for certain resources at

this time. See “Documentation Requirements” below for a list of these resources.

* You may be eligible for short-term rehabilitation services. Short-term rehabilitation services include one

commencement/admission in a 12-month period of up to 29 consecutive days of nursing home care and/or

certiﬁed home health care.

C. Resources/Assets

INSTRUCTIONS FOR SECTIONS 1 THROUGH 8:

• List all resources currently owned by you and/or your spouse/parent(s), including custodial accounts.

• Check the “NONE” box if you and/or your spouse/parent(s) do not own any of those resources.

• If applying for coverage of nursing home care, also list any accounts CLOSED in the past 60 months; include the

balance at closing and provide an explanation of where the balance was transferred to or how it was spent. On a

separate sheet of paper, provide an explanation of each transaction of $2,000 or more.

Note: Medicaid retains the right to review all transactions made during the transfer look-back period.

1. Checking/Savings/Credit Union Accounts/Certiﬁcates of Deposits (CDs): NONE

Bank Name Account Number Name of Owner(s)

Current

Account

Balance

Closed Accounts

Date Closed

Balance

at Closing

$ / / $

2. Retirement Accounts (Deferred Compensation, IRA and/or Keogh): NONE

Institution Name Account Number Name of Owner(s) Pay Out

Current

Account

Balance

Closed Accounts

Date Closed

Balance

at Closing

Yes No

$ / / $

Yes No

$ / / $

Yes No

$ / / $

Yes No

$ / / $

3. Annuities, Stocks, Bonds, Mutual Funds: NONE

Institution/Company

Name Account Number Name of Owner(s) Date Purchased

Current

Value

Closed Accounts

Date Closed

or Sold

Value

at Closing

$ / / $

DOH - 5178A 8/15 (page 4 of 8) NYS DOH

4. Life Insurance Policies: NONE

Insurance Company Policy Number Name of Owner(s)

Current

Cash Value

Current

Face Value

Cancelled Policies

Date

Cancelled

Cash Out

Value

$ $ / / $

5. Burial Assets/Burial Contracts: (Include copies): NONE

a. Do you and/or your spouse have a pre-paid funeral agreement for you or anyone else in your family?

Yes No

b. Do you and/or your spouse have a burial space or plot for you or anyone else in your family?

Yes No

c. Do you and/or your spouse have money in a bank account set aside for a burial fund?

Yes No

If yes, in what account(s) is your and/or your spouse’s burial fund?

Bank Name and Account Number Name of Owner(s) Value

$

d. Do you have life insurance to be used as your burial fund?

Yes No

If yes, what is your policy number(s)?

If yes, is the full cash value to be used for your burial expenses?

Yes No

e. Does your spouse have life insurance to be used as a burial fund?

Yes No

If yes, what is the policy number(s)?

If yes, is the full cash value to be used for burial expenses?

Yes No

6. Trust Accounts: If you and/or your spouse created or are the beneﬁciary of a trust,

submit a copy of the trust, including the current schedule of trust assets. NONE

Name of Trust Grantor Trustee(s) Assets Beneﬁciary Income

$ $

$

7. Vehicle(s): List all cars, trucks and vans. List all recreational vehicles, including campers,

snowmobiles, boats and motorcycles. NONE

Name of Owner(s) Year/Make/Model Fair Market Value Amount Owed In use? Date Sold

$

Yes No

/ /

$

Yes No

/ /

$

Yes No

/ /

DOH - 5178A 8/15 (page 5 of 8) NYS DOH

8. List Any Other Resources:

Resource Type Name of Owner(s) Value

$

E. Real Property (other than your home)

D. Homestead

Rental Property Vacation Property Time Share Vacant Land Other Property Rights

(In or outside of New York State)

If yes, provide the following information:

Do you and/or your spouse own or have a legal interest in any other real property? (Check any that apply)

Yes No

Name and Address of Owner(s) Address of Property Type of Ownership (Check one) Equity value

Individual Joint tenancy Life estate

$

Individual Joint tenancy Life estate

$

Individual Joint tenancy Life estate

$

Individual Joint tenancy Life estate

$

1. Do you and/or your spouse own or have a legal interest in your home, including a life estate? Yes No

2. If you are in a medical facility and own your home, do you intend to return to your home?

Yes No

If no, is anyone living in the home?

Yes No

Who is living in the home?

How is this person related to you and/or your spouse?

If you and/or your spouse’s child (of any age) is living in the home, is the child disabled?

Yes No

Note: If there is a legal impediment that prevents you from selling this property, the property

is not counted in determining Medicaid eligibility. Send proof of legal impediment.

3. Equity Value in Home:

If you own your home, what is the equity value in your home? $

Note: Equity value is the fair market value less any outstanding liens, mortgages, etc.

STOP HERE unless you or anyone in your household is institutionalized and applying for coverage of nursing

home care. However, Section I of this document MUST be signed.

DOH - 5178A 8/15 (page 6 of 8) NYS DOH

1. Transfers

a. In the last 60 months, did you, your spouse, or someone on your behalf transfer, change

ownership in, give away, or sell any assets, including your home or other real property?

Yes No

b. In the last 60 months, have you or your spouse created or transferred any assets

into or out of a trust?

Yes No

If you answered yes to either of the questions above, explain the transfer(s) below.

Attach additional sheets of paper, if needed.

Description of Asset (including income) Date of Transfer Transferred to Whom Amount of Transfer

$

c. Are you in the process of selling property? Yes No

d. In the last 60 months, did you, your spouse or someone on your behalf, change the deed or the

ownership of any real property, including creating a life estate?

Yes No

If yes, when?

e. If you purchased a life estate in another person’s home, did you live in the home for at least one

year after you purchased the life estate?

Yes No

f. In the last 60 months, did you, your spouse, or someone on your behalf purchase a mortgage, loan,

or promissory note?

Yes No

If yes, when?

g. In the last 60 months, did you, your spouse, or someone on your behalf purchase or change

an annuity?

Yes No

If yes, when?

2. Have you, your spouse, or someone acting on your behalf given a deposit to any health care or

residential facility, such as a nursing home, assisted living facility, continuing care retirement

community or life care community?

Yes No

If yes, send copy of agreement.

F. Asset Transfers

G. Tax Returns

Did you and/or your spouse ﬁle U.S. income tax returns in the last four years? Yes No

If yes, send complete copies of these returns including all schedules and attachments.

DOH - 5178A 8/15 (page 7 of 8) NYS DOH

X X

SIGNATURE OF APPLICANT/REPRESENTATIVE DATE SIGNED

X X

SIGNATURE OF APPLICANT’S SPOUSE DATE SIGNED

H. Important Information

Liens on Real Property

Upon receipt of Medicaid, a lien may be ﬁled and a recovery may be made against your real property under certain

circumstances if you are in a medical institution and not expected to return home. Medicaid paid on your behalf may

be recovered from persons who had legal responsibility for your support at the time medical services were obtained.

Medicaid may also recover the cost of services and premiums incorrectly paid.

Transfer of Assets

Federal and State laws provide that an individual may be found ineligible for nursing facility services for a period of time

if an individual or an individual’s spouse transfers an asset for less than fair market value within the look-back period. The

look-back period is the 60 months immediately prior to the date an individual is both institutionalized and has applied for

Medicaid.

Annuities

As a condition of Medicaid coverage for nursing facility services, applicants are required to disclose a description

of any interest the individual or the individual’s spouse has in an annuity. This disclosure is required regardless of

whether the annuity is irrevocable or a countable resource.

In addition to the purchase of an annuity, certain transactions made to an annuity by the applicant or the applicant’s

spouse within the look-back period, may be treated as a transfer unless:

• The State is named the remainder beneﬁciary in the ﬁrst position for at least the amount of Medicaid paid

on behalf of the annuitant; or

• The State is named in the second position after a community spouse or minor or disabled child, or in the ﬁrst

position if such spouse or representative of such child disposes of any such remainder for less than fair

market value.

If documentation is not submitted verifying that the State has been named remainder beneﬁciary, you may be

ineligible for coverage of nursing facility services.

If the annuity is a countable resource at the time of application, you/your spouse are not required to name the State

as remainder beneﬁciary.

I. Certiﬁcation and Authorization

I certify under penalty of perjury, that the information on this form is correct and complete to the best of my

knowledge. I understand that I must report any changes in this information within 10 days of the change.

If eligibility depends on the amount of my and my spouse’s resources, by signing this application we authorize

veriﬁcation of our resources with ﬁnancial institutions for the purpose of determining eligibility. Both spouses must

sign below. This authorization will end if my application for Medicaid is denied, or I am no longer eligible for Medicaid,

or I/we revoke this authorization in a written statement to my local Department of Social Services.

DOH - 5178A 8/15 (page 8 of 8) NYS DOH