Form DOH-5178A Supplement A "Supplement to Access Ny Health Care Application Doh-4220" - New York

What Is Form DOH-5178A Supplement A?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH-5178A Supplement A by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form DOH-5178A Supplement A "Supplement to Access Ny Health Care Application Doh-4220" - New York

233 times
Rate (4.5 / 5) 14 votes
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
1. Applicant(s) this Supplement is being completed for:
Marital
Social Security
If Deceased, List
Legal Last Name
Legal First Name
MI
Status
Number
Date of Birth
Date of Death
/
/
/
/
/
/
/
/
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.
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
1. Applicant(s) this Supplement is being completed for:
Marital
Social Security
If Deceased, List
Legal Last Name
Legal First Name
MI
Status
Number
Date of Birth
Date of Death
/
/
/
/
/
/
/
/
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.
DOH - 5178A 8/15 (page 1 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?
If yes, what is the date of death? ____ / ____ / ____
Yes
No
DOH - 5178A 8/15 (page 2 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:*
• Certified Home Health Agency services
• Adult day health care
• Residential treatment facility care
• Limited licensed home care
• Personal emergency response services
• Private duty nursing
• Personal care services
• Hospice in the community
• Managed long-term care in the community
• Hospice residence program
• Waiver and other services provided through a
• Assisted living program
home and community-based waiver program
• Consumer directed personal assistance 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.
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.
DOH - 5178A 8/15 (page 3 of 8)
NYS DOH
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
Closed Accounts
Current
Account
Balance
Bank Name
Account Number
Name of Owner(s)
Balance
Date Closed
at Closing
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
2. Retirement Accounts (Deferred Compensation, IRA and/or Keogh):
NONE
Closed Accounts
Current
Account
Balance
Institution Name
Account Number
Name of Owner(s)
Pay Out
Balance
Date Closed
at Closing
Yes
No $
/
/
$
Yes
No $
/
/
$
Yes
No $
/
/
$
Yes
No $
/
/
$
3. Annuities, Stocks, Bonds, Mutual Funds:
NONE
Closed Accounts
Institution/Company
Current
Date Closed
Value
Name
Account Number
Name of Owner(s)
Date Purchased
Value
or Sold
at Closing
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
DOH - 5178A 8/15 (page 4 of 8)
NYS DOH
4. Life Insurance Policies:
NONE
Cancelled Policies
Current
Current
Date
Cash Out
Insurance Company
Policy Number
Name of Owner(s)
Cash Value
Face Value
Cancelled
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
Page of 8