How to Fill Out and Submit the NY DOH-4220 Medicaid Application

The New York DOH-4220 Medicaid application is the paper form you use to apply for Medicaid when you are 65 or older, certified blind or disabled, chronically ill, or need coverage for a nursing home stay. It is published by the New York State Department of Health under the title “Health Insurance for Older Adults, People With Disabilities and Certain Other Populations,” with the most recent revision dated January 2023. Working-age adults and families without those circumstances apply through the NY State of Health marketplace instead, not on this form.

Who Uses the DOH-4220

You need this form if you are 65 or older, have a blindness or disability certification (or are willing to be evaluated for one), are chronically ill and need long-term care services, or are applying for Medicaid to pay for a nursing home or equivalent hospital care. Being on Medicare does not disqualify you; older adults often use Medicaid to cover what Medicare does not, including long-term care and prescription copays. If you are not sure which application applies to your situation, your county’s Local Department of Social Services can point you to the right one.

A short word on the money side before the form itself: New York sets both income and resource limits for this track of Medicaid, and your primary home, one vehicle, household goods, and retirement accounts in payout status are generally not counted. If your income is above the limit, you may still get coverage through the state’s surplus income (spend-down) program, in which the amount over the limit works like a monthly medical deductible.¹ Your Notice of Decision will spell out any surplus amount that applies to you.

Documents to Gather Before You Start

Missing paperwork is the most common reason applications stall or get denied. Pull everything together before you sit down with the form:

Identity and Social Security number for each person applying. If someone does not have an SSN, leave that field blank rather than delay the application.²
Proof of citizenship or immigration status: passport, birth certificate, naturalization certificate, or USCIS documents. Applicants already on Medicare or Social Security Disability do not need to document citizenship or identity separately.³
Proof of New York residency, such as a utility bill, lease, or mortgage statement in your name.
Income documentation: pay stubs, pension award letters, Social Security benefit statements. Report gross amounts, before taxes.
Resource documentation for Supplement A: bank and brokerage statements, life insurance policies showing cash value, deeds or tax assessments for real property.
Any existing health insurance information, including Medicare cards and private policy numbers, so the state knows whether Medicaid will be the primary or secondary payer.
Medical bills from the three months before your application if you want retroactive coverage considered.⁴

Filling Out the Main Form

You can download the DOH-4220 from the Department of Health website or pick up a copy at your county Department of Social Services office. Work through it top to bottom, and either fill in every field or write “N/A” so processing staff can see you addressed each question.

Personal and Household Information

Start with your full legal name, date of birth, address, and contact information. Then list everyone who lives in your household, whether or not they are applying. Include each person’s name, date of birth, SSN (if they have one and are applying), and relationship to you. The instructions are firm on this point: listing everyone allows the state to make a correct eligibility decision.²

Income

For each person in the household, list every kind of money coming in: wages, Social Security, pensions, rental income, interest, everything. Amounts are reported before taxes. Blank fields or “N/A” are fine where nothing applies. The state cross-checks what you report against federal and state databases, so accuracy on this page matters more than anywhere else on the form.

Signature and Certification

The declaration at the end of the main form is your certification that everything you reported is true, and it authorizes the state to verify your information with banks, employers, and government agencies. Sign and date it. If someone else is completing the form on your behalf, use the authorized representative section (see below).

When Supplement A Is Required

If you are 65 or older, certified blind or disabled, chronically ill, or applying for nursing home coverage, you also have to complete Supplement A (Form DOH-5178A). It goes deeper into your finances than the main application.² The sections are:

Section A, applicant and spouse information.
Section B, the type of care or services you are applying for.
Section C, resources and assets: bank accounts, stocks, bonds, mutual funds, life insurance cash value, burial funds, and any other countable assets.
Section D, homestead details, including value and whether you intend to return home if you are currently in a facility.
Section E, any other real property you own.
Section F, asset transfers, required only for nursing home applicants.
Section G, tax returns, also only for nursing home applicants.

Everyone using Supplement A completes A through E. Sections F and G are for nursing home applicants only. The supplement has its own certification and signature page at the end.⁵

The 60-Month Look-Back (Nursing Home Applicants)

If you are applying for Medicaid to pay for a nursing home, the state reviews every financial transaction you made during the five years before your application date. Federal law establishes that 60-month look-back window.⁶ Gifts, sales below fair market value, and other transfers that reduced your countable resources can trigger a penalty period during which Medicaid will not pay for your care.

The penalty length is the value of what you transferred divided by the regional monthly nursing home rate. Rates vary by region; for 2026, New York City’s rate is $15,282 per month, so a $45,000 transfer would produce roughly a three-month penalty during which you would pay the facility privately.⁷ Transfers made more than 60 months before your application date are not penalized. Section F is where you disclose every transfer; leaving them off can result in denial or a fraud referral.

Naming an Authorized Representative

Federal regulations let you designate someone (a family member, social worker, attorney, or friend) to sign the application, file renewals, receive notices, and speak with Medicaid on your behalf.⁸ Your signature on the representative section of the form makes the designation. If someone already holds power of attorney for you, or a court has appointed a legal guardian, the state must accept that authority without a separate designation. The representative stays in place until you change it or notify the agency. Setting this up at the time of application saves considerable trouble if your health makes paperwork and phone calls difficult later.

Where to Submit

Once your main form, Supplement A (if required), and supporting documents are complete and signed, send the package to the right office:

Outside New York City: your county Local Department of Social Services.²
In New York City: the Human Resources Administration (HRA), reachable at (718) 557-1399.⁹

If you are not sure which county office handles your case, the state Medicaid helpline is 1-800-698-4543.

Immediate Need for Home Care

If you urgently need Personal Care Services or Consumer Directed Personal Assistance Services and have no informal caregivers or alternative coverage, submit the DOH-4220 and Supplement A along with a physician’s order for services and a signed Attestation of Immediate Need (Form DOH-5786). The local office reviews your materials within four days, determines Medicaid eligibility within seven days once the file is complete, and issues a services determination within 12 days after that.⁹

After You Submit

You should receive a written confirmation that your case is under review. The state then has 45 days to decide most applications, or 90 days if eligibility turns on a disability determination.¹⁰ A caseworker may contact you or your representative for an eligibility interview, usually by phone, and may send written requests for additional documents. Treat any request letter as urgent; missing the response deadline is one of the most common reasons applications are denied.

Your Notice of Decision will approve you for full coverage, approve you with a monthly surplus income requirement, or deny the application with the reason stated.

Retroactive Coverage

When you apply, you can ask Medicaid to cover medical bills from the three months before your application month. If you were eligible during any part of that 90-day window, the state will pay or reimburse qualifying expenses.¹¹ Include any paid or unpaid bills from that period with your application so they can be evaluated at the same time.⁴

If You’re Denied

Your Notice of Decision has to state the reason for the denial and inform you of your right to a fair hearing. Common denial reasons include income or resources over the limit and documentation that was requested but never received. To request a hearing, call the New York Office of Temporary and Disability Assistance at 1-800-342-3334, use the OTDA website, or send the request by mail.¹² You have 60 days from the date on the denial notice.

At the hearing, an administrative law judge reviews the evidence independently. You can represent yourself, bring an attorney, or have someone else advocate for you. If the notice reduces or terminates benefits you were already receiving, requesting a hearing before the effective date can keep your existing benefits going while the hearing is pending, which the state calls “aid continuing.”

Annual Renewal

Medicaid eligibility is redetermined every year. In New York City, HRA mails a renewal packet about 30 days before your coverage ends, and the exact date depends on when you first applied. Outside the city, your county LDSS runs renewals on its own schedule. You can renew online through ACCESS HRA (in New York City), by mail, or in person at a Medicaid Community Office. Miss the deadline and coverage can be terminated; if that happens, call the HRA Medicaid Helpline at 888-692-6116 in New York City, or your county LDSS, to get re-enrolled quickly.¹³

1
New York State Department of Health. Explanation of the Excess Income Program
2
New York State Department of Health. DOH-4220I – Health Insurance for Older Adults, People With Disabilities and Certain Other Populations
3
New York City Human Resources Administration. DOH-4220 Access NY Health Care Application
4
New York State Department of Health. Medicaid Reference Guide – Retroactive Eligibility Period
5
New York State Department of Health. Supplement A – Supplement to Access NY Health Care Application DOH-4220
6
Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets
7
New York State Department of Health. GIS 25 MA/14 – Medicaid Regional Nursing Home Rates
8
eCFR. 42 CFR 435.923 – Authorized Representatives
9
New York State Department of Health. How to Apply for NY Medicaid
10
eCFR. 42 CFR 435.912 – Timely Determination of Eligibility
11
ACCESS NYC. Medicaid
12
OTDA. Request Hearing – Fair Hearings
13
NYC.gov. Medicaid Renewal Frequently Asked Questions