How to Fill Out the DOH-4220: New York Medicaid Health Insurance Application

To fill out the DOH-4220, New York’s Access NY Health Care application, you work through Sections A through J in black ink, listing every person in your household, reporting gross (pre-tax) income, disclosing any existing insurance, and signing Section J to certify the information is true. Attach proof of identity, residency, citizenship or immigration status, and income before you submit it to your Local Department of Social Services or, in New York City, the Human Resources Administration.¹ The state then has 45 days to decide, or 90 days if eligibility depends on a disability determination.²

Before You Start: Is the Paper Form Even Right for You?

Most adults, children, and pregnant women in New York whose eligibility is evaluated under Modified Adjusted Gross Income (MAGI) rules apply online through NY State of Health at nystateofhealth.ny.gov rather than on paper.³ The DOH-4220 is generally the right tool if you are 65 or older, blind, or disabled (the non-MAGI groups), if you need to apply through your local office, or if you prefer paper. Choosing the wrong path is one of the reasons applications get bounced, so confirm which track fits your household before you invest time in the form.

Gather Your Documents First

Missing paperwork is one of the most common reasons applications stall. The agency will mail you a request for anything absent, and if you don’t respond in time, the file gets denied on that basis alone. Pull everything together before you write anything on the form.

Identity, Residency, and Citizenship

A New York driver’s license or state photo ID. If the address on it doesn’t match where you actually live, bring a utility bill, lease, or landlord letter dated within the last six months.⁴
A U.S. birth certificate or naturalization certificate. Non-citizens need a Permanent Resident Card or other valid immigration document.⁴
Social Security numbers for every household member applying for coverage. The state uses SSNs to verify income and eligibility through federal databases.⁵

Income Proof

Pay stubs covering the last four weeks, showing gross pay before taxes.⁴
If you have no stubs, a signed, dated letter on company letterhead showing your gross wages.
Your most recent signed federal tax return with all schedules.
Profit-and-loss statements or 1099s if you’re self-employed.
Social Security award letters, pension statements, or unemployment letters for any other income.

Resources (Non-MAGI Applicants Only)

If you’re 65 or older, blind, or disabled, gather bank statements, life insurance policy information, and paperwork for any real property you own. Signing the DOH-4220 authorizes electronic verification of your financial accounts, so what you write should match what the banks report.

Working Through the Form, Section by Section

Use black ink and print clearly. Don’t leave fields blank; write “N/A” or “none” where something doesn’t apply. Skipping a required section slows everything down.

Section A: Applicant Information

Enter the full legal name, date of birth, and Social Security number of the person filing the application. The home address is where the applicants physically live. Add a separate mailing address only if you want mail sent elsewhere. Section A is also where you name an authorized representative, meaning someone permitted to discuss your case with the agency or receive notices for you.¹

Section B: Household Information

List every person living in your home, including anyone not applying for insurance. Household size sets the income threshold, so leaving someone out can produce a wrong eligibility determination in either direction and create problems down the line.¹

Section C: Family Income

Report income for every person listed in Section B. Use gross amounts, not take-home pay. If no one in the household has income, explain how you’re paying for food and housing. This section also asks about recent job changes, student status, and child-care costs paid while working or attending school.¹

Section D: Health Insurance

Disclose any current coverage for anyone applying, including employer plans, Medicare, COBRA, or a spouse’s policy. When someone has Medicaid plus other insurance, Medicaid pays second. If you’re 65 or older, or turning 65 within three months, you must apply for Medicare as a condition of Medicaid eligibility.¹

Section E: Housing Expenses

Enter monthly rent, mortgage payment, or other housing costs. If your rent is subsidized or you share expenses with a roommate, report only the portion you personally pay. Include property taxes if they’re bundled into your mortgage, and note water costs along with how often you pay them.¹

Section F: Blind, Disabled, Chronically Ill, or Nursing Home Care

Answer these questions if anyone on the application has a disability, serious illness, or needs nursing home care. For Medicaid, a disability generally means an illness or condition that limits daily activities and has lasted, or is expected to last, at least 12 months. Checking yes here triggers Supplement A, a separate attachment with additional medical questions.¹

Section G: Additional Health Questions

If you have paid or unpaid medical bills from the past three months, list them here and include copies. Medicaid can potentially cover those costs retroactively.¹

Section H: Absent Parent or Spouse

Complete this section if any applicant has a parent or spouse who does not live in the household. The state uses the information to check whether medical support is available from that person.

Section I: Health Plan Selection

If approved for Medicaid, you may be required to enroll in a managed care plan. Indicate a preference here.

Section J: Signature

Read the Terms, Rights and Responsibilities language, then sign and date. An unsigned application is returned without processing.

Where to Send It

Where the completed form goes depends on where you live. New York City residents submit through the Human Resources Administration, either online at ACCESS HRA (a069-access.nyc.gov/accesshra) or in person at a Medicaid office. HRA’s phone line is (718) 557-1399.⁶³ Residents outside the five boroughs submit to their county’s Local Department of Social Services, in person or by mail.

Whichever route you choose, photocopy the completed application and every attachment before you send anything. If you mail the form, use certified mail. The date the office receives your signed application controls when your coverage can start and how far back retroactive coverage reaches, so having a delivery record matters.

What Happens Next

The clock starts when the local office receives your signed application. New York regulations require a decision within 45 days on a standard application, or up to 90 days if eligibility hinges on a disability determination.²⁷ During review, the agency may mail a letter requesting additional documents. Respond by the deadline in that letter; missing it is grounds for denial on its own. When processing finishes, you’ll receive a formal Notice of Decision showing whether you were approved, denied, or found eligible for a different program.

Claiming Retroactive Coverage

Medicaid can potentially pay or reimburse medical bills from the three months before you applied. The retroactive window begins on the first day of the third month before your application month; for an application filed on June 15, the window covers March 1 through May 31.⁸ To claim it, list those bills in Section G and attach copies. The state then decides whether you would have been eligible during those earlier months based on your income and circumstances at the time.

If You’re Denied

A denial can be appealed. Under New York Social Services Law, any Medicaid applicant has the right to request a fair hearing within 60 days of the denial date.⁹ A fair hearing is an administrative proceeding where you or your representative can present evidence. You can request one online through the Office of Temporary and Disability Assistance, by phone, or by mail. If you are already receiving Medicaid and the state is cutting or reducing your benefits, requesting a hearing before the reduction’s effective date can keep your current benefits running during the appeal, an option known as “aid continuing.” If the state prevails, you could owe the cost of services received while the hearing was pending.

Be Honest on the Form

The DOH-4220 is a legal document, and your signature in Section J certifies that everything on it is true. Under 18 U.S.C. § 1035, knowingly making materially false statements in connection with health care benefits carries up to five years in prison, a fine, or both.¹⁰ At the state level, a fraudulent application means loss of eligibility and possible repayment of any benefits received. Honest mistakes are correctable. Deliberate concealment of income or assets is not.

1
New York State Department of Health. DOH-4220 New York Medicaid Application Form Instructions
2
Legal Information Institute. New York Codes, Rules and Regulations Title 18 360-2.4 – Decision
3
New York State Department of Health. How to Apply for NY Medicaid
4
New York State Department of Health. Documents Needed When You Apply for Health Insurance
5
eCFR. 42 CFR 435.910 – Use of Social Security Number
6
NYC.gov. Health Assistance – HRA
7
eCFR. 42 CFR 435.912 – Timeliness Standards
8
New York State Department of Health. Other Eligibility Requirements: Retroactive Eligibility Period
9
New York State Senate. New York Code SOS 22 – Appeals and Fair Hearings; Judicial Review
10
Office of the Law Revision Counsel. 18 U.S. Code 1035 – False Statements Relating to Health Care Matters