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NY DOH-4220I ES 2023-2026 free printable template

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Este documento se utiliza para solicitar la cobertura de Medicaid y el Family Planning Benefit Program para adultos mayores, personas con discapacidades y otros grupos específicos. Incluye instrucciones
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Are a New York State resident. Meet income eligibility requirements. (Examples: single adults earning up to $25,520; adults in family of four earning up to $52,400) Are U.S. citizens or meet immigration status requirements.
There is no monthly premium for families whose income is less than 2.2 times the poverty level. That's about $1150 a week for a three-person family, about $1387 a week for a family of four.
UPDATE on 2/22/2023: The New York State Department of Health has published the official Medicaid income eligibility levels. These levels have been raised to 138% of the FPL, which is the Federal Poverty Level. Individual income levels for 2023 are now $1677 monthly/$20,121 yearly and for couples $2268 monthly/$27,214.
Federal Poverty Level thresholds to qualify for Medicaid In 2023 these limits are: $14,580 for a single adult person, $30,000 for a family of four and $50,560 for a family of eight. To calculate for larger households, you need to add $5,140 for each additional person in families with nine or more members.
To qualify for either plan 1 or 2 your household income must be between 138% and 200% of the federal poverty level, be a United States citizen living in New York State, and not enrolled in Medicare or Medicaid or be under the age of 19 or older than 65.
The DOH-4220 - Access NY Health Care application can be used for all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home.
UPDATE on 2/22/2023: The New York State Department of Health has published the official Medicaid income eligibility levels. These levels have been raised to 138% of the FPL, which is the Federal Poverty Level. Individual income levels for 2023 are now $1677 monthly/$20,121 yearly and for couples $2268 monthly/$27,214.
Eligibility levels for parents are presented as a percentage of the 2023 FPL for a family of three, which is $24,860. Eligibility limits for single adults without dependent children are presented as a percentage of the 2023 FPL for an individual, which is $14,580.

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The DOH-4220i is a form used by healthcare providers in New York State to report certain information related to the diagnosis and treatment of patients.
Healthcare providers, including physicians and other licensed practitioners, who render services to patients and are required to report specific health information must file the DOH-4220i.
To fill out the DOH-4220i, providers need to provide accurate patient information, including demographics, diagnosis details, services rendered, and any other required data as outlined in the form instructions.
The purpose of the DOH-4220i is to collect data for public health surveillance and to ensure compliance with reporting requirements for healthcare services provided in New York.
The DOH-4220i must report patient demographic information, details of the diagnosis, services rendered, and any other relevant clinical information as specified by the state health department.
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