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MAP-909E…...………..........…Rev. 06/25/09 RENEWAL NOTIFICATION LOCATION: NOTICE DATE: CASE NUMBER: NUMBER OF ADULTS: NUMBER OF CHILDREN: PRIORITY: RVI CODE: TELEPHONE NUMBER:Dear Consumer:It is time to renew your Medicaid/Managed Long Term Care/Medicare Savings Program (QMB) coverage.Please carefully read the printed information that appears below and write-in all changes. Be sure to returnyour entire renewal form, including this page.Use the “instruction sheet” that is also enclosed to help you fill out this form. It will help you to understandhow to complete the form and to decide what documentation (proofs) to return along with it. You mustcomplete and sign this form and attach all required proof. 1. Look at the mailing address and telephone number above. Also look at all information below. If anything is wrong, or has changed since you last applied or renewed your coverage, write-in the most current information in the blank space. If the information printed is correct, check the “No Change” box. If you have recently moved from New York City to another county within New York State, but have not yet had a public health insurance case opened where you now live, you should complete and return this Renewal Form to usMAP-909E (Rev 06/25/09) Page 1 of 4
NOTE:X HOUSEHOLD INFORMATION: THIS SECTION IS PRE-PRINTED WITH THE NAMES OFHOUSEHOLD MEMBERS WHO ARE RECEIVING MEDICAID ON YOUR CASE. IT ALSO HAS PRE-PRINTED INFORMATION ABOUT THEM. PLEASE UPDATE THE INFORMATION FOR EACHHOUSEHOLD MEMBER IF IT IS WRONG OR IF IT HAS CHANGED. CHECK EACH “NO CHANGE” BOXWHERE THERE IS NO CHANGE. (PROVIDE PROOF OF ANY CHANGES TOCITIZENSHIP/IMMIGRATION STATUS.) Household Date of Sex Social Security Citizenship/ No Members Birth (M/F) Number Immigration Change Status1 []2 []3 []Y ADDRESS WHERE YOU LIVE: (IF YOU NEED LONG-TERM CARE SERVICES AND IF YOURADDRESS HAS CHANGED SINCE YOUR LAST APPLIED/RENEWED YOUR COVERAGE, PROVIDEPROOF.) No Change []Housing/Rent Payment: How Often? No Change []Z REAL ESTATE: (NO PROOF REQUIRED FOR 3A. PROOF REQUIRED IF YOU ANSWERED YESTO 3B.)A. Do You Own or Co-Own Your Home? Yes No If “Yes,” is your home equity value (marketvalue of home or the portion of the home that you own less all mortgages, liens or other debts against thehome) more than $750,000? Yes NoB. Do You Own Real Estate/Real Property other than your primary residence? Yes No If “Yes”,provide information requested below:Address of Property:___________________________________ Value of Property $_________________Income Received from Property: $________________________ How Often________________________MAP-909E (Rev 06/25/09) Page 2 of 4
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SECTIONS 4 THROUGH 7 ARE PRE-PRINTED WITH THE INFORMATION THAT WE CURRENTLY HAVEON FILE FOR YOUR HOUSEHOLD. PLEASE UPDATE THE INFORMATION WHERE IT IS WRONG,MISSING OR IF IT HAS CHANGED. CHECK EACH “NO CHANGE” BOX WHERE THERE IS NOCHANGE.[ MEDICARE HEALTH INSURANCE: (NO PROOF REQUIRED) No Change Premium Amount [] []\ OTHER HEALTH INSURANCE: (PROVIDE PROOF)Other Health Insurance such as Blue Cross/Blue Amount of How No Often (example: ChangeShield? Yes No Premium (if known) weekly, monthly)If “Yes,” provide name(s) of person(s) and name(s)of insurer below:_________________________________________ ________________ _______________ __________________________________________________ [] ________________ _______________ _________ []] INCOME: (IF YOU NEED LONG TERM CARE SERVICES OR MAY BE MEDICAID ELIGIBLEWITH A SURPLUS, PROVIDE PROOF)Name Type of Income Name of Amount How Often No Employer (before taxes (weekly/ Change (if income is from and bi- weekly/ employment) deductions) monthly) [] [] [] [] [] []^ RESOURCES: (IF YOU NEED LONG TERM CARE SERVICES, PROVIDE PROOF. IF YOU ARERENEWING MEDICARE SAVINGS PROGRAM (QMB-ONLY) COVERAGE, YOU MAY SKIP THISSECTION. RESOURCES ARE NO LONGER CONSIDERED WHEN DETERMINING MSP ELIGIBILITY.NOTE: INCLUDES CASH ON HAND, SAVINGS AND CHECKING ACCOUNTS, CERTIFICATES OFDEPOSIT, STOCK, BONDS, TRUST FUNDS, OWNERSHIP OF A BUSINESS, ETC. Resource Type(s) Resource Amount No Change [] [] [] [] []MAP-909E (Rev 06/25/09) [] Page 3 of 4
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If you have a Pooled Trust for which you have made deposits, provide proof of the deposits made from thedate you applied for public health insurance or your last renewal (whichever is latest). Provide one of thefollowing: • An accounting statement or signed letter from the Pooled Trust Administrator confirming receipt of the deposits • Copy of bank statements showing direct debits or cleared checks to the Pooled Trust • Copy of cancelled checks to the Pooled TrustIf you have a Pooled Trust for which you have not submitted the Joinder Agreement, you must provide acopy of the Joinder Agreement for approval by the Human Resources Administration, Office of Legal Affairs._ CHILDCARE/DEPENDENT CARE EXPENSES: (IF YOU NEED LONG TERM CARE SERVICES ORMAY BE MEDICAID ELIGIBLE WITH A SURPLUS, PROVIDE PROOF) CHILDCARE/DEPENDENT CARE HOW OFTEN EXPENSE AMOUNT` PREGNANCY AND DISABILITY: (IF ANYONE IS DISABLED AND YOU NEED LONG-TERM CARESERVICES OR MAY BE MEDICAID ELIGIBLE WITH A SURPLUS, PROVIDE PROOF DISABILITY-RELATED WORK EXPENSES.)Is anyone in your household pregnant? Yes No. (If yes, provide proof of expected date of delivery.Note: Pregnant women do not need to provide an SSN or proof of immigration status.)If anyone on this case blind, handicapped or disabled, do they have to pay special expenses (non-medical)in order to work? Yes NoIf yes: HOW OFTEN WORK-RELATED EXPENSE AMOUNT.Please be sure to answer all of the questions in all of the sections on this form. Remember to sign allof the forms that require a signature and attach all required proofs.I certify that the answers I have given are true and complete to the best of my knowledge. I have alsoread and understand the Terms Rights and Responsibilities.Signature of Consumer(or Representative): __________________________________________________ Date:_____________Signature of Spouse: __________________________________________________ Date:_____________MAP-909E (Rev 06/25/09) Page 4 of 4
