Get Ny Ldss-4150 2014-2025
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How to fill out the NY LDSS-4150 online
Filling out the NY LDSS-4150 form is a crucial step in determining presumptive eligibility for Medicaid for pregnant individuals. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently online.
Follow the steps to complete the NY LDSS-4150 form online.
- Click 'Get Form' button to access the NY LDSS-4150 and open it in the editor.
- In Section 1, provide the applicant's information, including first name, middle initial, last name, home address, phone number, date of birth, county of residence, presumptive eligibility determination date, and social security number (optional). Ensure that all required fields are accurately filled.
- In Section 2, indicate if the applicant has applied for Medicaid or cash assistance within the last three months. If applicable, provide details about the application. Follow up by checking if the applicant has coverage through Medicaid or Family Health Plus and address any private health insurance inquiries.
- Move to Section 3 to calculate the total family size. Include the pregnant woman, the spouse if living together, and all children under 21 residing in the household. Input the total at the end of this section.
- In Section 4, enter the gross monthly income for the household if the applicant is 21 or older. Include all qualifying income sources while excluding specific ones as noted in the instructions.
- Section 5 requires comparing the gross monthly income to the 223% federal poverty level. If eligible, record the health plan choice and primary care physician's name.
- Complete Section 6 by filling in the screener's information, including the name, signature, agency name, address, and phone number. The provider's signature affirms the eligibility determination.
- After reviewing all entered information for accuracy, you can save your changes, download, print, or share the completed form.
Start filling out the NY LDSS-4150 form online today to determine eligibility.
If your income increases while receiving Medicaid in New York, you must report the change immediately. Depending on how much your income goes up, you may still remain eligible for some assistance programs. It's crucial to understand how the NY LDSS-4150 could affect your coverage, as it may allow you to transition into other necessary programs. Always consult with a Medicaid advisor for precise guidance on your situation.
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