Medicaid Buy-In Program for Working People with Disabilities
Online Guide

Medicaid Documentation Checklist

This is a list of documents that the Medicaid programs accept. Please review the checklist to determine what documents you need to provide in order to apply for the MBI-WPD program. Individuals declaring at application to be a U.S. Citizen are no longer required to show proof of citizenship, identity and date of birth at application. For these applicants, a Social Security Number match is done between the Welfare Management System and an SSA-SSN verification system. After that, citizenship, identity and date of birth are all electronically verified. If the match fails, the individual may need to submit documentation but if it passes the match, no further documentation of these items is needed.

CURRENT IMMIGRATION STATUS

(Must be provided for any immigrant applying or for an immigrant renewing whose status has changed in the past 12 months.)

  • USCIS (INS) Form I-551 Resident Alien Card
  • USCIS Form I-94 Arrival/Departure Record
  • I-668B or I-766 Employment Authorization Card
  • Other documentation or correspondence to and from the federal immigration agency

DATE OF BIRTH

(Everyone must provide proof of date of birth.)

  • U.S. Birth Certificate
  • Official U.S. hospital/doctor birth records
  • U.S. baptismal certificate

CERTIFICATION OF DISABILITY

(Everyone must provide certification of disability, if you have no certification of disability or blindness, the LDSS may help you obtain certification.)

Social Security Disability Insurance Award letter/certificate, benefit check or correspondence from Social Security Administration
Social Security Administration (SSA) Letter from SSA placing you in a 36-month Extended Period of Eligibility or a letter stating that you are no longer eligible for the 1619(b) program due to excess income or resources
Railroad retirement benefits Award letter listing the disability as total and permanent
State/Local Disability Review Team Certificate Disability Review Team Certificate (LDSS-639)
Certification of blindness Certification from the Commission for the Blind and Visually Handicapped

RESIDENCY/HOME ADDRESS

(Everyone must provide proof of residency.)

  • ID card with address
  • Postmarked envelope, postcard, or magazine label with name and date
  • Driver's license issued within past 6 months
  • Utility bill (gas, electric, cable), bank statement or correspondence from a government agency
  • Letter/lease/rent receipt from the landlord, with home address
  • Property tax records or mortgage statement

INCOME

(Everyone must provide proof of income.)

Earned Income from Employer Current paycheck/stubs or letter from employer
Self-Employment Income Current signed income tax return or record of earnings and expenses
Rental/Roomer-Boarder Income Letter from roomer, boarder, tenant or check stub
Unemployment Benefits Award letter/certificate, benefit check, correspondence from NYS Dept. of Labor
Private Pensions/Annuities Statement from pension/annuity
Social Security Award letter/certificate, benefit check or correspondence from SSA
Child Support/Alimony Letter from the person providing support, letter from court, child support/alimony check stub
Workers' Compensation Award letter, check stub
Veteran's Benefits Award letter, benefit check stub, correspondence from Veteran's Administration
Military Pay Award letter, check stub
Interest/Dividends/Royalties Statement from bank, Credit Union, or financial institution. Letter from broker
Support from other Family Members Signed statement or letter from a family member
Income from a Trust Trust document

RESOURCES

Resources include: money in a bank or credit union, stocks, bonds, mutual funds, certificates of deposit, money market accounts, 401k plans, trusts, the cash value of life insurance, or property that someone owns. Do not include your home.

If you do not require long-term care services, you may attest to the amount of your resources. If you require community-based long-term care services you must provide proof of your current resources.

  • Bank statements
  • Life insurance policy
  • Copy of the deed and appraisal for real estate
  • Copies of stocks, bonds, securities other than your home
  • Trust document
  • Burial agreement

HEALTH INSURANCE PREMIUMS

(Provide, if applicable.)

  • Letter from employer
  • Premium statement
  • Pay stub

PRIVATE OR EMPLOYER BASED HEALTH INSURANCE

(Provide, if applicable.)

  • Insurance policy
  • Premium statement
  • Insurance card
  • Termination letter

CHILDCARE/DEPENDENT CARE EXPENSES

(Provide, if applicable.)

Written statement from day care center or other child/adult care provider.

PREGNANCY

If someone is now pregnant, a statement from a medical provider including the expected date of delivery is required, unless you have already given a statement to us. If you do not have this statement when applying, please get it as soon as possible and send it to your worker.

SPECIAL WORK EXPENSE FOR BLIND/DISABLED

If you are blind or disabled and must pay special non-medical expenses in order to work (for example, you need special equipment or transportation), provide the receipts that show what the expense is and who provides it.

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