MSP application documents checklist: NYC (HRA) vs the rest of New York

DOH-4328 is the short form for the Medicare Savings Program only (QMB or QI). HRA's brochure describes the choice plainly: apply for MSP-only with the short application, or for both MSP and Medicaid with the longer application. If you also want full Medicaid, you are in the longer form's territory, and the longer form does ask about resources, because full Medicaid has a resource limit ($33,038 for a single person and $44,796 for a couple in 2026, per the state's chart). This checklist covers the MSP-only path.

The state posts DOH-4328 in English, Spanish, Russian, Chinese, Bengali, Haitian Creole, Korean, Arabic, Polish, Italian, and several other languages, with a separate instruction sheet. Use the current revision; the copy on health.ny.gov is stamped 11/23 as of this review.

The state's instruction sheet says to include the following "verification documents (or equivalents)" with the form. Here is each one, with what the state lists as acceptable.

1. Medicare card. A photocopy of the front and back of the red, white, and blue card. If you only have the Social Security letter that gives your Medicare start date, send that and say the card has not arrived.
2. Proof of date of birth. One of: state driver's license, U.S. birth certificate, U.S. passport, Permanent Resident Card (green card), or a New York State Benefit Identification Card.
3. Proof of where you live. One of: a lease, letter, or rent receipt with your home address from your landlord; a utility bill (gas, electric, phone, cable, fuel, or water); property tax records or a mortgage statement; a government ID card with your address; a driver's license issued in the past six months; or a postmarked envelope or postcard sent to your home. The instruction sheet says the residence proof must be dated within six months of the day you sign the application, and a postmarked envelope cannot be used if it was sent to a P.O. Box.
4. Proof of income. For each source: pay stubs covering four weeks or a letter from your employer; pension information showing the amount and how often it is paid; your income tax return; the award letter for any benefit such as Social Security, unemployment, or veterans' benefits; or a letter from a renter, boarder, or tenant if you collect rent.
5. Proof of other health insurance premiums. If you pay for any health coverage other than Medicare, such as a retiree plan or a Medigap policy, send a letter from the employer, a premium statement, or a pay stub showing the deduction. This matters: New York subtracts certain health premiums from your income before comparing it to the limit, so a premium you forget to prove can leave you over the line on paper.
6. Immigration status, if you are not a U.S. citizen. Documents showing current status, such as an I-551 Permanent Resident Card or an I-766 Employment Authorization Card.

Two more things go in the envelope that are not proofs:

• Your signature and the date. The state's MSP page warns that the signature block is on the back of the form and that an unsigned form is not a complete submission. If both spouses are applying, both sign.
• A copy for yourself. The instruction sheet tells you to make a copy of the completed application for your records before mailing. Keep it with the date you mailed it.

Knowing the questions ahead of time cuts the gathering time in half. DOH-4328 asks for: your name, home and mailing address, date of birth, sex, and Social Security number (the form says an SSN is required for the MSP); whether you are a U.S. citizen and, if not, your alien number and dates; your Medicare number and whether you have Part A and Part B with the effective dates; whether you want the state to consider retroactive reimbursement of Medicare premiums; whether you pay other health premiums, child or spousal support, or receive payments from a trust; and a list of every source of income with the amount and how often it comes.

If you are married and living with your spouse, the instructions say you must complete both the Self and Spouse sections even if your spouse is not applying. If your spouse is applying too, the spouse sends the same set of documents.

The form has a yes-or-no box asking whether you want the state to consider retroactive reimbursement of your Medicare premium. If you check yes, the instructions on page two say you must send proof of income for the previous three months, not just the current month. HRA's brochure explains why the answer differs by program: QMB starts the first day of the month after eligibility is determined, while QI-1 is effective the month of application. Ask a HIICAP counselor which box to check for your case.

Inside the five boroughs, Medicaid and the MSP are run by the NYC Human Resources Administration (HRA), not a county office. HRA's brochure gives two mailing addresses, one for each form:

• MSP-only: HRA/Medical Assistance Program, Initial Eligibility Unit, 5th Fl., PO Box 24390, Brooklyn, NY 11202-9814.
• MSP and Medicaid together: HRA/Medical Assistance Program, MSP-CREP, 5th Fl., PO Box 24330, Brooklyn, NY 11202-9801.

Those addresses come from HRA's 2024 brochure. Confirm them on the HRA Medicaid Helpline at 1-888-692-6116 before you mail, because P.O. boxes change and a package sent to an old box can sit for weeks.

Other doors HRA lists: apply online through ACCESS HRA (the brochure says clients can apply for Medicaid and/or the MSP there), or bring the package to a Community Medicaid Office. HRA's locations page lists offices in every borough, such as Rider Avenue and Bainbridge Avenue in the Bronx, Fulton Street and Clermont Avenue in Brooklyn, Chrystie Street and 10th Avenue in Manhattan, Northern Boulevard and 88th Avenue in Queens, and Bay Street on Staten Island. Offices open and close (one Brooklyn site is listed as closed until further notice), so check nyc.gov/hra or call before you go.

HRA's Health Assistance page says applicants must provide proof of residency, identity, income, and immigration status, and adds that proof of Medicare is now required. That lines up with the state list above; the Medicare card copy is not optional.

Outside New York City, the state's MSP page says all paper applications must be mailed to the local Department of Social Services where you live. The state keeps a county-by-county list with addresses and phone numbers at health.ny.gov/health_care/medicaid/ldss.htm; the Nassau, Suffolk, Westchester, and Rockland offices are all on it. Write the county name, not the town, on the form.

The state page also says you may apply online with NY State of Health. That route exists, but the form and the paper checklist above are the path most counselors walk people through for an MSP-only application. Ask HIICAP which door fits your situation before you start an online account.

The instruction sheet says the local district will send you a Notice of Action within 45 days of filing. That letter says whether you get the MSP. If something is missing, expect a request for documents with a deadline rather than an outright denial; answer it by the date on the letter.

Once approved, the state tells Medicare, and the Part B premium ($202.90 a month in 2026) stops coming out of your Social Security check. That change can take a month or two and often arrives with a refund of premiums already deducted. Extra Help follows automatically. The instruction sheet ends with a line people skip: you must renew the MSP every year, and if no renewal notice arrives in the mail, contact HRA or your local Medicaid office and ask what you need to do. Our post on Medicaid renewal letters explains which office sends the renewal now and what the other fall notices mean.

• Sending original documents. Send copies.
• Forgetting the back of the Medicare card, or the back of the form where the signature goes.
• Using a residence proof older than six months.
• Leaving out a health premium you pay. It can be the difference at the income line.
• Skipping the Spouse section because your spouse is not applying. The state still wants it.
• Mailing to a borough office address instead of the P.O. box HRA lists for applications.
• Writing "Brooklyn" for county. It is Kings. Manhattan is New York County, Staten Island is Richmond.

Do I need bank statements for a Medicare Savings Program application in New York?

Not for MSP-only. The state's MSP overview says there is no resource test for the MSP programs, and the DOH-4328 instruction sheet does not ask for bank statements. You do need them if you apply for full Medicaid at the same time, because full Medicaid has a resource limit.

Can someone else fill out and sign the form for me?

The form has a signature line for an applicant or representative, with space for the representative's address and relationship. A family member or counselor can help you complete it. HIICAP counselors at 1-800-701-0501 do this for free.

What if I do not have a lease or a utility bill in my name?

The state list includes a letter from your landlord, a government ID with your address, and a postmarked envelope or postcard mailed to your home. Any one of those works if it is dated within six months of your signature.

How long does the decision take?

The state's instruction sheet says the district sends a Notice of Action within 45 days of filing. In practice, a complete packet with clear copies moves fastest.

Where do I send it if I live in Nassau, Suffolk, or Westchester?

To your county Department of Social Services, not to HRA. The state's county list at health.ny.gov has each address and phone number.