NY Manual
SHP Manual

New York Provider Manual
10.9 Transportation | 11.1 Emergent Care

10.10 Custodial Long-Term Care Placement

If a Healthfirst member is enrolled with Community Medicaid and is being placed for custodial services, the Nursing Home must contact Healthfirst immediately to obtain authorization.

Healthfirst will provide the authorization for custodial care and the MAP 2159i form.

As per the DOH guidelines, The Nursing Home is responsible for compiling all required documentation, as part of the request for custodial eligibility and application, and submission to LDSS/HRA within 90 days from the start date the member is authorized for custodial care including the following documents:

  • 2159i – Notice of Permanent Placement Medicaid Managed Care

  • MAP 648P – Receipt for Submission of “Request” from Residential Health Care Facilities (RHCF), submit 2 copies – 1 copy will be returned to the RHCF as a receipt

  • DOH 4220 – Access NY Health Care

  • DOH 4495A – Supplement A

  • MAP 2123 - Statement in support of claim

  • MAP 3043 – Authorization to Apply for Medicaid on My Behalf

  • MAP 3044 – Facility Submission of Application on Behalf of Consumer

  • MAP 258M - Medicare Buy-In

  • OCA-960 – Authorization for release of Health Information Pursuant to HIPAA

  • Patient Review Instrument (PRI) – Pages 1-4

  • Must submit a New Application for active in NYSOH (Health Benefits Exchange) clients

If applicable:

  • LDSS 486T - Medical Report Form

  • LDSS 1151 - Disability Interview Form

  • Signed HIPAA Releases (3 blank copies)

  • MAP 252F - AIDS Medical Form 

  • MAP 259D - Discharge Alert & MAP 259H – Intent to Return Home 

You may submit completed applications online through the Eligibility Data and Image Transfer System (EDITS) by registering with the MAP Authorized Resource Center (MARC).

If your facility is located in New York City, you can also mail applications to:

Medical Assistance Program

Nursing Home Eligibility Division

P.O. Box 24210

Brooklyn, New York 11202-9810 

If your facility is located in Westchester, Nassau, or Suffolk counties, you may mail applications to your Local Department of Social Services. For your local department of services address please visit www.health.ny.gov/health_care/medicaid/ldss.htm. 

Note: The nursing home facility must provide proof (see section below) to Healthfirst that the application was submitted to HRA/LDSS. Please note, Healthfirst may recoup reimbursement made for any period of eligibility.

Proof of Submission Requirements

Paper Submitters: Nursing homes must send two copies of the MAP-648P form to LDSS/HRA.  LDSS/HRA will return a copy to the nursing home as proof of submission. The nursing home must email a copy of this form to: NursingHomeHF@Healthfirst.org.


EDITS Submitters: Submitters using EDITS will receive and electronic notification “EASYng Case Status History” response form EDITS.  The nursing home must email a copy of this response to: NursingHomeHF@Healthfirst.org.

LDSS/HRA has forty-five (45) days from the date of application to complete the eligibility determination, including 60 months and look-back period and transfer of asset rules.

For SSI individuals, if a disability determination is required, the district has 90 days from the date of application or request for an increase in coverage to determine Medicaid eligibility.  The district may exceed these time periods if it is documented that additional time is needed for a consumer, to obtain and submit required documentation.



Once HRA/LDSS approve eligibility and determine NAMI amount it will be documented on monthly Nursing Home Report (specialty) file.

Authorization Requirements

Nursing Home facilities must obtain authorization from Healthfirst before providing nursing facility services to an eligible Healthfirst member.

  • Authorization may be requested by contacting Healthfirst’s Care Management Team

  • Healthfirst must be informed when any change to an authorized admission occurs


Bed Hold Authorization

The nursing home must notify Healthfirst when a bed hold authorization is required.

Reserved bed days related to leaves of absence for temporary hospitalizations shall be made at 50% of the Medicaid FFS rate for a maximum of 14 days in a 12 month period.

Reserved beds related to non-hospitalization leave of absence (therapeutic leave) shall be at 95% of the Medicaid rate for a maximum of 10 days in a 12 month period. 

Access to Care and Quality

Healthfirst closely monitors and coordinates the care for members who are typically frail and have multiple, chronic conditions that reside in nursing facilities that require long term care.

Patient care after placement:

  • Person Centered Care Plan

  • Healthfirst arranges for UAS-NY assessment every 6 months or when enrollee condition changes

  • Coordinates with NH to share assessment data

  • Healthfirst may review for service coverage and medical necessity

  • Healthfirst reauthorizes stay under concurrent review at identified intervals

  • Healthfirst ensures enrollee has a PCP

  • Healthfirst arranges for other covered services enrollee needs

Communication and Coordination of Care:

  • The nursing facility must inform Healthfirst care management of a change in member Status and Sentinel Event in order to assure UAS assessment.

  • The nursing facility must inform the Healthfirst care management of member discharge to the community

  • For any issues regarding the MAP 2195i form please contact the Healthfirst at NursingHomeHF@Healthfirst.org 

Discharge Planning

If a member chooses to transition back to the community, the Care Management team will work to assure the following:

  • Coordinate a formal patient centered discharge plan involving the member, the member’s family, and nursing facility to develop and ensure a safe and appropriate discharge plan back into the community.

  • Nursing Facility must work with Healthfirst to reinstate community LDSS coverage

  • Ensure that appropriate community supports are in place prior to discharge.

Billing Guidelines

The Billing Guidelines are located online at our website, www.healthfirst.org.