How to Fill Out and Submit the MAP-751w: Attachments and Filing

The MAP-751w is the New York City Human Resources Administration form for reporting a Medicaid case change that needs supporting paperwork. If you already have an active NYC Medicaid case and something significant shifts — a household member joins or leaves, someone on the case dies, your immigration status changes, or you need a budgeting adjustment — you check the matching box on the MAP-751w, attach the required documents, sign it, and send it to HRA. The form is a free PDF on the HRA Health Assistance page at nyc.gov.1Human Resources Administration. Health Assistance – HRA

When to Use the MAP-751w Instead of the MAP-751k

HRA runs two versions of the 751 form. The MAP-751k covers changes that need no proof, like a simple address correction or a lost EBT card. The MAP-751w is for everything that HRA has to verify before it can adjust your case. The form itself says it is “only to be used to correct/change the information listed on this form” and points staff to the MAP-751k when no documentation is needed.2NYC Human Resources Administration. MAP-751w Consumer/Provider Request to Change Information on File

Picking the wrong form delays your update. For an address change, use the MAP-751k or call the Medicaid helpline at 888-692-6116. For a spouse being added, a death on the case, or a budgeting request, use the MAP-751w — and expect it to sit if you send it without the documents.

Changes the Form Covers

You check one box for the action you want, then fill in whatever detail that section asks for. The categories on the current form are:2NYC Human Resources Administration. MAP-751w Consumer/Provider Request to Change Information on File

  • Close case completely (voluntary closure).
  • Combine two Medicaid cases into one.
  • MSSI case actions: reopen a closed SSI case, correct SSI coverage, activate an SSI case, or update SSI details.
  • Change the head of the case.
  • Add or remove an individual.
  • Notification of death.
  • Change in immigration status.
  • Upgrade eligibility to Personal Care, Community-Based Long-Term Care, or Nursing Home coverage.
  • Medicare Savings Program evaluation.
  • Convert a Medicaid case to an MSP case, or the reverse.
  • Budgeting changes (Disabled Adult Child, Medicaid Buy-In for Working People with Disabilities, MAGI budgeting, Pickle amendment, spend-down reduction, spousal impoverishment, spousal refusal).
  • Surplus actions: retroactive coverage, provisional coverage, or correcting existing coverage.
  • Pooled Trust: new joinder agreement or a budget for increased deposits.
  • Add or remove third-party health insurance.
  • Coverage date adjustments.
  • Suspend a case due to incarceration or unsuspend it after release.
  • Any change not listed, with space to describe it.

Documents You Need to Attach

The back of the form lists the proof HRA expects for each category. Sending the form without the right documents is the single most common cause of delay. For the most-used categories:2NYC Human Resources Administration. MAP-751w Consumer/Provider Request to Change Information on File

  • Close a case or remove an individual: your signed MAP-751w alone is enough.
  • Change the case head: a birth certificate, guardianship papers, or a letter from the Social Security Administration.
  • Add an individual: a completed DOH-4220 (Access NY Application) for the person being added.
  • Notification of death: a death certificate.
  • Change in immigration status: an I-94, I-551, I-766, I-797, evidence of continuous U.S. residence before January 1, 1972, or other authoritative immigration documents.
  • Upgrade to Personal Care, CBLTC, or Nursing Home: proof of income, proof of resources (current month for CBLTC; past 60 months for nursing home), and a completed DOH-5178A (Access NY Supplement A).
  • Medicare Savings Program evaluation: the documents listed on the MAP-628j, unless you already submitted them with your original Medicaid application.
  • MSSI case actions: documentation from the Social Security Administration and a DOH-4220.
  • Budgeting changes or surplus: the documents listed on the MAP-751x (Budgeting Change Documentation Guide), which is attached to the MAP-751w.
  • Pooled Trust: a copy of the Pooled Trust Joinder Agreement, proof of deposits, a Social Security disability determination or disability request forms, and a Power of Attorney if someone is acting for you.

The nursing home upgrade carries the heaviest paperwork: 60 months of resource records. Start pulling bank statements, investment account records, and property documents well before you submit.

Filling Out the Form

The MAP-751w is short. The top section asks for three identifiers:

  • Case name — the full legal name of the head of your Medicaid case.
  • Case number — your HRA Medicaid case number, on any HRA correspondence and in the Access HRA portal.
  • CIN — your Client Identification Number, printed on your Common Benefit Identification Card and on your managed care plan ID card.

Below that, check the box for the change you want. Some categories have sub-options; under Budgeting Changes, for example, you would also check something like Reduce Spend Down or Spousal Impoverishment. Fill in the additional fields the section asks for, such as case numbers to combine, names of people to add or remove, or the immigration status you are changing from and to.

At the bottom, print your name, sign, and date. If someone is submitting for you — an authorized representative, legal guardian, or person holding power of attorney — that person prints, signs, and dates the separate representative section. HRA will mail an eligibility notice about the change, so confirm your mailing address on file is current before you send anything.2NYC Human Resources Administration. MAP-751w Consumer/Provider Request to Change Information on File

How to Submit

The most direct route is fax to 917-639-0837.1Human Resources Administration. Health Assistance – HRA The transmission confirmation is worth keeping as proof of submission.

You can also mail the packet or drop it off in person at any open HRA Medicaid office; locations in every borough are listed on the HRA Medicaid Locations page.3Human Resources Administration. Medicaid Locations – HRA

Extra Copies for Budgeting Changes

If you are requesting a budgeting change and already have a surplus (spend-down) on your case, send a second copy of the MAP-751w to the Surplus Income Program along with the regular submission. If you receive Personal Care or CDPAP, or you are enrolled in a Managed Long-Term Care plan, also mail a copy to HRA Special Services, Home Care Services Program, 785 Atlantic Avenue, 7th Floor, Brooklyn, NY 11238. Certified mail with return receipt is worth it for that second copy; budgeting changes that touch long-term care coverage are the kind of request you want proof of delivery for.

After You Submit

HRA reviews the documents and processes the change. The form states that “an eligibility notice will be sent regarding the change you requested,” so watch your mail for that confirmation.2NYC Human Resources Administration. MAP-751w Consumer/Provider Request to Change Information on File If anything is missing or unclear, HRA will usually ask for more before acting, which adds weeks. Complete documentation on the first try is the best defense against delays.

If you get no response after several weeks, or your case does not reflect the change, call the NYC Medicaid helpline at 888-692-6116 to check status.1Human Resources Administration. Health Assistance – HRA Hold on to a copy of your signed form, your fax confirmation or mailing receipt, and copies of every document you sent. Those records are what you will need if you ever have to prove what went in and when.