DOH-4328 Form: New York Medicare Savings Program Application

What the DOH-4328 Is (and Is Not)

Form DOH-4328 is the dedicated application for New York's Medicare Savings Programs — QMB and QI. It is two pages, published by the New York State Department of Health, and available in multiple languages including English, Spanish, Chinese, Korean, and Russian.

This is not the full Medicaid application. If your parent needs only help with Medicare costs, DOH-4328 is the right form. If they also need full Medicaid coverage, the longer DOH-4482 (or MAP-2084K in New York City) plus Supplement A (DOH-5178A) is required instead.

What You Need Before Starting

Gather these before sitting down with the form:

• Social Security benefit letter showing gross monthly amount (the letter SSA mails each December works, or request one at ssa.gov)
• Pension or annuity statements if any
• Medicare card — front and back (to confirm Part A and Part B enrollment)
• Proof of New York residency — utility bill, lease, or state ID
• Photo ID — state driver's license, passport, or other government-issued ID

Because New York has no asset test for MSP, you do not need bank statements, retirement account records, or property deeds. If a caseworker asks for them on an MSP-only application, they are applying the wrong policy — the state eliminated the MSP asset test in 2008.

Filling Out the Form Section by Section

Section 1 — Applicant Information: Name, address, date of birth, Social Security number, and whether the applicant (and spouse, if applicable) has Medicare Part A and Part B, with their effective dates. Include a copy of the Medicare card.

Section 2 — Income: List gross monthly income from all sources. Social Security goes in before the Part B premium is deducted — the gross amount, not the net deposit. Pensions, wages, and any other income each get their own line.

Section 3 — Health Insurance: List any private health insurance policies the applicant pays for — Medigap, dental, vision. These premiums can reduce countable income during the eligibility determination.

Section 4 — Signature and Authorized Representative: The applicant signs and dates. If an adult child or advocate is filing on behalf of the applicant, they fill out the authorized representative section. A Power of Attorney can also sign.

Where to Submit the DOH-4328

The destination depends on where the applicant lives:

• New York City (all five boroughs): Submit through the ACCESS HRA online portal or mobile app, or mail to the HRA Medicaid office
• Upstate New York and Long Island: Submit to the county Department of Social Services (Medicaid division), or apply online through NY State of Health

In-person submission is also an option at local DSS or HRA offices. Mailing the form with copies of supporting documents is the simplest route for caregivers who live out of state.

After Submission

For a non-disability application, the agency has 45 calendar days to issue a written decision. If a disability determination is required, the period is 90 calendar days. If approved, the notice will specify QMB or QI, the effective date, and the monthly income calculation the agency used. If denied, the notice must explain why and outline fair hearing rights.

Once approved, the Part B premium buy-in takes 60–90 days to process through CMS and Social Security. The premium continues being deducted during that window, but Social Security issues a lump-sum refund once the buy-in goes through.

For a line-by-line walkthrough of the DOH-4328, income worksheets, and the full post-approval timeline, the New York Medicare Savings Programs Guide covers every step.

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