How to Fill Out Form DOH-4328: The Six-Month Rule, Two Mailing Addresses in NYC, and What Gets Applications Sent Back
If you have already applied to Social Security for Extra Help, you may have applied for this too without knowing it. Under federal law, Social Security transmits Extra Help application data to the state, and New York uses it to open a Medicare Savings Program determination. The state's own guidance to county staff says the data SSA sends is already verified and sufficient for identity documentation. So before you spend an afternoon on this form, call and ask whether a determination is already running.
Two pages. Most of what stalls this form is mechanical — a blank spouse column, a signature on the back nobody turned over, or a utility bill that is seven months old.
Two things worth checking first
You may not be over the line. New York's Medicare Savings Program limits are among the highest in the country and there is no asset test at all. People with a paid-off house and a retirement account decide they cannot qualify, and in this state that reasoning does not hold.
Two things reduce the income the state counts. Earned income is counted at less than half, so working part-time is not the obstacle it looks like. And premiums you pay for other health coverage — Medigap, a Medicare Advantage plan, dental, vision — are subtracted before the test is applied.
Between those two, a fair number of people who assume they are $200 over are not.
The five parts people get wrong
We will not tell you what to write in each box — your circumstances decide that. What we can tell you is which answers cause packets to come back.
If you are married and living with your spouse, the state instruction is explicit: complete both the "Self" and "Spouse" questions, even if the spouse is not applying. Leaving that side blank is the single easiest way to have the packet returned.
People finish page one, feel done, and post it unsigned. Turn the form over. And if both spouses are applying, both must sign. One signature on a two-applicant form is a return.
The instruction sheet says it plainly at Step 6: answer all the questions, sign, date, include the documentation. A question that does not apply still needs an answer — none, zero, or N/A. Blanks read as omissions.
There is a question about health insurance premiums you pay besides Medicare. This is not a trap — those premiums reduce your counted income. Leaving it blank does not protect you, it costs you. Attach the employer letter, the premium statement or the pay stub that proves it.
Step 6 of the state instructions says to keep a copy of the completed application. Take it literally — photograph every page. When someone calls in three weeks with a question about page two, you want page two in front of you.
The six documents, and the one that expires
| Document | What counts |
|---|---|
| Medicare card | A photocopy of the front and the back. |
| Date of birth | Driver's licence, US birth certificate, US passport, Permanent Resident Card, or NYS Benefit Identification Card. |
| Residence | Lease, landlord letter, rent receipt, utility bill, property tax record, mortgage statement, or a postmarked envelope. Dated within six months of your signature. A P.O. box envelope does not count. |
| Income | Four weeks of pay stubs, employer letter, pension paperwork showing amount and frequency, tax return, or an award letter for Social Security, unemployment or veterans benefits. A letter from a renter or boarder also counts. |
| Other health premiums | Employer letter, premium statement or pay stub. |
| Immigration status | Only if you are not a citizen. I-551 Green Card or I-766 Employment Authorization Card. |
→ swipe the table sideways
Source: NYS Department of Health, How to Complete the Medicare Savings Program Application DOH-4328, Steps 5–8.
The shaded row is the one that catches people. Six months from the day you sign, not from the day the document was issued to you. An old utility bill in a drawer proves nothing here, and a postmarked envelope only works if it was addressed to where you actually live. If your spouse is also applying, the spouse supplies the same six things.
New York runs QMB and QI only — there is no SLMB here — and the income limits are unusually high. The $33,038 resource figure on the state's page belongs to a different programme entirely.
New York's 2026 limits →Where it goes, and the New York City split
Everywhere outside the five boroughs, the form goes to the social services office in the county where you live. Not to Albany, and not to the Department of Health, even though the Department of Health publishes the form.
In New York City it goes to the Human Resources Administration — and here there is a split worth getting right.
| If you are applying for | Mail to |
|---|---|
| MSP only — the short application | HRA/Medical Assistance Program, Initial Eligibility Unit, 5th Fl., PO Box 24390, Brooklyn NY 11202-9814 |
| MSP and Medicaid — the longer application | HRA/Medical Assistance Program, MSP-CREP, 5th Fl., PO Box 24330, Brooklyn NY 11202-9801 |
→ swipe the table sideways
Source: NYC Human Resources Administration, Medicare Savings Program brochure. City residents can also apply through ACCESS HRA online, or request the form from the HRA Medicaid Helpline at 888-692-6116.
Two boxes, one digit apart, and different units open them. If you only want help with your Part B premium, use the first. If you want to be considered for full Medicaid as well, use the second and expect a longer form.
Whichever route you take, the local office has 45 days from the day you file to send a Notice of Action. That notice is the answer. If forty-five days pass and nothing arrives, call — silence is not a decision.
Seven things that go wrong
An Extra Help application at Social Security opens an MSP determination in New York automatically. Ask before you duplicate it.
Married and living together means both columns, whether or not your spouse wants anything. The state instruction says so in as many words.
The signature is on the reverse. Two applicants, two signatures.
Six months from the day you sign. And a postmarked envelope addressed to a P.O. box does not prove where you live.
They reduce your counted income. Omitting them helps nobody, least of all you.
MSP-only and MSP-plus-Medicaid go to different units. Sending the short form to the long-form address adds handling time nobody logs.
You recertify every year, and the state says if the renewal notice does not arrive you must contact the office yourself. People lose this benefit quietly, in the post.
Free help with the form
New York runs a counselling network called HIICAP through the local offices for the aging, with more than 700 trained counsellors statewide and one toll-free number that routes to your county. They will sit down and go through the form with you. It costs nothing and they sell nothing.
| The form | DOH-4328 — published in ten languages |
| Instructions | NYSDOH, How to Complete the MSP Application DOH-4328 |
| Find your county office | Local DSS directory |
| Medicaid Helpline | 1-800-541-2831 |
| New York City — HRA | 888-692-6116 · or apply on ACCESS HRA |
| Free counseling (HIICAP) | 1-800-701-0501 |
| 2026 limits | NYSDOH MSP page |
Related programs
The full procedureHow to apply for a Medicare Savings Program in New York→ The numbersNew York's limits, and what replaced SLMB→ The form that opens bothHow to fill out Form SSA-1020→ Everything else in this stateSenior benefits in New York→Tools you'll need
aging.ny.gov — HIICAP counseling
nyc.gov/hra — ACCESS HRA for city residents
shiphelp.org — free Medicare counseling, any state
eldercare.acl.gov — 1-800-677-1116
211.org — local help finder
Sources. New York State Department of Health, How to Complete the Medicare Savings Program Application DOH-4328 — spouse questions, signatures, verification documents, the six-month rule, mailing to the local district, and the 45-day Notice of Action. New York State Department of Health administrative directive on Medicare Savings Program applications initiated from Social Security Low Income Subsidy data, implementing Section 113 of MIPPA. New York City Human Resources Administration, Medicare Savings Program brochure — the two mailing addresses and the Medicaid Helpline number.
Verified: August 1, 2026.
This page explains how a state form is processed. It is not legal or financial advice and it is not an eligibility decision. Only your local social services district can determine whether you qualify. We do not tell you what to write in any box — your circumstances decide that.
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