GIS 12 MA/008: Clarification of Self-Employment Policy and Use of the Financial Status Form (Farm or Business), DOH-4469

To: Local District Commissioners, Medicaid Directors

From: Judith Arnold, Director - Division of Health Reform and Health Insurance Exchange Integration

Subject: Clarification of Self-Employment Policy and Use of the Financial Status Form (Farm or Business), DOH-4469

Effective Date: April 1, 2012

Contact Person: Local District Support Unit - Upstate (518) 474-8887, New York City (212) 417-4500

The purpose of this General Information System (GIS) message is to clarify the Department's policy regarding calculating self-employment income and the correct use of the Financial Status Form (Farm or Business), DOH-4469.

When an individual is self-employed, the annual income tax return is the primary document used to calculate the monthly income. As stated in GIS 09 MA/025, the DOH-4469 should only be used under the following circumstances:

  • when the applicant/recipient (A/R) indicates s/he does not file a tax return;
  • the business is new and a tax return had not been filed; or
  • the A/R indicates that last year's earnings are not representative of the current year's earnings.

The income and expenses of the last three months is used to complete the DOH-4469. The three month total is then averaged for a projected monthly income for prospective eligibility.

When the last three months is not an accurate picture of the business income, due to either unusually high or low income and/or expenses, then the district must request the last year's worth of income using four DOH-4469 worksheets. If the business is new and has been in operation for less than one year, then the request cannot exceed the number of months the business has been in operation.

Please direct any questions to your local district liaison.