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Welfare Management System .

Worker's Guide to Codes

Written By:
Catherine Waterman - NYS Office of Temporary & Disability Assistance
Barbara Gordon - NYS Department of Health - CHIP

Software Version 2017 .1

02/19/2017 .

As of August 29, 2012, any reference to the Food Stamp Program in this manual shall mean the
Supplemental Nutrition Assistance Program (SNAP) and any reference to Food Stamp benefits
or Food Stamps (FS) shall mean SNAP benefits.

Funded through a contract with

Research Foundation for the State University of New York I SUNY Buffalo State
Center for Development of Human Services
 WORKER'S GUIDE TO CODES
TABLE OF CURRENT PAGES
02/19/2017

Listed below in consecutive order, with their dates of issuance, are all of the current page numbers for
the Worker's Guide to Codes. This table can be used to verify that all updates are included in your copy
of the manual and have the correct date of issuance.

TITLE PAGE 1.3-5 02/15/2014

1.3-6 02/15/2014
Software Version 2017.1 02/19/2017
1.3-7 10/22/2012
1.3-8 10/22/2012
1.3-9 10/22/2012
1.3-10 10/20/2013
1.3-11 10/20/2013
1.3-12 10/20/2013
1.3-13 10/18/2014
TABLE OF CONTENTS
1.3-14 10/22/2012
.-i 02/19/2017 1.3-15 10/22/2012
.-ii 02/19/2017 1.3-16 10/22/2012
.-iii 02/19/2017 1.3-17 10/22/2012
.-iv 02/19/2017 1.3-18 06/19/2016
.-v 02/19/2017 1.3-19 02/21/2016
.-vi 02/19/2017 1.3-20 10/22/2012
.-vii 02/19/2017 1.3-21 10/22/2012
.-viii 02/19/2017 1.3-22 10/22/2012
.-ix 02/19/2017 1.3-23 02/21/2016
.-x 02/19/2017 1.3-24 10/18/2015
1.3-25 10/22/2012
INTRODUCTION 1.3-26 10/22/2012
.-xi 10/22/2012 1.3-27 10/22/2012
.-xii 10/22/2012 1.3-28 10/22/2012
1.3-29 02/21/2016
CHAPTER 1- 1.3-30. 06/19/2016
APPL/CATION 1.3-31 06/19/2016
1.1-1 Common Application Form - . 1.3-32 02/14/2015
DSS 2921 02/14/2015 1.3-33 02/14/2015
1.1"2 10/22/2012 1.3-34 02/14/2015
1.1-3 02/14/2015 1.3-35 02/14/2015
1.1-4 10/22/2012 1.3-36 02/14/2015
. 1.2-1 Turnaround Document - DSS 1.3-37 02/14/2015
3517 10/23/2016 1.3-38 02/14/2015
1.2-2 10/23/2016 1.3-39 06/19/2016
1.2-3 02/21/2016 1.3-40 06/19/2016
1.2-4 06/16/2013 1.3-41 02/14/2015
1.2-5 02/14/2015 1.3-42 02/14/2015
1.2-6 06/19/2016 1.3-43 02/14/2015
1.2-7 06/16/2013 1.3-44 02/14/2015
1.2-8. 02/21/2016 1.3-45 02/14/2015
1.3-1 10/22/2012 1.3-46 02/14/2015
1.3-2 10/22/2012 1.3-47 02/14/2015
1.3-3 10/22/2012 1.3-48 02/14/2015
1.3-4 10/22/2012 1.3-49 02/14/2015
1.3-50 02/14/2015

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1.3-51 02/14/2015 1.5-7 10/22/2012

1.3-52 02/14/2015 1.5-8 10/22/2012
1.3-53 02/14/2015 1.5-9 10/22/2012
1.3-54 02/14/2015 1.5-10 10/22/2012
1.3-55 02/14/2015 1.5-11 10/22/2012
1.3-56 02/14/2015 1.5-12 06/21/2014
1.3-57 02/14/2015 1.5-13 02/21/2016
1.3-58 02/14/2015 1.5-14 10/22/2012
1.3-59 02/14/2015 1.5-15 10/22/2012
1.3-60 02/14/2015 1.5-16 06/19/2016
1.3-61 02/14/2015 1.5-17 02/21/2016
1.3-62 02/14/2015 1.5-18 06/19/2016
1.3-63 02/14/2015 1.5-19 02/14/2015
1.3-64 02/14/2015 1.5-20 02/14/2015
1.3-65 02/14/2015 1.5-21 02/14/2015
1.3-66 02/14/2015 1.5-22 02/14/2015
1.3-67 02/14/2015 1.5-23 10/18/2015
1.3-68 02/14/2015 1.5-24 10/18/2015
1.3-69 10/18/2015 1.5-25 10/22/2012
1.3-70 02/14/2015 1.5-26 10/22/2012
1.3-71 02/14/2015 1.5-27 10/22/2012
1.3-72 02/14/2015 1.5-28 10/22/2012
1.3-73 02/14/2015 1.5-29 10/22/2012
1.3-74 02/14/2015 1.5-30 10/22/2012
1.3-75 02/14/2015 1.5-31 06/21/2014
1.3-76 02/14/2015 1.5-32 02/21/2016
1.4-1 10/18/2015 1.5-33 10/22/2012
1.4-2 06/21/2015 1.5-34 10/22/2012
1.4-3 02/19/2017 1.6-1 Regulatory Citations For
1.4-4 10/22/2012 Changes In PA/SNAP Grant 10/22/2012
1.4-5 02/19/2017 1.6-2 10/22/2012
1.4-6 02/21/2016 1.6-3 10/22/2012
1.4-7 02/21/2016 1.6-4 10/22/2012
1.4-8 02/21/2016 1.6-5 10/22/2012
1.4-9 02/19/2017 1.6-6 10/22/2012
1.4-10 02/21/2016 1.6-7 10/22/2012
1.4-11 02/21/2016 1.6-8 10/22/2012
1.4-12 02/21/2016
1.4-13 02/21/2016 CHAPTER 2-
1.4-14 02/21/2016 AUTOMATED BUDGETING AND ELIGIBILITY
1.4-15 10/23/2016 LOGIC (ABEL)
1.4-16 10/23/2016 2.1-1 06/21/2014
1.4-17 10/23/2016 2.1-2 02/14/2015
1.4-18 10/23/2016 2.1-3 06/21/2014
1.5-1 10/22/2012 2.1-4 02/21/2016
1.5-2 10/22/2012 2.1-5 10/18/2014
1.5-3 10/22/2012 2.1-6 10/22/2012
1.5-4 06/21/2014 2.1-7 10/22/2012
1.5-5 10/22/2012 2.1-8 10/22/2012
1.5-6 10/22/2012

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2.1-9 10/22/2012 3:1-35 02/19/2017

2.1-10 02/17/2013 3.1-36 02/19/2017
2.1-11 10/22/2012 3.1-37 02/19/2017
2.1-12 10/22/2012 3.1-38 02/19/2017
3.1-39 02/19/2017
CHAPTER3- 3.1-40 02/19/2017
DA TA ENTRY FORMS 3.1-41 02/19/2017
3.1-1 PA Single Issuance 3.1-42 02/19/2017
Authorization Form - DSS 3.1-43 02/19/2017
3575 06/21/2015 3.1-44 02/19/2017
3.1-2 06/21/2015 3.1-45 02/19/2017
3.1-3 06/21/2015 3.1-46 02/19/2017
3.1-4 06/2112015 . 3.1-47 02/19/2017
3.1-5 06/21/2015 3.1'48 02/19/2017
3.1-6 06/19/2016 02/19/2017
3.1-7 06/19/2016 3.1-50 Third Party Health Data Sheet
3.1-8 06/19/2016 - DSS 43843.1-50Associated
3.1-9 06/19/2016 Name And Address Form -
3.1-10 06/19/2016 · DSS 3517-253.1-50Fair
3.1-11 10/23/2016 Hearing Update Data Entry
3.1-12 06/21/2015 Form - DSS 3722 02/19/2017
3.1-13 02/21/2016 3.1-51 Screen NQRFOO: RFI SNN/
3.1-14 FS Single Issuance GIN Summary 02/19/2017
Authorization Form - DSS 3.1-52 Screen NQRF02 I NQRF03 /
3574 06/21/2015 NQRF04 02/19/2017
3.1-15 PA Recoupment Data Entry 3.1-53 02/19/2017
Form - DSS 3573 06/21/2015 3.1-54 Restriction/Exception Data
3.1-16 06/21/2015 Input Form - DSS 34783.1-54 02/19/2017
3.1-17 Facility .Involvement Data
Entry Form - DSS 3517-30 CHAPTER4-
Items 418-426 06/21/2015 MEDICAL ASSISTANCE PROGRAM
3.1-18 Third Party Data Sheet Form- 4.1-1 Turnaround Document - DSS
DSS 4198 06/21/2015 3517 10/23/2016
3.1-19 06/21/2015 4.1-2 10/23/2016
3.1-20 06/21/2015 4.1-3 06/18/2012
3.1-21 06/21/2015 4.1-4 02/14/2015
3.1-22 06/21/2015 4.1-5 06/21/2015
3.1-23 02/19/2017 4.1-6 06/21/2015
3.1-24 02/19/2017 4.1-7 10/23/2016
3.1-25 02/19/2017 4.1-8 10/23/2016
3.1-26 02/19/2017 4.1-9 02/19/2017
3.1-27 02/19/2017 4.1-10 02/14/2015
3.1-28 02/19/2017 4.1-11 02/15/2014
3.1-29 02/19/2017 4.1-12 02/15/2014
3.1-30 02/19/2017 4.1-13 02/15/2014
3.1-31 02/19/2017 4.1-14 10/17/2015
3.1-32 02/19/2017 4.1-15 02/15/2014
3.1-33 02/19/2017 4.1-16 02/14/2015
3.1-34 02/19/2017 4.1-17 06/16/2016

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4.1-18 02/15/2014 4.1-68 02/21/2016

4.1-19 02/21/2016 4.1-69 02/15/2014
4.1-20 02/21/2016 4.1-70 02/15/2014
4.1-21 10/23/2016 4.1-71 02/15/2014
4.1-22 10/23/2016 4.1-72 10/17/2015
4.1-23 10/23/2016 4.1-73 02/15/2014
4.1-24 10/17/2015 4.1-74 02/21/2016
4.1-25 10/17/2015 4.1-75 02/15/2014
4.1-26 10/17/2015 4.1-76 06/18/2012
4.1-27 10/17/2015 4.1-77 10/23/2016
4.1-28 10/17/2015 4.1-78 02/15/2014
4.1-29 10/17/2015 4.1-79 10/23/2016
4.1-30 02/15/2014 4.1-80 02/14/2015
4.1-31 10/17/2015 4.1-81 10/23/2016
4.1-32 10/18/2014 4.1-82 10/23/2016
4.1-33 10/17/2015 4.2-1 Turnaround Document - DSS
4.1-34 10/17/2015 3517 06/18/2012
4.1-35 02/15/2014 4.2-2 06/19/2016
4.1-36 02/15/2014 4.2-3 02/19/2017
4.1-37 10/17/2015 4.2-4 10/20/2013
4.1-38 10/17/2015 4.2-5 02/15/2014
4.1-39 10/18/2014 4.2-6 06/21/2010
4.1-40 10/17/2015 4.2-7 10/17/2015
4.1-41 10/17/2015 4.2-8 02/19/2017
4.1-42 10/17/2015 4.2-9 10/19/2009
4.1-43 10/17/2015 4.2-10 02/16/2010
4.1-44 10/17/2015 4.2-11 02/15/2014
4.1-45 02/14/2015 4.2-12 02/15/2014
4.1-46 10/17/2015 4.2-13 10/23/2016
4.1-47 02/19/2017 4.2-14 10/23/2016
4.1-48 10/17/2015 4.2-15 06/21/2014
4.1-49 10/23/2016 4.2-16 02/15/2014
4.1-50 02/21/2016 4.2-17 10/17/2015
4.1-51 02/15/2014 4.2-18 02/15/2014
4.1-52 10/17/2015 4.2-19 02/21/2016
4.1-53 02/15/2014 4.2-20 02/15/2014
4.1-54 02/14/2015 4.2-21 02/21/2016
4.1-55 02/21/2016 4.2-22 06/19/2016
4.1-56 02/15/2014 4.2-23 02/14/2015
4.1-57 02/15/2014 4.2-24 10/23/2016
4.1-58 02/15/2014 4.2-25 02/21/2016
4.1-59 02/15/2014 4.2-26 02/21/2016
4.1-60 02/15/2014 4.2-27 02/21/2016
4.1-61 10/17/2015 4.2-28 02/19/2017
4.1-62 02/15/2014 4.2-29 02/15/2014
4.1-63 02/15/2014 4.2-30 02/15/2014
4.1-64 10/17/2015 10/17/2015
4.1-65 10/23/2016 4.2-32 2/14/2015
4.1-66 10/23/2016 4.2-33 Data Input Form - DSS 3477
4.1-67 02/21/2016 (Screen WMPPIN) 02/15/2014

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4.2-34 06/21/2015 5.1-29 10/18/2014

4.2-35 Restriction/Exception Data 5.1-30 10/18/2014
Input Form - DSS 34784.2-35 10/23/2016 5.1-31 10/18/2014
4.2-36 10/23/2016 5.1-32 10/18/2014
4.3-1 MABEL Budget Record 5.1-33 10/18/2014
(WBM AWB) - MABEL Input 5.1-34 10/18/2014
Form (DSS 3585) 11/24/2003 5.1-35 10/18/2014
4.3-2 02/24/2015 5.1-36 10/18/2014
4.3-3 06/16/2013 5.1-37 10/18/2014
4.3-4 06/18/2012 5.1-38 10/18/2014
4.3-5 06/18/2012 5.1-39 10/18/2014
4.3-6 03/19/2001 5.1-40 10/18/2014
4.3-7 10/22/2012 5.1-41 10/18/2014
4.3-8 10/19/2009 5.1-42 10/18/2014
4.3-9 10/19/2009 5.1-43 10/18/2014
4 ..3-10 10/23/2016 5.1-44 10/18/2014
4.3-11 10/19/2009 5.1-45 10/18/2015
4.3-12 02/21/2016 5.1-46 10/18/2015
5.1-47 10/18/2015
CHAPTERS- 5.1-48 10/18/2015
REFERENCE 5.1-49 10/18/2015
5.1-1 10/18/2014 5.1-50 02/21/2016
5.1-2 02/14/2015 5.1-51 10/18/2014
5.1-3 02/14/2015 5.1-52 10/18/2014
5.1-4 . 02/14/2015 5.1-53 10/18/2014
5.1-5 02/14/2015 5.1-54 10/18/2014
5.1-6 02/14/2015 5.1-55 10/18/2014
5.1-7 10/18/2015 5.1-56 02/21/2016
5.1-8 10/18/2014 5.1-57 10/18/2014
5.1-9 10/18/2014 5.1-58 10/18/2014
5.1-10 10/18/2014 5.1-59 10/18/2015
5.1-11 10/18/2014 5.1-60 10/18/2014
5.1-12 06/19/2016 5.1-61 10/18/2014
5.1-13 10/18/2014 5.1-62 10/18/2014
5.1-14 10/18/2014 5.1-63 10/18/2014
5.1-15 06/19/2016 5.1-64 10/18/2015
5.1-16 10/18/2014 5.1-65 10/18/2015
5.1-17 02/21/2016 5.1-66 10/18/2014
5.1-18 10/18/2014 5.1-67 02/21/2016
5.1-19 10/18/2014 5.1-68 10/18/2014
5.1-20 10/18/2014 5.1-69 10/18/2014
5.1-21 10/18/2014 5.1-70 10/18/2014
5.1-22 10/18/2014 5.1-71 06/19/2016
5.1-23 10/18/2014 5.1-72 10/18/20~4
5.1-24 10/18/2014 5.1-73 10/18/2014
5.1-25 10/18/2014 5.1-74 10/18/2014
5.1-26 02/14/2015 5.1-75 10/18/2014
5.1-27 06/19/2016 5.1-76 10/18/2014
5.1-28 10/18/2014 5.1-77 10/18/2014
5.1-78 10/18/2014

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5.1-79 10/18/2014 6.1-4 02/19/2017

5.1-80 10/18/2014 6.1-5 02/19/2017
5.1-81 10/18/2014 6.1-6 02/19/2017
5.1-82 10/18/2014 6.1-7 02/19/2017
5.1-83 10/18/2014 6.1-8 02/19/2017
5.1-84 06/19/2016 6.1-9 02/19/2017
5.1-85 02/21/2016 6.1-10 02/19/2017
5.1-86 02/21/2016 6.1-11 02/19/2017
5.1-87 10/18/2014 6.1-12 02/19/2017
5.1-88 10/18/2014 6.1-13 02/19/2017
5.1-89 10/18/2014 6.1-14 02/19/2017
5.1-90 06/21/2015 6.1-15 02/19/2017
5.1-91 06/21/2015 6.1-16 02/19/2017
5.1-92 10/18/2014 6.1-17 02/19/2017
5.1-93 10/18/2014 6.1-18 02/19/2017
5.1-94 10/18/2014 6.1-19 02/19/2017
5.1-95 02/21/2016 6.1-20 02/19/2017
5.1-96 02/21/2016 6.1-21 02/19/2017
6.1-22 02/19/2017
CHAPTER 6- 6.1-23 02/19/2017
INDICES 6.1-24 02/19/2017
6.1-1 02/19/2017 6.1-25 02/19/2017
6.1-2 02/19/2017 6.1-26 02/19/2017
6.1-3 02/19/2017

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02/19/2017

TABLE OF CONTENTS

INTRODUCTION

Using This Guide··············································································'····································· xi

CHAPTER 1 •
APPLICATION

COMMON APPLICATION FORM· DSS 2921

Category Codes (CATEGORY) .............................................................................................. 1.1-1

Hispanic/Latino··········································'············································································ 1.1-1
Race/Ethnic Affiliation ............................................................................................................. 1.1-1
Language Spoken Codes (LANG) .......................................................................................... 1.1-2
Language Read Codes (LANG READ) ...................... :..................................................... ,...... 1.1-3

TURNAROUND DOCUMENT· DSS 3517

SECTION 05: CASE LEVEL CODES

M3E Indicator (M3E) - 053 ...................................................................................................... 1.2-1

Utility Guarantee Indicator (UTIL GUAR) - 044 ...................................................................... 1.2-1
Borough/Community District (B/CD) ....................................................................................... 1.2-1
Trust Indicator (Tl) - 061 ......................................................................................................... 1.2-2
Recertification Source (RCRT SRC) - 063 .................. :.......................................................... 1.2-2
SECTION 10: SUFFIX LEVEL CODES

Category Codes (CAT) - 209 .................................................................................................. 1.2-3

Language Spoken Codes (LANG) - 255 ................................................................................. 1.2-4
Language Read Codes (LANG READ) - 281 ......................................................................... 1.2-5
Homebound Indicator (HMBD) - 220 ...................................................................................... 1.2-6
MA Responsibility Area Indicators (MA RESP) - 219 ............................................................. 1.2-6
Emergency Indicator (EMG: IND) - 270 .................................................................................. 1.2-6
Spanish Indicator (SP IND) - 273 ............................................................................................ 1.2-6
Abbreviated CNS Notices (ABBR CNS)· 249 ................................................. ,...................... 1.2-7
PA Status Codes (PA: STAT) - 221 ........................................................................................ 1.2-7
PA Routing Codes (PA: ROUT) - 224 .................................................................................... 1.2-7
MA Status Codes (MA: STAT) - 240 ....................................................................................... 1.2-7
SNAP Status Codes (FS: STAT) - 230 ................................................................................... 1.2·7
SNAP Routing (FS: ROUT) - 233 ........................................................................................... 1.2·7
Safety Net Indicator (SNET IND)-274 ................................................................................... 1.2-7
Associated Code (ASSOC CD) - 290 ····:················································ .. ······························ 1.2-8
CASE REASON CODES

Opening Codes ....................................................................................................................... 1.3-1

PA (PA: REAS - 222) Only .................... ,........................................................................... 1.3-1
MA (MA: REAS - 241) Only .............................................................................................. 1 :3-4
SNAP (FS: REAS - 231) Only ........................................................................................... 1.3-5

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
ii

02/19/2017

TABLE OF CONTENTS (cont'd)

Case Reason Codes (cont'd)

Rejection Codes ...................................................................................................................... 1.3-7
PA (PA: REAS - 222) ........................................................................................................ 1.3-7
SNAP (FS: REAS - 231) Only ............................................ ,.............................................. 1.3-22
Closing Codes ......................................................................................................................... 1.3-27
PA (PA: REAS - 222) ........................................................................................................ 1.3-27
Change In Employment, Support or Income ............................................................... 1.3-28
Failure To Provide Verification .................................................................................... 1.3-32
Refusal To Comply With Eligibility Requirements ....................................................... 1.3-33
Moved Or Whereabouts Unknown .............................................................................. 1.3-41
Living Arrangements ................................................................................................... 1.3-42
Admission To Private Or Public Institution .................................................................. 1.3-43
Client Request. .......................................................................: .................................... 1.3-44
Change In Resources Causing Ineligibility .................................................................. 1.3-47
Failure To Comply With Recertification Procedures ................................................... 1.3-48
Duplicate Assistance ................................................................................................... 1.3-49
Investigatory - Eligibility Verification Review ............................................................... 1.3-51
Intentional Program Violations .................................................................................... 1.3-56
Miscellaneous ............................................................................................................. 1.3-60
60 Month Time Limit .................................................................................................... 1.3-63
SNAP (FS REAS - 231) Only........................... .... ..... . .............. .................. . .............. 1.3-65
SECTION 15: INDIVIDUAL LEVEL CODES

Sex Codes (SEX) - 315 ........................................................................................................... 1.4-1

Validate SSN Codes (VALIDATE) - 321 ................................................................................. 1.4-1
Disability Accommodation Indicator (DAI) - 367 ..................................................................... 1.4-1
PA Categorical Codes (CAT)- 372 ......................................................................................... 1.4-1
PA Status Codes (PA: STAT) - 330 ....................................................................................... 1.4-2
MA Status Codes (MA: STAT) - 340 ...................................................................................... 1.4-2
MA Coverage Codes (MA: COV CD) - 343 ............................................................................. 1.4-3
SNAP Status Codes (FS: STAT) - 350 ................................................................................... 1.4-3
State/Federal Charge Codes (ST/FED CODE) - 307 ............................................................. 1.4-4
State/Federal Charge Date (ST/FED DATE) -325 ................................................................. 1.4-4
Birth Verification Indicator (BVI)' - 366 ..................................................................................... 1.4-4
Teenage Service Act Indicator (TASA) - 304 .......................................................................... 1.4-5
ABAWD Ind. Code - 371 ......................................................................................................... 1.4-5
Employability Codes (EMP) - 375 and SNAP Employability Code - 370 ................................ 1.4-5
Medicare Savings Program (MSP) - 345 ................................................................................ 1.4-11
TPHl/Medicare Source Code (TPHl/MCR) - System Generated .......................................... 1.4-11
SSI Indicator (SSI) - 320 ......................................................................................................... 1.4-11
Bureau Of Child Support Indicator (BCS) - 328 ...................................................................... 1.4-11
Relationship Code (REL)-329 ............................................................................................... 1.4-12
Common Benefit Identification Card Code (CBIC CC) - 378 .................................................. 1.4-13
CBIC - Card Delivery Codes (CBIC CDC) - 383 ··················································'·················· 1.4-13
Student ID Code - 323 - (System Generated) ........................................................................ 1.4-13
Child/Teen Health Program Code (CHT)- 380 ....................................................................... 1.4-13
Veteran's Indicator (VET) - 324 .............................................................................................. 1.4-14
Office Of Treatment Monitoring Indicator (OTM) - 379 ........................................................... 1.4-14

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Alien Citizenship Indicator (ACI) - 382 ............................................ : ....................................... 1.4-14

Alien Reg. Number - 381 ........................................................................................................ 1.4-15
SNAP Eligible Elderly/Disabled Alien Indicator - 313 .............................................................. 1.4-15
Hispanic/Latino - 395 ............................................................................................................ : 1.4c15
Race/Ethnic - 396, 397, 398, 373, 374 ................................................................................... 1.4-15
Marital Status (MAR) - 387 .................................................................................................... 1.4-16
Educational Level (EDUC)- 388 ............................................................................................. 1.4-16
Highest Degree Obtained (HOO) - 390 ............................................................................. ,.... 1.4-16
Relationship Of Mother To Child (MO CHILD) - 391 ............................................................... 1.4-17
AFIS Exemption Indicator (AFIS EX) - 392 .......................................................... :.................. 1.4-17
Time Limit Exemption Indicator (TL-EX) - 393 ........................................................................ 1.4-17
IPV Indicator Flag (IPV)- 394 ....................... ,......................................................................... 1.4-17
Other Name Codes (CODE) - 361 ........... :.............................................................................. 1.4-17
INDIVIDUAL REASON CODES
Opening Codes ....................................................................................................................... 1.5-1
PA (PA: REAS- 331) and MA (MA: REAS- 341) ............................................................. 1.5-1
SNAP (FS: REAS - 351) ............................................................................................. 1.5-4
Rejection Codes ...................................................................................................................... 1.5-5
PA (PA: REAS - 331) ............................................................................ ,........................... 1.5-5
SNAP (FS: REAS-351) ................................................................................................... 1.5-12
Sanction Codes ....................................................................................................................... 1.5-15
PA (PA: REAS - 331) ........................................................... ,......................................... 1.5-15
SNAP (FS: REAS - 351) ............................ ., ............................................................ 1.5-23
Removal Codes .................................................... : ............................ :.................................... 1.5-25
PA (PA: REAS - 331) ..... ,................................................................................................. 1.5-25
SNAP (FS: REAS - 351) ................................................................................................... 1.5-31

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT

Increase In PA Grant .............................................................................................................. 1.6-1

Decreases In PA Grant ........................................................................................................... 1.6-2
Changes In SNAP Grant. ............................ :........................................................................... 1.6-8

CHAPTER 2-
AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABELi

SCREEN NSBL02: HOUSEHOLD/SUFFIX FINANCIAL DATA

SNAP Report Codes (FR) ........................................................................................................2.1-1
Shelter Proration Indicator Codes (PRO IND) ........................................................................ 2.1-1
Shelter Type Codes (SHEL T: TYPE) ...................................................................................... 2.1-1
Period Codes (PER) ............................................................................................................... 2.1-2
FSUA Indicator Codes (FSUA: IND) ....................................................................................... 2.1-2
Heat Type Codes (TYPE) ....................................................................................................... 2.1-2
Child In Household (CHILD) ................................................................................................... 2.1-2
Home Energy Assistance Program Indicator (HEAP) ............................................................. 2.1-2

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Screen NSBL02: Household/Suffix Financial Data (cont'd)

Housing Advantage Indicator (HAI) ........................................................................................ 2.1-3
FSUT Indicator Codes (FSUT: IND) ....................................................................................... 2.1-3
PA Case Type Codes (PA: TYPE) .......................................................................................... 2.1-3
PA/SNAP Status Codes (PA: STAT, FS: STAT) ..................................................................... 2.1-3
PA/SNAP Routing Codes (PA: RTG, FS: RTG) ...................................................................... 2.1-4
PA Additional Needs Type Codes (PA: ADDL: TY) ................................................................ 2.1-4
SNAP Categorical Eligibility Codes (CE) .......................... : ..................................................... 2.1-4
Fuel Indicator Codes (PA: FUEL) ........................................................................................... 2.1-4
Restriction Type Codes (RST) ................................................................................................ 2.1-4
Associated Codes (ASSOC: CD) ..................................................... : ...................................... 2.1-4
SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS
30+1/3 Indicator (30 1/3) ..................................................................., ..................................... 2.1-5
Expected Date Of Confinement Codes (EDC) ........................................................................ 2.1-5
Employment Training Indicator Code (ETI) ............................................................................. 2.1-5
Special Budgeting (SPEC) ...................................................................................................... 2.1-5
Relationship Indicator Codes (REL) ........................................................................................ 2.1-5
Employability Status Codes (EMP) ......................................................................................... 2.1-5
PA/SNAP Status Codes (PA: STS, FS: STS) ......................................................................... 2.1-5
Aged/Disabled Indicator Code (AID) ....................................................................................... 2.1-6
Financial/Alien Involvement Codes (INV) ............................................................................... 2.1-6
Income Source Codes (INCOME/RECURRING: SRC) .......................................................... 2.1-6
Income Frequency Codes (INCOME: FREQ) ......................................................................... 2.1-8
Program Indicator Code (PROG) ............................................................................................. 2. 1-8
Usage Codes (INCOME: U) .................................................................................................... 2.1-8
Income Exemption Codes (INCOME: CD) .............................................................................. 2.1-9
Deduction Type Code (DEDUCTIONS: TYP) ......................................................................... 2.1-9
Daycare Type Codes (DAYCARE: TYP) ................................................................................ 2.1-9
Associated Code (ASSOC: CD) .............................................................................................. 2.1-10
Individual Special Needs Type Codes (SPEC NOS: TY) ........................................................ 2.1-10
Restriction Type Codes (RST) ................................................................................................ 2. 1-10
SCREEN NSBL35: SAVED BUDGETS
Budget Source (BUD SRC) ..................................................................................................... 2.1-11

CHAPTER 3-
DA TA ENTRY FORMS

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575

Pick-Up Codes ........................................................................................................................ 3. 1-1

Special Grant Codes (ISSUANCE CODES) ........................................................................... 3.1-1
Special Housing Progam Indicator.......................................................................................... 3. 1-11
Shelter/Recoupment Indicator ............. ,.................................................................................. 3. 1-12
Restricted Indicator ................................................................................................................. 3.1-12
Shelter Type Codes (SHELTER: TYPE) ................................................................................. 3.1-12
Recoupment Indicator Codes ................................................................................................. 3.1-13

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Category Codes ...................................................................................................................... 3.1-13

Routing Location ..................................................................................................................... 3.1-13

FS SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3574

Issuance Codes ........................................................................................................ ,............. 3.1-14

PA RECOUPMENT DATA ENTRY FORM - DSS 3573

Action Codes ........................................................................................................................... 3.1-15

Offense Type Codes ............................................................................................................... 3.1-15
Offense Subtype Codes .......................................................................................................... 3.1-15
Bypass Restriction Indicator ................................................................................................... 3.1-16
Restriction/Direct Two Party Indicator..................................................................................... 3.1-16

FACILITY INVOLVEMENT DATA ENTRY FORM - DSS 3517-30 ITEMS 418-426

Incomplete Application Reason Codes ...................................................... :............................ 3. 1-17

THIRD PARTY DATA SHEET FORM - DSS 4198

Relationship To Policy/Holder Codes (REL) ........................................................................... 3.1-18

Policy Source ........................................................................................................................... 3.1-18
Policy Sequence Number ............... ,....................................................................................... 3.1-18
Coverage ................................................................................................................................ 3.1-18
Insurer Codes ......................................................................................................................... 3.1-19

THIRD PARTY HEALTH DATA SHEET - DSS 4384

MEDICARE COVERAGE UPDATE

Medicare Savings Program Indicator ...................................................................................... 3.1-50

ASSOCIATED NAME AND ADDRESS FORM - DSS 3517-25

Associated Address Codes ..................................................................................................... 3.1-50

FAIR HEARING UPDATE DATA ENTRY FORM - DSS 3722

Fair Hearing Codes (AID STATUS) ........................................................................................ 3.1-50

SCREEN NQRFOO: RFI SNN/CIN SUMMARY

RFI Indicator (RFI IND) ........................................................................................................... 3.1-51

SCREEN NQRF02 I NQRF03 / NQRF04

RFI Status (Inquiry Codes) .................................................. ,.................................................. 3.1-52

Resolution Codes (RES CODE) ............................................................................................. 3.1-52
Other - For Use In All Programs ............................................................................................. 3.1-54
System Generated Codes - For Use In All Programs ............................................................. 3.1-54

RESTRICTION/EXCEPTION DATA INPUT FORM - DSS 3478

Restriction/Exception Type ..................................................................................................... 3.1:54

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TABLE OF CONTENTS (cont'd)

CHAPTER4 •
MEDICAL ASSISTANCE PROGRAM

TURNAROUND DOCUMENT· DSS 3517

SECTION 10 ·MA CASE !SUFFIX) LEVEL CODES

MA Responsibility Area Indicator (MA RESP) - 219 ............................................................... 4.1-1
RECERTIFICATION SOURCE (RCRT SRC) - 063 ................................................................ 4.1-2
MA Status Codes (MA: STAT) · 240 ....................................................................................... 4.1-2
Resource Verification Indicator (RVI) - 282 ............................................................ : ............... 4.1-2
MA CASE REASON CODES
Opening Codes· MA (MA: REAS· 241) ................................................................................. 4.1-3
System Generated MA Codes .................................................................................... 4.1-9
Rejection Codes- MA (MA: REAS-241) ............................................................................... 4.1-10
Alien/Citizenship Status .............................................................................................. 4.1-10
Excess Income/Resources .......................................................................................... 4.1-12
Living Arrangements ................................................................................................... 4.1-17
Duplicate Assistance ................................................................................................... 4.1-18
Health Insurance ......................................................................................................... 4.1-19
Other Eligibility Requirements ..................................................................................... 4.1-20
Closing Codes - MA (MA: REAS - 241) .................................................................................. 4.1-24
Failure To Comply With Recertification Procedures ................................................... 4.1-25.
Excess Income And Resources .................................................................................. 4.1-30
Living Arrangements ................................................................................................... 4.1-41
Duplicate Assistance ................................................................................................... 4.1-45
Spousal Impoverishment. ............................................................................................ 4.1-52
Health Insurance ......................................................................................................... 4.1-53
Other .................................................. ,........................................................................ 4.1-56
Miscellaneous ............................................................................................................. 4.1-58
Disaster Relief ............................................................................................................. 4.1-60
PCAP Cases ............................................................................................................... 4.1-62
System Generated MA Codes .................................................................................... 4.1-66
Recertification Budget Notice Codes - MA (MA: REAS - 241) ................................................ 4.1-77
System Generated ...................................................................................................... 4.1-77
Confirmation Codes - MA (MA: REAS - 241) .......................................................................... 4.1-78
System Generated ...................................................................................................... 4.1-78
CNS MRT Deferral Document Codes ..................................................................................... 4.1-79

TURNAROUND DOCUMENT· DSS 3517

SECTION 15 ·MA INDIVIDUAL LEVEL CODES

MA Categorical Codes (CAT) - 372 ...................................................................................... 4.2-1
················································································································································ 4.2-1
MA Status Codes (MA: STAT) - 340 ...................................................................................... 4.2-3
MA Coverage Codes (MA: COV CD) - 343 ............................................................................ 4.2-3
Medicare Savings Program (MSP) - 345 ................................................................................ 4.2-3
AD EX Indicator - 365 ............................................................................................................. 4.2-4

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MA Employability Codes (EMP) - 375 ............ :........................................................................ 4.2-4

TPHl/MCR Indicator - System Generated ............................................................................... 4.2-5
Employer Purchase Indicator (EPI)- 344 ................................................................................ 4.2-5
MA INDIVIDUAL REASON CODES
Opening Codes - MA (MA: REAS - 341) ................................................................................. 4.2-6
Rejection Codes -.MA (MA: REAS - 341) ............................................................................... 4.2-9
Excess Income/Resources .......................................................................................... 4.2-9
Eligibility Requirements ............................................................................................... 4.2-13
Eligibility Requirements ............................................................................................... 4.2-14
Death ........................................................................................................................... 4.2-15
Receipt Of Multiple Or Concurrent Assistance ............................................................ 4.2-16
Living Arrangements ................................................................................................... 4.2-17
Health Insurance ......................................................................................................... 4.2-18
Other ............................................................................... ,........................................... 4.2-19
Closing Codes - MA (MA: REAS - 341) .................................................................................. 4.2-20
Excess Income/Resources .......................................................................................... 4.2-20
Eligibility Requirements ............................................................................................... 4.2-24
Receipt of Multiple Or Concurrent Assistance ............................................................ 4.2-25
Living Arrangements ......... : ......................................................................................... 4.2-26
Other ........................................................................................................................... 4.2-28
Sanction Codes - MA (MA: REAS - 341) ................................................................................ 4.2-31
Failure To ProvideNalidate SSN ................................................................................ 4.2-31
Other Failures ............................................................................................................. 4.2-32

DATA INPUT FORM- DSS 3477 !SCREEN WMPPINl

MA Restriction/Exception Record ........................................................................................... 4.2-33

MA Restricted/Exception ......................................................................................................... 4.2-33
Principal Provider Category ...................................................................................... ,............. 4.2-33
Payment Exception Type Codes (PA, MA) ............................................................................. 4.2-33
Prepaid Capitation Plan Subsystem Codes ............................................................................. 4.2-33
Enrollment Reason Codes ...................................................................................................... 4.2-33
Discenrollment Reason Codes ................................................................................................ 4.2-33
Prepaid Capitation Plan Provider ID ....................................................................................... 4.2-34

RESTRICTION/EXCEPTION DATA INPUT FORM - DSS 3478

MA Restriction/Exception Type Codes ................................................................................... 4.2-35

MABEL BUDGET RECORD !WBM AWBl - MABEL INPUT FORM !DSS 3585!

Version Number (VERSION) .................................................................................................. 4.3-1

Budget Type (BUDGET TYPE) ............................................................................................... 4.3-1
Case Name (CASE NAME) .................................................................................................... 4.3-1
Case Number (Case Number) ............................................................................................... , 4.3"1
Office (OFC) ............................................................................................................................ 4.3-1
Unit and/or Worker (UNIT ID) ................................................................................................. 4.3-1
Transaction Type (TRAN) ....................................................................................................... 4.3-1
Effective Period (EFFECTIVE PER) ....................................................................................... 4.3-2

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Months Excess Is Available (MO) ........................................................................................... 4.3-2

Number In Case (CA) ............................................................................................................. 4.3-2
Expanded Eligibility Code (EEC) ............................................................................................ 4.3-2
Expected Date Of Confinement (EDC 1) ................................................................................ 4.3-3
Expected Date Of Confinement (EDC 2) ................................................................................ 4.3-3
Age Indicator (Al) .................................................................................................................... 4.3-3
Fuel Type (FUEL TY) .............................................................................................................. 4.3-3
Shelter Type (SHELTER TY) .................................................................................................. 4.3-3
Shelter Amount (AMOUNT) .................................................................................................... 4.3-4
Water Amount (WATER AMOUNT} ........................................................................................ 4.3-4
Additional Allowances Type (ADD TY) ................................................................................... 4.3-4
Additional Allowance Amount (AMOUNT) .............................................................................. 4.3-5
Deeming Code (SSI DEEM) ................................................................................................... 4.3-5
Living Arrangement (SSI LA) .................................................................................................. 4.3-5
Number Of SSl-Related Children To Deem (NO DM) ............................................................ 4.3-5
Number Of Non-SSI Related Children To Allocate (NO-ALL) ................................................. 4.3-5
Medicare Savings Program (MSP) ......................................................................................... 4.3-5
Date Of Institutionalization (DT INS) ....................................................................................... 4.3-5
Personal Incidental Allowance (PIA) ....................................................................................... 4.3-6
Spousal Contribution Code (CON) .......................................................................................... 4.3-6
Spousal Contribution Amount (AMOUNT) .............................................................................. 4.3-6
Local Code (LOC) ................................................................................................................... 4.3-6
Income Average Indicator (EARNED INCOME A) .................................................................. 4.3-6
Line Number (LN) ................................................................................................................... 4.3-6
Categorical Indicators Code (CTG) - (Earned Income or resources) ...................................... 4.3-7
Child Identifier (N) ................................................................................................................... 4.3-7
Chronic Care Indicator (1) ........................................................................................................ 4.3-7
Earned Income Disregard (EID) .............................................................................................. 4.3-7
Earned Income Source (SRC) ..................................... , .......................................................... 4.3-7
Earned Income Period (PER) ................................................................................................. 4.3-8
Time Indicator (T) .................................................................................................................... 4.3-8
Gross Income (GROSS) ......................................................................................................... 4.3-8
Health Insurance (INSUR) ...................................................................................................... 4.3-8
Court Ordered Support Payments (CT-SUP) .......................................................................... 4.3-8
Work - Related Expenses (WK-REL) ...................................................................................... 4.3-8
Impairment-Related Work Expense (IRWE) ........................................................................... 4.3-8
Child Care (CH-CR) ................................................................................................................ 4.3-9
Child's Month And Year Of Birth (MO/YR) .............................................................................. 4.3-9
Unearned Income Line Number (UNEARNED INCOME LN) ................................................. 4.3-9
CTG Categorical Indicator (C) ............................................................................... ,................ 4.3-9
Child Identifier (N) ................................................................................................................... 4.3-9
Chronic Care Indicator (1) ........................................................................................................ 4.3-9
Unearned Income Source (SR) ............................................................................................... 4.3-10
Period (P) ................................................................................................................................ 4.3-11
Unearned Income Amount (AMOUNT) ................................................................................... 4.3-11
Unearned Income Exemption Code (CD) ............................................................................... 4.3-11
Exemption Amount (EXEMPT) ............................................................................................... 4.3-11
Resources (RESOURCES) ..................................................................................................... 4.3-11

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TABLE OF CONTENTS (cont'd)

Line Number (LN) ................................................................................................................... 4.3-11

CTG Categorical Indicator Code (C) - (Unearned income) ..................................................... 4.3-11
SSI Related Child Indicator (N) ........................................... ,................................................... 4.3-12
Chronic Care Indicator (1) ............................................................... :........................................ 4.3-12
Resource Code (CD) .............................................................................................................. 4.3-12
Resource Value (S-VAL} ......................................................................................................... 4.3-12

CHAPTER 5 •
REFERENCE

APPENDIX A • BENEFIT PRODUCTION

Reconciliation Codes .............................................................................................................. 5.1-1

APPENDIX B • OBSOLETE CASE REASON CODES

Opening Codes ....................................................................................................................... 5.1-2

PA (PA: REAS - 222) ........................................................................................................ 5.1-2
MA (MA: REAS-241) ....................................................................................................... 5.1-5
SNAP (FS: REAS - 231) .................................................................................................. 5.1-8
Rejection Codes ...................................................................................................................... 5.1-9
PA (PA: REAS - 222) .................................................................................................... 5.1-9
MA (MA: REAS - 241) .............................................................. ,....................................... 5.1-13
SNAP (FS: REAS-231) ................................................................................................... 5.1-16
Closing Codes ......................................................................................................................... 5.1-18
PA (PA: REAS - 222) ........................................................................................................ 5.1-18
MA (MA: REAS - 241) ....................................................................................................... 5.1-28
SNAP (FS: REAS - 231) .................................................................................................. 5.1-51
APPENDIX C • OBSOLETE INDIVIDUAL REASON CODES

Opening Codes ......................................................................................................................, 5.1-58

PA (PA: REAS-331) ........................................................................................................ 5.1-58
MA (MA: REAS - 341) ....................................................................................................... 5.1-59
SNAP (FS: REAS - 351) ................................................................................................... 5.1-60
Rejection Codes ...................................................................................................................... 5.1-61
PA (PA: REAS - 331) ....................................................................................................... 5.1-61
MA (MA: REAS- 341) ....................................................................................................... 5.1-64
SNAP (FS: REAS - 351) ................................................................................................... 5.1-66
Sanction Codes ................................. : ..................................................................................... 5.1-68
PA (PA: REAS - 331) ........................................................................................................ 5.1-68
MA (MA: REAS - 341) .. : .................................................................................................... 5.1-72
SNAP (FS: REAS - 351) ................................................................................................... 5.1-76
Removal. Codes ...................................................................................................................... 5.1-78
PA (PA: REAS· 331) ........................................................................................................ 5.1-78
MA (MA: REAS· 341) ....................................................................................................... 5.1-82
SNAP (FS: REAS - 351) ................................................................................................... 5.1-88
APPENDIX D • OTHER OBSOLETE CODES

Obsolete Single Issuance Codes ............................................................................................ 5.1-91

Obsolete ABEL Codes ................................... :........................................................................ 5.1-92

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Obsolete TAD Codes .............................................................................................................. 5.1-94

Obsolete MA Codes ............................................................ ,.......................... ,........................ 5.1-96
Resource Code (CD) .............................................................................................................. 5.1-96

CHAPTER 6-
INDICES

Item Name Index ..................................................................................................................... 6.1-1

Item Number Index ................................................................................................................. 6.1-9
Reason Code Index ................................................................................................................ 6.1-11
Case (Suffix) Level. ........................................................................................................... 6.1-11
Individual Level .................................................................................................................. 6.1-23

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INTRODUCTION

USING THIS GUIDE

The Worker's Guide to Codes (WGC) is a manual designed to assist workers to identify WMS code
values and their definitions that are specific to NYC Welfare Management System. It is a reference
source and NOT an instructional manual. Please refer to the Budgeting, Authorization of Grants, and the
Authorization of Medical Assistance manuals for specific information on how to use relative codes.

ORGANIZATION OF THE WGC

The Table of Contents outlines the organization of this guide. Refer to the Table of Contents and
familiarize yourself with this manual's layout. This manual has been organized into a chapter format.
Each chapter is devoted to a particular WMS form or system and their specific code definitions. Larger
chapters have been subdivided to aid in the management of future updates. These chapter groupings
are best noted in the page numbering.

m Chapter 1 is dedicated to the Common Application Form and the Turnaround Document. lhe
Common Application Form though only a single page is a sub-chapter, while the Turnaround
Document has more extensive sub-divisions. These units are Section 05: Case Level Codes,
Section 10: Case (Suffix) Level Codes, Reason Codes (Case Level), Section15: Individual Level
Codes, Reason Codes (Individual Level), and Regulatory Citations for Changes in PA/SNAP
Grant.

m Chapter 2 captures code values and definitions for the Automated Budgeting and Eligibility Logic
(ABEL) or, as some may refer to it as the External Budgeting system.

m Chapter 3 provides definitions for a variety of data entry forms.

m Chapter 4 is dedicated to the Medical Assistance Program. This chapter has been subdivided
into Section 10: MA Case (Suffix) Level Codes, which includes the Reason Codes, Section15:
MA Individual Level Codes, which also includes the Reason Codes, Data Input Form DSS 3477
(Screen WMPPIN), Data Input Form DSS 3478 (Screen WMRRIN), and MA Budgeting and
Eligibility Logic (MABEL).

m Chapter 5 is a reference to obsolete WMS Reason Codes. Seven appendices, labeled A through
G, are available. Appendices A and B list respectively obsolete PA Case and Individual Closing/
Removal Codes. Appendices C and D list respectively obsolete MA Case and Individual Closing/
Removal Codes. Appendices E and F list respectively obsolete SNAP Case and Individual
Closing/Removal Codes. Appendix G lists the obsolete PA Case Opening Codes.

m Chapter 6 offers the WGC indices. The Item Name Index provides the user with a page
reference to fields sorted alphabetically by the full field name. The Item Number Index offers a
page reference to the Turnaround Document fields sorted numerically by the fields' assigned
item number. The Reason Code Indices reference all the PA, MA, and SNAP reason codes.
Separate indices have been created, one listing Case and the other listing Individual Level
Reason Codes.

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USING THIS GUIDE ICONT'Dl

FINDING WHAT YOU NEED

The effort it takes the user to locate needed information will depend on one's familiarity with WMS and
this manual. As each user becomes comfortable using this reference, (s)he will develop individual
strategies in locating information. It is recommended that each user index the regularly used portions of
the WGC to meet their needs. This can easily be accomplished by using index divider sheets or any
other technique that works for the user.

There are numerous approaches to finding information:

o-. TABLE OF CONTENTS

As outlined earlier, each chapter is dedicated to one specific form or system, as in Chapter 2,
ABEL codes, or a group of like forms or systems, as in Chapters 3 and 4, data entry forms codes
and MA Program codes, respectively. Utilizing the Table of Contents is the best search choice if
the user is familiar with the form/system is known and feels comfortable searching through the
chapter subheadings to locate a page number.

o-. ITEM NAME INDEX

Knowing the field name would make this the most direct search choice. It also precludes
knowledge of which form or system the field is affiliated with.

o-. ITEM NUMBER INDEX

Using this index provides the best search choice if one is working directly from the Turnaround
Document and the item number is known.

o-. REASON CODE INDEX

Utilize these indices to access page references for all currently valid PA, MA, and SNAP case or
individual level reason codes.

~:, A word of caution regarding reason codes would be in order here. When determining the
appropriateness of a reason code be aware that many codes are category specific.
PJease check beyond the code definition. Multiple codes having the same definition may
exist. Upon closer inspection the user will realize that they should be used for different
categories. In addition, the user should also pay heed to the impact a specific PA code
may have on MA and SNAP benefits. What may first appear as multiple codes carrying
like definitions may prove different in the continuance or discontinuance of MA and SNAP
benefits.

o-. APPENDICES
Use the appropriate appendix for definitions of obsolete PA, MA, SNAP closing or removal codes
at the case or individual levels.

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CHAPTER 1 -
APPLICATION

COMMON APPLICATION FORM - DSS 2921

CATEGORY CODES (CATEGORY)

EAA (PA Center) Emergency Assistance for Adults (No change)
EAF (PA Center) Emergency Assistance for Families (No change)
FA {PA Center) Family Assistance (Former ADC, ADCU and HR Families Cases Should
be in the FA Category)
FS (SNAP Supplemental Nutrition Assistance Program (SNAP)
Center)
SNCA (PA Center) Safety Net Cash Assistance (Former HR, except HR Families, Cases
Should be in the SNCA Category)
SNFP (PA Center) Safety Net Federally Participating. To be used for FA cases in which the
head of household or an adult who is a mandatory member of the case
fails to comply with drug/alcohol [D/A] requirements, or in which su~h an
individual is deemed unemployable due to their d/a problem, but is in
compliance with d/a requirements and is in treatment.
SNNC (PA Center) Safety Net Non-Cash. To be used for Safety Net Cash Cases. that have
reached either the two year limit for Safety Net Ca.sh Assistance or the 60
month time limit for State Assistance (total of Family Assistance and
Safety Net Cash Assistance), singles who have been determined unable
to work due to drug/alcohol problems, but were compliant, i.e. in treatment,
or eventually for cases that have reached the 60 month Federal Time Limit
for FA.
MA (MA Center) Medical Assistance (No change)
MPE (MA Center) Presumptive Eligibility for Children
MSSI (MA Center) Medicaid Supplemental Security Income (No change)
ADC (PA Center) This category is no longer valid. Aid to Dependent Children (Will be re-
categorized to FA)
ADCU (PA Center) This category is no longer valid. Aid to Dependent Chil.dren Unemployed
(Will be recategorized to FA)
HR {PA Center) This category is no longer valid. Home Relief (Will be recategorized to
SNCA)
HRPG (PA Center) This category is no longer valid. Home Relief Pre Investigation (Clients
should be evaluated and transferred to one of the new categories)

HISPANIC/LATINO
H Enter Y if Hispanic/Latino, N if not Hispanic/Latino, or U if unknown

RACE/ETHNIC AFFILIATION
Enter Y for the race/ethnic affiliations that the client identifies with, N for the affiliations that the client
doesn't identify with, or U if the client refuses to self-identify.

American Indian/ Alaska Native

A Asian
B Black/ African American
P Native Hawaiian/ Pacific Islander
W White

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.1-2
10/22/2012

COMMON APPLICATION FORM - DSS 2921 !CONT'D\

LANGUAGE SPOKEN CODES (LANG)

A Blank Arabic Al Am. Ind. - Dakota KU Kurdish
B Blank Urdu AC Am. Ind. - Choctaw LI Lithuanian
C Blank Chinese-Mandarin AK Am. Ind. - Lakota MY Maay
D Blank French Creole AT Am. Ind. - Nakota MA Macedonian
E Blank English AV Am. Ind. - Navajo ML Malayalam
F Blank French AO Am. Ind. - Other MO Mongolian
G Blank Greek AS Am. Ind. - Zuni NE Nepali
H Blank Hebrew AM Amharic NO Norwegian
I Blank Italian AW Armenian OD Oneida
J Blank Japanese AZ Assyrian ON Onondaga
K Blank Korean BE Bengali OR Oro mo
L Blank Albanian BO Bosnian PA Pashto
M Blank German BU Bulgarian PE Pennsylvania Dutch
N Blank Hindi BR Burmese Pl Persian
P Blank Polish CA Cambodian PS Pidgin-Hawaiian
Q Blank Farsi CM Chamorro PU Punjabi
R Blank Russian CH Chinese-Toisanese RO Romanian
S Blank Spanish CF Chinese-Fujian SA Samoan
T Blank Thai. cc Creole-Criollo SC Seneca
V Blank Vietnamese co Creole-Haitian SE Serbian
W Blank Khmer CE Creole-Other SN Shinnecock
Y Blank Yiddish CR Croatian SL Slovak
Z Blank Portuguese CZ Czech so Somali
1 Blank African Languages DU Dutch sv · Mohawk (St. Regis Tribe)
2 Blank Chinese-Cantonese DZ Dzongkha SW Swahili
3 Blank Chinese-Other Fl Finnish SY Syriac
4 Blank Native American GU Gujarati Tl Tigrinya
5 Blank Serbo-Croatian HM Hmong TN Tona-Seneca
6 Blank Swedish HU Hungarian TO Tongan
7 Blank Tagalog IL llocano TU Turkish
8 Blank Laotian IN Indonesian TS Tuscarora
9 Blank Sign Language KA Karen TW Twi (Fanti)
AN Alaskan KW Kinyarwanda UK Ukranian
AA Am. Ind. -Apache Kl Kirundi (Rundi) UN Unkechauga
AE Am. Ind. - Crow KZ Kizigna YU Yugoslavian

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.1-3
02/14/2015

COMMON APPLICATION FORM - DSS 2921 !CONT'D\

LANGUAGE READ CODES (LANG READ)

A Blank Arabic AT Am. Ind. - Nakata LI Lithuanian

B Blank Urdu AV Am. Ind. - Navajo MY Maay
D Blank French Creole AO Am. Ind. - Other MA Macedonian
E Blank English AS Am. Ind. - Zuni ML Malayalam
F Blank French AM Amharic MO Mongolian
G Blank Greek AW Armenian NE Nepali
H Blank Hebrew AZ Assyrian NO Norwegian
I Blank Italian BA Braille OD Oneida
J Blank Japanese BE Bengali ON Onondaga
K Blank Korean BO Bosnian OR Oro mo
L Blank Albanian BU Bulgarian PA Pashto
M Blank German BR Burmese PE Pennsylvania Dutch
N Blank Hindi CA Cambodian Pl Persian
P Blank Polish CM Chamorro PS Pidgin-Hawaiian
Q Blank Farsi cs Chinese-Simplified PU Punjabi
.R Blank Russian CT Chinese-Traditional RO Romanian
S Blank Spanish cc Creole-Criollo SA Samoan
T Blank Thai co Creole-Haitian SC Seneca
V Blank Vietnamese CE Creole-Other SE Serbian
WBlank Khmer CR Croatian SN Shinnecock
Y Blank Yiddish CZ Czech SL Slovak
ZBlank Portuguese DU Dutch so Somali
1 Blank African Languages DZ Dzongkha sv Mohawk (St. Regis Tribe)
4 Blank Native American Fl Finnish SW Swahili
5 Blank Serbo-Croatian GU Gujarati SY Syriac
6 Blank Swedish HM Hmong Tl Tigrinya
7 Blank Tagalog HU Hungarian TN Tona-Seneca
8 Blank Laotian IL llocano TO Tongan
AN Alaskan IN Indonesian TU Turkish
AA Am. Ind. - Apache KA Karen TS Tuscarora
AC Am. Ind. - Choctaw KW Kinyarwanda TW Twi (Fanti)
AE Am. Ind. - Crow Kl Kirundi (Rundi) UK Ukranian
Al Am. Ind. - Dakota KZ Kizigna UN Unkechauga
AK Am. Ind. - Lakota KU Kurdish YU Yugoslavian

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.1-4
10/22/2012

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-1
10/23/2016

TURNAROUND DOCUMENT - DSS 3517

SECTION 05: CASE LEVEL CODES

M3E INDICATOR IM3EI - 053

1 Immediate action for administrative reasons
T CNS notice suppressed, manual notice required (Timely action)
A CNS notice suppressed, manual notice required (Adequate action)

UTILITY GUARANTEE INDICATOR IUTIL GUARl-044

O None
1 Con Edison
2· National Grid
3 Long Island Lighting (LILCO)
4 Both National Grid and Con Edison
*5 Con Edison Vendor
*6 National Grid Vendor
*7 Con Edison and National Grid Vendor
*8 Withdrawn Vendor
*9 Voluntary Con Edison
*A Voluntary Con Edison and National Grid
*B Removal: Case Closed While on Vendor Status
*C Voluntary National Grid

BOROUGH/COMMUNITY DISTRICT IB/CDI

These are system generated codes: .

BOROUGH CODES COMMUNITY DISTRICT CODES

1- Manhattan 01-12 Manhattan
2- Brooklyn 01-18 Brooklyn
3- Bronx 01-12 Bronx
4 - Queens 01-14 Queens
5- Staten Island 01-03 Staten Island

* Direct Vendor Codes may be used on single suffix cases only.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-2
10/23/2016 .

SECTION 05: CASE LEVEL CODES !CONT'D)

TRUST INDICATOR ITll - 061

Blank is an acceptable value for this field

y Yes
N No
E Supplemental Needs Trust Exception
Irrevocable Trust
L Luberto Transferred Case
p Pool Trust
R Revocable Trust
s Supplemental Needs Trust

RECERTIFICATION SOURCE IRCRT SRCI- 063

E SNAP recertification filed through My Benefits (NYS system)
N SNAP recertification filed through ACCESS NYC (NYC system)
v Recertification received via Vanguard file pass (System generated)
H Recertificaflon received via HHS-CONNECT online renewal (System generated)
w Recertification received via walk-in in-person
A Recertification received via DAB auto recert (System generated)
Recertification received through IVRS (System generated)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 .WORKER'S GUIDE TO CODES
1.2-3
02/21/2016

SECTION 10: SUFFIX LEVEL CODES

CATEGORY CODES !CAT! - 209

EAA (PA Center) Emergency Assistance for Adults (No change)
EAF (PA Center) Emergency Assistance for Families (No change)
FA (PA Center) Family Assistance (Former ADC, ADCU and HR Families Cases should be in
the FA category)
FS (SNAP Supplemental Nutrition Assistance Program (SNAP)
Center)
SNCA (PA Center) Safety Net Cash Assistance (Former HR, except HR Families, Cases should
be in the S.NCA category)
SNNC (PA Center) Safety Net Non-Cash. See page 1 for further details.
SNFP (PA Center) Safety Net Federally Participating. See page 1 for further details.
HX (MA Center) Basic Health Plan (NYSoH)
MA (MA Center) Medical Assistance (No change)
MPE (MA Center) Presumptive Eligibility for Children
MSSI (MA Center) Medicaid.Supplemental Security Income (No change)
ADC (PA Center) This category is no longer valid. Aid to Dependent Children (Will be re-
categorized to FA)
ADCU (PA Center) This category is no longer valid. Aid to Dependent Children - Unemployed
(Will be re categorized to FA)
HR (PA Center) This category is no longer valid. Home Relief (Will be re categorized to SNCA)
HRPG (PA Center) This category is no longer valid. Home Relief Pre Investigation (Clients should
be evaluated and transferred to one of the new categories)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-4
06/16/2013

SECTION 10: SUFFIX LEVEL CODES !CONT'D!

LANGUAGE SPOKEN CODES (LANG} • 255

A Blank Arabic Al Am. Ind. - Dakota KU Kurdish
B Blank Urdu AC Am. Ind. ·Choctaw LI Lithuanian
C Blank Chinese-Mandarin AK Am. Ind. · Lakota MY Maay
D Blank French Creole AT Am. Ind. · Nakota MA Macedonian
E Blank English AV Am. Ind. - Navajo ML Malayalam
F Blank French AO Am. Ind. ·Other MO Mongolian
G Blank Greek AS Am. Ind. ·Zuni NE Nepali
H Blank Hebrew AM Amharic NO Norwegian
I Blank Italian AW Armenian OD Oneida
J Blank Japanese AZ Assyrian ON Onondaga
K Blank Korean BE Bengali OR Oro mo
L Blank Albanian BO Bosnian PA Pash to
M Blank German BU Bulgarian PE Pennsylvania Dutch
N Blank Hindi BR Burmese Pl Persian
P Blank Polish CA Cambodian PS Pidgin-Hawaiian
Q Blank Farsi CM Chamorro PU Punjabi
R Blank Russian CH Chinese-Toisanese RO Romanian
S Blank Spanish CF Chinese-Fujian SA Samoan
T Blank Thai cc Creole-Criollo SC Seneca
V Blank Vietnamese co Creole-Haitian SE Serbian
W Blank Khmer CE CreolecOther SN Shinnecock
Y Blank Yiddish CR Croatian SL Slovak
Z Blank Portuguese CZ Czech so Somali
1 Blank African Languages DU Dutch sv Mohawk (St. Regis Tribe)
2 Blank Chinese-Cantonese DZ Dzongkha SW Swahili
3 Blank Chinese-Other Fl Finnish SY Syriac
4 Blank Native American GU Gujarati Tl Tigrinya
5 Blank Serbo-Croatian HM Hmong TN Tona-Seneca
6 Blank Swedish HU Hungarian TO Tongan
7 Blank Tagalog IL llocano TU Turkish
8 Blank Laotian IN Indonesian TS Tuscarora
9 Blank Sign Language KA Karen TW Twi (Fanti)
AN Alaskan KW Kinyarwanda UK Ukranian
AA Am. Ind. -Apache Kl Kirundi (Rundi) UN Unkechauga
AE Am. Ind. - Crow KZ Kizigna YU Yugoslavian

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-5
02/14/2015

SECTION 10: SUFFIX LEVEL CODES !CONT'D!

LANGUAGE READ CODES {LANG READ) - 281

A Blank Arabic AT Am. Ind. - Nakota LI Lithuanian
B Blank Urdu AV Am. Ind. - Navajo MY Maay
D Blank French Creole AO Am. Ind. - Other MA Macedonian
E Blank English AS Am. Ind. - Zuni ML Malayalam
F Blank French AM Amharic MO Mongolian
G Blank Greek AW Armenian NE Nepali
H Blank Hebrew AZ Assyrian NO Norwegian
I Blank Italian BA Braille OD Oneida
J Blank Japanese BE Bengali ON Onondaga
K Blank Korean BO Bosnian OR Oro mo
L Blank Albanian BU Bulgarian PA Pashto
M Blank German BR Burmese PE Pennsylvania Dutch
N Blank Hindi CA Cambodian Pl Persian
P Blank Polish CM Chamorro PS Pidgin-Hawaiian
Q Blank Farsi cs Chinese-Simplified PU Punjabi
R Blank Russian CT Chinese-Traditional RO Romanian
S Blank Spanish cc Creole-Criollo SA Samoan
T Blank Thai co Creole-Haitian SC Seneca
V Blank Vietnamese CE Creole-Other SE Serbian
WBlank Khmer CR Croatian SN Shinnecock
Y Blank Yiddish CZ Czech SL Slovak
Z Blank Portuguese DU Dutch so Somali
1 Blank African Languages DZ Dzongkha sv Mohawk (St. Regis Tribe)
4 Blank Native American Fl Finnish SW Swahili
5 Blank Serbo-Croatian GU Gujarati SY Syriac
6 Blank Swedish HM Hmong Tl Tigrinya
7 Blank Tagalog HU Hungarian TN Tona-Seneca
8 Blank Laotian IL llocano TO Tongan
AN Alaskan IN Indonesian TU Turkish
AA Am. Ind. - Apache KA Karen TS Tuscarora
AC Am. Ind. - Choctaw KW Kinyarwanda TW Twi (Fanti)
AE Am. Ind. - Crow Kl Kirundi (Rundi) UK Ukranian
Al Am. Ind. - Dakota KZ Kizigna UN Unkechauga
AK Am. Ind. - Lakota KU Kurdish YU Yugoslavian

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-6
06/19/2016

SECTION 10: SUFFIX LEVEL CODES !CONT'D!

HOMEBOUND INDICATOR IHMBDl - 220

y Yes

MA RESPONSIBILITY AREA INDICATORS IMA RESP! - 219

AN Acute Long Term Hospital Care Case
AS Acute Long Term Hospital Care Surplus Case
CC Community Care Case
CM Child Health Plus (CHP)
CS Community Care Surplus Case
DN Dialysis Case
DS Dialysis Surplus Case
FA Enrolled in FIDA Plan
FD Foster Discharge
FH Fair Hearing - Aid to Continue Case
GP Protective Services -Guardian Pending
HC Hospital Care Catastrophic Case (External Use Only)
HN Hospital Care Case
HS Hospital Care Surplus Case
IC Medicaid Suspension (Valid 4/01/08)
LB Luberto Vs Novello
LR Long Term Regular Chronic Care Case
LM Lombardi Care Case
LC Long Term Care
LT 1.S. High Risk Case
MC CED/Managed Long Term Care
MP Qualified Individual (Ql1)
MS Special Low Income Medicare Beneficiaries (SLIMB)
NA Home Health Aid Case
OB OTB Retirees (Center 534)
OF Assisted Living Program
OM Office of Mental Retardation
PA Home Attendant Care Case
PC Presumptive Eligibility for Children
PD Home Care-Working Person with Disability Case
PE Presumptive Eligibility Family Planning Benefit Program
PK Housekeeper Care Case
PM Homemaker Care Case
PS Protective Services
PU Undefined Home Care Program Case
QM Qualified Medicare Beneficiaries (QMB)
SA Home Health Aid Surplus Case
SH Shelter Case
SC Special Services For Children (SC) Case
WD Working Disabled

EMERGENCY INDICATOR IEMG: IND! - 270

F Current EAF Authorization on a FA, SNFP, SNCA, SNNC, or EAF Case
A Current EAA Authorization on SNCA, SNNC, or EAA Case
P Prior Emergency Authorization (Enter This Code When the Emergency Authorization
Period Ends

SPANISH INDICATOR ISP IND! - 273

S Notices will be in Spanish and English
E Notices will be in English only

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-7
06/16/2013

SECTION 10: SUFFIX LEVEL CODES ICONT'Dl

ABBREVIATED CNS NOTICES IABBR CNS! - 249

X Client opts to receive abbreviated CNS notices
Space Client does not opt to receive abbreviated CNS notices

PA STATUS CODES IPA: STAT! - 221

AC Active - Case to receive a recurring Grant
AP Applying - Eligibility for Benefits has not been Determined
CL Closed
NA Not Applying
RJ Denied - Application Rejected
SI Single Issue -Case is eligible but will not receive a recurring Grant
WD Withdrawn - Application for assistance withdrawn

PA ROUTING CODES IPA: ROUT! - 224

No longer data en.tered from the TAD. This data can be entered only through External Budgeting
Screen NSBL02.

MA STATUS CODES IMA: STAT!' 240

AC Active
AP Applying
CL Closed
NA Not Applying
RJ Denied

SNAP STATUS CODES IFS: STAT! - 230

AC Active
AP Applying
CL Closed
NA . Not Applying
RJ . Denied
SI Single Issue

SNAP ROUTING IFS: ROUT! - 233

No longer data entered from the TAD. This data can be entered only through External Budgeting
Screen NSBL02.

SAFETY NET INDICATOR ISNET IND! - 274

A Substance Abuse: For cases that comply or fail to comply with Drug/Alcohol
Treatment Requirements and are deemed unemployable due to their Drug/Alcohol
problem
S Safety Net Limit: For cases that reached the 24-Month case limit
C Cash Limit: For FA cases that have reached the 60-month limit, or SNCA cases that
have reached a total of 60 months SNCA and FA/SNFP combined

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.2-8
02/21/2016

SECTION 10: SUFFIX LEVEL CODES !CONT'D!

ASSOCIATED CODE !ASSOC CD! - 290

20 Optional 2nd contact mailing address

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-1
10/22/2012

CASE REASON CODES

OPENING CODES - PA !PA: REAS - 2221 Only

CODE CATEGORY
400 ALL Administrative Opening on Transitional Benefits Cases.
No Notice Required

A20 ALL PA case opened -- TA determination pending. (System Generated SJ

status only, for expedited SNAP cases.)
18 NYCRR 352.29

A30 ALL PA Approval -- same benefit each month

18 NYCRR 352.29

A32 ALL PA Approval -- first month prorated.

(Use opening codes A48 or A49 for the SNAP suffix.)
18 NYCRR 352.29

F54 ALL Open for Doe Retro Payment Only

18 NYCRR 351.8

Y19 FA/SNFP/ Case accepted for emergencies other than shelter or utility arrears. MA will
SNCA/SNNC/ remain in NA or AP status. For one-shot deals only.
EAF/EAA 18 NYCRR 351.8(c); 370.3(b); 372.1

Y37 FA/SNFP/ Case accepted for single issue payments that have been ordered by a Fair
SNCA/SNNC/ Hearing decision. MA will remain in NA or AP status. (Replaces 008.) This
EAF/EAA code is for Fair Hearing compliance.
Regulatory citation not applicable

Y38 FA/SNFP/ Case accepted only for emergency shelter arrears and/or emergency
SNCA/SNNC/ utility arrears which applicant agrees to repay. MA will remain in NA or AP
EAF status. (Replaces 009.) For one-shot deals only.
18 NYCRR 351.8(c)(4); 352.5(e); 352.7(g)(3)

Y39 SNFP/SNCA Case accepted only for emergency shelter arrears and/or emergency
SNNC/EAF/ utility arrears with no repayment agreement. MA will remain in NA or AP ·
EAA status. For one-shot deals only.
18 NYCRR351.8(c)(4); 352.5(e); 352.7(g)(3); 397.5(1)(1)(2)(3)

Y41 FA/SNFP/ Case accepted for immediate needs (pre-investigation). Case is applying
SNCA/SNNC/ for ongoing assistance. MA will remain in NA or AP status. (Replaces 033.)
EAF/EAA 18 NYCRR 351.8(c)(4)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-2
10/22/2012

CASE REASON CODES !CONT'D)

OPENING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
Y42 ALL Closed in Error. (Employment Unit approval is needed if case was closed
due to an Employment related reason.) Removes the last sanction.
18 NYCRR 352.29; 351.20

Y43 ALL Aid Continuing-Case Awaiting Fair Hearing decision.

No Notice Required

Y46 ALL Employment Unit Approved Override with documentation that allows the
opening of CvB or JOB Search closings or sanctions during the infraction
period. Removes the last sanction.
No Notice Required

To be used if:
1. Client was incarcerated
2. Client was hospitalized
3. There had been a change of address
4. Fair Hearing decision reversed and OES closing
5. Settled in conference by FH & C

Y47 ALL To be used to override an IPV sanction and open a case/suffix during the
infraction period. Use of this code is restricted to EPF as the Origination
Center
(Manual Notice Required).
18 NYCRR 352.29

Y51 ALL Open for Walker Retro Payment Only.

Y65 SNCA/SNNC To be used to override a Drug and Alcohol Closing or Rejection Code
FA/SNFP during the infraction period. Removes the last sanction.
No Notice Required

Y67 ALL Other PA opening code.

The PA regulatory citation depends on the circumstances.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-3
10/22/2012

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-4
10/22/2012

CASE REASON CODES !CONT'D!

OPENING CODES- MA !MA: REAS - 2411 Onlv

CODE CATEGORY
093 MA SSI SSI new opening on SOX, determined eligible for MA-SSL
(Case Type 22)
360-3

753 ALL Combined PA/MA App under review -- 30 days

18 NYCRR 360-2.5

800 ALL PA App does not want MA

Social Services Law 366(1)(a)(1)

839 ALL MA Approval on PA case

Social Services Law 366(1)(a)

H88 ALL Disabled child/children receiving medical/nursing care at home.

360-3

H91 FA/SNFP Medical bills equal to or greater than excess income.

SSI Related 360-4.8 (c)

H94 ALL Medical need - no recent change in financial circumstances.

360-3

Y58 ALL Based on your pregnancy, you have been determined presumptively
eligible for Medical Assistance for a maximum period of 45 days.
360-3

Y67 ALL Other MA opening code

The MA regulatory citation depends on the circumstances.

Y69 ALL Administrative.

360-3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-5
02/15/2014

CASE REASON CODES !CONT'D!

OPENING CODES - SNAP IFS: REAS - 231 l Only

CODE
A30 Same Benefit Each Month
If Shelter Type is 15, 16, 17, 28, 29, 42, or 43 then 18 NYCRR 387.8, 7 CFR
273.2 and 387 .16(f)
If any other Shelter Type then 18 NYCRR 387.14, CFR 273.2(j)(1)(1V)

· A34 SNAP Approval - Proof Provided in SECOND Thirty Days

If Shelter Type is 15, 16, 17, 28, 29, 42, or 43 then 18 NYC RR 387.8, 7 CFR
273.2 and 387 .16(f)
If any other Shelter Type then 18 NYCRR 387.8, CFR 273.2(j)(1)(1V)

A48 SNAP Approval -1st Month Prorated: Applied BEFORE the 16th
(To be used only with PA opening code A32 on the SNAP suffix of a PA/
SNAP case.)
If Shelter Type is 15, 16, 17, 28, 29, 42, or 43 then 18 NYCRR 387.8, 7 CFR
273.2 and 387 .16(f)
If any other Shelter Type then 18 NYCRR 387.8, CFR 273.2(j)(1)(1V)

A49 SNAP Approval - 1st Month Prorated: Applied AFTER the 15th
(To be used only with PA opening code A32 on the SNAP suffix of a PA/
SNAP case.)
If Shelter Type is 15, 16, 17, 28, 29, 42, or 43 then 18 NYCRR 387.8, 7 CFR
273.2 and 387.16(f)
If any other Shelter Type then 18 NYCRR 387.8, CFR 273.20)(1)(1V)

G34 SNAP Change after PA Approval Determination. (For use with expedited
SNAP cases.)
NYCRR 387.8, CFR 273.2(j)(1)(1V)

Q22 Expedited - Pended Verification

(To be used only for NPA/SNAP cases.)
18 NYCRR 387.8, 387.14, 387.15, and CFR 273.20)(1)(1V)

023 Expedited - Pending Verification

· (To be used only on the SNAP suffix of a PA/SNAP case.)
18 NYCRR 387.8, 387.14, 387.15, CFR 273.2(j)(1)(1V)

Y17 Meets eligibility requirements - Application Filed While in Jail/Prison. (Do

not use for Brad H.)
18 NYCRR 387.14, 387.15

Y 45 Other (Manual Notice Required)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-6
02/15/2014

CASE REASON CODES !CONT'D!

OPENING CODES- SNAP IFS: REAS - 231\ Only !cont'd\

CODE
Y46 Employment Unit Approved Override with documentation that allows the
opening of employment-related closings or sanctions during the infraction
period.
No Notice Required

To be used if:
1. Client was incarcerated
2. Client was hospitalized
3. There had been a change of address
4. Fair Hearing decision reversed and OES closing
5. Settled in conference by FH & C

Y51 Open for Walker Retro Payment Only.

029 Meets eligibility requirements - Application Filed While in Jail/Prison.

(Brad H.)
18 NYCRR 387.14, 387.15

064 Eligible as a result of Hurricane Katrina

099 Meets eligibility requirements - System Generated Only

810 Meets eligibility requirements-Six Month Cert. Period (System Generated)

18 NYCRR 387.10, 387.12

901 Override code to reopen case closed with Transitional SNAP.

18 NYCRR387.8

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-7
.10/22/2012

CASE REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 2221

CODE CATEGORY
E10 ALL Failure to Keep/Complete Initial Eligibility Interview: No Scheduled
Appointment
To be used when client fails to schedule an eligibility interview. Not to be
used for Bureau of Eligibility Verification (BEV), Engagement or Medical
Appointments.
18 NYCRR 350.3
MA Separate Determination, SNAP Separate Determination.

E30 ALL Excess Earned Income INo TMAl. Ineligible Budget Required
Your household's countable earned income exceeds the appropriate
(gross and/or net) income eligibility limit.
18 NYCRR 352.29
MA Separate Determination, SNAP Separate Determination.

E34 ALL Excess Income - Receipt of SSI Single Individual. Ineligible Budget
Required
Your household's countable income exceeds the budget limit.
18 NYC RR 352.29
MA Separate Determination, SNAP Separate Determination.

E35 ALL Excess Unearned Income. Ineligible Budget Required

Your household's countable unearned income exceeds the appropriate
(gross and/or net) income eligibility limit.
18 NYCRR 352.29
MA Separate Determination, SNAP Separate Determination

EBO ALL Unable to Locate

Your present whereabouts are unknown.
18 NYCRR 351.22(a)
MA No Separate Determination, SNAP No Separate Determination.

E61 ALL Not a Resident of District

You do not live in the district (New York City). ·
18 NYCRR 311.3
MA No Separate Determination, SNAP No Separate Determination.

E63 ALL Not a Resident of State

You do not live in New York State.
18 NYCRR 351.2(g)
MA No Separate Determination, SNAP No Separate Determination.

E64 ALL Moved Out of District Before Determination

You moved out of this district before determination.
18 NYCRR 351.8
MA No Separate Determination, SNAP Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-8
10/22/2012

CASE REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 2221 lcont'dl

CODE CATEGORY
E69 ALL Failed to Complete Public Assistance Eligibility Process
You failed to keep an employment-related appointment.
18 NYCRR 351.2, 351.8(a)(2), 351.21(a)
MA Separate Determination, SNAP Separate Determination

E72 ALL Institutionalized !HH=1l

You have been admitted or committed to an institution.
18 NYCRR 352.31(a) and 370.2
MA Separate Determination, SNAP No Separate Determination.

E73 ALL In Foster Care IHH=1 l

You are in foster care.
18 NYCRR 352.1 and 352.30(a)
MA No Separate Determination, SNAP No Separate Determination.

E86 ALL Unable to Prove Identity to an Investigatory Agency IHH=1 l

To be used only by originating center BFI
The documents that you presented to establish your identity are false.
18 NYCRR 351.1(b)(2)
MA No Separate Determination, SNAP No Separate Determination.

E95 ALL Died I NYCl IHH=1 l

Case rejected because the client is deceased.
18 NYCRR 351.8
MA Separate Determination, SNAP No Separate Determination.

EZ1 ALL Failed to Apply for SSI IHH=1 l

You failed to apply for SSI.
.18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)
MA Separate Determination, SNAP Separate Determination.

EZ2 ALL Failed to Appeal an SSI Denial IHH=1 l

You failed to appeal an SSI denial.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)
MA Separate Determination, SNAP Separate Determination.

EZ3 ALL Failed to Accept SSI IHH=1l

Although you were found eligible for SSI, you refused to accept the SSI
benefit.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)
MA Separate Determination, SNAP Separate Determination.

EZ4 ALL Failed to Complete Application Steps for 551 IWeCarel IHH=1l
You failed to complete the application steps for SSI that are required by
WeCare.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)
MA Separate Determination, SNAP Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-9
10/22/2012

CASE REASON CODES !CONT'D!

REJECTION CODES - PA {PA: REAS· 2221 lcont'dl

CODE CATEGORY
F10 ALL Failed to Keep Appointment for Initial Eligibility Interview
To be used when client fails to keep an appointment for an initial eligibility
interview. Not to be used for Bureau of Eligibility Verification (BEV),
Engagement or Medical Appointments.
18 NYCRR 350.3
MA Separate Determination, SNAP Separate Determination.

F17 ALL Failed to Validate Incorrect SSN IHH=1l

You failed to validate an incorrect social security number.
18 NYCRR 369.2 and 370.2
MA No Separate Determination, SNAP No Separate Determination.

F20. ALL Failed to Provide SSN IHH=1 l

You failed to give a valid social security number or apply for a social
security number.
18 NYCRR 369.2 and 370.2
MA No Separate Determination, SNAP No Separate Determination.

F33 FA Excess Income - Deemed Income· of Alien Sponsor. Ineligible Budget

Required
Case rejected because the income of the alien sponsor exceeds the
household's budgeted needs.
18 NYCRR 349.3 and 352.33
MA Separate Determination, SNAP Separate Determination.

F40 ALL Fail to Enroll in Group Health Plan !HH=1 l

You failed to apply for and/or use group health insurance benefits.
18 NYCRR 349.6
MA No Separate Determination, SNAP Separate Determination.

F52 ALL Fail to Provide Information - Federal Reporting

You failed to provide information on your income and resources for federal
reporting requirements .
18 NYCRR 351.1(b)
MA Separate Determination, SNAP Separate Determination.

F53 ALL Refusal by Parent to Applv for Child

You are ineligible to receive public assistance because you refused to
apply for a child in the household, under age 18 and not receiving SSL
18 NYCRR 352.30(a)
MA Separate Determination, SNAP Separate Determination.

F63 ALL In Prison IHH=1 l

You are admitted or committed to a prison.
18 NYCRR 352.31(a) and 370.2
MA No Separate Determination, SNAP No Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-10
10/20/2013

CASE REASON CODES !CONT'D!

REJECTION CODES - PA !PA: REAS - 2221 !cont'd!

CODE CATEGORY
F81 ALL Refused Photo ID - Single Individual
You refused to have a photo identification card made.
18 NYCRR 383.3
MA Separate Determination, SNAP Separate Determination.

F84 ALL Failed to Sign Lien !HH=1l

You refused to sign a lien agreement on property.
18 NYCRR 352.27
MA Separate Determination, SNAP Separate Determination.

F92 ALL Ineligible Alien !HH=1l

You proved neither citizenship nor eligible alien status.
18 NYCRR 349.3
MA Separate Determination, SNAP No Separate Determination.

F93 ALL Failure/Refusal to Sign Citizenship/Alien Declaration !HH=1l

You are an alien and you did not sign the citizenship or satisfactory alien
status declaration.
18 NYCRR 351.2(h)
MA Separate Determination, SNAP No Separate Determination.

F98 ALL Client Requests Child Care in Lieu of Temporary Assistance

You want to receive a childcare guarantee instead of public assistance.
Social Services Law Section 410-w
MA Separate Determination, SNAP Separate Determination.

G41 ALL Voluntary Quit or Reduced Earnings -Applicant !HH=1l

You either quit a job or reduced earnings in order to receive public
assistance. The applicant who voluntary quit his/her job or reduced
earnings is ineligible for public assistance for 90 days from the date of
voluntary quit or reduced earnings.
18 NYCRR 385.13(a)
MA Separate Determination, SNAP Separate Determination.

G46 ALL Ineligible for Child Care in Lieu of Temporary Assistance !Excess
Income!·
Your request for Child Care in Lieu of Cash Assistance (CILOCA) has
been denied because you or the other parent in the household has excess
income.
18 NYCRR 415.2(a)(1)(ii); SSL 410w
MA Separate Determination, SNAP Separate Determination.

G60 ALL Unable to Locate - BEV

Bureau of Eligibility Verification (BEV) has been unable to find you.
18 NYCRR 351.22(a)
MA No Separate Determination, SNAP No Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-11
10/20/2013

CASE REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
G89 ALL Client Reauest - Written - PA & MA
Your application for public assistance and medical assistance is rejected
because you wanted your case closed.
18 NYCRR 351.22(e)
MA No Separate Determination, SNAP Separate Determination.

G92 ALL Client Request - Written - PA Onlv

Your application for public assistance is rejected because you wanted your
case closed.
18 NYCRR 351.22(e)
MA Separate Determination, SNAP Separate Determination.

G95 ALL Died , BEV

Bureau of Eligibility Verification (BEV) has determined that the individual is
deceased.
18 NYCRR 351.8
MA No Separate Determination, SNAP No Separate Determination.

G96 ALL Client Request - Verbal - PA Only

Your application for public assistance is rejected because you asked to
close your case.
18 NYCRR 351.22(e)
MA Separate Determination, SNAP Separate Determination.

G99 ALL Client Request - Verbal - PA & MA

Your application for public assistance and medica.1 assistance is rejected
because you asked to close your case.
18 NYCRR 351.22(e)
MA No Separate Determination, SNAP Separate Determination.

M13 ALL Duplicate Assistance - Active Cash Assistance Case in Other State
!HH=1l
You failed to provide proof that you requested your out-of-state case to be
closed.
18 NYCRR 351.1 (b)(2)(ii), 351.2, 351.8(a)(2)(i), 351.9
MA No Separate Determination, SNAP No Separate Determination

M15 ALL Failure to Sign Repayment Agreement/Earnings Assignment

You refused to sign an agreement to repay excess payments and assign
future earnings to repay public assistance excess payments.
Social Services Law Section 158(7)
MA Separate Determination, SNAP Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-12
10/20/2013

CASE REASON CODES !CONT'D)

REJECTION CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
M25 ALL Failure to Respond to a Computer Match Call-In
You failed to return the request for information about the employment
earnings identified in the computerized matching system.
18 NYCRR 351.22(e)
MA No Separate Determination, SNAP Separate Determination.

M35 ALL Lump Sum - No Good Reason Provided

You received money that was considered a lump sum.
18 NYCRR 352.29(h)
MA Separate Determination, .SNAP Separate Determination.

M37 ALL Lump Sum - Shortened Ineligibility Period. Ineligible Budget

Required
You received money that was considered a lump sum.
18 NYCRR 352.29(h)
MA Separate Determination, SNAP Separate Determination.

M48 ALL Parent's Offer of a Home - Minor Not Pregnant/Parenting

You are less than 21 years old, and your parent(s) are responsible for
supporting you. You refused to live in suitable housing provided by a
parent or guardian or in an approved adult supervised living arrangement.
18 NYCRR 370.2
MA Separate Determination, SNAP Separate Determination.

M55 ALL Ineligible for Child Care in Lieu of Temporary Assistance

Your application for Public Assistance has been withdrawn because you
want to apply for Child Care in Lieu of Cash Assistance (CILOCA).
(Use for reasons other than excess income.)
18 NYCRR 415.2(a)(1)(ii); SSL 410w
MA Separate Determination, SNAP Separate Determination.

M66 ALL Receiving PA in Another Case

You already get public assistance as a member of another case and you
are still a member of that household.
18 NYCRR 351.1
MA No Separate Determination, SNAP No Separate Determination.

M67 ALL Part of Another PA Application

You already get public assistance as a member of another case and you
are still a member of that household.
18 NYCRR 351.1
MA No Separate Determination, SNAP No Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-13
10/18/2014

CASE REASON CODES !CONT'DI

REJECTION CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
M71 ALL Continue Applicant Voluntary Quit Sanction !HH=1 l
You either quit a job or reduced earnings in order to receive public
assistance.
18 NYCRR 352.30 and 18 NYCRR 385.13
MA Separate Determination, SNAP Separate Determination.

M76 ALL Continue Multi-Benefit 10 Year Sanction !HH=1 l

You fraudulently misrepresented your identity or residence to receive
multiple public assistance benefits at the same time. You are ineligible to
receive public assistance and SNAP for ten years:
18 NYCRR 351.2(k)
MA Separate Determination, SNAP No Separate Determination.

M77 ALL Continue Drug/Alcohol Sanction !No infraction record created)

You violated substance abuse treatment rules.
18 NYCRR 352.30
* MA Separate Determination, SNAP Separate Determination.

M78 ALL Continue IPV Sanction IHH=1l

You had committed an Intentional Program Violation previously.
18 NYCRR 359.9
* MA Separate Determination, SNAP Separate Determination.
M79 ALL Fail to Report Absence of Child IHH=1 l
You did not notify that a child was absent from your hbme.
18 NYCRR 351.2(k) and 352.30
MA Separate Determination, SNAP Separate Determination.

M88 ALL Failure to Comply with Automated Finger Imaging Requirement. Not
Homebound or Group Resident
The applicant refused to comply with the finger imaging requirements.
18 NYCRR 351.2
MA Separate Determination, SNAP Separate Determination.

* If between ages 21 and 64 (not yet 65) with PA categorical code 09, 14, or 26, then MA No Separate
Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-14
10/22/2012

CASE REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 222! !cont'd)

CODE CATEGORY
M98. ALL Receipt of Concurrent Assistance IHH=1 l
Your identity matches that of a person who is already receiving public
assistance.
18 NYCRR 351.8(a)(2)(i), 351.1 (b)(2)(ii), 351.2 and 351.9
MA No Separate Determination, SNAP No Separate Determination.

M99 ALL Receipt of Concurrent Assistance - AFIS Match - Without Aid to

Continue IHH=1l
Your identity matches that of a person who is already receiving public
assistance.
18 NYCRR 351.8(a)(2)(i), 351.1 (b)(2)(ii), 351.2 and 351.9
MA No Separate Determination, SNAP No Separate Determination.

MX1 ALL Failure to Take Part in Rehab -1st Occurence IHH=1l !Will create
infraction record)
You refused to participate in an outpatient alcohol or substance abuse
rehabilitation program without good cause or, you failed to sign the
required consent form for disclosure of your medical and non-medical
records from your outpatient substance treatment program. Therefore, you
Code MX2-0utput code
will not be able to receive public assistance for the period of 45 days. In
for a 120-day sanction
order to avoid any further delay in your receipt of assistance at the end of
Code MX3-0utput code the sanction period you may reapply for assistance at any time at the
for a 180-day sanction
Income Support Center that formerly served you.
18 NYCRR 351.2(i)
• MA Separate Determination, SNAP Separate Determination.

N10 ALL Failure to Keep/Complete Eligibility Appointment

You failed to keep or complete the appointment.
18 NYCRR 350.3
MA Separate Determination, SNAP Separate Determination.

N13 ALL Failure to Use/Apply for Benefit/Resource

You failed to use/apply for available benefits and/or resources.
18 NYCRR 351.2
MA Separate Determination, SNAP Separate Determination.

• If between ages 21 and 64 (not yet 65) with PA categorical code 09, 14, or 26, then MA No Separate
Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-15
10/22/2012

CASE REASON CODES !CONT'D)

REJECTION CODES - PA IPA: REAS - 222) !cont'd)

CODE CATEGORY
N14 ALL Filing Unit Member Failed to Apply
Your application for public assistance has been rejected because at least
one member on the application is under age 18. That means brothers,
sisters and parent must apply.
18 NYCRR 352.30
MA Separate Determination, SNAP Separate Determination.

N15 ALL Failure to KeepAppt. - BEV/FEDS Home Visit

You did not keep the appointment to meet with the agency investigator in
your home.
18 NYCRR 351.4
MA Separate Determination, SNAP Separate Determination.

N16 ALL Failure to Contact Agency

You failed to contact the agency.
18 NYCRR 351.22(a)
MA Separate Determination, SNAP Separate Determination.

N17 ALL Failure to Complete Eligibility Process

You failed to complete the public assistance eligibility process.
18 NYCRR 351.2, 351.8(a)(2) and 351.21(a)
MA Separate Determination, SNAP Separate Determination.

N19 ALL Failed to Comply with Requirement to Look for Work !Applicant Job
Search I
Applicant failed to comply with the requirement to look for work as
assigned by the district. Therefore, the household's application for public
assistance is being denied.
18 NYCRR 385.9(e)
MA Separate Determination, SNAP Separate Determination.

N21 ALL Failed to Complete an Employment Assessment !Applicant

Employment Assessment)
An applicant failed to complete an employment assessment, as required
by the agency. Therefore, the household's application for public assistance
is being denied.
18 NYCRR 385.&(a) (HH w/dependent child) or 385.7(a) (HH w/o dependent
child)
MA Separate Determination, SNAP Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-16
10/22/2012

CASE REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 2221 lcont'dl

CODE CATEGORY
P20 ALL DOE - Did Not Keep Eligibility Appointment
You cannot be considered for status as a Doe class member because you
didn't keep your eligibility appointment.
18 NYCRR 352.2
MA No Separate Determination, SNAP No Separate Determination.

P44 ALL Fail to Comply with Drug/Alcohol Screening IHH=1 I

You did not take part in or complete the alcohol and/or substance abuse
screening requirement.
18 NYCRR 351.2(i)
* MA Separate Determination, SNAP Separate Determination.

P45 ALL Fail to Comply with Drug/Alcohol Assessment IHH=1l

You failed to comply with the alcohol and/or substance abuse assessment
requirement.
18 NYCRR 351.2(i)
* MA Separate Determination, SNAP Separate Determination.

P46 ALL Fail to Comply with Drug/Alcohol Release Information IHH=1\

You did not sign or you revoked the consent for the release of treatment
information for an alcohol and/or substance abuse problem to this
department.
18.NYCRR 351.2(i)
* MA Separate Determination, SNAP Separate Determination.

U40 ALL Excess Resources

Your amount of resources exceeds the limit.
18 NYCRR 352.23
MA Separate Determination, SNAP Separate Determination.

U41 SNFP/SNCA/ Transfer of Resources

SNNC Your household gives away or transfers a resource to get public
assistance.
18 NYCRR 370.2
MA Separate Determination, SNAP Separate Determination.

U42 ALL Excess Resources - Refused to Sell Property

You refused to sell real property whose value exceeds the resource limit.
18 NYCRR 352.23
MA Separate Determination, SNAP Separate Determination.

• If between ages 21 and 64 (not yet 65) with PA categorical code 09, 14, or 26, then MA No Separate
Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-17
10/22/2012

CASE REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 222! !cont'd!

CODE CATEGORY
U44 ALL Excess Resources - Deemed from Alien Sponsor
The total amount of resources of the alien sponsor exceeds the resource
limit.
18 NYCRR 349.3 and 352.33
MA Separate Determination, SNAP Separate Determination.

V21 ALL Failure to Provide Verification

You failed to provide verification of information to determine whether the
case is eligible for public assistance.
MA Separate Determination, SNAP Separate Determination.
18 NYCRR 351.6

V23 ALL Failure to Provide Verification - Parent/Spouse

You failed to provide verification of income and/or resources from a parent/
spouse.
18 NYC RR 351.6 and 352.30
MA Separate Determination, SNAP Separate Determination.

V24 ALL Failure to Provide Verification - Step/Grandparent

You failed to provide verification of income and/or resources from a step/
grandparent who is legally responsible for a person on \he case.
18 NYCRR 351.6 and 352.30
MA Separate Determination, SNAP Separate Determination.

V25 ALL Failure to Provide Verification - Filing Unit

You did not provide information on non-applying household members.
18 NYCRR 351.6 and 352.30
MA Separate Determination, SNAP Separate Determination.

W10 ALL Fail to Keep Investigatory Appointment

You did not keep the appointment with the agency investigator.
18 NYCRR 351.4
MA Separate Determination, SNAP Separate Determination.

W11 ALL Failure to Keep Appointment for Medical Assessment

You did not go for an examination by the doctor that the agency referred
to.
18 NYCRR 351.1 and 351.2
MA Separate Determination, SNAP Separate Determination.

W23 ALL Failure to Provide Verification - Parent/Spouse

You failed to provide verification of income and/or resources from a parent/
spouse.
18 NYCRR 351.6 and 352.30
MA Separate Determination, SNAP Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-18
06/19/2016

CASE REASON CODES !CONT'D>

REJECTION CODES - PA IPA: REAS - 222! !cont'd!

CODE CATEGORY
W35 ALL Fleeing Felon
You are currently a fleeing felon.
18 NYCRR 351.2(k)(3)(i)
MA Separate Determination, SNAP No Separate Determination.

W40 ALL Failure/Refusal to Become Employable IHH=1l

Public assistance has been denied because the client failed to do what
was needed to become employable. Client would not accept referral to, or
take active part in, medical care or vocational rehabilitation or training. The
individual is ineligible for public assistance until he/she participates in such
medical care, rehabilitation or treatment.
18 NYCRR 385.12(a)
MA Separate Determination, SNAP Separate Determination.

W44 ALL Probation Violator

You are currently in violation of probation.
18 NYCRR 351.2(k)(3)(ii)
MA Separate Determination, SNAP No Separate Determination

W45 ALL Parole Violator

You are currently in violation of parole.
18 NYCRR 351.2(k)(3)(ii)
MA Separate Determination, SNAP No Separate Determination

WE1 ALL Failure to Comply with Employment Requirements IHH=1 l

A nonexempt PA applicant failed to comply with an employment
requirement other than applicant employment assessment or applicant job
search. Until compliance.
18 NYCRR 385.12
MA Separate Determination, SNAP Separate Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-19
02/21/2016

CASE REASON CODES !CONT'D)

REJECTION CODES - PA !PA: REAS - 2221 !cont'd)

CODE CATEGORY
WS1 ALL IPV: 6 Mos. -1st Offense <$1000 !HH=11
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was less than $1,000 you are
disqualified from receiving public assistance for 6 months.
18 NYCRR 359.9
* MA Separate Determination, SNAP Separate Determination.
WS2 ALL IPV: 12 Mos. - 2nd Offense/ <$3900 !HH=1l
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 2nd .occurrence and/or
the amount you wrongly received was less than $3,900 you are
disqualified from receiving public assistance for 12 months.
18 NYCRR 359.9
* MA Separate De.termination, SNAP Separate Determination.
WS3 ALL IPV: 12 Mos. -1st Offense/ $1000-3900 !HH=1l
You have been found guilty of cdmmitting an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was between $1,000-$3,900 you are
disqualified from receiving public assistance for 12 months.
18 NYCRR 359.9
* MA Separate Determination, SNAP Separate Determination ..

• If between ages 21 and 64 (not yet 65) with PA categorical code 09, 14, or 26, then MA No Separate
Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-20
10/22/2012

CASE REASON CODES !CONT'D)

REJECTION CODES - PA IPA: REAS - 222! !cont'd)

CODE CATEGORY
WS4 ALL IPV: 18 Mos. - 3rd Offense IHH=1l
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 3rd occurrence you
are disqualified from receiving public assistance for 18 months.
18 NYCRR 359.9
• MA Separate Determination, SNAP Separate Determination.

WS5 ALL IPV: 18 Mos. -1st Offense/ >$3900 IHH=1l

You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months.
18 NYCRR 359.9
• MA Separate Determination, SNAP Separate Determination.

WS6 ALL IPV: 18 Mos. - 2nd Offense/ >$3900 IHH=11

You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 2nd occurrence and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months.
18 NYCRR 359.9
·• MA Separate Determination, SNAP Separate Determination.

WS7 ALL IPV: 5 Yrs. - 4th or Subsequent Offense IHH=11

You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 4th or subsequent
occurrence you are disqualified from receiving public assistance for 5
years.
18 NYCRR 359.9
• MA Separate Determination, SNAP Separate Determination.

• If between ages 21 and 64 (not yet 65) With PA categorical code 09, 14, or 26, then MA No Separate
Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-21
10/22/2012

CASE REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 2221 lcont'dl

CODE CATEGORY
WSB ALL IPV: Court Ordered Disqualification IHH=1l
Court ordered disqualification is based on the finding of the court that the
client has been found guilty of committing an IPV. The period is
determined by the court and may differ from those above. Your application
for public assistance is rejected because you've been found guilty of
committing an Intentional Program Violation (IPV) either through an
adm.inistrative disqualification hearing, a judicial decision, you signed a
disqualification consent agreement or signed a waiver to an administrative
hearing. As this was the_ occurrence and/or the amount you wrongly
received was $_you are disqualified from receiving public assistance for
_months.
18 NYCRR 359.9
* MA Separate Determination, SNAP Separate Determination.
Y50 ALL Client Request To Withdraw Application
(Adequate Notice)
Your application for public assistance is rejected because you requested to
withdraw your application. If you decide that you do want public
assistance, you may reapply at any time.
MA Separate Determination, SNAP No Separate Determination.

Y94 ALL Client Request To Withdraw Application - PA Only

(Adequate Notice)
Your application for public assistance is rejected because you requested to
withdraw your application. If you decide that you do want public assistance
or Medicaid, you may reapply at any time.
MA No Separate Determination, SNAP No Separate Determination.

Y95 ALL Application For Emeraency Assistance Only

MA Separate Determination, SNAP Separate Determination.
ygg ALL Other - Manual Notice Required
MA Separate Determination, SNAP Separate Determination.

* If between ages 21 and 64 (not yet 65) with PA categorical code 09, 14, or 26, then MA No Separate
Determination.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-22
10/22/2012

CASE REASON CODES !CONT'D!

REJECTION CODES- SNAP IFS: REAS - 2311 Only

CODE VALUE
943 Not in Receipt of SNAP (SYSTEM GENERATED)

E10 Failure to Keep/Complete Interview: No Schedule Appointment.

18 NYCRR 350.3

E29 Failure to Provide Verification, Alien Sponsor

18 NYCRR 387.8 (c), 387.9 (a) (7), 387.9 (b), 387.10, 387.14 (a)

E30 Excess Earned Income

18 NYCRR 387.10

E35 Excess Unearned Income

18 NYCRR 387.10

E61 Not a Resident of District

18 NYCRR 387.9 (a)

E63 Not a Resident of State

18 NYCRR 387.9 (a)

E?O Ineligible Boarder

18 NYCRR 387.1, 387.14 (a), 387.16 (b)

E71 In Commercial Boarding Home

18 NYCRR387.1

E72 Institutionalized (HH=1)

18 NYCRR 387.1, 387.14 (a) (5)

E74 Elderly/Disabled Ineligible for Separate Household Status

18 NYCRR387.1

E75 Refusal of Everyone in Household to Apply

18 NYCRR 387.1(w), 387.9(a)

E76 Living with Child

18 NYCRR 387.1

E77 Living with Parent

18 NYCRR387.1

E78 Living with Child's Other Parent

18 NYCRR387.1

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-23
02/21/2016

CASE REASON CODES ICONT'Dl

REJECTION CODES.:.. SNAP IFS: REAS - 2311 Only (cont'd!

CODE VALUE
E86 Unable to Prove Identity to an Investigatory Agency (HH=1)
To be used only by originating center BFI
18 NYCRR 387.8(b)(1)(i)

E95 Died (HH=1)

18 NYCRR387.1

F15 Failure to Verify Date of Birth (HH=1)

18 NYCRR 387.1, 387.8 (c), 387.9 (a)

F19 Refusal to Cooperate with Quality Control

18 NYCRR 387.9 (a)(7)(ii)

F21 Failure to Apply/Provide SSN (HH=1)

18 NYCRR 387.9 (a), 387.10 (b), 387.16 (c)

F30 Trafficking in SNAP Benefits of $500 or More (HH=1)

18 NYCRR 359.9 (c) .

F37 Excess Income, SNAP Disaster Area

Federal Regulation 7 CFR 280.1

F49 Excess Resources, SNAP Disaster Area

Federal Regulation 7 CFR 280.1

F63 In Prison (HH=1)

18 NYCRR 387.1, 387.14 (a) (5)

F70 Parental Control of Child

18 NYCRR 387.1

F71 Child Under Parental Control

18 NYCRR387.1

F86 Failure to Verify Alien Status (HH=1)

18 NYCRR 387.1, 387.8 (b), 387.9 (a) (2) and 387.14 (a)

F90 Ineligible Student (HH=1)

18 NYCRR 387.1, 387.9 (a)

F92 Ineligible Alien (HH=1)

18 NYCRR 387.1, 387.8 (b), 387.9 (a) (2) and 387.14 (a)

F94 Able Bodied Adult Without Dependents (ABAWD), (HH=1)

18 NYCRR 385.3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-24
10/18/2015

CASE REASON CODES !CONT'D!

REJECTION CODES - SNAP IFS: REAS - 231! Only !cont'd!

CODE VALUE
G65 Not a Resident of Disaster Area
Federal Regulation 7 CFR 280.1

IP1 Out-of-State IPV

Department Regulation 359.9

J05 SNAP Separate Determination

18 NYCRR 387.20(a)

M13 Duplicate Assistance -Active Cash Assistance Case in Other State (HH=1).
Client failed to provide proof that he/she requested his/her out-of-state case to be closed.
18 NYCRR 387.9(a)(1), SSL 273.3(a)

M26 Failure to Provide Verification of Wage Match

18 NYCRR 387.8 (c), 387.14 (a)

M27 Failure to Provide Verification of UIB Match

18 NYCRR 387.8 (c), 387.14 (a)

M34 Excess Income, Strikers Income

18 NYCRR 387.160)

M66 Receiving SNAP in Another Case

18 NYCRR 387.1

M67 Part of Another SNAP Application

18 NYCRR387.1

M90 Client Request, Written or Face to Face

18 NYCRR 387.20

M91 Client Request; Phone

18 NYCRR 387.20

M97 Receiving Multiple Benefits (HH=1)

18 NYCRR 381.1

M98 Duplicate Assistance (non-AFIS), in NYS (HH=1)

18 NYCRR 351.2 (a), 351.9

N10 Failure to Keep/Complete Appointment

18 NYCRR 387.7 (a), 387.14 (a)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-25
10/22/2012

CASE REASON CODES !CONT'D!

REJECTION CODES-SNAP IFS: REAS - 231\ Only !cont'd)

CODE VALUE
N31 Voluntary Quit, 1st Occurrence (HH=1)
18 NYCRR 385.13

N32 Voluntary Quit, 2nd Occurrence (HH=1)

18 NYCRR385.13

N33 Voluntary Quit, 3rd Occurrence (HH=1)

18 NYCRR 385.13

N66 Duplicate Assistance (PARIS Match), Interstate

18 NYCRR 351.2.(a), 351.9

N90 IPV, Traded SNAP for Firearms, Ammunition, or Explosives (HH=1)

18 NYCRR 359.9

NF1 IPV: Purchased Illegal Drugs With SNAP, 1st Violation (HH=1)
18 NYCRR 359.9

NF2 IPV: Purchased Illegal Drugs with SNAP, 2nd Violation (HH=1)
18 NYCRR 359.9

R99 Referred to MAP for separate determination (SYSTEM GENERATED)

U40 Excess Resources

18 NYCRR 387.17

U41 Transfer of Resources

18 NYCRR 387.9 (a) ·

U44 Excess Resources, Alien Sponsor's Resources

18 NYCRR 387.1, 387.9 (b), 387.10

V21 Failure to Provide Verification

18 NYCRR 387.8 (c), 387.9 (a) (7), 387.14 (a)

W35 Fleeing Felon

NYCRR 351.2(k)(3)(i)

W44 Probation Violator

18 NYCRR 351.2(k)(3)(ii)

W45 Parole Violator

18 NYCRR 351.2(k)(3)(ii)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES .
1.3-26
10/22/2012

CASE REASON CODES !CONT'D!

REJECTION CODES - SNAP IFS: REAS - 2311 Only !cont'd!

CODE VALUE
WF1 SNAP IPV Infraction, 1st Occurrence (HH=1)
Department Regulations 387.10, 359.3

WF2 SNAP IPV Infraction, 2nd Occurrence (HH=1)

Department Regulations 387.10, 359.3

WF3 SNAP IPV Infraction, 3rd Occurrence (HH=1)

Department Regulations 387.10, 359.3

Y12 Receiving SNAP as part of another PA case

Federal Regulation 7 CFR 273.3

Y94 Client Request To Withdraw Application

Your application for SNAP is rejected because you requested to withdraw your
application. If you decide that you do want SNAP, you may reapply at any time.

Y99 Other

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/22/2012

CASE REASON CODES !CONT'D!

SPECIAL NOTICE
CLOSING CODES - PA IPA: REAS - 2221

1. Any closing code that has the word "ALL" listed unoer category can be used to close an EAA/
EAF case.

2. The ADC (Aid To Dependent Children), ADCU (Aid to Dependent Children-Unemployed) and HR
Family (Home Relief) categories will be replaced by FA (Family Assistance).

3. The HR category will be replaced by SNCA (Safety Net Cash Assistance).

4. Members of HRPG (Home Relief Pre Investigation) category will be evaluated and transferred to
one of the new categories.

5. SNFP (Safety Net Federally Participating) is a new category used for case members who fail to
comply with Drug/Alcohol requirements or DIA abusers deemed unemployable due to their DIA
problems.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/22/2012

CASE REASON CODES !CONT'D>

CHANGE IN EMPLOYMENT, SUPPORT OR INCOME
CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
E30 FA/SNFP/ Excess Income !No TMAI
SNCA/SNNC Public assistance has been discontinued because income exceeds the
appropriate (gross and/or net) income eligibility limit.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 359.29; MA: 360-2.6; SNAP: 18 NYCRR 387.17

E31 FA/SNFP Increased Employment Earnings ITMA Eligible)

Public assistance has been discontinued due to increased employment
earnings that exceed the household's budgeted needs.
MA continued for 12 months, SNAP Separate Determination (See Note).
PA: 18 NYCRR 359.29; MA: 360-2.6; SNAP: 18 NYCRR 387.17

E32 ALL Excess Income - Increased Support Collection - !MA Extension!

Public assistance has been discontinued because the increase in the
amount of support exceeds the household's budgeted needs.
MA continued for 4 months, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.29; MA: 360-3.3 (c); SNAP: 18 NV.CRR 387.17

E33 ALL Excess Income - Increased Earnings ITMA Guaranteed!

Public assistance has been discontinued because increased earnings
exceed the budgeted household's needs .. *Note: To be utilized when there
has been a case number change, to ensure Transitional Medical
Assistance (TMA) to any member of the household.
MA continued for 12 months, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.29; MA: 360 -3.3; SNAP: 18 NYCRR 387.17

E34 ALL Excess Income - Receipt of SSI IHH=1l

Public assistance has been discontinued because the SSI payment
amount exceeds the household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 352.29; MA: 360 2.6; SNAP: 18 NYCRR 387.17

E35 ALL Excess Unearned Income !No TMAl

Public assistance has been discontinued because unearned income
exceeds the appropriate (gross and/or net) income eligibility limit. (Not to
be used for excess SSI or childcare income.)
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 352.29; MA: 360-2.6; SNAP: 18 NYCRR 387.17

E36 FA/SNFP Excess Income -Increased Support Collection

(No MA Extension)
Public assistance has been discontinued because of the increase in the
amount of support exceeds the household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.29; MA: 360-2.6; SNAP: 18 NYCRR 387.17
Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-29
02/21/2016

CASE REASON CODES !CONT'D!

CHANGE IN EMPLOYMENT, SUPPORT OR INCOME (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
E38 ALL Lump Sum
Public assistance has been discontinued because the amount of the lump
sum payment exceeds the household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 352-29; MA: 360-2.6; SNAP: 18 NYCRR 387-17

E39 ALL Excess Income - COLA

Public assistance has been discontinued because the amount of the Cost-
of-Living Adjustment increased the income so that it exceeds the
household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.29; MA: 360: 2.6; SNAP: 18 NYCRR 387.17

E40 ALL Excess Income - Budgeting Error

Public assistance has been discontinued because an error in budgeting
income has been found . and corrected. The income exceeds the
household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 352.29; MA: 360-2.6; SNAP: 18 NYCRR 387.17

EZ5 ALL Excess Income - Receipt of SSI !HH=1 I

Public assistance has been discontinued because the SSI payment
amount exceeds the household's budgeted needs.
MA Separate Determination, SN.AP No Separate Determination
PA: 18 NYCRR 352.29; MA: 360 2.6; SNAP: 18 NYCRR 387.17

F33 FA/SNFP Excess Income - Deemed Income of an Alien Sponsor

Public assistance has been discontinued because the income of the alien
sponsor exceeds the household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 349.3, 352.29, 352.33; MA: 360-2.6;
SNAP: 18 NYCRR 387.17

F34 ALL Excess Income. Section 8. Lower Standard of Need

Public assistance has been discontinued because income exceeds the
appropriate (gross and/or net) income eligibility limit. Use when changes
concerning Section 8 vouchers result in a lower standard of need.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 352.1, 352.3, 352.14, 352.29, 352.30, 352.31; MA: 360-2.6;
SNAP: 18 NYCRR 387.14, 18 NYCRR 387.15

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-30
06/19/2016

CASE REASON CODES !CONT'D)

CHANGE IN EMPLOYMENT, SUPPORT OR INCOME (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
F39 SNCA/SNNC Excess Income - COLA
Public assistance has been discontinued because an increase in income
from a cost of living adjustment in Social Security or SSI exceeds the
household's budgeted needs.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 1.8 NYCRR 352.29, 352.31, 352.32; MA: 360-2.2;
SNAP: 18 NYCRR 387.17

G40 SNCA/SNNC Excess Income - Budgeting Error

Public assistance has been discontinued because the case was opened in
error due to an incorrect budget calculation.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 352.29; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G41 ALL Voluntary Quit or Reduced Earnings -Applicant !HH=1l

This code is used to deny a PA application in single-issuance status that
was opened to authorize expedited SNAP benefits or a single issuance
pending the eligibility determination, and the applicant quit a job or
voluntarily reduced the number of hours worked in order to qualify for initial
or increased PA. The individual is ineligible for PA for 90 days from the
date of the job quit or voluntary reduction in the number of hours worked.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 385.13; MA: 360-2.2; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-31
06/19/2016

CASE REASON CODES !CONT'D)

CHANGE IN EMPLOYMENT, SUPPORT OR INCOME (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 lcont'dl

CODE CATEGORY
N41 ALL Voluntary Quit IHH=11
Public assistance has been discontinued because the recipient quit his/her
job or voluntarily reduced the number of hours worked without good cause.
Until compliance.
MA continued; SNAP Separate Determination
PA: 18 NYCRR 385.12; MA: 360-2.6; SNAP: 18 NYCRR 387.17

N45 ALL Voluntary Quit IHH=11

Public assistance has been discontinued because the recipient quit his/her
job or voluntarily reduced the number of hours worked without good cause.
Until compliance.
MA continued; SNAP No Separate Determination
PA: 18 NYCRR 385.12; MA: 360-2.6; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC. case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-32
02/14/2015

CASE REASON CODES !CONT'D!

FAILURE TO PROVIDE VERIFICATION
CLOSING CODES - PA IPA: REAS - 222! !cont'd!

CODE CATEGORY
V20 ALL Failure to Provide Verification
Public assistance has been discontinued because the client failed to
provide verification of information to determine whether the case is eligible
for public assistance.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

V23 FA/SNFP Failure to Provide Verification - Parent/Spouse

Public assistance has been discontinued because the client failed to
provide verification of income and/or resources from a parent/spouse.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 351.6, 352.30; MA: 360-2.6; SNAP: 18 NYCRR 387.17

V24 ALL Failure to Provide Verification - Grandparent

Public assistance has been discontinued because the client failed to
provide verification of income and/or resources from a grandparent who is
legally responsible for a person on the case.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 351.6, 352.30 MA: 360-2.6 SNAP: 387.17

V25 ALL Failure to Provide Verification - Filing Unit

Public assistance has been discontinued because the client did not
provide information on non-applying household members.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18NYCRR 351.6, 352.30; MA: 360-2.6; SNAP: 18 NYCRR 387.17

V26 ALL Failure to Provide Verification - Stepparent

Public assistance has been discontinued because the client failed to
provide verification of income and/or resources from a stepparent who is
legally responsible for a person on the case.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6, 352.30; MA: 360-2.6; SNAP: 18 NYCRR 387.17

W23 SNCA/SNNC Failure to Provide Verification - Parent/Spouse

Public assistance has been discontinued because the client failed to
provide verification of income and/or resources from a parent/spouse.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 351.6, 352.30; MA: 360-2.6; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-33
02/14/2015

CASE REASON CODES !CONT'D!

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS
CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
E65 ALL Failed to Complete an Employment Assessment !Applicant
Employment Assessment)
This code is used to deny a public assistance! application in single
issuance (SI) status that was opened to authorize expedited SNAP
benefits or a single issuance pending the eligibility determination and an
individual falis to comply with applicant employment assessment.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 385.6(a) (HH w/dependent child), 385.7(a) (HH w/o dependent
child); MA: 360-3.3;SNAP: 18 NYCRR 387.8 .

E69 ALL Failed to Comply with Requirement to Look for Work !Applicant Job
Search)
This code is used to deny a public assistance application in single
issuance (SI) status that was opened to authorize expedited SNAP
benefits or a single issuance pending the eligibility determination and an
individual falis to comply with applicant job search requirements
MA Separate Determination, SNAP Separate Determination ..
PA: 18 NYCRR 385.9(e), 385.12; MA 360-3.3; SNAP: 18 NYCRR 387.8

E86 ALL Unable to Prove Identity to an Investigatory Agency !HH=1l

To be used only by originating center BFI
The documents that the client presented to establish his/her identity are
false.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.1(b)(2); SNAP: 18 NYCRR 387.8 (b)(1)(i)

E92 ALL Failure to Provide Proof of Citizenship or Eligible Alien Status !HH=1 l
Public assistance has been discontinued because the client proved neither
citizenship nor legal residency.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 349.3; MA: 360-2.6; SNAP: 18 NYCRR 387.1 387.9 (a)

EZ1 ALL Failed to Apply for SSI !HH=1l

Public assistance has been discontinued because the client failed to apply
for SSI.
MA Separate Determination, SNAP Separate Determination.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-34
02/14/2015

CASE REASON CODES !CONT'D>

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D)
CLOSING CODES - PA IPA: REAS - 222! lcont'dl

CODE CATEGORY
EZ2 ALL Failed to Appeal an SSI Denial IHH=1l
Public assistance has been discontinued because the client failed to
appeal an SSI denial.
MA Separate Determination, SNAP Separate Determination.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

EZ3 ALL Failed to Accept SSI IHH=1l

Public assistance has been .discontinued because the client was found
eligible for SSI but refused to accept the SSI benefit.
MA Separate Determination, SNAP Separate Determination.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

EZ4 ALL Failed to Complete Application Steps for SSI !WeCarel IHH=1 I
Public assistance has been discontinued because the client failed to
complete the application steps for SSI that are required by WeCare.
MA Separate Determination, SNAP Separate Determination.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

F17 ALL Failure to Validate Incorrect SSN IHH=1 I

Public assistance has been discontinued because the client failed to
provid!9 a valid SSN or prove that an application was filed.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 369.2 (ADC), 370.2 (HR); MA: 360-2.6;
SNAP: 18 NYCRR 387.1, 387.8 (c), 387.9 (a), 387.16 (c)

F20 ALL Failure to Provide SSN !HH=1l

Public assistance has been discontinued because the client failed to
provide a valid SSN or verification that they had applied.
MA No Separate Determination, SNAP No Separate Determination.
PA: (FA/SNFP) 18 NYCRR 369.2, (SNCA/SNNC) 370.2;
MA: 360-2.6; SNAP: 18 NYCRR 387.1, 387.8 (c), 387.9 (a), 387.16 (c)

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits ifthere is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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02/14/2015

CASE REASON COOES !CONT'D)

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
F40 ALL Failure to Enroll In a Group Health Plan IHH=1l
Public assistance has been discontinued because the client has failed to
apply for and/or use group health insurance benefits.
MA No Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 349.6; MA: 360-2.2; SNAP: 18 NYCRR 387.8

F53 ALL Refusal by Parent to Apply for Child .

Public assistance has been discontinued because the client refused to
apply for child in the household, under age 18 and not receiving SSI.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 352.30(a)

F76 ALL Minor Failed to Complete High School Education !HH=1l

Public assistance has been discontinued because client is less than 18
years old, unmarried, has a child at least 12 weeks old and failed to
participate in a program to attain a high school diploma or an alternative
educational or training program.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.2 (k); MA: 360-2.6; SNAP: 18 NYCRR 387.17

F81 ALL Refused Photo ID IHH=1l

Public assistance has been discontinued because the client refused to
have a photo identification card made.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 383.3; MA: 360-2.6; SNAP: 18 NYCRR 387.17

F84 ALL Failure to Sign Lien IHH=1 l

Public assistance has been discontinued because the client refused to
sign a lien agreement on property.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.27; MA: 360-2.6; SNAP: 18 NYCRR 387.17

M15 SNCA/SNNC Failure to Sign Repayment or Earnings Assignment

Public assistance has been discontinued because the client refused to
sign an agreement to repay excess payments and assign future earnings
to repay public assistance excess payments.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 370.2; MA: 360-2.2; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.3-36
02/14/2015

CASE REASON CODES !CONT'D!

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D)
CLOSING CODES - PA !PA: REAS - 2221 !cont'd!

CODE CATEGORY
M25 ALL Failure to Respond to a Computer Match Call-In
Public assistance has been discontinued because the client failed to
contact the office to discuss computer match information.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18NYCRR 351.22 (e); MA: 360-2.2;
SNAP: 18NYCRR 387.8 (c), 387.14 (a)

M44 SNCA/SNNC Failure to Get A Medical Statement !HH=1l

Public assistance has been discontinued because the recipient has failed
to provide a medical statement from a medical professional.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.21 (f); MA: 360-2.2; SNAP: 18 NYCRR 387.17

M88 ALL Failure to Comply with Automated Finger Imaging Requirements. Not
Homebound or Group Home Resident
Public assistance has been discontinued because the client failed to
comply with finger imaging requirements.
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18 NYCRR 351.2 351.9; MA: 360-2.2; SNAP: 18 NYCRR 387.17

N12 ALL Failure to Apply for or Use Benefits or Resources

Public assistance has been discontinued because the client failed to apply
for or use available benefits or resources.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.2; MA: 360-2.2; SNAP: 18 NYCRR 387.17

N14 ALL Household Member Failed to Apply

Public assistance has been discontinued because a member(s) of the
household failed to apply for public assistance.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.30; MA: 360-2.6; SNAP: 18 NYCRR 387.17

N16 ALL Failure to Contact Agency

Public assistance has been discontinued because the client failed to
contact the agency regarding eligibility for assistance.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.22 (a); MA: 360-3.3; SNAP: 387.8

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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02/14/2015

CASE REASON CODES !CONT'D)

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D)
CLOSING CODES - PA IPA: REAS - 222! !cont'd!

CODE CATEGORY
N17 ALL Failure to Complete Eligibilitv Process
Public assistance has been discontinued because the client failed to keep
an eligibility-related appointment.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.2,351.8 (a) (2), 351.21 (a); MA: 360-3.3;
SNAP: 18 NYCRR 387.8

N20 ALL Failure to Notify of Minor's Temporarv Absence IHH=1l

Public assistance has been discontinued because NAME, a minor was .
absent from your home for more than 45 days and DSS was not notified
within the first 5 days.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 349.4; MA: 360-2.6; SNAP: 387.17

N44 ALL Failure to Get Medical Statement IHH=1l

Public assistance has been discontinued because the client failed to get a
medical statement.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYC RR 351.21 (f)

N88 FA/SNFP Failure to Comply with the Automated Finger Imaging System IAFISl
Requirements. Homebound or Group Home Resident IHH=11
Public assistance has been discontinued because the client failed to
comply with finger imaging requirements.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.2, 351.9; MA: 360-2.2; SNAP: 18 NYCRR 387.17

P44 SNCA/SNNC Failure to Comply with Drug and /or Alcohol Screening IHH=11
Public assistance has been discontinued because you did not take part in
or complete the alcohol/substance abuse screening requirement.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.2 (i); MA: 360-2.6; SNAP: 18 NYCRR 387.17

P45 SNCA/SNNC Failure to Comply with Drug and/or Alcohol Assessment IHH=11
Public assistance has been discontinued because you did not take part in
or complete the alcohol/substance abuse screening requirement.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.2 (i); MA: SSL 366(1) (a) (1);
SNAP: 18NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits ifthere is a child under 18, or a person under 22
living with a parent.

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CASE REASON CODES !CONT'D\

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd\

CODE CATEGORY
P46 SNCA/SNNC Failure to Sign or Revoked the Treatment Informational Consent
Form IHH=11
Public assistance has been discontinued because you did not sign or you
revoked the consent for the release of treatment information to this
department.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.2 (i); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.17

PX1 ALL Failure to Take Part in Rehabilitation Program - First OffenselHH=11

Public assistance has been discontinued because the client did not take
Code PX2-0utput code for part in and complete a rehabilitation program. The client cannot get public
a 120-day sanction assistance for 45 days.
Code PX3-0utput code for MA Separate Determination, SNAP Separate Determination (See Note).
a 180-day sanction PA: 18 NYCRR 351.2 (i); MA: 360-2.2 (d) 370.2; SNAP: 18 NYCRR 387.17

W11 ALL Failure to Keep Appointment for Medical Assessment

Public assistance has been discontinued because the client failed to keep
•an examination appointment with a doctor we referred you to.
MA Separate Determination, SNAP Separate Determination.
351.2, 351.8(a)(2)

VE1 ALL Intentional Misrepresentation of a Disability IHH=11 90 Dav Sanction

Public assistance has been discontinued because the client without good
Code VE2-0utput code for reason intentionally misrepresented he/she suffered from an impairment
a 150-day sanction that would limit his/her assignment to work activities or make him/her
Code VE3-0utput code for exempt from assignment to work activities.
a 180-day sanction MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 385.12; MA: 18NYCRR 360-2.6; SNAP: 387.17

W40 ALL Failure/Refusal to Become Employable IHH=11

Public assistance has been discontinued because an exempt but
potentially employable individual refused or failed to accept referral to or
participate in reasonable medical care, rehabilitation or treatment without
good cause. Individual is ineligible for public :;issistance until compliance
with such medical care, rehabilitation or treatment or the district
determines that such medical care or treatment is no longer required.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 385.12(a); MA: 18 NYCRR 360-2.6;
SNAP 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits ifthere is a child under 18, or a person under 22
living with a parent.

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CASE REASON CODES !CONT'D!

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D)
CLOSING CODES - PA !PA: REAS - 222) !cont'd!

CODE CATEGORY
WC1 SNCA Failure to Comply with Employment Requirements Determined by the
Refugee Service Agency !HH=1l 90 day Sanction !Manual Notice
Required!
Code WC2-0utput code Public assistance has been discontinued because the client failed to report
for a 180-day sanction to a job interview, accept employment, or voluntarily quit a job they were
referred to by the Refugee Service Agency.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 373.6 (h); MA: 360-1.2, 360-2.1, 360-2.2
SNAP: 12 NYCRR 1300.3 (c), 1300.12 (e), 1300.13

WX1 FA/SNFP/ Failure to Comply with Employment Requirements IHH=1l

SN CA/SN NC Public assistance has been discontinued because the client failed to keep
an appointment to complete an employment requirement. Until
compliance.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 385.9, 385.12; MA: 360-1.2, 360-2.1, 360-2.2;
SNAP: 18 NYCRR 387.13

WX4 FA/SNFP/ Failure to Comply with Employment Requirements IHH=1 l

SNCA/SNNC Public assistance has been discontinued because the client failed to keep
an appointment to complete an employment requirement. Until
compliance.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 385.9, 385.12; MA: 360-1.2, 360-2.1, 360-2.2;
SNAP: 18 NYCRR 387.13

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RESERVED FOR EXPANSION

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CASE REASON CODES ICONT'Dl

MOVED OR WHEREABOUTS UNKNOWN
CLOSING CODES - PA IPA: REAS - 222\ lcont'dl

CODE CATEGORY
E60 ALL Unable to Locate
Public assistance has been discontinued because the client's
whereabouts are unknown.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22; MA: 360-2.2; SNAP: 18 NYCRR 387.9 (a)

E66 ALL Not a Resident of the State

Public assistance has been discontinued because the client moved out of
state.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.2 (g); MA: 360-3.5, SNAP: 18 NYCRR 387.9 (a)

G61* ALL Not a Resident of the District*

Public assistance has been discontinued because the client does not live
in the district (New York City). This case may have been opened in error,
or the client moved more than two months before and did not report the
move.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 311.3; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G62 ALL Moved out of District

Public assistance has been discontinued because the client has moved
from New York City and did not request continuation of public assistance.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 311.3; MA: 351.2 (g) (1); SNAP: 18 NYCRR 387.9 (a)

* This code may also be used when the effective closing date of the timely notice falls into the
second month after the move (ex. July move, September closing effective date). ·

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CASE REASON CODES !CONT'D)

LIVING ARRANGEMENTS
CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
M48 SNCA/SNNC Refused Parent's Offer of a Home
Public assistance has been discontinued because the under age 21 client
refused the offer of housing in the parent's home or the home of the legal
guardian.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 370.2; MA: 360-2.6; SNAP: 18 NYCRR 387.17

M49 ALL Refused Offer of a Home

Public assistance has been discontinued because you are unmarried, less
than 18 years old, pregnant or residing with and providing care for a minor
dependent child, and you refuse to reside in suitable housing provided by
a parent or guardian or in an approved adult supervised living
arrangement.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 369.2; MA: SSL 366 (1) (a) (1); SNAP: 18 NYCRR 387.17

M50 ALL Refused Offer of a Home - Rejection of Claim that Housing

Arrangement Isl Would Jeopardize Health and Safetv
Public assistance has been discontinued because you are unmarried, less
than 18 years old, pregnant or residing with and providing care for a minor
dependent child, and you refuse to reside in suitable housing provided by
a parent or guardian or in an approved adult supervised living
arrangement. We have investigated and rejected your claim that the
housing arrangement (s) would jeopardize your health and safety.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 369.2; MA: SSL 366 (1) (a) (1); SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits ifthere is a.child under 18, or a person under 22
living with a parent.

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CASE REASON CODES !CONT'D!

ADMISSION TO PRIVATE OR PUBLIC INSTITUTION
CLOSING CODES - PA !PA: REAS - 2221 !cont'd!

CODE CATEGORY
*E72 ALL Institutionalized !HH=1l
Public assistance has been discontinued because the client has been
institutionalized.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 352.31(a) 370.2; MA: 360-2.2;
SNAP: 18 NYCRR 387.1, 387.14 (a) (5)

E73 ALL In Foster Care

Public assistance has been discontinued because the children are in
Foster Care and there is no plan for them to return home.
MA No Separate Determination, SNAP Separate Determination.
PA: 18NYCRR 352.30 (a), 369.4 (c); MA: 360-2.6; SNAP: 18 NYCRR 387.17

F63 ALL In Prison !HH=1l

Public assistance has been discontinued because the client has been
committed to prison.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.31 (a), 370.2; MA: 360-2.2
SNAP: 18 NYCRR 387.1, 387.14 (a) (5)

F64 ALL In Prison Outside of NYS !HH=1l

Public assistance has been discontinued because the client has been
committed to prison outside New York State or to a Federal penitentiary
within New York State.
MA No Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 352.31(a), 370.2; MA: 360-2.2
SNAP: 18 NYCRR 387.1, 387.14 (a) (5)

939 ALL In Prison !HH=1l - SYSTEM GENERATED

Public assistance has been discontinued because the client has been
committed to prison.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.31 (a), 370.2; MA: 360-2.2
SNAP: 18 NYCRR 387.1, 387.14 (a) (5)

Note: Adequate Notice

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D)

CLIENT REQUEST
CLOSING CODES - PA IPA: REAS - 2221 (cont'd!
CODE CATEGORY
EM4 ALL Client Request - Eligibility Mail-Out - PA and MA !Adequate Notice!
Public assistance has been discontinued because the client asked for the
case to be closed on the returned Eligibility Mail Out form.
MA No Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22(f); MA: 360-2.6; SNAP: 18 NYCRR 387.17

EM5 ALL Client Request - Eligibility Mail-Out - PA only !Adequate Notice!

Public assistance has been discontinued because the client asked for the
case to be closed on the returned Eligibility Mail Out form.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22(f); MA: 360-2.6; SNAP: 18 NYCRR 387.17

EM? ALL Client Request - Eligibility Mail-Out - PA. SNAP & MA !Adequate
Notice!
Public assistance has been discontinued because the client asked for the
case to be closed on the returned Eligibility Mail Out form.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f); MA: 360-2.6; SNAP: 18 NYCRR 387.17

F98 ALL Client Request Childcare in Lieu of TA - PA Only - <Verbal!

Public assistance has been discontinued because the client requests
childcare in lieu of Temporary Assistance.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d)

G87 ALL Client Request - Eligibility Mail-Out - PA Only !Adequate Notice!

Public assistance has been discontinued because the client asked for the
case to be closed on the returned Eligibility Mail Out form.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

CLIENT REQUEST (CONT'D)
CLOSING CODES PA !PA: REAS· 222! !cont'd)

G88 ALL Client Request • PA. SNAP & MA - !Written! !Adequate Notice)
Public assistance has been discontinued because the client asked for the
case to be closed in writing.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

G89 ALL Client Request • PA & MA - !Written! !Adequate Notice)

Public assistance has been discontinued because the client wrote asking
for the PA and MA portions of the case to be closed.
MA No Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360,2.6; SNAP: 18 NYCRR 387.17

G90 ALL Client Request - PA & SNAP · !Written) !Adequate Notice)

Public assistance has been discontinued because the client wrote asking
that the PA and SNAP portions of the case be closed.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

G92 ALL Client Request • PA Only - !Written! !Adequate Notice)

Public assistance has been discontinued because the client wrote asking
the PA portion of the case be closed.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

G94 ALL Client Request - PA & SNAP - !Verbal!

Public assistance has been discontinued because the client asked that the
PA and SNAP portions of the case be closed.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18NYCRR 387.20

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

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CASE REASON CODES !CONT'D>

CLIENT REQUEST (CONT'D)
CLOSING CODES - PA !PA: REAS - 222! (cont'd!

CODE CATEGORY
G96 ALL Client Request - PA Only - !Verbal!
Public assistance has been discontinued because the client asked that the
PA portion of the case be closed.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.20

G97 ALL Client Request- PA Only - ITMA Eligible! !Verbal!

Public assistance has been discontinued because the client asked that the
PA portion of the case be closed.
This code is used only for clients who are employed and have a budget
deficit.
MA continued for 6 months, SNAP Separate Determination (See Note)
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-3.3 (c); SNAP: 18 NYCRR
387.17

G98 ALL Client Request - PA, SNAP & MA - !Verbal!

Public assistance has been discontinued because the client asked that the
case be closed.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

G99 ALL Client Request - PA & MA - !Verbal!

Public assistance has been discontinued because the client asked that the
PA and MA portions of the case be closed.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

244 ALL Client Request - Eligibility Mail-Out (SYSTEM GENERATED)

(Adequate Notice)
Public assistance has been discontinued because the client asked for the
case to be closed on the returned Eligibility Mail Out form.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.6; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

CHANGE IN RESOURCES CAUSING INELIGIBILITY
CLOSING CODES - PA !PA: REAS - 222! !cont'd!

CODE CATEGORY
146 ALL Excess Resources - 60+ Client No Longer In Household
Public assistance has been discontinued because the member of the
household who was age 60 or older is no longer in the household and the
resource limit has been lowered. There are now excess resources.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.23; MA: Citations to be provided later
SNAP: Citations to be provided later.

U40 ALL Excess Resources

Public assistance has been discontinued because the total resource
amount exceeds the resource limit.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.23; MA: 360-2.6; SNAP: 18 NYCRR 387.17

U41 SNCA/SNNC Transfer of Resources

Public assistance has been discontinued because the client transferred or
gave away resources that should be used to support the household
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 370.2; MA: 360-2.2; SNAP: 18 NYCRR 387.17

U42 ALL Excess Resources - Refused to Sell Property

Public assistance has been discontinued because the client refused to sell
real property whose value exceeds the resource limit.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.23; MA: 360-2.6; SNAP: 18 NYCRR 387.17

U43 ALL Excess Resources - End of Six Month Period

Public assistance has been discontinued because the client failed to sell
real property within the allowed six-month period.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 352.23 (b); MA: 360-2.6; SNAP: 18 NYCRR 387.17

U44 FA/SNFP Excess Resources - Deemed Resources of Alien Sponsor

Public assistance has been discontinued because the total amount of
resources of the alien sponsor exceeds the resource limit
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 349.3,352.33; MA: 360-2.6; SNAP: 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D\

FAILURE TO COMPLY WITH RECERTIFICATION PROCEDURES
CLOSING CODES - PA IPA: REAS - 2221 !cont'd\

CODE CATEGORY
G10 ALL Failure to Recertify on !DATE\
Public assistance has been discontinued because the client failed to
appear for face-to-face recertification interview.
MA See Note, SNAP No Separate Determination
PA: 352.22 (a), 351.22 (b); MA: 360-2.2 (e) (f)
SNAP: 387.8, 387.14, 387.15

G20 ALL Failure to Recertify - Home Visit

Public assistance has been discontinued because the client failed to keep
home recertification appointment I interview.
MA No Separate Determination; SNAP No Separate Determination
PA: 18NYCRR 351.22 (a) (b); MA: 360-2.6
SNAP: 18NYCRR 387.8, 387.14, 387.15

E91 ALL Refusal to Cooperate During Recertification Process

Public assistance has been discontinued because the client's behavior
prevented the agency from obtaining the necessary information for making
an eligibility determination.
MA Separate Determination, SNAP No Separate Determination.
PA: 18NYCRR 351.1 (b)(2); MA: 360-2.6
SNAP: 18NYCRR 351.1(b)(2)

G36 ALL Failure to Complete the TA 16 Month\ Mail in Recertification For

Cases on 12 Month Recertification Schedule
Public assistance has been discontinued because the client failed to return
recertification forms or recertification forms were incomplete.
MA Separate Determination, SNAP Separate Determination.'
PA: 18NYCRR 351.21; MA: 360-2.6: SNAP:CFR 273.12 (f) & 7 U.S.C. 2020 (s)

G37 ALL Failure to Complete the TA 16 Month\ Mail in Recertification For

Cases on 12 Month Recertification Schedule
Public assistance has been discontinued because the client failed to return
recertification forms or recertification forms were incomplete.
MA Separate Determination, SNAP No Separate Determination
PA: 18NYCRR 351.21; MA: 360-2.6; SNAP: 18 NYCRR 387.17 (d)

Note: MA Separate Determination unless date of closing is equal to or more than 12 months from date
last recertified.

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CASE REASON CODES ICONT'Dl

DUPLICATE ASSISTANCE
CLOSING CO~ES - PA IPA: REAS • 222! lcont'dl

CODE CATEGORY
M13 ALL Duplicate Assistance - Active Cash Assistance Case in Other State
IHH=1l
Public assistance has been discontinued because the client failed to
provide proof that that he/she requested his/her out-of-state case to be
closed.
MA No Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 351.1(b)(2)(ii), 351.2, 351.8(a)(2)(i), 351.9

M97 ALL Receiving Multiple Benefits IHH=1l

Public assistance has been discontinued because the client fraudulently
misrepresented his/her identify or residence to receive multiple public
assistance benefits at the same time. The client is ineligible to receive
public assistance and SNAP benefits for 10 years beginning DATE.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.2 (k) (2), 359.9 (d) (1); MA: 360-2.2
SNAP: 351.2, 351.9

*M98 ALL Duplicate Assistance - Non AFIS. In NYS

Public assistance has been discontinued because the client's identity
matches another person who is receiving public assistance in New York
State.
MA No Separate Determination, SNAP No Separate Dete.rmination.
PA:" 351.8 (a) (2) (i) 351.1 (b) (2) (ii), 351.2, 351.9; MA: 360-2.2 (e), (f);
SNAP: 351.2 (a) 351.9

*M99 ALL Duplicate Assistance - AFIS. In NYS

Public assistance has been discontinued because the client's identify
matches another person who is receiving public assistance in New York
State.
MA No Separate Determination, SNAP No Separate Determination.
This code is used when there has been an Automated Finger Imaging
Automated Match (AFIS).
PA: 351.9; MA: 360-2.2 (e) (f); SNAP: 351.2 (a), 351.9

* Adequate.

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CASE REASON CODES !CONT'D!

DUPLICATE ASSISTANCE (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 lcont'dl

CODE CATEGORY
N66 ALL Duplicate Assistance. PARIS Match Interstate
Public assistance has been discontinued because the client's identity
matches another person who is receiving public assistance in another
state. (Must be used with originating ID CFI only.)
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.9
MA: 360-2.2 (e) (f); SNAP: 18 NYCRR 351.2 (a), 351.9

N67 ALL Duplicate Assistance, PARIS Match ISvstem Generated)

Public assistance has been discontinued because the client's identity
matches another person who is receiving public assistance in another
state. (Must be used with originating ID CFI only.)
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.9
MA: 360-2.2 (e) (f); SNAP: 18 NYCRR 351.2 (a), 351.9

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

INVESTIGATORY - ELIGIBILITY VERIFICATION REVIEW
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
E18 ALL Failed to Keep BEV Office Appointment
Public Assistance has been discontinued because the client failed to keep
an office appointment with Bureau of Eligibility Verification Investigator.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.4; MA: 360-2.2; SNAP: 18 NYCRR 387.17

E19 ALL Failed to Keep BFI Appointment

Public assistance has been discontinued because the client failed to keep
an office appointment with Bureau of Fraud Investigator.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.4; MA: 360-2.2; SNAP: 18 NYCRR 387.17

F62 ALL Moved Out of District- BEV Only

Public assistance has been discontinued because the client has moved
from New York City and did not request continuation of public assistance.
MA Separate Determination SNAP No Separate Determination.
PA: 18 NYCRR 311.3; MA: 351.2 (g) (1); SNAP: 18 NYCRR 387.9 (a)

G01 ALL Failure to Provide Verification - !SYSTEM GENERATED!

(0 =zero) Public assistance has been discontinued because the client failed to
provide verification of mortgage, lease, rent receipts, or utility bill to
determine whether the case is eligible for public assistance.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.1 and 351.2; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G16 ALL Failed to Respond to Two or More BEV Notices Left at Residence
Public assistance has been discontinued because the client failed to
contact the agency regarding eligibility for assistance.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.22 (a); MA: 360-3.3; SNAP: 18 NYCRR 387.8

G17 ALL Several Attempts at Home Visit

Public assistance has been discontinued because the client failed to be
home after four attempts were madei to visit the client at home. The fourth
visit was scheduled at a day and time that was agreed upon. The client
was not available at the pre-arranged time.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.28; MA: 360-2.6; 18 NYCRR 387.17; SNAP: 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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02/14/2015

CASE REASON CODES !CONT'D!

INVESTIGATORY - ELIGIBILITY VERIFICATION REVIEW (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
G21 ALL Failure to Cooperate with BEV - Income
Public assistance has been discontinued because the client refused to
answer questions regarding income.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G22 ALL Failure to Cooperate with BEV - Assets

Public assistance has been discontinued because the client refused to
answer questions regarding your assets.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G23 ALL Failure to Cooperate with BEV - Residence

Public assistance has been discontinued because the client refused to
answer questions regarding your residence.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G24 ALL Failure to Cooperate with BEV - Legally Responsible Spouse

Public assistance has been discontinued because the client refused to
answer questions regarding your legally responsible spouse.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G25 ALL Failure to Cooperated with BEV - Dependent Child

Public assistance has been discontinued because the client refused to
answer questions regarding your dependent child.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G26 ALL Failure to Cooperate - Refused to Answer Questions

Public assistance has been discontinued because the client failed to
answer questions regarding eligibility for Safety Net A1?sistance.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G27 ALL Failure to Cooperate - Documentation of Identity

Public assistance has been discontinued because the client failed to
answer questions regarding documentation of your identity.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

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CASE REASON CODES !CONT'D!

INVESTIGATORY - ELIGIBILITY VERIFICATION REVIEW (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
G28 ALL Failure to Cooperate - Proof of Identity
Public assistance has been discontinued because the client failed to
answer questions regarding proof as to your identity which is inconsistent
with what we have.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G29 ALL Failure to Cooperate - Property

Public assistance has been discontinued because the client failed to
answer questions regarding your property.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

G60 ALL Unable to Locate - BEV Only

Public assistance has been discontinued because Bureau of Eligibility
Verification has been unable to find you.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.22; MA: 360-2.2; SNAP: 18 NYCRR 387.9 (a)

G81 ALL Non-Cooperative Caretaker - Only Child/All Children Without Valid

SSN or Application for SSN
Public assistance has been discontinued because the client failed to
provide a valid Social Security Number or valid application for a Social
Security Number for each child in the public assistance case.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 369.2, 370.2; MA: 360-2.6; SNAP: 18 NYCRR 387.20 (a)

G95 ALL Died - BEV Only IHH=1l !Adequate)

Public assistance has been discontinued because Bureau of Eligibility
Verification has determined that the individual is deceased.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.8; MA: 360-2.2; SNAP: 18 NYCRR 387.1

H19 ALL Failure to Provide Proof of U.S Citizenship and Identity - SSA/BVI
Match IHH=1 l
Public assistance has been discontinued because, after failing the SSA/
BVI match, the client failed to provide proof of identity and U.S. citizenship
or satisfactory immigration status.
MA No Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.1(b)(2)(ii), 351.2, 351.5, 351.6, 351.8(a)(2)(ii);
MA: 360-1.2, 360-2.3, 360-3.2(j), 369-ee

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits ifthere is a child under 18, or a person under 22
living with a parent.

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CASE REASON CODES ICONT'Dl

INVESTIGATORY - ELIGIBILITY VERIFICATION REVIEW (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODE CATEGORY
M81 ALL Failed to Provide Verification - !SYSTEM GENERATED!
Public assistance has been discontinued because the client failed to
provide birth certificate, baptismal certificate, or adoption papers, or failed
to provide verification of driver's license, non-drivers photo ID, or military
ID.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.1(b), 351.2(a); MA: 360-2.6; SNAP: 18 NYCRR 387.20 (a)

M82 ALL Failed to Provide Verification - !SYSTEM GENERATED!

Public assistance has been discontinued because the client failed to
provide school attendance records.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.2, 351.6, 369.4; MA: 360-2.6; SNAP: 18 NYCRR 387.20 (a)

N15 ALL Failure to Keep Appointment with BEV/FEDS Home Visit

Public assistance has been discontinued because the client failed to keep
the appointment at the client's home with the agency investigator.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.4; MA: 360-2.2; SNAP: 18 NYCRR 387.17

N?O ALL Failure to Provide Verification - !SYSTEM GENERATED!

Public assistance has been discontinued because the client failed to
provide a deed, savings statement or bank book.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 351.2, 352.23; MA: 360-2.6; SNAP: 18 NYCRR 387.20 (a)

N71 ALL Failed to Provide Verification - !SYSTEM GENERATED!

Public assistance has been discontinued because the client failed to
provide Naturalization papers or passport.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 349.3(b), 351.1(b); MA: 360-2.6; SNAP: 18 NYCRR 387.20 (a)

N72 ALL Failed to Provide Verification - !SYSTEM GENERATED\

Public assistance has been discontinued because the client failed to
provide a social security card.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 369.2 and 370.2; MA: 360-2.6; SNAP: 18 NYCRR 387.20 (a)

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

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CASE REASON CODES !CONT'D!

INVESTIGATORY - ELIGIBiLITY VERIFICATION REVIEW (CONT'D)
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
R10 ALL Failed to Keep FEDS Office Appointment with Agencv Investigator
Public assistance has been discontinued because the client failed to keep
an office appointmnt with the agency investigator.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.4; MA: 360-2.2; SNAP: 18 NYCRR 387.17

R11 ALL Failed to Keep FEDS Office Appointment with Inspector General
Public assistance has been discontinued because the client failed to keep
an office appointment with the Inspector General.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.4; MA: 360-2.2; SNAP: 18 NYCRR 387.17

V50 ALL Failure to Verify - BEV

Public assistance has been discontinued because the client failed to
provide BEV with information to determine whether the case is eligible for
public assistance.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 351.6; MA: 360-2.2; SNAP: 18 NYCRR 387.17

Y78 ALL Ineligible Based Upon BEV Evaluation - Manual Notice Required
Based on the reasons for rejection in the Bureau of Eligibility Verification
report select the appropriate closing language and citations from the WGC
manual, which match the closing reason.
MA Separate Determination. SNAP Separate Determination is required
unless the reason for not being eligible also renders the client ineligible for
. SNAP.

Y86 ALL Other Reason !BEV! - Manual Notice Required

To be used only for BEV closings.
Should only be used when reason for closing PA requires a SNAP Separate
Determination
MA Separate Determination, SNAP Separate Determination .
PA: 18 NYCRR351.5, 351.6, 351.21; MA: 360-2;
.SNAP: 18 NYCRR 387.9

Y87 ALL Other Reason !BEV! - Manual Notice Required

To be used only for BEV closings.
MA Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR351.5, 351.6, 351.21; MA: 360-2;
SNAP: 18 NYCRR 387.9

Note: If FA/SNFP case is eligible for 5 months of Transitional SNAP Benefits. If SNCA/SNNC case is
eligible for 5 months of Transitional SNAP Benefits if there is a child under 18, or a person under 22
living with a parent.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

INTENTIONAL PROGRAM VIOLATIONS
(IPV) ORIGINATING ID - !EPEi ONLY
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
WS1 ALL 6 Months 1st Offense - Less Than $1.000 IHH=1l
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was less than $1,000 you are
disqualified from receiving public assistance for 6 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again, reapply with no less than 30
days remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

WS2 ALL 12 Months 2nd Offense-Less Than $3,900 IHH=1l

You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 2nd occurrence and/or
the amount you wrongly received was less than $3,900 you are
disqualified from receiving public assistance for 12 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again, reapply with no less than 30
days remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

INTENTIONAL PROGRAM VIOLATIONS (IPV) - ORIGINATING ID - !EPFl ONLY
CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODE CATEGORY
WS3 ALL 12 Months 1st Offense Amt. Between $1.000 & $3.900 IHH=1l
You have .been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or· signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was $ you are disqualified from
receiving public assistance for 12 months. You may reapply for public
assistance 90 days before the expiration date, though to prevent a delay in
getting assistance again, reapply with no less than 30 days remaining
before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

WS4 ALL 18 Months if 3rd Offense !HH=1l

You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 3rd occurrence and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again, reapply with no less than 30
days remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D)

INTENTIONAL PROGRAM VIOLATIONS (IPV) - ORIGINATING ID- !EPFl ONLY
CLOSING CODES - PA (PA: REAS - 2221 !cont'd!

CODE CATEGORY
wss ALL 18 Months if 1st0ffense More Than $3.900 !HH=1l
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was more than . $3,900 you are
disqualified from receiving public assistance for 18 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again, reapply with no Jess than 30
days remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 {a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

WS6 ALL 18 Months if 2nd Offense More Than $3,900 !HH=1 I

You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 2nd occurrence ,and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again, reapply with no less than 30
days remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (aj, 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

INTENTIONAL PROGRAM VIOLATIONS (IPV) - ORIGINATING ID - !EPFl ONLY
CLOSING CODES - PA !PA: REAS - 222! lcont'dl

CODE CATEGORY
WS7 ALL 5 Years 4th or Subsequent Offense !HH=1l
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 4th or subsequent
occurrence and/or the amount you wrongly received was $ you are
disqualified from receiving public assistance for 5 years. You may reapply
for public assistance 90 days before the expiration date, though to prevent
a delay in getting assistance again, reapply with no less than 30 days
remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11(a),387.15

wsa ALL Court Ordered Disqualification !HH=1 l

Court ordered disqu-.lification is based on the finding of the.Court
that the client has been found guilty of committing an IPV. The period
is determined by the court and may differ from those above.
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the _ _ occurrence
and/or tile amount you wrongly received was $ you are disqualified
from receiving public assistance for months. You may reapply for
public assistance 90 days before the expiration date, though to prevent a
delay in getting assistance again, reapply with no less than 30 days
remaining before your disqualification period ends.
MA Separate Determination, SNAP Separate Determination.
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1);
SNAP: 18 NYCRR 387.10 (b) (5), 387.11 (a), 387.15

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D\

MISCELLANEOUS
CLOSING CODES - PA IPA: REAS - 2221 !cont'd\

CODE CATEGORY
E95 ALL Died IHH=11 !Adequate Notice\
Public assistance has been discontinued because the only person
receiving public assistance in the household has died.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.8; MA: 360-2.2

F11 ALL Failure to Access Benefits (SYSTEM GENERATED)

Public assistance has been discontinued because at least two full months
of benefits have not been used.
MA Separate Determination; SNAP Separate Determination (See Note).
PA: 351.22; MA: 360-2.6; SNAP: 18 NYCRR 387.17

F92 ALL Ineligible Alien IHH=11 !Timely\

Close the case because the client is not an eligible alien.
MA Separate Determination, SNAP No Separate Determination.
18 NYCRR 387.1, 387.8 (b), 387.9 (a) (2) and 387.14 (a)

G39 ALL Died IHH=1l !Timely\ !SYSTEM GENERATED\

Public assistance has been discontinued because the only person
receiving public assistance in the household has been reported as dead by
SSA or another tape match.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 351.8; MA: 360-2.2

G55 ALL In OASAS Chemical Dependence Residential Rehabilitation Services

for Youth Program
Public assistance has been discontinued because the institution in which
the client resides has been converted to an OASAS-certified Chemical
Dependence Residential Rehabilitation Service for Youth program.
MA Separate Determination, SNAP No Separate Determination.
18 NYCRR 352.29, 352.31(a); 14 NYCRR Part 817

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES ICONT'Dl

MISCELLANEOUS (CONT'D)
CLOSING CODES - PA IPA: REAS - 222\ !cont'd\

CODE CATEGORY
M68 ALL Added to Another Case
Public assistance has been discontinued because the client was added to
another public assistance case.
MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 352.1; MA: 360-2.6; SNAP: 18 NYCRR 387.1

W35 ALL Fleeing Felon

Client is currently a fleeing felon.
MA Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 351.2(k)(3)(i)

W44 ALL Probation Violator

Client is currently in violation of probation.
MA Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 351.2(k)(3)(ii)

W45 ALL Parole Violator

Client is currently in violation of parole.
MA Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 351.2(k)(3)(ii)

Y14 ALL Doe Retro Payment Only !Adequate\

The client's application for a Doe retro payment was approved, but the
client does not want ongoing public assistance.
MA No Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 351.8

Y52 ALL Walker Retro Payment Only !Adequate)

Case was opened for Walker retro payment only.
MA No Separate Determination, SNAP No Separate Determination
PA: 18 NYCRR 351.8

Y93 ALL Case Number Change - No Notice Required

MA No Separate Determination, SNAP No Separate Determination.
PA: 18 NYCRR 355.5; MA; 360-2.2; SNAP; 18 NYCRR 387.1

Y95 ALL Case Closed After Being Accepted for Emergency Assistance -
Manual Notice Required !Adequate\
Public assistance is being discontinued because the household is no
longer in need of cash assistance.
There was no application for MA benefits; SNAP Separate Determination.
PA: 18 NYCRR 351.8; MA: Not Applicable; SNAP: 18 NYCRR 387.17

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

MISCELLANEOUS (CONT'D)
CLOSING CODES - PA IPA: REAS - 222! !cont'd)

CODE CATEGORY
Y96 ALL Case Closed After Being Accepted for Emergency Assistance
Manual Notice Required
Public assistance is being discontinued because the household is no
longer in need of cash assistance.
There was no application for MA benefits; SNAP No Separate Determination.
PA: 18 NYCRR 351.8; MA: Not Applicable; SNAP: 18 NYCRR 387.5

Y98 ALL Other - Manual Notice Required

This code is to be used if none of the other reasons for closing a case are
applicable.
MA Separate Determination, SNAP Separate Determination.
PA: Unknown; MA: Unknown; SNAP: Unknown
ygg ALL Other - Manual Notice Required
This code is to be used if none of the other reasons for closing a case are
applicable.
MA Separate Determination, SNAP Separate Determination.
PA: Unknown; MA: 360-2.2; SNAP: 18 NYCRR 387.17

401 FA/SNCA Administrative Closing on Transitional Benefits Cases

There was no application for MA benefits; SNAP No Separate Determination.
Citations not required.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

60 MONTH TIME LIMIT
CLOSING CODES - PA IPA: REAS - 222! !cont'd!

CODE CATEGORY
G30 FA/SNFP Close FA Due to 60 Month Limit- No Safety Net Application Filed
Family Assistance is ending because household includes member who will
have reached 60-month limit. Client did not apply for Safety Net.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: Soc. Serv. Law 158 & 18NYCRR 350.4; MA: 18 NYCRR 360-2.6
SNAP: 18NYCRR 387.17

G31 FA/SNFP Close FA Due to 60 Month Limit - Deny SNA Reason Other than Job
Search !Separate Notice Required!
Family Assistance is ending because household includes member who will
have reached 60~month limit. Safety Net Assistance application denied for
pther than Job Search.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: Soc. Serv. Law 158 & 18NYCRR 350.4; MA 18NYCRR 360-2.6
SNAP: 18NYCRR 387.17

G32 FA/SNFP Close FA Due to 60 Month Limit - Deny SNA - Refusal to Sign
Repayment
Household is ineligible for Public Assistance in Safety Net Assistance
category. Client refused to sign repayment agreement or assignment of
future earning or both.
MA Separate Determination, SNAP Separate Determination (See Note).
PA: 18 NYCRR 369.4 (d) & 370.2 (c) (11), MA: 18NYCRR 360-2.6
SNAP: 18NYCRR 387.17

G33 FA/SNFP Close FA Due to 60 Month Limit - Deny SNA - Refusal to Apply for
Child
Household is ineligible for Public Assistance in Safety Net Assistance
category. Client did not apply for child (ren).
MA Separate Determination, SNAP Separate Determination (See Note)
PA: 18NYCRR 369.4 (d) & 370.2 (c) (6); MA: 18NYCRR 360-2.6
SNAP: 18NYCRR 387.17

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CASE REASON CODES !CONT'D\

60 MONTH TIME LIMIT (CONT'D)
CLOSING CODES - PA !PA: REAS - 222\ !cont'd\

CODE CATEGORY
P30 FA/SNFP Close FA Due to 60 Month Limit - Deny SNA - Failure to Comply with
Job Search
Family Assistance is ending because household includes member who will
have reached 60-month limit. Client failed to participate in work activity.
MA Separate Determination, SNAP Separate Determination
. PA: 12NYCRR 1300.9 (e), 18NYCRR 350.4 & 369.4 (d); MA: 366 (4) (q)
SNAP: 18NYCRR 387.17

P31 FA/SNFP Close FA Due to 60 Month Limit - Deny SNA • Failure to Comply with
Employment Assessment
Family Assistance is ending because household includes member who will
have reached 60-month limit. Client did not keep appointment to complete
employment assessment.
MA Separate Determination, SNAP Separate Determination
PA: 12NYCRR 1300.6 (a), 18NYCRR 350.4 & 369.4 (d); MA: 360-2.6
SNAP: 18NYCRR 387.17

P32 FA/SNFP Close FA Due to 60 Month Limit - Deny SNA - Refusal to Take a Job
Family Assistance is ending because client refused to accept a job.
MA Separate Determination, SNAP Separate Determination
PA: 18 NYCRR 351.2; MA: 18 NYCRR 360-2.6
SNAP: 18NYCRR 387.17

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CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231! Only

CODE EDIT VALUE

811 Transitional SNAP - Increase in SNAP - !System Generated!

812 Transitional SNAP - Same SNAP Amount - !System Generated!

813 Transitional SNAP - Separate Determination at Higher Amount-

!System Generated!

814 Transitional SNAP - Separate Determination Same Amount- !System

Generated!

815 SNAP - Separate Determination Non-TBA - !System Generated!

826 SNAP Extend on PA Case - Non TBA - !System Generated)

E28 Failure/Refusal to Provide Information - Alien Sponsor !Timely!

Close case for failure to provide verification of alien sponsor Information.
18 NYCRR387.8(c), 387.9 (a) (7), 387.9 (b), 387.10, 387.14 (a)

E29 R Failure/Refusal to Provide Verification at Recertification Alien

Sponsor
(Adequate)
Close case at recertification for failure to provide alien sponsor
information.
18 NYCRR 387.8 (c), 387.9 (a) (7), 387.9 (b), 387.10, 387.14 (a)

E30 Excess Income !Timely!

Close case when income exceeds the appropriate (gross and/or net)
income eligibility limit.
18 NYCRR 387.10

E39 Excess Income - COLA !Timely!

Close case when income exceeds either the gross and/or the net income
test (s) due to changes in the cost of living adjustment (COLA) for Social
Security or SSI.
18 NYCRR 387.10, 387.12, 387.15

E40 Excess Income-Budgeting Error !Timely!

Close case that has excess income but opened due to an error in
calculating the budget.
18 NYCRR 387.10

Edits
B- Can be used at recertification or during the certification period.
R- To be used at recertification only.

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CASE REASON CODES !CONT'D)

CLOSING CODES - SNAP IFS: REAS - 2311 lcont'dl

CODE VALUE
E50 Failed to Return 6 Month Periodic Report !Timely!
Close case because the periodic report has not been returned.
18 NYCRR 387.17

E51 Failed to Return 6 Month Periodic Report - Questions !Timely!

Close case because all questions on the periodic report were not
answered.
18 NYCRR 387.17

E52 Failure to Complete 6 Month Periodic Report - Signature !Timely!

Close case because the periodic report was not signed.
18 NYCRR 387.17

E54 Failure to Complete 6 Month Periodic Report - Dated Early !Timely!

Close case because the periodic report was signed and dated before the
last day of the report period.
18 NYCRR 387.17

E61 Not a Resident of New York City !Adequate)

Close case when the household no longer resides in New York City.
18 NYCRR 387.9 (a)

E63 Not a Resident of State !Adequate)

Close case when the household no longer resides in New York State.
18 NYCRR 387.9 (a)

E70 Ineligible Boarder !Timely\

Close case because the person (s) is an ineligible boarder.
18 NYCRR 387.1, 3117.14 (a), 387.16 (b)

E71 In commercial Boarding Home !Timely!

Close case because the person (s) resides in a commercial boarding
home.
18 NYCRR 387.1

E72 Institutionalized !Adequate!

Close case because the person (s) resides in an institution whose
residents are not eligible to receive SNAP.
18 NYCRR 387.1, 387.14 (a) (5)

E76 R Living with Child IRecert Closing! !Adequate!

Close case at recertification, where a parent (s) is living with his/her
child(ren) and the parent(s) is not eligible or disabled. The parent(s)
cannot have separate household status.
18 NYCRR 387.1

Edits
B- Can be used at recertification or during the certification period.
R- To be used at recertification only.

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CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231! !cont'd!

CODE EDIT VALUE

E77 ~ Living With Parent !Recert Closing! !Adequate!
Close case at recertification, where a child (ren) is living with his/her
parent (s) and the parent (s) is not elderly or disabled. The child (ren)
cannot have separate household status.
18 NYCRR 387.1

E78 R Living with Child's Other Parent !Recert Closing! !Adequate!

Close case at recertification when a parent joins a household that consists
of his/her child and the child's other parent.
18 NYCRR 387.1

E86 Unable to Prove Identity to an lnvestiqatorv Agency IHH=1l

To be used only by originating center BFI
Close a one-person case because the documents that the person
presented to establish his/her identity are false.
18 NYCRR 387.8(b)(1)(i)

E95 Died !Adequate!

Close a one-person case due to death.
18 NYCRR387.1

F15 R Failure to Verifv Date of Birth IHH=1 l !Adequate!

Close one-person case when the person fails to verify Date of Birth.
18 NYCRR 387.1, 387.8 (c), 387.9 (a)

F17 Failure to Validate Incorrect Social Security Number IHH=1 l !Timely!

Close a one person case when that person fails to validate a Social
Security Number that the match with SSA records indicates is invalid.
18 NYCRR 387.1, 387.8 ( c), 387.9 (a), 387.10 (b), 387.16 (c)

F19 Refusal to Cooperate with Quality Control !Timely!

Close case for refusal to cooperate with a quality control review.
18 NYC RR 387 .9 (a) (7) (ii)

F21 R Failure to Provide Social Security Number !Recert Closing! !HH=1l

!Adequate!
Close case at recertificaiton for failure to apply for or provide a Social
Security number.
18 NYCRR 387.9 (a), 387.10 (b), 387.16 (c)

F22 R Failure to Verify Social Security Number !Recert Closing! !HH=1l

!Adequate!
Close a one-person case when the person fails to verify their. Social
Security number.
18 NYCRR 387.1, 387.8 (c), 387.9 (a)

Edits
8- Can be used at recertification or during the certification period.
R- To be used at recertification only.

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CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231! !cont'd!

CODE VALUE
F30 Trafficking in SNAP Benefits of $500 or more IHH=1 l !Timely!
Close case permanently because the client has been convicted of
trafficking in SNAP in the amount of $500 or more.
18 NYCRR 359.9 (c)

F65 B Will Receive SNAP in a PA Case !Adequate!

Close case because all members are receiving SNAP in a PA case.
18 NYCRR 387.1

F70 R Parental Control of Child !Adequate!

Close case when an adult household member is living with and his
parental control over a child (not his/her own) under 18. The adult
household member does not want the child included in the application.
However, in this situation the child and adult must be included in the same
SNAP household even if they do not usually purchase and prepare meals
together.
18 NYCRR 387.1

F71 R Child Under Parental Control !Adequate!

Close case when child under 18 is living with an adult who has parental
control and is not his/her parent. The child does not want the adult
included in the application. However, in this situation the child and adult
must be included in the same SNAP household even if they do not usually
purchase and prepare meals together.
18 NYCRR 387.1

F85 Refusal to Verify Alien Status !Timely!

Close the case because client (s) refused to verify alien status.
18 NYCRR 387.1, 387.8 (b), 387.9 (a) (2) and 387.14 (a)

F86 R Refusal to Verify Alien Status !Recert Closing! !Adequate)

Close the case because the client (s) refused to verify alien status at
recertification.
18 NYCRR 387.1, 387.8 (b), 387.9 (a) (2) and 387.14 (a)

F90 Ineligible Student IHH=1l !Timelyl

Close one-person case because the student does not meet the SNAP
eligibility requirements.
18 NYCRR 387.1, 387.9 (a)

F92 Ineligible Alien !Timely!

Close the case because the client (s) is (are) not an eligible alien (s).
18 NYCRR 387.1, 387.8 (b), 387.9 (a) (2) and 387.14 (a)

Edits
B- Can be used at recertification or during the certification period.
R- To be used at recertification only.

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CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231! !cont'd)

CODE VALUE
F94 Able Bodied Adult without Dependents !ABAWDl !HH=1 I !Timely!
Close a one-person case because client is an able bodied adult who has
not met the ABAWD requirements for three or more months in the past 36
month period.
18 NYCRR 385.3

F96 Opened in Error-Excess Income ITimelyl

Close case that was opened in error, because of excess income.
18 NYCRR 387.10

IP1 Out-of-State IPV

Close case because client has been found guilty of committing an
Intentional Program Violation in another state.
Department Regulation 359.9

G39 ALL Died !HH=1l ITimelyl !SYSTEM GENERATED!

Close one-person case because client has been reported as dead by SSA
or another tape match.
18 NYCRR 351.8

G53 Failure to Return 6 Month Periodic Report - Proof ITimelyl

Close case because the client failed to return the proof requested in the
periodic report.
18 NYCRR 387.17

146 B Excess Resources - Elderly Person Isl not In Home ITimelvl

Close case because there is no longer an elderly person (s) in the case
and the case is now subject to a lower resource limit
18 NYCRR 387.1, 387.10 (a), 387.15

J05 Automatic SNAP Separate Determination - SNAP Default Code !At

Recertl !System Generated!

M13 Duplicate Assistance -Active Cash Assistance in Other State !HH=1l

Close one-person case because the client failed to provide proof that he/
she requested his/her out-of-state case to be closed.
18 NYCRR 387.9(a)(1), SSL 273.3(a)

Edits
8- Can be used at recertification or during the certification period
R- To be used at recertification only.

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CASE REASON CODES !CONT'D\

CLOSING CODES - SNAP IFS: REAS - 231! !cont'd!

CODE VALUE
M20 Failure to Provide Information During Certification Period !Timely!
Close case for refusal to cooperate/failure to provide requested
information within the certification period.
18 NYCRR 387.8 (c), 387.9 (a) (7), 387.14 (a)

M24 Failure to Resolve a Computer Match !Adequate!

Close case for failure to resolve information received in a computer match.
18 NYCRR 387.8 (c), 387.14 (a)

M25 Failure to respond to a Computer Match Call-In !Timely!

Close case for failure to respond to a request to contact the agency to
discuss information received in a computer match.
18 NYCRR 387.8 (c ), 387.14 (a)

M26 B Failure to Provide Verification of Wage Match at Recertification

!Adequate!
Close case at recertification for failure to provide verification of information
received from a Wage Match.
18 NYCRR 387.8 (c), 387.14 (a)

M27 B Failure to Provide Verification of UIB Match at Recertification

!Adequate!
Close case at recertification for failure to provide verification of information
received from a UIB match.
18 NYCRR 387.8 (c), 387.14 (a)

M53 Failed to Complete 6 Month Periodic Report - Partial Proof !Timely\

Close case because the recipient failed to provide complete proof of the
statements made in the mailer.
18 NYCRR 387.17

M68 Added to another SNAP Case !Timely!

Close case because all members are receiving SNAP in another case.
18 NYCRR 387.1

M90 Client Request - Written or Verbal In Person !Adequate!

Close case at the client's written or verbal in person request.
18 NYCRR 387.20

Edits
B- Can be used at recertification or during the certification period
R- To be used at recertification only.

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CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231! !cont'd)

CODE EDIT VALUE

M91 B Client Request -Phone !Timely!
Close case at client's request made by phone.
18 NYCRR 387.20

M97 Receiving multiple Benefits IHH=1l !Timely!

Close case for 10 years because the client fraudulently misrepresented
his/her identity or residence in order to receive multiple SNAP benefits at
the same time.
18 NYCRR 381.1

M98 Duplicate Assistance. Non-AFIS. In NYS !Adequate!

Close the case because the client's identity matches another person who
is receiving SNAP in New York State.
18 NYCRR 351.2 (a), 351.9

N10 R Failure to Keep Appointment !Adequate)

Close case for failure to keep a face-to-face appointment or complete a
telephone interview. This code is only used at recertification if a recipient
submits a recertification application but fails to be interviewed.
18 NYCRR 387.7 (a), 387.14 (a)

N18 Failure to Validate Incorrect Social Security Number !Timely!

Close multi-person case for failure to validate a Social Security Number
that match with Social Security Administration records that indicates is
invalid.
18 NYCRR 387.1, 387.8 (c), 387.9 (a), 387.10 (b), 387.16 (c)

N41 B Voluntarv Quit IHH=1 l !Timely! llst Occurrence = 2 months)

Close the case because the recipient quit his/her job or earned at least 30
times the Federal minimum wage or voluntarily reduced the number of
hours worked to less than 30 hours per week.
18 NYCRR 385.13

N42 B Voluntary Quit !HH=1l !Timely\ !2nd Occurrence= 4 months!

Close the case because the recipient quit his/her job or earned at least 30
times the Federal minimum wage or voluntarily reduced the number of
hours worked to less than 30 hours per week.
18 NYCRR 385.13

Edits
B- Can be used at recertification or during the certification period
R- To be used at recertification only.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D)

CLOSING CODES - SNAP IFS: REAS - 2311 lcont'dl

CODE EDIT VALUE

N43 B Voluntary Quit IHH=1l !Timelyl !3rd Occurrence= 6 months)
Close the case because the recipient quit his/her job or earned at least 30
times the Federal minimum wage or voluntarily reduced the number of
hours worked to less than 30 hours per week.
18 NYCRR 385.13

N66 Duplicate Assistance. PARIS Match. Interstate !Timely)

Close the case because the client's identity matches another person who
is receiving SNAP in another state. (Must be used with originating ID F25
only.)
18 NYCRR 351.2 (a), 351.9

N67 Duplicate Assistance. PARIS Match !System Generated) !Timely)

Close the case because the client's identity matches another person w.ho
is receiving SNAP in another state. (Must be used with originating ID CFI
only.)
18 NYCRR 351.2 (a), 351.9

N90 B IPV-Traded SNAP for Firearms. Ammunition or Explosives

!Adequate)
Close case permanently because of a guilty conviction for using SNAP to
obtain firearms, ammunition or explosives.
18 NYCRR 359.9

NF1 Purchased Illegal Drugs with SNAP-IPV !1st Violation! !Adequate)

IHH=1l
Close the case for 12 months because the client has been convicted of
using SNAP to obtain illegal drugs.
18 NYCRR 359.9

NF2 Purchased Illegal Drugs With SNAP-IPV !2nd Violation) !Adequate)

IHH = 11
Close the case permanently because the client has been convicted a
second time using SNAP to obtain illegal drugs.
18 NYCRR 359.9

U41 Transfer of Excess Resources !Timelyl

Close case because resources were transferred knowingly for the purpose
of qualifying or attempting to qualify for SNAP benefits.
18 NYCRR 387.9 (a)

U44 Excess Resources of Alien Sponsor !Timely)

Close case because resources of an alien sponsor exceed SNAP limits.
18 NYCRR 387.1, 387.9 (b), 387.10

Edits
B- Can be used at recertification or during the certification period
R- To be used at recertification only.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231! lcont'dl

CODE EDIT VALUE

U45 B Increased Resources !Recert Closing! ITimelvl
Close case because at recertification we find resources exceed SNAP
limits. The worker must enter: Information required ori the PA/FS Resource
Calculation screen (WCN018).
18 NYCRR387.9

U97 B. Opened in Error-Excess Resources !Timely!

Close case that was opened in error, because of excess resources.
18 NYCRR 387.9

V21 B Failure to Provide Verification !Adequate!

Close case for failure to provide requested verification.
18 NYCRR 387.8 (c}, 387.9 (a) (7), 387.14 (a)

WE1 Failure to Comply with Employment Requirements !HH=1l !Timely!

Close one-person case that fails to comply with employment requirements
(1st occurrence- 2 months and until compliance)
18 NYCRR 385.9, 385.12

WE2 Failure to Comply with Employment Requirements !HH=1l !Timely!

Close one-person case that fails to comply with employment requirements.
(2nd occurrence -4 months and until compliance)
18 NYCRR 385.9, 385.12

WE3 Failure to Comply with Employment Requirements !HH=1l !Timely!

Close one person that fails to comply with employment requirements.
(3rd and subsequent occurrences-6 months and until compliance)
18 NYCRR 385.9, 385.12

W35 Fleeing Felon

Close case because client is a fleeing felon:
18 NYCRR 351.2(k)(3)(i)

W44 Probation Violator

Close case because client is currently in violation of probation.
18 NYCRR 351.2(k)(3)(ii)

W45 Parole Violator

Close case because client is currently in violation of parole.
18 NYCRR 351.2(k)(3)(ii)

Edits
8- Can be used at recertification or during the certification period
R- To be used at recertification only.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES !CONT'D>

CLOSING CODES - SNAP IFS: REAS - 2311 !cont'd)

CODE VALUE
X66 Duplicate Assistance. PARIS Match !Svstem Generated) !Timely!
Close the case because the client's identity matches another person who
is receiving SNAP in another state. (Must be used with originating ID CFI
only.)
18 NYCRR 351.2 (a), 351.9

Y10 R Failure to Recertify !No Notice Required)

Close cases that failed to respond in a timely manner to the SNAP call-in-
notice.
18 NYCRR 387.5

Y24 Client Request - SNAP - Eligibility Mail Out !Manual Closing)

!Adequate)
Close the SNAP portion of a PA/SNAP case because on the returned
Eligibility Mail Out form, the client asked that the SNAP portion of the case
be closed.
18 NYCRR 387.17

Y26 Client Request - SNAP & MA - Eligibility Mail Out !Adequate)

Close the SNAP portion of a PA/SNAP case because on the returned
Eligibility Mail Out form, the client asked that the SNAP and MA portions of
the case be closed.
18 NYCRR 387.17

Y29 Failure to Provide Verification-Expedited SNAP !No Notice)

Close case for failure to provide verification when expedited SNAP was
approved.
18 NYCRR 387.8, 387.9, 387.14

Y52 Walker Retro Payment Only !Adequate)

Case was opened for Walker retro payment only.

Y66 R Overdue Recertification !System Generated)

Manual Notice Require ITime!vl
Close the SNAP portion of a PA/SNAP case because the recertification
period for SNAP has expired.

Y93 Case Number change !No Notice Required)

Close case because of a case number change.

Y99 Other !Timely!

Edits
B- Can be used at recertification or during the certification period
R- To be used at recertification only.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CASE REASON CODES ICONT'Dl

CLOSING CODES-SNAP IFS: REAS - 231! (cont'd)
CODE EDIT VALUE
Z11 -- SNAP Separate Determination - SYSTEM GENERATED

399 Duplicate Assistance within NYS

If all SNAP individuals match. (This code is used when there has been an
Automated Finger Imaging System Match- AFIS) (Adequate)
18 NYCRR 351.2 (a), 351.9

914 Client Request IWrittenl SNAP Default Code - SYSTEM GENERATED

939 In Prison IHH=1l !Timely! - SYSTEM GENERATED

Close case because the client(s) has been admitted or committed to
prison.
18 NYCRR 387.1, 387.14 (a) (5)

944 Client Request IVerball SNAP Default Code - SYSTEM GENERATED

968 Forced Closing !SYSTEM GENERATED!

976 Added to Another Case SNAP Default Code - SYSTEM GENERATED

977 Not Head of SNAP Household !Multi-suffix Case Closing) SNAP

Default Code - SYSTEM GENERATED

992 Orig. ID EPF Only - SNAP !Intentional Program) Violation !Manual

Notice I
Close a one-person case when the person has been found guilty of
Intentional Program Violation and is disqualified. An individual closing
reason code must be entered to indicate the period of ineligibility
18 NYCRR 387.1, 399.9

Edits
B- Can be used at recertification or during the certification period.
R- To be used at recertification only.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-1
10/18/2015

TURNAROUND DOCUMENT - DSS 3517 !CONT'D!

SECTION 15: INDIVIDUAL LEVEL CODES

SEX CODES ISEXl - 315

F Female
M Male
U Unborn

VALIDATE SSN CODES !VALIDATE! - 321

1 SSN Present but Not Yet Validated
2 SSN Applied For but Not Yet Available
3 SSN Applied For and Denied
4 SSN Not Applied For
5 SSN Indicator not on ODP database (Conversion Code)
7 SSN Assigned by SSA
8 SSA Validated SSN
9 SSN Failed SSA Validation
A SSN not on SSA file
B No match on name
D No match on DOB
E Client known to SSA By This #-xxx-xx-xxxx (Number sent to SSA is wrong due to a
transposition or one digit off error.) Note: See RFI for the correct number
N State benefit eligible alien
X Deceased

DISABILITY ACCOMMODATION INDICATOR !DAil - 367

(This field is data enterable at the line level for all clients. The suffix receives the accommodation that is
entered for the payee or alternate payee.)

V1 Large Print (18 pt)

V2 Audio CD
V3 Data CD
V4 Braille

PA CATEGORICAL CODES ICATl - 372

USE FOR CHILDREN ON FA/SNFP CASES ONLY
01 FA/SNFP Death of a Parent
02 FA/SNFP Incapacity of Parent
03 FA/SNFP lmprisonement Parent
05 FA/SNFP Divorce, Annulment, Legally Separate Parent
06 FA/SNFP Abandonment/Desertion by Parent
08 FA/SNFP Unemployment Principal Wage Earner

09 Children in Intact Household, No FA/SNFP Deprivation; or Single Person Safety-Net/Adult-

Orily Households [USE FOR ALL CASES]
10 Aged - 65 Years of Age or Over [USE FOR ALL CASES]
11 Blind, Verification Required [USE FOR ALL CASES]

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-2
06/21/2015

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D>

PA CATEGORICAL CODES !CATI - 372 !CONT'Dll

12 Disabled [MA ONLY OR FOR ALL PA CASE TYPES IF THE PERSON ON THE PA CASE
IS IN RECEIPT OF SSI OR SSA DISABILITY]
13 FA/SNFP Dependent Relative (Parent or Legally Responsible Relative on FA/SNFP Case)
[USE FOR FA/SNFP/SNNC CASES]
14 Essential Person [USE FOR ALL CASES]
15 Pregnant Woman, No FA/SNFP Deprivation [USE FOR FA/SNFP/SNNC CASES]
18 Emergency Shelter Federal Participation [MA/MA-SS I ONLY]
20 IVE Adoptive Subsidy [FOR CHILDREN ON MA CASES ONLY]
26 Parent in an Intact Household [USE FOR ALL CASES]
31 Resident of Public Emergency Shelter - Not Title XIX- Reimbursable
[MA ONLY]
32 Non-NYS IV-E Foster Case [MA/MA-SSI ONLY]
33 Non IV-E Adoptive/Special Needs [MA/MA-SSI ONLY]
34 Non-NYS IV-E Adoptive [MA/MA-SSI ONLY]
35 Presumptive Eligibility Home Care [MA ONLY]
39 FNP Parent Living with his/her Child (ren) Above the PA standard
[MA ONLY]
40 CAP [MA ONLY]
44 Expanded Coverage - Infants (Must have MA Coverage Code 01 or 30)
[USE FOR FA/SNFP/SNNC CASES]
48 Pregnant Woman with a Deprivation [USE FOR FA/SNFP/SNNC CASES]
50 Special Supplement (s) Client-FNP for Medicaid (NYC Only)
FS NPA Individual on a PA Case [USE FOR ALL CASES]
BLANK - Unborn [USE FOR ALL CASES)

PA STATUS CODES IPA: STAT!- 330

AC Active
AP Applying
CL Closed
DD Dead
NA Not Applying
RJ Denied
SI Single Issue
SN Sanctioned
WD Withdrawn

MA STATUS CODES !MA: STAT! - 340

AC Active
AP Applying
CL Closed
NA Not Applying
RJ Denied
SN Sanctioned
DD Dead

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-3
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SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

MA COVERAGE CODES IMA: COV CD! - 343

0.1 · Full Coverage
02 Outpatient Coverage Only
04 No Coverage-PA Cases Only
06 Provisional Coverage (FHP)
07 Emergency Medical Coverage
08 Presumptive Eligibility - Home Care
09 Medicare Premium, Co-insurance and Deductible Only
10 Eligibility for All Services except Long Term Care
11 Full Coverage-FNP Except Emergency Medical Care (Legal Alien During 5 Year Ban)
13 Presumptive Eligibility - Prenatal Care A
14 Presumptive Eligibility - Prenatal Care B
15 Perinatal Care
*16 HR Coverage - (Disabled as of version 2004.1)
17 ·Eligibility for Payment of Health Insurance Premium Only
19 Community coverage with community-based long-term care (Case type 20 only)
20 Community coverage without long-term care (Case types 20 & 24 only)
21 Outpatient coverage with community-based long-term care (Case type 20 only)
22 Outpatient coverage without long-term care (Case type 20 only)
23 Outpatient coverage with no Nursing Facility Services (Case type 20 only)
24 . Community coverage without long-term care (legal alien during 5-year ban) (Case type 20
only)
30 PCP - Full Coverage
31 PCP - Guarantee (System Generated)
*32 PCP/Home Relief Coverage - (Disabled as of version 2004.1)
*33 PCP Guarantee/Home Relief Coverage - (Disabled as of version 2004.1)
34 Family Health Plus Coverage
36 Family Health Plus Guarantee (System Generated)

SNAP STATUS CODES IFS: STAT! - 350

AC Active
AP Applying
CL Closed
DD ·Dead
NA Not Applying
RJ Denied
SI Single Issue
SN Sanctioned
WO Withdrawn

* These Coverage Codes will be removed from the manual at a later date.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-4
10/22/2012

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

STATE/FEDERAL CHARGE CODES !ST/FED CODE! - 307

03 Federal Charge American Repatriate
05 State Charge OMH or OPWDD Release
30 Refugee Assistance Programs (RCA/RMA). Can only be used if ACI Ind is A, H, R, or D.
50 Home Care-State Charge - MA Only
60 Maintenance of Effort (MOE) Qualified Alien with less than 5 years in status (Can only be
used if ACI Ind is B, K, S, or G)
63 Converted Due To 60 Month TANF Limit (MOE)
65 FFP Eligible Pregnant PRUCOLAlien age 21 or over
66 FFP PRUCOL Child under 21 or Pregnant PRUCOL under 21
67 State Charge/PRUCOL (Can only be used if ACI Ind is 0 or T)
68 Qualified Alien (No children under 18 or pregnant women). Can only be used if ACI Ind is B,
F, K, S, orG.
88 State Charge/Federal Charge Expired

STATE/FEDERAL CHARGE DATE !ST/FED DATE! - 325

Charge Code Category Date Limit of State/Federal Charge
03 ALL Date of Entry 3 months
301 SNCA/SNNC Date Asylum Granted 8 months
60 2 . SNCA/SNNC 8/22/96 or later 5 years from date of entry
63 ALL Date Converted to SN None
67 3 SNCA/SNNC 8/22/96 or later 5 years from date of entry
684 SNCA/SNNC 8/22/96 or later 5 years from date of entry
88 ALL Date Charge Expired Indefinite

BIRTH VERIFICATION INDICATOR !BVll - 366

1 Verified (System Generated)
2 Verified through automated newborn process (System Generated)
3 Verified by a worker (Data enterable)
4 Verified via EDITS/POS (System Generated)
5 Deemed verified (System Generated)
6 Verified Medicare client (Both System Generated and Data Enterable)
B Verified but not consistent with SSA data (System Generated)
C Verified but deceased (System Generated)
D Verified but deceased and not consistent with SSA data (System Generated)

ACI Indicator of A, H, R, or D is required for code 30.

2 ACI Indicator of B, K, S, or G is required for code 60.
3 ACI Indicator of 0 or Tis required for code 67.
4 ACI Indicator of B, F, K, S, or G is required for code 68.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-5
02/19/2017

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

TEENAGE SERVICE ACT INDICATOR ITASAl - 304

1 Pregnant Teen
2 Teen Parent (Including Fathers)
3 Neither Pregnant Nor Parenting Teen

ABAWD IND. CODE - 371

A ABAWD/Non-waived area. Individual is 18-49 years of age, does not meet an ABAWD
exemption, and lives in a non-waived area. For work-limited individuals (Employability Code
16 .or 64), individual is able to work 20 or more hours per week.
N Non-ABAWD. Individual is under 18 or 50 years of age or older; or pregnant; or SNAP
household includes an individual under age of 18 or individual is not able to work at least 20
hours per week.
W ABAWD/Waived area. Individual is 18-49 years of age, does not meet ABAWD exemption
and is able to work 20 or more hours per week, but lives in a waived area.
X ABAWD excluded based on district exclusion policy.

EMPLOYABILITY CODES IEMPl - 375 AND SNAP EMPLOYABILITY CODE - 370

PA/SNAP EMPLOYABILITY CODES

IND.IVIDUALS UNDER THE AGE OF 16 MUST BE ASSIGNED CODE 30, EXCEPT UNBORNS

PA PA DEFINITION SNAP SNAP DEFINITION CATEGORY ABAWD

CODE CODE IND
16 Work-limited/Non-exempt 16 Work-limited/Non-exempt FA/SNFP. N
SNCA/SNNC A,N,W,X
17 Teen head of household or * * FA/SNFP N
married teen enrolled in SNCA/SNNC A,N,W,X
secondary school, equivalerit
or other edu.cation directly
related to employment/Non-
exempt
20 Non-exempt 20 Required to work/Non- FA/SNFP N
exempt SNCA/SNNC A,N,W,X
24 Pregnant (within 30 days of 24. Pregnant (within 30 days of ALL N
medically verified date of medically verified date of
delivery)/Exempt delivery)/Exempt
* No equivalent SNAP code. Worker should determine the most sU1table SNAP code based on SNAP
E&T rules.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-6
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D>

EMPLOYABILITY CODES !EM Pl - 375 AND SNAP EMPLOYABILITY CODE - 370 !CONT'D!

PA/SNAP EMPLOYABILITY CODES

INDIVIDUALS UNDER THE AGE OF 16 MUST BE ASSIGNED CODE 30, EXCEPT UNBORNS

PA PA DEFINITION SNAP SNAP DEFINITION CATEGORY ABAWD

CODE CODE IND
27 Employed part-time or full- 27 Employed or self-employed FA/SNFP N
time/Non-exempt less than 30 hours per week SNCA/SNNC A,N,W,X
AND earning less than the
equivalent of 30 hours times
the federal minimum wage
on a weekly basis (currently
$217.50 per week)/Non-
exempt
28 Employed or self-employed ALL N
30 or more hours per week
OR earning at least the
equivalent of 30 hours times
the federal minimum wage
on a weekly basis (currently
$217.50 per week) or higher/
Exempt
29 True single parent or 29 A parent or household ALL N
caretaker of child under 6 member who is responsible
years of age/Non-exempt for care of a child under 6 in
the household/Exempt
30 Child under 16 years/Exempt 30 Child under 16 years/Exempt ALL N
31 Parent or caretaker relative 31 Parent or caretaker relative ALL N
of a child in the household of a child in the household
under 12 months of age/ under 12 months of age/
Exempt Exempt
32 Advanced age (60 years or 32 60 years of age or older/ ALL N
older)/Exempt Exempt

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-7
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES ICONT'Dl

EMPLOYABILITY CODES IEMPl - 375 AND SNAP EMPLOYABILITY CODE - 370 ICONT'Dl

PA/SNAP EMPLOYABILITY CODES

INDIVIDUALS UNDER THE AGE OF 16 MUST BE ASSIGNED CODE 30, EXCEPT UNBORNS

PA PA DEFINITION SNAP SNAP DEFINITION CATEGORY ABAWD

CODE CODE IND
35 Child who is not the head of 35 Age 16 or 17, not the head of ALL N
household and is in school household OR 16 or 17
full-time (age 16-18)/Exempt attending school or an
employment training
program on at least a half-
time basis/Exempt
* Age 18, regardless of FA/SNFP N
attending high school SNCA/SNNC A,N,W,X
36 Incapacitated/disabled (more 36 Incapacitated/disabled (more ALL N
than 6 months)/Exempt than 6 months)/Exempt
38 Parent needed in the home 38 Responsible for the care of ALL N
full-time to care for an an incapacitated person full-
incapacitated/disabled time (the incapacitated
household member/Exempt person does not need to live
in the household)/Exempt
40 Parent or non-parent needed 40 Responsible for the care of FA/SNFP N
in the home part-time to care an incapacitated person part- SNCA/SNNC A,N,W,X
for an incapacitated/disabled time (the incapacitated
household member/Non- person does not need to live
exempt in the household)/Non-
exempt
41 · Temporary illness or 41 Temporary illness or ALL N
incapacity (1-3 month incapacity (1-3 month
exemption)/Exempt exemption)/Exempt
42 Temporary illness or 42 Temporary illness or ALL N
incapacity (4-6 month incapacity (4-6 month
exemption)/Exempt exemption)/Exempt
* No equivalent SNAP code. Worker should determine the most sU1table SNAP code based on SNAP
E&T rules.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4·8
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D)

EMPLOYABILITY CODES IEMPl • 375 AND SNAP EMPLOYABILITY CODE • 370 !CONT'D\

PA/SNAP EMPLOYABILITY CODES

INDIVIDUALS UNDER THE AGE OF 16 MUST BE ASSIGNED CODE 30, EXCEPT UNBORNS

PA PA DEFINITION SNAP SNAP DEFINITION CATEGORY A BAWD

CODE CODE IND
43 Incapacitated/disabled (SSI 43 Incapacitated/disabled (SSI ALL N
application filed)/Exempt application filed)/Exempt
(based on medical doc.)
OR SSI applicant/pending
SSI recipient who has
applied for SNAP benefits
through joint processing at
the SSA office/Exempt
44 Incapacitated/disabled (in 44 Incapacitated/disabled (in ALL N
receipt of SSl)/Exempt receipt of SSl)/Exempt
45 Work requirements waived/ 45 Work requirements waived/ ALL N
Exempt Exempt
46 Expired employment waiver/ * * FA/SNFP N
Non-exempt SNCA/SNNC A,N,W,X
47 Incapacitated/disabled 36 " Incapacitated/disabled (more ALL N
Time limit exemption (more than 6 months)/Exempt
than 6 months)
48 Needed in the home to care 38 Responsible for the care of ALL N
for incapacitated child full- an incapacitated person full-
time - Time limit exemption time (the incapacitated
person does not need to live
in the household)/Exempt
49 Temporary illness or 42 Temporary illness or ALL N
incapacity " Time limit incapacity (4-6 month
exemption (4-6 month exemption)/Exempt
exemption)
+ + 52 Receiving or pending receipt ALL N
of Unemployment Insurance
Benefits (UIB)/Exempt
* No equivalent SNAP code. Worker should determine the most suitable SNAP code based on SNAP
E&T rules.
+ No equivalent PA code. Worker should determine the most suitable PA code based on PA
requirements.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-9
02/19/2017

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

EMPLOYABILITY CODES !EMPl - 375 AND SNAP EMPLOYABILITY CODE - 370 !CONT'D!

PA/SNAP EMPLOYABILITY CODES

INDIVIDUALS UNDER THE AGE OF 16 MUST BE ASSIGNED CODE 30, EXCEPT UNBORNS

PA PA DEFINITION SNAP SNAP DEFINITION CATEGORY ABAWD

CODE CODE IND
54 Parent in receipt of SSDI/ 54 In receipt of Social Security ALL N
Exempt Disability Income (SSDI)/
Exempt
57 Partial employment waiver/ * * FA/SNFP N
Non-exempt SNCA/SNNC A,N,W,X
58 Non-parent needed in the 38 Responsible for the care of ALL N
home full-time to care for an an incapacitated person full-
incapacitated/disabled time (the incapacitated
household member/Exempt person does not need to live
in the household)/Exempt
63 Substance abuse/Exempt 63 Determined unable to work ALL N
due to substance abuse/
Exempt
64 Substance abuse/Non- 64 Substance abuse/Non- FA/SNFP N
exempt exempt SNCA/SNNC A,N,W,X
70 Contesting employability 70 Exemption claimed pending ALL N
determination, including the medical documentation/
disability review process/ Exempt
Exempt ·.

+ + 72 Student enrolled in ALL N

recognized school (not high
school), job skills training, or
institution of higher
education at least half-time
(meets student requirements
in 18 NYCRR 387.1)/Exempt
99 Unborn ALL
• No equivalent SNAP code. Worker should determine the most sU1table SNAP code based on SNAP
E&T rules.
+ No equivalent PA code. Worker should determine the most suitable PA code based on PA
requirements.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-10
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

EMPLOYABILITY CODES !EMPl - 375 !CONT'D!

MA ONLY EMPLOYABILITY CODES

INDIVIDUALS UNDER THE AGE OF 18 MUST BE ASSIGNED CODE 30; EXCEPT AB/AD CHILDREN
AND UNBORNS

CODE CATEGORY DEFINITION

17 ALL Teen parent age 16-19 without HS Diploma.
20 ADCU/HR Mandatory employable.
24 ALL Pregnancy.
27 ALL Employed.
30 ALL Child less than 18 years old.
31 ALL Caretaker of child under 3 years of age on same MA case.
32 ALL Advanced age - 65 years and older.
33 ADCU Caretaker with other adult on same MA case in employment
compliance.
34 ALL Caretaker of child under 3 not on same MA case.
35 ALL Child 18 expected to graduate by 19th birthday.
36 ALL Incapacitated 30 days to 1 year.
38 ALL Needed in home full time to care for incapacitated/disabled family
member - Exempt
40 ALL Needed in home part time to care for incapacitated/disabled family
member - Non-exempt
41 ALL Temporary illness - 3 month exemption.
42 ALL Temporary incapacity - 6 month exemption
43 ALL Incapacitated - SSI application filed.
44 ALL In receipt of SSI and/or SSI Disability.
53 ALL Person 18-21 not employed.
60 HR 55 years or older - not employed in the last 5 years.
63 ALL Substance abuser - in rehabilitation.
64 ALL Substance abuser - waiting for rehabilitation.
70 ADC/SS I Disability Type I.
71 ADC/SS I ADC caretaker relative of child 19 or younger (not born) in the same
MA case.
72 ALL ADC caretaker relative of child between the ages of 6 to 19 not in
same MA Only case.
74 ADC/SS I Disability Type II.
99 ALL Unborn

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-11
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

MEDICARE SAVINGS PROGRAM !MSPl - 345 .

P Qualified Medicare Beneficiaries (QMB)
L Specified Low Income Medicare Beneficiary (SLIMB)
U Qualified Individual 1 (Ql1)
X New Value for QDWI. (Has not yet been defined by DOH/TPHI)

In Eligibility, if the value P,L,U, or X is entered then MA Coverage code of 09 must be entered,
If Coverage Code 09 is entered then one of the four indicators (P,L,U, or X) must be entered.

TPHl/MEDICARE SOURCE CODE ITPHl/MCRl - SYSTEM GENERATED

TPHI - Third Party Health Insurance
Y Client Has TPHI
N Client Does Not Have TPHI
MCR - Medicare
Y Yes
N No

SSI INDICATOR !SSll - 320

1 Active
2 Pending
3 Closed, Denied, or Suspended (Appeals Exhausted)
4 Deemed Eligible
5 Closed SSI, Continue RSDI

BUREAU OF CHILD SUPPORT INDICATOR IBCSl - 328

Also known as Office of Child Support Enforcement

A1 Appropriate for referral to Office of Child Support Enforcement (OCSE)

B1 No Referral: Both parents in household (In-Wedlock)
D1 No referral: Absent parent deceased. Death has been verified either by Public Assistance
staff or by Child Support staff.
G1 No referral: Good cause. The Office of Child Support Enforcement may not pursue child
support activity.
H Individual is head of household or other adult in household. (Note: This may be the individual,
16 years old or older, who is referred to the Child Support office, but it is not the child.)
Referral: Individual is an independent 16-20 year old.
K2 Referral received by OCSE: Individual is now known to the Child Support Management
System (CSMS). There is NO good cause.
p 1 Referral: Good cause. Child support enforcement activity should proceed, without the
involvement of the client.

For these values the individual must be less than 21 years old.
2 These v.alues will appear because of a systems match between CSMS and WMS. These values should
not be data entered.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-12
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D\

BUREAU OF CHILD SUPPORT INDICATOR IBCSl - 328 ICONT'Dl

T1 Temporarily no referral: Good cause claimed at the Office of Child Support Enforcement.
Re-evaluate at end of pregnancy to determine whether child support enforcement activity
may proceed.
w 2 Referral received by OCSE: OCSE will proceed without the client. The individual is now
known to the Child Support Management System (CSMS). There is good cause.

RELATIONSHIP CODE !REL! - 329

01 Applicant/Payee
02 Legal Spouse
03 Non-Legal Union (No Child in Common)
04 Son
05 Daughter
06 Step-Son
07 Step-Daughter
08 Niece or Nephew
09 Grandson or Granddaughter
10 Grandmother or Grandfather
11 Aunt or Uncle
12 Essential Person
13 Other FA/SNFP Relationship
14 Other Relationship (Not FA/SNFP Relationship)
15 Legal Guardian (Not FA/SNFP Relationship)
16 Ward (Not ADC Eligible Relationship)
17 Cousin
18 None
19 Parent
20 Sister or Brother
21 Step-Parent
22 Step-Sister or Step-Brother
23 Half Sibling
24 Putative Father
25 Acknowledging Father
26 Great Grandparent
27 Great Grandchild
28 Alternate Payee
29 Unknown (System Generated Only)
30 Non-Legal Union with Child in Common
31 Unknown
99 Unborn

1 For these values the individual must be less than 21 years old.
2 These values will appear be.cause of a systems match between CSMS and WMS. These values should
not be data entered.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-13
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

COMMON BENEFIT IDENTIFICATION CARD CODE !CBIC CCI -378

P Photo Card Requested
N Non-Photo Card Requested
X No Card Requested
R No Card Requested, Client is on a Medicaid Roster

CBIC - CARD DELIVERY CODES !CBIC CDC! - 383

A Agency Pick-Up - Cards will NOT be Automatically Produced. Card must be Picked Up by
Client at Over the Counter Card Sites.
M Mail.ad - Cards will be Automatically Produced and Mailed.

STUDENT ID CODE- 323 - !SYSTEM GENERATED!

1 School registration verified by BOE
D Discharged from School
P Pending
T Transfer
3 Duplicate Student ID Number
5 Invalid Student ID Number
6 Unknown to BOE
7 Name does not match
8 Sex does not match
9 Date of birth does not match
X Individual known to BOE but status unknown
Z Registration verified by BOE but address does not match database

CHILD/TEEN HEAL TH PROGRAM CODE ICHTl - 380

1 Requesting CHT Medical Services, but not Support and Dental Services
2 Requesting CHT Medical Services and Support, but not Dental Services
3 Requesting CHT Medical, Support and Dental Services
4 Requesting CHT Medical and Dental Services, but not Support Services
5 Requesting CHT Dental Services, but not Medical and Support Services
6 Requesting CHT Support and Dental Services, but not Medical Support
7 Already Receiving CHT Services
8 Declines CHT ·
9 Undecided

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-14
02/21/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D\

VETERAN'S INDICATOR !VET\ - 324

These codes are to be used for persons 18 or older. They are listed in priority order. If a person falls into
more than one category use the lowest number. For example, if the person is both disabled [Code 3] and
a recently separated veteran [Code 5] used code 3.

1 Special Disabled Veteran (Disability of 30% or more)

2 Vietnam-era Veteran
3 Disabled Veteran
4 Combat Theater Veteran
5 Recently Separated Veteran
6 Other Veteran
7 Spouse or Dependent of Veteran
9 Not A Veteran

OFFICE OF TREATMENT MONITORING INDICATOR IOTMl - 379

A Client Alcohol Dependent
D Client Drug Dependent

ALIEN CITIZENSHIP INDICATOR IACll - 382

A Person granted asylum.
B Certain battered aliens who are the immediate relatives (spouse or child) of a US citizen or
lawful permanent resident alien who have been battered or subject to extreme cruelty by the
spouse or parent.
C Citizen.
D Federally certified victim of human trafficking.
E Non-qualified aliens eligible for emergency Medicaid.
F Persons granted conditional entry.
G Persons paroled into the US for at least one year.
H Cuban-Haitian Entrant
J Persons whose deportation is being withheld.
K Persons lawfully admitted for permanent residence.
M Persons on active duty in the US armed forces and/or their spouses or unmarried dependent
children.
0 PRUCOL individual who may be eligible through TANF/Safety Net.
P FFP pregnant special PRUCOL or child under 21.
R Persons admitted as refugees, including Amer-Asians, and victims of human trafficking.
S Persons lawfully admitted for permanent residence who have worked or can be credited with
40 qualifying quarters of coverage as defined under Title II of the Social Security Act.
T Persons paroled into the US for less than one year.
V Honorably discharged veterans of the US armed forces and/or their spouses or unmarried
dependent children.
9 Pregnant Woman (System Generated)

Codes A, F, G, H, J, K, M, R, S, T and V require an Alien Registration Number (data element 381).

Codes A, 8, D, F, G, H, J, K, M, R, S, T and V require a Date of Entry (data element 347).

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-15
10/23/2016

S.ECTION 15: INDIVIDUAL LEVEL CODES !CONT'D!

ALIEN REG. NUMBER - 381

This field is only entered for aliens. The first position of the alien registration number must be A and the
next 9 positions must be numeric. Numbers that are all the same or are sequential in both directions,
such as A555555555 or A123456789, are not allowed, except for the following special numbers:

AOOOOOOOOO Lost or expired documentation, pending verification of the alien status and
number. Requires entry of 99/99/9999 for Date of Status (389) and Date of Entry
(347).
A000999999 Human trafficking victim

SNAP ELIGIBLE ELDERLY/DISABLED ALIEN INDICATOR - 313

Enter the SNAP Eligible Elderly/Disabled Alien Indicator if the individual is a qualified elderly or disabled
alien who is within the 5-year ban for SNAP.

x Qualified elderly/disabled alien within 5-year ban for SNAP

HISPANIC/LATINO - 395
An entry of Yes (Y) or No .(N) must be input for this entry. An entry of (U) Unknown is for MA cases only
or MA only individuals on PA cases. An entry is not made for an unborn

HISPANIC/LATINO (H)-395

RACE/ETHNIC - 396. 397. 398. 373. 374

An entry of Yes (Y) or No (N) must be input for this entry. An entry of (U) Unknown is for MA cases only
or MA only individuals on PA cases. An entry is not made for an unborn

AMERICAN INDIAN/ALASKA NATIVE (I )- 396

ASIAN (A)- 397
BLACK/AFRICAN AMERICAN (B)- 398
NATIVE HAWAIIAN/PACIFIC ISLANDER (P)- 373
WHITE (W)- 374

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-16
10/23/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D>

MARITAL STATUS IMARI - 387

Only for persons 18 or older

1 Married, living together

2 Single, never married
3 Married, but separated
4 Informal separation
5 Divorced
6 Widowed
7 Annulment
8 Abandonment/Desertion

EDUCATIONAL LEVEL IEDUCl - 388

This code refers to highest grade level completed. If a child is in the 3rd grade, the highest level
completed is the 2nd grade.

00 Has Not Attended School, is Pre-Kindergarten or Kindergarten

01-12 Refers to Grades 1-12

HIGHEST DEGREE OBTAINED IHDOI - 390

Only for Persons 16 or Older
0 No Degree
1 High School Diploma, GED or National External Diploma Program
2 Associate's Degree
3 Bachelor's degree
4 Master's Degree or Higher
5 Other Credentials (degree, certificate, diploma, etc.)
9 Not Applicable, Never Attended School

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-17
10/23/2016

SECTION 15: INDIVIDUAL LEVEL CODES !CONT'D)

RELATIONSHIP OF MOTHER TO CHILD IMO CHILD! - 391

Enter for ALL Children Under 18 Years of Age OR Under 19 Years of Age and in School Full Time. If the
child's mother exists on the TAD then the mother's line number will be entered in this field, else:

98 Mother Not in Household

99 Mother Not in Case, but Living in Same Household

AFIS EXEMPTION INDICATOR !AFIS EXl - 392

1 Finger Imaged (System Generated)
2 Exempted Left and Right Index Fingers Permanently Unavailable· or Unusable (System
Generated)
3 Temporarily Unavailable or Unusable, One Finger (System Generated)
4 Temporarily Unavailable or Unusable, Two Fingers (System Generated)
5 Exempted Individual, Good Cause Reason
6 Exempted Homebound Individual (System Generated)
7 Exempted Receiving SSI (System Generated)
8 Exempted Congregate Care Facility (System Generated)
A County Specific Approved Exemption
P Purged from AFIS

TIME LIMIT EXEMPTION INDICATOR !TL-EXl - 393

X Exempt
A Exempt Due to Fair Hearing/Aid Continue

IPV INDICATOR FLAG llPVl - 394

Originating Center must be EPF

B IPV sanction for PA & FS

P IPV sanction for PA only ·
F IPV sanction for FS only
L Lift sanction flag

OTHER NAME CODES !CODE! - 361

A Also Known As
M Maiden Name

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.4-18
. 10/23/2016

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-1
10/22/2012

INDIVIDUAL REASON CODES

OPENING CODES- PA IPA: REAS - 3311 and MA !MA: REAS - 3411

CODE CATEGORY
A2 ALL Illness, injury, or other impairment of recipient
PA: SNCA/SNNC 370.2 (a) FA/SNFP 369.2 (g}, 352.29; MA: 360-3

A5 ALL Lay-off, discharge or other reason

PA: 370.2 (a}, 369.2 (g), 352.29; MA: 360-3

CO* ALL Loss of or reduction in support of child due to death of parent

PA: 369.2 (g), 352.29 MA: 360-3

C1 ALL Leaving home by parent and stopping or reducing support for reason of
divorce.
PA: 369.2 (g}, 352.29 MA: 360-3

C2 ALL Leaving home by parent and stopping or reducing support for. reason of
separation.
PA: 369.2 (g), 352.29 MA: 360-3

C3 ALL Leaving home by parent and stopping or reducing support ·for reason of
desertion
PA: 369.2(g), 352.29 MA: 360-3

C4 ALL Leaving home by parent and stopping or reducing support for reason of
other (hospital, prison)
PA: 369.2 (g}, 352.29 MA: 360-3

DO* ALL Loss of or reduction in support from person outside home

PA: 369.2 (g), 352.29 MA: 360-3

05 ALL Loss of or reduction in support from other person in home as a result of

death
PA: 352.1, 352.29 MA: 360-3

06 ALL Loss of or reduction in support from other person in home as a result of

leaving home and stopping or reducing support (hospitalized, etc.)
PA: 352.1, 352.29 MA: 360-3

* 0 =zero

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-2
10/22/2012

INDIVIDUAL REASON CODES !CONT'D>

OPENING CODES- PA IPA: REAS -3311 and MA IMA: REAS - 3411 !cont'd!

CODE CATEGORY
D? ALL Loss of or reduction in support from other person in home as a result of
illness, injury or other impairment
PA: 352.1, 352.29; MA: 360-3

DB · ALL Loss of or reduction in support from other person in home as a result of

lay-off, discharge or other reason
PA: 352.1, 352.29; MA: 360,3

E5 ALL Loss of or reduction in support from other person in home as a result of

loss of or reduction in other income
PA: 18 NYCRR 352.1, 352.29; MA: 360-3

FO* ALL Loss of or reduction in support from other person in home as a result of
other material changes
PA: 18 NYCRR 352.1, 352.29; MA: 360-3

GO* ALL Change in state law or agency policy increase need of because of

PA: 18 NYCRR 352.1 (Additional Regulatory citations may be needed

as circumstances warrant) 358-3.3 (a) (3); MA: 360-3

G5 ALL Return of recipient or relative (ill or previously institutionalized)

PA: 18 NYCRR 352.30; MA: 360-3

G6 ALL Other reason

PA: Citation would depend on the circumstances; MA: 360-3

HO* ALL Living below agency standards

PA: 352.1, 352.29; MA: 360-3

H5 ALL Other
PA: Citation would depend on the circumstances; MA: 360-3

10* SNCA/SNNC Transfer from FA/SNFP

PA: 18 NYCRR 355.5, 370.2 (a); MA: 360-3

11 FA/SNFP Transfer from Home Relief

PA: 355.5, 369.2; MA: 360-3

• 0 =zero

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-3
10/22/2012

INDIVIDUAL REASON CODES !CONT'D)

OPENING CODES - PA !PA: REAS - 3311 and MA !MA: REAS - 3411 !cont'd)

CODE CATEGORY
12 ALL Transfer from Emergency Assistance to Families
PA: 355.5, 369.2; MA: 360-3

13 ALL Adding newborn child PA/MA eligible from current date

Citations to be provided late

V? SNCA/SNNC/ To be used to override a Drug and Alcohol Sanction Code during the
FA/SNFP infraction period. It removes the.last sanction from history
No Notice Issued.

Y48 ALL Approved Override with documentation that allows the opening of CvB or
JOB Search sanction during the infraction period.
No Notice Required

064 ALL Eligible as a result of Hurricane Katrina

96 ALL Client now willing to comply with departmental policy

Citations to be provided later

97 ALL Aid Continuing - Case awaiting Fair Hearing Decision

(To be used with approval of OES)
No Notice Issued

101 ALL Manual Notice Required

To be used to override an IPV sanction and open a line during the
infraction period. Use of this code is restricted to EPF as the Originating
Center
PA: 18 NYCRR 359.9 (a), 352.30 (g); MA: SSL 366 (1) (a) (1)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-4
06/21/2014

INDIVIDUAL REASON CODES !CONT'D!

OPENING CODES - SNAP IFS: REAS - 351 l

CODE VALUE
LL Meets Eligibility Requirements
387.14, 387.15

LM Reopen line closed with F19

LX Override Code to reopen individual line closed with Transitional SNAP.

387.8

LZ Override Code to reopen individual line automatically sanctioned for an employment-

related infraction.

064 Eligible as a result of Hurricane Katrina

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-5
10/22/2012

INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 3311

When rejecting or sanctioning a line using the codes listed below. See MA note 1, 2 or 3 in definition of
the code to determine which of the following rules apply to MA status:

E72, F84, F88, M97, N20, VE1, W40, WE1, WE2, WE3, WS1 -WS8.

Note:

If FA case MA is continued. If individual is under 21, MA Status is continued. If individual is 21 or

older (non-FA), MA status is discontinued. ·

2 If individual is under 21 MA status is continued. If individual is 21 or older with categorical code 09,
14, 26 MA status will default to sanction.

3 If FA case MA is continued. If individual is< 21 or> 64 MA is continued. If individual is between 21-

64 and Safety Net MA discontinued.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-6
10/22/2012

INDIVIDUAL REASON CODES !CONT'D>

REJECTION CODES - PA IPA: REAS - 3311 !cont'd!

CODE CATEGORY
E72 ALL Institutionalized
Application for Public Assistance is denied because the client has been
institutionalized.
MA See Note 3; SNAP Status RJ.
PA: 18 NYCRR 352.31(a) 370.2; MA: 360-2.2;
SNAP: 18 NYCRR 387.1, 387.14 (a) (5)

E73 ALL In Foster Care

Application for public assistance has been denied because the child (ren)
are in Foster Care and there is no plan for them to return home.
MA Status RJ; SNAP Status RJ.
PA: 18NYCRR 352.30 (a), 369.4 (c); MA: 360-2.6;
SNAP: 18 NYCRR 387.17

E86 ALL Unable to Prove Identity to an Investigatory Agency

To be used only by originating center BFI
Application for public assistance is denied because the documents that the
applicant presented to establish his/her identity are false.
MA Status RJ; SNAP Status RJ.
PA: 18 NYC RR 351.1 (b)(2)

E94 ALL Receiving SSI

Application for public assistance is denied because, the client's SSI
payment amount exceeds the individual's budgeted needs.
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 352.29; MA: 360-2.6

E95 ALL Died

Application for public assistance is denied because the client is deceased.
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 351.8; MA: 360-2.6

Note:
3 If FA case MA is continued. If Individual is< 21 or> 64 MA continues. If Individual is between 21-64
and Safety Net MA is discontinued.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-7
10/22/2012

INDIVIDUAL REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 331 l I cont' di

CODE CATEGORY
F50 ALL Death before Determination - No Medical Bills in Retro Period
We have determined that the applicant is deceased and there are no
outstanding medical bills.
MA Status RJ; SNAP Status RJ
PA: 18NYCRR 351.8 (A) (3) (ii); MA: 360-2.5

F51 ALL Death before Determination - Insufficient Information

We have determined that the applicant is deceased and we have
insufficient information to complete the Medical Assistance application
process.
MA Status RJ; SNAP Status RJ
MA: 18NYCRR 351.8; MA: 360-2.2, 360-2.3

F60 ALL Left Household

Application for public assistance is denied because the client left the
household.
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 351.22 (d), 352.30, 352.32; MA: 360-2.2

F63 ALL In Prison

Application for public assistance is denied because the client was
committed to prison.
MA Status RJ; SNAP Status RJ.
PA: 18NYCRR 352.31 (a) 370.2; MA: 360-2.2

F66 ALL Will Receive PA in Another Case

Application for public assistance is denied because the client has been
added to another public assistance case.
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 352.1; MA: 360-2.2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-8
10/22/2012

INDIVIDUAL REASON CODES !CONT'D>

REJECTION CODES- PA IPA: REAS - 3311 lcont'dl

CODE CATEGORY
F75 ALL Temporary Absence of Minor
Application for public assistance is denied because client was absent from
household for 45 days or more, without good cause.
MA Status AP; SNAP Status RJ.
PA: 18 NYCRR 349.4; MA: 366 (4) (q).

F76 ALL Minor Parent Not in School

Application for public assistance is denied because client is less than 18
years old, unmarried has a child at least 12 weeks old and failed to
participate in a program to attain a high school diploma or an alternative
educational or training program.
MA Status AP; SNAP Status RJ.
PA: 18 NYCRR 351.2 (k) (4); MA: 360-2.6

FBB ALL Failure to Comply With Finger Imaging Requirement - Non Legally
Responsible Adult
Application for public assistance is denied because applicant failed to
comply with finger imaging requirements.
MA See Note 1; SNAP Status RJ.
PA: 18 NYCRR 351.2 351.9; MA: 360-2.2

F92 ALL Failure to Provide Proof or Citizenship or Eligible Alien Status

Application for public assistance is denied because the client failed to
provide proof of citizenship or of being a legal alien resident.
MA Separate Determination; SNAP Status RJ.
PA: 18 NYCRR 349.3; MA: 360-2.6

F93 FA/SNFP Failure I Refusal to Sign Citizenship/Alien Declaration

Application for public assistance is denied because the client failed to sign
the citizenship or satisfactory alien status declaration on the application
form.
MA See Note 2; SNAP Status RJ
PA: 18 NYC 351.2 (h); MA: 18 NYCRR 360-2.6;
SNAP: 18 NYCRR 1300.3 (d)

M13 ALL Duplicate Assistance - Active Cash Case Assistance in Other State
Application for public assistance is denied because the client failed to
provide proof that he/she requested his/her out-of-state case to be closed.
MA Status RJ; SNAP Status RJ
PA: 351.1 (b)(2)(ii), 351.2, 351.8(a)(2)(i), 351.9

Note:
If FA case MA is continued. If Individual is< 21 or> 64 MA continues. If Individual is between 21-64
and Safety Net MA is discontinued.
2 If FA case MA is continued. If individual is under 21, MA Status is continued. If individual is 21 or
older (non-FA), MA status is discontinued.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-9
10/22/2012

INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 331! !cont'd)

CODE CATEGORY
M33 FA/SNFP Excess Income - Deemed Income of Alien Sponsor
Application for public assistance is denied because the deemed income of
the alien sponsor exceeds the client's budgeted needs.
MA Status AP; SNAP Status RJ.
PA: 18 NYCRR 349.3 352.33; MA: 360-2.2

M97 ALL Receiving Multiple Benefits

Application for public assistance is denied because client fraudulently
misrepresented his/her identity or residence to receive multiple public
assistance benefits at the same time. The client is ineligible to receive
public assistance and SNAP benefits for 10 years beginning: Date
MA Status AP, SNAP Status RJ.
PA: 18 NYCRR 351.2 (k) (2), 359.9 (d) (1), MA: 366 (1) (a) (1)

M98 ALL Duplicate Assistance - Non AFIS In NYS

Application for public assistance is denied because the client's identity
matches another person who is receiving public assistance in New York
State.
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 351.9; MA: 360-2.2 (e) (f)

M99 ALL Duplicate Assistance - AFIS In NYS

This code is used when there has been an Automated Finger Imaging
Match (AFIS)
Application for public assistance is denied because the client's identity
matches another person who is receiving public assistance in New York
State. ·
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 351.9; MA: 360-2.2 (e) (f)

N31 ALL Voluntarv Quit

Applicant is denied public assistance because he/she quit a job or
voluntarily reduced the number of hours worked in order to qualify for initial
or increased public assistance. The individual is ineligible for public
assistance for 90 days from the date of the job quit or voluntary reduction
in the hours worked.
MA Status AP; SNAP Status AP.
PA: 18 NYCRR 385.13; MA: 366 (1)(a)(1)

N44 ALL Fail to Get Medical Statement

Application for public assistance is denied because applicant failed to get
medical statements to document exemption from work requirements.
MA Status AP; SNAP Status AP.
PA: 18 NYCRR 351.21(f), 385.2; MA: 360-2.6

NEW YO.RK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-10
10/22/2012

INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES- PA IPA: REAS - 3311 !cont'd!

CODE CATEGORY
N49 ALL Minor Parent Refused Offer of a Home
Application for public assistance is denied because you are unmarried,
less than 18 years old, pregnant or residing with and providing care for a
minor dependent child, and you refuse to reside in suitable housing
provided by a parent or guardian or in an approved adult supervised living
arrangement.
MA Status AP; SNAP Status RJ.
PA: 18 NYCRR 369.2; MA: 360-2.6

N50 ALL Minor Parent Refused Offer of a Home - Rejection of Claim that
Housing Arrangementlsl would Jeopardize Health and Safety
Your application for public assistance is denied because you are
unmarried, less than 18 years old, pregnant or residing with and providing
care for a minor dependent child, and you refuse to reside in suitable
housing provided by a parent or guardian or in an approved adult
supervised living arrangement. We have investigated and rejected your
claim that the housing arrangement(s) would jeopardize your health and
safety.
MA Status AP, SNAP Status RJ.
PA: 18 NYCRR 369.2; MA: 360-2.6

N66 ALL Duplicate Assistance - PARIS Match. Interstate

Application for public assistance is denied because the client matches
another person who is receiving public assistance in another state.
MA Status RJ; SNAP Status RJ.
PA: 18 NYCRR 351.8 (a) (2) (i), 351.1 (b) (2) (ii), 351.2, 351.9;
MA: 360-2.2 (e) (f)

P44 ALL Failure to Comply with Drug and/or Alcohol Screening

Application for public assistance is denied because the NAME did not take
part in or complete the alcohol/substance abuse screening requirement.
MA See Note 2 , SNAP continued.
PA: 18 NYCRR 351.2 (i); MA: 360-2.6

P45 ALL Failure to Comply with Drug and/or Alcohol Assessment ,

Application for public assistance is denied because NAME did not take part
in or complete the alcohol/substance abuse assessment requirement.
MA See Note2 , SNAP continued.
PA: 18 NYC RR 351.2 (i); MA: SSL 366 (1) (a) (1)

Note:
2 If individual is under 21 MA status is continued. If individual is 21 or older with categorical code 09,
14, 26 MA status will default to sanction.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-11
10/22/2012

INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 331! !cont'd!

CODE CATEGORY
P46 SNCA/SNNC Failure to Sign or Revoked the Treatment lnformationalConsent Form
Application for publie assistance is denied because you did not sign or you
revoked the consent for the release of treatment information to this
department.
MA discontinued, SNAP continued.
PA: 18 NYCRR 351.2 (i); MA: SSL 366 (1) (a) (1)

U44 FA Excess Resources - Deemed Resources of Alien Sponsor

Application for public assistance is denied because the total amount of
resources of the alien sponsor exceeds the resource limit.
MA Status AP; SNAP Status AP.
PA: 18 NYCRR 349.3, 352.33; MA: 360-2.6

W12 ALL Failure to Keep Appointment for DSS Medical Assessment !Non LRRl
You did not go for an examination by the doctor that you were referred to.
MA Separate Determination, SNAP Separate Determination
Department Regulations 351.2, 351.8(a)(2)

W35 ALL Fleeing Felon

Client is a fleeing felon.
MA Status AP, SNAP Status RJ
18 NYCRR 351.2(k)(3)(i)

W44 ALL Probation Violator

Client is currently in violation of probation.
MA Status AP; SNAP Status RJ
PA: 18 NYCRR 351.2(k)(3)(ii)

W45 ALL Parole Violator

Client is currently in violation of parole.
MA Status AP; SNAP Status RJ
PA: 18 NYCRR 351.2(k)(3)(ii)

Y98 ALL Other - Manual Notice Required

This code is to be used if none of the other reason codes for denial are
applicable.
MA Status RJ, SNAP Status AP.
PA: Unknown; MA: 360-2.2

ygg ALL Other - Manual Notice Required

This code is to be used if none of the other reason codes for denial are
applicable.
MA Status RJ, SNAP Status AP.
PA: Unknown; MA: 360-3.3; SNAP: 18 NYCRR 387.17

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-12
06/21/2014

INDIVIDUAL REASON CODES !CONT'D>

REJECTION CODES- SNAP <FS: REAS - 351!

CODE VALUE
E72 Institutionalized
18 NYCRR 387.1, 387.14 (a) (5)

E86 Unable to Prove ldentitv to an lnvestigatorv Agency

To be used only by originating center BFI
The documents that the client presented to establish his/her identity are false.
18 NYCRR 387.8(b)(1)(i)

E95 Died
SNAP denied because client is deceased.
18 NYCRR 387.1

E96 Failure to Apply for SNAP on Behalf of a Newborn

SNAP has been denied because an infant is being converted from an "unborn" to a
'newborn". The infant's caretaker must add child to case.
18 NYCRR 387.10, 387.12

F15 Failure to Verify Date of Birth

Client refuses to verify Date of Birth.
18 NYCRR 387.1, 387.8(c), 387.9(a)

F19 Refusal to Cooperate with Quality Control

Client refuses to cooperate with Quality Control.
18 NYCRR 387.9 (a)(7)(ii)

F21 Failure to Provide Social Security Number during Recertification Interview

Client refuses to furnish a Social Security number, or refuses to apply for a Social
Security Number.
18 NYCRR 387.9(a), 387.10(b), 387.16(c)

F22 Failure to Verify Social Security Number

Client refuses to verify Social Security number
18 NYCRR 387.1, 387.8(c), 387.9(a)

F30 Trafficking in SNAP Benefits of $500 or More

Client denied permanently because he/she has been convicted of trafficking in SNAP in
the amount of $500 or more.
18 NYCRR 359.9(c)

F60 Left Household

Household member leaves the household.
18 NYCRR 387.1, 387.10(a), 387.15

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-13
02/21/2016

INDIVIDUAL REASON CODES ICONT'Dl

REJECTION CODES- SNAP IFS: REAS - 351) lcont'dl

CODE VALUE
F63 In Prison
18 NYCRR 387.1, 387.14 (a) (5)

F85 Refusal to Verify Alien Status During Certification Period

Alien refuses to verify his/her alien status.
18 NYCRR 387.1, 387.8(b), 387.9(a)(2), 387.14(a)

F86 Refusal to Verify Alien Status

Alien refuses to verify his/her alien status.
18 NYCRR 387.1, 387.8(b), 387.9(a)(2), 387.14(a)

F90 Ineligible Student

Ineligible student resides in the household.
18 NYCRR 387.1, 387.9(a)

F91 Boarder·
Ineligible boarder resides in the household.
18 NYCRR 387.1, 387.14(a), 387;16(b)

F92 Ineligible Alien

Ineligible alien resides in the household.
18 NYCRR 387.1, 387.8(b), 387.9(a)(2), 387.14(a)

F94 Able Bodied Adult without Dependents IABAWDl

Ineligible able bodied adult who has not met the ABAWD requirements for three or more
months in the past 36 month period.
18 NYCRR 387.13(n)

IP1 Out-of-State IPV

Client has been found guilty of committing an Intentional Program Violation. in another
state.
Department Regulation 359.9

M13 Duplicate Assistance -Active Cash Assistance Case in Other State

The client failed to provide proof that he/she requested his/her out-of-state case to be
closed.
18 NYCRR 387.9(a)(1), SSL 273.3(a)

M97 Receiving Multiple Benefits

Denied for 10 years because the client fraudulently misrepresented his/her identity or
residence in order to receive multiple SNAP benefits at the same time.
18 NYCRR 381.1

M98 Duplicate Assistance. Non-AFIS. In NYS

Client is receiving SNAP on another case in NYS.
18 NYCRR 351.2(a), 351.9

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-14
10/22/2012

INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES- SNAP IFS: REAS - 3511 !cont'd!

CODE VALUE
N31 Voluntary Quit - 1st Occurrence 160 days and until compliance)
Client denied because he/she hasquit his/her job or earned atleast 30 times the Federal
minimum wage or voluntarily reduced the number of hours worked to less than 30 per
w·eek. ·
18 NYCRR 385.13

N32 Voluntary Quit - 2nd Occurrence 1120 days and until compliance)
Client denied because he/she hasquit his/her job or earned at least 30 times the Federal
minimum wage or voluntarily reduced the number of hours worked to less than 30 per
week.
18 NYCRR 385.13

N33 Voluntary Quit - 3rd Occurrence 1180 days and until compliance)
Client denied because he/she hasquit his/her job or earned at least 30 times the Federal
minimum wage or voluntarily reduced the number of hours worked to less than 30 per
week.
18 NYCRR 385.13

N66 Duplicate Assistance, PARIS Match, Interstate

Client is receiving SNAP in another state.
18 NYCRR 351.2(a), 351.9

N90 IPV-Traded SNAP for Firearms. Ammunition or Explosives

Client denied because of a conviction for using SNAP to obtain firearms, ammunition, or
explosives.
18 NYCRR 359.9

W35 Fleeing Felon

Client is a fleeing felon.
18 NYCRR 351.2(k)(3)(i)

W44 Probation Violator

Client is currently in violation of probation.
18 NYCRR 351.2(k)(3)(ii)

W45 Parole Violator

Client is currently in violation of parole.
18 NYCRR 351.2(k)(3)(ii)

Y99 Other - Manual Notice Required

This code is to be used if none of the other reasons for closing a case are applicable.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-15
10/22/2012

INDIVIDUAL REASON CODES !CONT'D!

.SANCTION CODES- PA IPA: REAS - 331!

CODE CATEGORY
E21 ALL Failure to Provide Child's SSN
Public assistance has been discontinued because the client failed to
provide a social security card or apply for a Social Security card for each
child on the case.
MA discontinued, SNAP discontinued.
PA: (FA/SNFP) 18 NYCRR 369.2, (SNCA/SNNC) 370.2; MA: 360-2.6

EZ1 ALL Failed to Apply for SSI

Public assistance has been discontinued because the client failed to apply
forSSI.
MA continued, SNAP continued.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

EZ2 ALL Failed to Appeal an SSI Denial

Public assistance has been discontinued because the client failed to
appeal an SSI denial.
MA continued, SNAP continued.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

EZ3 ALL Failed to Accept SSI

Public assistance has been discontinued because the client was found
eligible for SSI but refused to accept the SSI benefit.
MA continued, SNAP continued.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

EZ4 ALL Failed to Complete Application Steps for SSI !WeCarel

Public assistance has been discontinued because the client failed to
complete the application steps for SSI that are required by WeCare.
MA continued, SNAP continued.
18 NYCRR 352.30(f), 369.2(h), 370.2(b)(5)

F17 ALL Failure to Validate Incorrect SSN.

Note: Cannot be used for individuals with category codes 15,36,48.
MA discontinued, SNAP di.scontinued.
PA: (SNCA/SNNC) 18 NYCRR 370.2, (FA/SNFP) 18 NYCRR 369.2;
MA: 360-2.6

F20 ALL Failure to Provide SSN

Public assistance has been discontinued because the client failed to
provide a Social Security number or apply for a Social Security number.
Note: .Cannot be used for individuals with category codes 15,36,48.
MA discontinued, SNAP discontinued.
PA: (SNCA/SNNC) 18 NYCRR 370.2, (FA/ SNFP) 18 NYCRR 369.2;
MA: 360-2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-16
06/19/2016

INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES - PA IPA: REAS - 3311 !cont'd)

CODE CATEGORY
F40 ALL Failure to Enroll in Group Health Plan
Public assistance has been discontinued because the client has failed to
sign up and use group health insurance benefits.
MA discontinued, SNAP continued.
PA: 18 NYCRR 349.6; MA: 360-2.2

F84 ALL Failure to Sign Lien

Public assistance has been discontinued because the client refused to
sign a lien agreement on property..
MA See Note1, SNAP continued.
PA: 18 NYCRR 352.27; MA: 360-2.6

MX1 FA/SNFP Failure to Take Part in Rehabilitation Program - 1st Offense

Public assistance has been discontinued because the client did not enroll
Code MX2- Output Code or continue to take part in the rehabilitation program. The client cannot get
for a 120- Day Sanction public assistance for 45 days.
Code MX3- Output Code
MA See Note 1 , SNAP continued.
for a 180-Day Sanction
I PA: 18 NYCRR 351.2 (i); MA: 366 (1) (a) (1)

N20 ALL Failure to Notify of Minors Temporary Absence

This is because (NAME) did not notify us within five days of when he/she
knew that (Minor's Name) would be absent from the household for 45 days
or more. (Name) will not be eligible to receive assistance for (# Months).
(Name) may apply for a cash grant at any time, but cannot get cash grant
before (Date= Sanction duration + 1 day).
MA See Note 1, SNAP continued
PA: 18NYCRR 349.4, MA: 360-2.6

N41 ALL Voluntary Quit 1st Occurrence

This is because the PA recipient quit a job or reduced the number of hours
worked without good cause. Until compliance.
MA Continued; SNAP continued
18 NYCRR 385.12, 385.13; MA: 360-2.6

If FA case MA is continued. If individual is under 21, MA Status is continued. If individual is 21

or older (non-FA), MA status is discontinued.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-17
02/21/2016

INDIVIDUAL REASON CODES ICONT'Dl

SANCTION CODES- PA IPA: REAS - 331) !cont'd)

CODE CATEGORY
P44 ALL Failure to Comply with Drug and/or Alcohol Screening
Public assistance has been discontinued because NAME did nottake part
in or complete the alcohol/substance abuse screening requirement.
MA See Note2 , SNAP continued.
PA: 18 NYCRR 351.2 (i); MA: 360-2.6

P45 ALL Failure to Comply with Drug and/or Alcohol Assessment

Public assistance has been discontinued because NAME did not take part
in or complete the alcohol/substance abuse assessment requirement.
MA See Note 2, SNAP continued.
PA: 18 NYC RR 351.2 (i); MA: SSL 366 (1) (a) (1)

P46 SNCA/SNNC Failure to Sign or Revoked the Treatment lnformationalConsent Form

Public assistance has been discontinued because you did not sign or you
revoked the consent for the release of treatment information to this
department.
MA discontinued, SNAP continued.
PA: 18 NYCRR 351.2 (i); MA: SSL 366 (1) (a) (1)

PX1 FA/SNFP Failure to Take Part in Rehabilitation Program -1st Offense

Public assistance has been discontinued because the client did not take
Code PX2- Output Code part in and complete the rehabilitation program. The client cannot get
for a 120- Day Sanction public assistance for 45 days.
Code PX3- Output C_ode
MA See Note 1 , SNAP continued.
for a 180-Day Sanction
PA: 18 NYC RR 351.2 (i); MA: 366 (1) (a) (1)

VE1 ALL Intentional Misrepresentation of a Disability - 90 Day Sanction

This is because you without good reason intentionally misrepresented that
VE2- Output code for 150 you suffered from an impairment that would limit your assignment to work
day sanciion. activities or make you exempt from assignment to work activities.
VE3- Output code for 180 MA continued, SNAP continued
day sanction.. ·PA: 18 NYCRR 385.2, 385.12 (d) MA: 18NYCRR 360-2.6

If FA case MA is continued. If individual is under 21, MA Status is continued. If individual is 21

or older (non-FA), MA status is discontinued.

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INDIVIDUAL REASON CODES !CONT'D)

SANCTION CODES - PA IPA: REAS - 3311 lcont'dl

CODE CATEGORY
V30 ALL Failure to Comply with IV-D
This is because the client failed to meet the cooperation requirement of the
child support enforcement program.
Budget Reduction Code. Case status will not change.
MA continued; SNAP continued
PA: 18 NYCRR 369.2; MA: 18 NYCRR 360-2.6
SNAP: 18 NYCRR 387.10, 387.12

W40 ALL Failure/Refusal to Become Employable

This is because the client failed to do what was needed to become
employable. Client would not accept referral to, or take active part in,
medical care or vocational rehabilitation or training.
MA continued, SNAP continued
PA: 18 NYCRR 385.12(a); MA: 18 NYCRR 360-2.6

WC1 SNCA Failure to Comply with Employment Requirements Determined by the

Refugee Service Agency 90 day sanction.
Code WC2 - Output code !Manual Notice Required)
for 180 day sanction Public assistance has been discontinued because the client failed to report
to a job interview, accept employment, or voluntarily quit a job they were
referred to by the Refugee Service Agency.
MA continued, SNAP continued
PA:18 NYCRR 373.6 (h); MA: 360-2.1, 360-2.2

WE1 ALL Failure to Comply with Employment Requirements

Individual failed to comply with employment requirements. Until
compliance.
MA continued, SNAP continued
18 NYC RR 385.9, 385.12; MA: 366 (1) (a) (1)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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INDIVIDUAL REASON CODES /CONT'D!

SANCTION CODES- PA IPA: REAS - 3311 !cont'd!

CODE CATEGORY
WS1 ALL Orig. ID: EPF Only IPV - 6 Months 1st Offense - $1.000
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was $1,000 you are disqualified from
receiving public assistance for 6 months. You may reapply for public
assistance 90 days before the expiration date, though to prevent a delay in
getting assistance again reapply with no less than 30 days remaining
before your disqualification period ends. Your case will not automatically
be reopened when it ends.
MA continued, SNAP continued.
PA: 18 NYC RR 359.9 (a), 352.30 (g) MA: SSL 366 (1) (a) (1)

WS2 ALL Orig. ID: EPF Only IPV - 12 Months 2nd0ffense-Less than $3,900
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 2nd occurrence and/or
the amount you wrongly received was less than $3,900 you are
disqualified from receiving public assistance for 12 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again reapply with no less than 30
days remaining before your disqualification period ends. Your case will not
automatically be reopened when it ends.
MA continued, SNAP continued.
PA: 18 NYC RR 359.9 (a), 352.30 (g) MA: SSL 366 (1) (a) (1)

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INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES - PA IPA: REAS - 331! !cont'd)

CODE CATEGORY
WS3 ALL Orig. ID: EPF OnlvlPV -12Months1st Offense Between $1.000 &
$3.900
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was $ you are disqualified from
receiving public assistance for 12 months. You may reapply for public
assistance 90 days before the expiration date, though to prevent a delay in
getting assistance again reapply with no less than 30 days remaining
before your disqualification period ends. Your case will not automatically
be reopened when it ends.
MA continued; SNAP continued.
PA: 18 NYCRR 359.9 (a), 352.30 {g) MA: SSL 366 (1) (a) (1)

WS4 ALL Orig. ID: EPF Only IPV -18 Months if 3rd Offense
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 3rd occurrence and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again reapply with no less than 30
days remaining before your disqualification period ends. Your case will not
automatically be reopened when ii ends. ·
MA continued; SNAP continued.
PA: 18 NYCRR 359.9 (a), 352.30 (g) MA: SSL 366 (1) (a) (1)

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INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES - PA IPA: REAS - 331! !cont'd!

CODE CATEGORY
WS5 ALL Orig. ID: EPF Only IPV -18 Months if 1st0ffense More Than $3.900
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 1st occurrence and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again reapply with no less than 30
days remaining before your disqualification period ends. Your case will not
automatically be reopened when it ends.
MA continued, SNAP continued.
PA: 18 NYC RR 359.9 (a}, 352.30 (g) MA: SSL 366 (1) (a) (1)

WS6 ALL Orig. ID: EPF Only IPV - 18 Months if 2nd-Offense More Than $3.900
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 2nd occurrence and/or
the amount you wrongly received was more than $3,900 you are
disqualified from receiving public assistance for 18 months. You may
reapply for public assistance 90 days before the expiration date, though to
prevent a delay in getting assistance again reapply with no less than 30
days remaining before your disqualification period ends. Your case will not
automatically be reopened when it ends.
MA continued; SNAP continued.
PA: 18 NYC RR 359.9 (a), 352.30 (g) MA: SSL 366 (1) (a) (1)

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SANCTION CODES - PA IPA: REAS - 3311 !cont'd!

CODE CATEGORY
WS? ALL Orig. ID: EPF Only IPV - 5 Years 4th or Subsequent Offense
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the 4th or subsequent
occurrence and/or the amount you wrongly received was $ you are
disqualified from receiving public assistance for 5 years. You may reapply
for public assistance 90 days before the expiration date, though to prevent
a. delay in getting assistance again reapply with no less than 30 days
remaining before your disqualification period ends. Your case will not
automatically be reopened when it ends.
MA continued; SNAP continued.
PA: 18 NYC RR 359.9 (a), 352.30 (g) MA: SSL 366 (1) (a) (1)

WSB ALL Orig. ID: EPF OnlylPV - Court Ordered Disqualification Court ordered
disqualification is based on the finding of the court that the client has
been found qyilty of committing an IPV. The period is determined by
the court and may differ from those above.
You have been found guilty of committing an Intentional Program Violation
(IPV) either through an administrative disqualification hearing, a judicial
decision, you signed a disqualification consent agreement or signed a
waiver to an administrative hearing. As this was the _ _ occurrence
and/or the amount you wrongly received was$ you are disqualified
from receiving public assistance for months. You may reapply for
public assistance 90 days before the expiration date, though to prevent
a delay in getting assistance again reapply with no less than 30 days
remaining before your disqualification period ends. Your case will not
automatically be reopened when it ends.
MA continued; SNAP continued.
PA: 18 NYCRR 359.9 (a), 352.30 (g) MA: SSL 366 (1) {a) (1)

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INDIVIDUAL REASON CODES ICONT'Dl

SANCTION CODES - SNAP IFS: REAS - 3511

CODE VALUE
F20 Failure to Provide Social Securitv Number during Certification Period
Client refuses to furnish a Social Security number, or refuses to apply for a Social
Security Number.
18 NYCRR 387.1, 387.9(a), 387.10(b), 387.16(c)

IP1 Out-of-State IPV

Client has been found guilty of committing an Intentional Program Violation in another
state.
Department Regulation 359.9

N41 Voluntary Quit: Recipient. 1st Occurrence 12 months and until compliance!
Sanction line because recipient has quit his/her job of at least 30 hours per week or
voluntarily reduces the number of hours worked to less than 30 per week.
18 NYCRR 385.13

N42 Voluntary Quit: Recipient. 2nd Occurrence 14 months and until compliance)
Sanction line because recipient has quit his/her job of at least 30 hours per week or
voluntarily reduces the number of hours worked to less than 30 per week.
18 NYCRR 385.13

N43 Voluntary Quit: Recipient. 3rd Occurrence !6 months and until compliance) .
Sanction line because recipient has quit his/her job of at least 30 hours per week or
voluntarily reduces the number of hours worked to less than 30 per week.
18 NYCRR 385.13

NF1 Purchased Illegal Drugs with SNAP-IPV - 1st Violation

Remove the person from the case for 12 months because of a conviction for using SNAP
to obtain illegal drugs.
18 NYCRR 359.9

NF2 Purchased Illegal Drugs with SNAP-IPV - 2nd Violation

Remove the person permanently from the case because of a second conviction for using
SNAP to obtain illegal drugs.
18 NYCRR 359.9

WE1 Failure to Comply With Employment Requirement 1st Occurrence !2 months and
until compliance)
Individual failed to comply with employment requirements.
18 NYCRR 385.9, 385.12

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INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES- SNAP IFS: REAS - 351! !cont'd!

CODE VALUE
WE2 Failure to Comply With Employment Requirement 2nd Occurrence 14 months and
until compliance!
Individual failed to comply with employment requirements.
18 NYCRR 385.9, 385.12

WE3 Failure to Comply With Employment Requirement 3rd Occurrence 16 months and
until compliance)
Individual failed to comply with employment requirements.
18 NYCRR 385.9, 385.12

WF1 SNAP Intentional Program Violation: Infraction 1st Occurrence !Orig. ID EPF Only!
Client Intentionally violated the SNAP rules and will not be able to get SNAP for 1 year.
18 NYCRR 387.10 and 359.3

WF2 SNAP Intentional Program Violation: Infraction 2nd Occurrence !Orig. ID EPF Only)
Client intentionally violated the SNAP rules and will not be able to get food
stamps for 2 years.
18 NYCRR 387.10 and 359.3

WF3 SNAP Intentional Program Violation: Infraction 3rd Occurrence !Orig. ID EPF Only)
Client intentionally violated the SNAP rules and will not be able to get SNAP ever again
because this is the third violation.
18 NYCRR 387.10 and 359.3

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INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES - PA IPA: REAS - 331 l

CODE CATEGORY
E72 ALL Institutionalized
Public assistance has been discontinued because the client was admitted
or committed to an institution.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 352.31 (a); MA: 360-2.6

E73 ALL In Foster Care

Public assistance has been discontinued because the child is in Foster
Care and there is no plan for him/her to return home.
MA discontinued, SNAP continued.
PA: 18 NYCRR 352.30, 369.4; MA: 360-1.2, 360-2, 360-3.3

E86 ALL Unable to Prove Identity to an Investigatory Agency

To be used only by originating center BFI
Public assistance has been discontinued because the documents that the
client presented to establish his/her identity are false.
MA discontinued, SNAP discontinued
PA: 18 NYCRR 351.1(b)(2)

E90 ALL Client Requested Removal from Case

Public assistance has been discontinued because the client asked to be
· removed from the case.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.2

E94 ALL Receiving SSI

Public assistance has been discontinued because the client's SSI
payment amount exceeds the individual's budgeted needs.
MA continued, SNAP continued.
PA: 18 NYCRR 352.29; MA: 360-2.6

E95 ALL Died

Public assistance is discontinued because the client is deceased.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 351.8; MA: 360-2.6

E96 FA/SNFP Failure to Apply for Public Assistance on Behalf of a Newborn

Public assistance has been discontinued because an infant is being
converted from an "unborn" to a "newborn".
MA continued, SNAP discontinued.
PA: 18NYCRR 366 (g); MA: Not Applicable

E97 ALL Client Requested Removal from Case

Public assistance has been discontinued because the client asked to be
removed from the case.
MA continued, SNAP discontinued.
PA: 18 NYCRR 351.22(f), 358-3.3(d); MA: 360-2.2

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INDIVIDUAL REASON CODES !CONT'D)

REMOVAL CODES - PA IPA: REAS - 331) lcont'dl

CODE CATEGORY
F60 ALL Left Household
Public assistance has been discontinued because the client left the
household.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 351.22,352.30, 352.32; MA: 360-2.2

F61 ALL No Longer Essential to Household !Essential Person)

Public assistance has been discontinued because there is no longer any
need for client to provide care to another member of the householcl.
MA continued, SNAP continued.
PA: 18 NYCRR 369.3 (c) (2); MA: 360-2.2

FS3 ALL In Prison

Public assistance has been . discontinued because the client was
committed to prison.
MA discontinued, SNAP discontinued.
PA: 18NYCRR 352.31 (a) 370.2; MA: 360-2.2

F64 ALL In Prison Outside of NYS

Public assistance has been discontinued because the client was
committed to prison outside New York State or to a Federal penitentiary
within New York State.
MA discontinued, SNAP discontinued.
PA: 18NYCRR 352.31 (a) 370.2; MA: 360-2.2

F66 ALL Will Receive PA in Another Case

Public assistance has been discontinued because the client has been
added to another public assistance case.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 352.1; MA: 360-2.2

F75 ALL Temporarv Absence of Minor

Public assistance has been discontinued because client was absent from
household for 45 days or more, without good cause.
MA continued, SNAP continued.
PA: 18 NYCRR 349.4; MA: 366 (4) (q).

F76 ALL Minor Parent Not in School

Public assistance has been discontinued because client is less than 18
years old, unmarried has a child at least 12 weeks old and failed to
participate in a program attain a high school diploma or an alternative
educational or training program.
MA continued, SNAP continued.
PA: 18 NYCRR 351.2 (k) (4); MA: 360-2.6

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INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES - PA {PA: REAS - 3311 !cont'd!

CODE CATEGORY
F88 ALL Failure to Comply With Finger Imaging Requirement - Non Legally
Responsible Adult
Public assistance has been discontinued because of your failure to comply
with finger imaging requirements.
MA continued, SNAP continued.
PA: 18 NYCRR 351.2 351.9; MA: 360-2.2

F92 ALL Failure to Provide Proof or Citizenship or Eligible Alien Status

Public assistance has been discontinued because the client failed to
provide proof of citizenship or of being a legal alien resident.
MA Separate Determination, SNAP continued.
PA: 18 NYCRR 349.3; MA: 360-2.6

F93 ALL Failure/Refusal to Sign Citizenship/Alien Declaration

Application for public assistance is denied because the client failed to sign
the citizenship or satisfactory alien status declaration on the application
form.
MA continued, SNAP Status RJ
PA: 18 NYC 351.2 (h); MA: 18 NYCRR 360-2.6

H14 ALL Failure to Provide Proof of U.S Citizenship and Identity - SSA/BVI
Match
Public assistance has been discontinued because, after failing the SSA/
BVI match, the client failed to provide proof of identity and U.S. citizenship
or satisfactory immigration status.
MA discontinued, SNAP continued.
PA: 18 NYC RR 351.1 (b)(2)(ii), 351.2, 351.5, 351.6, 351.8(a)(2)(ii);
MA: 360-1.2, 360-2.3, 360-3.2(j), 369-ee

M13 ALL Duplicate Assistance - Active Cash Assistance Case in Other State
Client failed to provide proof that he/she requested his/her out-of-state
case to be closed.
MA discontinued, SNAP discontinued
PA: 18 NYC RR 351.1 (b)(2)(ii), 351.2, 351.8(a)(2)(i), 351.9

M33 FA/SNFP Excess Income - Deemed Income of Alien Sponsor

Public assistance has been discontinued because the deemed income of
the alien sponsor exceeds the client's budgeted needs.
MA continued, SNAP continued.
PA: 18 NYCRR 349.3 352.33; MA: 360-2.2

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INDIVIDUAL REASON CODES !CONT'D)

REMOVAL CODES- PA IPA: REAS - 331) lcont'dl

CODE CATEGORY
M97 ALL Receiving Multiple Benefits
Public assistance has been discontinued because client fraudulently
misrepresented his/her identity or residence to receive multiple public
assistance benefits at the same time. The client is ineligible to receive
public assistance and SNAP benefits for 10 years beginning DATE.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 351.2 (i) (2), 359.9 {d) (1); MA: 366 (1) (a) (1)

M98 ALL Duplicate Assistance - Non AFIS In NYS

Public assistance has been discontinued because the client's identity
matches another person who is receiving public assistance in NY State.
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 351.9; MA: 360-2.2 (e) (f)

M99 ALL Duplicate Assistance - AFIS In NYS

Public assistance has been discontinued because the client's identity
matches another person who is receiving public assistance in NY State.
MA discontinued, SNAP discontinued.
This code is used when there has been an Automated Finger Imaging
Match (AFIS)
PA: 18 NYCRR 351.9; MA: 360-2.2 (e) (f)

N44 ALL Fail to Get Medical Statement

Public Assistance has been discontinued because the client failed to get
medical statements to prove medical disability exists.
MA Continued; SNAP Status AP.
PA: 18 NYCRR 351.21 (f); MA: 360-2.6

N49 ALL Minor Parent Refused Offer of a Home

Public assistance has been discontinued because you are unmarried, less
than 18 years old, pregnant or caring for a minor dependent child, and you
refuse to reside in suitable housing provided by a parent or guardian or in
an approved adult supervised living arrangement.
MA continued, SNAP continued.
PA: 18 NYCRR 369.2; MA: 360-2.6

N50 ALL Refused Offer of a Home - Rejection of Claim that Housing

Arrangementlsl would Jeopardize Health and Safety
Public assistance has been discontinued because you are unmarried, less
than 18 years old, pregnant or caring for a minor dependent child, and you
refuse to reside in suitable housing provided by a parent or guardian or in
an approved adult supervised living arrangement. We have investigated
and rejected your claim that the housing arrangement(s) would jeopardize
your health and safety.
MA continued, SNAP continued.
PA: 18 NYCRR 369.2; MA: 360-2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES - PA IPA: REAS - 331! !cont'd!

CODE CATEGORY
N66 ALL Duplicate Assistance - PARIS Match Interstate
Public assistance has been discontinued because the client matches
another person who is receiving public assistance in another state. (Must
be used with originating ID CFI only.)
MA discontinued, SNAP discontinued.
PA: 18 NYCRR 351.8 (a) (2) (i), 351.1 (b) (2) (ii), 351.2, 351.9;
MA: 360-2.2 (e) (f)

U44 FA Excess Resources - Deemed Resources of Alien Sponsor

Public assistance has been discontinued because the total amount of
resources of the alien sponsor exceeds the resource limit.
MA continued, SNAP continued.
PA: 18 NYCRR 349.3, 352.33; MA: 360-2.6

W12 ALL Failure to Keep Appointment for DSS Medical Assessment !Non LRRl
Client failed to keep an appointment with the doctor that the client was
referred to.
MA continued, SNAP Separate Determination
"Department Regulations 351.2, 351.8(a)(2)

W35 ALL Fleeing Felon

Client is currently a fleeing felon.
MA continued, SNAP discontinued.
PA: 351.2(k)(3)(i)

W44 ALL Probation Violator

Client is currently in violation of probation.
MA continued, SNAP discontinued
PA: 18 NYCRR 351.2(k)(3)(ii)

W45 ALL Parole Violator

Client is currently in violation of parole.
MA continued, SNAP discontinued
PA: 18 NYCRR 351.2(k)(3)(ii)

2 If individual is. under 21 MA status is continued. If individual is 21 or older with categorical code 09,
14, 26 MA status will default to sanction. ·

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INDIVIDUAL REASON CODES ICONT'Dl

REMOVAL CODES- PA IPA: REAS - 331! lcont'dl

CODE CATEGORY
Y97 ALL Re-affiliated for SNAP ourposes
MA continued, SNAP continued.
PA: 351.21 (f}; MA: 360-1.2, 360-2, 360-3.3

Y98 ALL Other - Manual Notice Required

This code is to be used if none of the other reasons for closing an
individual are applicable.
No MA extension, SNAP continued.
PA: Unknown; MA: 360-2.2

ygg ALL Other - Manual Notice Required

This code is to be used if none of the other reasons for closing an
individual are applicable.
MA continued, SNAP continued.
PA: Unknown; MA: 360-3.3

921 ALL Active Unborn Now Activated to Newborn

Public assistance has been discontinued because the unborn has been
activated for MA/SNAP.
MA continued, SNAP continued.
This code is system generated when there has been an Automated
Newborn Activation transaction.

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INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES- SNAP IFS: REAS - 3511

CODE VALUE
E86 Unable to Prove Identity to an Investigatory Agency
To be used only by originating center BFI
The documents that the client presented to establish his/her identity are false.
18 NYCRR 387.8(b)(i)(1)

E95 Died
Case member dies.
18 NYCRR 387.1

E96 Failure to Apply for SNAP on Behalf of a Newborn

SNAP has been discontinued because an infant is being converted from an "unborn" to a
'newborn". The infant's caretaker must add child to case.
18 NYCRR 387.10, 387.12

F15 Failure to Verify Date of Birth

Client refuses to verify Date of Birth.
18 NYCRR 387.1, 387.8(c), 387.9(a)

F19 Refusal to Cooperate with Quality Control

Client refuses to cooperate with Quality Control.
18 NYCRR 387.9 (a)(7)(ii) '

F21 Failure to Provide Social Security Number during Recertification Interview

Client refuses to furnish a Social Security number, or refuses to apply for a Social
Security number.
18 NYCRR 387.9(a}, 387.10(b), 387.16(c)

F22 Failure to Verify Social Security Number

Client refuses to verify Social Security number
18 NYCRR 387.1, 387.8(c), 387.9(a)

· F30 Trafficking in SNAP Benefits of $500 or More

Close the line permanently because the client has been convicted of trafficking iri SNAP
in the amount of $500 or more.
18 NYCRR 359.9(c)

F60 Left Household

Household member leaves the household.
18 NYCRR 387.1, 387.10(a), 387.15

F85 Refusal to Verify Alien Status During Certification Period

Alien refuses to verify his/her alien status.
18 NYCRR 387.1, 387.8(b), 387.9(a)(2}, 387.14(a)

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INDIVIDUAL REASON CODES !CONT'D>

REMOVAL CODES -SNAP IFS: REAS. 351! !cont'd)

CODE VALUE
F86 Refusal to Verify Alien Status IRecert Closing)
Alien refuses to verify his/her alien status.
18 NYCRR 387.1, 387.8(b), 387.9(a)(2), 387.14(a)

F90 Ineligible Student

Ineligible student resides in the household.
18 NYCRR 387.1, 387.9(a)

F91 Boarder
Ineligible boarder resides in the household.
18 NYCRR 387.1, 387.14(a), 387.16(b)

F92 Ineligible Alien

Ineligible alien resides in the household.
18 NYCRR 387.1, 387.8(b), 387.9(a)(2), 387.14(a)

F94 Able Bodied Adult without Dependents IABAWDl

Ineligible able bodied adult who has not met the ABAWD requirements for three or more
months in the past 36 month period.
18 NYCRR 385.3

M13 Duplicate Assistance - Active Cash Assistance Case in Other State

Client failed to provide proof that he/she requested his/her out-of-state case to be closed.
18 NYCRR 387.9(a)(1), SSL 273.3(a)

M97 Receiving Multiple Benefits

Close the line for 10 years because the client fraudulently misrepresented his/her identity
or residence in order to receive multiple SNAP benefits at the same time.
18 NYCRR 381.1

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/22/2012

INDIVIDUAL REASON CODES ICONT'Dl

REMOVAL CODES-SNAP CFS: REAS - 351! lcont'dl

CODE VALUE
M98 Duplicate Assistance - Non AFIS. In NYS
Client is receiving SNAP on another case in NYS.
18 NYCRR 351.2(a), 351.9

N66 Duplicate Assistance - PARIS Match. Interstate

Client is receiving SNAP in another state. (Must be used with originating ID CFI only.)
18 NYCRR 351.2(a), 351.9

N90 IPV-Traded SNAP for Firearms. Ammunition or Explosives

Close line because of a conviction for using SNAP to obtain firearms, ammunition, or
explosives.
18 NYCRR 359.9

W35 Fleeing Felon

Client is currently a fleeing felon.
18 NYCRR 351.2(k)(3)(i)

W44 Probation Violator

Client is currently in violation of probation.
18 NYCRR 351.2(k)(3)(ii)

W45 Parole Violator

Client is currently in violation of parole.
18 NYCRR 351.2(k)(3)(ii)

Y99 Other-Manual Notice Required

This code is to be used if none of the other reasons for closing a case are applicable

968 Forced Closing - SYSTEM GENERATED

18 NYCRR 387.1

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.5-34
10/22/2012

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-1
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT

INCREASE IN PA GRANT

1. Change in Household Size

PA: 352.30, 352.32 (e)

MA: 360-2.2(a), 360-2.2(b), 360-2.2 (c), 360-4.2

SNAP: 387.1(!), 387.17 (e)

2. Reduction In Income

PA: 352.29

MA: 360-4.3, 360-4.6

SNAP: 387.10(b), 387.17(e)

3. Decrease In Amount or Completion of Recoupment

PA: 352.11, 352.31 (d)

MA: N/A

SNAP: 387.19 (a) (5)

4. Increase In Shelter Costs.

PA: 352.3

MA: N/A

SNAP: 387.10 (a), 387.12 (e)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-2
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT !CONT'D>

DECREASES IN PA GRANT

1. Failure without Good Cause to Provide Information about Return of Absent Parent

PA: 369.2 (b), 369.2 (g)

MA: 360-2.2

SNAP: N/A

2. Ineligible Alien Removed From Grant

PA: 349.3 (b), 351.2 (h)

MA: 360-3.2 (f)

SNAP: 387.9 (a), 387.10 (b) 387.10 (b), 387.16 (c)

3. Decrease In Dependent Care Costs.

PA: 352. 7, 352.19

MA: N/A

SNAP: 387.12 (d)

4. Failure To Comply With Employment Related Requirements.

PA: 385.5, 385.14, 392.10

MA: N/A

SNAP: 387.13

5. Fraud

PA: 348.4, 352.31 (d)

MA: 360-4.4 (c)

SNAP: 399.9

6. Failure to Provide or Apply for Social Security Number

PA: 369.2 (b), 370.2 (c)

MA: 360-2.3 (a)

SNAP: 387.9 (a), 387.10 (b), 387.16 (c)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-3
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT !CONT'D!

DECREASES IN PA GRANT !CONT'D!

7. Receipt of or Increase In Earned Income

PA: 352.29, 352.29

MA: 360-4.3 (f)

SNAP: 387.10

8. Refused to Enroll or Refused to Provide Information Regarding Employer Group

Health Information

PA: 349.6

MA: 360-3.2 (d, 360-3.2 (e)

SNAP: N/A

9. Non-Compliance with Employment Related Requirements

PA: 385.5, 385.14

MA: N/A

SNAP: 387.13

10. Non-Compliance with WIN Demonstration

PA: 392.9 (a), 392.10

MA: N/A

SNAP: 387.13

11. Change in Household Size

PA; 352.30

MA: 360-2.2 (a) (b) (c), 360-4.2

SNAP: 387.1 (t), 387.10 (a)

12. No Longer Incapacitated

PA: 351.21

MA: 360-2.2

SNAP: 387.1 (m)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-4
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT ICONT'Dl

DECREASES IN PA GRANT !CONT'D!

13. Resident of Private or Public Institution

PA: 352.8

MA: 360-3.3 (b), 360-3.1 (g)

SNAP: 387.1 (t)

14. Failure to Comply With Our Request To Determine Your Employability and Availability
To Participate in Bureau of Employment Services Program. (30 Day Sanction)

PA: 385.14

MA: N/A

SNAP: 387.13

15. Failure Without Good Cause To File A Petition Requesting Support From A Legally
Responsible Relative.

PA: 369.2 (b), 370.4, 351.2 (e)

MA: 360-4.3 (f)

SNAP: N/A

16. Transferred Property For The Purpose Of Qualifying For Assistance.

PA: 370.2 (c)

MA: 360-4.4 (c)

SNAP: 387.9

17. Increase In Recoupment Amount

PA: 352.31 (d)

MA: N/A

SNAP: 387.19 (a)

18. Recovery, Lien and/or Assignment Excluding or Including Homestead.

PA: 352.23, 352.27 (a)

MA: 360.2.3 (a), 360-4.7 (a)

SNAP: N/A

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-5
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT !CONT'D)

DECREASES IN PA GRANT !CONT'D\

19. Refusal To Cooperate

PA: 352.30 (c)

MA: 360-2.3 (a)

SNAP: 387.8 (a)

20. Excess Resources.

PA: 352.23 (b)

MA: 360-3.8 (c), 360-4.7 (b), 360-4.8 (a)

SNAP: 387.9 (a)

21. Decreased Shelter Costs.

PA: 352.3, 352.32 (e)

MA: N/A

SNAP: 387. 10 (a), 387. 12 (e)

22. Ineligible Striker.

PA: 369.5 (d)

MA: N/A

SNAP: 387.16 U)

23. Receipt of or increase In Support Due To Absent Parent's Return.

PA: 352.32 (b), 352.30 (a)

MA: 360-4.3

SNAP: 387.10

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-6
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT !CONT'D>

DECREASES IN PA GRANT !CONT'D!

24. Receipt of or increase In Support Due to Marriage of Parent.

PA: 352.14 (a), 352.29, 352.31, 352.32 (b)

MA; 360-4.3

SNAP: 387.10

25. Receipt of or Increase In Support From Absent Father Outside Home

PA: 351.2 (d), 352.14 (a), 352.29, 352.32 (b)

MA: 360-4.3 (f)

SNAP: 387.10

26. Receipt of or Increase In Support From Person (Other Than Father) Outside Home.

PA: 351.2 (d), 352.29, 352.32 (b)

MA: 360-7

SNAP: 387.10

27. Refused To Accept or Complete Training or Education.

PA: 385.5, 385.14

MA: N/A

SNAP: 387.13 (e)

28. Receipt of or Increase In Unearned Income.

PA: 352.29, 352.32

MA: 360-4.3

SNAP: 387.10

29. Failure To Provide Verification

PA: 351.6

MA: 360-2.3 (a)

SNAP: 387.8 (c), 387.14 (a)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-7
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT ICONT'Dl

DECREASES IN PA GRANT ICONT'Dl

30. Voluntary Quit.

PA: 18 NYCRR 385.11, 385.15

MA: N/A

SNAP: 387.13 (i)

31. Refused To Work Register and Seek Work.

PA: 18 NYCRR 385.5, 385.14

MA: N/A

SNAP: 387.9 (a), 387.13

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
1.6-8.
10/22/2012

REGULATORY CITATIONS FOR CHANGES IN PA/SNAP GRANT !CONT'D!

CHANGES IN SNAP GRANT

1. Change in income

387.10 (b)

2. Change in shelter costs.

387.12 (e)

3. Change in household size.

387.1 (t)

4. Change in dependent care costs.

387.12 (d)

5. An elderly/disabled household entitled to an uncapped excess shelter deduction. (To

be used when household becomes eligible/ineligible for the change in grant for this
reason.

387.1 (m), 387.12 (e) (2)

6. Change in medical costs.

387.12 (c)

7. Change in allotment.

387.19 (a) (5)

8. Change due to failure of household member to provide an SSN. (Person (s) not to be
counted as member of household but income is to be prorated)

387.9 (a) (2), 387.10 (b) (3), 387.16 (c) (2)

9. Change due to failure of household member to verify alien status. (Person (s) not to be
counted as member of household but income is to be prorated).

387.9 (a) (2), 387.10 (b) (3), 387.16 (c) (2)

10. Change due to failure of non-head of household to comply with Work Registration
Requirements.

387.9 (a) (4), 387(!) (4) (v), 387.13 (e)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-1
06/21/2014

CHAPTER 2-
AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEU

SCREEN NSBL02: HOUSEHOLD/SUFFIX FINANCIAL DATA

SNAP REPORT CODES IFRl

S Recert report for PA/SNAP cases with earned income
N Periodic mailer for NPA/SNAP cases with earned income

SHELTER PRORATION INDICATOR CODES !PRO IND\

A Enhanced Shelter Calculation
H HASA 30% Income Deduction Shelter Supplement (System Generated)
I SNAP Ineligible Student
L Allow Entry Of PA Shelter Amount To Exceed SNAP Shelter Amount
M Danks Housing Situation - Two or more households (suffixes) living together as separate
economic units with no legal responsibility among the households (suffixes). Each suffix
receives unprorated Basic, HEAi, HEAii & Fuel Allowance and Zero PA Shelter
N Non-Danks Housing Situation - Two households (active suffixes) living together as one
economic unit with no legal responsibility among the household (suffixes). Each suffix
receives prorated Basic, HEAi HEAii & Fuel Allowance and unprorated PA Shelter
Allowance. ·
0 (Letter 0) Budgets A Zero PA Shelter Allowance For Single Suffix Cases Or Multi-Suffix
Cases With Only One Active Suffix
P Three Generation Household - Grandmother/Mother (Between 18 and 21 Years of Age)/
Child
R NPA/SNAP Residential Treatment Facility Budget
S Danks Housing Situation - Two household (active suffixes) living together as separate
economic units with no legal responsibility among the household (suffixes). Each suffix
receives unprorated Basic, HEAi, HEAii, Fuel and PA Shelter Allowance.
Z Non-Danks Housing Situation - Two or more households (suffixes) living together one
economic unit with no legal responsibility among the household (suffixes). Each suffix
receives prorated Basic, HEAi, HEAii & Fuel Allowance and Zero PA Shelter Allowance.

SHELTER TYPE CODES !SHELT: TYPE!

01 Unfurnished Apartment or Room
02 NYCHA Apartment - Utilities Included
03 Own Home (Includes Trailer)
04 Room and Board (Use Action Type 02 - PA Only)
06 Hotel/Motel Temporary
11 Room Only
13 Residential Programs For Victims Of Domestic Violence (Less than 3 Meals Per Day)
14 Residential Programs For Victims Of Domestic Violence (3 Meals Per Day)
15 Congregate Care Level 1 (NYC I Nassau I Suffolk I Westchester I Rockland)
16 Congregate Care Level 2 - State Certified (NYC I Nassau I Suffolk I Westchester I Rockland}
19 Approved Medical Facilities - Non Hospital (Use Action Type 02- PA Only)
23 Undomiciled
24 NYCHA Apartment - Utilities Not Included
25 Rented Private Home
26 Furnished Apartment

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-2
02/14/2015

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEL!

SCREEN NSBL02: HOUSEHOLD/SUFFIX FINANCIAL DATA !CONT'D\

SHELTER TYPE CODES ISHELT: TYPE\ !CONT'D\

27 Residential Treatment Center - Non -Level 2
28 Congregate Care Level 1-Rest of State
29 Congregate Care Level 2-State Certified -Rest of State
30 Scatter Site Homeless Housing Non Tier I/Non Tier II Less than 3 meals daily
31 Residential Treatment Center-Level 2 Facility-NYC, Nassau, Suffolk, Westchester, and
Rockland
32 Residential Treatment Center-Level 2 Facility-Rest of State
33 Homeless Shelter -Tier I or Tier II (Less Than 3 meals Per Day)
34 Homeless Shelter-Tier II (Three Meals Per Day)
35 Homeless Shelter-Non Tier I Non Tier II
38 Subsidized Housing - Deep Subsidy -Voucher Program/Project Based Section 8
39 Subsidized Housing - Shallow Subsidy - Section 236/Section 202
40 NYCHA/Section 8 Voucher - 30% Limit
42 Congregate Care Level 3 - Adult Homes and DOH Enriched Housing
43 Congregate Care Level 2 - OMH/OPWDD Supervised/Supportive Apartments
44 Supportive/Specialized Housing

PERIOD CODES !PERI

03 Weekly
04 Biweekly
05 Semi-Monthly (Twice per Month)
06 Monthly
07 Bimonthly (Every Two Months)
08 Quarterly (Every Three Months)

FSUA INDICATOR CODES IFSUA: IND\

X Eligible for Combined FS SUA Standard For Heat (AC)/Utility/Phone or Actual Amount

HEAT TYPE CODES !TYPE!

1 Natural Gas
2 Oil
3 Electric
4 Coal
9 Other Fuel
Blank Heat Included with Shelter (System generates "H" on Inquiry screen)

CHILD IN HOUSEHOLD !CHILD!

X Child in Household

HOME ENERGY ASSISTANCE PROGRAM INDICATOR !HEAP\

S Shared Housing Situation - Household Not Eligible for HEAP Benefits

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-3
06/21/2014

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABELi

SCREEN NSBL02: HOUSEHOLD/SUFFIX FINANCIAL DATA !CONT'D\

HOUSING ADVANTAGE INDICATOR !HAil

1 Work Advantage (Shelter is $50 or less)
2 Fixed Income Advantage (Shelter is $0)
3 Children Advantage (Shelter is $0)
4 HRAAdvantage (Shelter is $0)
5 · HRA Work Advantage (Shelter is $50 or less)
6 HRA Fixed Income Advantage (Shelter is $0)
7 HRA Children Advantage (Shelter is $0)
9 New HRA Housing Advantage - 1st year
W Work Advantage - 1st year
F Fixed Income Advantage - 1st year

FSUT INDICATOR CODES !FSUT: IND\

X Eligible for Combined FS SUA Standard For Utility/Phone

PA CASE TYPE CODES IPA: TYPE\

FA (PA Center) Family Assistance (Replaces ADC, ADCU and HR Families)
SNCA (PA Center) Safety Net Cash Assistance (Replaces HR, except HR Families)
SNNC (PA Center) Safety Net Non-Cash. To be used for Safety Net Cash cases that have
reached the two year limit for cash assistance, the 60 month for the total of
Family Assistance and Safety Net Cash Assistance, or Singles who have been
determined unable to work due to drug/alcohol problems, but were compliant,
Le in treatment.
SNFP (PA Center) Safety Net Federally Participating. To be used for FA cases in which the head ·
·of household or an adult who is a mandatory member of the case fails to
comply with drug/alcohol [d/a] requirements, or in which such an individual is
deemed unemployable due to their d/a problem, but is in compliance with d/a
requirements and is in treatment.
EAA (PA Center) Emergency Assistance for Adults (No change)
EAF (PA Center) Emergency Assistance for Families (No change)

PA/SNAP STATUS CODES IPA: STAT. FS: STAT!

AC Active ·
AP Applying
CL Closed
NA Not Applying
RJ Denied
SI Single Issue

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-4
02/21/2016

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEU

SCREEN NSBL02: HOUSEHOLD/SUFFIX FINANCIAL DATA !CONT'D!

PA/SNAP ROUTING CODES IPA: RTG. FS: RTGl

E220 HPD
E500 TEAP
ROXX Returning to administering IM Center (or SNAP Center)

PA ADDITIONAL NEEDS TYPE CODES IPA: ADDL: TYl

06 Refrigerator Rental (use with Shelter Type Code 06)
09 Chattel Mortgages
22 Water Proration
40 Temporarily Absent lndividual(s) In Congregate Care Facility
47 Family Eviction Prevention Supplement
65 Shelter Allowance Supplement

SNAP CATEGORICAL ELIGIBILITY CODES ICE!

System Generated Codes
S Sanctioned for SNAP
Y Categorically Eligible - All Receiving TA and/or SSI
N Categorically Eligible - Not All Receiving TA and/or SSI
A Aged/Disabled not Categorically Eligible

FUEL INDICATOR CODES IPA: FUELi

X Exclude Suffix Not Paying Fuel Cost From Fuel Allowance
1-9 Indicates the Number of Temporarily Absent Individuals.

RESTRICTION TYPE CODES !RST\

1 Direct Involuntary
2 Two-Party Involuntary
3 Direct Voluntary (Restrict Actual Rent Paid)
4 Two-Party Voluntary (Restrict Actual Rent Paid)
5 Direct Voluntary
6 Two - Party Voluntary
# Delete a Restriction

ASSOCIATED CODES !ASSOC: CD!

70 Shelter (Use with Restriction Codes 1, 2, 3, 4, 5 & 6)
71 Water (Use with Restriction Codes 1, 2, 5 & 6 only)
72 Fuel (Use with Restriction Codes 1, 2, 5 & 6 only)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-5
10/18/2014

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABELi

SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS

30+1/3 INDICATOR !30 1/31

Blank This field must be left blank.

EXPECTED DATE OF CONFINEMENT CODES !EDCl

N Not Eligible for Pregnancy Allowance
S Stop Pregnancy Allowance (System Generated)

EMPLOYMENT TRAINING INDICATOR CODE !ETll

T Training and Employment Assistance Program (TEAP)

SPECIAL BUDGETING !SPEC!

Y Individual is In the household and is less than 19 years old, or is 19 or over and diagnosed
with AIDS or HIV
N Individual is not In the household, or individual is in the household and is 19 or older and not
diagnosed with AIDS or HIV
E Individual is less than 19, in the household and in receipt of SSI, and exempt from the budget
calculation

RELATIONSHIP INDICATOR CODES !REL!

Y SSI Individual Would be in Filing Unit (Disabled for FA and SNFP 11 /07)
N Individual with SSI is Not in Filing Unit

EMPLOYABILITY STATUS CODES !EMPl

01 Dependent Student-Employed Fulltime or Part-time.
02 Non-Dependent Student-Employed Fulltime or Part-time.
04 Non-Student Employed Full Time or Part Time
10 Striker
13 Late Reporting of Employment, Ineligible for Earned Income Deductions

PA/SNAP STATUS CODES !PA: STS; FS: STSl

AC Active
AP Applying
CL Closed
NA Not Applying
RJ Denied
SI Single Issue
SN Sanctioned
WO Withdrawn

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-6
10/22/2012

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEL!

SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS !CONT'D!

AGED/DISABLED INDICATOR CODE IA/Dl

X Aged or Disabled

FINANCIAL/ALIEN INVOLVEMENT CODES !INVl

Y Individual resides in the household
N Individual does not reside in the household
A SNAP-ineligible alien in transitional housing who is active for PA and inactive for SNAP.
Applies to shelter types 06, 30, 33, and 34.

INCOME SOURCE CODES !INCOME/RECURRING: SRCl

01 Salary, Wages
02 On the Job Training
04 Annuity Mortgage Loan
05 Family Day Care Provider Income
06 Net Business Income/Self- Employment Income
07 Office of Vocational Rehabilitation
08 Net Income from Rental of House, Store or Other Property; Worked More than 20 hours Per
Week
09 Net Income from Rental of House, Store or Other Property; Worked Less than 20 hours Per
week
10 Volunteers in Service to America (VISTA)
11 Income from Boarder, Boarder/Lodger
12 Net Income from Lodger
13 Adoption Subsidy
14 Court Ordered Alimony, Spousal Support, Child Support Payment
15 Dividends, Interest or Periodic Receipts from Stocks, Bonds, Mortgages, Bank Accounts,
Trust Funds, Annuities, Credit Unions, Estates, etc.
16 Black Lung Disease Program
17 Educational Grants and Loans
18 Disabled Veteran's Benefits (Service Connected)
19 Disabled Veteran's Benefits (Non-Service Connected)
20 Lump Sum Payment
21 NYS Disability Insurance
22 Railroad Retirement Benefit
23 Railroad Retirement Benefit - Dependent
24 Pensions, Retirement Benefit
25 Severance Pay
26 Sick Pay (Individual Provided Insurance)
27 Social Security Disability Benefit
28 Social Security Survivors Benefit
29 Social Security Retirement Benefit
30 Social Security Dependent Benefit
31 SSI Benefit

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-7
10/22/2012

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEL!

SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS !CONT'D!

INCOME SOURCE CODES llNCOME/RECURRING: SRCl !CONT'D!

32 Union Benefits
33 Workers Compensation
34 Income In Kind
35 Earned Income Credit
36 Unemployment Insurance Benefits
37 Subsidized Employment
38 Public Assistance Grant
39 Comprehensive Employment Opportunity Support Center (CEOSC)
40. Sick Pay (Employer Provided Insurance)
42 Prior PA Budget Deficit- PA Incremental Sanction - Individual is Not Sanctioned
for SNAP for the same Reason as the PA Sanction
43 SNAP Ineligible Individual - Individual Active for PA and Ineligible for SNAP due.to a SNAP
Disqualification
44 PA/Budget Reduction - PA Budget Deficit is reduced due to Non Compliance with IV-D
Requirements for Recipient or Re-Applying Household
45 PA Budget Reduction-PA Budget Deficit is Reduced Due To Non-Compliance with IV-D
Requirements for Applicant Households.
46 PA Prorata Sanction-Recipient or Re-Applying Households Sanctioned Due to Non-
compliance with Employment or Drug/Alcohol Requirements
47 PA Prorata Sanction-Applicant Households Sanctioned Due to Non-Compliance with
Employment or Drug/Alcohol Requirements.
48 Income from Spina Bifida
49 Individual Active for PA and Inactive for SNAP - Living as Separate SNAP Household -
Individual is either Ineligible or has chosen Not to Receive SNAP
50 Income from Non-Legally Responsible Persons in Household
51 Income from Non-Legally Responsible Persons Outside the Household
**52 Income from Legally Responsible Relative
53 Income from Stepparent
54 Income from Sponsor
55 Veteran's Benefits or Pension
56 Income from Applying Legally Responsible Relative
57 Earnings from WIA
59 Foster Payments (For Individual Less than 21 Years of Age)
60 OVESID Training Allowance (Formerly OVR)
61 Alimony Spousal/Child Support Assigned to the Agency
62 EiC Lump Sum
63 Lump Sum Severance Pay .
65 Earnings from WIA/OJT
66 Alimony Arrears
**Invalid As of 12/A/04

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-8
10/22/2012

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEL!

SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS !CONT'D\

INCOME SOURCE CODES !INCOME/RECURRING: SRCl !CONT'D\

67 Safety Net Self Support
68 Court Ordered Spousal Support/Alimony
69 Family Support Arrears
71 Excess Support Payment
75 Census Income
76 Youth Build
78 MKB FA/SNCA Income
79 SSI Individual Invisible to WMS
80 PA only Earned Income
81 PA Only Unearned Income
82 Individual In Care - SNAP Only (Congregate Care)
83 Individual In Care - PA/SNAP (Congregate Care)
84 Individual In Care - SNAP Only (RTC)
85 Individual In Care - PA/SNAP (RTC)
86 SNAP Ineligible Alien Does Not Contribute to Shelter Costs
87 Child Support Bonus Payment (System Generated)
88 STEP-School to Work Employment Program
90 Contribution from Parent/Grandparent
91 HUD Utility Allowance-Payment Made to Client or Utility Company
92 SNAP Ineligible Alien-Contributes to Shelter Costs
94 Retrospective Supplementary Income
96 Included in SNAP Household for SNAP Categorical Eligibility
97 SNAP Ineligible Student - Student Active for PA and Ineligible for SNAP
98 Other Earned Income
99 Other Unearned Income

INCOME FREQUENCY CODES !INCOME: FREQ!

B Biweekly 1 Once per Month
M Monthly 2 Twice per Month
S Semi- Monthly 3 Three Times per Month
W Weekly 4 Four Times per Month
5 Five Times per Month

PROGRAM INDICATOR CODE IPROGl

B Both PA and SNAP
F SNAP Only
P PA Only
I PA Only (Ineligible Student)
L Both PA and SNAP (LRR lndivdual)

USAGE CODES !INCOME: Ul

1 through 7 Number of Boarder/Lodgers or Lodgers

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-9
10/22/2012

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC IABELl

SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS !CONT'D\

INCOME EXEMPTION CODES CINCOME: CD\

01 Family Day Care Provider Income Exemption Amount (Use With Income Source Code 05)
02 SNAP PASS Exempt Income Amount (Use With Income Source Code 31)
03 Boarder/Lodger Exempt Income Amount - 2 Meals or Less (Use with Income Source
Code 11- Applied in SNAP Budget Calculation Only)
04 Boarder/Lodger Exempt Income Amount - 3 Meals (Use with Income Source Code 11)
07 Lodger Exempt Income Amount (Use With Income Source Code 12 -Applied in PA Budget
Calculation Only)

DEDUCTION TYPE CODE !DEDUCTIONS: TYPl

78 Child Support Exclusion

DAYCARE TYPE CODES !DAYCARE: TYPl

98 Day Care Fee Amount (Used to calculate SNAP Only)
99 Case Not Eligible for Day Care Supplementation (Used to calculate SNAP Only)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-10
02/17/2013

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEL)

SCREEN NSBL06: INDIVIDUAL INCOME/NEEDS !CONT'D!

ASSOCIATED CODE !ASSOC: CD!

61 TPHI

INDIVIDUAL SPECIAL NEEDS TYPE CODES !SPEC NOS: TY\

01 Restaurant Allowance - Dinner ($29.00 Monthly)
02 Restaurant Allowance - Lunch and Dinner ($47.00 Monthly)
03 Restaurant Allowance - Breakfast, Lunch and Dinner ($64.00 Monthly)
13 Home Delivered Meals
14 Restaurant Allowance- Breakfast ($17.00)
15 Restaurant Allowance- Lunch ($18.00)
16 Restaurant Allowance - Breakfast and Lunch ($35.00 monthly)
19 Third Party Health Insurance
21 · Essential Person
23 Restaurant Allowance- Breakfast and Dinner ($46.00 monthly)
25 Carfare (Homeless PA Recipients)
31 Restaurant Allowance - Dinner ($65.00 Monthly)
32 Restaurant Allowance - Lunch and Dinner($ 83.00 Monthly)
33 Restaurant Allowance - Breakfast, Lunch and Dinner ($100.00 Monthly)
34 Restaurant Allowance - Breakfast ($53.00 Monthly)
35 Restaurant Allowance - Lunch ($54.00 Monthly)
36 Restaurant Allowance - Breakfast and L.unch ($71.00 Monthly)
37 Restaurant Allowance - Breakfast and Dinner ($82.00 Monthly)
50 Separate SNAP Household Supplement
51 Transportation and Nutritional Drink Allowance

RESTRICTION TYPE CODES fRSTl

1 Direct Involuntary
2 Two Party Involuntary
5 Direct Voluntary
6 Two-Party Voluntary
# Delete a Restriction

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-11
10/22/2012

AUTOMATED BUDGETING AND ELIGIBILITY LOGIC !ABEL!

SCREEN NSBL35:SAVED BUDGETS

BUDGET SOURCE !BUD SRCl

A Address Match
B MRB - New Budget
C COLA
E EID/Childcare
F FIA3A
H HEAP
I Internal Budget
M MRB - Pending Budget
N NYGHA
R Case Re-Align
S Separate Determination
T Thrifty Food Plan
U FSUA Re-Budget
W NYGWAY
X External Budget (Worker entered)
Y Ext-GIN Switch
Z Int-GIN Switch

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
2.1-12
10/22/2012

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-1
06/21/2015

CHAPTER 3-
DATA ENTRY FORMS

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575

PICK-UP CODES
1 Special Roll Check
2 Pended Until 45th Day of SNFP/SNCA/SNNC Eligibility
4 Same Day Immediate Needs
5 Emergency Public Assistance Check (E-Check)
6 Emergency Check Issued Via The E-Check Authorization Print Process
7 Emergency Cash Payment (E-Cash)
9 EBT Emergency PA Single Issue Special Grant

SPECIAL GRANT CODES !ISSUANCE CODES!

*CODE TYPE OF ALLOWANCE COMMENTS
02 REGULAR ALLOWANCE Use only once in a s/m period. ·
(Recurring Needs)
03 SUPPLEMENTATION OF
CURRENT.MONTH
04 SUPPLEMENTATION OF To correct an administrative error for a period of up to 12
PREVIOUS MONTH months.
05 PREGNANCY ALLOWANCE Use Code 05 for FA/SNFP cases only. If the allowance is for a
SNCA/SNNC case, use code 03.
When the EDC date is entered in a budget, WMS will
generate a pregnancy allowance in the foµrth month or later of
a medically verified pregnancy. Disbursing a single issuance for
the fourth and fifth month is no longer necessary, unless, it is
for missed benefits.
07 REPLACEMENT OF LOST Replacement may not exceed original amount.
STOLEN/UNDELIVERED
CHECKS
08 REPLACEMENT OF Cancelled check number and date must be entered on DSS
CANCELLED CHECK 3575. May not be used for EAA cases.
09 RENT ONLY Supplementation of current month or previous month(s) rent
while in receipt of PA, or for a direct vendor payment - valid for
FEPS. This code can be used to pay only rent, property taxes
and/or mortgage arrears. No PA funds can be used to pay for
dispossess fees, attorney charges, other legal fees or court
costs related to housing. For SNCA Cases a two-party check
may be authorized as an aid to management of funds.
* NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
Up to $999.99 AJOS I/PAA I
$1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
$2,000 and over ADMIN JOS I (Deputy Director)
• All special grant code 99's and must have approval from ah ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-2
06/21/2015

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL 'GRANT CODES !ISSUANCE CODES\ !CONT'D\

*CODE TYPE OF ALLOWANCE COMMENTS
10 UTILITY GRANT TO For accumulated nat.ural gas and or electric arrears, prior to
PREVENT TURN OFF/ receiving PA. No more than four months allowed if the arrears
RESTORE SERVICES have occurred in same dwelling, not to be used for payment of
(PRIOR T.o PA) water bills.
14 REPLACEMENT OF LOST For EAF cases, enter "EAF" in category box on DSS-3575.
OR STOLEN CASH Maybe authorized only once in a consecutive 12-month period.
Consultant: Case Consultant (212) 331,5533 180 Water Street
21st floor.
15 PAYMENT OF EAA cases only.
INSTALLMENT DEBT (EAA)
16 TRANSPORTATION TO For Waverly JC-Transportation Unit Only.
POINTS OUTSIDE NYC
17 CARFARE FOR HOMELESS This code appears on Benefits Issuance History Screen
ADULTS NQCS5A when special Individual Needs Code 25 is entered
through External Budgeting. Code 17 cannot be data entered
through the PA Single Issuance subsystem.
18 EXPENSES CONNECTED To maintain current dwelling. Use for repairs of refrigerator/
WITH MAINTAINING stove and fumigation fees only.
HOUSING
19 REPLACEMENT OF
HEATING EQUIPMENT,
STOVE, OR
REFRIGERATOR
20 DISPOSSESS FEES/ Cannot be used with code 09
RELATED COST
21 STORAGE FEES Must be two-party check.
22 MOVING EXPENSES
23 HASA CARFARE HASA carfare due to Fair Hearing decision.
24 THIRD PARTY HEALTH This code appears on Benefit Issuance History Screen
INSURANCE NQCS5A when Special Individual Needs Code 19 is entered
through External Budgeting. Code 24 cannot be data entered
through the SI Benefit subsystem.
25 SHELTER AND/OR REPAIR For repair allowance.
ALLOWANCE FOR
HOMEOWNER
• NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
• Up to $999.99 AJOS I/PAA I
• $1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
$2,000 .and over ADMIN JOS I (Deputy Director)
All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-3
06/21/2015

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL GRANT CODES !ISSUANCE CODES! !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
27 THIRD PARTY HEALTH For FIA Transitional Benefits Unit.
INSURANCE PAYMENT
28 Bl-WEEKLY SUPPLEMENT
WEPCARFARE
29 Bl-WEEKLY RECURRING
WEP CARFARE
30 RENT PAYMENTS IN Restricted to applicants only. Refer to current procedure for
EXCESS OF MAXIMUM conditions under which the grant can be issued.
31 PRE-PA RENT ARREARS
35 EAU PAYMENT Originating Center must be IPM.
38 SECURITY DEPOSIT
PRIVATE HOUSING
39 RENT IN ADVANCE TO Funds not previously issued.
SECURE AN APARTMENT
40 RENT IN ADVANCE TO Covers a period for which the shelter allowance was previously
AVOID EVICTION issued. Must be a two party check. This code produces a
system generated recoupment.
41 UTILITY GRANT TO Must be a two-party "E" check and the worker must enter a
PREVENT TURN OFF OR Recoupment Indicator on form DSS-3575. The grant may cover
RESTORE UTILITY bills for the most recent four months immediately prior to the
SERVICES date of the request.
(MISMANAGEMENT) NOTE: If a utility advance is required due to an administrative
error, use code 04.
"Pre-Approval Needed from Center Director"
42 BROKER'S AND FINDER'S
FEES
43 ACCRUED RENT WHILE ON For any accrued rent arrears more than 12 months. If
PA duplication, use code 40.
44 IMMEDIATE NEEDS GRANT
45 DISASTER SUSTENANCE May be granted as EAA/EAF.
46 DISASTER CLOTHING May be granted as EAA/EAF
47 DISASTER HOUSEHOLD May be granted as EAA/EAF payment can be divided into two
FURNISHINGS AND grants if a large sum is to be issued.
REPLACEMENTS
* NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
Up to $999.99 AJOS I/PAA I
$1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
$2,000 and over ADMIN JOS I (Deputy Director)
All special grant code 99's and must have approval from an ADMIN JOS II (Center D'irector)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-4
06/21/2015

PA SINGLE ISSUANCE AUTHORIZATION FORM· DSS 3575 !CONT'D\

SPECIAL GRANT CODES !ISSUANCE CODES\ !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
48 DISASTER SHELTER- Rent in advance for temporary housing (includes hotel fees).
TEMPORARY HOUSING May be granted as EAA/EAF.
49 DISASTER May be granted as EAA/EAF.
TRANSPORTATION TO
HOME OF FRIEND OR
RELATIVE OR TO A
SHELTER
50 NON-RECOUPABLE Must be issued as a two-party "E" check. Period covered
UTILITY GRANT (NO cannot exceed 4 months. May be granted as EAA/EAF
MISMANAGEMENT)
51 CHILD CARE FEES TO The client must provide proof of attendance at the fair hearing
ATTEND FAIR HEARING and a letter from the child care provider.
54 CHILD SUPPORT BONUS For FIA Office of Central Processing (OCP) only.
PAYMENT -- MANUAL
ISSUANCE
55 EMPLOYMENT AND
TRAINING SPECIAL NEEDS

56 REPLACEMENT OF CHILD
SUPPORT BONUS
PAYMENT (CODES 54 OR
70)
58 EMERGENCY CHILDCARE May be used for EAF case. Use this code to issue emergency,
FEES temporarily child care which has been authorized by the office
of Information. Liaison and Adjustment Services.
59 NYCHA RENT ARREARS Must be a direct vendor payment.
60 ESTABLISHMENT OF A
HOME
62 MAINTENANCE OF HOME EAA cases only. Up to 4 months of shelter arrears may be paid
per issuance, with no limit to the number of issuances. Utilities
are limited to 4 months or 2 bi-monthly billing periods.
63 MISMANAGEMENT OF EAA cases only.
CASE
64 SNAP For NPA recipients only.
• NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
Up to $999.99 AJOS I/PAA I
$1000 to $1,999.99 AJOS II/PAA II {Assistant Deputy Director)
• $2,000 and over ADMIN JOS I (Deputy Director)
• All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM.

 WORKER'S GUIDE TO CODES
3.1-5
06/21/2015

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL GRANT CODES !ISSUANCE CODES! !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
65 TRAINING EXPENSE JOBS Originajing center must be TBU.
EXTENDED SUPPORTIVE
SERVICES
66 HOMES BILLING SYSTEM For Inquiry only. Not data entered by Job Centers.
PAYMENT
67 HOMES BILLING SYSTEM For Inquiry only. Not data entered by Job Centers.
RECOUPMENT
68 PRORATED FINAL System Generated. Not data entered by Job Centers.
ISSUANCE
70 CHILD SUPPORT BONUS System Generated. Not data entered by Job Centers.
PAYMENT
71 EXCESS CURRENT No longer valid for payment periods past 06/30/2009.
SUPPORT PAYMENT
72 EXCESS ARREARS
SUPPORT PAYMENT
73 SUPPLEMENTATION OF Due to Fair Hearing Decision
REGULAR GRANT
74 BENEFIT RESTORATION Due to Fair Hearing Decision
75 RENT HELD IN ESCROW
76 SNCA JOB SEARCH Grants cannot exceed $60.00 per month.
CARFARE EXPENSES
77 COURT ORDERED
RETROACTIVE PAYMENT
80 EMERGENCY HEAP Must be a two-party check.
PAYMENT
81 REPLACEMENT OF LOST/ For EAAcases. Replacement of check only. For replacing cash
STOLEN SSI BENEFITS use code 45
82 DIRECT HEAP PAYMENT
TO LIPA
84 NPA HEAP PAYMENT
86 AIRS (AIDS) Issued by MIS only for shelter.
90 DIRECT HEAP PAYMENT
TO CON ED
* NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
Up to $999.99 AJOS I/PAA I
• $1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and over ADMIN JOS I (Deputy Director)
• All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-6
06/19/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL GRANT CODES !ISSUANCE CODES! !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
91 DIRECT HEAP PAYMENT
TO NATIONAL GRID
92 DIRECT VENDOR TO CON Issued by MIS only.
ED
93 DIRECT VENDOR TO Issued by MIS only.
NATIONAL GRID
94 UTILITY VENDOR REFUND Issued by MIS only.
96 HEAP FAIR HEARING
97 REPLACEMENT OF HEAP Must be issued as an "E" check.
CHECK
98 REGULAR HEAP VENDOR
PAYMENT
99 OTHER Specify reason for the use of code 99 (when code 01- 98 do not
apply). Additional signature needed from the Center Director.
AG RENT ADVANTAGE System generated.
PROGRAM PHASE 2
A7 SPECIAL RENT ISSUED TO System generated.
LANDLORD BY OHS
BB TBRA LANDLORD BONUS TBRA landlord bonus payment. Must be a single payment of
exactly $1,000 or two payments of exactly $500, issued on the
same day.
B1 OLD RENT ADVANTAGE System generated.
PROGRAM
B2 NEW ADVANTAGE RENT System generated.
PROGRAM
B3 HASA 30% PROGRAM Recurring payment to landlord of HASA case
B4 HASA 30% PROGRAM Used to issue a replacement of a 83 issuance that has a WMS
(REPLACEMENT) reconciliation status of 1 (stop payment), 2 (cancelled), P
(purged), S (stale dated), or Z (cashed but funds returned to
HRA).
BG TENANT-BASED RENTAL Amount issued cannot exceed $5,000 for any one payment. A
ASSISTANCE (TBRA) 86 payment will not be allowed if it has the exact same dollar
amount and payment period of another rent/shelter type
payment.
• NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
• Up to $999.99 AJOS I/PAA I
• $1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and over ADMIN JOSI (Deputy Director)
• All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-7
06/19/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL GRANT CODES !ISSUANCE CODES! !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
87 SEPS PAYMENT Recurring rent allowance for single individuals or adult families
residing in shelters or in substandard living conditions outside
the shelter system. Minimum payment is $1223. Maximum
payment is $5000.
88 SEPS BONUS Bonus issued to broker. Payment cannot exceed $1000.
DO ONE-SHOT DEAL RENT Used to issue a replacement of a one-s.hot rent issuance check
REPLACEMENT CHECK that was cashed by the wrong landlord. Not recoupable.
(NON-RECOUPABLE)
D5 DIVERSION PAYMENT For specific non-recurring payment for situation or episode of
immediate need. Can be used on active cases or closed cases
with TB indicator.
D7 TRANSITIONAL SERVICES Used to authorize employment related expenses. Can be used
PAYMENT on active cases or closed cases with TB Indicator. SNCA/
SNNC must have individual with ST/FED Code 63.
D8 DIVERSION RENTAL For specific short-term payment (four months or less) to deal
PAYMENT with crisis situation that requires a rent payment. Can be used
on active cases or closed cases with TB indicator. SNCA/
SNNC must have an individual with ST/FED Code 63.
D9 DIVERSION Used to issue a non-recurring payment for employment related
TRANSPORTATION transportation expenses. Can be used on active cases or
PAYMENT closed cases with TB indicator.
F1 LEGALLY EXEMPT IN- Not data enterable.
HOME CHILD CARE NON-
RELATIVE (FULL TIME)
F2 DAY CARE FAMILY HOME Not data enterable.
(FULL TIME)
F3 DAY CARE GROUP FAMILY Not data enterable.
(FULL TIME)
F4 DAY CARE CENTER (FULL Not data enterable.
TIME)
F5 LEGALLY EXEMPT IN- Not data enterable.
HOME CHILD CARE .
RELATIVE (FULL TIME)
• NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
. OTHER LEVELS ARE SPECIFIED ABOVE:
• Up to $999.99 AJOS I/PAA I
• $1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and over ADMIN JOS I (Deputy Director)
• All special grant code 99's and must have approval from an ADMIN JOS II (CenterDirector)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-8
06/19/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL GRANT CODES !ISSUANCE CODES! !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
F6 LEGALLY EXEMPT FAMILY Not data enterable.
CHILD CARE RELATIVE
(FULL TIME)
F7 LEGALLY EXEMPT FAMILY Not data enterable.
CHILD CARE NON-
RELATIVE (FULL TIME)
F8 SCHOOL AGE CHILD CARE Not data enterable.
PROGRAM (FULL TIME)
F9 LEGALLY EXEMPT GROUP Not data enterable.
CHILD CARE (FULL TIME)
G2 EMERGENCY CLOTHING Used for cases included in the Reynolds lawsuit.
VOUCHER
HO HEATING EQUIPMENT
REPAIR/REPLACEMENT
ESTIMATES
H5 HEAP EMERGENCY
BENEFIT - REPAIR
HEATING EQUIPMENT
H7 HEAP EMERGENCY
BENEFIT - REPLACE
HEATING EQUIPMENT
L7 LOVEH LAWSUIT Used for cases included in the Lovely H. lawsuit.
L9 HERCULES LAWSUIT Used for cases included in the Hercules lawsuit.
N2 CHILD SUPPORT DUE Used to issue child support money for cases that were not
CLIENT - PERIOD OF closed in a timely manner.
INELIGIBILITY
P1 LEGALLY EXEMPT IN- Not data enterable.
HOME CHILD CARE NON-
RELATIVE (PART TIME)
P2 DAY CARE FAMILY HOME Not data enterable.
(PART TIME)
P3 DAY CARE GROUP FAMILY Not data enterable.
(PART TIME)
* NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
• Up to $999.99 AJOS I/PAA I
• $1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and over ADMIN JOS I (Deputy Director)
• All special grant code 99's and must have approval from an ADMIN JOS II (Center Directbr}

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-9
06/19/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 ICONT'Dl

SPECIAL GRANT CODES !ISSUANCE CODES! ICONT'Dl

*CODE TYPE OF ALLOWANCE COMMENTS
P4 DAY CARE CENTER (PART Not data enterable.
TIME)
PS LEGALLY EXEMPT IN- Not data enterable.
HOME CHILD CARE
RELATIVE (PART TIME)
P6 LEGALLY EXEMPT FAMILY Not data enterable.
CHILD CARE RELATIVE
(PART TIME)
P7 LEGALLY EXEMPT FAMILY Not data enterable.
CHILD CARE NON-
RELATIVE (PART TIME)
PS SCHOOL AGE CHILD.CARE Not data enterable.
PROGRAM (PART TIME)
P9 LEGALLY EXEMPT GROUP Not data enterable.
CHILD CARE (PART TIME)
SO LINC2 RENT PROGRAM - Supplemental LINC2 payment for OHS and HRA shelter
SUPPLEMENT SUBSIDY vulnerable population. The SO payment is in addition to the S5
payment and represents the amount of subsidy that exceeds
the standard table amount. Used for CLOSED (RJ or CL) PA
cases.
S1 LINC1 RENT PROGRAM - Initial LINC1 payment for OHS and HRA shelter families with
INITIAL SUBSIDY employment.
S2 UNC2 RENT PROGRAM - Initial LINC2 payment for OHS and HRA shelter vulnerable
INITIAL SUBSIDY population. Used for ACTIVE PA cases.
S3 LINC3A RENT PROGRAM - Initial LINC3A payment for HRA DV (Domestic Violence)
INITIAL SUBSIDY population residing in HRA shelters.
S4 .LINC3B RENT PROGRAM - Initial LINC3B payment for HRA DV (Domestic Violence)
INITIAL SUBSIDY population residing in OHS shelters.
SS LINC2 RENT PROGRAM - Initial LINC2 payment for OHS and HRA shelter vulnerable
INITIAL SUBSIDY population. Used for CLOSED (RJ or CL) PA cases.

*NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
Up to $999.99 AJOS I/PAA I
• '$1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and overADMIN JOSI (Deputy Director)
• All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-10
06/19/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D)

SPECIAL GRANT CODES <ISSUANCE CODES) !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
S6 LINC1 RENT PROGRAM - Supplemental LINC1 payment for OHS and HRA shelter
SUPPLEMENT SUBSIDY families with employment. The S6 payment is in addition to the
S1 payment and represents the amount of subsidy that
exceeds the standard table amount.
S7 LINC2 RENT PROGRAM - Supplemental LINC2 payment for OHS and HRA shelter
SUPPLEMENT SUBSIDY vulnerable population. The S7 payment is in addition to the S2
payment and represents the amount of subsidy that exceeds
the standard table amount. Used for ACTIVE PA cases.
SS LINC3A RENT PROGRAM - Supplemental LINC3A payment for HRA DV (Domestic
SUPPLEMENT SUBSIDY Violence) population residing in HRA shelters. The S8 payment
is in addition to the S3 payment and represents the amount of
subsidy that exceeds the standard table amount.
S9 LINC3B RENT PROGRAM - Supplemental LINC3B payment for HRA DV (Domestic
SUPPLEMENT SUBSIDY Violence) population residing in OHS shelters. The S9 payment
is in addition to the S4 payment and represents the amount of
subsidy that exceeds the standard table amount.
SA LANDLORD LINC BONUS $1000 incentive award to encourage landlords to rent to a LINC
PAYMENT case. Award is a one-time payment per apartment rental.
SB LINC4 RENT PROGRAM - Initial LINC4 payment for persons aged 60 and over.
INITIAL SUBSIDY
SC LINC5 RENT PROGRAM - Initial LINC5 payment for adults who are working part-time.
INITIAL SUBSIDY
SD LINC6 RENT PROGRAM - Initial LINC6 payment. (Population to be determined.)
INITIAL SUBSIDY
SE LINC? RENT PROGRAM - Initial LINC? payment. (Population to be determined.)
INITIAL SUBSIDY
WA CITY FEPS RENT IN Issued separately from the case's regular City FEPS rent
ADVANCE amount. Payment cannot be greater than $5,000 for any one
payment.
WB CITY FEPS LANDLORD $1,000 bonus payment to encourage landlords to rent to a City
BONUS PAYMENT FEPS case. Award is a one-time payment per apartment rental.
WC CITY FEPS RENT Regular City FEPS rent. Payment cannot be greater than
$5,000 for any one payment.

*NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
• Up to $999.99 AJOS I/PAA I
$1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and over ADMIN JOS I (Deputy Director)
All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-11
10/23/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SPECIAL GRANT CODES !ISSUANCE CODES! !CONT'D!

*CODE TYPE OF ALLOWANCE COMMENTS
W3 MKB RETROACTIVE Used to issue retroactive MKB payments.
PAYMENT
W4 MKB RETROACTIVE SNAP Used to issue retroactive MKB SNAP as cash.
ISSUED AS CASH
W5 SUPPLEMENT FEPS RENT Used to issue rent arrears that were approved through FEPS.
ARREARS (RECOUPABLE) Generates an automated recoupment action.
W6 SUPPLEMENT FEPS RENT Used to issue non-recoupable rent arrears that were approved
ARREARS (NON- through FEPS.
RECOUPABLE)
W7 HOUSING DEVELOPMENT Used to authorize a grant toward the purchase of an interest in
COOPERATIVE UNIT a cooperative unit in a low-cost housing development.

*NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
Up to $999.99 AJOS I/PAA I
$1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
$2,000 and over ADMIN JOS I (Deputy Director)
All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

SPECIAL HOUSING PROGAM INDICATOR

System generated. Not worker enterable.
1 LINC1
2 LINC2
3 LINC3
4 LINC4
5 LINC5
6 LINC6
7 HOME
8 SEPS
9 CFEPS
0 Stop
F FEPS
A Stop LINC1
B Stop LINC2
C Stop LINC3
D Stop LINC4
E stop LINC5
G Stop LINC6
H Stop HOME
I Stop SEPS
J Stop CFEPS
K stop FEPS

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-12
06/21/2015

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 ICONT'Dl

SHELTER/RECOUPMENT INDICATOR
01 Initiates Recoupment and Restricts Rent Without ten-day Timely Notice period
02 Initiates Recoupment and Restricts Rent With ten-day Timely Notice
05 No Recoupment or Restriction
06 Initiates Recoupment Only Without ten-day Timely Notice Period-No Restriction
11 Initiates Recoupment Only With ten-day Timely Notice- No Restriction

RESTRICTED INDICATOR.
1 Unrestricted
2 Vendor As Authorized (Direct Payment)
8 Other
9 Restricted (Two - Party)

SHELTER TYPE CODES !SHELTER: TYPE)

01 Unfurnished Room or Apartment (For PA SI Codes 40 and 41 this code is defined as "M3E
indicator is signed.")
02 NYCHA Apartment Utilities Included (For PA SI Codes 40 and 41 this code is defined as
"M3E Indicator is signed")
03 Own Home (Includes Trailer)
04 Room and Board
05 No recoupment generated (To be used with PA SI Codes 40 and 41.)
06 Hotel Motel Temporary
08 Subsidized Housing-Certificate Program
11 Room Only
13 Residential Programs for Victims for Domestic Violence - less than 3 meals per day
14 Residential Programs for Victims of Domestic Violence- 3 meals per day
15 Congregate Care Level 1 (NYC I Nassau I Suffolk I Westchester I Rockland)
16 Congregate Care Level 2 - State Certified (NYC I Nassau I Suffolk I Westchester I Rockland)
19 Approved Medical Facilities - Non Hospital
20 Rental Supplement
23 Undomiciled
24 NYCHA Utilities Not Included (Rent Public)
25 Rented Private Home
26 Furnished Room or Apartment
27 Residential Treatment Center - Non -Level 2
28 Congregate Care Level 1-Rest of State
29 Congregate Care Level 2-State Certified -Rest of State
30 Scatter Site Homeless Housing Non Tier I/Non Tier II Less than 3 meals daily
31 Residential Treatment Center-Level 2 Facility-NYC, Nassau, Suffolk, Westchester, and
Rockland
32 Residential Treatment Center-Level 2 Facility-Rest of State
33 Homeless Shelter - Tier 1 or lier II (Less than 3 meals Per Day)
34 Homeless Shelter - Tier 11 (3 meals per day)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-13
02/21/2016

PA SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3575 !CONT'D!

SHELTER TYPE CODES !SHELTER: TYPE! !CONT'D!

35 Homeless Shelter - Non-Tier 1 or 11
38 Subsidized Housing - Deep Subsidy -Voucher Program/Project Based Section 8/Section 236
39 · Subsidized Housing -Shallow Subsidy - Section 236 /Section 202
40 Section 8 Voucher - 30% Limit
41 Jiggets-Approved Excess Shelter
42 Congregate Care Level 3 - Adult Homes and DOH Enriched Housing
43 Congregate Care Level 2 - OMH/OPWDD Supervised/Supportive Apartments
44 Supportive/Specialized Housing

RECOUPMENT INDICATOR CODES

01 Indicates Recoupment and Restricts Rent Without a Ten-Day Timely Notice Period
02 Indicates Recoupment and Restricts Rent With a Ten - Day Timely Notice
05 No Recoupment or Restriction

CATEGORY CODES
EAA Emergency Aid to Adults
EAF Emergency Aid to Families
FA NEW CATEGORY Family Assistance
SNCA NEW CATEGORY Safety Net Cash Assistance
SNFP NEW CATEGORY Safety Net Federally Participating
SNNC NEW CATEGORY Safety Net Non- Cash
ADC THIS CATEGORY IS NO LONGER VALID. Aid to Dependent Children
ADCU THIS CATEGORY IS NO LONGER VALID. Aid to Dependent Children Unemployed
HR THIS CATEGORY IS NO LONGER VALID. Home Relief
HRPG THIS CATEGORY IS NO LONGER VALID. Home f3.elied Pre-Investigation Grant

ROUTING LOCATION

R001 180 Water St/Landlord Ombudsman

R090 Office of Project Management
R091 Office of Project Management
R094 Con Edison SI utility payments entered by the center into POS
R095 National Grid SI utility payments entered by the center into POS
R096 Con Edison SI utility payments entered by the center into WMS
R097 National Grid SI utility payments entered by the center into WMS

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-14
06/21/2015

FS SINGLE ISSUANCE AUTHORIZATION FORM - DSS 3574

ISSUANCE CODES
PA
06 Prorated/Partial PA
10 Daily Supplement (Includes Replacement of Food Destroyed in a Disaster)
14 Single Issuance - Full Month
18 Disaster Related Issuance
20 Daily Retroactive Benefit
24 Replace Stolen Benefits
36 Disaster Related Issuance (Dispersed as Paper Check)
38 Disaster Card Issuance
52 Expedited Service, Verified For PA/SNAP cases
54 Expedited Service -Not verified for PA/SNAP cases
66 RTC Supplementation (NOT DATA ENTERABLE - SYSTEM GENERATED)
90 RTP Negative SNAP Adjustment (NOT DATA ENTERABLE - SYSTEM GENERATED)
LS Lovely H. lawsuit
V1 Fair Hearing Compliance to issue retroactive benefits that go beyond 12 months prior to the
issuance
W8 SNAP Issuance for reconstituted household (Same Day Issuance system only)

NPA
08 Prorated/Partial PA
12 Daily Supplement (Includes Replacement of Food Destroyed in a Disaster)
16 Single Issuance - Full Month
19 Disaster Related Issuance
22 Daily Retroactive Benefit
26 Replace Stolen Benefit .
37 Disaster Related Issuance (Dispersed as Paper Check)
39 Disaster Card Issuance
53 Expedited Service - EBT, Verified for NPA/SNAP Cases
55 Expedited Service - Not Verified for NPA/SNAP cases
G3 Reynolds SI Retroactive SNAP Benefits
V2 Fair Hearing Compliance to issue retroactive benefits that go beyond 12 months prior to the.
issuance
W7 SNAP Issuance for reconstituted household (Same Day Issuance system only)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-15
06/21/2015

PA RECOUPMENT DATA ENTRY FORM - DSS 3573

ACTION CODES
0 Reversal of Voluntary Repayment Transaction
1 New Claim
2 Change in Data
3 Suspend Claim
4 Delete Claim
5 Fair Hearing- Aid to continue
6 Lift Fair Hearing - Aid to continue
7 Transfer Recoupment to New Case
8 Reinitialize Claim
9 Voluntary Repayment

OFFENSE TYPE CODES

A Excess Resources
C Concealment
D Duplicate Check Fraud
E Agency Error
F Fraud (Conviction by a court or recipient admission of fraudulent receipt of benefits. Can be
entered only by CFl-The Bureau of Client Fraud Investigation.) ·
Q Utility Direct Vendor (System Generated)
R Rent Advance
S Rent Payments In Excess of Maximum
U Utility Advance
X Contested Reduction

OFFENSE SUBTYPE CODES

01 Receipt of Employment Earnings by the Grantee/Spouse
02 Receipt of Employment Earnings by a Family Member other than Grantee/Spouse
03 Receipt of Unemployment Insurance Benefits
04 Receipt of OASDI Benefits by the Grantee/Spouse
05 Receipt of OASDI Benefits for a Dependent Child/Children
06 Receipt of SSI Benefits by the Grantee/Spouse (HR cases in which no DSS - 2424/M2 was
Signed)
07 Receipt of SSI Benefits for a Dependent Child/Children (HR cases only)
08 Receipt of State Disability Benefits
09 Receipt of Workf)len's compensation
10 State Disability or Workmen's Comp (Vet Disability)
11 Receipt of Pension Benefits from a Public or Private Source (Includes Railroad Retirement)
12 Receipt of Union or other work- related Benefits
13 Receipt of Military Service Benefits (Inc Pension)
14 Receipt of Income Tax Refunds
15 Receipt of Non-Exempt Educational Stipends (In excess of Necessary School Expense)
16 Decrease in Rentals Needs (Incl. Elimination/Reduction of Rent Due to Bldg. Violation or
Abandonment)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-16
06/21/2015

PA RECOUPMENT DATA ENTRY FORM - DSS 3573 ICONT'Dl

OFFENSE SUBTYPE CODES !CONT'D!

17 Forfeiture of Broker's or Finder's Fees, Moving Expenses, Security Deposit or Payments
Made to the Landlord (at the former address) required by the security Deposit Agreement
Due to Non Payment of Rent or Failure to Return Refunded Security Deposit
18 Receipt of Income from a Legally Responsible Relative (Includes Alimony Child Support)
19 Receipt of Unrestricted Income from a Non-Legally Responsible Relative/Friend
20 Receipt of Life Insurance Benefits (Including Refund on Policy for Military Service Life
Insurance)
21 Receipt of Income from Legal Settlement or property
22 Receipt of Income from a Lodger/Boarder-Lodger
23 Elimination or Reduction of the need for a Restaurant Allowance
24 Dependent Child's/Children's Death or Departure from the Household
25 Adult Family member's Departure from the Household
26 Elimination or Reduction of Child Care Fees
27 Elimination or Reduction of Need for Training or Employment Expenses
28 Elimination of Need for a Pregnancy Allowance
29 Receipt or Possession of a Liquid Asset (Including Bank Accounts/Bonds)
30 Receipt of Foster Care Allowance for a Dependent child
31 Receipt of Public Assistance on more than 1 case
32 Receipt of Proceeds of another Recipients PA check (Recipients cashed another's check
and/or instead of own)
33 Receipt of an advance for moving expenses, Brokers' Fees and/or Finders' Fees which were
issued due to Non-Payment of Rent
34 Court Order Support
36 Failed to sell real property while in receipt of recurring benefits
88 Over Issuance for the Payment Period in which the case was closed (System Generated
Code)
99 Miscellaneous

BYPASS RESTRICTION INDICATOR

Y Yes
N No

RESTRICTION/DIRECT lWO PARTY INDICATOR

1 Direct Restriction
2 Two -Party Restriction

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-17
06/21/2015

FACILITY INVOLVEMENT DATA ENTRY FORM - DSS 3517-30 ITEMS 418-426.

INCOMPLETE APPLICATION REASON CODES

IA Code Incomplete Application Reason

01 Application Forms

02 Personal Demographics/Relationship

03 Social Security Number

04 Citizenship/Alien Status

05 Residence/Residency

06 Documentation of Medical Condition

07 ORD Required for Additional Medical Documents

08 Shelter Costs

09 Earned Income

10 Social Security Benefits (OASDI)

11 Private Pension Benefits

12 Other Income

13 Resources

14 Medicare

15 TPHI

16 Legally Responsible Relative

17 Current /Past Maintenance

69 Other

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-18
06/21/2015

THIRD PARTY DATA SHEET FORM - DSS 4198

RELATIONSHIP TO POLICY/HOLDER CODES IRELl

Enter a code for each person listed:
1 Self
2 Spouse
3 Child
4 Other
5 Custodial Child
6 Stepchild
7 IV-D Child
8 IV-D Spouse

POLICY SOURCE
Check off one of the following:
A COBRA Premium
B AIDS Program
C LOSS Pays Center
D LOSS Pays Employer
E LOSS Reimburse Client
F IV-D Court Ordered
G Absent Parent Voluntary
H Employment
I Union
J Fraternal Organization
K Tuition Fee
L Private Pay
M Accident (Not Worker's Comp. Related)
N Other
0 Military Service
P Worker's Compensation
Q Retirement Benefit
* Not Applicable

POLICY SEQUENCE NUMBER

Generated by eMedNY System

COVERAGE
06 Clinic 05 EMRG Room 19 PSCH lnpat
01 Comp Med A 04 Home HLTH 20 PSCH Out
02 Comp Med B 22 Hospice 17 SUB AB INP
15 Dental 03 Inpatient 18 SUB AB OUT
12 Drug CoPay 09 Nursing HM 14 TRANSP
11 Drug MaJor MED 16 Opitical 21 X-RAY
10 Drug Recovery 07 Phys Hosp
13 DME 08 Phys Offic

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-19
06/21/2015

THIRD PARTY DATA SHEET FORM - DSS 4198 CCONT'Dl

INSURER CODES
CODES CARRIER
02 HIP OUTPATIENT
05 ER

4
44
45
47
48
49
50

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-20
06/21/2015

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D)

INSURER CODES !CONT'D)

CODES CARRIER
69 COALITION FOR CARE

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-21
06/21/2015

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

INSURER CODES ICONT'Dl

CODES
63
64
65

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-22
06/21/2015

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
'
3.1-23
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'DI

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-24
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-25
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES

B2
B3
B4
B5

BB
BBA

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-26
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

INSURER CODES !CONT'D!

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-27
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D\

INSURER CODES !CONT'D\

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-28
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

INSURER CODES ICONT'Dl

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-29
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D)

CODES

E I
ED
ED
EE
EF
EHA
M

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-30
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'Dl

INSURER CODES !CONT'D!

CODES

ASSOCIATION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES

3.1-31
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D\

INSURER CODES !CONT'D)

CODES
E

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-32
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D>

INSURER CODES !CONT'D!

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-33
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

INSURER CODES ICONT'DI

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-34
02/19/2017

THIRD PARTY DATA SHEET FORM- DSS 4198 ICONT'Dl

INSURER CODES ICONT'Dl

CODES
B

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-35
02/19/2017

THIRD PARTY DATA SHEET FORM· DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-36
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-37
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D)

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-38
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES

PLAN

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUiDE TO CODES
3.1-39
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-40
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D)

INSURER CODES !CONT'D!

CODES

42
43
44
45
46
47
48

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-41
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 CCONT'Dl

INSURER CODES CCONT'Dl

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-42
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-43
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

TRADE WELFARE

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-44
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D!

INSURER CODES !CONT'D!

CODES
85

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-45
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 !CONT'D\

INSURER CODES !CONT'D\

CODES
95

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-46
02/19/2017

THIRD PARTY DATA SHEET FORM· DSS 4198 ICONT'Dl

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-47
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

INSURER CODES ICONT'Dl

CODES

WB233
WB234
8235
236
237

NEWYORKSTATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-48
02/19/2017

THIRD PARTY DATA SHEET FORM - DSS 4198 ICONT'Dl

INSURER CODES ICONT'Dl

CODES

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-49
02/19/2017

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-50
02/19/2017

THIRD PARTY HEALTH DATA SHEET - DSS 4384

MEDICARE COVERAGE UPDATE

MEDICARE SAVINGS PROGRAM INDICATOR

P Qualified Medicare Beneficiaries (QMB)
L Specified Low Income Medicare Beneficiary (SLMB)
U Qualified Individual (Ql-1)
X New Value for QDWI. (Has not yet been defined by DOH/TPHI)

ASSOCIATED NAME AND ADDRESS FORM - DSS 3517-25

ASSOCIATED ADDRESS CODES

01 Case Member Not At Case Residence
06 Committee
07 Guardian
10 Recipient of Second MA ID Card
19 Optional 2nd Mailing Address (MA Only)

FAIR HEARING UPDATE DATA ENTRY FORM - DSS 3722

FAIR HEARING CODES !AID STATUS\

1 · Client has settled in Conference
2 Aid Continuing
3 Non-Aid Continuing
4 Conditional Aid-Continuing
5 Client Lost Fair Hearing Agency Upheld
6 Client won Fair Hearing, Client Upheld
7 Erroneous Closing Entered, Administrative Error
8 Case Has Been Suspended By An Immediate Closing
'9 Settled in Conference, Agency Favor. (This only applies to employment-related closings.)
P Pause. This will suspend a V21 eligibility case denial or case closing, or a Y29 case
. closing, leaving transaction in 04 (pending) status indefinitely.
L Reviewed, requested appropriate documentation returned, proceed with next action.
The "paused" transaction will be purged from pending.
R Client submitted documentation that was insufficient/inappropriate, proceed with V21 or Y29.
The "paused" transaction will be unsuspended and processed to RJ or CL status.
* To be used only for cases closed by the Office of Employment Services

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-51
02/19/2017

SCREEN NQRFOO: RFI SNN/CIN SUMMARY

The following codes refer to new screens for Resource File Integration (RFI). With the Introduction of
Software for Version 93.1

RFI INDICATOR IRFI IND!

VALUE MEANING

x Unresolved RFI exists on case

Space No hits received for anyone on the case or all hits have been resolved.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-52
02/19/2017

SCREEN NQRF02 / NQRF03 / NQRF04

RFI SCREEN NQRF02 WAGE REPORTING INFORMATION

RFI SCREEN NQRF03 UIB INDIVIDUAL INFORMATION
RFI SCREEN NQRF04 SSA/RSDI INDIVIDUAL INFORMATION

RFI STATUS !INQUIRY CODES!

VALUE . MEANING
u Unresolved RFI data

R RFI data is resolved

N Response received -no data found

w Unresolved RFI data due to problem with SSN

v SSA has verified SSN only

Space Query sent but no response received

RESOLUTION CODES IRES CODE!

(These codes can be data entered on the bottom of the Inquiry Screens listed above)
VALUE MEANING
FOR PUBLIC ASSISTANCE AND SNAP

P01 Client required to file an SS-5 to correct SSA'S records. (Can be used only on WTPY
screen NQRF04)

P02 Demographics changes on WMS

P03 Application/Individual rejected-failure to respond to request to verify RFI data.

P04 Application/Individual rejected-ineligible due to RFI data

P05 RFI does not affect eligibility-currently correct

PO? Case is eligible but made active at a reduced grant due to RFL

POB Referred to BCFL

P90 Override RFI information. (Can be used on WTPY screen only.)

FOR MEDICAL ASSISTANCE

M01 Social Security data reviewed.

M02 Case or individual rejected-failure to respond to RFI information request or financially

ineligible because of information on RFL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-53
02/19/2017

SCREEN NQRF02 I NQRF03 I NQRF04 !CONT'D!

RESOLUTION CODES !RS CODES! !CONT'D!

FOR MEDICAL ASSISTANCE

M03 RFI data investigated, financial eligibility not affected, RFI data budgeted as
appropriate.

M04 Case/individual closed at recertification for failure to respond to RFI information

request, or financial ineligibility due to RFI.

M05 Fair Hearing aid to continue or determination override RFI matches.

M06 RFI individual not the same as client or assets do not belong to client. (Does not
include bank error.)

MO? Bank error. Resources in this account are not client's, nor do they belong to anyone
on case, in the household or anyone related to this case.

M09 Westmiller case; unpaid medical bills exist; resources budgeted.

M 10 Separately designated burial fund or funeral agreement. May include interest.

M 11 Up to $500 of the resources are gifts and/or minor's wages only. Up to $500
disregarded.

M 12 · Guardian applied for.

M13 Guardian was appointed.

M 14 Excess resources reimbursed or no longer Westmiller.

M15 Transfer of assets - non-HR applicant(recipient. Account still open.

M16 Transfer of assets - non-HR applicant/recipient. Account closed.

M 17 Case closed and referred to Office of Revenue and Investigation (ORI).

M18 Connect case.

M19 · CASA coverage adjustment to pay vendor. Emergency processing.

M20 Transfer of assets - HR applicant/recipient. Transfer not allowed.

M21 Pregnant woman.

M22 Court-ordered unassailable resource. Does not affect current eligibility until client's
18th birthday.

M23 Court-ordered unassailable resource. Does not affect current eligibility until client's
21st birthday.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
3.1-54
02/19/2017

SCREEN NQRF02 I NQRF03 I NQRF04 ICONT'Dl

RESOLUTION CODES IRS CODES! ICONT'D\

FOR MEDICAL ASSISTANCE

M24 AHIP; expanded eligibility with no resource test.

M25 Joint account. Recipient eligible for MA.

M90 For MAP Systems Office use only. (For use on WTPY screens only.)

OTHER - FOR USE IN ALL PROGRAMS

Delete existing resolution code.

SYSTEM GENERATED CODES- FOR USE IN ALL PROGRAMS

S97 SSN is valid and there are no SSA benefits

S98 Match data replaced with more recent information

S99 Client not in AP status when hit received.

RESTRICTION/EXCEPTION DATA INPUT FORM - DSS 3478

RESTRICTION/EXCEPTION TYPE
05 Pharmacy
06 Physician
08 Clinic
35 Comprehensive.Medicaid Case Management
38 ICF/DD Residents Exempt from Utilization Thresholds
50 Parental CONNECT (WMS Coverage Code 15)
51 Medicaid Eligible (WMS Coverage Code 01 or 30) Plus CONNECT
54 Exempt from HR Restrictions (System Generated, Output only)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-1
10/23/2016

CHAPTER4-
MEDICAL ASSISTANCE PROGRAM
TURNAROUND DOCUMENT - DSS 3517
SECTION 10 - MA CASE !SUFFIX! LEVEL CODES
MA RESPONSIBILITY AREA INDICATOR !MA RESP)- 219
AG State Investigative Agency - State AG cases
AN Acute Long Term Hospital Care Case
AS Acute Long Term Hospital Care Surplus Case
BH Bridges to Health Foster Care Case
CC Community Care Case
CM Child Health Plus (CHP) to Medicaid
CS Community Care Surplus Case
DN Dialysis Case
DS Dialysis Surplus Case
FA Enrolled in FIDA Plan
FD Foster Discharge
FH Fair Hearing - Aid to Continue Case
GP Protective Services -Guardian Pending
HC Hospital Care Catastrophic Case (External Use Only)
HN Hospital Care Case
HP HARP from NYSoH to WMS
HS Hospital Care Surplus Case
IC Medicaid Suspension (Valid 4/01/08)
IG State Investigative Agency - State IG cases
LB Luberto Vs Novello ·
LM Lombardi Care Case LCLong Term Care
LR Long Term Regular Chronic Care Case
LT LS. High Risk Case
MC CED/Managed Long Term Care
MP Qualified Individual (Ql1)
MS Special Low Income Medicare Beneficiaries (SLIMB)
NA Home Health Aid Case
OB OTB Retirees (Center 534)
OF Assisted Living Program
OM Office of Mental Retardation
PA Home Attendant Care Case
PC Presumptive Eligibility for Children
PD Home Care-Working Person with Disability Case
PE Presumptive Eligibility Family Planning Benefits Program
PK Housekeeper Care Case
PM Homemaker Care Case
PR Pre-release clients
PS Protective Services
PT Pooled Trust Case
PU Undefined Home Care Program Case
QM Qualified Medicare Beneficiaries (QMB)
SA Home Health Aid Surplus Case
SH Shelter Case
SC Special Services For Children (SC) Case
WD Working Disabled
WS Waiver Services Case

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-2
10/23/2016

SECTION 10 - MA CASE !SUFFIXl LEVEL CODES ICONT"Dl

APPLICATION SOURCE CODE !MA: STAT\ - 062

C Telephone application from F24
E Application registered through My Benefits (NYS system)
K ACCESS NYC from F24
N Application registered through ACCESS NYC
P Application is to be sent to the Asset Verification System (AVS)
Q Telephone Application for F43
U ACCESS NYC from F43
X Cases transferred from the Health Exchange to WMS
Y ACCESS NYC from F11
Z ACCESS NYC from F11

RECERTIFICATION SOURCE IRCRT SRCl - 063

P WMS Transactions to be sent to the Asset Verification System (AVS)

MA STATUS CODES !MA: STAT! - 240

AC Active
AP Applying
CL Closed
IC Medicaid Suspension
NA Not Applying
RJ Denial

RESOURCE VERIFICATION INDICATOR IRVll - 282

1: Resources verified for 36 months
2: Resources verified only for current month
3: Resources not verified
4: Transfer of resources
5: System generated transfer from NYSoH (Only valid with Case Opening codes 613, 614, 615,
616and621)
6: Transfer from NYSoH (Only valid with Case Opening codes 613, 614, 615, 616 and 621)
9: System generated exempt from resource verification

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-3
06/18/2012

MA CASE REASON CODES

OPENING CODES - MA !MA: REAS - 2411

CODE CATEGORY REASON
A03 MA Suspended. Coverage at Incarceration of Inmate of NYS or Local Facility HH=1
Inmate of a New York State or local correctional facility.
1.8NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL
A08 MA Authorized Medicaid Coverage, CHP to Medicaid (NYC)
We have accepted your Medicaid application date_ _for all Medicaid covered
care and services effective__for:
Please review the Medical Assistance Utiliz,ation Threshold Information, found in
the Medical Assistance section of the booklet, "LDSS-
88:
If you submitted paid medical bills for direct reimbursement, you will be notified
separately of our decision.
Regulations 18NYCRR 360-4.1,360-4.2,360-4.3,360-4.4, 360-4.5, 360-4.6 and y 360-4.7
A09 MA Notice of Intent to Change Medical Coverage Enrolled in MLTC NYC
(Housing Disregard)
We will reduce your Medicaid coverage from all covered care and services to
community coverage with community-based long-term care effective for:
This reduction is because you are no longer receiving nursing facility services.
You have enrolled in a Managed Long Term Care health plan, which provides
services for individuals who are chronically ill and/or who have disabilities.
Because you have been discharged from a nursing home facility and have
enrolled in a MlTC plan, a housing allowance of$ _ _ is used to determine you
Medicaid eligibility.
We have enclosed a budget worksheet so you can see how we determined your
eligibility, If you need assistance, please contact your social serves district.
Regulation 18 NYCRR 360-2.3, 360-4.7, 360-4.8, Section 366-a(2) and 366.14 of SSL
A24 MA Reinstate MA, Incarcerated Individual Released (NYC)
We will reinstate Medical Assistance coverage, subject to any limitations. This is
because you are no longer an inmate in a NYS or local correctional Facility.
Regulation 18NYCRR 360 and Section 366(1-a) of SSL
A26 MA Reinstate FHP to MA, Incarcerated Individual Released (NYC)
We will reinstate Medical Assistance coverage, subject to any limitations. This is
because you had coverage under FHP prior to incarceration.
Regulation 18 NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL
A27 MA Reinstate FPBP, Incarcerated Individual Released (NYC)
We will reinstate Medical Assistance coverage·. This is because had coverage
under the Family Planning Benefit Program prior to incarceration.
Regulation 18NYCRR 360-3.4(a)(1) and Section 366(1)(a)(1) and 366(1-a) of SSL
A28 MA/FHP Reinstate MA, Individual Discharged from a Psychiatric Center (NYC)
We will reinstate Medicaid coverage effective_ _ _ _ _ _ __
This is because you have been discharged from a psychiatric center.
I you start receiving nursing facility services on a permanent basis, notify your
social services district immediately.
Regulations 18NYCRR 360-2.2, 360-2.3, 360-3.4 (a)(1) and Sections 366(1)(c) & (
d)and 366a(5)(d) of SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-4
02/14/2015

MA CASE REASON CODES !CONT'D)

OPENING CODES - MA !MA: REAS - 2411

CODE CATEGORY REASON
A29 MA/FHP FHP to MA, Individual Discharged from a Psychiatric Center (NYC)
We will reinstate Medical Assistance coverage to all Medicaid covered care and
services effective- - - - - -
This is because you had coverage under Family Health Plus prior to admission to
a psychiatric facility and have been discharged.
Regulation 18NYCRR 360-2.2, 360-2.3, 360-3.4(a)(1) and Sections 366 1 (c) & (d) and
366a(5)(d) and 369(ee) of SSL.
A41 MA/FHP Suspend MA Coverage for 21-64 Year Old Admitted to a Psychatric Center, HH=1
(NYC)
We will suspend Medicaid/Family Health Plus/family Health P
plus Premium Assistance Program/Family Planning Benefit Program coverage
effective: _ _ .
Your Medicaid benefits will be reinstated when you are discharged.
Regulation 18 NYCRR 360-3.4(a)(2) and Section 366(1)(c) and (d) of the SSL
A44 FPBP Reinstate FPBP, Individual Discharged from a Psychiatric Center (NYC)
We will reinstate your Family Planning Benefit Program coverage effective _ _ .
This is because you had coverage under Family Planning Benefit Program prior to
admission to a psychiatric facility and have been discharged.
Regulation 18 NYCRR 360-3.4(a)(1) and Sections 366 (1)(a)(1) and 366 (1) (c) and (d)
of the SSL.
A62 MA Accept MA Coverage for Treatment of Inpatient Emergency Medical Conditions,
Inmate of a Correctional Facility
We have accepted your application dated for Medicaid but, due to your
immigration status, only for coverage for the treatment of inpatient emergency
medical conditions.
The coverage is effective for:
Because of your immigration and inmate status, Medicaid cannot pay for medical
care, services or supplies you received while physically residing in a correctional
facility, except for the treatment of inpatient emergency medical conditions. All
other Medicaid coverage will be suspended while you are incarcerated,
Regulation 18NYCRR 360-3.2(j), 360-3.4(a)(1 ), 366(1-a), 366(1 )(a)(1) and Section 122
of the SSL.
A64 MA Suspend MA Coverage for Treatment of Inpatient Emergency Medical conditions,
Inmate of a Correctional Facility
We will suspend Medicaid coverage effective for:
Because of your immigration and inmate status, Medicaid cannot pay for medical
care, services or supplies you receive while physically residing in a correctional
facility, except for the treatment of inpatient emergency medical conditions.
This decision is based on Sections 122 and 366((1)(e)(1) of the SSL.
A67 MA Reinstate MA Coverage for Treatment of Emergency Medical Conditions, Individual
Released from a Correctional Facility
We will reinstate Medicaid coverage for care an services necessary for the
treatment of an emergency medical condition effective for:
This is because you are no longer an inmate of a correctional facility.
You are eligible for Medicaid coverage only for care and services necessary for
the treatment of an emergency medical condition.
This decision is based on Sections 122 and 366(1)(e)(1) of the SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-5
06/21/2015

MA CASE REASON CODES !CONT'D!

OPENING CODES - MA !MA: REAS - 241! !CONT'D

CODE CATEGORY REASON
021 MA Open MA Case Discharged from Foster Care - True Chafee
The following individual will receive Medicaid under the Client Identification
Number noted below, effective_ _ __
This is because you were discharged from foster care and are between the ages
of18and21.
Regulation 18 NYCRR 360-3.2(j) and SSL 366(3-a).
022 MA Open MA Case Discharged from Foster Care - Chafee
Regulation 18NYCRR 360-3.2(j) and SSL366(3-a).
023 MA Foster Care IV-E KinGap .
Regulation Section 458-d of Social Services Law
024 MA Foster Care Non IV-E KinGap
Regulation Section 458-d of Social Services Law
025 MA. Foster Care Non NYS or Out of State IV-E KinGap
Regulation section 458-d of Social Services Law
092 MA/SSI SSI recipient not yet appearing on SOX determined eligible for MA-SSI
Regulation 360-3
095 FHP/PAP Premium Assistance Program-Parents at Case Level
MA 369-ee
H21 MA Notice of Intent to Change Medicaid Coverage Disenrolled in MLTC NYC
(Housing Disregard)
Regulation 18 NYC RR 360-2.3, 360-4.1, 360-4.1, 360-4.4, 360-4.5, 360-4. 7 360-4.8, and
sections 366-a(2) and 366.14 of SSL
H28 MA Medical Assistance/Family Planning Benefits Program
For FPBP eligible at or below 200% of FPL. At the case and individual level for
Category codes 68 or 69 only.
H43 MA MAGI-Like Consumers (NYC) (System Generated)
Section 366(1 )(b) of the Social Services Law
H60 MA Accept Medicaid Application for Retroactive Period Only, All Covered Care and
Services, Ongoing Coverage through the New York State of Health
Your health care coverage is a.uthorized through the New York State of Health.
You requested for coverage for medical bills in the three month period prior to your
application to the New York State of Health. We have made a decision concerning
your request.
This decision is based on Social Services Law section 364-i(7)
H62 MA Accept Medicaid Application for Retroactive Period Only, Excess Income (1 Month
Spend Down Met), Ongoing Coverage through the New York State of Health
We will suspend Medicaid/Family Health Plus/family Health Plus Premium
Assistance Program/Family Planning Benefit Program coverage effective: _ _ .
Your Medicaid benefits will be reinstated when you are discharged.
Regulation based on section 364-i(7) of the SSL
H64 MA Override Opening Code for Nursing Home and MLTC cases (Manual Notice
Requited)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-6
06/21/2015

MA CASE REASON CODES !CONT'D!

OPENING CODES - MA !MA: REAS - 241! !CONT'D!

CODE CATEGORY REASON
H65 MA-MPE Ongoing Coverage through the New York State of Health
Your health care coverage is authorized through the New York State of Health.
You requested coverage under the Family Planning Benefit Program prior to you
application to the New York State of Health.
We have accepted your application date for Family Planning Benefit
Program effective for the period to for:
If you submitted paid medical bills for direct reimbursement, you will e notified
separately of our decisions.
This decision is based on SSL section 366(1 )(b)(6)
H66 MA MAGI-Like Consumers (NYC)
Section 366(1 )(b) of the Social Services Law
H67 FHP Eligible single/childless couples (can only be used on FHP cases).
MA: 369-ee
H68 FHP Parents at the case level (can only be used on FHP cases)
MA: 369-ee
H69 FHP Pregnant women on MA case.
MA: 369-ee
H70 MBl-DBG Medicaid Buy - In (Disabled Basic Group) Eligible at or below 150%
Regulation 366(1 )(a)(12) and 367-a(12) of the Social Service Law
H71 MBl-MI Medicaid Buy - In (Medically Improved) Eligible at or below 250% but greater than
150%
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law
H72 MA Pay-In Excess Income
Regulation 360-4.8 (c)
H73 Qll Qualified Individual
Opening code for Qualified Individuals - Ql1
H74 FHP Parents and Expanded Eligibility Children
Regulation
H76 MA Excess Income, Managed Long Term Care
Section 366-a(2) of the Social Services Law.
H77 MA-
SSI Related Blind arid disabled individuals who lose eligibility for SSI payments;
As a result of becoming entitled to Title II child's insurance benefits as a disabled
adult child (DAC) or because of an increase in such benefits. Note: MBL budget
type 04 (SSI Related), or 05 (SSl-FA) or 06 (SSI- SNCA) must be used
Regulation 360-3:3 (c)
H78 MA Not Eligible for MA- Eligible for Health Insurance Premium Payment Only.
Regulation 360-7.5 (H) '
H79 MA Household Member Eligible for MA and Eligible for COBRA Health
Insurance Continuation Payments.
Regulation 360-3, 360-7.5 (H)
H81 FHP-PAP FHPlus-Premium Assistance Program with Combo Coverage
We have accepted your application dated for Family Health Plus/Family
Health Plus_Premium Assistance Program.
Regulation 18 NYCRR 360-2.2(d)(2) and Sections 366(1)(a)(1) and 369-ee of the SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-7
10/23/2016

MA CASE REASON CODES ICONT'Dl

OPENING CODES - MA IMA: REAS - 2411 !CONT'D!

CODE CATEGORY REASON
H82 FHP-PAP FHP-PAP with Combo Coverage (S/CC)
We have accepted your application dated __for Family Health Plus/Family
Health Plus-Premium Assistance Program.
Regulation 18 NYCRR 360-2.2(d)(2) and Sections 366(1)(a)(1) and 369-ee of the SSL
H83 IV!A Institutionalized Spouse (Manual Notice Required)
Expected to remain in medical institution for 30 consecutive days- Chronic Care
Budgeting used.
Regulation 360.14 (c)
H84 MA Inpatient Hospital bills equal to or greater than excess resources combined;
with excess income (if applicable).
Regulation 360-3
H85 MA-SSI
Related Medicare Premium, Co-Insurance and Deductible Only. (SLIMB/QMB)
Regulation 360-3.
H88 All Disabled child/children receiving medical/nursing care at home.
Regulation 360-3
H91 FA/SNFP
SSI Related Medical bills equal to or greater than excess income.
Regulation 360-4.8 (c)

H94 All Medical need - no recent change in financial circumstances.

Regulation 360-3
H96 All Determined MA Eligible using Expanded Eligibility Criteria
Case contains excess resources, excess income or both (replaced 039)
Regulation 360-3
H98 FHP-PAP Premium Assistance Program-Parents and Expanded Eligibility Children
MA 369-ee
H99 MA Administrative Renewal for Aged, Blind and Disabled Coverage Unchanged (NYC)
Regulation 18 NYC RR 360-2.3 and _Section 366-a of SSL
P47 MA Reinstate MA Coverage (30 Days Prior to Release)
We will reinstate Medicaid coverage when the following individual is released to
the community correctional facility:
Prior to release, a common Benefit Identification Card will be mailed to the
correctional facility. This card will be made available to you upon release to the
community
Y27 . FPBP-PE Presumptive Eligibility Family FPBP - Case Type 21 (No Notice Required)
Y56 MPE Presumptive Eligibility
Y57 MPE Based on your need for 1'10me care services, you have been determined
presumptively eligible for a maximum period of 60 days.
Regulation 360-3
Y58 MPE Based on your pregnancy, you have been determined presumptively
eligible for Medical Assistance for a maximum period of 45 days.
Regulation 360-3
Y59 MPE Presumptive Eligibility for Children (Manual Notice)
Regulation SSL 364-1 (4) (a-e)
Y67 MA Other
Y68 MA RVI Fair Hearing Opening Code in Undercare
Y69 All Administrative
Regulation 360-3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-8
10/23/2016

MA CASE REASON CODES !CONT'D!

OPENING CODES - MA IMA: REAS - 2411 !CONT'D!

CODE CATEGORY REASON
605 MA MLTC Extension Valid for Medicaid (CT 20)
The Medicaid case for the following individual has been referred to the Human
Resources Administration:
This is because you have requested services which can only be accessed through
your local department of social services.
609 MA BHP Transfer Remains in WMS (Manual Opening)
We will restore Medicaid coverage effective for the following individual(s):
This because you have been identified as an individual who must have their
eligibility determined by your local department of social services rather than by
New York's health plan marketplace, NY State of Health.
18 NYCRR 360-2
616 MA Authorize Medical Coverage, Referral Received from NYSoH
NYSoH Transition (Manual Opening)
621 MA Authorize Medicaid Coverage, Referral Received from NYSoH
This eligibility can only be determined by your local Department of Social Services
622 MA Enrolled in HARP and transferred from NYSoH to WMS
666 MA Fair Hearing Opening CodeMA 369-ee
667 MA Graus 2 months extension MA cases awaiting Recert update (System Generated)
669 12-Month Automatic Extension (System Generated)
Due to disaster of 09/11 /01
806 MA Reinstate MA, Incarcerated Individual Released (System Generated)
Regulation 18NYCRR 360 and Section 366(1-a) of the SSL
812 MA Recalculation of Contribution Toward Chronic Care Single COLA
Regulation 18 NYCRR 360-4.9 and 360-4.3 and section 366
813 MA Reinstate, Incarcerated Individual Released (System Generated)
Regulation 18NYCRR 360-4.4(a)(1) and Section 366(1)(a)(1) and 366(1-a) of SSL
814 MA Reinstate FHP to MA, Incarcerated Individual Released (System Generated)
Regulation 18 NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL
822 MA Open MA Case Discharged from Foster Care - Chafee (System Generated)
Regulation 18NYCRR 360-3.20) and SSL 366(3-a).
853 MA Transition of MA Eligibility, (Upstate to NYC) (System Generated)
A Medical Assistance case will be opened.
Regulation 18NYCRR Sections 351.2 (g)(1) and 360-4.8 (b) 3~4-j and 369-ee of SSL
865 MPE Presumptive Eligibility for Children (System Generated)
Regulation SSL 364-1 (4) (a-e)
889 MA Open MA Case Discharged From Foster Care (System Generated)
Regulation 18 NYCRR 360-2.6
923 All This is because the infant's mother was receiving Medical Assistance at the time of
the infant's birth or within three (3) months prior to the infant's birth.
Establish MA only (System Generated)
Regulation 366-g

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-9
02/19/2017

MA CASE REASON CODES ICONT'Dl

OPENING CODES - MA !MA: REAS - 2411 !CONT'D!

SYSTEM GENERATED MA CODES

CODE CATEGORY REASON

P47 MA Reinstate MA Coverage (30 Days Prior to Release)
We will reinstate Medicaid coverage when the following individual is released to
the community correctional facility:
Prior to release, a common Benefit Identification Card will be mailed to the
correctional afacility. This cared will be made available to you uppon release to
the community.
093 MA-SSI SSI New Opening on SOX, Determined Eligible for MA-SSI (Case Type 22)
Regulation 360-3
414 MA Presumptive Eligibility FPBP - Case Type 21 (No Notice Required)
415. MA Administrative Renewal for Aged, Blind and Disabled Coverage Unchanged (NYC)
602 MA BHP Closed 620 (System Generated)
608 MA HX Transfer of BHP Ineligible (System Generated)
A Medicaid case has been opened for the following individual (s) by the HumanResources
Administration:
We will continue your current coverage while we determine if you remain eligible Medicaid
coverage. This eligibility can only be terminated by your local department of social
services.
613 MA Authorized Medicaid Coverage, Referral Received from NYSoH
Age 65 and Over with or without Medicare
The Medicaid case for the following individual has been referred to the Human
Resources Administration. Your eligibility for Medicaid must be determined on a different
basis that takes into account both your income and certain deductions that were not
applied by the Marketplace. ·
This eligibility can only be determined by your local Department of Social Services.
614 MA Authorized Medicaid Coverage, Referral Received from NYSoH
Age 64 or Under in receipt of Medicare
The Medicaid case for the following individual has been referred to the Human Resources
Administration:
Your eligibility for Medicaid must be determined on a different basis that takes into
account both your income and certain deductions that were not applied by the
Marketplace. This eligibility can only be determined by your local department of
social services.
615 MA Authorized Medicaid Coverage, MLTC Referral Received from NYSoH
The Medi6aid case for the following individual has been referred to the Human
Resources Administration: ·
This is because you have requested services which can only be accessed through your
local department of social services.
632 MA Suspend MA Coverage for Treatment of Inpatient Emergency Medical Conditions,
Inmate of a Correctional Facility (System Generated)
We will suspend Medicaid coverage effective for:
Because of your immigration and inmate status, Medicaid cannot pay for medical care,
services or supplies you receive while physically residing in a correctional facility, except
for the treatment of inpatient emergency medical conditions.
This decision is based on Sections 122 and 366(1)(e)(1) of the SSL
633 MA Reinstate MA Coverage for Treatment of Emergency Medical Conditions, Individual
Released from a Correctional Facility
This decision is based on Sections 122 and 366(1)(e)(1) of the SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-10
02/14/2015

MA CASE REASON CODES !CONT'D!

REJECTION CODES - MA IMA: REAS - 2411

ALIEN/CITIZENSHIP STATUS
CODE CATEGORY REASON
EE3 MA Deny Medical Emergency and MA due to Excess Income Non-Immigrant/
Undocumented Immigrant Certified Blind/Aged or Certified Disabled
We have denied your application for Medicaid for emergency medical care/
services. This is because you are not a citizen, qualified alien or permanently
residing in the United States under color of law (PRUCOL), you may receive
Medicaid coverage only for the treatment of emergency medical conditions, or for
medical services provided to pregnant women, if you are otherwise eligible.
Regulation 18 NYCRR 360-4.8 and 360-3.20) and Section 122 of the SSL.
EE4 MA Deny Medical Emergency and MA due to Excess Income Non-Immigrant/
Undocumented Immigrant Certified Blind/Aged or Certified Disabled
We have denied your application for Medicaid for emergency medical care/
services. This is because you are not a citizen, qualified alien or permanently
residing in the United States under color of law (PRUCOL), you may receive
Medicaid coverage only for the treatment of emergency medical conditions, or for
medical services provided to pregnant women, if you are otherwise eligible.
Regulation 18 NYCRR 360-4.8 and 360-3.2(j) and Section 122 of the SSL.
EES MA Deny Medical Emergency and MA due to Excess Income Non-Immigrant/
Undocumented Immigrant Certified BHnd/Aged or Certjfied Disabled
We have denied your application for Medicaid for emergency medical care/
services. This is because you are not a citizen, qualified alien or permanently
residing in the United States .under color of law (PRUCOL), you may receive
Medicaid coverage only for the treatment of emergency medical conditions, or for
medical services provided to pregnant women, if you are otherwise eligible.
Regulation 18 NYCRR 360-4.8 and 360-3.2(j) and Section 122 of the SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-11
02/15/2014

MA CASE REASON CODES !CONT'D\

REJECTION CODES - MA !MA: REAS - 2411 !CONT'D!

ALIEN/CITIZENSHIP STATUS (CONT'D)
CODE CATEGORY REASON
F92 All Deny MA/FHP Failure to Provide Proof of Citizenship. Identity and/or Current
Immigration Status !HH=1 I
We have denied your application for Medicaid/Family Health Plus/FHP-PAP. This .
is because you have failed to provide documentation of citizenship, identity and or
current immigration status.
Regulation 18 NYCRR 351.1(b)(2)(ii), 351.2, 351.5, 351.6 351.8(a092)(ii), 360-1.2,360-
2.3 and Section 369-ee of the SSL.
F93 All
Deny MA/FHP Failed to Complete Declaration of Citizenship/lmmigration!HH=11
This is because in order to get Assistance, we must have a written declaration for
each applying household member stating that the individual is either a US citizen,
National, Native American or is in a satisfactory immigration status.
Regulations 18NYCRR 360-2.3, 360-3.2U) and Sections 369-ee of the SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-12
02/15/2014

MA CASE REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 241! !CONT'D!

EXCESS INCOME/RESOURCES
CODE CATEGORY REASON
E04 FHP Deny FHP/FHP-PAP. MA Ineligible. Excess Income - SCC.
!Including 19-20 Years Old Not Living w/Parentsl
Message 1:
We have denied your application for Medicaid/Family Health Plus/FHP - PAP
program. You are not eligible for Medicaid because your gross income of$_ is
over 185% of the Medicaid Standard of$ .
Message 2:
You are not eligible for Medicaid because your net income (gross income less
Medicaid deductions) of$_ is over the Medicaid Standard of$_.
Regulation 18 NYCRR 360-4.1, 360-4.7 and 360-4.8 and Sections 366(1)(a)(1) and
369-ee of the SSL
E22 FHP Deny FHP/FHP-PAP. Ineligible for Medicaid. Excess Income !Parents, Including 19
-20 Years Old Living with or without parent)
We have denied your application for Medicaid/Family Health Plus/FHP-PAP. You
are not eligible for Medicaid because your net income (gross income less
medicaid deductions) of$_ is over the allowable medicaid income limit of$_.
Regulation 18 NYCRR 360-4.1, 360-4.7 and 360-4.8 and Sections 366(1)(a)(1) and
369-ee of the SSL.
E30 All Deny Medicaid/Family Health Plus/FHP-PAP. Excess Income
We have denied your application for Medicaid/Family Health Plus/FHP-PAP. You
are not eligible for Medicaid because your net income (gross income less
Medicaid deductions) of$_ is ovior the allowable Medicaid income limit of$_.
Regulation 18NYCRR 360-2.3, 360-4.1, 3604.4,360-4.5, 360-4.7 and 360-4.8, Sections
366(1 )(a)(11 ), 366-a(2),366(4)(q)(1) and 369-ee of the SSL.
E35 MA Deny Medicaid/Family Health Plus/FHP-PAP Excess Income. ISCCl
We have denied your application for Medicaid/Family Health Plus/FHP-PAP.
Message 1:
You are not eligible for Medicaid because your gross income of $_is over the
185% of the Medicaid standard of$_.
Message 2:
You are not eligible for Medicaid because your net income (gross income less
Medicaid deductions) of$_ is over the Medicaid Standard of$_.
Regulation 18 NYCRR 360-4.1, 360-4.7 and 360-4.8 and Sections 366(1)(a)(1),
366(1)(a)(11) and 369ee of the SSL.
E59 MA Deny MA Excess Income Pregnant Woman
We have denied your application for Medicaid. This is because your net income of
$ is more than 200% of the Federal Poverty Level of $_ _which is the
income limit for a pregnant woman.
Regulation18NYCRR 360-4.1, 360-4.7 and 360-4.8

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-13
02/15/2014

MA CASE REASON CODES !CONT'D)

REJECTION CODES - MA !MA: REAS - 2411 !CONT'D)
EXCESS INCOME/RESOURCES ICONT'Dl
CODE CATEGORY REASON
E82 MA Deny Family Planning Services, Excess Income
We have denied your application for Family Planning Benefit Program dated _ _
for:. This is because your net income (gross income less Medicaid deductions)
of$_ is over $_ _ . which is the income limit for the Family Planning Benefit
Program.To apply for Medicaid with a spenddown, you must meet one of the
following requirements: be under age 21, Over age 65, pregnant, certified blind,
certified disabled or a parent(s) of a child under 21.
Regulation 366(1)(a)(11) and a(11) of the Social Service Law

F09 MBl-WPD Deny MBl-WPD. Excess Income above 250% of FPL

We have denied your application for Medicaid coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD). This is because your
net income (gross income less Medical Assistance deductions) of $_is over the
MBl-WPD income limit of$_._.
Regulation 18 NYCRR 360-4.1, 360-4.3, 360-4.4, 360-4.6, 360-4.7, and 360-4.8 and
Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the SSL.
F26 MBl-WPD Deny MBl-WPD. Excess Resources
We have denied y·our application for Medicaid coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD). This is because your
countable resources of$_ are over the allo.wable Medicaid resource limit of
$_.
Regulation 18 NYCRR 360-4.1, 360-4.3, 360-4.4, 360-4.6, 360-4.7, and 360-4.8 and
Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the SSL.
F28 MBl-WPD Deny MBl-WPD. Excess Income and Excess Resources
We have denied your application for Medicaid coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD). This is because your
net income (gross income less Medical Assistance deductions) of $_is over the
MBl-WPD income limit of$_. In addition your countable resources of $_are
over the allowable Medicaid resource limit of$_.
Regulation 18 NYCRR 360-4.1, 360-4.3, 360-4.4, 360-4.6, 360-4.7, and 360-4.8 and
Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the SSL.

NEV\' YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-14
10/17/2015

MA CASE REASON CODES !CONT'D>

REJECTION CODES - MA !MA: REAS - 241\ !CONT'D\

EXCESS INCOME/RESOURCES CCONT'Dl
CODE CATEGORY REASON
FE1 MA Deny MA Excess Income. Child Age 6-18 INYCl
We have denied your application for Medicaid dated_ _for:
This is because your net income of$_ is more than 133% of the Federal
Poverty Level of$_. which is the income for persons ages six through eighteen
years.
Regulations 18NYCRR 360-4.1, 360-4.7 and 360-4.8, and Section 366(1)(a((11) and
366(4)(p)(1) of the Social Services Law
G18 FHP Deny Medicaid/FHP/FHP-PAP. Excess Income of Parents and Children
We have denied your application for Medicaid/Family Health Plus/FHP-PAP. You
are not eligible because your gross income of$_ is over the Family Health Plus
Income limit.
Message 1: Children Up to Age One
Your net income (gross income less Medicaid deductions) of$_ is more than
200% of the Federal Poverty Level$_.
Message 2: Children Ages 1-5
Your net income (gross income less Medicaid deductions) of$_ is more than
133% of the Federal Poverty Level$_.
Message 3: Children Ages 6-19
Your net income (gross income less Medicaid deductions) of$_ is more than
100% of the Federal Poverty Level$_.
Regulation 18 NYCRR 360-2.3, 360-4.1, 360-4.4, 360-4.5, 360-4.17 and 360-4.8,
Sections 366(1 )(a)(11 ), 366-a(2), 366(4)(q)(1) and 369-ee of the SSL.
G57 MA Deny Medicaid.Ineligible. Income Over 138%
We have denied your application for Medicaid dated ___for:
This is because you are not eligible for Medicaid because your gross income of
$_ _ is over the allowable Medicaid income limit of$_ _ __
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess INcome Program" and
"Optional Pay-in Program."
If you are interested in receiving Medicaid coverage with a spenddown, call the
Unit telephone number listed above within 30 days of the effective date of this
notice.
Regulation SSL 366(1)(b) and 366-a(2)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-15
02/15/2014

MA CASE REASON CODES ICONT'Dl

REJECTION CODES - MA IMA: REAS - 2411 !CONT'D)

EXCESS INCOME/RESOURCES (CONT'Dl
CODE CATEGORY REASON
H33 MA Deny Medicaid. Excess Income. Applicant Age 65 and Older. Certified Blind or
Certified Disabled
We have denied your application for Medicaid dated for:
This is because your net income (gross income less Medicaid deductions) of
$_ _is over the allowable Medicaid income limit of$_ _. The amount over the
limit is called excess resources or spendown. Your monthly excess income
amount is$_ _ . You are over the limit by $ . Also, you do not have paid
or unpaid medical expenses not covered by insurance that are equal to or more
than your ex.cess income amount. Please look at the enclosed budget calculation
to see how we figured your excess income.
If you incur medical bills in the amount of your excess income, you may reapply.
Please read the enclosed "Explanation of the Excess Resource Program".
Regulation 18 NYCRR 360-4.8.
H34 MA Deny Medicaid. Ineligible. Excess Income
We have denied your application for Medicaid dated for:
This is because you are not eligible for Medicaid because your gross of$ is
over the allowable Medicaid income limit of$ _ _ __
If your income is too high, you may still be able to get health care coverage.
If annual income is greater than 400% of the FPL, health insurance can still be
purchased through New York State bf Health.
Sections 366(1)(b) and 366-a(2) of the Social Services Law
H35 MA Deny Medicaid. Ineligible. Income Over 223% FPL
We have denied your application for Medicaid dated _ _ for:
This because is because you are not eligible for Medicaid because your gross
income of$ is over the allowable Medicaid income limit of$_ __
However, you may be eligible for Medicaid spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-In Program."
Sections 366(1)(b) and 366-a(2) of the Social Services Law.
H36 MA Deny Medicaid. Ineligible. Income Over 154%
We have denied your application for Medicaid dated _ _ for:
This because is because you are not eligible for Medicaid because your gross
income of$ is over the allowable Medicaid income limit of$_ __
However, you may be eligible for Medicaid spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-In Program."
Sections 366(1 )(b) and 366-a(2) of the Social Services Law.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-16
02/14/2015

MA CASE REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 241! !CONT'D!

EXCESS INCOME/RESOURCES !CONT'D)
CODE CATEGORY REASON
H37 MA Deny Medicaid. Ineligible. Income Over 155%
We have denied your application for Medicaid dated _ _ for:
This because is because you are not eligible for Medicaid because your gross
income of$ is over the allowable Medicaid income limit of$ _ __
However, you may be eligible for Medicaid spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-In Program."
Sections 366(1)(b) and 366-a(2) of the Social Services Law.
H25 MA Peny MA Excess Resources !DAB\
We have denied your application for Medicaid dated _ _ for:
This because your countable resources $_ are over the allowable Medicaid
resource limit of$_. The amount over the limit is called excess resources or
spenddown. Your Excess resource amount is$ . Also, we have not
received documentation that you have spent your excess resources by
establishing or adding to a burial trust/fund. Please look at the budget
calculations section to see how we figured your excess resources. If you incur
medical bills in the amount of your excess resources in the future or If the amount
of your resources goes down, you may reapply. Please read the enclosed
"Explanation of the Excess Resource Program".
Regulation 18 NYCRR 360-4.8
H26 MA Deny Medicaid. Excess Income and Resources fSSl-Relatedl
We have denied your application for Medicaid dated __for:
This is because your net income (gross income less Medicaid deductions) of
$__ is over the allowable Medicaid income limit of$_ _ . In addition, your
countable resources of$ _ _ are over the allowable Medicaid resource limit of
$ . The amounts over the limits are called excess income and excess
resources or spenddown. Your monthly excess income amount is $ . Your
excess resource amount is $ . Also, we have not received documentation
that you have spent your excess resources by establishing or adding to a burial
trust/fund.
Please look at the enclosed budget calculation to see how we figured your excess
income and excess resources.
If you incur medical bills in the amount of your excess resources and expect to
have medical bills which are equal to or more than your excess income, or your
income resources goes down, you may reapply. Please read the enclosed
"Explanation of the Excess Resource Program".
Regulation 18 NYCRR 360-4.8.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-17
06/16/2016

MA CASE REASON CODES !CONT'D>

REJECTION CODES - MA !MA: REAS - 2411 !CONT'D>

LIVING ARRANGEMENTS
CODE CATEGORY REASON
EGO All Deny Medicaid/Family Health Plus/FHP-PAP/- Unable to Locate
We .have denied your application for Medicaid. This is because we have been
unable to find you.
Regulation 18NYCRR 351-B(a), 360-2.2(f),360-2.3 and Sections 366(1)(a)(11) and
369-ee of the SSL
E63 All Deny Medicaid/Family Health Plus/FHP-PAP/- Not a Resident of State
We have denied your application for Medicaid. This is because you are not a
resident of this State.
Regulation 18NYCRR 351-2(g)(1), 360-3.5, 360-3.6 and SSL 366(1)(a)(11), 366(1)(b)
and 369-ee
E72 All Deny Medicaid/Family Health Plus/FHP-PAP/. Public Institution
We have denied your application for Medicaid/Family Health Plus/FHP-PAP/. This
is because you live in a public institution which provides medical care for you.
Regulation 18NYCRR_360-3.4 and Sections 366(1)(a)(11) and 369-ee of the SSL
E73 All Deny Medicaid/Family Health Plus/FHP-PAPI. Foster Care
We have denied your application for Medicaid/Family Health Plus/FHP-PAP. This
is because the individual will receive Me~icaid coverage through the Foster Care
Program.
Regulation 18 NYCRR 360-2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-18
02/15/2014

MA CASE REASON CODES !CONT'D)

REJECTION CODES - MA !MA: REAS - 2411 ICONT'Dl

DUPLICATE ASSISTANCE
CODE CATEGORY REASON
M02 MA Deny Application Due to Receipt of Medicaid through New York State of Health
I NY Cl
We have denied your application for Medicaid dated for:
This is because your identity matches that of a person who is already receiving
Medicaid coverage through New York State of Health, account number_ __
Because the identities match, we have determined that you and that person are
the same person.
Regulation 18 NYCRR 351.9 and Section 366(1)(b) of the SSL.
M13 All Deny Medicaid/Family Health Plus/FHP-PAP/. Currently in Receipt of Medicaid
in Another State
We have denied your application for medicaid/family Health Plus/FHP-PAP/. This
is because you already receive Medicaid in the State of_.
Regulation 18 NYCRR 351.9 and Sections 369-ee and 366(1)(a)(11) of the SSL.
M66 All Deny Medicaid/Family Health Plus/FHP-PAP/, Currently in Receipt of Medicaid
on Another Case
We have denied your application for Medicaid/Family Health Plus/FHP-PAP/. This
is because you are already receiving Medicaid/Family Health Plus/FHP-PAP/
under case name __
Regulation 18 NYCRR 360-3.3 and Sections 369-ee and 366(1 )(a)(11) of the SSL.
M67 All Deny Medicaid/Family Health Plus/FHP-PAP/, Part of Another MA Application
We have denied your application for Medicaid/Family Health Plus/FHP-PAP/. This
is because you are part of the application of_and you are still a member of that
household. We will decide if you can get assistance as a member of that case.
Regulation 18 NYCRR 360-3.3 and Sections 369-ee and 366(1)(a)(11) of the SSL.
M98 All Deny Medicaid/Family Health Plus/FHP-PAP/. Currently in Receipt of
Concurrent Benefits
We have denied your application for Medicaid/Family Health Plus/FHP-PAP/. This
is because your identity matches that of a person who is already receiving
assistance in District Name.
Regulation 18 NYCRR 351.9

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-19
02/21/2016

MA CASE REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS -2411 !CONT'D!

HEAL TH INSURANCE
CODE CATEGORY REASON
G48. FHP Deny FHP-PAP, ESHI Not Cost Effective. lneliaible for FHP Due to Equivalent
Health Insurance
We have denied your application for Family Health Plus/FHP-PAP. This is
because it is not cost effective for the Family Health Plus-Premium Assistance
Program to pay the premiu~ for your employer sponsored health insurance.
Regulation 18 NYC RR 360-2.2(d)(2) and Sections 366(1)(a)(1) and 369-ee of the SSL
V18 All Deny MAIFHP TPHI Resources - Refusal !MANUAL NOTICE REQUIRED!
We have denied your application for Medicaid/Family Health Plus/FHP-PAP.
Message 1:
This is because you refused to provide information on employer or other than
employer sponsored group health insurance plan.
Message 2:
This is because you refused to enroll in employer or other than employer
sponsored group health insurance plan.
Regulation 18 NYCRR 360-3.2(h) and Section 369.ee of the SSL
Y84 FHP Deny FHP, Failure to Provide FHP Plan and Provider Selection Form
!MANUAL NOTICE REQUIRED!
We have denied your application for Family Health Plus dated . Choosing a
health plan is an eligibility requirement of the Family Health Plus Program. We told
you if you did not return the completed plan enrollment form we would not be able
to continue your health insurance coverage.
Regulation 360-4.1, 360-4.8
884 All Deny MSP from LIS Application Failure to Provide Documentation
!SYSTEM GENERATED!
We have denied your application for the Medicare Savings Program. This is
because you failed to provide the requested information required to establish your
eligibility for MSP.
SSL 367-a(3) and Regulation 18 NYCRR 360-7.7

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-20
02/21/2016

MA CASE REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 2411 !CONT'D!

OTHER ELIGIBILITY REQUIREMENTS
CODE CATEGORY REASON
BH1 TA Denial, Transition to NY State of Health, Recipient in the Five Year Ban (BHP)
(System Generated)
Because of the immigration status of individuals on your application, eligibility for
Medicaid coverage for the following individuals must be determined by New York's
health plan marketplace, NY State of Health:
This decision is based on Sections 366(1 )(g) and 369-gg of the SSL.
F17 All Deny Medicaid/Family Health Plus/FHP-PAP/, Incorrect/Fraudulent
Social Security Number IHH=1 l
We have denied your application for Medicaid/Family Health Plus/FHP-PAP/. This
is because you did not give us the correct Social Security number (s).
Regulation 18 NYCRR 360-2.3 (a) and Sections 366(1 )(a)(11) and 369-ee of the SSL
F20 All Deny Medicaid. Failure to Provide Social Security Number
We have denied your application for Medicaid. This is because you did not give us
a Social Security number (s) or apply for a Social Security number (s).
Regulation 18 NYCRR 351.2(c), 360-2.3(a) and Section 369-ee of SSL
FSO All Deny MA Death before Determination - No Medical Bill in the Retro Period
We have denied your application for Medicaid/FHP/FHP-PAP/. This is because
this individual died before the process was completed and did not have medical
bills.
Regulation 18 NYCRR 360-2.2 and 360-2.3
F51 All Deny MA Death Before Determination - Insufficient Information to Make Decision
Deny MA Death before Determination - No Medical Bill in the Retro Period
We have denied your application for Medicaid/FHP/FHP-PAP/. This is because
our records indicate that this individual is decease and we have insufficient
information to complete the application process.
Regulation 18 NYCRR 360-2.2 and 360-2.3

G58 Qil Deny Ql-1 Annual Fund Exhausted

We have denied your application for Medicare Part B premium. The funding
provided to New York State by the federal government for this program has been
expended for the year.
This decision is based on: Subdivision 3 Section 367-a of the SSL
G59 Qil Deny Qualified Individual IQl-1!. Over Income
We have denied your application for Qualified lndividuals-(Ql-1). This is because
your net income (gross income less Medical Assistance deductions) of$ _ _ is
over the Ql-1 income limit $_ _ .
Subdivision 3 of Section 367-a of the SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-21
10/23/2016

MA CASE REASON CODES !CONT'D\

REJECTION CODES - MA !MA: REAS - 241) !CONT'D!

OTHER ELIGIBILITY REQUIREMENTS (CONT'Dl
CODE CATEGORY REASON
GBB All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP.Client Request !WRITTEN!
We have denied your application for Medicaid/FHP/FHP-PAP/FPBP. This is
because you said that you did not want assistance.
Regulation 18 NYCRR 360-2.6 and Sections 366(1)(a)(11) and 369.ee of the SSL
G98 All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP. Client Request !VERBAL!
We have denied your application for Medicaid/FHP/FHP-PAP/FPBP. This is
because you said that you did not want assistance.
Regulation 18 NYCRR 360-2.6 and Sections 366(1)(a)(11) and 369.ee of the SSL
HOS All Duplicate Application !AMP Date Required!
We have denied your application for Medicaid/Family Health Plus-Premium
Assistance Program/Family Planning Benefit Program dated for:
This is because you are already have a pending application for Medicaid/Family
Health Plus/Family Health Plus-Premium Assistance Program/Family Planning
Benefit Program dated _ __
Regulation 18 NYC RR 360-3.3 and Sections 369-ee and 366(1 )(a)(11) of the SSL
This decision is based on Section 366(1)(b) ofthe Social Services Law.
H24 All Deny Retroactive Eliqibility lfor Payment of Bills Offlinel
!MANUAL NOTICE REQUIRED!
Based on a review of your application for retroactive Medical Assistance, we have
determined that your application does support a finding of retroactive MA
eligibility. Retroactive MA eligibility for the period _ _ to has been
authorized for you. An authorization letter will be sent to you to verify your
eligibility for the retroactive period.
Regulation 18 NYCRR 360.16, 360-1.2, Part 350, Part 351
H42 MA Deny Medicaid, Individual Revoked Authorization for AVS
We have denied your application for Medicaid dated for:
This is because in order to get Medicaid, you and your spouse (if married) must
provide a signed authorization allowing Medicaid to verify your and your
spouses's resources with financial institutions.
This decision is based on 42 U.S.C. 1396w and Section 366-a(2) of the SSL.
HHS MA HX Applicant Submission INYCl
This is to inform you that we will continue Medicaid until for the
following individuals:
We have forwarded your information to New York's health benefit exchange, New
York State of Health.
This decision is based on Section 366(1)(b) of the Social Services Law.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-22
10/23/2016

MA CASE REASON CODES !CONT'D!

REJECTION CODES - MA IMA: REAS -2411 !CONT'D!

OTHER ELIGIBILITY REQUIREMENTS (CONT'D)
CODE CATEGORY REASON
HH9 MA HX Referral !NYC!
We received your application dated _ _for Medicaid coverage. Your
application for the following individuals is being sent to New York's health benefit
exchange, New York State of Health:

M25 All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP. Failed to Respond to Computer

Match Call-In Letter
We have denied your application for Medicaid/FHP/FHP-PAP/FPBP. This is
because we sent a letter to you asking you to contact us, and you failed to do so.
We asked you to contact us with information about computer match.
Regulation 18 NYCRR 351.1(b)(2)(ii), 351.22(e) and 360-2.3 and Section 369-ee and
366(1 )(a)(11) of the SSL
M32 All Deny. Eligible for Cash Assistance !MANUAL NOTICE REQUIRED!
We have denied your application for Medical Assistance dated __ . This is
because you are already receiving medical assistance coverage under TA case
number_.
Regulation 18 NYC RR 360-3.3 and Sections 369.ee and 366(1)(a)(11) of the SSL
*U13 All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP. Failure to Provide Information
We have denied your application for Medicaid/FHP/FHP-PAP/FPBP. This is
because we must have proof of certain things to decide if you can get Medicaid.
These are the documents we told you we need_.
Regulations 18 NYCRR 360-2.0(e), 360-2.2(f) and 360-2.3.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-23
10/23/2016

MA CASE REASON CODES !CONT'D\

. REJECTION CODES - MA !MA: REAS - 2411 !CONT'D\

OTHER ELIGIBILITY REQUIREMENTS (CONT'Dl
CODE CATEGORY REASON
U23 All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP. Information Non Applying
Legally Responsible Relative. Applicant Under 21
We have denied your application for Medicaid/FHP/FHP-PAP/FPBP. This is
because you failed or refused to give us information about income of LLR.
Regulations 18 NYCRR 352.23(a), 351.2(e) and 360-2.13 and Section 369-ee of SSL
V13 All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP. Failure to Utilize Benefits
We have denied your application for Medicaid/FHP/FHP-PAP. This is because
when a person might be able to get some other benefits which can reduce or end
the persons need for assistance, the person must apply for such benefits.
Regulation 18 NYCRR 360-2.3 and Section 369-ee of the SSL
Y50 All Deny Medicaid/FHP/FHP-PAP/FPBP, Client Request to Withdraw Application
We have denied your application for Medicaid/FHP/FHP-PAP/FPBP. This is
· because you requested to withdraw your application.
Y99 All. Deny, Other !MANUAL NOTICE REQUIRED!
Deny case for which there is no other appropriate reason code. No notice is
generated by CNS.
299 MPE No Presumptive Eligibility !MANUAL NOTICE REQUIRED!
We have determined that your application for Presumptive Medical Assistance for
your home care needs does not support a finding of presumptive eligibility. You
will be contacted regarding your application for ongoing Medical Assistance.
Regulation 18 NYCRR 360-3.7, Part 531
830 All Documentation
We have denied your application for Medical Assistance dated __ . This is
because you failed to provide information/documentation required by this agency
to establish your eligibility for Medical Assistance.
Regulation 18 NYCRR 352-1.2, 360-2.3, Part 351

* Use MRi Codes on pages 4.1-72 through 4.1-74 to list items.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-24
1011712015

MA CASE REASON CODES !CONT'D!

IMPORTANT NOTE

AS OF 2000.1 MIGRATION, THE REQUIREMENT TO LIST THE NAMES AND GINS OF CLIENTS ON
MEDICAID CLOSINGS HAS BEEN ELIMINATED. ALL OF THE LANGUAGE FOR MEDICAID
CLOSllNG CODES HAS BEEN MODIFIED TO REFLECT THIS CHANGE.

CLOSING CODES - MA !MA: REAS - 241!

THE FOLLOWING PARAGRAPH MUST BE SENT TO THE CLIENT WHEN ISSUING A MANUAL NOTICE FOR
THE CLOSING CODES U16, E12, U13, U20, G13.

You may request a Fair Hearing if you disagree with any decision explained
in this notice. You have 60 days from the date of this notice to request a fair
hearing. HOWEVER YOU MUST REQUEST A FAIR HEARING BEFORE THE
EFFECTIVE DATE ABOVE IF YOU WANT YOUR MEDICAID TO CONTINUE
UNCHANGED UNTIL THE FAIR HEARING DECISION. You may also request
an informal conference. A request for a local conference alone will not
result in continuation of benefits and does not meet the 60-day deadline for
requesting a Fair Hearing.

NOTICES WHICH ARE SENT TO THE CLIENT UTILIZING CNS ALREADY INCLUDE THIS
LANGUAGE

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-25
10/17/2015

MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241HCONT'Dl

FAILURE TO COMPLY WITH RECERTIFICATION PROCEDURES
CODE CATEGORY REASON
E12 MA Failed to Comply with Recertification - Didn't Return Form (NYC) (Manual)
We will discontinue Medicaid effective _ _
We are discontinuing Medicaid because.you or your representative did not return
the recertification form by _ _ __
If your Medicaid is. discontinued, all your Medicaid services, including your home
care services, will be discontinued.
This decision is based on Section 366-a(5) of the Social Services Law.
G14 MA Failed to Return MA Recertification/Renewal Form
We will discontinue Medicaid/Refugee Medical Assistance effective !Date).
You may request a Fair Hearing if you disagree wit.h any decision explained in this
notice. You have 60 days from the date of this notice to request a Fair Hearing.
We are discontinuing Medicaid/Refugee Medical Assistance because you or your
representative failed to return the Medicaid/Refugee Medical Assistance
Recertification/Renewal form by IDatel.
Decision is based on Section 366-a(5) of the Social Services Law.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-26
10/17/2015

MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA !MA: REAS - 2411 ICONT'Dl

FAILURE TO COMPLY WITH RECERTIFICATION PROCEDURES !CONT'D\
CODE CATEGORY REASON
G56 FPBP Discontinue FPBP Fail to Return Renewal (NYC)
We will discontinue your Family Planning Benefits coverage effective_ _ . This
is because you or your representative has failed to return the family Planning
Benefits Recertification/Renewal form by _ __
You may request a Fair Hearing if you disagree with any decision explained in this
Notice. You have 60 days from the date of this notice to request a Fair Hearing.
However, YOU MUST REQUEST A FAIR HEARING BEFORE THE
DISCONTINUE EFFECTIVE DATE SHOWN ABOVE IF YOU WANT YOUR
MEDICAL ASSISTANCE TO CONTINUE UNCHANGED UNTIL THE FAIR
HEARING DECISION. You may also request an informal local conference. A
request for a local conference alone will not result in continuation of benefits and
does not meet the 60-day deadline for requesting a Fair Hearing.
If your Family Planning Benefits coverage is discontinued, all of your Family
Planning Benefits services will become unavailable to you. You or your
representative must return the Recertification/Renewal Notification in order for us
to determine your eligibility for continuing coverage.
Regulation 360-2.2(e) and 360-2.3 and Section 366(1)(b)(6)
U13 MA Failed to Comply with Recertification - Didn't Return Information NYC
We will discontinue Medicaid effective - - -
We are discontinuing Medicaid because you or your representative did not return
all of the information necessary to determine continued eligibility for Medicaid by

This decision is based on 42 U.S.C. 139w, Section 366-a(5)(a) of the SSL and
Regulations 18 NYCRR 35.1(b)(2)(ii), 351.2, 351.5, 351.6, 351.8(a)(2)(ii) and 373-2.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKE.R'S GUIDE TO CODE~
4.1-27
10/17/2015

MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241! ICONT'Dl

FAILURE TO COMPLY WITH RECERTIFICATION PROCEDURES !CONT'D)
CODE CATEGORY REASON
• U20 MA Did Not State Unable to Get Information NYC
We will discontinue Medicaid effective _ _ __
We are discontinuing Medicaid because you did not provide us with certain
documents that we must have to decide if you can continue to get Medicaid.
If your Medicaid is discontinued, all your Medicaid services, including your home
care services, will be discontinued.
These are the documents we told you we need, but you did not give them to us
and you did not tell us you could not get them: (List Items)
If you already sent them to us, please call the Unit's office telephone number listed
in the box above to make sure that they have been received and processed. lfwe
have not processed them yet, you must request a Fair Hearing before the
effective date above to continue receiving Medical Assistance after the date of
discontinuance.
This decision is based on Sections 366-a(2) and (5) of the SSL.

* Use MRT Codes on pages 4.1-72 through 4.1-7 4 to list items.

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 WORKER'S GUIDE TO CODES
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MA CASE REASON CODES !CONT'D)

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

FAILURE TO COMPLY WITH RECERTIFICATION PROCEDURES CCONT'Dl
CODE CATEGORY REASON
U21 MA Unable to Get Information But Not A Good Reason
We will discontinue Medical Assistance beginning . This is because
we must have proof of certain things to decide if you can continue to get Medical
Assistance. You did not give us all the things we need to decide if you can get
Medical Assistance. Theses are the things we told you we needed but that you did
not give us: (list items)
You told us you could not get these things but you did not have a good reason.
Regulation 349.3 (b), 351.1 (b) (2) (ii), 351.2 351.5, 351.6, 351.8 (a) (2) (ii), 351.2 (h) and
360-2.3
U23 MA Failure to Provide Required Information about Legally Responsible Relatives
We will discontinue Medical Assistance beginning . This is because
you failed or refused to give us information about the income/resources. of your
legally responsible relative(s). You did not give us the following information about
(Names of Relatives).
You did not tell us that you were unable to get this information.
We must have proof of the information about the income and resources of non-
applying legally responsible relatives, even if those relatives do not live with you.
Regulation 352.23(a), 351.2(e), 360-2.3
U61 MA/FPBP Didn't Return Information NYC
We will discontinue your Family Planning Benefits coverage effective__ . This is
because you or your representative did not return all of the information necessary
to determine continued eligibility for Medical Assistance.
You may request a Fair Hearing if you disagree with and decision explained in this
Notice. You have 60 days from the date of this notice to request a Fair Hearing.
However,YOU MUST REQUEST A FAIR HEARING BEFORE THE
DISCONTINUE EFFECTIVE DATE SHOWN ABOVE IF YOU WANT YOUR
MEDICAL ASSISTANCE TO CONTINUE UNCHANGED UNTIL THE FAIR
HEARING DECISION. You may also request an informal local conference. A
request for a local conference alone will not result in continuation of benefits and
does not meet the 60-day deadline for requesting a Fair Hearing.
If your Family Planning Benefits coverage is discontinued, all of your Family
Planning Benefits services will become unavailable to you. You or your
representative must submit these documents ih order for us to determine your
eligibility for continuing coverage.
Decision is based on Regulations 18 NYRR 360-2.2(e) and 360-2.3 and Section
366(1)(b)(6) of the Social Service Law.

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10/17/2015

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

FAILURE TO COMPLY WITH RECERTIFICATION PROCEDURES (CONT'D)
CODE CATEGORY REASON
983 All Did Not Return Forms For Recertification (System Generated)
We will discontinue Medical Assistance/Family Health Plus effective . We
are discontinuing your Medical Assistance/Family Health Plus because you or
your representative has failed to return the Medical Assistance/Family Health Plus
Recertification Renewal Notification form by . (See G14)
Regulation 18 NYCRR 351.22, 360-2.2(e), 360-2.2(f), and 360-2.3
994 MA Failed to Comply w/Recertification - Didn't Return Form (NYC) (System Generated)
We will discontinue Medicaid effective---~-
We are discontinuing Medicaid because you or your representative did not return
the recertification form by _ _ __
If your Medicaid is discontinued, all your Medicaid services, including your home
care services, will be discontinued.
If you are now enrolled in a Medicaid Managed Care plan, you will no longer be
·enrolled in your health plan.
This decision is based on Section 366-a(5) of the Social Services Law.
995 All Failed to Comply with Recertification - Didn't Return Info NYC (System Generated)
We will discontinue Medicaid effective - - -
We are discontinuing Medicaid because you or your representative did not return
all of the information necessary to determine continued eligibility for Medicaid by

Decision is based on 42 U.S.C. 1396w, Section 366-a(5)(a) of the SSL and

Regulations 18NYCRR 351.1 (b)(2)(ii), 351.2, 351.5, 351.6, 351.8(a)(2)(ii) and 373-2.
997 MA Pregnant Woman Did Not Return Forms (System Generated)
We will discontinue Medical Assistance effective . This is because you or
your representative did not return the recertification form. If you need a new
recertification packet, you can get one by calling or writing to us. If you come to
our office in person, bring this notice with you.
Regulation 360-2.2 (e), 360-2.2 (f), 360 -2.3
998 MA Pregnant Woman Did Not Return Information (System Generated)
We will discontinue Medical Assistance effective . This is because you or
your representative did not return all of the information necessary to determine
continued eligibility for Medical Assistance. We need these items which are not in
our files or which might have changed since you gave them to us before: (list
items).
Regulation 360-2.2 (e), 360-2.2 (f), 360-2.3

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02/15/2014

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

EXCESS INCOME AND RESOURCES
CODE CATEGORY REASON
E11 MA Excess Income, End of Second Recertification Period
We will discontinue Medical Assistance effective . This is because, since
your last recertification, you failed to submit paid or unpaid medical bills that were
equal to or more than your excess income. If you have or incur medical bills that
equal or exceed our excess income amount and you want Medical Assistance,
you may reapply.
Regulation 360-4.8

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 WORKER'S GUIDE TO CODES
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10/17/2015

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 241\ !CONT'D\

EXCESS INCOME AND RESOURCES ICONT'Dl
CODE CATEGORY REASON
E30 MA Excess Income
We will discontinue Medical Assistance beginning . This is because your
net income is over the allowable Medical Assistance income limit of$_ _ . You
are over the limit by $ . The amount over the limit is called excess income.
Also, you do not have paid or unpaid medical bills that are equal to or more than
the amount your income is over the limit.
Please look at the enclose budget calculation to see how we figured your
excess income. If you incur medical bills in the amount of your excess income in
the future, you m.ay reapply.
Please read the enclosed "Explanation of the Excess Income Program".
Regulation 360-4.8 ·
E31 MA Excess Income - MA to TMA Eligible Increased Earnings/ New Employment
We will discontinue Medicaid beginning . This is because your income
(less Medicaid deductions) of$ is over the allowable Medicaid income
limit of$ . However, if the increase was due to increased earnings, or new
employment, you may be eligible for Transitional Medical Assistance.
To be eligible for full coverage 12 month TMA extension the family must have
received Medicaid under the LIF category for one of the six previous months, lost
Medicaid eligibility because of increased earning or new employment. If you are
not eligible for the TMA extension, your Medicaid will be discontinued on the
effective date listed on page one of this notice. Please look at the budget
calculation section to see how we figured your excess income.
Regulation 18 NYCRR 360-4.8
E32 MA Excess Income Child/Spousal Support Extension
We will discontinue Medical Assistance beginning _ _ _ . This is because your
income (less Medical Assistance deductions) of$ is over the allowable
Medical Assistance income limit of$ _ __
However, if the increase was due to increased spousal or child support, you may
be eligible for a four-month extension of you Medical Assistance coverage. Please
look at the budget calculation section to see how we figured your excess income.
Note: Not applicable for S/CC
Regulation 18 NYCRR 360-4.8
E33 MA Excess Income MA to TMA Guarantee-Increased Earnings/New Employment
We will discontinue Medicaid beginning . This is because your income
(less Medicaid deductions) of$ is over the allowable Medicaid income
limit of$ . However, if the increase was due to increased earnings, or new
employment, you may be eligible for Transitional Medical Assistance.
To be eligible for full coverage 12 month TMA extension the family must have
received Medicaid under the LIF category for one of the six previous months, lost
Medicaid eligibility because of increased earning or new employment. If you are
not eligible for the TMA extension, your Medicaid will be discontinued on the
effective date listed on page one of this notice. Please look at the budget
calculation section to see how we figured your excess income.
Regulation 18 NYCRR 360-4.8

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MA CASE REASON CODES !CONT'D!

CLOSING CODES· MA !MA: REAS· 241! !CONT'D!

EXCESS INCOME AND RESOURCES (CONT'D\
CODE CATEGORY REASON
E36 MA Excess Income - Child/Spousal Support
We will discontinue Medical Assistance beginning . This is because you
income (less Medical Assistance deductions) is over the allowable Medical
Assistance income limit. The amount over the limit is called excess income or
spenddown. Your monthly excess income amount is $_ _ . Also, you do not
have unpaid medical expenses not covered by insurance that are equal to or more
than your excess income amount.
Regulation 18 NYC RR 3604.8
E89 FPBP FPBP Excess Income Over 200%
We will discontinue Medicaid effective for:
This because your net income (gross income less Medicaid deductions) of$__
is more than 200% of the Federal Poverty Level of$_ which is the income limit.
Regulation 18 NYCRR 360..J.7(d), 3604.1, 3604.7 and 360-4.8 and Section 364-i of
the SSL

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MA CASE REASON CODES !CONT'D!

CLOSING CODES· MA !MA: REAS· 241! !CONT'D!

EXCESS INCOME AND RESOURCES CCONT'Dl
CODE CATEGORY REASON
F09 MBl-WPD Ineligible Excess Income above 250% of FPL
We will discontinue Medical Assistance coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective_ _ . This is
because your net income (gross income less Medical Assistance deductions) of
$_is over the MBl-WPD income standard of$_.
Please look at the budget section to see how we figured you income.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-In Program."
Regulation 18 NYCRR 360-4.8 and Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12)
and 369ee of the Social Services Law
F26 MBl-WPD Excess Resources
We will discontinue your Medical Assistance coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective_ _ .
This is because your countable resources of$_ are over the MBl-WPD
resource limit.
Because your countable resources are over the allowable. medical assistance
resource limit, you are not eligible for Medical Assistance.
The amount over the limit is called excess resources or speriddown. We have not
received documentation that you have spent your excess resources by
establishing or adding a burial trust/fund.
If you incur medical bills in the amount of your excess resources or if the amount
of your resources goes down in the future, you may reapply .
. Regulation 18 NYCRR 360-4.8 and Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of
the Social Services Law
F28 MBl-WPD Excess Income and Resources
We will discontinue your Medical Assistance coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective_ _ .
This is because your net income (gross income less Medical Assistance
deductions) of $_is over the MBl-WPD income limit of$_ and your countable
resources of $_are over the MBl-WPD resource limit.
You are not eligible for Medical Assistance because your net income (gross
income less Medical Assistance deductions) is over the allowable Medical
Assistance income limit and your countable resources are over the allowable
resource limit. The amounts over the limits are called excess income and
resources or spenddown.
We have. not received documentation that you have spent your excess resources
by establishing or adding to a.burial trust/fund.
If you incur medical bills in the amount of your excess resources and expect to
have medical bills which are equal to or more than your excess income, or if your
income or resources go down, you may reapply.
Regulation 18 NYCRR 360-4.1, 360-4.3, 360-4.1, 360-4.6, 360-4.7, 360-4.8 and
Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the Social Services Law

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MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241l ICONT'Dl

EXCESS INCOME AND RESOURCES (CONT'D)
CODE CATEGORY REASON
E82 MA Discontinue Family Planning Services, Excess Income
We will discontinue the Family Planning Benefit Program effective __ , This is
because your net income (gross income less Medicaid deductions) of
of$_ is over the allowable Medicaid income limit of$_, which is the income
limit for the Family Planning Benefit Program.
To apply for Medicaid with a spendown, you must meet one of the following
requirements: be under age 21, Over age 65, pregnant, certified blind, certified
disabled or a parent(s) of a child under 21.
Regulation 366(1)(a)(11) and a(11) of the Social Service Law

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02/15/2014

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 2411 ICONT'Dl

EXCESS INCOME AND RESOURCES !CONT'Dl
CODE CATEGORY REASON
G58 QI1 Annual Fund Exhausted
We will discontinue Medical Assistance coverage for the Qualified
Individual -1 (Ql1) program effective_ _ .
This means that Medical Assistance will no longer pay for your Medicare Part B
premium.
The funding provided to New York State by the federal government for this
program has been expended for the year. There is no additional money available .
at this time to reimburse individuals for their Medicare Part B premiums. Please
apply in January of next year when funding is again available for this program.
This decision is based on: subdivision 3 of Section 367-a of the Social Services Law

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MA CASE REASON CODES !CONT'Dl

CLOSING CODES - MA !MA: REAS - 2411 ICONT'Dl

EXCESS INCOME AND RESOURCES ICONT'Dl
CODE CATEGORY REASON
G57 MA Discontinue Medicaid. Ineligible. Income Over 138%
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective - - - - -for:
This is because you are not eligible for Medicaid because your gross income of
$ is over the allowable Medicaid income limit of$- - - -
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-IN Program."
This decision is based on Sections 366(1 )(b) and 366-a(2) of the SSL.

G59 QI1 Discontinue Qualified Individual (QT-1) Over Income (NYC)

We will discontinue Medical Assistance Program coverage for the Qualified
Individuals -1 (Ql-1) Program effective__ .
This means that Medical Assistance will no longer pay for your Medicare Part B
premium.
This is because your net income (gross income less Medical Assistance
deductions) of $__is over the Ql-1 income limit of$ __ .
Please look at the budget calculation section to see how we figure your income.
This decision is based on: subdivision 3 of Section 367-a of the Social Services Law
H25 MA Discontinue Medicaid. Excess Resources IDABl
We will discontinue Medicaid effective . This is because your net income
limit is $__ . You are over the limit by $ . The amount over the limit is
called excess resources or spendown.
Also, you do not have paid or unpaid medical bills that are equal to or more than
the amount your resources are over the limit. In addition, we told you that you
could spend your excess resources on allowable burial expenses. You did not do
so in the time period you were allowed. Please look at the enclosed budget
calculation to see how we figured your excess resources.
If you incur medical bills in the amount of your excess resources in the future or If
the amount of your resources goes down, you may reapply. Please read the
enclosed "Explanation of the Excess Resource Program".
Regulation 18 NYCRR 360-4.8.

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

EXCESS INCOME AND RESOURCES ICONT'Dl
CODE CATEGORY REASON
H26 MA Discontinue Medicaid. Excess Income and Resource. Applicant Age 65 and Older,
Certified Blind or Certified Disabled
We will discontinue Medicaid effective . This is because your net income
(gross income less Medicaid deductions) off$__ is over the allowable Medicaid
income limit of__ . In addition, your countable resources of$_ _ are over.the
allowable Medicaid resoun;e limit of$_. the amounts over the limits are call
excess income and excess resources of spendown.
Also, we have not received documentation that you have spent your excess
resources by establishing or adding to a burial trust/fund.
Please look at the enclosed budget calculation to see how we figured your excess
resources.
If you incur medical bills in the amount of your excess resources in the future or If
the amount of your resources goes down, you may reapply. Please read the
enclosed "Explanation of the Excess Resource Program".
Regulation 18 NYCRR 360-4.8.
H33 MA Discontinue Medicaid. Excess Income, Applicant Age 65 and Older. Certified Blind
or Certified Disabled
We will discontinue Medicaid effective . This is because your net income
(gross income less Medicaid deductions) of$__ is over the allowable Medicaid
income limit of$_. The amount over the limit is called excess resources or
spendown. Also, you do not have paid or unpaid medical expenses not covered
by insurance that are equal to or more than your excess income amount.
This applies to Medicaid recipients who are 65 years of age or older, certified blind
or certified disabled.
If you incur medical bills in the amount of your excess income, you may reapply.
Please read the enclosed "Explanation of the Excess Resource Program".
Regulation 18 NYCRR 360-4.8.
H34 MA Discontinue Medicaid, Excess Income
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective for:
This is because you are not eligible for Medicaid because your gross income of
$ is over the allowable Medicaid income limit of$- - - -
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-IN Program."
This decision is based on Sections 366(1 )(b) and 366-a(2) of the SSL

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

EXCESS INCOME AND RESOURCES !CONT'D)
CODE CATEGORY REASON
H35 MA Discontinue Medicaid. Ineligible. Income Over 223% FPL
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective for:
This is because you are not eligible for Medicaid because your gross income of
$ is over the allowable Medicaid income limit of$_ _ __
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-IN Program."
This decision is based on Sections 366(1 )(b) and 366-a(2) of the SSL
H36 MA Discontinue Medicaid. Ineligible. Income Over 154%
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective - - - - -for:
This is because you are not eligible for Medicaid because your gross income of
$ is over the allowable Medicaid income limit of$- - - -
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-IN Program."
This decision is based on Sections 366(1 )(b) and 366-a(2) of the SSL
H37 MA Discontinue Medicaid. Ineligible. Income Over 155%
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective _____for:
This is because you are not eligible for Medicaid because your gross income of
$ is over the allowable Medicaid income limit of$ _ _ __
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-IN Program."
This decision is based on Sections 366(1 )(b) and 366-a(2) of the SSL

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MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D\

EXCESS INCOME AND RESOURCES ICONT'Dl
CODE CATEGORY REASON
H44 MA Ineligible. FP Exceed the MAGI Limit Due to COLA Increase - 223%
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010. Under these rules, we
compared your gross income to the Modified Adjusted Gross Income (MAGI) limit
We will discontinue Med.icaid effective_ _ __
This.decision is based on Sections 366(1)(b)(3) and 366(1)(b)(6) of the SSL.
H45 MA Ineligible. Exceed the MAGI Limit Due to COLA Increase - 155%
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection and Affordable Care Act of 2010. Under these rules we
compared your gross income to the Modified Adjusted Gross Income (MAGI) limit
We will discontinue Medicaid effective- - - -
This decision is based on Sections 366(1)(b)(3) and 366(1)(b)(6) of the SSL.

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MA INDIVIDUAL REASON CODES ICONT'DI

CLOSING CODES - MA !MA: REAS - 3411 ICONT'DI

EXCESS INCOME AND RESOURCES ICONT'Dl
H46 MA Ineligible, Exceed the MAGI Limit Due to COLA Increase - 138%
H47 MA Ineligible. Exceed the MAGI Limit Due to COLA Increase - 100%
U54 MA Transfer of Resources Institutionalized Individual. Excess Income
!Manual Notice Required!
We will discontinue Medical Assistance beginning . You are not eligible for
Medical Assistance coverage for the following services until (date): nursing facility
services (Residential Health Care Facilities, Residential Treatment Facilities or
Intermediate Care Facilities for the Developmentally Disabled}; nursing facility
services provided in a hospital; home and community-based wavered services.
Please look at the section called "Explanation of the Effect of Transfers of
Resources on Medical Assistance Eligibility" for an explanation of what types of
transfers prevent you from receiving full Medical Assistance coverage.
Regulation 360-4.4, 360-4.7, 360-4.8

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA:REAS - 2411

LIVING ARRANGEMENTS
CODE CATEGORY REASON
A63 MA Suspend MA Coverage for Treatment of Inpatient Emergency Medical Conditions,
Inmate of a Correctional Facility
We will suspend Medicaid coverage effective for:
Because of your immigration and inmate status, Medicaid cannot pay for medical
care, services or supplies you receive while physically residing in a correctional
facility, except for the treatment of inpatient emergency medical conditions. All
other Medicaid coverage will be suspended while you are incarcerated.
You are eligible for Medicaid coverage only for the treatment of inpatient
emergency medical conditions.
Based on Sections 122, 366(1-a) and 366(1)(e)(1) of the SSL.
EF2 MA Disc Medicare Savings Program of Inmate of NYS or Local Correctional Facility
We will discontinue Medical Assistance payment of the Medicare Part B premium
effective_ _ .
This decision is based on Social Service Law 367-a(3)(d)(1)
EF3 MA Disc MA Payment of Health Insurance Premiums
The Medical Assistance program will discontinue paying for your health insurance
premiums effective__ .
EF6 All Disc Medicaid Payment of Health Insurance Premiums for an Individual Admitted to
Psychiatric Center (NYC)
The Medicaid program will discontinue paying for your health insurance premiums
effective This is because we have determined that it is not cost
effective.
EF7 MA/FHP Disc, MA/FHP, Individual Discharged from a Psychiatric Center to custody of United
States Immigration and Customs Enforcement (NYC)
We will discontinue Medicaid/Family Health Plus effective_ _ _ __
This is because you are being discharged from a psychiatric center to the custody
of the United State Immigration and Customs Enforcement (ICE).
Regulation 366(1) (c) and (d) of the SSL.
EFB MA/FHP Disc MA/FHP, Individual Discharged from a Psychiatric Center to another State's
Law Enforcement (NYC)
We will discontinue Medical/Family Health Plus effective_ _ for:
This is because you are being discharged form a psychiatric center to another
state's law enforcement.
This decision is based on Sections 366(1) (c) and (d) of the SSL.
EMS MA/FHP Disc MA/FHP, Individual Discharged from a Psychiatric Center to the custody of the
Federal Bureau of Prisons (NYC)
We will discontinue Medicaid/Family Health Plus effective______.
Regulation Sections 366(1) (c) and (d) of the SSL:.

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CLOSING CODES - MA IMA:REAS - 241! CON'D

LIVING ARRANGEMENTS (CONT'Dl
CODE CATEGORY REASON
EGO All Unable to Locate (NYC)
We will discontinue Medicaid/Family Planning Benefit Program effective _ __
This is because we have been unable to find you.
If you are now enrolled in a Medicaid Managed Care plan, you will no longer be
enrolled in your health plan.
If however, you receive this notice and are still in need of Medicaid/Family
Planning Benefit Program, please contact us.
Regulation 366(1)(d)(1) of the Social Services Law.
E62* MA Between 21- 65, in a Psychiatric Institution
We will discontinue Medical Assistance effective . This is because you are
receiving inpatient psychiatric services and are between 21 and 65 years of age.
Persons who are receiving inpatient psychiatric services in an institution for the
care of the mentally disabled are only eligible for Medical Assistance if they are
under 21 years of age or 65 years of age or older.
Regulation 360-3.4
*adequate

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CLOSING CODES - MA IMA:REAS - 2411 CON'D

LIVING ARRANGEMENTS ICONT'Dl
CODE CATEGORY REASON
E63* All Not a State Resident, Adequate (NYC)
We will discontinue Medicaid/Family Planning Benefit Program effective _ _ .
This is because you are not a resident of this State. You are a resident of another
state. Medicaid/Family Planning Benefit may only be granted to an eligible
resident of New York State, or to a person temporarily in the State who requires
immediate medical care that is not otherwise available.
Regulation 366(1)(d)(1) of Social Services Law.
E66 All Not a State Resident, Timely (NYC)
(See E63 above for language and citations)
This code is used as the equivalent of E63 when the closing will clock-down.
Regulation 3366(1)(d)(1) of Social Services Law.
G47 MSSI Disc MA-SSI Not a Resident of District (NYC)
This is to inform you that we will continue your Medicaid until _ _ . This is
because the Social Security Administration notified us that you moved out of
New York City. Your Medicaid will be transferred to your new district of residence
effective_ _ . You will continue to be eligible for Medicaid.
Regulation 18NYCRR Section 360-2.2(b) and Sections 62(7) and 364-j of SSL
E73 MA Foster Care
We will discontinue Medical Assistance effective . This is because the
individual is in foster care. However the individual will receive Medical Assistance
coverage through the Foster Care Program.
Regulation 360-2.6
E79* All Not Provided in Current Living Arrangement (NYC)
We will discontinue Medicaid/Family Planning Benefit Program effective--~·
This is because you now live in a public institution which provides medical care for
you.
Individuals who live in certain institutions such as the institution in which you live
are not eligible for Medicaid/Family Planning Benefit Program. An example of a
public institution not covered by Medicaid/Family Planning Program is Veteran's
Administration (VA) hospital.
Regulation Sections 366(1 )(b)(6) and 366(1 )(e)(1 )of the Social Services Law
F63 All In Prison ,
We will suspend Medical Assistance/Family Health Plus effective . This is
because you are an inmate in a NYS or local correctional facility. Although
Medical Assistance cannot pay for medical care, services or supplies you receive
while you are physically residing in a correctional facility, your Medical Assistance
case is NOT being closed.
lfwe are also paying your Medicare Part A and/or Part B premium, we will
discontinue payment of this premium.
NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL
· • Adequate Notice

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-44
10/17/2015

MA CASE REASON CODES !CONT'D\

CLOSING CODES - MA !MA: REAS - 241\ !CONT'D\

LIVING ARRANGEMENTS (CONT'D\
CODE CATEGORY REASON
F64 All In Prison outside of NYS (valid 4/1/08)
We will discontinue Medical Assistance/Family Health Plus effective Date. This is
because you are an inmate of. a correctional facility outside of New York State or a
federal penitentiary within New York State. If we are also paying your Medicare
Part A and/or Part B premium, we will discontinue payment of this premium.
NYCRR18 360-3.4 and Sections 366 (1-a) and 369-ee of SSL
F99 All Incarcerated Individual Released to Custody of US lmmig & Customs Enforce
We will discontinue Medical Assistance/Family Health Plus effective_. This is
because you are being released tot in custody of the US Immigration and
Customs Enforcement (ICE).
NYCRR 18 360-3.2(j) and Sections 366(1-a) of the SSL
G62 All Not a Resident of District, NYC to Upstate (NYC)
This to inform you that we will continue Medicaid/Family Planning Benefit Program
and/or Medicare Savings Program until (end of month +1 day\.
You told us that you moved out of New York City on (AMP date).
Because you have informed us of your move, your case will be transferred to you
new district of residence effective (end of month +1 day).
This decision is based Sections 365(1) and 364-j of the Social Service Law.
G77 All Not a Resident of District - (Does Not Inform District of Move)
We will discontinue Medical Assistance/Family Health l?lus effective See Note. This
is because records indicate you are no longer a resident of New York City and did
not tell us of your move. We must provide Medical Assistance/ Family Health Plus
only to persons who are residents of New York City.
If you want your Medical Assistance/Family Health Plus to continue, you must
contact the Department of Social Services in the district where you now live. We
recommend that you do this as soon as possible.
Note: No MA Extension
This decision is based on: Regulation 18 NYCRR 311.3, 351.2 (g) (1) and Sections
62.5 and 369-ee of the Social Services Law.
M68 All Added to Another Case
We will discontinue Medical Assistance effective ___ . This is because you
were added to another Medical Assistance case.
Regulation 360-2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-45
02/14/2015

MA CASE REASON CODES !CONT'D\

CLOSING CODES - MA !MA: REAS - 241! !CONT'D!

DUPLICATE ASSISTANCE
CODE CATEGORY REASON
MOS MA Discontinue MA, Concurrent Benefits, Individual with Coverage on HX
We will discontinue Medical Assistance/Family Planning Benefit Program effective
for:
This is because we believe you are already receiving Medicaid.
Your identity matches that of a person who is already receiving Medicaid through
New York State of Health account# . Because the identities match,
we have determined that you and that person are the same person.
This decision is based on Regulation 18 NYCRR 351.9 and Section 366(1)(b) of the
SSL.
M97 All Receiving Multiple Benefits - HH=1 (Timely)
We will discontinue Medical Assistance effective . This is because you ·
fraudulently misrepresented your identity or residence to receive multiple Medical
Assistance benefits at the same time.
Regulation 18 NYCRR 360-2.2
M98' .All Concurrent Benefits Intra-State (Within State)
We will discontinue Medical Assistance effective . This is because we
believe you are already receiving Medical Assistance. Your identity matches that
of a person who is already receiving Medical Assistance in (LOCATION). Because
the identities match, we have determined that you and that person are the same
person.
When the identity of any applicant or recipient matches that of a person who is
already receiving Medical Assistance, that person is not eligible for additional
Medical Assistance. (Adequate)
Regulation 18 NYCRR 351.9
N66 All Concurrent Benefits Interstate (Between States) NYC
We will discontinue. Medicaid/Family Planning Benefit Program effective _ _ _ .
This is because your identity matches that of a person who is already receiving
Medical Assistance in State Name. Because the identities match, we have
determined that you and that person are the same person.
When the identity of any applicant or recipient matches that of a person who is .
already receiving Medicaid, that person is not eligible for additional Medicaid/
Family Planning Benefit Program.
Regulation 18 NYCRR 351.9 and sections 365(1)(a) and 366(1)(b)(6) of SSL
N67 MA/MPE Concurrent Benefits Interstate (Between States) NYC (System Generated)
We will discontinue Medicaid/Family Planning Benefit Program effective_ _ _ .
This is because your identity matches that of a person who is already receiving
Medical Assistance in State Name. Because the identities match, we have
determined that you and that person are the same person.
When the identity of any applicant or recipient matches that of a person who is ·
already receiving Medicaid, that person is not eligible for additional Medicaid/
Family Planning Benefit Program.
Regulation 18 NYCRR 351.9 and sections 365(1)(a) and 366(1)(b)(6) of SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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10/17/2015

MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241l ICONT'Dl

DUPLICATE ASSISTANCE (CONT'Dl
CODE CATEGORY REASON
576 All Receiving Medical Assistance on More than One Case
You are currently receiving Medical Assistance on more than one Medical
Assistance case. Since you are eligible to receive Medical Assistance on only one
case, we are closing case# . (Timely)
Regulation 18 NYCRR 360-2.6
•Adequate

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-47
02/19/2017

MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241! !CONT'D!

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS

CODE CATEGORY REASON
F12 All Failure to Apply for SSI
We will discontinue Medicaid effective - - -
This is because a person must apply for benefits that can reduce or end the
person's need for Medicaid. You appear to be eligible for Social Security benefits,
and we told you to apply for them, and you failed to apply for these benefits at the
Social Security Office.
Regulation 18 NYCRR 360-2.3(c)(1)
F17 All Incorrect or Fraudulent Social Security Number
We will discontinue Medicaid/Family Planning Benefit Program effective _ __
This is because each person receiving Medicaid/Family Planning Benefit must
give the agency their correct Social security number. We have determined that
you did not give us your correct Social Security number.
Decision is based on Sections 366(1 )(b)(6) and(5) of the SSL.
F20 All Failure to Provide a Social Security Number (HH = 1)
We will discontinue Medicaid/Family Planning Benefit Program effective _ __
For each member of the household for whom an application for Medicaid/Family
Planning Benefit Program is made, a Social Security number must be provided to
the agency or the agency must be provided with proof that an application has
been made for a Social Security number for such person. You did not give us the
Social Security number or apply for a Social Security number.
Decision based .on Sections 366(1)(b)(6) and (5) of the SSL.
F40 All Failure to Enroll in a Group Health Plan
We will discontinue Medical Assistance beginning . This is because when
a group health insurance plan is available for free where you work you must sign
up for such health insurance plan. You have refused to sign up for a group health
insurance plan where you work, even though it is free.
Regulation 18 NYCRR 360-3.2 (d)
H49 All Agency Affirmed/Defaults/Withdrawals Fair Hearing Actions
Code allowed to be used ONLY by Fair Hearings Centers 527, 546. 567 and 588.
(For Fair Hearings ONLY, Notice Not Required)

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 WORKER'S GUIDE TO CODES
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10/17/2015

MA CASE REASON CODES !CONT'D>

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D>

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'Dl
CODE CATEGORY REASON
F92 All Non-Qualified PRUCOL Alien Ineligible For Full MA
We will discontinue Medicaid/Family Health Plus effective . This is
because you have failed to provide documentation of citizenship, identity and/or
current immigration status.
Regulation 18 NYCRR 351.1(b)(2)(ii), 351.2, 351.5, 351.6,351.8(a)(2)(ii), 360-1.2, 360-
2.3 and Section 369-ee of the SSL
G11 All Failure to Appear for Interview Appointment with Agency
We will discontinue Medical Assistance effective . This is because you
did not keep your appointment for an interview on (Date). You are not eligible for
Medical Assistance if either you or a person representing you does not appear for
a personal interview to establish continuing eligibility.
If you think we did not tell you about the interview appointment or if you have
another good reason for not keeping the interview appointment, tell your worker
the reason. If you do not have a good reason for not keeping your interview
appointment, and you still want Medical Assistance, you will have to reapply.
Regulation 18 NYCRR 360-2.2 (f), 351.22
G66 MSP Failed to Return Renewal (Recertification) Form Ql-1/SLIMB (NYC)
We will discontinue your participation in the Medicare Savings Program effective
(Date).
If your Medicare Savings Program participation is discontinued, your Medicare
Premiums will no longer be paid by New York State. You or your representative
must return the Recertification/Renewal Notification in order for us to determine
your eligibility for participation in the Medicare Savings Program.
Regulation 18NYCRR 360-2.2(e) and Section 367(a) of the Social Service Law.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-49
10/23/2016

MA CASE REASON CODES (CONT'D!

CLOSING CODES - MA (MA: REAS - 2411 !CONT'D!

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS !CONT'D)
CODE CATEGORY REASON
H19 All Failure to Provide Proof of U.S. Citizenship and Identity - SSA/BVI Match
We will discontinue Medicaid/Family Planning Benefit Program effective _ _ .
You said you were a U.S citizen/national; however we were unable to verify that
this is true. You failed to respond to a request to provide documentation that you
are a U.S. citizen/national. The Medicaid program requires proof of identity and
U.S. citizenship or satisfactory immigration status. You failed to provide proof of
your identity and U.S. citizenship.
If you have submitted all of the required documentation, please call the Unit's
office number listed in the box above to make sure they have been received and
processed. If we have not processed them yet, you must request a Fair Hearing
before the effective date above to continue receiving Medicaid after the date of
discontinuance.
This decision is based on Sections 122, 366-a(2) and (5) of the Social Service Law.
H48 MA Discontinued Medicaid, Individual Revoked Authorization for AVS
We will discontinue Medicaid effective for:
This is because in order to get Medicaid, you and your spouse (it married) must
provide a signed authorization allowing Medicaid to verify your and your spouse's
resources with financial institutions.
This decision is based on 42 U.S.C. 1396w and Section 36-a(2) of the SSL
M24 All Failed to Submit Computer Match Information
We will discontinue Medical Assistance effective . This is because we
asked you to bring us information about (computer match) for (nanie Is) by (date)
and you failed to do so. We need this information to determine your continuing
eligibility for Medical Assistance. If you already submitted this information or need
help to get it, tell us right away by calling the general information number printed
above.
Regulation 351.1 (b) (2) (ii), 351.22 (e~, 360-2.3, 18 NYCRR 360-4.4
M25 All Failed to Respond To Computer Match Call-In Letter NYC
We will discontinue Medicaid/Family Planning Benefit Program effective _ __
This is because we sent a letter to you asking you to contact us by (date) and you
failed to do so. We asked you to contact us with information about (computer
match) for (name(s)). ·
We need this information to determine your continuing eligibility for Medicaid/
Family Planning Benefit Program.
If you did contact us by (date), tell us right away by calling the general information
number printed above.
This decision is based on Sections 366(1)(b)(6), 366-a(2) and (5) of the SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-50
02/21/2016

MA CASE REASON CODES !CONT'D\

CLOSING CODES - MA IMA: REAS - 241\ ICONT'Dl

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS ICONT'Dl
CODE CATEGORY REASON
M89 Medicare Savings Program Failed to Return Required Documentation Ql-1/SLIMB
We are discontinuing your participation in the Medicare Savings Program because
you or your representative did not return all of the information necessary to
determine continued participation in the Medicare Savings Program.
If your Medicare Savings Program participation is discontinued, your Medicare
Premiums will no longer be paid by New York State.
This decision is based on Regulation 18NYCRR 360-2.2(e) and Section 367(a) of the
Social Service Law.
V13 All Failure to Utilize Benefits
We will discontinue Medicaid effective _ __
This is because when a person might be able to get some other benefits or
resources that can reduce or end the person's need for Medicaid, the person must
apply for and use such benefits. Although we told you to, you failed to apply for or
use_ __
This decision is based on Regulation 18 NYCRR 360-2.3(c)(1).
Y84 FHP Failure to Provide Health Plan and Provider Selection Form
We will discontinue Family Health Plus effective _ _ . Choosing a health plan is
an eligibility requirement of the Family Health Plus Program. We told you if you did
not return the completed plan enrollment form we would not be able to continue
your health insurance coverage.
MA: 360-4.1, 360-4.8
840 All TMU - Report of Resources and Unearned Income
TMU has determined that you have failed to provide documentation relating to a
report of resources and unearned income.
Regulation 360-1.2, 360-2.2, 360-2.3, PART 351
841 All TMU - Excess Resources
TMU has determined that your resources exceed the level that Medicaid allows
for a household of your size.
Regulation 360-4.6, 360-4.7, 360-1.2, 360-3.3
842 All TMU - Transfer of Assets
TMU has determined that you transferred assets for the purpose of qualifying for
Medical Assistance. You will be ineligible to receive Medical Assistance benefits
for a _ _month period. You have the opportunity to submit documentation to
rebut this presumption.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-51
02/15/2014

MA CASE REASON CODES !CONT'D

CLOSING CODES - MA !MA:REAS - 241!

OTHER ELIGIBILITY REQUIREMENTS (CONT'D)
CODE CATEGORY REASON
HHS MA HX Applicant Submission (NYC)
This is to inform you that we will continue Medicaid until for the
following individuals:
We have forwarded your information to New York's health benefit exchange, New
York State of Health.
This is because starting January 1, 2014, certain individuals must have their
eligibility determined by New York State of Health:
This decision is based on Section 366(1)(b) of the SSL.
HH9 MA HX Referral (NYC)
We received your application dated _ _ for Medicaid coverage. Your
application for the following individuals is being sent to New York's health benefit
exchange, New York State of Health:
This is because starting January 1, 2014, certain individuals must have their
eligibility determined by New York State of Health.
Regulation 366(1)(a)(11) and a(11) of the Social Service Law.
606 MA BHP Fail to Renew NYSoH Coverage
We will discontinue Medicaid effective for:
You may request may request a Fair Hearing if you disagree with any decision
explained in this notice.
We are discontinuing your Medicaid because you or your representative have
failed to sign in to your account in NY State of Health and renew your coverage by

This decision is based on Section 336-a(S) of the Social Services Law.

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-52
10/17/2015

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

SPOUSAL IMPOVERISHMENT
CODE CATEGORY REASON
H10 All Failure to Provide Resource Information - No Undue Hardship
We will discontinue Medical Assistance effective . This is because the
amount/value of your spouse's resources is unknown. This information about the
resources of your spouse was necessary to determine your continuing eligibility
for Medical Assistance and we have decided that an undue hardship does not
exist.
Regulation 360-4.10 (c).
H11 All Failure to Provide Resource Information - Undue Hardship
We will discontinue Medical Assistance effective . This is because the
amount/value of your spouse's resource is unknown. This information about the
resources of your spouse was necessary to determine your continuing eligibility
for Medical Assistance and, even though we have decided that an undue hardship
exists, you would not sign a form that allows us to seek from your spouse the
amount his/her countable resources are over the maximum community spouse
allowance, although you are physically and mentally able to sign this form.
Regulation 360-4.1 O (c)
X12 All Failure to Execute an Assignment of Support (Manual Notice Required)
We will discontinue Medical Assistance effective . This is because you
would not sign a form which allows us to seek $ from your spouse
(husband/wife), although you are physically and mentally able to sign this form.
$ is the amount your spouse's countable resources are over the maximum
community spouse resource limit of$ . Your spouse refuses to make this
amount available to you. Please see the budget page on how we figured the
amount your spouse should have made available.
Regulation 360-4.10 (c)
X13 All Excess Resources for Institutionalized Spouse (Manual Notice Required)
We will discontinue Medical Assistance effective . This is because you and
your spouse (husband/wife) have countable resources that are over the resource
limits. You and your spouse's total countable resources are $_.
Your spouse who lives at home is allowed to keep. $(max CSRAl
The difference is the amount available to you. $ . The allowable resource
limit is $_ _ .
You are over the resource limit by $_ _.
You also do not have medical bills that are equal to or more than ($the amount
over the resource standard). An applicant is ineligible for Medical Assistance if his
or her resources are over the resource limit unless there are incurred medical bills
that are equal to or greater than the amount over the resource limit.
Regulation 360-4.10 (c)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-53
02/15/2014

MA CASE REASON CODES !CONT'D!

CLOSING CODES • MA !MA: REAS • 241 l !CONT'D!

HEALTH INSURANCE
CODE CATEGORY REASON
X50 MA COBRA Coverage of Group Health Insurance Premiums • Regular (Manual Notice)
We will discontinue Medical Assistance Program coverage for your group health
insurance premiums under the COBRA Continuation Coverage Program effective
_ _for the following person(s):
Instruction: Choose one or more of the following messages:
Message 1 (No longer entitled to COBRA continuation coverage)
This is because you are no longer entitled to COBRA continuation coverage for
the following reason _ __
Message 2 (Over net income)
This is because your household's net income of($ ) is over the net income
limit of$_._. Please look at the budget page to see how we figured your income.
Message 3 (Over resources)
This is because your household's countable resources $ are over the
resource limit of$ . Please look at the budget page to see how we figured
you resources.
Message 4 (Not cost effective)
This is because we determined that it is no longer cost effective to pay your health
insurance premiums.
Message 5 (Employer has less than 75 employees)
This is because Medical Assistance payment of COBRA continuation premiums is
available when the coverage is through an employer of 75 or more employees.
Message 6 (Other)
This is because: _ _ .
Choose Message A (Use if all members of the household are discontinued).
You are responsible for payment of your premiums after the effective date.
Regulation 360-7.5

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-54
02/14/2015

MA CASE REASON CODES ICONT'DI

CLOSING CODES - MA IMA: REAS - 241\ ICONT'Dl

HEALTH INSURANCE (CONT'D)
CODE CATEGORY REASON
X51 MA COBRA Coverage of Group Health Insurance Premiums (Manual Notice Required)
Prior Conditional Acceptance
We will discontinue Medical Assistance coverage for group health insurance
premiums under the COBRA Continuation Coverage Program effective _ __
We had previously accepted the following person(s): (list names) for the COBRA
Continuation Coverage Program.
Message 1
This is because you are no longer entitled to COBRA continuation coverage for
the following reason __ .
Message 2 (Over net income)
This is because your household's net income of($ is over the net income
limit of$ . Please look at the budget page to see how we figured your
income.
Message 3 (Over resources)
This is because your household's countable resources of$ are over the
resources limit of$ . Please look at the budget page to see how we figured
your resources.
Message 4 (Not cost effective)
This is because we determined that it is no longer cost effective to pay your health
insurance premiums.
Message 5 (Employer has less than 75 employees)
This is because Medical Assistance payment of COBRA continuation premiums is
only available when the coverage is through an employer of 75 or more
employees.
Message 6 (Other)
This is because: __ .
Choose Message A (Use if all members of the household are discontinued)
You are responsible for all premium bills we paid for you.
Regulation 360-7.5

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-55
02/21/2016

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 241! !CONT'D!

HEALTH INSURANCE ICONT'Dl
CODE CATEGORY REASON
X52 MA Medicare Buy - In Program QMB - (Manual Notice Required)
We will discontinue Medicare Buy - In coverage effective . This means
that Medical Assistance can no longer pay your Medicare premiums, deductible
and coinsurance.
Choose one or More Messages:
This is because your household's net income is $ . The allowable income
limit is (100% of poverty). You are over the allowable limit. Please look at the
budget page to see how we figured your income.
This is because your household's countable resources are $ . The
allowable limit is (twice the SSI resource levell You are over the allowable limit.
Please look at the budget page to see how we figured your resources.
This is because your household's net income and countable resources are over
the income and resource limits. Your net income is $ . The allowable
income limit is (100% of poverty). Your countable resources are$ . The
allowable resource limit is (twice the SSI resource levell. Please look at the
budget page to see how we figured your income and resources.
This is because you are not (enrolled in/eligible for) Medicare Part A from the
Federal Social Security Administration.
This is because _ _
Regulation 360-7 .7 (Use for all)
631 MA Suspend MA Coverage for Treatment of Inpatient Emergency Medical C<;mditions,
Inmate of a Correctional Facility (System Generated)
We will suspend Medicaid coverage effective for:
Because of your immigration and inmate status, Medicaid cannot pay for medical
care, services or supplies you receive while physically residing in a correctional
facility, except for the treatment of inpatient emergency medical conditions. All
other Medicaid coverage will be suspended while you are incarcerated.
You are eligible for Medicaid coverage only for the treatment of inpatient
emergency medical conditions.
This decision is based on Sections 122, 366(1-a) and 366(1)(e)(1) of the SSL.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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02/15/2014

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 241\ !CONT'D\

OTHER
CODE CATEGORY REASON
DOO MA Deceased
(This code operates the same as E95 and G39 but will a have clocking down
period)
E95* All Deceased (NYC)
We will discontinue Medicaid/Family Planning Benefit Program effective _ __
This is because records indicate that this person is deceased.
If you are now enrolled in a Medicaid Managed Care plan, you will no longer be
enrolled in your health plan.
Regulation 366-a(5)(a) and 366(1 )(b)(6) of the SSL.
G39 MA Deceased (NYC)(System Generated)
We will discontinue Medicaid/Family Planning Benefit Program effective_ __
This is because records indicate that this person is deceased.
If you are now enrolled in a Medicaid Managed Care plan, you will no longer be
enrolled in your health plan.
Regulation 366-a(5)(a) and 366(1)(b)(6) of the SSL.
G88' All Client's Request - Written Req·uest (NYC)
We will discontinue Medicaid/Family Planning Benefit Program effective _ __
for:
This is because you said that you did not want Medicaid/Family Planning Benefit
Program.
This decision is based on Sections 366(1 )(b)(g) and 366-a(5)(a) of the SSL.
H61 MA Closing Code used to Close H60 Only Retroactive Cases
(System Generated)

'Adequate

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-57
02/15/2014

MA CASE REASON CODES (CONT'D!

CLOSING CODES - MA CMA: REAS - 241\ (CONT'D!

OTHER CCONT'Dl
CODE CATEGORY REASON
G98 All Client's Request Verbal, NYC (Timely)
We will discontinue Medicaid/Family Planning Benefit Program effective _ _ .
. this is because on you said that you did not want Medicaid/Family
Planning Benefit Program.
This decision is based on Sections 366(1)(b)(6) and 366-a(5)(a) of the SSL.
Y02 MA Special Immigrant Visa Closing - Used for Iraqi and Afghan Immigrants ACl=R
(Manual Notice Required)
We are sending you this notice to tell you that the Medical Assistance Program will
discontinue your public health insurance coverage effective_ _ . You have
reached the end of your initial period of Medicaid eligibility as an Afghan or Iraqi
Special Immigrant. .
Section 525 of Title Vof Division G of Public Law 110~181 and Section 1244(g) of the
National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181 and
Section 1059 of the National Defense Authorization Act. of 2006, Public Law 109-163
Y03 MA One Time Auto-Close for Homeless Lapsed Cases
(No notice generated, immediate closing)

Y25 All Client's Request - Medicaid (MA) - Eligibility Mail Out (Manual Closing)
Medicaid has bee,n discontinued because on the returned Eligibility Mail Out form,
the client asked that the MA portion of the case be closed.
Regulation 360-2.6
Y26 All Client's Request - Medicaid (MA) and FS - Eligibility Mail Out
Medicaid has been discontinued because on the returned Eligibility Mail Out form,
the client asked that the MA and FS portions of the case be closed.
Regulation 360-2:6
Y30 FPBP/PE Ineligible for FPBP Excess Income (Manual notice required)
Y31 FPBP/PE Failed to Return Documents (Manual notice required
Y99 All other (Manual Notice Required)
Close cases for which there is no other appropriate reason code. No notice is
generated by the system. Workers must manually complete the notice.
We will discontinue Medical Assistance effective . This is because you
failed to (worker fill in).
Regulation for Social Service Department (worker fill in)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-58
02/15/2014

MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS· 241! ICONT'Dl

MISCELLANEOUS
CODE CATEGORY REASON
178 MPE Emergency Medical Condition
We will discontinue your Medical Assistance coverage effective_ _ because:
Message 1
You were granted Medical Assistance solely for the treatment of an emergency
medical condition, this time limited coverage has now expired.
Regulation18 NYCRR 360-3.2(j)(2)(ii)
Message 2
You were granted Medical Assistance solely for the treatment of an emergency
medical condition, but you are now an inmate in a New York State or local
correctional facility. Medical Assistance cannot pay for medical care, services or
supplies you receive while you are physically residing in a correctional facility.
Regulation18 NYCRR 360-3.4(a)(1)
194 MSSI Ineligible for MA-SSI
You are no longer eligible for SSI and have been determined ineligible for MA-SSI.
Regulation18 NYCRR 360-2.6, 360-3.3
740 All Forced Closing.
991 MSSI Discontinue SSI - Separate MA Determination
Your eligibility for SSI has been discontinued or suspended. A separate
determination of your continuing eligibility for MA will be made.
Regulation 18 NYCRR 360-2.2 (Stenson). Adequate Notice
198 All 60 Day Presumptive Eligibility Period Ended/Ineligible for MA
Based on your need for_ _ , you were determined presumptively eligible for
Medical assistance for a maximum period of 60 days. After a review of your
application you have been determined ineligible for ongoing Medical Assistance.
Regulation 18 NYCRR 360-3.7, 358-3.3, Part 531

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MA CASE REASON CODES ICONT'Dl

RESERVED FOR EXPANSION

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 WORKER'S GUIDE TO CODES
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02/15/2014

MA CASE REASON CODES !CONT'D!

CLOSING CODES· MA !MA: REAS· 2411 !CONT'D!

DISASTER RELIEF
CODE CATEGORY REASON
322 MPE Other (Adequate Notice)
This decision is based on (Worker Fill).
323 MPE Excess Income/Non-Resident/Non-Qualified Alien (timely)
Under the Disaster Relief program, you have been receiving time-limited health
care coverage, which will end on the effective date of this notice. You applied for
Medicaid/Family Health Plus to have your health care coverage continue after the
end of Disaster Relief. Your application for Medicaid/Family Health Plus is denied
because:
Choose one of the following for the Manual Notice
1.Your gross income is over the Family Health Plus of$ and your net
income (gross income less Medicaid Assistance deductions) is over the Public
Assistance Standard of need of$ . Persons who are 21 through 64 years
of age and are not pregnant, certified blind or disable, or caring for their related
children under the age of 21 must meet the requirements of the Public Assistance
Program in order to be eligible for Medical Assistance. Please look at the attached
budget explanation (MAP-2060) to see how we figure your income.
Regulation 366(1 )(a)(1) and 396-ee
2.Your gross income of$ _ _ is over the Family Health Plus income limit of
$_ _ and your net income (gross income less Medical Assistance deductions)
of$ is over the Medical Assistance income limit of$ . Please see
the attach budget explanation of the (MAP-2060) for details on how we calculate
your income.
Regulation 366, 369-ee, and 18 NYCRR 360-4.8
3.You have excess income in the amount of$ per month. The enclosed
information explains how an individual may become eligible for Medical
Assistance under the Excess Income/Optional Pay-in-Program. (See attach forms
MAP-931-Explanation of the Excess Income Program, and MAP-931A,
Explanation of the Pay-in-Program.)
Regulation
4.You are not a resident of New York City.
Regulation 62 and 18 NYCRR 360-2.2
5.You are not a citizen, qualified alien, or person permanently residing in the
United States under Color of Law (PRUCOL). Persons who are not citizens,
qualified aliens, or PRUCOL may receive Medical Assistance coverage only for
the tr.eatment of emergency medical conditions or for medical services provide to·
pregnant women, if they are otherwise eligible. (See attached form MAP-2020A.
Definition of Qualified Aliens and PRUCOL.)
Regulation Section 122 of Social Services Law and GIS 01MA026

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MA CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 2411 ICONT'Dl

DISASTER RELIEF (CONT'D)
CODE CATEGORY REASON
972 MPE Failure to Provide Documentation
Under the Disaster Relief Medicaid/Family Health Plus program you have been
receiving time-limited health care coverage, which will end effective _ _ _ __
You applied for Medicaid/Family Health Plus to have your health care coverage
continue after the end of Disaster Relief. We have denied your application for
Medicaid/Family Health Plus.
This is because you or your representative did not return all of the information
necessary to determine if you can get Medicaid/Family Health Plus. We need the
following documents. These are the documents we told you we needed, but you
did not give them t<;> us and did not tell us you could not get them: _ _ _ __
If you have not submitted the documents, you need to bring them to us at the
. above address before the effective date above.
If you have submitted all of the required information, please call the unit's office
telephone number listed in the box above to make sure the documents have been
received and processed.
Regulation18 NYCRR 360-2, 369-ee

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CLOSING CODES - MA IMA: REAS - 2411 ICONT'Dl

PCAP CASES
CODE CATEGORY REASON
ESB Failure to Return PCAP Recertification Renewal Form (NYC)
We will discontinue Medicaid effective _ _
We are discontinuing your Medicaid because you or your representative failed to
return the Medicaid Recertification/Renewal Notification form by _ _ .
We are discontinuing your Medicaid because you or your representative failed to
return the Medicaid Recertification/Renewal Notification form by _ _ __
This decision is based on Section 366-a(S) of the Social Services Law.
E83* MA Client's Request - Written (Infant Extension)
We will discontinue Medical Assistance effective . This is because you
wrote to us that you wanted your case closed. You wrote that on your
recertification letter processed in this office on (processing date).
Regulation 360-2.6
The following infant (s) born on (date of birth) will continue to receive Medical
Assistance until the end of the month in which the infant(s) becomes age one (list
names and GINS of infant)
Regulation (s) 360-3.3 (c)

•Adequate

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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02/15/2014

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 241! !CONT'D!

PCAP CASES (CONT'Dl
CODE CATEGORY REASON
EBB* MA Client's Request - Written PCAP CHents
We will discontinue Medical Assistance effective . This is because you
wrote to us that you wanted your case closed. You wrote that on your
recertification letter processed in this office on (processing date).
Regulation 360-2.6
E93* MA Client's Request~ Written, PCAP Clients (Infant Extension)
We will discontinue Medical Assistance effective . This is because you
wrote to us that you wanted your case closed, you wrote
that on your recertification letter processed in this office on (processing date).
Regulation 360-2.6
The following infant (s) born on (date of birth) will continue to receive Medical
Assistance until the end of the month in which the infant(s) becomes age one (List
names and GINS of infant[s])
Regulation 360-3.3 (c)
GB3 MA Client's Request - Verbal (Infant Extension)
We will discontinue Medical Assistance effective . This is because on - - -
you asked us to close your case.
The following infant (s) born will continue to receive Medical
Assistance until the end of the month in which the infant (s) becomes age one
(List names and CINSl
Regulation 360-3.3 (c)
G93 MA Client's Request - Verbal
We will discontinue Medical Assistance effective - - -. This is because
on you asked us to close your case.
Regulation 360-2.6

*Adequate

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CLOSING CODES - MA !MA: REAS - 241\ !CONT'D!

PCAP CASES !CONT'Dl
CODE CATEGORY REASON
* U15 MA Failure to Comply With Recert Procedure - Didn't Return Information
We will discontinue Medical Assistance effective- - -
We are discontinuing Medical Assistance because you or your representative did
not return all of the information necessary determine continued eligibility
for Medical Assistance.
If your Medical Assistance is discontinued, all your Medical Assistance services,
including your home care services, will be discontinued.
We need these documents which are not in our files or which might have
changed since you gave them to us before might have. These are the
documents we told you we need but you did not give them to us and did not
tell us you could not get them.
If you have submitted all of the required documents, please call the Unit's
office telephone number listed in the box above to make sure they have
been received and processed. If we have not processed them yet, you must
request a Fair Hearing before the effective date above to continue receiving
Medical Assistance after the date of discontinuance.
Regulations 60-2.2(e), 360-2.3
The following infant(s) born on will continue to receive Medical
Assistance until the end of the month in which the infant(s) become age one:
Regulations 360-3.3(c)

* Use MRT Codes on pages 4.1-72 through 4.1-7 4 to list items.

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 WORKER'S GUIDE TO CODES
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10/23/2016

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 241! !CONT'D!

PCAP CASES CCONT'Dl
CODE CATEGORY REASON
980 Failure to Comply With Recert Procedure - Didn't Return
Information (System Generated)
We will discontinue Medical Assistance effective_ __
We are discontinuing Medical Assistance because you or your representative
did not return all of the information necessary to determine continued eligibility for
Medical Assistance.
If your Medical Assistance is discontinued, all your Medical Assistance
services, including your home care services, will be discontinued.
We need these documents which are not in our files or which might have
changed since you gave them to us before. These are the documents we told
you we need but you did not give them to us and did not tell us you could
not get them.
If you have submitted all of the required documents, please call the Unit's office .
telephone number listed in the box above to make
sure they have been received and processed. If we have not
processed them yet, you must request a Fair Hearing before the effective
date above to continue receiving Medical Assistance after the date of
discontinuance.
Regulations 360-2.2(e), 360-2.3The following infant(s) born on will
continue to receive Medical
Assistance until the end of the month in which the infant(s) become age one
Regulations 360-3.3(c)
985 Failure to Return PCAP Recertification Renewal Form (NYC) (System Generated)
We will discontinue Medicaid effective _ _
We are discontinuing your Medicaid because you or your representative failed to
return the Medicaid Recertification/Renewal Notification form by _ _ .
If your Medicaid is discontinue, all your Medicaid Services. including, your home
care services, will be discontinue. You or your representative must return the
Recertification/Renewal Notification form in order for us to determine your
eligibility for Medicaid
This decision is based on Section 366-a(5) of the Social Services Law.

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 ICONT'Dl

SYSTEM GENERATED MA CODES
CODE CATEGORY REASON
(Viewable only on CNS)
166 All Authorization Lapsed More Than 90-Days
This case has been closed automatically because its authorization has lapsed
more than 90 days. (System generated output code).
No citation required.
416 FPBP FPBP Remainder 12 Month Extension (With Transportation) (Manual Entry Only)
Your Family Planning Benefit Program case has been renewed.
We will continue Family Planning Benefit Program coverage unchanged until
for:
Regulation Section 366 (1 )(b(6) of the SSL.
417 FPBP/FPEP FPBP/FPEP Remainder 12 Month Extension (Without Transportation)
We will change your coverage from Family Planning Benefit Program coverage to
the Family Planning Extension Program effective We will continue
Family Planning Benefit Extension coverage until for:
You have already received 12 months of family planning services coverage. To
complete the balance of the 24 months of family planning services coverage, we
must change your coverage to the Family Planning Extension Program for 12
months.
Regulation Sections 364-j, 366(1 )(b) and 366(1 )(b)(6) of the SSL
450 MA/FHP Medicaid/FHP Ineligible, Income Over 223% FPL (System Generated)
We have re-determined your eligibility for Medicaid coverage under the new rules
of the Patient Protection & Affordable Care Act of 2010. Under these rules, we
compared your gross income to the Medicaid eligibility income levels.
We will discontinue Medicaid/Family Health Plus effective for:
This is because you are not eligible for Medicaid because your gross income of
$_ _ is over the allowable Medicaid income limit of$_ __
Regulation 18NYCRR 366(1 )(b) and 366-a(2) of the SSL.
567 MA Disc - Excess Income Due to COLA for Ql-1 Individuals (NYC)
We will discontinue Medical Assistance effective for: - - - -
This is because your household's net income of$ is more than the Medical
Assistance income limit of$ for your household size.
Please look at the enclosed budget calculation to see how we figured your
income.
Regulation 366(1 )(a)(1) and subdivision 3 of Section 367-a of the SSL
603 MA Continuous Eligibility for MA Recipients (NYC)
Even though the individual(s) listed below are no longer eligible for medicaid, we
will continue/extend Medicaid coverage until for:
This decision is based on Social Services Law 366(4)(c)
620 MA Transition Medicaid to NY State of Health-Recipients in the Five Year Ban
Because of the immigration status of individuals on your Medicaid case, eligibility
for Medicaid coverage for the following individuals must now be determined by
New York's health plan marketplace, NY State of Health:
This decision is based on Section 369-gg of the SSL.

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02/21/2016

CLOSING CODES - MA IMA: REAS - 2411 ICONT'Dl

SYSTEM GENERATED MA CODES ICONT'Dl
CODE CATEGORY REASON
666 Fair Hearing (System Generated
701 Combined PA MA Disc for Same Reason Incarcerated Prior to April 1, 2008
We will discontinue your Medical Assistance effective_ _ . This is for the same
reason as your Public Assistance is being discontinued. However, you will no
longer be enrolled in you health plan.
Regulation 18NYCRR 360-3.4 and Section 366(1 )(c) of the SSL
702 All Disc PA/MA, Continue MA, Chafee Eligible
We will continue Medicaid coverage. This is because you were discharged from
foster care and are age 18, 19 or 20.
Regulation SSL 366 (3-a)
703 All Disc MA, Incarceration Out-of-State or Federal Penitentiary Located Within NYS
We will discontinue Medicaid effective_ _ .This is for the same reason as your
Public Assistance is being discontinued.
This decision is based on Regulation 18NYCRR 360-3.4 and Section 366(1-a) of the
Social Services Law.
706 PA MA Disc for Same Reason, Discontinue MSP
We will discontinue Medicaid effective_ for. This is for the same reason as your
Public Assistance is being discontinued.
Regulation 18NYCRR 351.9, 351.2 (g)(1), 360-2.3, 360-2.3, 360-3.4, 360-3.5 and SSL
366(1 )(b).
714 MA Case Discharged from Foster Care - True Chafee (System generated when
Chafee Indicator 'T' is present)
718 FPBP/FPEP 24 Month Extension (NYC)
We will discontinue your Medicaid effective_ _ :
Even though the individual(s) listed are no longer eligible for Medicaid as
explained in this notice, we will continue Family Planning Benefit Program
Extenuation coverage until _ _ .
Because. you received Medicaid when you were pregnant, you are eligible for an
additional 24 months of family planning services coverage, regardless of the
outcome of the pregnancy.
Regulation 18NYC 364-j, 366(1)(a)(11) and 369-ee of the SSL
719 FPBP Initial 12 Month Extension (NYC)
We will discontinue your Medicaid effective_ _ for:
Even though the individual(s) listed are no longer eligible for Medicaid as
explained in this notice, we will continue Family Planning Benefit Program cover
until _ _ __
You will receive this coverage under the Family Planning Benefit Program for 12
months at a time.
Regulations 18 NYCRR 360-3.2(j), Section 122 of SSL

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

SYSTEM GENERATED MA CODES (CONT'D\
CODE CATEGORY REASON
(Viewable only on CNS

721 MA Transition Medicaid Coverage to NY State of Health, Recipient in the Five Year Ban
(Similar language used for Rosenberg B notices - BHP related)
Because of the immigration status of individuals on you Medicaid case, eligibility
for Medicaid coverage for the following individuals must now be determined by
New York's health plan marketplace, NY State of Health:
This decision is based on Sections366(1)(g) and 369-gg of the SSL.
730 PA Denied/ MA Application Under Review NYC
We are reviewing your application to see if the following person(s) may be eligible
for Medical Assistance. We may write to you asking for additional information we
need to determine your eligibility for Medical Assistance.
Regulation 18 NYCRR 360-2.2(a)(2)
731 PA Denied/MA Application Under Review
We are reviewing your application to see if the following person(s) may be eligible
for Medical Assistance. We may write to you asking for additional information we
need to determine your eligibility for Medical Assistance.
Regulation 18 NYCRR 360-2.2(a)(2)
732 Combined PA/MA Denial
We have denied your Medical Assistance application. This is for the same
reason as your Public Assistance application was denied.
736 MA Extension for CHP Transition
Even through the individual(s) listed are no longer eligible for Medical Assistance
as explained in this notice we will continue/extend the Medical Assistance
coverage until_for_: Name_Client ID#_.
this is to give use time to enroll the child(ren) in the Child Health Plus B Program.
739 Combined PA/MA Application Under Review
A decision about the following individual's application for Medical Assistance/
Family Health Plus has not yet been made. When a decision is made, you will
receive a notice explaining it.
Regulation 18 NYCRR 360-2.5
741 Combined PA/MA Discontinuance
We will discontinue Medical Assistance effective ___ . This is for the same
reason as your Public Assistance is being discontinued.
Regulations 360-3.6
Note: Medical Assistance benefits will stop the same day as PA.

MA CASE REASON CODES !CONT'D!

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02/15/2014

CLOSING CODES - MA !MA: REAS - 241\ !CONT'D!

SYSTEM GENERATED MA CODES (CONT'D\
CODE CATEGORY REASON
(Viewable only on CNS)
750 Discontinue PA/MA Death
We will discontinue Medical Assistance effective for: - - -
This is for the same reason that Public Assistance was discontinue for the above
individual as explained in the Public Assistance section of this notice
Regulation 360-2.6
756 PA/MA Continue Unchange- Full Coverage
These persons will continue to be entitled to full services under Medical
Assistance Program.
Regulation 360-2.6
759 Continue MA until FHP Determination
We will continue your Medical coverage for two months until . This Is
because recipients whose income is less than 100% of poverty may be eligible for
the Family Health Plus Program. We will write you soon asking for the information
we need to determine your eligibility for Family Health Plus. If you do not respond,
your Medical Assistance case may be closed at that time.
Regulation 360-2.6

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

SYSTEM GENERATED MA CODES ICONT'Dl
CODE CATEGORY REASON
761 Combined PA MA Discontinuance
We will discontinue your Medical Assistance effective for
This is for the same reason as your Public Assistance is being discontinued.
Managed Care: If you are enrolled in a Medical Assistance managed care health
plan, you can use your Health Plan Card to get health plan services until the end
of the month in which your Medical Assistance is discontinued.
Regulation cite is dependent on the PA Reason Code.
763 MA Support Extension
We will continue Medical Assistance coverage for four months until _ _ . This is
because recipients in a Medical Assistance case closed due to receipt of or
increase in child or spousal support are eligible for an additional four months of
Medical Assistance coverage.
Regulation 360-3.3(c)
770 Failure to Participate in a Drug/Alcohol Program (Client under 21 years old)
While we determine if you are still eligible for Medical Assistance, we will continue
Medical Assistance coverage unchanged for: . We will soon write to you
asking for information we need to determine your continuing eligibility for Medical
Assistance.
Regulation 360-2.6, 360-2.2 (d), 370.2
This code is generated by CNS codes GX1, GX2 and Gx3
772 Pregnant Woman/Postpartum Extension
Even though the individual(s) listed are no longer eligible for Medical Assistance
as explained in this notice, we will continue Medical Assistance coverage until
_ _for: _ _ .
This is because a pregnant woman who is eligible for Medical
Assistance at any time during her pregnancy continues to be
eligible for Medical Assistance until the end of the month
following the 60th day after her pregnancy ends. When the
child is born he/she will be eligible for Medical Assistance until
age one.
Regulation 360-4.1, 360-4.7, 360-4.8
773 Combined PA/MA Continue of Newborn
Even though the individual(s) listed are no longer eligible for Medical Assistance
as explained in this notice, we will continue/extend the Medical Assistance for the
following infant(s) born on until the end of the month in which the
infant(s) becomes age one:
If you have any questions, call the general information number printed on page
one of the Notice.
Regulation 360-3.3(c).
774 Disc PA, Continue MA, District to District Move
The following Individuals will continue to receive Medicaid _ _ . Because you
have informed us of your move, your coverage will be transferred to your new
district of residence, effective_ _ . You will receive more information about your
coverage from your new district.
Regulation cited is dependent on the PA Reason Code.
This code is generated for failure to recertify (PA code G10) or coverage code 30

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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MA CASE REASON CODES !CONT'Dl

CLOSING CODES - MA !MA: REAS - 241! !CONT'Dl

SYSTEM GENERATED MA CODES (CONT'Dl
CODE CATEGORY REASON
775 Combined PA/MA Continued Unchanged - Pending Decision
While we determine if you are still eligible for Medical Assistance, we will continue
Medical Assistance coverage unchanged. We will soon write to you asking for
information we need to determine your continuing eligibility for Medical
Assistance. If you do not respond when we write, your Medical Assistance case
may be closed at that time.
Regulation cited is dependent on the PA Reason Code.
776 Foster Care
The following individual will continue to receive Medical Assistance coverage
through the Foster Care Program effective (date).
Regulation 360-2.6 This code is generated by PA code E73
777 Managed Care - Guaranteed Eligibility
We will discontinue your Medical Assistance effective . This is for the
same reason your Public Assistance is being discontinued. However, the following
individual(s) are enrolled in a managed care program and are eligible to receive
the medical services available through the managed care program until _ __
Coverage is limited to the services authorized by your managed care provider,
and Medical Assistance/Family Planning services. Please check your member
handbook for a list of these services.
Regulation 360-10.5
778 Combined PA/MA Transitional Medical Assistance (TMA) Acceptance (12-Months).
Your Medical Assistance will continue for 12 months until for the
following persons as long as you have a dependent child under age 21 living with
you: (list name).
This is because your income (less Medicaid deductions including child support
costs) is over the Low Income Family income limit due to increased earnings, new
employment or loss of earned income disregards. You will continue to receive
Transitional Medical Assistance for the entire 12 months as long as: you remain
employed; and a dependant child under age 21 continues to live with you.
Regulation 360-3.3 (c)
This code is generated by CNS codes E31 .or E33
780 Combined PA/MA Support Extension
We will continue Medical Assistance coverage for four months until . This
is because recipients in a Family Assistance (FA) case closed due to receipt of or
increase in child or spouse support are eligible for an additional four months of
Medical Assistance coverage.
Regulation 360- 3.3 (c)
PA Code E32 generates this code

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D\

SYSTEM GENERATED MA CODES ICONT'Dl
CODE CATEGORY REASON
781 Failure to Participate in Drug/Alcohol Program (Ages 21- 65)
We will discontinue your Medical Assistance effective . This is for the
same reason as your Public Assistance is being discontinued. However, if you
take part in a drug and/or alcohol treatment program, you may reapply for Medical
Assistance at any time.
Regulation 360-2.2 (d), 370.2
This code is generated by PA codes PX1, PX2 and PX3
782 Added to Another Case
We will discontinue your Medical Assistance effective . This is because
you will be part of the Public Assistance case of (case name). Your Medical
Assistance will be provided in that case.
Regulation 3.52.1
783 Continuous Eligibility for Children (NYC Only)
Even though the individual(s) listed are no longer eligible for Medical Assistance
as explained in the notice, we will continue Medical Assistance
until for: _ _ .
This is because children up to age nineteen years of age who are determined
Eligible for Medical Assistance remain eligible for benefits for twelve continuous
months or until they reach the age of nineteen, whichever is earlier.
Regulation 366(4)(q).
784 Discontinue PA/MA Immediate (NYC ONLY)
We will discontinue your Medical Assistance effective for_ _ . This is for
the same reason as your Public Assistance is being discontinued
Regulation cite is dependent on the PA Reason Code
785 Failed to Participate in Drug/Alcohol Rehabilitation Program
We will discontinue your Medical Assistance effective (date). This for the same
reason as your Public Assistance case is being discontinued.
However, if you take part in a drug/or alcohol treatment program, you may reapply
for Medical Assistance at any time.
Regulation 360-2.2 (d) and 370-2
This code is generated for MA coverage code 30

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 2411 !CONT'D!

SYSTEM GENERATED MA CODES !CONT'D\
CODE CATEGORY REASON
786 Failure to Participate in Drug/Alcohol PCP (Guarantee) (NYC Only)
Instruction: An automated notice should be generated for PA and MA closing
when a recipient is enrolled in managed care program (coverage code 31 or 33)
and eligible for guaranteed eligibility.
We will discontinue your Medical Assistance effective . This is for the
same reason your Public Assistance is being discontinued. However if you take
part in a drug and/or .alcohol treatment program, you may reapply for Medical
Assistance any time. ·
The following individual is enrolled in a managed care program.and is eligibleto
receive the .medical services available through the managed care program until
___ . Coverage is limited to the services authorized by your managed care
·provider, and Medical Assistance/Family Planning services. Please check your
member handbook for a list of these services. If you have any questions, call the
general information number printed on page one of this notice.
Regulation 360-2.2 (d), 370.2 and18 NYCRR 360-10.5
This code is generated by PA codes PX1, PX2 and PX3.
787 Reinstate PA/ MA PA Sanction Ended (NYC Only)
We will reinstate Medical Assistance effective for_ _ .
This is because your Medical Assistance was stopped for a reason that applied to
both Public Assistance and Medical Assistance. This reason no longer exists, so
you are eligible for Medical Assistance as well as Public Assistance.
Regulation 360-3.3
799 Combined PA MA FS Non Sanction MA PA (NYC Only)
Name) cannot be included in your Medical Assistance case for the same reason
that individual cannot be included in your Public case. (Name) must comply with
this requirement in order to be included in the Medical Assistance case.
The Medical Assistance regulation cited is dependent on the reason for sanction.
808 MA Disc MA, Deceased (NYC) (System Generated)
We will discontinue Medicaid for the above individuals effective: __ .
This is because we have been informed by the Social Security Administration that
this person is deceased.
Regulation 18 NYCRR 360-2 ,
816 MA Suspended Coverage at Incarceration of Inmate of NYS or Local Facility HH=1
Inmate of a New York State or local correctional facility.
18NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-74
02/21/2016

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 241! !CONT'D!

SYSTEM GENERATED MA CODES (CONT'D)
CODE CATEGORY REASON
846 FPBP Discontinue FPBP Fail to Return Renewal (NYC)
We will discontinue your Family Planning Benefits coverage effective_ __
This is because you or your representative has failed to return the Family
Planning Benefits Recertification/Renewal form by _ __
You may request a Fair Hearing if you disagree with any decision explained in
this Notice. You have 60 days form the date of this notice to request a Fair
Hearing.
If your Family Planning Benefits coverage is discontinued, all of your Family
Planning Benefits services will become unavailable to you.
Regulations 18 NYCRR 360-2.2(e) and 360-2.3 and 366(1)(b)(6) of the SSL.
847 FPBP Didn't Return Information NYC
We will discontinue your Family Planning Benefits coverage effective_ _ . This is
because you or your representative did not return all of the information necessary
to determine continued eligibility for Medical Assistance.
You may request a Fair Hearing if you disagree with and decision explained in this
Notice. You have 60 days from the date of this notice to request a Fair Hearing.
You may also request an informal local conference. A request for a local
conference alone will not result in continuation of benefits and does not meet the
60-day deadline for requesting a Fair Hearing.
If your Family Planning Benefits coverage is discontinued, all of your Family
Planning Benefits services will become unavailable to you. You or your
representative must submit these documents jn order for us to determine your
eligibility for continuing coverage.
This decision is based on Regulations 18 NYCRR 360-2.2(e) and 360-2.3 and
Section 366(1 )(b)(6) of the Social. Services Law.
850 MA TMA Transitional Benefits (Truncation)
Client no longer meets statutory requirements. MA case closing at the end of
transaction month. Reason and citation must be specified by worker.
18 NYCRR 360-3.3
857 ALL Suspend MA Coverage for 21-64 Year Old Admitted to a Psychiatric Center, HH=1
(NYC)
We will suspend Medicaid/Family Health Plus/family Health Plus Premium
Assistance Program/Family Planning Benefit Program coverage effective
IT+14) Your Medicaid benefits will be reinstated when you are discharged.
Regulation 18 NYCRR 360-3.4(a)(2) and Section 366(1)(c) and (d) of the SSL
866 MA/MSP Failed to Return Renewal (Recertification) Form for Ql-1/SLIMB (NYC)
We will discontinue your participation in the Medicare Savings Program effective
<Date).
Regulation 18NYCRR 360-2.2(e) and Section 367(a)
867 MA/MSP Failed to Return Renewal (Recertification) Form for Ql-1/SLIMB (NYC)
We are discontinuing your participation in the MSP because you or your
representative did not return all of the information necessary determine continued
participation in the Medicare Savings Program.
Regulation 18NYCRR 360-2.2(e) and Section 367(a)
MA CASE REASON CODES !CONT'D!

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-75
02/15/2014

CLOSING CODES - MA IMA: REAS - 241! !CONT'D!

SYSTEM GENERATED MA CODES ICONT'Dl
CODE CATEGORY REASON
905 MA/FHP Exceed FHP Limit and are Ineligible for Surplus
We will discontinue Medical Assistance/Family Health Plus effective . This
is because on January 1, your household income (will increase/increased) due to
a cost-of-living adjustment (Cola) in a Social Security benefit. This increase in
income must be used to figure your Medical Assistance/Family Health Plus
eligibility.
Regulation 18NYCRR 360-4.1,360-4.8 Section 369-ee and 366 (1)(a)(1)
911 MSSI Medical Assistance Case Opened In Error
Your Medical Assistance case was opened in error. Due to a computer Problem,
we thought that you were in receipt of Supplemental Security Income (SSI)
benefits which would make you automatically. eligible for Medical As~istance.
Since you were not in receipt of SS!, you must have a face to face interview so
that we can determine if you can still get Medical Assistance.
Regulation 18NYCRR 360-2.6 and 360-3.3
939 MA/FHP In Prison (HH=1) (Valid 4/1/08)
We will suspended Medical Assistance/Family Health Plus coverage
effective_ _ . This is because you are an inmate in a New York State or local
correctional facility. Your Medical Assistance case is NOT being closed.
18NYCRR 360-3.4(a)(1) and Section 366(1-a) of the SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-76
06/18/2012

MA CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 241! !CONT'D!

SYSTEM GENERATED MA CODES (CONT'D)
957 MSSI No Longer Eligible For SSI
You were granted Medical Assistance because you were eligible for SSI. We have
been informed by the Social Security Administration that you are no longer eligible
for SSI because you are not in the United States. Medicaid may only be granted to
an eligible resident of New York State, or to a person temporarily in the State who
requires immediate medical care that is not otherwise available.
Regulation 18NYCRR 360-2.6 and 360-3.2, 360-3.3, 360-3.5
958 MA Rosenberg C
You did not complete and return information requested in an earlier notice.
18 NYCRR 360-2.2(e), 360-2.2(f) and 360-2.3
959 MA Rosenberg C - Managed Care
You did not complete and return information requested in an earlier notice.
18 NYCRR 360-2.2(e), 360-2.2(f) and 360-2.3
. 962 MA Excess Income due to Increase in Social Security Benefit
You will be receiving increased Social Security Benefits as of . Your Social
Security amount will be . Due to this increase we have determined that as
of you are no longer eligible for full Medicaid coverage because you have
more income than Medicaid allows for a household of your size.
Regulation18 NYCRR 360-1.2, 360-3.3, 360-4.6,360-4.7, 360-4.8
966 Spenddown Increase due to COLA Increase
We will increase the amount of your excess income from $_ _ _to $_ _ _ a
month effective: _ _for: _ _
This is because your income has increased due to an increase in Social Security
Benefits on January 1, _ _ .
Because of this, your income (less Medical Assistance deductions) is over the
allowable Medical Assistance income limit The amount over the limit is called
excess income or spenddown. Your monthly excess income amount is$_ _ .
Please look at the budget calculation section to see how we figured your excess
income.
Regulations 18 NYCRR 360-4.1 and 360-4.8.

R99 All Separate Determination

Referred to MAP for Separate Determination (Output Only).
Regulation 360-2.2, 360-2.4

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-77
10/23/2016

MA CASE REASON CODES !CONT'D>

RECERTIFICATION BUDGET NOTICE CODES - MA !MA: REAS -2411

SYSTEM GENERATED
CODE CATEGORY REASON
Recertification Budget Notice (viewable only on CNS)
802 Continue MA/i=HP/FP8P Unchanged, No A/C (NYC).
803 Spenddown to MA Level, No A/C (NYC).
804 No Change in Excess Income Amount No A/C (NYC).
805 Increase in Excess Income Spenddown Amount (NYq.
806 Decrease in Excess Income Spenddown Amount, No A/C.
807 Chronic Care - Excess Income Unchanged No A/C
808 Chronic Care - Excess Income Change Individual
841 Continue MA Unchanged, (Timely)
848 Spenddown to MA Level, (Timely)
849 No Change in Excess Income Amount, (Timely)
854 Decrease in Excess Income Spenddown Amount, (Timely)
855 Continue Payment of Medicare QM8, (Adequate)
856 Continue Payment of Medicare Part 8, SLIM8 (Adequate)
857 Continue Payment of Health Insurance Premiums (Adequate)
858 Continue Payment of Medicare QM8, Timely (NYC)
859 Continue Payment of Medicare Part 8, SLIM8, Timely
863 Continue MA Payment of Health Insurance Premiums Timely (NYC)
868 FHPlus to FHPlus-PAP (Timely) No A/C (NYC)
869 FHPlus to FHP plus-PAP (Timely) No A/C (NYC) - S/CC
887 Continue MA/FP8P (NON-SSI Related Individuals)
888 FHP Ending, Continue MA/FP8P (NON-SSI Related) NYC

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-78
02/15/2014

MA CASE REASON CODES !CONT'D!

CONFIRMATION CODES - MA !MA: REAS - 241!

SYSTEM GENERATED
CODE CATEGORY REASON
MC1 Confirmation of Managed Care Plan Selection (MA)
Thank-you for choosing a Medicaid health plan. We want to confirm the choice
you made. is the health plan choice made for the following
individual: _ _ . You must begin to use your health plan on (effective
date), as long as you are still eligible for Medicaid. If you need health care before
this date, use your Medicaid card at any doctor's office or clinic that takes
Medicaid. If you find any mistakes, call the New York Medicaid CHOICE Helpline
1-800-505-5678, Monday through Friday 8:30 a.m. to 8:00 p.m. and Saturdays,
from 10:00 a.m to 6:00p.m.
For people with hearing problems, please call the TT/TDD number, which is 1-
888-329-1541. The call is free. Your new health plan card will come in the mail.
Keep your health plan card and Medicaid card in a safe place; you'll need both. If
you don't like the health plan you chose you have 90 days from (the
effective date) to change health plans.
If you do not change your plan in 90 days, you must stay in the plan for 9 more
months, unless you have a good reason to leave it. To change health plans, call
the New York Medicaid CHOICE Helpline at 1-800-505-5678.
MC2 Confirmation of Managed Care Plan Selection (FHP)
Thank-you for choosing a Family Health Plus health plan. We want to confirm the
choice you made. Plan is the health plan choice made for the following
individual: __
You may begin to use your health plan on (effective date). If you find any
mistakes, call the New York Medicaid CHOICE Helpline at 1-800-505-5678. You
can call the call the Helpline, Monday through Friday 8:30 a.m. to 8:00 p.m. and
Saturdays, from 10:00 a.m. to 6:00p.m.
For people with hearing problems, please call the TTY/TDD number, which
is 1-888-329-1541. The call is free. Your new health plan card will come in the
mail. Keep your health plan card in a safe place.
If you don't like the health plan you chose you have 90 days from (effective date)
to change health plans. If you do not change your plan in 90 days, you must stay
in the plan for 9 more months, unless you have a good reason to leave it. To
change health plans, call the New York Medicaid CHOICE Helpline at 1-800-505-
5678.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-79
. 10/23/2016

MA CASE REASON CODES ICONT'Dl

CNS MRTDEFERRAL DOCUMENT CODES

This is a list of Medicaid Recertification Tracking System (MRT) Document Codes that are used
when MA Case Closing Code U13 (or 995 are used) is entered in CNS. A prompt shall appear on the screen
requiring the entry of the appropriate MRT Code.

CODE REASON

A01 Prior agency photo identification card

A02 Social security card for each family member
A03 Birth or baptismal certificate for each family member
A04 Letter from agency you are known to
A05 Driver's license
A06 Military discharge papers
AO? Marriage certificate or divorce or separation papers
AOB Death certificate
A09 Certification of Naturalization
A 1O Alien registration card or other USCIS document
A 11 Passport and/or visa
A12 Guardianship papers
A13 Individual/Spouse .Failed to Submit Signed authorization for AVS
A 16 Spouse's Signature Requested (AVS)
A 17 Missing Signature or Spouse on Authorization to Verify Resources (AVS)
801 Rent receipt and lease
802 Statement from landlord indication who lives with you
803 Utility bills
804 Mortgage statements: property and school tax bills
805 School records and/or latest report card for children
806 Statement from family doctor or clinic that children live with you
807 Letter from person (s) you live with verifying that they supply room and board
C01 Pay stubs for previous four (4) weeks or statement from employer showing all
deductions
C02 Unemployment insurance book
C03 Statement of rental and/or room and board income

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-80
02/14/2015

MA CASE REASON CODES !CONT'D!

MRT DEFERRAL CODES !CONT'D!

CODE REASON
C04 Support payments - divorce or separation papers
C05 Statement about childcare e~penses

COG Documentation of additional income, which allows you to meet your rent and other
household expenses. The income reported to us is less than your reported rent
and other household expenses
CO? Completed form "Request for Information on Income Producing Property" Include
a copy of the Annual Mortgage Statement and the current Escrow Analysis. If there
is no mortgage, submit copies of the current Real Estate Tax Bill, Water!Waiver Bill
and Fire Insurance Statement.
COB Award letter for Social Security - Call 1- 800- 772-1213 to get an award letter.
C09 Award letter for Military or Veterans' benefits.
C10 Award letter for pensions
C11 Award letter for Railroad Retirement
C12 Award letter for Insurance endowments.
C13 Award letter for New York State Disability.
C14 Award letter for Worker's Compensation
C 15 If self employed: business records Schedule C /Schedule E and Form 1040
C16 Income tax returns
DO? Life insurance policies and current cash surrender value statement from the company.
DOB Stocks, bonds, certificates of deposit and money market fund accounts
D09 Real estate deeds.
D10 Credit union account statements
D13 Information about any pending lawsuit.
D14 Closing papers on property sale.
D15 Information about inheritance.
D16 Information about lottery and other gambling winnings.
D17 Current bank records, Current credit union records, Current retirement records (IRA and Keogh).
D18 Bank, credit union and retirement records (IRA and Keogh) for the last 60 months including
closed accounts.
D19 Statement from Financial Institution Documenting
D20 Statement Explaining Reasons for Large Withdrawal
D21 Copy of Pre-need Burial Agreement and Signed Medicaid Disclosure.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1 -81
10/23/2016

MA CASE REASON CODES !CONT'D>

MRT DEFERRAL CODES !CONT'D>

CODE REASON
D22 Statement from Nursing Facility Verifying Private Payment, amount of Private Payment, Period Covered by
Private Payment, Nursing Facility's Daily Rate.
D23 Trust Agreement with Schedule 'Pl..
E01 If anyone is pregnant, a doctor's statement giving the expected date of delivery
E02 Medical Form LDSS-486, Medical Report for Determination of Disability
E03 Disability Interview, Form DSS -1151
E04 Dialysis Treatment Letter
E05 Additional Medical Documentation
F01 Explanation of Past Maintenance
F02 Explanation ofCurrent Maintenance
F03 . Completed Absent Parent Questionnaire.
G01 Failure to Provide Completed Application and/or Documentation
H01 Sign DAB Renewal Notification Where Indicated.
H02 Completed DAB Renewal Notification.
K01 Verification on Medicare Card
K02 Verification of Medicare Premiums
K03 Verification of Medicare Supplemental Insurance
K04 Verification of Health Insurance and Coverage
KOS Verification of Health Insurance Premiums
K06 Verification of Accident Insurance
K07 Verification of Accident Insurance Premiums

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.1-82
10/23/2016

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-1
06/18/2012

TURNAROUND DOCUMENT - DSS 3517

SECTION 15 - MA INDIVIDUAL LEVEL CODES

MA CATEGORICAL CODES !CATI - 372

01 LIF Child Death of a Parent (Deprivation)
02 LIF Child Incapacity Parent (Deprivation)
03 LIF Child Imprisonment Parent (Deprivation)
05 LIF Child divorce, Annulment, or Legally Separated Parent
06 LIF Child Abandonment/Desertion by Parent
08 LIF Child Unemployment Principal Wage Earner Formerly ADC-U
09 LIF Child No Deprivation or Single or Childless Couple (S/CC)
10 Aged (OAA)
11 Blind (AB)
12 Disabled (AD)
13 LIF Dependent Relative (Deprivation)
14 Essential person (PA Only)
15 Pregnant Women No Deprivation (Use for Intact Households)
20 IVE Adoption Subsidy (MA Cases Only for Children)
21 ADC-Related Adult (deprivation) (Case Type 20)
22 ADC-Related Child (deprivation)(Case Type 20)
25 ADC-Related Adult (no deprivation) (Case Type 20)
26 LIF Adult Intact Family (No Deprivation)
32 Non-NYS IV-E Foster Care (MA or MA-SSI)
33 Non-IV-E Adoption Special Needs (MA or MA-SSI)
34 Non-NYS IV-E Adoption (MA or MA-SSI)
35 Presumptive Eligibility Home Care Nursing/Hospice (MPE only)
36 Presumptive Eligibility Pregnant Women (MPE only)
39 FNP Parent Living with his/her Child (ren) Above the PA Standard (MA Only)
42 ADC-Related Pregnant Women (MA Level) (Case Type 20)
43 Expanded MA Levels. Pregnant Women (Case Type 20)
44 Expanded Coverage, Child Less Than 1, But Eligible at 100% of Poverty
46 Expanded Coverage, Child From 1to5 Under 133% FPL
47 Expanded Coverage, Child From 6 to 19, Under 100% FPL
,48 LIF Pregnant Women (Deprivation)
50 Special Supplement (s) Client-FNP for Medicaid (NYC only).
51 Expanded Coverage Infant Less Than 1, Eligibility at 200% FPL
56 FHP Single and Childless Couples. Individuals 19-20 not living with parents
57 FHP Parents living with minor children. Individuals 19-20 living with parents
58 FHP Pregnant women eligible at 100% of the Federal poverty level (valid only on case type
20)
59 FHP Pregnant women between 100% and 200% of FPL (Valid only on case type 20)
65 Presumptive Eligibility Children
66 Disaster Relief, System Generated for MPE cases for Special Disaster Relief load to case
Type 21
68 Family Planning Coverage (FP)
69 Family Planning Coverage (FNP)
70 Medicaid Buy-In - Disabled Basic Group
71 Medicaid Buy-In - Medically Improved
73 Woman in Postpartum period
84 Expanded Coverage, Child From 6 to 19, Income.Level> 100% FPL and< or equal to 133%
FPL
85 IV-E KinGap Foster Care
86 Non-IV-E KinGap Foster Care
87 Non-NYS IV-E KinGap Foster Care

NEW YORK STATE WELFARE MANAGEMENTSYSTEM

 WORKER'S GUIDE TO CODES
4.2-2
06/1912016

TURNAROUND DOCUMENT - DSS 3517 (CONT'D)

SECTION 15 - MA INDIVIDUAL LEVEL CODES

MA CATEGORICAL CODES !CATl-372

90 Child 6 -19 with 100% - 133% FPL
91 ADC/LIF Related Child
92 Pregnant Women with a FPL::;_ 223% (Aid Category code P7)
93 Single & Childless Couples & 19 < 21 living alone with a FPL> 100% .:::_ 138% (Aid Category
code HO)
94 Parents &Caretaker Relatives with a FPL.:::_ 138% (Aid Category code H1)
95 19 < 21 living with Parents with a FPL> 138% .:::_ 155% (Aid Category code H1)
96 19 < 21 living with Parents with a FPL.:::_ 138% (Aid Category code 90)
97 Individual not a parent or caretaker relative. Income =< 100% FPL (Only valid with MA
Opening codes 613, 614, 615, and 616. Only valid for Case Type 20)
98 Individual not a parent or caretaker relative. Income >100% = < 138% FPL. (Only valid for MA
Case Type 20)

CHAFEE INDICATOR !NOT ON TAD!- 349

T True Chafee ID not valid on individuals over 21 (Manual Process)
1 Guarantee (Auto Process Only) - Chafee child 18-21 years old
7 Guarantee (Manual Openings, valid only at Centers 5A7, 580, and specified supercenters)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-3
02/19/2017

MA STATUS CODES !MA: STAT\ - 340

AC Active
AP Applying
CL Closed
IC Medicaid Suspension
NA Not Applying
RJ Denied
SN Sanctioned
DD Dead

MA COVERAGE CODES !MA: COV CDI - 343

01 Full Coverage
02 Outpatient Coverage Only
04 No Coverage-PA Cases Only
06 Provisional Coverage (FHP)
07 Emergency Medical Coverage
08 Presumptive Eligibility - Home Care Nursing/Hospice (MPE only)
09 Medicare Premium, Co-insurance and Deductible Only
10 Eligibility for All Services except Long Term Care
11 Full Coverage-FNP Except Emergency Medical Care (Legal Alien during 5 year ban)
13 Presumptive Eligibility - Prenatal Care A (MPE only)
14 Presumptive Eligibility - Prenatal Care B (MPE only)
15 Pre natal Care
17 Eligibility for Payment of Health Insurance Premium Only
18 Family Planning Only Eligible at or Below 200% of FPL
19 Community Coverage with community based Long Term Care - (Case Type 20)
20 Community Coverage without Long lerm Care (Case Type 20 & 24 Only)
21 Outpatient Coverage with comm based long term care - (Case Type 20)
22 Outpatient Coverage without Long Term Care (Case Type 20 Only)
23 Outpatient Coverage with no Nursing Facility Services (Case Type 20 Only)
24 Community Coverage without Long Term Care (Legal Alien during 5 year ban)
(Case Type 20 Only)
25 l/P Hospital Only - FNP for Individuals Age 21-64 Admitted to Psychiatric Facilities
(Case Types 20 & 24)
26 l/P Hospital Only - FP for Incarcerated Individuals (Case Types 20 & 24)
27 Family Planning Extension Program (without transportation)
1
30 PCP - Full Coverage
31 PCP - Guarantee - (System Generated)
34 Family Health Plus Coverage
36 Family Health Plus Guarantee - (System Generated)

MEDICARE SAVINGS PROGRAM !MSPl - 345

P Qualified Medicare Beneficiary (QMB)
L Specified Low Income Medicare Beneficiary (SLIMB)
U Qualified Individual 1 (Qil)
X New Value for QDWI - Has not been defined by DOH

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-4
10/20/2013

SECTION 15 - MA INDIVIDUAL LEVEL CODES !CONT'D!

AD EX INDICATOR - 365
The Aged/Disabled field must be entered in a (MMDDYY) date format.
Note: Required with employment code (74) only.

MA EMPLOYABILITY CODES !EMP\- 375

INDIVIDUALS UNDER THE AGE 18 MUST BE ASSIGNED CODE 30, EXCEPT AB/AD CHILDREN AND
UN BORNS

CODE CATEGORY PEFINITION

17 All Teen parent age 16-19 without HS Diploma.
20 FA/SN CA Employable.
24 All Pregnancy.
27 All Employed.
30 All Child less than 18 years old.
31 All Caretaker of child under 3 years of age on same MA case.
32 All Advanced age - 65 years and older.
33 FA Caretaker with other adult on same MA case in employment compliance.
34 All Caretaker of child under 3 not on same MA case.
35 All Child 18 expected to graduate by 19th birthday.
36 All Incapacitated 30 days to 1 year.
38 All Needed in home full time to care for incapacitated/disabled family member-Exempt

40 All Needed in home part time to care for an incapacitated/disabled family member- Non
Exempt
41 All Temporary illness - 3-month exemption.
42 All Temporary incapacity - 6-month exemption
43 All Incapacitated - SSI application filed.
44 All In receipt of SSI and/or SSI Disability.
53 All Person 18 -21 not employed.
60 SNCA 55 years or older - not employed in the last 5 years.
63 All Substance abuser - in rehabilitation.

64 All Substance abuser - waiting for rehabilitation.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-5
02/15/2014

SECTION 15 - MA INDIVIDUAL LEVEL CODES !CONT'D!

MA EMPLOYABILITY COOE IEMPl - 375 !CONT'D!

INDIVIDUALS UNDER THE AGE 18 MUST BE ASSIGNED CODE 30, EXCEPT AB/AD CHILDREN AND
UNBORNS

CODE CATEGORY DEFINITION

70 FA/SSI Disability Type I.

71 FA/SSI FA caretaker relative of child 19 or younger (not born) in the same MA case.

72 All FA caretaker relative of child between the ages of 6 to 19 not in same MA

Only case.

74 FA/SSI Disability Type II.

99 All Unborn

TPHl/MCR INDICATOR - SYSTEM GENERATED

This is displayed as a combined field in the individual data area of the TAD. The 1st position in the field is
TPHI, the 2nd position is MCR.
TPHI -Third Party Health Insurance
Y Client Has TPHI
N Client Does Not Have TPHI
MCR - Medicare
Y Yes
N No

EMPLOYER PURCHASE INDICATOR IEPll- 344

Employer purchase FHP Indicator
Space - Not a Member of EPI (System Generated)
1 - 1199 Employee in 1199 Manage Care Plan (System Generated)
2 - Client no Longer Eligible for Partnership FHP (System Generated)
3 - Employer withdrew from Plan (System Generated)
4 - 1199 Employee in non-1199 Managed Care Plan (System Generated)
5 - Client Has Case Type 20, and Coverage Code is not Equal to 30 (System Generated)
6 - Client in FHP-PAP Program (System Generated)
B - Client no Longer Eligible for Partnership FHP .
C - Employer Withdrew from Plan
D - 1199 Employee in non-1199 Managed Care Plan
E - Client Has Case Type 20, and Coverage Code is not Equal to 30 or 34
F - 1199 Employee in 1199 Managed Care Plan.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM'

 . WORKER'S GUIDE TO CODES
4.2-6
06/21/2010

MA INDIVIDUAL REASON CODES

OPENING CODES - MA !MA: REAS - 341\

CODE CATEGORY
14 All Inpatient Hospital bills equal to or greater than excess resources
combined with excess income (if applicable) HEO use only.
MA: 360-3

15 SSI Related Medicare Premium, co-insurance and deductible only.

MA: 360-3

19 MA- FA/SNFP Beginning of extension of eligibility for MA after findings of

ineligibility for PA resulting from loss of 30 + 1/3 disregard.
MA: 360-3

JO MA- FA/SNFP Beginning of four month extension of eligibility for MA after finding of
ineligibility for FA resulting from employment or receipt of support
MA: 360-3

J1 FA/SNFP Medical bills equal to or greater than excess income.

MA - SSl-Related MA: 360-3

J2 SSI SSI recipient not yet appearing on SOX-determined eligible for MA-SS!.
MA: 360-3
J3 SSI SSI new opening on SOX, determined eligible for MA-SSI (Case Type 22)
MA: 360-3

J4 All Medical need - no recent change in financial circumstances.

MA: 360-3

JS All Administrative
MA: 360-3

A4 MA - SNCA/SNNC Parents over 21 and under 65, in an intact family, living with child(ren)
under 21 or single FNP parents living with dependent 18, 19 or20 year old
children who have income and/or resources above the PA standard
MA: 360-3

A7 MA Pay - In Excess Income

Regulation 360-4.8

• 0 =Zero

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-7
10/17/2015

MA INDIVIDUAL REASON CODES !CONT'D!

OPENING CODES - MA !MA: REAS - 3411 !CONT'D!

CODE CATEGORY
A03 MA/FHP Suspended Coverage at Incarceration of Inmate of NYS or Local Facility
Inmate of a New York State or local correctional facility. (Valid 4/01/08)
18NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL
A41 MA/FHP Suspend MA Coverage for 21-64 Year Old Admitted to a Psychiatric Center, HH=1
(NYC)
We will suspend Medicaid/Family Health Plus/family Health Plus Premium
Assistance Program/Family Planning Benefit Program coverage effective: _ _ .
Your Medicaid benefits will be reinstated when you are discharged.
Regulation 18 NYCRR 360-3.4(a)(2) and Section 366(1)(c) and (d) of the SSL
A64 MA Suspend MA Coverage for Treatment qf Inpatient Emergency Medical Conditions,
Inmate of a Correctional Facility
We will suspend Medicaid coverage effective for:
Because of your immigration and inmate status, Medicaid cannot pay for medical care,
services or supplies you receive while physically residing in a correctional facility, except.
for the treatment of inpatient emergency medical conditions.
This decision is based on Sections 122, 366(1-a) and 366(1)(e)(1) of the SSL
095 FHP/ESI Parents at Case Level
MA 369-ee
H28 MA Medical Assistance/Family Planning Benefits Program.

H66 MA MAGI-Like Consumers {NYC)

Section 366(1 )(b) of the Social Services Law
H67 FHP Single and Childless Couple Eligible for FHP
Eligible single and childless couples can only be used on FHP
MA: 369-ee
H68 FHP FHP Parents
·FHP Parents level can only be used on FHP cases.
MA: 369-ee
H69 FHP Pregnant Wom11n on MA Case
FHP eligible pregnant woman active on a MA Case Type 20.H
MA: 369-ee
H74 FHP Family Health Plus Parent and Expanded Eligibility Children
FHP Parents and children with expanded eligibility (can only be used on FHP cases)
MA: 369-ee
H97 FHP/ESI Pregnant Women
MA 369-ee
H98 FHP/ESI Parents and Expanded Eligibility Children
MA 369-ee
H70 MBl/DBG Medicaid Buy-In (Disabled Basic Group) Eligible at or below150%.
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law
H71 MBl-MI Medicaid Buy-In (Medically Improved) Eligible at or below 250% but greater than
150%.
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-8
02/19/2017

MA INDIVIDUAL REASON CODES !CONT'D!

OPENING CODES - MA !MA: REAS - 241! !CONT'D!

CODE CATEGORY REASON
P47 MA Reinstate MA Coverage (30 Days Prior to Releas) (Both Manual and System
Generated)
We will reinstate Medicaid coverage when the following individual is released to t
the community from the correctional facility:
Prior to release, a common Benefit Identification Card will be mailed to the
correctional facility. This card will be made available to you upon release to the
communtty.
920 MA Add Newborn To Case (System Generated)
This is because the infant's mother was receiving Medical Assistance at the time of the
infant's birth
MA: 366-g
921 MA Unborn/Newborn Conversion (System Generated)
This is because the infant's mother was receiving Medical Assistance at the time of the
infant's birth. The infant was listed on case as unborn.
If the mother was enrolled in managed care on the date of the infant's birth, the infant
will be included in the same managed care plan as the mother.
MA: 366-g

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-9
10/19/2009

MA INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 3411

EXCESS INCOME/RESOURCES
CODE CATEGORY REASON
E04 FHP Deny FHP, MA Ineligible, Excess Income, S/CC
We have denied Medicaid/Family Health Plus for:
Message 1: Gross Income Over 185% Medicaid Standard
You are not eligible for Medical Assistance because your gross income of$_ is over
185% of the Medicaid Standard of$_.
Message 2: Net Income over the Medicaid Standard
You are not eligible for Medicaid because your net income (gross income less Medical
Assistance deductions) of$_ is over the Medicaid Standard of$_.
For All:
We also evaluated your eligibility for Family Health Plus. You are not eligible because your
gross income of$_ is over the FHP income limit of$_.
18 NYCRR 360-4.1, 360-4.7, and 360-4.8 Sections 366(1)(a)(1) and 369-ee of SSL
E22 FHP Deny FHP, MA Ineligible, Excess Income, FP
We have denied Medical Assistance/Family Health Plus for: You are not eligible for
Medical Assistance because your net income (gross income less Medical Assistance
deductions) of$_ is over the allowable Medical Assistance income limit of$_. The
amount over the limit is called excess income or spenddown. Your monthly excess income
amount is $_. If you incur medical bills in the amount of your excess income or if y9ur
income goes down, you may reapply.
We also evaluated your eligibility for Family Health Plus you are nbt eligible because your
gross income of$_ is over the FHP income limit.
18 NYCRR 360-4.1, 360-4.7 and 360-4.8 and Sections 366(1)(a)(1), and 369-ee
E59 MA Pregnant Woman, Excess Income
We have denied Medical Assistance for:_. This is because your net income of$ _ __
is more than 200% of the Federal Poverty Level of $_ _which is the .income limit for a
pregnant woman. Since your income is over 200% of the Federal Poverty Level, we
compare your income to the Medical Assistance limit.
Your net income of $_is over the allowable Medical Assistance income limit of$_.
Your monthly excess income is $_. If you incur medical bills in the amount of your
excess income, you may reapply.
MA:18NYCRR 360-4.1, 360-4.7 and 360-4.8
F09 MBl-WPD Ineligible Excess Income above 250% of FPL
We have denied your application for Medical Assistance under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective_ _ . This is
because your net income (gross income less Medical Assistance deductions) of
$_is over the MBl-WPD income limit of$_.
Please look at the budget section to see how we figured your income.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-In Program."
Regulation 18 NYCRR 360-4.8 and Sections 366(1)(a)(12),.366(1)(a)(13), 367-a(12) of
the Social Services Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-10
02/16/2010

MA INDIVIDUAL REASON CODES !CONT'D\

REJECTION CODES - MA !MA: REAS· 341! !CONT'D\

EXCESS INCOME/RESOURCES ICONT'Dl

CODE CATEGORY REASON

F26 MBl-WPD Excess Resources (Manual Notice)
We have denied your application for Medical Assistance under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective __ . This is
because your countable resources of$_ are over the MBl-WPD resource limit.
Because your countable resources are over the allowable medical assistance
resource limit, you are not eligible for Medical Assistance.
The amount over the limit is called excess resources or spenddown. We have not
received documentation that you have spent your excess resources by
establishing or adding a burial trust/fund.
If you incur medical bills in the amount of your excess resources or if the amount
of you
Regulation 18 NYCRR 360-4.8 and Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of
the Social Services Law
F28 MBl-WPD Excess Income above 250% of FPL and Excess Resources (Manual Notice)
We have denied your application for Medical Assistance under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD). This is because your
net income (gross income less Medical Assistance deductions) of $_is over the
MBl-WPD income limit of$_ and your countable resources of $_are over the
MBl-WPD resource limit.
You are not eligible for Medical Assistance because your net income (gross
income less Medical Assistance deductions) is over the allowable Medical
Assistance income limit and your countable resources are over the allowable
resource limit. The amounts over the limits are called excess income and
resources or spenddown.
We have not received documentation that you have spent your excess resources
by establishing or adding to a burial trust/fund.
If you incur medical bills in the amount of your excess resources and expect to
have medical bills which are equal to or more than your excess income, or if your
income or resources go down, you may reapply.
Regulation 18 NYCRR 360-4.1, 360-4.3, 360-4.1, 360-4.6, 360-4.7, 360-4.8 and
Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the Social Services Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-11
02/15/2014

MA INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 3411 !CONT'D!

EXCESS INCOME/RESOURCES !CONT'D)

CODE CATEGORY REASON

FE1 MA Deny MA Excess Income. Child Age 6-18 !NYC!
We have denied your application for Medicaid dated_ _for:
This is because your net income of$_ is more than 133% of the Federal
Poverty Level of$_ which is the income for persons ages six through eighteen
years.
Regulations 18NYCRR 360-4.1, 360-4.7 and 360-4.8, and Section 366(1)(a((11) and
366(4)(p)(1) of the Social Services Law
G57 MA Deny Medicaid. Ineligible. Income Over 138% !NYC!
Message 1 (Deny MA)

We have denied your application for Medicaid dated for:

Message 2 (Disc MA)

We have re-determined your eligibility for Medicaid coverage under the new rules of the
Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective for:

For All:
This is because you are not eligible for Medicaid because your gross of $_ _is over the
allowable Medicaid income limit of$ _ __
However, you may be eligible for Medicaid with a spenddown.
Please read the·Sections "Explanation of the Excess Income Program" and "Optional Pay-
in Program."
Sections 366(1 )(b) and 366-a(2) of the Social Services Law.
H36 MA Deny Medicaid. Ineligible. Income Over 154% !NYC!
Message 1 (Deny MA)
We have denied your application for Medicaid dated _ _ _for:

Message 2 (Disc MA)

We have re-determined your eligibility for Medicaid coverage under the new rules of the,
Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective for:

Use for All:

This is because you are not eligible for Medicaid because your gross of$ is over
the allowable Medicaid income limit of$ _ _ _.
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and "Optional
Pay-in Program."
Sections 366(1 )(b)(3) and 366-a(2) of the Social Services Law.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-12
02/15/2014

MA INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 341 I !CONT'D!

EXCESS INCOME/RESOURCES ICONT'Dl

CODE CATEGORY REASON

H37 MA Deny Medicaid. Ineligible. Income Over 155% !NYC!
Message 1 (Deny MA)
We have denied your application for Medicaid dated _ _ _for:

Message 2 (Disc MA)

We have re-determined your eligibility for Medicaid coverage under the new rules of the
Patient Protection and Affordable Care Act of 2010.
We will discontinue Medicaid effective for:

Use for All:

This is because you are not eligible for Medicaid because your gross of$ is over
the allowable Medicaid income limit of$ _ __
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and "Optional
Pay-in Program."
Sections 366(1 )(b)(3) and 366-a(2) of the Social Services Law.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-13
10/23/2016

MA INDIVIDUAL REASON CODES (CONT'D!

REJECTION CODES - MA IMA: REAS -341! !CONT'D)

ELIGIBILITY REQUIREMENTS
CODE CATEGORY REASON
F81 MA Photo ID Refusal (MA Only)
We have denied your application for Medical Assistance dated:~
This is because you failed or refused to have your picture taken for a photo
identification card. Getting a photo ID is a requirement of the Medical Assistance
Program.
MA: 360-2.2
F92 All Failure to Provide Proof of Citizenship, Identity and or Current Immigration Status
We have denied Medicaid/Family Health Plus coverage for: Name.
This is because you have failed to provide documentation of citizenship, identity
and or current immigration status.
Regulation 18NYCRR 351.1 (b)(2)(ii), 351.2, 351.5, 351.6, 351.8(a)(2)(ii), 360-1.2, 360-
2.3 and 369-ee of the SSL
H42 MA Deny Medicaid. Individual Revoked Authorization for AVS
We have denied your application for Medicaid dated for:
This is because in order to get Medicaid, you and your spouse (if married) must
provide a signed authorization allowing Medica.id to verify your and your
spouses's resources with financial institutions.
This decision is based on 42 U.S.C. 1396w and Section 366-a(2) of the SSL.
F93 All Failure/Refusal to Sign Citizenship/Alien Declaration
We have denied your application for Medical Assistance dated: _ __
This is because you failed to sign Citizenship and Alien Declaration.
MA: 360-2.6
HHB MA HX Applicant Submission (NYC)
This is to inform you that we will continue Medicaid until _ _ _ for the following
individuals:
This decision is based on Section 366(1 )(b) of the Social Services Law.
HH9 MA Individual HX Referral (NYC)
We received your application dated for Medicaid coverage. Your
application for the following individuals is being sent to New York's health benefit
exchange, New York State of H.ealth:
This is because starting January 1, 2014, certain individuals must have their
eligibility determined by New York State of Health.
New York State of Health will use your application to determine your eligibility.
18 NYCRR 360-3.3 and Sections 369-ee and 366(1)(a)(11) Social Service Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-14
10/23/2016

MA INDIYIDUAL REASON CODES !CONT'D>

REJECTION CODES - MA !MA: REAS - 3411 !CONT'D!

ELIGIBILITY REQUIREMENTS
CODE CATEGORY REASON
V97 All Failure to Report to Child Support Enforcement Unit (IV-D Requirement)
We have denied your application for Medical Assistance dated: _ _ .
This is because you did not report to the Child Support Enforcement Unit on date
to help obtain medical support or establish paternity for your Child(ren) whose
parent(s) does not live with him/her or was born out of wedlock. Failure to report
to the Child Support Enforcement unit without good cause is grounds for denying
or closing Medical Assistance/Family Health Plus. However, if you are pregnant,
you do not have to help the Child Support Enforcement Unit until at least two
months after the baby is born. If you are pregnant, let us know.
Regulation 18NYCRR 346,347, 360-3.2(b), 369.2(b), 369.2(b) (3) and section 369ee
Y84 FHP Failure to Provide Health Plan and Provider Selection Form
We have denied your application for Family Health Plus dated: _ _
Choosing a health plan is an eligibility requirement of the Family Health
Plus Program. We told you if you did not return the completed plan enrollment
form we would not be able to continue your health insurance coverage.
MA: 360-4.1, 360-4.8

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-15
06/21/2014

MA INDIVIDUAL REASON CODES ICONT'Dl

REJECTION CODES - MA IMA: REAS - 341! ICONT'Dl

DEATH
CODE CATEGORY REASON
F50 MA Death Before Determination - No Unpaid Medical Bills
We have denied your application for Medical Assistance dated _ _
This is because this individual died before the Medical Assistance application
process was completed and there were no unpaid medical bills.
MA: 360-2.2 and 360-2.3.
F51 MA Death Before Determination Insufficient information
We have denied your application for Medical Assistance dated _ _ .
This is because our records indicate that this individual is deceased and we
have insufficient information to complete the Medical Assistance application
process. If there are unpaid Medical bills a representative may contact us to
complete the process.
MA: 360-2.2 and 360-2.3.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-16
02/15/2014

MA INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS - 3411 !CONT'D!

RECEIPT OF MULTIPLE OR CONCURRENT ASSISTANCE
CODE CATEGORY REASON
F66 All Currently in Receipt of Assistance Within Same District
We have denied Medical Assistance for:_. This is because you are already
receiving Medical Assistance/Family Health Plus under another case.
18 NYCRR 360-3.3 and Sections 369-ee and 366(1)(a)(11) Social Service Law
M02 MA Deny Application Due to Receipt of Medicaid through New York State of Health
(NYC)
We have denied your application for Medicaid dated for:
This is because your identity matches that of a person who is already receiving
Medicaid coverage through New York State of Health, account number_ __
Because the identities match, we have determined that you and that person are
the same person.
Regulation 18 NYC RR 351.9 and Section 366(1 )(b) of the SSL.
M98 All Concurrent Benefits - Intrastate (Within State)
We have denied Medical Assistance/Family Health Plus for:_. This is because
your identity matches that of a person who is already receiving Medical
Assistance. When the identity of an applicant or recipient matches that of a
person who is already receiving Medical Assistance, that person is not eligible for
additional Medical Assistance/FHP.
18 NYCRR 351.9
N6!l All Concurrent Benefits Interstate (Between States)
We have denied Medical Assistance/Family Health Plus for:_. This is because
your identify matches that of a person who is already receiving Medical
Assistance/FHP in_. When the identity of an applicant or recipient matches that
of a person who is already receiving Medical Assistance, that person is not
eligible for additional Medical Assistance/FHP.
18NYCRR 351.9 and Section 369-ee of Social Service Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-17
10/17/2015

MA INDIVIDUAL REASON CODES !CONT'D\

REJECTION CODES - MA IMA: REAS - 341! !CONT'D\

LIVING ARRANGEMENTS
CASE CATEGORY REASON
E72 All Institutionalized
We have denied Medical Assistance/Family Health Plus for:_. This is because
you are in a public institution which provides medical care for you.
18 NYCRR 360-3.4 and Section 369-ee of the Social Service Law
E73 All Child Entering Foster Care
We have denied Medical Assistance/Family Health Plus for:_. This because the
individual will receive Medical Assistance through the Foster Care Program
18 NYCRR 360-2
F60 All Left Household
We have denied Medical Assistance/Family Health Plus for:_.
This is because you left the household.
18 NYCRR 360-2.6 and Sections 366(1)(a)(11) and 369-ee
F63 All In Prison
We have denied Medical Assistance/Family Health Plus for:_. This
Is because you are in a public institution which provides medical care for you.
18 NYCRR 360-3.4 and Section 369-ee of the Social Service Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-18
02/15/2014

MA INDIVIDUAL REASON CODES ICONT'Dl

REJECTION CODES - MA IMA: REAS - 3411 ICONT'Dl

HEALTH INSURANCE
CODE CATEGORY REASON
Y84 FHP Failure to Provide Health Plan and Provider Selection Form
We have denied Family Health Plus effective _ _. Choosing a health
plan is an eligibility requirement of the Family Health Plus Program. We told
you if you did not return the completed plan enrollment form we would not be
able to continue your health insurance coverage.
MA: 360-4.1, 360-4.8

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-19
0212112016

MA INDIVIDUAL REASON CODES ICONT'Dl

REJECTION CODES - MA !MA: REAS - 3411 ICONT'Dl

OTHER
CODE CATEGORY REASON
M13 All Deny Medicaid/Family Health Plus/FHP-PAPIFPBP. Currently in Receipt of Medicaid
in Another State
We have denied your application for medicaid/family Health Plus/FHP-PAP/FPBP.
This is because you already receive Medicaid in the State of_.
Regulation 18 NYCRR 351.9 and Sections 369-ee and 366(1)(a)(11) of the SSL.
M66 All Deny Medicaid/Family Health Plus/FHP-PAPIFPBP. Currently in Receipt of Medicaid
on Another Case
We have denied your application for Medicaid/Family .Health Plus/FHP-PAP/
FPBP. This is because you are already receiving Medicaid/Family Health Plus/
FHP-PAP/FPBP under case name _ _
Regulation 18 NYCRR 360-3.3 and Sections 369-ee and 366(1 )(a)(11) of the SSL.
M67 All Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Part of Another MA Application
We have denied your application for Medicaid/Family Health Plus/FHP-PAP/
FPBP. This is because you are part of the application of_and you are still a
member of that household. We will decide if you can get assistance as a member
o that case.
Regulation 18 NYCRR 360-3.3 and Sections 369-ee and 366(1)(a)(11) of the SSL.
Y98 All Other- Manual Notice Required (No MA Extension)
This code is to be used if none of the other reason codes for rejection of individual
are applicable.
MA: 360-2.2
Y99 All other- Manual Notice Required
This code is to be used if none of the other reason codes for rejection of individual
are applicable.
MA: 360-2.2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-20
02/15/2014

MA INDIVIDUAL REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS • 341 I

EXCESS INCOME/RESOURCES
CODE CATEGORY REASON
E24 FHP Disc FHP Turning 65, Ineligible for MA Exe Inc (NYC)
We will discontinue Family Health Plus effective_. For:_.
This is because Family Health Plus provides health insurance coverage
to certain individuals age 19 through 64 only who have income over the
Medicaid limits: Until you turned 65 years of age, we compared your income to
the Family Health Plus income limits. Now we compare your income and
resources to the Medicaid limits.
You are not eligible for Medicaid because your net income (gross income less
Medicaid deductions) of$__ is over the Medicaid income limit of$_. The
amount over the limit is called excess income or spenddown. Your monthly
excess income amount is $_.
If you incur medical bills in the amount of your excess income, or if your income
goes down, you may reapply for Medicaid.
1BNYCRR 3604.8 and Section 369-ee of the SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-21
02/21/2016

MA INDIVIDUAL REASON CODES !CONT'D\

CLOSING CODES - MA !MA: REAS - 341\ !CONT'D!
EXCESS INCOME/RESOURCES fCONT'Dl
CODE CATEGORY REASON
F09 MBl-WPD Ineligible Excess Income above 250% of FPL (Manual Notice)
We will discontinue Medical Assistance under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective _ _ . This is because
your net income (gross income less Medical Assistance deductions) of $_is over the
MBl-WPD income Standard of$_.
Please look at the budget section to see how we figured your income.
Please read the Sections: "Explanation of the Excess Income Program" and "Optional
Pay-In Program."
Regulation 18 NYCRR 360-4.8 and Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the Social
Services Law
F26 MBl-WPD Excess Resources (Manual Notice)
We will discontinue your Medical Assistance coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD) effective _ _ . This is because
your countable resources of$_ are over the MBl-WPD resource limit.
Because your countable resources are over the allowable medical assistance resource
limit, you are not eligible for Medical Assistance.
The amount over the limit is called excess resources or spenddown. We have not received
documentation that you have spent your excess resources by establishing or adding a
burial trust/fund.
If you incur medical bills in the amount of your excess resources or if the amount of you
Regulation 18 NYCRR 360-4.8 and.Sections 366(1)(a)(12), 366(1)(a)(13), 367-a(12) of the Social
Services Law
F28 MBl-WPD Excess Income above 250% of FPL and Resources (Manual Notice)
We will discontinue Medical Assistance coverage under the Medicaid Buy-
In program for Working People with Disabilities (MBl-WPD). This is because your net
income {gross income less Medical Assistance deductions) of $_is over the MBl-WPD
income limit of$_ and your countable resources of $_are over the MBl-WPD
resource limit.
You are not eligible for Medical Assistance because your net income (gross income less
Medical Assistance deductions) is over the allowable Medical Assistance income limit and
your countable resources are over the allowable resource limit. The amounts over the
limits are called excess income and resources or spenddown.
We have not received documentation that you have spent your excess resources by
establishing or adding to a burial trust/fund.
If you incur medical bills in the amount of your excess resources and expect to have
medical bills which are equal to or more than your excess income, or if your income or
resources go down, you may reapply.
Regulation 18 NYCRR 360·4.1, 360-4.3, 360-4.1, 360-4.6, 360-4.7, 360-4.8 and Sections
366(1 )(a)(12),.366(1 )(a)(13), 367-a(12) of the Social Services Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-22
06/19/2016

MA INDIVIDUAL REASON CODES !CONT'D)

CLOSING CODES - MA !MA: REAS - 3411 ICONT'Dl

EXCESS INCOME/RESOURCES (CONT'D)
CODE CATEGORY REASON
H38 FHP/FHP-PAP Discontinue FHP. Ineligible. Income Over 138% FPL
This is to inform you that the Family Health Plus Program is being discontinued;
therefore we have re-determined your eligibility for Medicaid coverage under the
new rules of the Patient Protection and Affordable Care Ace of 2010.
We will discontinue Family Health Plus effective for:
You are not eligible for Medicaid because your gross income of $_ _ is over the
Medicaid income limit of$ _ __
However, you may be eligible for Medicaid with a spenddown.
Please read the Sections: "Explanation of the Excess Income Program" and
"Optional Pay-In Program."
This decision is based on Sections 366(1 )(b), 366-a(2) and 369-ee of the SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-23
02/14/2015

MA INDIVIDUAL REASON CODES (CONT'D)

CLOSING CODES - MA <MA: REAS - 3411 !CONT'D\

ELIGIBILITY REQUIREMENTS (CONT'Dl
CODE CATEGORY REASON
V97 All Fail to Report to Child Support Enforcement Unit (IV-D Requirement)
We will discontinue Medical Assistance/ Family Health Plus effective date.
This is because you did not report to the Child Support Enforcement Unit on date
to help obtain medical support or establish paternity for your Child(ren) whose
parent(s) does not live with him/her or was born out of wedlock. Failure to report
to the Child Support Enforcement unit without good cause is grounds for denying
or closing Medical Assistance/Family Health Plus. However, if you are pregnant, ·
you do not have to help the Child Support Enforcement Unit until at least two
months after the baby is born. If you are pregnant, let us know.
Regulation 18NYCRR 346,347, 360-3.2(b), 369.2 (b), 369.2(b) (3) and section 369ee
Y84 FHP Failure to Provide Health Plan and Provider Selection Form (Manual Notice)
We will discontinue Family Health Plus effective _ _ . Choosing a health
plan is an eligibility requirement of the Family Health Plus Program. We told
you if you did not return the completed plan enrollment form we would not be
able to continue your health insurance coverage.
MA: 360-4.1, 360-4.8

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-24
10/23/2016

MA INDIVIDUAL REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 341 l !CONT'D!

ELIGIBILITY REQUIREMENTS
CODE CATEGORY REASON
F92 All Failure to Provide Proof of Citizenship, Identity and/or Current Immigration Status
We will discontinue Medical Assistance/Family Health Plus effective _ _ .
This is because you failed to provide documentation of citizenship, identity and or
current immigration status.
MA: 360-2.6
F93 All Fail to Complete Declaration of Citizenship/Immigration
We will discontinue Medical Assistance/Family Health Plus effective_.
This is because in order to get Medical Assistance/Family Health Plus, we must
have a written declaration for each applying household member stating that the
individual is either a United States citizen, National, Native American or is in a
satisfactory immigration status.
18 NYCRR 360-2.3, 360-3.2(j) and Section 369-ee
G82 MA Transition Medicaid to NY State of Health-Recipients in the Five Year Ban
Because of the immigration status of individuals on your Medicaid case, eligibility
for Medicaid coverage for the following individuals must now be determined by
New York's health plan marketplace, NY State of Health:
We will continue Medicaid coverage until . To avoid a break in coverage,
you will need to sign in to your account in NY State of Health between (_ __,
and( _ _~
This decision is based on Section 369-gg of the SSL.
H48 MA Discontinued Medicaid, Individual Revoked Authorization for AVS
We will discontinue Medicaid effective for:
This is because in order to get Medicaid, you and your spouse (it married) must
provide a signed authorization allowing Medicaid to verify your and your spouse's
resources with financial institutions.
This decision is based on 42 U.S.C. 1396w and Section 36-a(2) of the SSL
HHS MA HX Applicant Submission (NYC)
This is to inform you that we will continue Medicaid until _ _ for the following
individuals:
This decision is based on Section 366(1 )(b) of the Social Services Law.
HH9 MA Individual HX Referral
This is to inform you that we will continue Medicaid until (MA coverage "To" date)
for the following individuals:
We have forwarded your information to New York's health benefit exchange, New
York State of Health.
This decision is based on Section 366(1 )(b) of the SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-25
02/21/2016

MA INDIVIDUAL REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 341) ICONT'Dl

RECEIPT OF MULTIPLE OR CONCURRENT ASSISTANCE
CODE CATEGORY REASON
F66* All Currently in Receipt of Assistance Within Same District
We will discontinue Medical Assistance/Family Health Plus effective_. This is
because you are already receiving Medical Assistance/Family Health Plus under
another case.
18 NYCRR 360-3.3 and Sections 369-ee and 366(1)(a)(11) Social Service Law
MOS MA Disconti.nue MA, Concurrent Benefits, Individual with Coverage on HX
We will discontinue Medicaid/Family Planning Benefit Program effective _ _
for:
This is because we believe you are already receiving Medicaid.
Regulation 18 NYCRR 351.9 and Section 366(1)(b) of the SSL
M98* All Concurrent Benefits - Intrastate (Within State)
We will discontinue Medical Assistance/Family Health Plus effective:_. This is
because your identity matches that of a person who is already receiving Medical
Assistance. When the identity of an applicant or recipient matches that. of a
person who is already receiving Medical Assistance, that person is not eligible for
additional Medical Assistance/FHP.
18 NYCRR 351.9
N66 All Concurrent Benefits Interstate (Between States) PARIS Match
We will discontinue Medical Assistance/Family Health Plus effective _,for:_.
This is because your identify matches that of a person who is already receiving
Medical Assistance/FHP in_. When the identity of an applicant or recipient
matches that of a person who is already receiving Medical Assistance, that person
is not eligible for additional Medical Assistance/FHP.
1BNYCRR 351.9 and Section 369-ee of Social Service Law

*Adequate

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-26
02/21/2016

MA INDIVIDUAL REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 341\ !CONT'D!

LIVING ARRANGEMENTS
CODE CATEGORY REASON
EF2 All MA/FHP Disc Medicare Savings Program of Inmate of NYS or Local Correctional
Facility
We will discontinue Medical Assistance payment of the Medicare Par:t B premium
effective_ _ .
This decision is based on Social Service Law 367-a(3)(d)(1)
EF3 All Disc MA Payment of Health Insurance Premiums
The Medical Assistance program will discontinue paying for your health insurance
premiums effective_ _ .
Regulation 18 NYCRR 360-3.4(a)(2) and Sections 366(1)(c) and (d) of the SSL.
EF4 All Suspend MA Coverage for 21-64 Year Old Admitted to a Psychiatric Center (NYC)
We will suspend Medicaid/Family Health Plus/family Health Plus Premium
Assistance Program/Family Planning Benefit Program coverage effective_ _for:
Regulation 18 NYC RR 360-3.4(a)(2) and Sections 366(1 )(c) and (d) of the SSL.
EFS All Disc MSP for an Individual Admitted to Psychiatric Center (NYC)
We will discontinue Medicaid payment of the Medicare part B premium
effective_ _for: This is because it is not cost effective.
Section 367-a of the Social Service Law
E72' All Institutionalized
We will discontinue Medical Assistance/Family Health Plus effective_for:_.
This is because you are in a public institution which provides medical care for you.
18 NYC RR 360-3.4 and Section 369-ee of the Social Service Law
E73 All Child Entering Foster Care
We will discontinue Medical Assistance/Family Health Plus effective_ for:_.
This because the individual will receive Medical Assistance through the Foster
Care Program
18 NYCRR 360-2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-27
02/21/2016

MA INDIVIDUAL REASON CODES !CONT'DI

CLOSING CODES - MA !MA: REAS - 3411 !CONT'D!

LIVING ARRANGEMENTS
CODE CATEGORY REASON
F60 All Left Household
We will discontinue Medical Assistance/Family Health Plus effective_for:_.
This is because client left the household.
18 NYCRR 360-2.6 and Sections 366(1)(a)(11) and 369-ee of Social Service Law
F63 All In Prison
We will suspend Medical Assistance/Family Health Plus effective . This is
because you are an inmate in a NYS or local correctional facility. Although
Medical Assistance cannot pay for medical care, services or supplies you receive
while you are physically residing in a correctional facility, your Medical Assistance
case is NOT being closed.
If we are also paying your Medicare Part A and/or Part B premium, we will
discontinue payment of this premium.
NYCRR 360-3.4(a)(1) and Section 366(1-a) of SSL
F64 All In Prison outside of NYS (valid 4/1/08)
We will discontinue Medical Assistance/Family Health Plus effective Date. This is
because you are an inmate of a correctional facility outside of New York State or a
federal penitentiary within New York State.
NYCRR18 360-3.4 and Sections 366 (1-a) and 369-ee of SSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-28
02/19/2017

MA INDIVIDUAL REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 3411 !CONT'D!

OTHER
CODE CATEGORY REASON
424 FPBP FPBP Truncation
This code allows MA coverage to be truncated on any of the following extension
codes: 718, 719, 416, and 417.
DOD MA Deceased
(This code operates the same as E95 and G39 but will a have clocking down
period)
E90* All Client Requested Removal from Case NYC
We will discontinue your Medicaid/Family Planning Benefit Program
effective for:
This is because you asked us to close your Medicaid/Family Planning Benefit
Program case.
This decision is based on Sections 366(1 )(b){6) and 366-a(5)(a) of the SSL.
E95* All Died
We will discontinue your Medical Assistance/Family effective_ _ . This is
because the client died.
MA: 360-2.6
H14 All Failure to Provide Proof of U.S. Citizenship and Identity - SSA/BVI Match
We will discontinue Medicaid/Family Planning Benefit Program effective _ _for:
You said you were a U.S citizen/national; however, we were unable to verify that
this is true. You failed to respond to a request tci provide documentation that you a
U.S. citizen/national. The Medicaid program requires proof of identity and US.
citizenship or satisfactory immigration status. You failed to provide proof of your
identity and U.S. citizenship.
If you have submitted all of the required documentation, please call the Unit's
office number listed in the box above to make sure they have been received and
processed. This decision is based on Sections 122, 366-a(2) and (5) of the
SSL.
H49 All Agency Affirmed/Defaults/Withdrawals Fair Hearing Actions
Code allowed to be used ONLY by Fair Hearings Centers 527, 546. 567 and 588.
(For Fair Hearings ONLY, Notice Not Required)
Y02 MA Special Immigrant Visa Closing - Used for Iraqi and Afghan Immigrants ACl=R
Manual Notice Required
We are sending you this notice to tell you that the Medical Assistance Program will
discontinue your public health insurance coverage effective_ _ . You have
reached the end of your initial period of Medicaid eligibility as an Afghan or Iraqi
Special Immigrant.
Section 525 of Title Vof Division G of Public Law 110-181 and Section 1244(g) of the
National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181 and
Section 1059 of the National Defense Authorization Act of 2006, Public Law 109-163
Y98 All Other - Manual Notice Required (MA Extension)
This code is to be used if none of the other reasons for closing an individual are
applicable.
MA: 360-2.2
Y99 All Other - Manual Notice Required
Close individual for which there is not other· appropriate reason code. No notice is
generated by the system. Workers must manually complete the notice.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-29
02/15/2014

This decision is based on Department Regulation(s)

*Adequate

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-30
02/15/2014

MA INDIVIDUAL REASON CODES !CONT'D)

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-31
10/17/2015

MA INDIVIDUAL REASON CODES !CONT'D)

SANCTION CODES - MA !MA: REAS - 3411

FAILURE TO PROVIDENALIDATE SSN
CODE CATEGORY REASON
E21 MA Failure to Provide Child's SSN
We will discontinue Medical Assistance effective . This is because the
· client failed to provide a Social Security card for each child on the case.
MA: 360-2.6
F17 All · Incorrect/Fraudulent Social Security Number (HH = 1)
We will discontinue Medical Assistance/Family Health Plus effective
___ . This is because each person receiving Medical Assistance
should have given the agency their correct Social security number.
We determined that you did not give us your correct Social Security
number.
Regulation 18 NYCRR 360-2.3 (A)
F20 All Failure to Provide SSN
We will discontinue Medical Assistance effective _ _ . This is because the client
failed to provide a SSA card, or apply for a SSA card.
MA: 360-2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-32
2/14/2015

MA INDIVIDUAL REASON CODES !CONT'D\

SANCTION CODES - MA !MA: REAS - 3411 !CONT'D\

OTHER FAILURES
CODE CATEGORY REASON
F40 All Failure to Enroll in Group Health Plan
We will discontinue Medical Assistance effective . Medical Assistance has
been discontinued because the client failed to sign up for and use group health
insurance benefits.
MA: 360-2.2
F84 All Failure to Sign Lien
We will discontinue Medical Assistance effective- - -. This is because the
client refused to sign a property lien agreement.
MA: 360-2.6
F12 All Failure to Apply For SSI
We will discontinue Medical Assistance effective . This is because the
client failed to apply for, or complete an application for SSI.
MA: 360-2.6
H04 SNCA/SNNC Failure to Comply with Office of Child Support Enforcement
Language-TBD

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-33
02/15/2014
DATA INPUT FORM-DSS 3477 (SCREEN WMPPIN)
MA RESTRICTION/EXCEPTION RECORD
SOURCE CODES !SYSTEM-GENERATED!
G System Generated Code
E User Entered Record
MA RESTRICTED/EXCEPTION
STATUS FLAG CODES !SYSTEM-GENERATED!
1 Active 2 Inactive
PRINCIPAL PROVIDER CATEGORY
00 No Principal Provider
01 Private Skilled Nursing
02 Private Intermediate Care
03 Public Skilled Nursing
04 Public Intermediate Care
05 OMRD Developmental
06 OMH Psychiatric Center
07 Acute Hospital -Long Term Care
08 Hospital -Excess
09 Hospital Catastrophic
10 Child Care Facility
12 OMR Small Residential Unit (SRU)
14 Personal Care Services
16 Assisted Living Program (ALP)
DL Delete
PAYMENT EXCEPTION TYPE CODES IPA. MAI
1 Per Diem Payments To. Provider Not Allowed
2 Per Diem Payments to Provider Allowed
3 Payment for Alternate Care Not Allowed
PREPAID CAPITATION PLAN SUBSYSTEM CODES
Benefits Package - User Entered in Concert with Provider ID and County Code#
Prepaid Capitation Plan Capitation Code
3 Individual Enrollee
0 End of capitation

ENROLLMENT REASON CODES

01 Enrollment Override
02 Voluntary Enrollment (all input methods)
05 Mandatory Enrollment via Auto Assign
07 Automated Enrollment of a Newborn
08 HX to WMS Enrollment (Online Only using Worker ID HXTWM. User ID restricted) ·
09 One-Step Enrollment (NYS Only)

DIS-ENROLLMENT REASON CODES

59 Lost FHP Eligibility
65 Plan Termination
66 Retro Active Disenrollment (plan must void claims subsequentto disenrollment date)
85 Death
86 Client Request
93 Client or LDSS Initiated/Excluded or Exempt
95 Lost Medicaid Eligibility-Automated Re-Enrollment within 90 days
97 Moved Out of Plan's Service Area

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-34
06/21/2015

DATA INPUT FORM - DSS 3477 (SCREEN WMPPIN) (CONT'D)

PREPAID CAPITATION PLAN PROVIDER ID

PID PROVIDER ID

*PROVIDERS VALID FOR NYC

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-35
10/23/2016

RESTRICTION/EXCEPTION DATA INPUT FORM - DSS 3478

MA RESTRICTION/EXCEPTION TYPE CODES

02 Podiatry
03 Dental
05 Pharmacy
06 Physician
08 Clinic
09 In-Patient Hospital
10 Dental
11 Physician Group
12 Physicia.n Assistant/Nurse Practitioner
13 Alternative Pharmacy
23 OMH Child Waiver-Home and Community Based Services (HCBS)
25 OMR-Sub-Chapter Exception
30 HHCP Long Term Home Health Care Program
31 Community Alternative System Agency (CASA) Community Based {Disabled as of 6/18/07)
32 CASA Individual in SNF/HRF (Disabled as of 6/18/07)
35 Case Management
38 UT Exempt
39 Aid Continuing
40 SNF-Expense Level (Disabled as of 6/18/07)
41 ICF-DD Expense Level (Disabled as of6/18/07)
42 Hospital/SNF Expense Level (Disabled as of 6/18/07)
43 Hospital/I CF-DD Expense Level (Disabled as of 6/18/07)
44 HCBS Non Intensive
45 HCBS Intensive AHRH
46 OMR Home and Community Based Services (HCBS) Enrolled
47 Supervised CRs
48 Supportive IRAs and CRs
49 Supportive IRAs
50 Parental CONNECT (WMS Coverage Code 15)
51 Medicaid Eligible (WMS Coverage Code 01 or 30) Plus CONNECT
53 · HR Underserved
54 Exempt from HR Restrictions (System Generated, Output only)
55 MCC Pharmacy
56 MCC Physician
58 MCC Clinic
59 MCC Hospital
60 Nursing Home Transition & Diversion Medicaid Waiver
62 Care at Home (CSH I)
63 CAH II
64 CAH Ill
65 CAH IV
66 CAHV
67 CAH VI
68 CAHVll
69 CAH VIII

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.2-36
10/23/2016

RESTRICTION/EXCEPTION DATA INPUT FORM - DSS 3478 (CONT'D)

MA RESTRICTION/EXCEPTION TYPE CODES !CONT'D\

70 CAH IX
71 CAH X
72 Bridges to Health Seriously Emotionally Disturbed (B2H SED) ·
73 Bridges to Health Developmentally Disabled (B2H DD)
74 Bridges to Health Medically Fragile (B2H MedF)
81 (TBI) Traumatic Brain Injury
82 Cash and Counseling (Project in Progress)
83 Alcohol and Substance Abuse ASA (Project in Progress)
84 Base/Community Rehabilitation & Support (CRS) with Clinical Treatment
8S Base/Community Rehabilitation & Support (CRS) without Clinical Treatment
86 Intensive Rehabilitation and Ongoing Rehabilitation Services (IR/OR)
90 Managed Care Excluded
91 Managed Care Exempt
92 DOH Exempt
93 MLTC Eligible
94 OMH Exempt
9S OMRDD Waivered Services Look Alikes
96 (SPM) Seriously and Persistently Mentally Ill Adults and (SED) Seriously Emotionally Disturbed
Children
B7 Not Qualified to Enroll in BHP
G1 Transgender Individual Male to Female
G2 Transgender Individual Female to Male
H1 HARP Enrolled without HCBS Eligibility
H2 HARP Enrolled with Tier 1 HCBS Eligibility
H3 HARP Enrolled with Tier 2 HCBS Eligibility
H4 HIV SNP HARP- Eligible without HCBS Eligibility
HS HIV SNP HARP - Eligible with Tier 1 HCBS Eligibility
H6 HIV SNP HARP - Eligible with Tier 2 HCBS Eligibility
H7 Opted out of HARP
H8 State Identified for HARP Assessment
H9 HARP Eligible Pending Enrollment
N1 Regular SNF Rate - MC Enrollee
N2 SNF AIDS - MC Enrollee
N3 SNF Neuro-Behavioral - MC Enrollee
N4 SNF Traumatic Brain Injury - MC Enrollee ·
NS SNF Ventilator Dependent - MC Enrollee
N6 MLTC Enrollee placed in SNF/Partial Cap 21+ Nursing Home Certifiable
N7 NH Budgeting Approved
S1 Surplus Client not Eligible for Medicaid Managed Care or Medicaid Advantage Enrollment

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-1
11 /24/2003 .

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585)

VERSION NUMBER IVERSIONl

SYSTEM GENERATED. Indicates the number of the budget currently stored on the database for the case
number entered. If no budget has previously been stored, this field will be blank.

BUDGET TYPE (BUDGET TYPEl

REQUIRED ENTRY. Enter the appropriate code to identify the type of budget to be calculated

Code Definitions Effective Code Definitions Prior to

November, 1997 per Welfare Reform November 1997

01 LIF-Related 01 ADC -Related

02 $/CC-Related 02 HR-Related
04 SSI - Related, (AB/AD/OAA) 05 SSl-Related, ADC Related
05 SSI - Related, (AB/AD/OAA) 06 SSl-Related, (AB/AD/OAA)
LIF - Related HR-Related
06 SSI - Related, (AB/AD/OAA) 09 Chronic Care, ADC-Related
S/CC - Related 10 Chronic Care, HR-Related
07 Chronic Care
08 Chronic Care, SSl-Related,
(AB/AD/OAA)

CASE NAME !CASE NAME!

Enter the Case Name (up to 25 Characters) as determined by local district procedures.

CASE NUMBER !CASE NUMBER!

SYSTEM GENERATED from information entered on MA Budget Calculations screen (WBMAMU)

OFFICE IOFCl
Enter appropriate office ID.

UNIT AND/OR WORKER !UNIT IDl

ENTRY ALWAYS REQUIRED. Enter Unit ID and/or worker ID as determined by local procedures.

TRANSACTION TYPE ITRANl

ENTRY ALWAYS REQUIRED. Enter appropriate transaction type:

(02) Opening
(03) Reject (output only)
(05) Change
(07) Closing (output only)
(10) Reopening

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-2
02/24/2015

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

EFFECTIVE PERIOD !EFFECTIVE PER!

ENTRY ALWAYS REQUIRED. Enter the effective FROM and TO dates to be covered by this calculated
entry budget (MM/DD/YY) to (MM/DD/YY). The maximum allowable Effective Period is 12 months.
WITH THE EXCEPTION OF BUDGET TYPES 08-10 WITH BUDGET EFFECTIVE FROM DATES OF
10/1/89 OR LATER, BUDGETS SPANNING DATES IN WHICH MA LEVELS, TAX TABLE AMOUNTS
AND ALLOWANCE CHANGES OCCUR CAN BE CALCULATED. SUCH BUDGETS WILL BE BASED
ON THOSE FIGURES IN EFFECT ON THE EFFECTIVE "FROM" DATES OF THE CALCULATED
BUDGETS.

MONTHS EXCESS IS AVAILABLE IMO!

An entry here will calculate the amount of the excess income for the number of months entered.
Acceptable values range from 2 to 6. This field is only used for BT 01, 04 05 and 06.

NUMBER IN CASE ICAl

ENTRY ALWAYS REQUIRED. Enter the number of individuals in budgeting unit (except unborns). If
case includes only unborn (s), enter Zero.

EXPANDED ELIGIBILITY CODE !EEC!

An entry in this field indicated that the calculated budget is based on a percentage of the Federal Poverty
Level (FPL) The exact percentage utilized is determined by the code. ·
These codes are as follows:

A AIDS Insurance. Compares net income to 185% of the Federal Poverty Level. (BT 04 Only)
E Disabled Adult Children (DAC)
H COBRA Insurance. Compares net income to 100% of the Federal Poverty Level (BT 04 Only).
M MAGI - Medicaid/Family Planning Benefits Program
Income eligibility is at or below:
223% (Pregnant Women), 223% {Infants), 154% (Child 1-5)
110% (Child 6-18), 154% (Child 6-18), 138% (Parents/Caretaker relatives)
138% (19 & 20 yr olds living w/parents), 155% (19 & 20 yr olds living w/parents)
100% (Singles/CC and 19 & 20 yrs living alone), 138% (Singles/CC and 19 & 20 yr living alone),
223% (Family Planning Program) of the Federal Poverty Level (BT 01 Only).
T Transitional Medical Assistance. Compares the adjusted gross earned income to 185% of the
Federal Poverty Level {BT 01 Only)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-3
06/16/2013

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

EXPECTED DATE OF CONFINEMENT CEDC 11

Enter the expected Date of Confinement when there is an unborn (s) in the case. The budget summary screen
will generate $50, when appropriate, when computing the PA standard of need. The amount of the MA level will
be increased by one.
EXPECTED DATE OF CONFINEMENT !EDC 21
If there are two pregnant individuals EDC2 field is used for the second person.
AGE INDICATOR !All
Enter appropriate indicator:
N Less than 60 years of age
Y Equal to or greater than 60 yrs of age
FUEL TYPE !FUEL TYi
Enter appropriate Fuel Type as follows:
0 H~at included in shelter costs
1 Natural Gas
2 Oil
3 Electric
4 Coal
5 Other
SHELTER TYPE (SHELTER TY!
Shelter Type and amount are required fields for Budget Types 01, 02, 05, 06, 07, 09 and 10. Enter the
appropriate Shelter Type Code as follows:
01 Rent
02 Rent Public
03 Own Home
04 Room & Board
05 Hotel Permanent
06 Hotel Temporary
11 Room Only
12 Non-Level 11 Alcohol Treatment Facility
15 Congregate Care Level 1 - NYC, Nassau, Suffolk, Westchester
16 Congregate Care Level 11- NYC, Nassau, Suffolk, Westchester
20 Emergency Assistance Rehousing Program
22 Shelter for Victims of Domestic Violence
23 Undomiciled
28 Congregate Care Level 1 - Upstate
29 Congregate Care Level 11- Upstate
33 Homeless Shelter Tier 11 Less than three meals/day
34 Homeless Shelter Tier 11-Three meals per day (U)
35 Homeless Shelter -Non Tier 1 or Tier 11 (Additional Allowance Codes 01, 02, 03 and 13 are not allowed)
36 Shelter for Homeless - Less than three meals/day
37 Residential Program for Victims of Domestic Violence- Less than three meals/day.
42 Congregate Care Level Ill - Adult Homes and DOH Enriched Housing.
44 Supportive/Specialized Housing - Aids Related.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-4
06/18/2012

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585)

SHELTER TYPE !SHELTER TYi !CONT'D

54 Housing Disregard (MLTC) - Northern Counties Upstate
55 Housing Disregard (MLTC) - Central Counties Upstate
56 Housing Disregard (MLTC) - Rochester Counties Upstate
57 Housing Disregard (MLTC) - Western Counties Upstate
58 Housing Disregard (MLTC) - Northern Metropolitan Counties Upstate
59 Housing Disregard (MLTC) - NYC (Bronx, Brooklyn, Manhattan, Queens and Staten Island)
60 Housing Disregard (MLTC) - Long Island
63 Congregate Care Level Ill - Housing Disregard (MLTC)

NOTE: When there is a "T" in the EEC field no entry is permitted in Shelter Type field.

SHELTER AMOUNT !AMOUNT\

Enter the total actual monthly amount paid for shelter. If there is no shelter cost, enter zero.

NOTE: This field may be left blank only when BT is 04, 07 and 08 and the "SHELTER" field is blank or
when the Shelter Type Code is 15, 16, 23, 28, 29, 33 or 34. In all other situations if Shelter amount is
Zero, a 0 must be input in the amount field.

WATER AMOUNT !WATER AMOUNT\

If Water is a separate item of need and the Shelter Type is coded (01) Rent, or (03) Own Home, Enter
the actual Water cost.

ADDITIONAL ALLOWANCES TYPE (ADD TYi

Enter the appropriate Additional Allowance Type Code as follows:

01 Dinner
02 Lunch and Dinner
03 Breakfast, Lunch and Dinner
13 Home Delivered Meals
19, Additional Community Maintenance Allowance (Budget Types 08, 09 and
10 only) With From date 10/1 /89 or later
20 Transitional Child Care
21 Maintenance Allowance for Dependent Members of Institutionalized individual's former
household (BT 8, 9 & 10 only)
22 Family Member Allowance (added to MMMNA) ST'S 08-10
25 Home Attendant Line Operating System (HALO); not used in budget calculation
26 Medical Bill Total/ LS
99 Other (Occupational Child Care)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-5
06/18/2012

·MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

ADDITIONAL ALLOWANCE AMOUNT CAMOUNTl

Enter the monthly amount of the Additional Allowance, based on the allowance type code used, as
follows:

01 2900 Per Person

02 4700 Per Person
03 6400 Per Person
13 3600 Per Person

For Codes 01, 02 and 03 add $36.00 to above amounts for Pregnant Women aand children.

If the case is entitled to an Additional Allowance as indicated by one of the above codes, multiply the
amount by the number of persons in the CA field before entry.

DEEMING CODE CSSI DEEM!

Enter the appropriate code that will indicate to the system the deeming procedure to use in budgeting.
This is a required field for BT 04 (i.e. SSI Related).
1 Deem to SSI -Related spouse
2 Deem to SSl-Related Child (ren)
3 Deem to SSl-Related spouse and child (ren)
4 No deeming

LIVING ARRANGEMENT CSSI LAl

Use of this code indicates to the system the current MA Level, Federal Benefit Rate level to use during
certain phases of the SSI budgeting process. An entry is required for BT'S 04 -10.

1 Single Person
2 Couple

NUMBER OF SSl-RELATED CHILDREN TO DEEM CNO OM!

Enter the number of SSl-related children (under 18 years old) in the case to whom income and
resources are to be deemed. This field is used for BT'S 04-06. (Maximum number that can be entered is
4). Leave blank if not applicable.

NUMBER OF NON-SSI RELATED CHILDREN TO ALLOCATE CNO-ALLl

Enter the number of Non SS I-related children (under 18 years old) to whom income must be allocated
before income is deemed to the SS I-related individual (s). This field is used for BT'S 05, 06, 09 and 10.
(Maximum number that can be entered is 9). Leave blank if not applicable.

MEDICARE SAVINGS PROGRAM CMSPl

Enter correct code to generate calculation of Buy-In Determination. Valid for BT'S 04-10 only.
A Entry of A allows all Buy-In Determination calculation outcomes in MABEL for QMB, SLIMS, and
011, eligible budgets 04, 05, and 07.

DATE OF INSTITUTIONALIZATION IDT INS!

Enter the date the person became institutionalized.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-6
03/19/2001

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

PERSONAL INCIDENTAL ALLOWANCE !PIA!

Enter the appropriate code to indicate the amount of the Personal Incidental Allowance to be budgeted.

1 $35.00 for residents of ICF'S

2 $50.00 for residents of other Chronic Care Facilities
Note: Above amounts effective 07/01/88.
3 Home and community Based Waivered Services (System generated ... Entry of PIA code 3 on the
Budget Record Screen will cause the system to use the MA level in the PIA field once Chronic
care budgeting begins).
4 Maximum of $90.00 Reduced pension for Veterans in Nursing facilities.

SPOUSAL CONTRIBUTION CODE ICON!

Enter the appropriate code to indicate the spouse's contribution to the cost of care. There is a required
field for BT'S 08-10. Contribution codes are as follows:

1. Contributing the amount required by regulation

2. Contributing more than the amount required by regulation
3. Contributing less than the amount required by regulation adjudicated
4. Contributing less than amount required by regulation - not adjudicated
5. Refuses to contribute

SPOUSAL CONTRIBUTION AMOUNT !AMOUNT\

If the Spousal contribution code is 2, 3, or 4 the amount that the spouse is contributing is to be entered.
If the code is used the amount is system calculated/generated.

LOCAL CODE !LOCI

Not applicable in New York City. Leave Blank.

INCOME AVERAGE INDICATOR !EARNED INCOME Al

A "Y" in this field on the Budget Record Screen indicates that income source gross amount & related
deduction information appearing on screen has been system generated as a result of income averaging.

LINE NUMBER ILNl

Enter the line number of person with the income for each occurrence of earned income.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-7
10/22/2012

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

CATEGORICAL INDICATORS CODE ICTGl - !EARNED INCOME OR RESOURCES!

Enter the appropriate code, which indicates the categorical relatedness of the individual in receipt of the
income.
If there is earned income, an entry in this field is required for BT'S 04-06 only.
1 SSI - Related Adult - Aged
2 SSI- Related Adult - Blind
3 SSI- Related Adult - Disabled
4 Non-SSI Related Adult (LIF - Related)
5 Non-SSI Related Adult (S/CC - Related)
6 SSl-Related Child - Blind
7 SSl-Related Child - Disabled
8 Non-SSI Related Child

CHILD IDENTIFIER !Nl

If a child in the budgeting unit has income, enter a number for the child whose income is being recorded.
SSI - related children can be assigned a value of 1- 4. Non-SS I related Children can be assigned a value
of 1 - 9.

CHRONIC CARE INDICATOR Cl!

If earned income is received by a person in chronic care, enter "X" (May be used only for BT's 07-10)

EARNED INCOME DISREGARD !EID!

If there is earned income, enter one of the following codes:

1 Calculate LIF (Undercare)

4 Calculate LIF/ADC - $30 & 1/3
5 Calculate LIF/ADC - $30
6 Calculate LIF/ADC (Applicant only)

EARNED INCOME SOURCE ISRCl

Enter the appropriate code for the source of the earned income as follows:
01 Salaries, Wages (Employer Provided Sick pay)
05 Commission Income
06 Other Earnings
08 Severance pay
09 Family Day Care Provider Income
11 Income-In Kind Shelter
12 Lump Sum Payment
13 Lump Sum Payment Received by Current Wage Earner

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-8
10/19/2009

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

EARNED INCOME SOURCE ISRCI !CONT'D

20 Net Business Income
40 Earnings from Job Training Partnership Act
44 Office of Vocational Rehabilitation
45 Income from a Boarder/Lodger
46 Net Income from Rental of House, Store or other property
48 Income from a Roomer

EARNED INCOME PERIOD !PERI

Enter the appropriate period code for the income amount to be entered. When income averaging is
used, "6'' will be generated in this field.

3 Weekly 7 Bi Monthly
4 Bi -Weekly 8 Quarterly
5 Semi Monthly 9 Yearly
6 Monthly

TIME INDICATOR !Tl

Enter the appropriate code. Codes are as follows:

F Employed Full Time and Part Time

N Employed in second job (same person) not entitled to Work Deductions

THE FOLLOWING INCOME ENTRIES MUST BE WITHIN THE TIME FRAME INDICATED BY THE PERIOD
CODE.

GROSS INCOME !GROSSI

Enter the individual's average Gross Amount of Earned Income for the period indicated by the Period
Code.

HEALTH INSURANCE !INSURI

Enter the Health Insurance costs paid for the period indicated by the period code ·
(Not valid entries for BT 02).

COURT ORDERED SUPPORT PAYMENTS ICT-SUPI

If appropriate, enter the monthly amount

WORK- RELATED EXPENSES IWK-RELl

Expense disregard allowed for blind individuals (CTG 2 or 6) during SS I-related budgeting (BT'S 04-10)

IMPAIRMENT-RELATED WORK EXPENSE !IRWEI

Enter the monthly amount of impairment related work expense. Entry is allowed only when an individual
has a categorical indicator code of 3 (Disabled) or 7 (SSl-Related Child Disabled).

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-9
10/19/2009

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

CHILD CARE !CH-CR!

Enter the Childcare costs for the period indicated by the Period code. For BT 04, enter the total childcare
expense in the first CHLO-CR occurrence. For the other budget types, enter the actual cost of child care
paid per child.

CHILD'S MONTH AND YEAR OF BIRTH !MO/YR!

Enter the month and year child was born.
Enter the appropriate information for the second earned income as defined above.

UNEARNED INCOME LINE NUMBER !UNEARNED INCOME LNl

Allows for entry of 6 unearned incomes. Enter the line number of person with unearned income for each
occurrence of unearned income.

CTG CATEGORICAL INDICATOR !Cl

Enter the appropriate code, which indicates the categorical relatedness of the individual in receipt of the
income as follows:

1 SSl-Related Adult - Aged

2 SSl-Related Adult - Blind
3 SSI Related Adult - Disabled
4 Non SSI Related Adult LIF/ADC
5 Non-SSI Related Adult S/CC
6 SSl-Related Child - Blind
7 SSl-Related Child - Disabled
8 Non-SSI Related Child

CHILD IDENTIFIER !Nl

Enter a number for the child whose income is being recorded. Acceptable values are 1-9.
SSI -related children can be assigned a value of 1-4. LIF/ADC-Related Children can be assigned a value
of 1 - 9.

CHRONIC CARE INDICATOR Ill

Enter "X", if applicable, to indicate the unearned income is received by a person in Chronic Care.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-10
10/23/2016

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

UNEARNED INCOME SOURCE !SR\

Enter the appropriate unearned income source code as follows:

01 Adoption Subsidy
02 Alimony/Spousal Support
03 Any Dividends, Interest, or Periodic Receipts from Stocks, Bonds, Mortgages, Bank
Interest, Trust Funds, Annuities, Credit Union, Estates, etc.
06 Child Support Payment
07 Disabled Veterans Benefits (Non-Service Connected)
10 GI-Dependency Allotment
11 Disabled Veterans Benefits (Service Connected)
16 Gross Rental Income from Owned Home
18 Income from Friends or Non-Legally Responsible Relatives (received on a
recurring basis)
19 Income from Friends or Non-Legally Responsible Relatives outside the household
(received on a recurring basis)
26 Lump Sum Payments (Budget types 01,02, 04, 05 and 06)
28 German or Austrian Reparation Payments (LIF, S/CC & Chronic Care budgeting, Not
allowed with Categorical Indicator Codes 6, 7, & 8)
30 Income from Job Training ~artnership Act (Formerly CETA)
31 Net Income from Rental of House, Store, or other Property
32 Net Royalties
33 NYS Disability Insurance
35 Railroad Retirement Benefit - Dependent
38 Railroad Retirement Benefit
39 Retirement Benefits (Pensions)
41 Sick Pay (Private Insurance)
42 Social Security Disability Benefit
43 Social Security Survivor's Benefit
44 Social Security Retirement Benefit
46 Social Security Benefit-Dependent
47 Social Security Benefit - DAC
48 Social Security Benefit - Pickle
49 Unemployment Insurance Benefit
50 Union Benefits
51 OVR (Office of Vocational Rehabilitation) Training allowance
55 Veterans Pension or Benefit
59 Worker's Compensation
60 Income-In - Kind Provided by LRR-Shelter (MA Only) (Budget types 01, 02, 05 and 06)
64 Income-In - Kind Provided by LRR-Meals (MA Only) (Budget types 01, 02, 04, 05 and 06)
70 Other Income - In- Kind
75 Deemed Income from a Stepparent
82 Contribution from a stepparent
99 Other

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-11
10/19/2009

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

PERIOD !Pl
Enter the appropriate Period Code as follows:
3 Weekly 7 Bi-Monthly
4 Bi-Weekly 8 Quarterly
5 Semi-Monthly 9 Yearly
6 Monthly

UNEARNED INCOME AMOUNT !AMOUNT!

Enter the gross amount of the Unearned Income for the period indicated.

UNEARNED INCOME EXEMPTION CODE !CD!

Enter the appropriate unearned income exemption code. Up to 2 exemptions can be entered for each
unearned income source.

01 Health Insurance Premium

02 .Court Ordered Support (See Appendix)
06 20% RSDI
11 One-Third SSI Child Support
12 Cost of Living RSDI
14 VA Aid and Attendance/Housebound Allowance (BTS 04-10 only)
15 Social Security Benefit (DAC)
16 VA Limited Pension
17 VA Unusual Medical Expense (UME)
20 other Amounts Limited by Designated use
21 Medicare

EXEMPTION AMOUNT !EXEMPT!

Enter the amount (s) to be exempted from the monthly gross unearned income. Amount(s) should be for
the same period as the unearned income. When Code 11 (One-Third Child Support) is used for an SSI
related child (ren), this field is left blank. The system will calculate the correct one-third-exemption
amount.

RESOURCES!RESOURCESl
Allows for entry for six resources

LINE NUMBER !LNl

Enter the line number of person with the resource for each occurrence.

CTG CATEGORICAL INDICATOR CODE !Cl - !UNEARNED INCOME!

Enter the appropriate code which indicates the categorical relatedness of the individual who owns the
resource. This field is used for BT'S 04-10 only.
1 SSI - Related Adult - Aged
2 SSI - Related Adult - Blind
3 SSI - Related Adult - Disabled
4 Non - SSI Related Adult (LIF Related)
5 Non - SSI Related Adult (S/CC Related)
6 SSI - Related Child - Blind
7 SSI -.Related Child - Disabled
8 Non - SSI Related Child

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
4.3-12
02/21/2016

MABEL BUDGET RECORD (WBM AWB) - MABEL INPUT FORM (DSS 3585) (CONT'D)

SSI RELATED CHILD INDICATOR !Nl

Enter a number to identify the SSI related child. Acceptable values are 1-4. If the child has income, use
the same number <;is assigned for earned or unearned income. This field is for BT 04

CHRONIC CARE INDICATOR !II

Enter the "X", if appropriate, to indicate the resource is owned by a person in Chronic Care.

RESOURCE CODE !CD!

Enter the appropriate code as below:

01 Cash on Hand
02 Bank Accounts
03 Stocks, Bonds, Securities
04 Promissory Notes
05 Mortgages, Conditional Sales Contracts
06 Trust Funds
07 PIA Savings Accounts (only for BT's 7-10 when Chronic Care Indicator is "X")
08 Lump Sum Payment (includes tax refunds, insurance settlements, Inheritances, etc).
10 German Reparation Payments
22 Equity Value of Automobile
42 Straight Life - Countable cash value
43 Endowment Insurance
44 Exempt Cash Value of Life Insurance for SSl-Related Budgeting
45 Burial Reserve to be disregarded for SSI budgeting
86 Retirement Accounts
98 Other Liquid Resources

RESOURCE VALUE IS-VAL!

Enter the value of each available resource that is not exempt.

After the screen has been completed with all field entries move the cursor to the XMT position. Depress
XMT key. If the Budget Record Screen is error-free, a MA Budget Summary Screen will result(* see
note). The worker is able to take a print of the budget summary screen pressing the "Prior Case Next"
Key. The worker is also able to obtain a copy of the Budget Record Screen by paging back by
depressing the FCTN and F-2 Key simultaneously and then depressing the "Prior Case Next " Key.

*NOTE: If any errors are made, the fields in error will appear as "blinking fields".

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-1
10/18/2014

CHAPTER 5-
REFERENCE

APPENDIX A - BENEFIT PRODUCTION

RECONCILIATION CODES

CODE VALUE
0 Issued
1 Stop payment (checks only)
2 Cancelled
3 Redeemed - no error
4 Unmatched redemption
5 Unmatched stop payment
6 Unmatched cancellation
7 Redeemed in error/Partial redemption
8 Redeemed against stop payment (checks)
9 Redeemed against cancellation without error
A Redeemed in error against cancellation
B Duplicate issue
c Duplicate cancellation
D Duplicate redemption
E Expunged
I Illegal cancellation
J Benefits issued through conversion system
p Purged issue
s Requested stale dating/Auto stale dating
T Transacted
x Unidentified redemption transaction
z Vendor refund

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-2
02/14/2015

APPENDIX B - OBSOLETE CASE REASON CODES

OPENING CODES - PA IPA: REAS - 2221

CODES USED UNTIL 12/04/00

CODE CATEGORY REASON

012 ADC Illness, injury or other impairment of other ADC grantee

015 ADC/ADCU Lay-off, discharge or other reason of ADC father

016 ADC/ADCU Lay-off, discharge or other reason of ADC mother

017 ADC,ADCU Lay-off, discharge or other reason of other ADC grantee

046 FA/SNFP CAP; this code is used to accept a PA application as a FA case enrolled in the
Child Assistance Program

047 FA/SNFP Transfer from FA to CAP; this code is used to reopen a closed FA case in CAP

048 FA/SNFP Transfer from CAP to FA; This code is used to reopened an FA case that has
been closed by CAP. (This code can be used by all income Support Centers
except 017)

CODES USED UNTIL 02/20/07

CODE CATEGORY REASON

002 ALL Illness, injury, or impairment of recipient.

005 FA/SNFP Lay-off, discharge, or other reason.

SNCA/SNNC

008 ALL Case accepted for Single Issue payments that have been ordered by a Fair
Hearing decision. (MA will remain in AP status.)

009 SNFP/SNCA Case accepted only for emergency shelter arrears and/or emergency utility
SNNC/EAF arrears which applicant agrees to repay.

010 FA/SNFP Illness, injury, or other impairment of FA father.

011 FA/SNFP Illness, injury, or other impairment of FA mother.

020 ALL Loss of or reduction in support of child due to death of parent.

021 FA/SNFP Leaving home by parent and stopping or reducing support for reason of
divorce.

022 ALL Leaving home by parent and stopping or reducing support for reason of
separation.

023 ALL Leaving home by parent and stopping or reducing support for reason of
desertion.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-3
02/14/2015

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D>

OPENING CODES - PA IPA: REAS - 2221 !cont'd!

CODES USED UNTIL 02/20/07 (CONT'D)

CODE CATEGORY REASON

024 ALL Leaving home by parent and stopping or reducing support for reason of other
(hospital, prison).

030 ALL Loss of or reduction of support from person outside the home. (FA father
absent throughout 6 months preceding application.)

033 ALL . Case accepted for immediate needs (pre-investigation), pre-determination

grants and one-shot deals.

035 ALL Loss of or reduction in support from other person in home as a result of death.

036 ALL Loss of or reduction in support from other person in home as a result of
leaving home and stopping or reducing support (hospitalization, etc.).

037 ALL Loss of or reduction in support from other person in home as a result of illness,
injury or other impairment.

038 ALL Loss of or reduction in support from other person in home as a result of lay-off,
discharge, or other reason.

040 ALL Loss of or reduction in support from other person in home as a result of loss of
or reduction in support from person outside home.

045 ALL Loss of or reduction in support from other person in home as a result of loss of
or reduction in other income.

050 ALL Loss of or reduction in support from other person in home as a result of other
material changes.

060 ALL Change in state law or agency policy increases need because of:

064 ALL Eligible as a result of Hurricane Katrina or Hurricane Irene.

065 ALL Return of recipient or relative (ill or previously institutionalized).

066 ALL Closed in error. (Employment Unit approval is needed if case was closed due
to an employment-related reason.)

070 ALL Living below agency standards .

075 .ALL Other.

080 FA/SNFP Transfer from Family Assistance or Safety Net Federal Participation.

081 FA/SNFP Transfer from Safety Net Cash Assistance.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-4
02/14/2015

APPENDIX B • OBSOLETE CASE REASON CODES !CONT'D!

OPENING CODES - PA IPA: REAS • 2221 !cont'd)

CODES USED UNTIL 02/20/07 (CONT'D)

CODE CATEGORY REASON

082 ALL Transfer from Emergency Assistance to Families.

097 ALL Aid Continuing· Case awaiting Fair Hearing decision.

098 ALL Employment Unit approved override with documentation that allows the
opening of CvB or JOB Search closings or sanctions during the infraction
period.

101 ALL To be used to override an IPV sanction and open a case/suffix during the
infraction period. Use of this code is restricted to EPF as the Origination
Center.

114 ALL To be used to override a sanction without deleting prior infraction record.

623 SNCA/SNNC To be used to override a Drug and Alcohol Closing or Rejection Code during
FA/SNFP the infraction period. Removes the last sanction.

CODES USED AFTER 02/20/07

CODE CATEGORY REASON

Y18 ALL Work Advantage One Shot Deal (Discontinued 10/22/12)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-5
02/14/2015

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

OPENING CODES - MA !MA: REAS - 241 I
CODES USED UNTIL 02/20/2012
CODE CATEGORY REASON
018 MA Medical Assistance/Family Planning Benefits Program
For FPBP eligible at or below 200% of FPL. At the case and individual level for
Cat codes 68 or 69 only.
044 MA Parents over 21 and under 65, in an intact family living with child(ren).
(Discontinued 6/18/12)
061 MA RVI Fair Hearing Opening Code in Undercare
063 MPE Transitional opening code for disaster relief to presumptive eligibility.
(Discontinued 6/18/12)
067 FHP "Eligible single/childless couples (can only be used on FHP cases).
MA: 369-ee
068 FHP Parents at the case level (can only be used on FHP cases.)
MA: 369-ee
069 FHP Pregnant women on MA case.
MA: 369-ee
071 MA Pay-In Excess Income
Regulation 360-4.8 (c)
074 Fi-IP Parents and Expanded Eligibility Children
Regulation
075 MA Other
Regulation
076 MPE Presumptive Eligibility
Regulation
077 MA-
SSI Related Blind and disabled individuals who lose eligibility for SSI payments;
as a result of becoming entitled to Title II child's insurance benefits as a disabled
adult child (DAG) or because of an increase in such benefits. Note: MBL budget
type 04 (SSI Related), or 05 (SSl-FA) or 06 (SSI- SNCA) must be used
Regulation 360-3.3 (c)
078 MA Not Eligible for MA- Eligible for Health Insurance Premium Payment Only.
Regulation 360-7.5 (H)

079 MA Household Member Eligible for MA and Eligible for COBRA Health Insurance
Continuation Payments (Discontinued 6/18/12).

083 MA Institutionalized Spouse

Expected to remain in medical institution for 30 consecutive days- Chronic Care
Budgeting used.
Regulation 360.14 (c)
084 MA Inpatient Hospital bills equal to or greater than excess resources combined;
with excess income (if applicable).
Regulation 360-3
085 MA-SSI
Related Medicare Premium, Co-Insurance and Deductible Only. (SLIMB/QMB)
Regulation 360-3.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-6
02/14/2015

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D)

OPENING CODES - MA !MA: REAS - 241! !cont'd!
CODES USED UNTIL 02/20/2012 (CONT'D)
CODE CATEGORY REASON
086 MPE Based on your need for home care services, you have been determined
presumptively eligible for a maximum period of 60 days.
Regulation 360-3

087 MPE Based on your pregnancy, you have been determined presumptivelyeligible for
Medical Assistance for a maximum period of 45 days.
Regulation 360-3

088 All Disabled child/children receiving medical/nursing care at home.

Regulation 360-3

089 FA/SNFP Beginning of extension of eligibility for MA after finding of ineligibility for PA
resulting from loss of 30 + 1/3 or $30 disregard. (Discontinued 6/18/12)

090 FA/SNFP Beginning of four-month extension of eligibility for MA after finding of ineligibility
for FA resulting from employment or receipt of support. (Discontinued 6/18/12)

091 FA/SNFP
SSI Related Medical bills equal to or greater than excess income.
Regulation 360-4.8 (c)

092 MA-SSI SSI recipient not yet appearing on SOX determined eligible for MA-SSI
Regulation 360-3

094 All Medical need - no recent change in financial circumstances

Regulation 360-3
095 All Administrative
Regulation .360-3
096 All Determined MA Eligible using Expanded Eligibility Criteria
Case contains excess resources, excess income or both (096 replaced 039)
Regulation 360-3
506 Qll Qualified Individual
Opening code for Qualified Individuals - 011
169 MPE Presumptive Eligibility for Children (Manual Notice)
Regulation SSL 364-1 (4) (a-e)
467 FHP/PAP Premium Assistance Program-Eligible Single/Childless Couple
MA 369-ee
468 FHP/PAP Premium Assistance Program-Parents at Case Level
MA 369-ee
474 FHP/PAP Premium Assistance Program-Parents and Expanded Eligibility Children
MA 369-ee
670 MBl-DBG Medicaid Buy - In (Disabled Basic Group) Eligible at or below 150%
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law
671 MBl-MI Medicaid Buy - In (Medically Improved) Eligible at or below 250% but greater than
150%
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-7
10/18/2015

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

OPENING CODES - MA !MA: REAS - 241! !cont'd!
CODES USED AFTER 02/20/2012
CODE CATEGORY REASON
856 FHP Transition of MA/FHP Eligibility, (Upstate to NYC)(System Generated)
A Medical Assistance/Family Health Plus case will be opened.
Regulation 18NYCRR Sections 351.2 (g)(1)and 360-4.8 (b) 364-j and 369-ee of SSL
H92 FHP-PAP Premium Assistance Program-Eligible Single/Childless Couple
MA 369-ee

H93 FHP-PAP FHPlus-PAP with Combo Coverage, Parents and Expanded Eligibility Children
18 NYCRR 360-2.2(d)(2), 360-4.7 and 360-4.7 and 360-4.8 and SectionSSL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-8
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

OPENING CODES- SNAP IFS: REAS - 2311

CODE REASON
064 Eligible as a result of Hurricane Katrina or Hurricane Irene.

A32 1st month prorate - applied before the 16th. (Discontinued 10/20/08.)

A33 1st month prorate - applied after the 15th. (Discontinued 10/20/08.)

A36 FS approval - first month denied, eligible in succeeding months.

(Discontinued 10/20/08.)

A39 FS approval - NYSNIP. (Discontinued 10/20/08.)

A40 FS approval - Group Home Standardized Benefit (GHSB). {Discontinued

06/22/09.)

A42 FS approval - NYSNIP: 1st month prorated; applied before the 16th.
(Discontinued 10/20/08.)

A43 Approval - NYSNIP 1st month prorate - applied after the 15th.
(Discontinued 10/20/08.)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-9
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 2221

CODES USED UNTIL 11/21/05

CODE CATEGORY REASON

057 ALL Failure of All Household Members to Apply

109 ALL Diverted from PA by Agency/Contractor Efforts

118 SNCA/SNNC Failed to Comply with the Automated Finger Imaging System (AFIS)
Requirements

119 ALL Duplicate Assistance Within NYS (This Code is Used when there has been an
Automated Finger Imaging Match (AFIS)

122 FA/SNFP Failed to Comply with the Automated Finger Imaging System (AFIS)

123 SNCA/SNNC Non-Qualified Alien Emergency Medical Condition - Excess Income (SNCA/
SNNC Related)

124 SNCA/SNNC Non-Qualified Alien Emergency Medical Condition - Excess Resources

(SNCA/SNNC Related)

125 FA/SNFP Non-Qualified Alien - Emergency Medical Condition - Excess Income and
Resources (FA/SNFP Related)

126 FA/SNFP Qualified Alien Five Year Ban - Em,ergency Medical Condition Excess Income
(FA/SNFP Related)

127 FA/SNFP Qualified Alien Five Year Ban - Emergency Medical Condition Excess
Resources (FA/SNFP Related)

201 ALL Excess Income

202 SNCA/SNNC Excess Income

205 ALL Excess Resources (Includes Lump Sum Payments)

206 SNCA/SNCC Excess Resources (Includes Lump Sum Payments)

220 ALL Undocumented Alien

225 ALL Non Resident

230 ALL Failure to Sign a Treatment Program Consent Form

231 ALL Recovery, Lien Assignment Homestead

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-10
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

REJECTION CODES - PA IPA: REAS - 222! lcont'dl

CODES USED UNTIL 11/21/05 (CONT'D)

CODE CATEGORY REASON

240 ALL Refuses to Register or Seek Work

245 ALL Failed to Keep EVR Appointment

246 ALL Ineligible Based on EVR Evaluation

250 ALL Refuses Other Source of Employment Offered

255 ALL Refuses to Accept Training or Education

265 ALL Unable to Locate

270 ALL Moved Out of District

275 ALL Death Before Determination: No Outstanding Medical Bills

276 ALL Death Before Determination: Outstanding Medical Bills

277 SNCA/SNNC Non-Compliance with Outpatient Rehabilitation Program for Alcohol or

Substance Abuse - (HH=1)

282 ALL Fleeing Felon - Probation or Parole Violator

283 ALL Failure to Comply With Drug/Alcohol Screening

284 ALL Minor Failed to Complete High School Education

285 ALL Other

286 ALL Other

290 SNCA/SNNC Transferred Property for Purpose of Qualifying for Assistance

291 ALL Refused to Provide Information: Employer Group Health Insurance Plan

292 ALL Refused to Enroll in Employer Group Health Insurance Plan

293 ALL Refused to Provide Information: Other Than Employer Health Insurance Plan.

294 ALL Refused to Enroll in Other Than Employer Based Group Health Insurance
Plan

307 ALL Receiving Multiple Benefits

308 FA/SNFP Refused Offer of a Home

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-11
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES CCONT'Dl

REJECTION CODES - PA IPA: REAS - 2221 lcont'dl

CODES USED UNTIL 11/21/05 (CONT'D)

CODE CATEGORY REASON

319 ALL Other

360 ALL Duplicate Assistance Within NYS

361 ALL Duplicate Assistance - Interstate

521 ALL 6 Month 1st Offense - Less Than $1,000 (HH=1) - MANUAL NOTICE

522 ALL 12 Months 2nd Offense-Less Than $3,900 (HH=1) - MANUAL NOTICE

523 ALL 12 Months 1st Offense Between $1,000 & $3,900- (HH=1)

524 ALL 18 Months if 3rd Offense - (HH=1)

525 ALL 18 Months if 1st Offense More Than $3,900 - (HH=1)

526 ALL 18 Months if znd Offense More Than $3,900 - (HH=1)

527 ALL 5 Years 4th or Subsequent Offense - (HH=1)

528 ALL Court Ordered Disqualification - (HH=1)

. 625 ALL Failed to Furnish or Apply for a Social Security Number

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-12
06/19/2016

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 2221 !cont'd!

CODES USED AFTER 11/21/05

CODE CATEGORY REASON

F12 ALL Failed to Apply for SSI (HH=1). (Discontinued 06/21/10).

F35 ALL Fleeing Felon/Probation-Parole Violator (HH=1). (Discontinued 10/20/08).

F44 ALL Fail to Comply with Drug/Alcohol Screening (HH=1).

(Replaced by P44 on 02/16/2010)

F45 ALL Fail to Comply with Drug/Alcohol Assessment (HH=1).

(Replaced by P45 on 02/16/2010)

F46 ALL Fail to Comply with Drug/Alcohol Release Information (HH=1).

(Replaced by P46 on 02/16/2010)

F53 ALL Refusal by Parent to Apply for Child

F98 ALL Client Request Childcare in Lieu of TA - PA Only

FX1-3 ALL Failed to Take Part in Rehab (HH=1)

(Replaced by MX1-3 on 02/16/2010)

G44 ALL Probation Violator. (Discontinued 10/19/09)

G45 ALL Parole Violator. (Discontinued 10/19/09)

M40 ALL Intentionally provided incorrect information. (Discontinued 2/17/13)

WE2 ALL Failure to comply with employment requirements - 2nd occurrence (HH=1 ).
(Discontinued 06/19/2016)

WE3 ALL Failure to comply with employment requirements - 3rd and subsequent
occurrences (HH=1). (Discontinued 06/19/2016)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-13
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES /CONT'D!

REJECTION CODES- MA !MA: REAS - 241!

CODE CATEGORY REASON

103 FHP Excess Income - Single/Childless Couples, including 19-20 Years Old Not
Living w/Parents

104 FHP Excess Income - Parents, Including 19-20 Years Old Living w/Parents

105 FHP Receipt of Equivalent Health Insurance

112 ALL lncorrecUFraudulent Social Security Number (HH=1)

113 MA Excess Income Child 6 to 18 Above 100% FPL (Non CNS)

123 MA Deny Medical Emergency and MA Exe Inc/Res Non-lmmigranU

Undocumented Immigrant FP

124 MA Over Resources

125 MA Over Income and Resources

126 ALL Deny MA Excess Income/Resources Non-Immigrant/Undocumented

Immigrant Medical Emergency (SCC)

127 MA Over Resources (SCC)

128 MA Deny MA/FHP Non-Immigrant/Undocumented Immigrant No Medical

Emergency

129 Deny Qualified Alien - 5 Year Ban - No Emergency

134 ALL Qualified Individual (QI - 1) Over Income NYC Only

163 MA Excess Income & Resources Child 6 to 18 above 100% FPL

164 FHP FHP Excess Resources (NYC)

167 FHP FHP Excess Income/Resources (NYC)

168 FHP Deny FHP - Public Employee

200 Failure to keep appointment for eligibility interview

201 ALL Excess Income MA- SSI Related

202 MA/SNCA/ Excess Income

SNNC

205 FA/SNFP Excess Resources - SSI Related - Under 21

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1 -14
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

REJECTION CODES- MA !MA: REAS - 241l !cont'd)

CODE CATEGORY REASON

206 SNCNSNNC Excess Resources

217 SNCNSNNC Failed Gross Income Test

218 ALL Failed to provide documentation to establish eligibility

219 ALL Refused to furnish or apply for a Social Security number

220 MA Deny MNFHP Failure to Provide Proof of Citizenship, Identity and/or Current
Immigration Status

225 ALL Not a Resident of District

230 ALL Assignment of Property

235 Persons Under 21 - Legally Responsible Relative

247 ALL Referred for Assistance

265 ALL Unable to Locate

270 ALL Moved Out of District

275 ALL Death before Determination

283 Failure to comply with drug/alcohol screening

285 ALL Other

289 ALL Refused other benefits that would reduce or eliminate need for Medical
Assistance

290 ALL Transferred property for the purpose of qualifying for assistance

291 ALL Refused to provide information on an employer sponsored group health

insurance plan

292 ALL Refused lo enroll in an employer sponsored group health insurance plan.

293 ALL Refused to provide information on other than an employer sponsored group
health insurance plan.

294 ALL Refused to enroll in an other than an employer sponsored group health
insurance plan.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-15
06/19/2016

APPENDIX B • OBSOLETE CASE REASON CODES !CONT'D!

REJECTION CODES- MA !MA: REAS· 2411 !cont'd!

CODE CATEGORY RE:ASON

296 ALL Retroactive Eligibility (for Payment of Bills Offline)

297 ALL Duplicate Application

298 ALL Eligible for Cash Assistance

299 ALL No Presumptive Eligibility

307 ALL Receiving Multiple Benefits

354 FHP Excess Income of Parents and Children

357 FHP Failure to Provide FHP Plan and Provider Selection Form

381 MBl-WPD Ineligible Excess Income above 250% of FPL

382 MBl-WPD Ineligible Excess Resources

383 MBl-WPD Ineligible Excess Income above 250% of FPL and Excess Resources

886 Ql1 Fund Exhausted

887 Ql1 Over Income

E06 MA Deny MA Non-Immigrant/Undocumented Immigrant No Medical Emergency

(HH=1)

E61 ALL Not a Resident of District (New York City)

F32 MA Deny MA Excess Income Child 6 to 18

F55 MA Deny MA Excess Income, Child Age 1-5 (NYC)

F56 Deny Child age 1-5, Excess Income and Excess Resource - (Manual Notice
Required)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-16
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D)

REJECTION CODES - SNAP IFS: REAS - 231l

CODES VALUE
119 Duplicate Assistance within NYS - AFIS

122 Failure to comply with Finger Imaging Requirements.

214 Death of all household members.

223 Institutionalization of only Applicant.

224 Combined with other PA/FS Case.

226 Combined with other NPA/FS Case.

227 Income exceeds allowable maximum.

228 Rejected as a result of WRS/UIB clearance.

229 Failure to resolve Computer Match Discrepancy.

237 Resources exceed allowable maximum.

238 Refusal to verify income.

239 Refusal to verify residence.

248 Refusal to verify resources.

249 Refusal to verify household size.

254 Refusal to verify Citizenship/Alien Status.

257 Refusal of case head to verify identity.

258 Failure to report to Application Interview.

259 Refusal to verify questionable information.

262 Failure to comply with Food Stamp work registration.

263 Voluntary Quit

264 Refusal to apply for SSN.

266 Already Active

267 Moved out of NYC

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-17
02/21/2016

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

REJECTION CODES - SNAP IFS: REAS - 231! !cont'd!

CODES. VALUE
268 Whereabouts Unknown.

273 other

355 Ineligible Alien

356 Ineligible Alien for Food Assistance Program

F35 Fleeing Felon/Parole Violator (HH=1). (Discontinued 10/20/08.)

F95 Alien Ineligible for Food Assistance Program (FAP), (HH=1). (Discontinued 10/18/10)

G44 Probation Violator. (Discontinued 10/19/09)

G45 Parole Violator. (Discontinued 10/19/09)

M88 Failure to Comply with the Automated Finger Imaging System (AFIS) Requirements,
Not Homebound or Group Home Resident (Discontinued 6/18/12)

M99 Duplicate Assistance (AFIS) in NYS (HH=1) (Discontinued 10/22/12)

WE1 Failure to Comply with Employment Requirements, 1st Occurrence (HH=1)

WE2 Failure to Comply with Employment Requirements, 2nd Occurrence (HH=1)

WE3 Failure to Comply with Employment Requirements, 3rd and Subsequent Occurrence
(HH=1)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-18
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D)

CLOSING CODES - PA IPA: REAS - 222)

CODES USED UNTIL 12/04/00

CODE CATEGORY REASON

025 ALL Died. FS disc, MA disc.
026 FA Increased Earnings of Father. FS cont'd, MA cont'd.
027 FA Increased Earnings of Mother. FS cont'd, MA cont'd.
031 FA Increased Earnings of Mother (BCS). FS cont'd, MA cont'd
032 ALL Increased Earnings of husband or wife. FS cont'd, MA cont'd.
041 SNCA Increased Earnings of husband or wife. FS cont'd, MA disc.
042 ALL Increased Earnings of person living in your home. FS cont'd, MA disc.
051 FA Employment/ Increased Earnings of dependent child. FS cont'd, MA cont'd.
052 ALL Employment through Division Employment Services. FS cont'd, MA cont'd.
053 FA Parent returned to former job. FS cont'd, MA cont'd.
054 FA Parent returned to former full time employment. FS cont'd, MA cont'd.
056 FA Employment Income/ Increased Earnings. FS cont'd, MA cont'd.
058 FA/SN CA Household members that must be included in case refuse to apply. FS cont'd, MA
cont'd.
100 FA Employment through NY State Employment Service. FS cont'd, MA cont'd.
110 FA Parent now employed full time thorough NYSES. FS cont'd, MA cont'd.
116 ALL Refused to sign Learnfare authorization form for DSS. FS cont'd, MA cont'd.
120 FA Parent secured job Employment Income. FS cont'd MA cont'd.
130 FA Parent was employed part time have returned to full time.
1372 ALL Your emergency financial needs. FS disc, MA N/A.
140 FA Parent returned to the home and is providing support. FS cont'd, MA cont'd.
141 FA Office of Child Support Enforcement located parent in household. FS cont'd, MA
cont'd
142 ALL Client did not cooperate with the Quality control Reviewer. FS cont'd, MA cont'd.
143 ALL In Violation of parole, probation or fleeing to avoid prosecution.FS disc, MA cont'd.
144 ALL Client did not take part in or complete the alcohol/substance abuse screening
requirement. FS cont'd, MA disc.
145 ALL Client did not take part in or complete the alcohol/substance abuse assessment
requirement. FS cont'd, MA disc.
146 ALL Client did not sign or revoked the consent for the release of treatment information
to this department. FS cont'd, MA disc.
147 ALL Less than 18, unmarried, has child at least 12 weeks failed to participate in
program to attain H.S. diploma. FS cont'd, MA cont'd.
148 ALL . Client did not cooperate with the Quality control reviewer. FS cont'd, MA disc.
149 ALL H/H member 60 or older no longer in H/H resource limit lower. FS disc, MA cont'd.
150 FA Married and receiving sufficient support. FS cont'd, MA cont'd
151 SNCA Minor less than 18 years old, unmarried, pregnant or residing with and providing
care for a minor dependent child. Ineligible for self and dependent child by
refusing to live in an approved, suitable housing arrangement. FS cont'd, MA disc.
152 ALL Agency has investigated and rejected the claim that the home would jeopardize
the health and safety of minor less than 18 years old, unmarried, pregnant or
residing with and providing care for a minor dependent child. Ineligible unless
minor and child reside in an approved suitable living arrangement. FS cont'd, MA
disc.
153 ALL Client fraudulently misrepresented identity or residence to receive multiple public
assistance benefits at the same time. Ineligible to receive public assistance and
food stamp benefits for 10 years. FS disc, MA cont'd.
154 ALL A minor was absent form the home for 45 days or more DSS not notified in the
first 5 days (H/H=1). FS cont'd, MA cont'd.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-19
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - PA IPA: REAS - 222! lcont'dl

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

155 ALL Minor less than 18 years old, unmarried, pregnant or residing with and providing
care for a minor dependent child. Ineligible for self and dependent child by
refusing to live in an approved, suitable housing arrangement. FS cont'd, MA
cont'd.
156 ALL Agency has investigated and rejected the claim that the home would jeopardize
the health and safety of minor less than 18 years old, unmarried, pregnant or
residing with and providing care for a minor dependent child. Ineligible unless
minor and child reside in an approved suitable living arrangement.
FS cont'd, MA cont'd.
158 SNFP Failed to provide verification of income and/or resources from a grandparent who
is legally responsible for a person on the case. FS cont'd, MA cont'd.
159 SNFP Failed to provide verification of income and/or resources form a stepparent who is
legally responsible for a person on the case. FS Cont'd, MA cont'd.
160 FA Child support from father sufficient to meet needs. FS cont'd, MA cont'd.
161 FA Increased support from legally responsible relative. FS cont'd, MA cont'd.
162 ALL In possession of assets that exceed allowable PA & FS amount. FS disc, MA
cont'd.
170 ALL Sufficient support from relative or friend living outside home. FS cont'd, MA cont'd.
173 ALL Refused to provide info on employer group health insurance plan. FS cont'd, MA
disc.
174 ALL Refused to enroll in employer group health plan. FS cont'd, MA disc.
175 ALL Refused to provide info on other than employer health plan. FS cont'd, MA disc.
176 ALL Refused to enroll in other than employer health plan FS cont'd, MA disc.
181 SNCA Unemployment Insurance Benefits sufficient to meet needs. FS cont'd, MA disc.
1801 FA Unemployment Insurance Benefits sufficient to meet needs.FS cont'd, MA cont'd.
1852 ALL Client's identity matches another person who is receiving public assistance in
New York State. FS disc, MA disc.
1862 ALL Client's identity matches another person who is receiving public assistance in
New York State (AFIS). FS disc, MA disc.
187 SNCA Refused to comply with finger imaging requirements (HH>1). FS disc, MA disc
188 SNCA Refused to comply with finger imaging requirements (HH=1 ). FS disc, MA disc
189 FA Client and or another adult member of H/H refused to comply with finger imaging
requirements. FS disc, MA cont'd.
203 ALL Income from Military Service Education Benefits is sufficient. FS cont'd, MA cont'd
204 FA Income from Military Service Allotment is sufficient. FS cont'd, MA cont'd.
207 ALL Sufficient Social Security Benefits to meet budgetary needs. FS cont'd, MA cont'd.
208 FA Income from Military Service or Federal pension is sufficient. FS cont'd, MA
cont'd.
209 FA Income from Military Service or Federal Service Life insurance. FS cont'd, MA
cont'd.
210 ALL Income from Railroad Retirement Benefits is sufficient. FS cont'd, MA cont'd.
211 ALL Income from Worker's Compensation is sufficient. FS cont'd, MA cont'd.
212 ALL Income from New York State Disability Benefits is sufficient. FS cont'd, MA cont'd.
213 FA Income from City or State Civil Service Pension is sufficient. FS cont'd, MA cont'd.
215 ALL Income from Supplemental Security Income is sufficient. FS cont'd, MA cont'd.
216 FA Pension received from a Non-Governmental Program is sufficient.
FS cont'd, MA cont'd.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-20
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

221 SNCA Pension received from a Non-Governmental Program is sufficient. FS cont'd, MA
disc.
222 FA Life Insurance Benefits sufficient to meet budgetary needs. FS cont'd, MA cont'd.
232 FA Inherited Money or Property sufficient to meet budgetary $1,000. FS cont'd, MA
cont'd
233 FA Income from Lodger (s) and/or Boarder/Lodger (s) is sufficient. FS cont'd, MA
cont'd
234 ALL Increased support from person living in home sufficient. FS cont'd, MA cont'd.
235 ALL Pension received from a person living in home sufficient. FS cont'd, MA cont'd.
236 ALL Funds from a legal settlement you receive from person in home. FS cont'd, MA
cont'd.
242 ALL Requested your case be closed. FS cont'd, MA cont'd.
243 FA Requested your case be closed (Bureau Child Support). FS disc, MA cont'd.
251 SNCA Refused other source of employment offered.
252 ALL Bank account amount exceeds maximum permitted for PA $1,000.
FS cont'd, MA cont'd.
253 SNCA Bank account amount exceeds maximum permitted for PA $1,000. FS disc, MA
disc.
260 FA Decrease in expenses income is sufficient to meet needs. FS cont'd, MA cont'd.
261 SNCA Decrease in expenses income is sufficient to meet needs. FS cont'd, MA disc.
271 ALL Gross semi-monthly income exceeds 185% of State standard. FS cont'd.
274 2 ALL Failed to keep initial application appointment (Used to close an immediate needs
case that has been opened with opening code 033). FS Closed.
280 SNCA Reclassified from FA to SN not eligible for FA exemptions. FS cont'd, MA cont'd.
281 SNCA Reclassified from FA to SN not eligible for FA exemptions.FS cont'd, MA disc.
287 SNFP/SNCA/ Failed to keep EVR appointment (manual notice). FS disc, MA disc.
SN NC/FA
288 SNFP/SNCA/ Ineligible based on EVR evaluation (manual notice). FS disc.
SN NC/FA
2952 ALL Client did not return to complete interview (Used to close an immediate needs
case that has been opened with opening code 033). FS Closed.
301 SNCA Income from Military Service or other Federal pension. FS cont'd, MA disc.
302 SNCA Failed to sign consent form regarding substance abuse. FS cont'd, MA disc.
304 SNCA Income from Military Service Allotment Benefits is sufficient. FS cont'd, MA disc.
305 ALL Clients identified as receiving public assistance in another state. FS disc, MA disc.
313 SNCA Income from City or State Civil Service Pension is sufficient. FS cont'd, MA disc.
320 FA Arithmetical recomputation resulted in correction of budget. FS cont'd, MA cont'd.
321 SNCA Arithmetical recomputation resulted in correction of budget. FS cont'd, MA disc.
331 SNCA Life Insurance Benefits sufficient to meet budgetary needs. FS cont'd, MA disc.
332 SNCA Inherited Money or Property sufficient to meet budgetary needs.
FS cont'd, MA disc.
333 SNCA Income from Lodger (s) and/or Boarder/Lodger (s) is sufficient.
FS cont'd, MA disc.
441 3 SNCA Output Code for code 815, 3rd offense results in a 180-day sanction.
442 3 SNCA Output Code for code 825, 2nd offense results in a 150-day sanction.
446 SNCA Output Code for code 539, 2nd offense results in a 150-day sanction.
447 2 SNCA Refused to accept or complete a job placement referred by OES. FS cont'd.
449 3 SNCA Output Code for code 568, 3rd offense results in a 180-day sanction.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-21
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - PA IPA: REAS - 222! !cont'd!

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

448 2 SNCA Refused to accept or complete On The Job Training in TEAP. FS cont'd.
460 2 FA Adult relative eligible to receive payments in ADC left household.FS cont'd, MA
cont'd.
470 FA Child for whom you receive payments in ADC has left household.FS cont'd, MA
cont'd
471 FA Only dependent Child is 19 not eligible for assistance in household.
FS cont'd, MA cont'd
472 FA Children are 18 will not graduate HS before 19 ineligible for ADC.FS cont'd, MA
cont'd
500 ALL Failed to keep appointment with Bureau of Client Fraud. FS cont'd, MA disc.
501 ALL Failed to provide information concerning Social Security Benefits. FS cont'd, MA
disc.
502 ALL Failed to provide documents to establish proof of birth. FS cont'd, MA disc.
503 ALL Failed to furnish pay stub to recompute your current needs. FS cont'd, MA disc.
504 ALL Failed to keep an appointment with Income Support Center.
507 ALL Failed to file a petition with the family court requesting support. FS cont'd, MA
disc.
508 ALL Failed to keep appointment with Office of the Inspector General. FS cont'd, MA
disc.
509 SNCA Failed to pursue your claim for SSI benefits. FS cont'd, MA cont'd.
510 ALL Failed to comply with policy regarding assignment of your property.FS & MA
cont'd.
511 3 SNCA Failed to report to a HR/FS JOB Search Scheduled Appointment'.
(Initial occurrence 90 Day Sanction). FS disc.
512 3 SNCA Output Code for code 511, 2nd offense results in a 150-day sanction.
513 3 SNCA Output Code for code 511, 3rd offense results in a 180-day sanction.
514 3 SNCA Output Code for.code 815, 2nd offense results in a 150-day sanction.
516 SNCA Output Code for code 817, 2nd offense results in a 150-day sanction.
517 SNCA Output Code for code 817, 3rd offense results in a 180-day sanction.
518 3 SNCA Output Code for code 544, 2nd offense results in a 150-day sanction.
519 3 SNCA Output Code for code 544, 3rd offense results in a 180-day sanction.
530 3 SNCA Failed to report to a HR JOB Search Scheduled appointment. (Initial occurrence
90 Day Sanction).
539 3 SNCA Refused to accept or complete a vocational training program referred by OES (90-
day sanction). FS cont'd.
544 3 SNCA Failed to cooperate with a training program referred by NYS Job Service (90-day
sanction) FS cont'd. ·
545 3 SNCA Failed to provide at the HR/FS JOB Search appointment a completed Job Search
Handbook. (Initial Occurrence 90-Day Sanction). FS disc.
546 3 SNCA Output Code for code 545, 2nd offense results in a 150-day sanction.
547 3 SNCA Output Code for code 545, 3rd offense results in a 180-day sanction.
549 3 SNCA Output Code for code 821, 3rd offense results in 180-day sanction.
551 2 ·SNCA Output code for code 447, 2nd offense results in a 150-day sanction.
552 2 SNCA Output code for code 447, 3rd offense results in a 180-day sanction.
553 FA Failed to accept employment referred by BEGIN. FS cont'd, MA cont'd.
556 2 SNCA Output code for code 448, 2nd offense results in a 150-day sanction.
558 3 SNCA Output Code for code 530, 2nd offense results in a 150-day sanction.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-22
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'DI

CLOSING CODES - PA IPA: REAS - 2221 lcont'dl

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

5592 SNCA Output code for code 448, 3rd offense results in a 180-day sanction.
5503 SNFP/SNCA/ Failed to keep appointment scheduled by OES cooperate with their efforts to
SNNC place you in a job or training (90 Day Sanction). FS disc.
561 FA Refused to accept or complete training in BEGIN. FS disc, MA cont'd.
562 ALL Refused to accept or complete training in NYSESP. FS disc, MA cont'd.
563 3 SNCA Output Code for code 530, 3rd offense results in a 180-day sanction.
564 ALL Refused to accept or complete training in Wildcat. FS cont'd, MA cont'd.
565 3 SNFP/SNCA/ Output Code for code 560, 2nd offense results in a 150-day sanction.
SNNC
5553 SNFP/SNCA/ Output Code for code 560, 3rd offense results in a 180-day sanction.
SNNC
5683 SNCA Failed to have a medical evaluation to determine eligibility and participate in OES
(90-day sanction). FS cont'd.
569 3 SNCA Output Code for code 568, 2nd offense results in a 150-day sanction.
571 ALL Failed to keep appointment for photo identification card. FS cont'd, MA cont'd.
572 ALL Failed to submit referral form indicating application for Social Security or
Supplemental Security lncomfi>. FS cont'd, MA disc.
573 ALL Client did not pick up four consecutive Public Assistance payments. FS disc, MA
disc.
574 ALL Failed to report for recertification interview. FS disc, MA disc.
575 ALL In possession of assets which exceed allowable PA amount. FS cont'd, MA
cont'd.
576 ALL Receiving Public Assistance on more than one case. FS disc, MA disc.
577 SNCA Failed to report for scheduled medical examination at HSS. FS cont'd, MA cont'd.
578 4 ALL Failed to keep appointment with Income Support Center or OES to evaluate
employability status. FS cont'd, MA disc.
579 ALL Failed to submit information to determine continuing eligibility of child who has
reached age 16,17, 18, 19, 20, 21. FS cont'd, MA cont'd.
583 ALL Failed to return with Face to Face request documentation. FS disc, MA disc.
584 ALL Refused or failed to provide complete and consistent information to establish that
funds in a savings account constitute a permissible reserve. FS disc, MA disc.
585 ALL Refused to provide complete information relating to savings account. FS & MA
disc.
587 ALL Failed to keep at home scheduled interview arranged by appointment letter to
discuss continuing eligibility for Public Assistance, Food Stamps and Medicaid. A
second letter was left at the home scheduling another appointment at IM center.
Failed to appear for this interview. FS disc, MA disc.
588 FA Client did not cooperate with the Quality control Reviewer. Client given more than
one chance to cooperate. Client did not give a good reason why they did not
cooperate. FS cont'd.
5892 ALL Income from Increased employment earnings is sufficient. FS disc, MA disc.
592 ALL Client failed to comply/cooperate with the Eligibility Verification Review (EVR). Did
not respond to notification to contact EVR. FS disc, MA disc.
5932 ALL Failed to return the Quarterly Status Report. FS disc, MA cont'd.
594 ALL Failed to provide information/documentation requested to evaluate continuing
eligibility for Public Assistance, Medicaid, and Food Stamps. FS disc, MA cont'd.
595 ALL Failed to complete and or return the request for information about employment
earnings. FS disc, MA disc

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-23
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES (CONT'D!

CLOSING CODES - PA IPA: REAS - 2221 !cont'd!

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

596 ALL Refused to comply/cooperate with Eligibility Verification Review. FS disc, MA disc.
5973 SNCA Failed to provide at the HR JOB search appointment a completed JOB Search
Handbook. (Initial Occurrence 90-day sanction).
598 3 SNCA Output Code for code 597, 2nd offense results in a 150-day sanction.
599 3 SNCA Output Code for code.597, 3rd offense results in a 180-day sanction.
600 2 SNNC Agency's information as of DATE client has been admitted to a private institution.
FS disc, MA disc.
6013 SNCA Output Code for code 825, 3rd offense results in a 180-day sanction.
6102 SNNC Agency's information as of DATE client has been admitted to a public institution.
FS disc, MA disc.
611 ALL Other Reasons. Specify reason. FS cont'd, MA disc.
612 ALL Other Reasons. FS disc, MA disc.
624 ALL Member of H/H who does not want public assistance, but whose needs or income
is being used to determine H/H continuing eligibility failed to furnish or apply for
Social Security number. FS cont'd, MA cont'd.
6302 SNNC Agency's information as of DATE client has been admitted to a penal correctional
institution. FS disc, MA disc.
750 ALL Agency's information as of DATE clients needs are being included in the grant of
another person in the home receiving the same type of assistance. FS disc, MA
disc.
761 ALL Client is receiving assistance in a Foster Care Program. FS cont'd, MA disc.
762 ALL Client is receiving assistance in a Shelter Care Program. FS cont'd, MA disc.
763 ALL Client is receiving assistance from a Private Agency. FS cont'd, MA cont'd.
803 3 SNCA Output Code for code 829, 2nd offense results in a 150-day sanction.
807 3 SNCA Output Code for code 829, 3rd offense results in a 180 day sanction
809 3 SNCA Failed to adhere to WEP sponsor agency's rule. FS cont'd.
811 3 SNCA Output Code for code 809, 3rd offense results in a 180-day sanction.
815 3 SNCA Failed to report to the NYS Job Service (90 day sanction). FS cont'd.
817 SNCA Failed to report to an employer referred by NYS Job Service (90-day sanction).
FS cont'd.
8193 SNCA Output Code for code 539, 3rd offense results in a 180-day sanction.
8213 SNCA Refused to accept or complete an educational training program referred by OES
(90-day sanction). FS cont'd.
8233 SNCA Output Code for code 821, 2nd offense results in a 150-day sanction.
824 ALL Failed to appear at a private employer referred by Division of Employment
Services. FS cont'd, MA cont'd.
825 SNCA Failed to report to an employer referred by NYS Job Services. FS cont'd.
828 SNFP/SNCA/ Voluntarily terminated employment, reduced earning capacity, failed to furnish
SNNC sufficient information to show that you did so for a purpose other than qualifying
for continued or increase .Public Assistance. May reapply i_n 75 days.
FS disc, MA cont'd.
8293 SNCA Failed to report/cooperate with the Work Experience Program Intake Section.
(90-day sanction). FS cont'd.
831 SNCA Failed to attend a treatment program for drugs or alcohol. FS cont'd, MA cont'd.
832 SNCA (18-21 Failed to attend a treatment program for drugs or alcohol. FS cont'd, MA cont'd.
833 SNCA Failed to respond to request for written confirmation of participation in appropriate
drug or alcohol abuse program. FS cont'd, MA cont'd.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-24
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - PA IPA: REAS - 2221 !cont'd)

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

834 SNCA (18-21) Failed to respond to request for written confirmation of participation in appropriate
drug or alcohol abuse program. FS cont'd, MA cont'd.
8353 SNFP/SNCA/ Agency's information as of DATE is that the client failed to keep an appointment
SNNC with the Substance Abuse Case control worker to evaluate participation in an
appropriate rehabilitation program, (HH=1). FS cont'd, MA cont'd.
836 SNCA (18-21) Agency's information as of DATE is that the client failed to keep an appointment
with the Drug and Alcohol Abuse Referral Unit to evaluate your participation in an
appropriate rehabilitation program. FS cont'd, MA cont'd.
837 SNCA Agency's information as of DATE is that the client failed to provide medical
information needed to determine potential for rehabilitation or return to self
support. FS cont'd, MA cont'd.
838 SNCA Agency's information as of DATE is that the client failed to provide medical
information needed to determine their potential for rehabilitation or return to self
support. FS cont'd, MA cont'd.
8393 SNCA Output Code for code 809, 2nd offense results in a 150-day sanction.
8433 SNCA Failed to participate in or complete an outpatient alcohol or substance abuse
rehabilitation program (45 day sanction). FS cont'd.
844 3 SNCA Output Code for code 843, 2nd offense results in a 120-day sanction.
845 3 SNCA Output Code for code 843, 3rd offense results in a 180-day sanction.
872 2 ALL Client permanently moved to another district within the State. FS disc, MA disc.
875 3 SNFP/SNCA/ Client failed to sign a consent form for release of information regarding outpatient
SNNC substance abuse treatment. Ineligible to receive public assistance until
compliance but no less than 45 days. FS cont'd, MA disc.
8763 SNFP/SNCA/ Output Code for code 875, 2nd offense results in a 120-day sanction.
SNNC
8773 SNFP/SNCA/ Output Code for code 875, 3rd offense results in a 180-day Sanction.
SNNC
881 ALL Client has temporarily moved to another district outside the State. FS disc, MA
disc.
882 ALL Client has permanently moved to another district outside the State. FS disc, MA
disc.
890 ALL Clients whereabouts are unknown. FS disc, MA disc.
895 ALL Other Reasons (To be used only for EVR closings). FS disc, MA cont'd.
896 ALL Other Reasons. (To be used only for EVR Closings). FS disc, MA disc.
897 ALL other Reasons. (To be used only for EVR closings). FS disc, MA cont'd.
900 ALL After a field investigation, it has been determine that the client is not residing a the
address of record. FS disc, MA disc.
911 SNFP After a field investigation, it has been determine that the client is not residing at
the address of record. (To be used only when closing information has been
supplied by ACS). FS disc, MA disc.
960 2 ALL Case number changed. FS disc, MA disc.
9702 ALL Merged with another suffix. (System Generated). FS disc, MA disc.
974 ALL Fail to Respond to Computer Match FS Default Code - SYSTEM GENERATED
990 ALL Other, specify reason. FS cont'd, MA cont'd.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-25
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - PA IPA: REAS - 2221 !cont'd!
NOTES FOR CODES USED UNTIL 12/04/00:
1 Used if household contains any person under age 21
2 Adequate Notice
3 If individual is under 21, MA status is continued. If individual is 21 or older, and the AMP date is
less than 11/1/1997, MA status is discontinued. Otherwise, MA continues.
4 This code is to be used at originating center OES only and is limited to a household size of 1.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-26
02/14/2015

. APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - PA !PA: REAS - 222! !cont'd!

CODES USED AFTER 12/04/00

CODE CATEGORY REASON

E41 FA/SNFP Voluntary Quit or Reduced Earnings (HH=1)
ESQ FA/SNFP Failed to Return Quarterly Report
E51 FA/SNFP Failed to Return Quarterly Report - All Questions
E52 FA/SNFP Failure to Complete Quarterly Report - Signature
E54 FA/SNFP Failure to Complete Quarterly Report - Dated Early
E81 SNCA/SNNC Refused Photo ID (HH=1)
E84 SNCA/SNNC Failure to Sign Lien (HH=1)
F12 ALL Failure to Apply for SSI (HH=1). (Discontinued 06/21/10)
F19 ALL Refusal to Cooperate with Quality Control
F35 ALL Fleeing Felon - Probation or Parole Violator (HH=1 ). (Discontinued 10/20/08.)
F43 SNCA/SNNC Failure to Complete -In Patient Rehabilitation
F44 ALL Failure to Comply with Drug and/or Alcohol Screening (HH=1).
(Replaced by P44 on 02/16/2010)

F45 ALL Failure to Comply with Drug and/or Alcohol Assessment (HH=1 ).
(Replaced by P45 on 02/16/2010)

F46 ALL Failure lb Sign or Revoked the Treatment Informational Consent Form (HH=1)
(Replaced by P46 on 02/16/2010)

G12 SNCA/SNNC Failure to Apply for SSI (HH=1). (Discontinued 06/21/10)

G19 ALL Refusal to Cooperate with Quality Control (Discontinued 06/18/07)
G44 ALL Probation Violator
G45 ALL Parole Violator
G50 SNCA/SNNC Failed to Return Quarterly Report
G51 SNCA/SNNC Failed to Complete Quarterly Report - All Questions
G52 SNCA/SNNC Failure to Complete Quarterly Report - Signature
G53 ALL Failure to Return Complete Quarterly Report - Proof
G54 SNCA/SNNC Failure to Complete Quarterly Report - Dated Early

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-27
06/19/2016

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - PA IPA: REAS - 222! !cont'd) .

CODES USED AFTER 12/04/00

CODE CATEGORY REASON

GX1-3 ALL Failed to Take Part in Rehabilitiation Program (HH=1)
(Replaced by PX1-3 on 02/16/2010)

M17 ALL Failure to Complete Employment Process

M51 SNCA/SNNC Failed to Complete Quarterly Report - Selected Questions

M53 ALL Failed to Complete Quarterly Report - Partial Proof
N13 FA/SNFP Failure to Apply for or Use Benefits or Resources

N42 ALL Voluntary Quit 2nd Occurrence (HH=1) (Discontinued 06/19/2016)

N43 Voluntary Quit 3rd and Subsequent Occurrences (HH=1)

(Discontinued 06/19/2016)
N46 ALL Voluntary Quit 2nd Occurrence (HH=1) (Discontinued 06/19/2016)
N47 Voluntary Quit 3rd and Subsequent Occurrences (HH=1)
(Discontinued 06/19/2016)
N49 ALL Refused Offer of a Home (H H= 1)
N50 ALL Refused Offer of a Home - Rejection of Claim
N51 FA/SNFP Failure to Complete Quarterly Report - Selected Questions
V40 SNCA/SNNC Excess Resources
V42 SNCA/SNNC Excess Resources - Failed to Sell Property
V43 SNCA/SNNC Excess Resources - End of Six Month Period
W24 SNCA/SNNC Failure to Provide Verification - Stepparent/Grandparent
W25 SNCA/SNNC Failure to Provide Verification - Filing unit
WX2 FA/SNFP/ Failure to Comply with Employment Requirements - 2nd Occurrence (HH=1)
SNCA/SNNC (Discontinued 06/19/2016)
WX3 FA/SNFP/ Failure to Comply with Employment Requirements - 3rd and Subsequent
SNCA/SNNC Occurrences (Discontinued 06/19/2016)
WX5 FA/SNFP/ Failure to Comply with Employment Requirements - 2nd Occurrence (HH=1)
SNCA/SNNC (Discontinued 06/19/2016)
WX6 FA/SNFP/ Failure to Comply with Employment Requirements - 3rd and Subsequent
SNCA/SNNC Occurrences (Discontinued 06/19/2016)
Y83 ALL Opened in Error via Newborn Process

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-2!1
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES- MA IMA: REAS - 241!

DEATH OF RECIPIENT (USED UNTIL 12/13/93)

CODE CATEGORY REASON

025 ALL The only person on the case currently in receipt of Medical Assistance is now
deceased. (Adequate notice.)
18 NYCRR 360,2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-29
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES <CONT'D)

CLOSING CODES - MA !MA: REAS - 241) !cont'd)

CHANGE IN EMPLOYMENT, SUPPORT, OR INCOME (USED UNTIL 12/13/93)

COPE CATEGORY REASON

026 ADC/ADCU The employment or increased earnings of the father living in the home exceed
SS I-Related {s) the allowable Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8

027 ADC/ADCU The employment or increased earnings of the mother living in the home
SSI - Related exceed (s) the allowable Medicaid income standard for a household of your
size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8

031 ADC/ADCU The employment or increased earnings of the mother living in the home
SSI- Related exceed (s) the allowable Medicaid income standard for a household of your
size. (To be used only when the closing information has been supplied by the
Bureau of Child Support).
189 NYCRR 360-4.6, 360-4.7, 360-4.8

032 HR Families The employment or increased earnings of yourself or of your husband/wife

SSI- Related living in the home exceed (s) the allowable Medicaid income standard for a
household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-3.3, 360-1.2 PART 352

041 HR Single The employment or increased earnings of yourself or of your husband/wife

Adults/ living in the home is sufficient to meet the budgetary needs of your family unit.
Couples (lfthe household contains any person under age 21, use code 032.)
18 NYCRR 360-4.6, 360-4. 7, 360-3.3, 360-3.8,360-1.2, PART 352

120 ADC/ADCU A parent secured a job and the income from employment exceed (s) the
allowable Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8

130 ADC/ADCU The parent who employed part - time is now employed full time and the
income from employment exceed (s) the allowable
18 NYCRR 360-4.6, 360-4.7, 360-4.8

140 ADC The child(ren)'s parent has returned to the home and is providing support
SS I-Related which exceed (s) the allowable Medicaid income standard for a household of
your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8

150 ADC You have married and are receiving support which exceed(s) the allowable
SSI- Related Medicaid income standard for a household of your size
18 NYCRR 360-4.6, 360-4.7, 360-4.8

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-30
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D)

CLOSING CODES - MA IMA: REAS - 241! !cont'd!

CHANGE IN EMPLOYMENT, SUPPORT, OR INCOME (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

170 ALL The support you receive from a relative or friend living outside the home
exceed (s) the allowable Medicaid income standard for a household of your
size.
18 NYC RR 360-4.6, 360-4. 7, 360-4.8, 360-3.3, 360-1.2, PART352

180 ADC/ADCU The Unemployment Insurance Benefits you receive exceed (s) the allowable
HR Families Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2, PART 352

181 HR Single The unemployment Insurance Benefits you receive are sufficient to meet your
Adults/ budgetary needs.
Couples 18 NYCRR 360-4.6, 360-4.7, 360-3.3, 360-3.8, 360-1.2,
PART 352

207 ALL The Social Security Benefits you receive exceed(s) the allowable Medicaid
income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2 PART 352

208 ADC/ADCU The income you receive from a Military Service or other Federal pension
HR Families exceed (s) the allowable Medicaid income standard for a household of your
SSI- Related size.
18 NYCRR 360-3.3, 360-4.6, 360-4.7, 360-4.8,360-1.2, PART 352

301 HR Single The income you receive from a Military Service or other
Adults/ Federal pension is sufficient to meet your budgetary needs.
Couples 18 NYC RR 360-4.6, 360-4. 7, 360-3.3, 360-3.8, 360-1.2,
PART 352

209 ADC/ADCU The income you receive from a Military Service or other Federal Service Life
HR Families Insurance exceed (s) the allowable Medicaid income standard for a household
SS I-Related of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2
PART 352

203 ALL The income you receive from Military Service Education Benefits exceed (s)
the allowable Medicaid income standard for a household of your size.
18 NYC RR 360-4.6, 360-4. 7, 360-4.8, 360-3.3,360-1.2, PART 352

302 HR/Single The income you receive from a Military Service or other Federal Service Life
Adults/ Insurance is sufficient to meet your budgetary needs.
Couples 18 NYCRR 360-4.6, 360-4.7, 360-3.3, 362-3.8, 360-1.2,
PART 352

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-31
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 241! !cont'd!

CHANGE IN EMPLOYMENT, SUPPORT, OR INCOME (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

204 ADC/ADCU The income you receive from a Military Service Allotment exceed (s) the
HR Families allowable Medicaid income standard for household of your size. ·
SSI Related 18 NYCRR 360-4.6, 360-4. 7, 360-4.8, 360-3.3, 360-1.2,
PART 352

304 HR Single The income you receive from a Military Service allotment exceed (s) the
Adult/ allowable Medicaid income standard for a household of your size.
Couples 18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-3.8,
360-1.2, PART 352

210 ALL The income you receive from Railroad Retirement Benefits exceed (s) the
allowable Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3,360-1.2, PART 352

211 ALL The income you receive from Worker's Compensation exceed (s) the
allowable Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3360-1.2, PART 352

212 ALL The income you receive from New York State Disability Benefits exceed (s) the
allowable Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3,360-1.2, PART 352

213 ADC/ADCU The income you receive from a City or State Civil Service Pension exceed (s)
HR Families the allowable Medicaid income standard for a household of your size.
SSI -Related 18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3,360-1.2, PART 352

313 HR Single The income you receive from a City or State Civil Service Pension is sufficient
Adults/ to meet your budgetary needs
Couples 18 NYCRR 360-4.6, 360-4.7, 360-3.3, 360-3.8,360-1.2
PART 352

216 ADC/ADCU The pension of benefits you receive from a non-governmental program
Adults/ exceed (s) the allowable Medicaid income standard for a household of your
Couples size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3,360-1.2, PART 352

221 HR Single The pension or benefits you receive from a non- governmental program is
Adults/ sufficient to meet your budgetary needs.
Couples 18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2,
PART352

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-32
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS - 2411 !cont'd!

CHANGE IN EMPLOYMENT, SUPPORT, OR INCOME (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

222 ADC/ADCU You have received Life Insurance Benefits which exceed(s) the allowable
HR Families Medicaid income standard for a household of your size.
SS I-Related 18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2,
PART 352

·331 HR Single You have received Life Insurance Benefits sufficient to meet
Adults/ your budgetary needs.
Couples 18 NYCRR 360-4.6, 360-4. 7, 360-3.3, 360-3.8, 360-1.2,
PART 352

233 HR Single The income you receive from Lodger (s) and/or Boarder/Lodger (s) exceed (s)
Adults/ the allowable Medicaid income standard for a household of your size.
Couples 18 NYCRR 360-4.6, 360-4.7, 360-3.3, 360-1.2
PART 352

333 HR Single The income you receive from Lodger (s) and/or Boarder/Lodger (s) is
Adults/ sufficient to meet your budgetary needs.
Couples 18 NYCRR 360-4.6, 360-4.7, 360-3.3, 360-3.8,360-1.2., PART 352

234 ALL The support or increase in support you receive from a person iving in the
home exceed (s) the allowable Medicaid income standard for a household of
your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2,
PART 352

589 ALL The income you receive from increased employment earnings
is sufficient to meet your budgetary needs. (Adequate notice.)
18 NYCRR 360-1.2, 360-2.5, 360-3.3, 360-4.3,
PART 352

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-33
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS - 241! !cont'd!

NO CHANGE IN INCOME OR RESOURCES (USED UNTIL 12/13/93)

CODE CATEGORY REASON

242 ALL Our information as of _____ is that you have requested that your case
be closed.
18 NYCRR 360-2.6

260 ADC/ADCU There has been a decrease in your expenses. Your income exceeds allowable
HR Families Medicaid income standard for a household of your size.
SS I-Related 18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3, 360-1.2
PART 352

261 HR Single There has been a decrease in your expenses. Your income is now sufficient to
Adults/ meet your budgetary needs.
Couples 18 NYCRR 360-4.6, 360-4. 7, 360-3.3, 360-3.8, 360-1.2
PART 352

269 ADC/ADCU You were entitled to the first $30 and one- third of the remainder
HR Families income disregard for four months. That period has expired and the amount
formerly dis-regarded will now be counted in your income. Therefore, your
income exceed (s) the allowable
Medicaid income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.2,360-1.2 PART 352

271 HR Federal and state law provides that if your gross monthly income exceed s
185% of the state standard of need you will no longer me.et the Public
Assistance eligibility standard which is a requirement for Medical Assistance
eligibility. The monthly standard of need for your household is$ (specify) but
your monthly gross income is $(specify) which is more than 185% of the
standard of need. Accordingly, you are no longer eligible for assistance.
18 NYCRR 352.18 (a), 360-1.2, 360-3.3, 360-3.8

272 ADC/ADCU You were entitles to a $30 monthly earned income disregard for
HR Families twelve months. That period has expired and the amount formerly disregarded.
Will now be counted in your income. Therefore, your income exceed (s) the
allowable Medical income standard for a household of your size.
18 NYCRR 360-4.6, 360-4.7, 360-4.8, 360-3.3,360-1.2, PART 352

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-34
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS - 2411 !cont'd)

CHANGE IN SITUATION CAUSING ELIGIBILITY (USED UNTIL 12/13/93)

CODE CATEGORY REASON

320 ALL An arithmetical recomputation has resulted in a correction of your budget.
Your income exceed (s) the allowable Medicaid income standard for a
household of your size.
18 NYCRR 360-4.6, 360-4.8, 360-3.3, 360-1.2, PART 352

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-35
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D\

CLOSING CODES- MA !MA: REAS - 241! !cont'd!

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (USED UNTIL 12/13/93)

CODE CATEGORY REASON

173 ALL You refused to provide information on your employer group health insurance
plan.
18 NYCRR 360-3.2

174 ALL You refused to enroll in your employer group health insurance plan.
18 NYCRR 360-3.2

175 ALL You refused to provide information on other than employer based group health
insurance plan.
18 NYCRR 360-3.2

176 ALL You refused to enroll in other than employer based group health insurance
plan.
18 NYCRR 360-3.2

447 HR You refused to accept or complete a job placement program to which you were
referred by the Office of Employment Services. We have determin.ed that your
Code 551-0utput Code ·action was willful and without good cause. You are disqualified from receiving
for a 120 Day Sanction Medical Assistance for 60 days and until such time as you are willing to
Code 552-0utput Code comply with this requirement.
for a 180 Day Sanction 18 NYCRR 360-3.3, 360-1.2, PART 385

500 ALL You failed to keep an appointment with the Bureau of Client Fraud
Investigation (HRA) or failed to contact the Bureau of Client Fraud
investigation (HRA) to reschedule said appointment.
18 NYCRR 360-1.2, 360-2.3, PART 351

504 ALL You failed to keep an appointment with the Medical Assistance Office to
discuss your eligibility for Medical Assistance and failed to contact the Medical
Assistance Office to reschedule the appointment.
18 NYCRR 360-1.2, 360-2.2, 360-3.3, PART 351

507 ALL You were asked to file a petition with the Family Court requesting medical
support from your legally -responsible relative (s), and you failed to do so.
18 NYCRR 360-1.2, 360-2.2, 360-2.3, PART 369

508 ALL You failed to keep an appointment with the Office of the Inspector General
(HRA), or failed to contact the Office of the Inspector General (HRA) to
reschedule said appointment.
18 NYCRR 360-1.2, PART 351

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-36
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 2411 lcont'dl

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

510 ALL You have failed to comply with our policies regarding assignment or utilization
of your non-exempt property.
18 NYCRR 360-4.4

511 HR Single You failed to report to HR/FS Job Search Scheduled Appointment
(Initial Occurrence - 75-Day Sanction).
Code 512-0utput code 18 NYCRR 360-1.2, 360-3.3, PART 385
for a 150 Day Sanction
Code 513-0utput Code
for 180 Day Sanction

530 HR Single You failed to report to report to HR Job Search Schedule Appointment (Initial
Occurrence - 75 Day Sanction).
Code 558-0utput Code 18 NYCRR 360-1.2, 360-3.3, PART 385
for a 150 Day Sanctio
Code 563-0utput Code
for a 180 Day Sanction

539 HR You refused to accept or to complete a vocational training program to which

you were referred by the Office of Employment Services. We have determined
Code 446-0utput Code that your action was willful and without good cause. You are disqualified from
for a 120 Day Sanction receiving Medical Assistance for 60 days and until such time as you are willing
Code 819-0utput Code to comply with this requirement.
for a 180 Day Sanction 18 NYCRR 360-1.2, 360-3.3, PART 385

544 HR You failed to report to or cooperate with a training program to which you were
referred by the New York State Job Service. We have determined that your
Code 518-0utput Code action was willful and without good cause. You are disqualified from receiving
for a 120 Day Sanction Medical Assistance for 60 Days and until such time as you are willing to
Code 519-0utput Code comply with this requirement.
for 180 Day Sanction 18 NYCRR 360-1.2, 360-3.3, PART 385

545 HR Single You failed to cooperate with HR/FS Job Search Rules and and Regulations
(Initial Occurrence - 75 Day Sanction).
Code 546-0utput Code 18 NYCRR 360-1.2, 260-3.3, PART 385
for a 150 Day Sanction
Code 547-0utput Code
for a 180 Day Sanction

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-37
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241! lcont'dl

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

560 HR You failed to report to an appointment schedule for you by the Office of
Employment Services or failed to cooperate with their efforts to place you on a
Code 565-0utput Code job or in training. We have determined that your action was willful and without
for a 120 Day Sanction good cause you are disqualified from receiving Medical Assistance for 60 days
Code 566-0utput Code and until such time as you are willing to comply with this requirement.
for a 180 Day Sanction 18 NYCRR 360-1.2, 360-3.3, PART 385

597 HR Single You failed to cooperate with HR Job Search Rules and Regulations. (Initial
Occurrence - 75 Day Sanction)
Code 598-0utput Code 18 NYCRR 360-1.2, 360-3.3, PART 385
for a 150 Day Sanction
Code 599-0utput Code
for a 180 Day Sanction

562 HR You refused to accept or complete training in the New York State Employment
Service Program. We have determined that your action was willful and without
good cause.
18 NYCRR 360-3.3, 360-1.2, PART 385

568 HR You failed to comply with our request to have a medical evaluation to
determine your employability and availability to participate in the Office of
Code 569-0utput Code Employment Services Programs. We have determine that your action was
for a 120 Day Sanction willful and without good cause. You are disqualified from receiving Medical
Code 449-0utput Code Assistance for 60 days and until such time as you are willing to comply with
for a 180 Day Sanction this requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385

574 ALL You failed to report for your recertification interview for Medical Assistance.
18 NYCRR 351.21, 351.22, 360-1.2, 360-2.2, 360-3.3

577 ALL You failed to comply with our request to have medical evaluation.
18 NYCRR 385.4, 360-1.2 .

581 HR You failed to comply with employment related requirements.

18 NYCRR 360-1.2, 360-3.3, PART 385 .

583 ALL You failed to provide information/documentation required by this agency to

establish your continuing eligibility for Medical Assistance.
18 NYCRR 360-2.3, 360-1.2, PART 351

'
NEW YORK STATE WELFARE MANAGEMENT SYSTEM
 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX 8 - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES- MA IMA: REAS - 2411 lcont'dl

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

584 ALL You refused or failed to provide complete and consistent information to
establish that the funds in your savings account constitute a permissible
reserve.
18 NYCRR 360-4.8, 360-3.3, 360-1.2, PART 352

587 ALL You were not at home for a schedule interview arranged by appointment letter
to discuss your continuing eligibility for Medical Assistance.
18 NYCRR 360-1.2, 360-2.2, PART 351

815 HR You failed to report to the New York State Job Service for a job placement
interview. We have determined that your Code 516- Output Code for a 120
Code 514-0utput Code Day Sanction action was willful and without good cause. You are disqualified
for a 120 Day Sanction from receiving Medical Assistance for 60 days and until such time as you are
Code 441-0utput Code willing to comply with this requirement.
for a 180 Day Sanction 18 NYCRR 360-1.2, 360-3.3, PART 385

817 HR You failed to report to an employer to whom you were referred by the New
York State Job Service.
Code 516-0utput Code Code 823 - Output Code for a 120 Day Sanction
for a 120 Day Sanction
Code 517-0utput Code We have determined that your action was willful and without good cause. You
for a 180 Day Sanction are disqualified from Medical Assistance for 60 days and until; such as you are
willing to comply with this requirement.
18 NYCRR 360-1.2, 360-3.3, PART 385

821 HR You refused to accept or complete an educational training program to which

you were referred by the office of Employment Services.
Code 823-0utput Code
for a 120 Day Sanction We have determined that your action was willful and without good cause. You
Code 549-0utput Code are disqualified from receiving Medical Assistance for 60 Days and until such
for a 180 Day Sanction time as you are willing to comply with this requirement.
18 NYCRR 360-1.2, 360-3.3, PART 385

825 HR You failed to accept an employer's offer to work through the New York State
Job Service.
Code 442-0utput Code
for a 120 Day Sanction We have determined that your action was willful and without good cause. You
Code 601-0utput Code are disqualified from receiving Medical Assistance for 60 days and until such
for a 180 Day Sanction time as you are willing to comply with this requirement.
18 NYCRR 360-1.2, 360-3.3, PART 385

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES ·
5.1-39
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - MA !MA: REAS - 241) !cont'd\

REFUSAL TO COMPLY WITH ELIGIBILITY REQUIREMENTS (CONT'D) (USED UNTIL 12/13/93)

CODE CATEGORY REASON

827 HR You voluntarily terminated your employment or reduced your earning capacity
and failed to furnish sufficient information to show that you did so for a
purpose other than qualifying for continued or increased Medical Assistance.
You are ineligible for 75 days and until such times as you are willing to comply
with work requirement.
18 NYCRR 385.8, 360-1.2, 360-3.3

832 ALL You failed to attend a treatment program for drug addicts or alcoholics.
18 NYCRR 385.4, 360-1.2, 360-3.3

833 ALL You failed to respond to our letter requesting written confirmation of your
participation in an appropriate rehabilitation program for drug or alcohol
abuse.
18 NYCRR 385.4, 360-1.2, 360.3. PART 385

837 ALL You failed to provide medical information needed to determine your potential
for rehabilitation or return to self support.
18 NYCRR 385.4, 360-1.2, 360-3.3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 241\ lcont'dl

ADMISSION TO PRIVATE OR PUBLIC INSTITUTION (USED UNTIL 12/13/93)

CODE CATEGORY REASON

600 HR You have been admitted to a private institution. (Adequate notice.)
18 NYCRR 360-1.2, 360-1.3, 360-3.3, PART 352

610 HR You have been admitted to public institution. (Adequate notice.)

18 NYCRR 360-3.4, 360-3.3, 360-1.2, PART 352

630 ALL You have been admitted to a penal or correctional institution. (Adequate
notice.)
18 NYCRR 360-3.4, 360-3.3, 360-1.2, PART 352

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX B • OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS - 2411 !cont'd!

RECEIPT OF OTHER TYPES OF ASSISTANCE (USED UNTIL 12/13/93)

CODE CATEGORY REASON

763 HR You are receiving assistance from a private agency.
18 NYCRR 351.22, 360-3.3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS - 2411 !cont'd)

MOVED OR WHEREABOUTS UNKNOWN (USED UNTIL 12/13/93)

CODE CATEGORY REASON

872 ALL You have permanently moved to another district within the State; therefore you
are no longer eligible for Medical Assistance from this district. If you continue
to be in need of Medical Assistance you should contact the local social
services agency in your new county of residence. (Adequate notice.)
18 NYCRR 311.3, 311.4

882 ALL You have permanently moved to another district outside the State; therefore
you are no longer eligible for Medical Assistance from this district.
18 NYCRR 311 A

890 ALL Your present whereabouts are unknown to us; therefore, you are not eligible
for Medical Assistance benefits.
18 NYCRR 351.2 (b), 360-1.2

900 . ALL After a field investigation, it has been determined that you are not residing at
the address of record.
18 NYCRR 351.2, 360-1.2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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APPENDIX B - OBSOLETE CASE REASON CODES CCONT'Dl

CLOSING CODES - MA !MA: REAS - 241! !cont'd!

MISCELLANEOUS (USED UNTIL 12/13/93)

CODE CATEGORY REASON

190 FA/SNFP End of four month extension of Medical Assistance eligibility after a finding of
ineligibility for FA resulting from unemployment

197* MSSI You are no longer eligible for SSI and have been determined ineligible for MA-
SSI (Immediate Closing).

779 Multi - Suffix Re-affiliated Client

While we evaluate if you are still eligible for Medical Assistance, we will
continue Medical Assistance coverage unchanged. This code is generated by
PA Individual Reason Code Y97.
This decision is based on Department Regulation (s) 360-2.6

784 Combined PA/MA Discontinuance

We will discontinue your Medical Assistance effective (date). This is for the
same reason that your Public Assistance is being discontinued. The regulation
cited is dependent on the PA Reason Code. This code is generated for
individual closing codes F63 and E72. The MA coverage date is the mailing
date.

962 ALL You will be receiving increased Social Security Benefits as of_·_. You are
no longer eligible for full Medicaid coverage because you have more income
than Medicaid allows for a household of your size.
18 NYCRR 360-1.2, 360-3.3, 360-4.6, 360-4.7, 360-4.8

963 ALL Your resources exceed the level that Medicaid allows for a household of your
size.
18 NYCRR 360-1.2, 360-3.3, 360:4.6, 360-4.7,360-4.8

964 SSl-Related You have failed to complete the mail recertification process.
18 NYCRR 360-2. 1, 360-2.2

990 ALL Other reasons Specify reason - This code is used only if none of the foregoing
reasons are applicable.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA IMA: REAS - 2411 !cont'd!

TMA-MA TRANSITIONAL BENEFITS ON CLOSED PA CASES (USED UNTIL 12/13/93)

CODE CATEGORY VALUE

851 ADC/ADCU MA suffix one month extension.
HR/HRPG 18 NYCRR 360-3.3 (c)

852 ADC/ADCU MA suffix three month extension.

HR/HRPG 18 NYCRR 360- 3.3 (c)

401 ADC/ADCU Administrative closing on Transitional Benefits Cases.

HR/HRPG

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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APPENDIX B - OBSOLETE CASE REASON CODES <CONT'D!

CLOSING CODES- MA IMA: REAS - 2411 lcont'dl

CODES USED AFTER 12/13/93

COPE CATEGORY VALUE

E04 FHP Excess Income Single/Childless Couple MA/FHP

EDS FHP Excess Income Due to COLA Increase (Discontinued 10/18/14)

E07 FHP Excess Income Due to COLA Increase and Ineligible for Surplus
(Discontinued 10/18/14)

E15 MA Pregnant Woman Didn't Return Form

E17 MA Incorrect/fraudulent Social Security Number.

E22 FHP Excess Income, Family Health Plus

E23 FHP Equivalent Health Insurance

E24 FHP Individual Reaching Age 65 Excess Income

E26 FHP Persons Turning 65 Excess Resources

E27 FHP Persons Turning 65 Ineligible for MA Excess Income/Resources

E35 MA Excess Income, Single/Childless Couples

E37 MA-SN Parents; Over Income

E39 MA Excess Income Due to COLA Increase (Discontinued 10/18/14)

E40 MA-SN Excess Income/ Resources S/CC

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2015

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS - 241! !cont'd!

CODES USED AFTER 12/13/93

CODE CATEGORY VALUE

E42 MA Excess Income CHP Transition child 6-18 Above 100% FPL

E43 MA Excess Income and Resources - CHP Transition child 6-18 Above 100% FPL
(CNS).

E49 MA Excess Income Child Turning One Year Old

E61 MA Not a Resident of District.

E68 MA Excess Income/Resources Child Turning One Year Old

E87 Failure to Comply with Recert Procedure PCAP Client Didn't Show for
Interview Newborn Extension (Discontinued 6/18/12)

EF1 MA/FHP Admitted/Committed to Prison Prior to 410108

EF4 ALL Suspend MA coverage for 21-64 Year Old Admitted to Psychiatric Center,
HH=1 (NYC) (Discontinued 6/18/12)

EF5 All Disc MSP for an Individual Admitted to a Psychiatric Center (NYC)
(Discontinued 6/18/12)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-47
10/18/2015

APPENDIX B • OBSOLETE CASE REASON CODES /CONT'D!

CLOSING CODES- MA IMA: REAS - 2411 !cont'd)

CODES USED AFTER 12/13/93

COQE CATEGORY VALUE

F13 MA/FHP Disc MA/FHP Fail to Return Recert Post Partum (Discontinued 10/19/09)

F31 MA-SN Parents; Over Income/Resources

F32 MA Excess Income Child 6-18 Above 100% of FPL

F43 MA Failure to accept treatment for alcoholism and drugs.

F44 MA Failure to comply with drug and/or alcohol screening (HH=1).

F45 MA Failure to comply with drug and/or alcohol assessment.

F46 MA Failure to sign or revoked the treatment informational consent form (HH=1).

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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APPENDIX B ·OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES- MA !MA: REAS· 2411 !cont'd!

CODES USED AFTER 12/13/93

CODE CATEGORY VALUE

F55 MA Excess Income, Children Age 1-5

F56 MA Excess Income and Excess Resources Children age 1 - 5

F57 MA Excess Income, Children at Least Six Years of Age.

F58 MA Excess Income and Resources, Children at Least Six Years of Age.

F59 MA Excess Resources

F68 MA Excess Income and Resources- Child 6-18 Above 100%Federal Poverty Level
(CNS)

F69 MA Excess Income and Excess Resources

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2015

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - MA IMA: REAS - 241! !cont'd)

CODES USED AFTER 12/13/93

CODE CATEGORY VALUE

F87 MA-FHP Discontinue FHP Excess Resources (NYC)

F89 FHP Discontinue FHP Excess Income/Resources (NYC)

FE1 MA Discontinue MA Excess Income, Child Age 6-18 (NYC)

G10 MA/FHP Didn't Show for Interview (Discontinued 6/18/12)

G48 FHP Disc FHP-PAP, ESHI Not Cost Effective, Ineligible for FHP Due to Equivalent
Health Insurance

H02 FHP Discontinue FHP - Public Employee (Discontinued 10/22/12)

H38 FHP/FHP-PAPDiscontinue FHP, Ineligible, Income Over 138% FPL

H39 FHP/MA Discontinue FHP, Ineligible, Income Over 223% FPL

H40 FHP/MA Discontinue FHP, Ineligible, Income Over 154% FPL

H41 FHP/MA Discontinue FHP, Ineligible, Income Over 155% FPL

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-50
02/21/2016

APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - MA IMA: REAS - 2411 !cont'd)

CODES USED AFTER 12/13/93

!;<QDE CATEGORY VALUE

M88 ALL Failed to Comply with Automated Finger Imaging Requirements, 18-21 Year
Old. (Discontinued 10/19/09)

M99 ALL Concurrent benefits - AFIS Match

U14 MA Didn't Show for Interview Pregnant Woman (Discontinued 6/18/12)

U16 MA Did Not Return Information, Pregnant Woman (Discontinued 10/19/09)

U65 Not a Resident of District (MA Extension)

UN3 FHP Failure to Return TPHI Documentation (Case Type 24 Only) (Discontinued
2016.1)

V30 MA Failure to comply with child support enforcement unit.

649 FHP Failure to Return TPHI Documentation (MA Case Type 24 Only) (System
Generated)

902 FHP Individuals Who Exceed the FHP Limit due to COLA Increase (Discontinued
10/18/14)

955 MA Continue MA- Recipient Must Call for Recert Interview (Discontinued 6/18/12)

971 MPE Failure to Appear for an Interview (Discontinued 6/18/12)

993 MPE Did Not Show For Interview (System Generated)

996 MA Failure to Comply with Recert Procedure PCAP Client Didn't Show (System
Generated) (Discontinued 6/18/12)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-51
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES /CONT'D!

CLOSING CODES - SNAP IFS: REAS - 231 l

CODES USED UNTIL 05/08/00

CODE VALUE
388 Failure to Comply with Finger Imaging Requirements
18 NYCRR 387.17

411 Ineligible Alien (HH=1)

Close the FS portion of a PA/FS case permanently because the alien/client has lost
eligibility as a result of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996.
18 NYCRR 387.9 (a) (2)

740 Forced Closing

NIA
901 Death of all Household Members (Notice not required)
18 NYCRR 387.20 (c) (1)

902 Change in Rent Expense

18 NYCRR 387.10 (a), 387.12 (e)

903 Change in Utility Expense

18 NYCRR 387.10 (a), 387.12 (e)

904 · Change in Child Care Expense

18 NYCRR387.10 (a), 387.12 (d)

905 Change in Telephone Expense

18 NYCRR 387.10 (a), 387.12 (e)

906 Change in Medical Expense

18 NYCRR 387.10 (a), 387.12 (c)

907 Change in Household composition

18 NYCRR 387.10 (a)

908 Institutionalization of only recipient in single person case

18 NYCRR 387.1 (t) (4) (vi), (vii) or (viii)

909 Combined with other PA/FS Household.

18 NYCRR 387.1 (t)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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APPENDIX B - OBSOLETE CASE REASON CODES ICONT'Dl

CLOSING CODES - SNAP IFS: REAS - 2311 !cont'd!

CODES USED UNTIL 05/08/00 (CONT'D)

CODES VALUE
910 Combine with other NPNFS Household.
18 NYCRR 387.1 (t)

915 Receipt of or increase in Boarder/Lodger income beyond allowable maximum

18 NYCRR 387.10 (a)

916 Receipt of or increase in employment income beyond allowable maxim

(Excludes jobs VIA NYSES)
18 NYCRR 387.10 (a)

917 Receipt of earned income from job secured thru NYSES and increase exceeds
allowable maximum.
18 NYCRR 387.10 (a)

918 Receipt of or increase (other than COLA) in Social Security benefits beyond allowable
maximum.
18 NYC RR 387.10 (a)

919 COLA in Social Security increases Social Security benefits beyond allowable
maximum.
18 NYCRR 387.10 (a)

920 Receipt of or increase (other than COLA) in SSI benefits beyond allowable maximum.
18 NYCRR 387.10 (a)

921 COLA in SSI increase SSI benefits beyond allowable maximum

18 NYCRR 387.10 (a)

922 Receipt of or increase in UIB benefits beyond allowable maximum

18 NYC RR 387.10 (a)

923 Receipt of or increase in relative contributions/support beyond allowable maximum

18 NYCRR 387.10 (a)

924 Receipt of or increase in income of non-household member

N/A

925 Failure to verify income (to be used only by the Income Clearance Program (ICP)
18 NYCRR 387.8 (c)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D\

CLOSING CODES - SNAP IFS: REAS - 231! !cont'd!

CODES USED UNTIL 05/08/00 (CONT'D)

CODES EDIT VALUE

926 Receipt of or increase in other unearned income
18 NYCRR 387.10 (a)

927 Failure to provide information required to establish eligibility for Food Stamp
benefits (to be used in instances where a recipient fails to comply with a
computer match call- in letter).
18 NYCRR 387.8 (c)

928 Resources exceed allowable maximum

18 NYCRR 387.9 (b)

931 R Failure to verify residence

18 NYCRR 387.8 (c), 387.17 (f)

932 R Failure to verify residence

18 NYCRR 387.8 (c), 387.17 (f)

933 R Failure to verify resources

18 NYCRR 387.8 (c), 387.17 (f)

934 R Failure to verify household size

18 NYCRR 387.8 (c), 387.17 (f)

935 R Failure to verify citizenship/alien status

18 NYCRR 387.8 (c), 387.17 (f)

936 R Failure of case head of provide identification document

18 NYCRR 387.8 (c), 387.17 (f)

937 R Failure to file recertification application

18 NYCRR 387.8 (c), 387.17 (f)

938 R Failure to verify questionable information at recertification

18 NYCRR 387.8 (c), 387.17 (f)

940 Change in Food Stamp Regulations.

N/A

V29 Failure to Provide Verification-Expedited FS (Timely)

18 NYCRR 387.8, 387.9, 387.14

R- To be used at recertification only

S- System generated Mass Recalculation closing codes

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-54
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APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D)

CLOSING CODES - SNAP IFS: REAS - 2311 !cont'd)
\

CODES USED UNTIL 05/08/00 (CONT'D)

CODES EDIT VALUE

946 s-- Adjusted household size is 0
18 NYCRR 387.1 (t)

947 s Failed Gross Income test

18 NYCRR 387.10 (a)

948 s Failed Net F.S.I. test.

18 NYCRR 387.10 (a)

949 s Coupon Amount less than or = 0

18 NYCRR 387.10 (a), 387.15

950 Failure to verify questionable information.

18 NYCRR 387.8 (c)

951 Failure to comply with Food Stamp Work Regulations

18 NYCRR 387.9 (a) (4), 387.1 (t) (4) (iv), 387.13 (e)

952 Terminated employment voluntarily

18 NYCRR 387.13 ( i)

954 Refused to comply with Social Security Number regulations

18 NYCRR 387.9 (a) (5), 387.1 (t) (4) (iv)

956 Failure to attend drug/alcohol treatment program.

NIA

958 Failure to cooperate with NYSDSS FS quality control review

18 NYCRR 7 CFR 273.2 (d) (2)

961 Concealed receipt of duplicate assistance on more than one case.

18 NYCRR 387.1 (t)

971 Originally ineligible: agency error in budget calculation

18 NYC RR 387.10 (a)

973 Failure to report for ID Card

N/A

975 Case number change: reopened under different number

N/A

R- To be used at recertification only

S- System generated Mass Recalculation closing codes

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-55
10/18/2014

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 2311 !cont'd!

CODES USED UNTIL 05/08/00 (CONT'D)

CODES VALUE
981 Recipients request: written
18 NYCRR 358-3.3 (e) (1) (xi)

983 Recipients request: not written

18 NYCRR 358-3.3 (e) (1) (xi)

985 Moved out of NYC: written reqwest

18 NYCRR.387.9 (a) (1)

988 Moved out of NYC: Verbal request

18 NYCRR 387.9 (a) (1)

989 Whereabouts unknown

18 NYC RR 387.9 (a) (1)

992 Intentional Program Violation

18 NYCRR 387. 1 (t) (4) (iii) 399.9 (c), 399.9 (g)

999 Other

F1 Purchase Illegal Drugs with FS-IPV (1st Violation (hh=1). Close the
FS portion of a PA/FS case for 12 months because the client has been convicted of
using FS to obtain illegal drugs.
18 NYCRR 359.9

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-56
02/21/2016

APPENDIX B - OBSOLETE CASE REASON CODES !CONT'D!

CLOSING CODES - SNAP IFS: REAS - 2311 !cont'd!

CODES USED AFTER 05/08/00

CODES VALUE
F35 Fleeing Felon Probation/Parole Violator (HH=1) (Timely). (Discontinued 10/20/08.)
18 NYCRR 387.1

F95 Ineligible Alien for Food Assistance Program (Timely). (Discontinued 10/18/10.)
18 NYCRR 388.3

G44 Probation Violator

18 NYCRR 351.2(k)(3)(ii)

G45 Parole Violator

18 NYCRR 351.2(k)(3)(ii)

M88 Failure to Comply with the Automated Finger Imaging System (AFIS) Requirements,
Not Homebound or Group Home Resident (Discontinued 6/18/12)

M99 Duplicate Assistance, AFIS, in NYS (Adequate) (Discontinued 10/22/12)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-57
10/18/2014

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-58
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES

OPENING CODES - PA IPA: REAS - 331 l

CODE CATEGORY REASON

064 ALL Eligible as a result of Hurricane Katrine or Hurricane Irene.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-59
10/18/2015

APPENDIX C ' OBSOLETE INDIVIDUAL REASON CODES <CONT'D!

OPENING CODES- MA !MA: REAS - 341!
CODE CATEGORY
018 MA Medical Assistance/Family Planning Benefits Program (Discontinued 6/18/12)

067 FHP Single and Childless Couple Eligible for FHP (Discontinued 2/20/12)
Eligible single and childless couples can only be used on FHP
MA: 369-ee
068 FHP FHP Parents (Discontinued 2/20/12)
FHP Parents level can only be used on FHP cases.
MA: 369-ee
069 FHP Pregnant Woman on MA Case (Discontinued 2/20/12)
FHP eligible pregnant woman active on a MA Case Type 20.
MA: 369-ee
074 FHP Family Health Plus Parent and Expanded Eligibility Children (Discontinued 2/20/12)
FHP Parents and children with expanded eligibility (can only be used on FHP cases)
MA: 369-ee
467 FHP/ESI Eligible Single/Childless Couple (Discontinued 2/20/12)
MA 369-ee
468 FHP/ESI Parents at Case Level (Discontinued 2/20/12)
MA 369-ee
469 FHP/ESI Pregnant Women (Discontinued 2/20/12)
MA 369-ee
474 FHP/ESI Parents and Expanded Eligibility Children (Discontinued 2/20/12)
MA 369-ee
670 MBl/DBG Medicaid Buy-In (Disabled Basic Group) Eligible at or below150%.
(Discontinued 2/20/12)
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law
671 MBl-MI Medicaid Buy-In (Medically Improved) Eligible at or below 250% but greater than
150%. (Discontinued 2/20/12)
Regulation 366(1)(a)(12) and 367-a(12) of the Social Service Law
A07 MA/FHP Individual Closed as Incarcerated in Error (NYC) (Valid 4/01/08) Restore Medical
Assistance/Family Health Plus (Discontinued 6/18/12)

H18 MA Medical Assistance/Family Planning Benefits Program (Discontinued 10/22/12)

H92 FHP/ESI Eligible Single/Childless Couple

MA 369-ee

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

OPENING CODES- SNAP IFS: REAS - 351!

CODE VALUE
064 Eligible as a result of Hurricane Katrina or Hurricane Irene.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-61
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 3311

CODES USED UNTIL 11/18/02

CODE CATEGORY REASON

C6 FA/SNFP Not eligible for CAP

PO ALL Undocumented Alien

PS ALL Non-Resident

TS ALL Unable to Locate

uo ALL Moved Out of District

us ALL Death before Determination: No Outstanding Medical Bills.

U6 ALL Death before Determination: Outstanding Medical Bills.

vs ALL Other
V6 ALL Other

WO FA/SNFP Transferred Property for Purpose of Qualifying for Assistance

SNCA/SNNC
X1 ALL Failure to Comply with Finger Imaging Requirements-Non Legally
Responsible Adult.

119 ALL Duplicate Assistance In NYS: This code is used when there has
been an Automated Finger Imaging Match (AFIS).

123 SNCA/SNNC Non-Qualified Alien-Emergency Medical Condition-Excess Income

(SNCA Related)

124 SNCA/SNNC Non-Qualified Alien Emergency Medical Condition-Excess

Resources

12S FA/SNFP Non-Qualified Alien Emergency Medical Condition-Excess Income

SNCA/SNNC and Resources (FA Related)

126 FA/SNFP Qualified Alien Five Year Ban-Emergency Medical Condition

Excess Income (FA] Related)

127 FA/SNFP Qualified Alien Five Year Ban-Emergency Medical Condition Excess
Resources ([FA Related)

282 ALL Fleeing Felon-Probation or Parole Violator

284 ALL Minor Failed to Complete High School Education

307 ALL Receiving Multiple Benefits

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-62
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 331! !cont'd!

CODES USED UNTIL 11/18/02 (CONT'D)

CODE CATEGORY REASON

360 ALL Duplicate Assistance Non-AFIS, In NYS

361 ALL Duplicate Assistance Interstate

531 ALL 6 Month 1st Offense- Less Than $1,000

532 ALL 12 Months 2nd Offense-Less Than $3,900

533 ALL 12 Months 1st Offense Between $1,000 & $3,900

534 ALL 18 Months if 3rd Offense

535 ALL 18 Months if 1st Offense More Than $3,900

536 ALL 18 Months if 2nd Offense More Than $3,900

537 ALL 5 years 4th or Subsequent Offense

538 ALL Court Ordered Disqualification

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - PA IPA: REAS - 3311 !cont'd)

CODES USED AFTER 11/18/02

CODE CATEGORY REASON

F35 ALL Fleeing Felon - Probation or Parole Violator, (Discontinued 10/20/08.)

G44 ALL Probation Violator

Client is currently in violation of probation. (Discontinued 10/19/09)
MA Status AP; FS Status RJ
PA: 18 NYCRR 351.2(k)(3)(ii)

G45 ALL Parole Violator

Client is currently in violation of parole. (Discontinued 10/19/09)
MA Status AP; FS Status RJ
PA: 18 NYCRR 351.2(k)(3)(ii)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-64
10/18/2015

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES ICONT'Dl

REJECTION CODES- MA IMA: REAS - 3411

CODE CATEGORY VALUE

PO* ALL Undocumented Alien

P5 ALL Non-Resident

R2 ALL Duplicate Application

R4 ALL Failed To Provide Information/Documentation

T5 ALL Unable to Locate

UO* ALL Moved out of District

E06 MA Non Immigrant/Undocumented Immigrant - No Medical Emergency

E20 FHP Excess Income of Parents and Children

E94 ALL Receiving SSI

E95 ALL Died

F32 MA-FHP MA Excess Income Child 6 through 18

F55 MA Child Age 1-5, Excess Income

F56 MA Child age 1-5, Excess Income and Excess Resource

F68 MA/FHP Excess Income and Resources Child 6 Through 18 Above 100% Federal
Poverty Level

F75 ALL Absent from Household Without Good Cause

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-65
10/18/2015

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REJECTION CODES - MA !MA: REAS" 341 l !cont'd!

CODE CATEGORY VALUE

F87 MA-FHP FHP Excess Resources (NYC) (Budget Type 01 & 04 only)

F89 MA/FHP FHP Excess Income/Resources (NYC) (Budget Type 01 & 04 only)

G48 FHP Deny FHP-PAP, ESHI Not Cost Effective, Ineligible for FHP Due to Equivalent
Health Insurance

H01 FHP Discontinue FHP - Public Employee

M97 ALL Receipt of Multiple Benefits - 1O YR.

M99 ALL Concurrent Assistance - AFIS Match

Client is already receiving Medical Assistance/Family Health Plus.
18 NYCRR 351.9

X40 FHP Failed to Choose Plan FHP FP (NYC)

X43 FHP Failed to Choose Plan FHP SCC (NYC)

X44 FHP Failed to Choose Plan FNP Parent (NYC)

NEW YQRK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-66
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D)

REJECTION CODES - SNAP IFS: REAS - 351!

CODES USED UNTIL 11/18/02

CODE VALUE
F1 FS Ineligible Student
387.9 (a) (3), 387. 1 (ee), 387.1 (t) (4) (i)

F2 Ineligible Alien
387.9 (a) (2), 387.1 (t) (4) (ii)

F3 Striker
387.16 Ul
F4 Failure to Apply/Provide SSN
387.9 (a) (5)

F5 Other FS Rejection

F6 Dead
387.20 (c) (i)

356 Ineligible Alien for Food Assistance Program

388.3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1,67
02/21/2016

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES ICONT'Dl

· REJECTION CODES -SNAP CFS: REAS - 3511 (cont'd)

CODES USED AFTER 11/18/02

CODE VALUE
F35 Fleeing Felon Probation/Parole Violator. (Discontinued 10/20/08.)
387.1

F95 Alien Ineligible for Food Assistance Program

Client denied because he/she is an alien who is not eligible to participate in
the Food Assistance Program. (Discontinued 10/18/10)
18 NYCRR 388.3

G44 Probation Violator.

Client is currently in violation of probation. (Discontinued 10/19/09)
18 NYCRR 351.2(k)(3)(ii)

G45 Parole Violator

Client is currently in violation of parole. (Discontinued 10/19/09)
18 NYCRR 351.2(k)(3)(ii)

M99 Duplicate Assistance. AFIS, in NYS

An Automated Finger Imaging match (AFIS) has identified the ciient as
receiving FS on another case in NYS. (Discontinued 10/22/12)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-68
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES- PA IPA: REAS - 331\

CODES USED UNTIL 11/18/02

CODE CATGORY REASON

13* ALL Failed to provide information about an absent parent or spouse.

14 ALL Failed to file a petition requesting medical support.

20 SN CA/SN NC Failed to cooperate with the Work Experience Program Intake.

21 SNCA Failed to report to or failed to cooperate with the Work Experience Program

22 ALL Failed to report to a scheduled appointment with the BEGIN.

23 ALL Failed to report to a scheduled appointment with the BEGIN Career Planning
Program.

24 SNCA/SNNC Failed to report to or failed to cooperate with the Work Experience Program
. Intake Section.

23 ALL Failed to report to a scheduled appointment with the BEGIN Career Planning
Program.

24 SNCA/SNNC Failed to report to or failed to cooperate With the Work Experience Program
Intake Section.

25 SNCA/SNNC Failed to adhere to the Sponsor Agency's regulations governing your

participation. (WEP) 90 day sanction.

26 SNCA Failed to adhere to the Sponsor Agency's regulations governing your

participation. (WEP) 150 day sanction

27 SNCA Failed to adhere to the Sponsor Agency's regulations governing your

participation. (WEP) 180 day sanction.

28 ALL Failed to continue attending the BEGIN Career Planning meetings.

29 ALL Failed to report to the BEGIN Job Club.

30 ALL Failed to report to continue attending the BEGIN Job Club sessions.

31 ALL Failed to report to a scheduled appointment at the BEGIN Language Program.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-69
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES - PA IPA: REAS - 3311 !cont'd!

CODES USED UNTIL 11/18/02 (CONT'D)

CODE CATGORY REASON

32 ALL Failed to continue attending the BEGIN Language program.

33 ALL Failed to report to a scheduled appointment at the BEGIN Work-Study

Program.

35 ALL Failed to continue attending the BEGIN Work-Study Program.

36 ALL Failed to continue your attendance in the TEAP Program.

37 SNCA/SNNC Failed to report to an appointment scheduled by the Job Placement Unit.

38 SNCA/SNNC Failed to report to an appointment scheduled by the Job Placement Unit, or

failed to cooperate with efforts to be place on a job or in training. (150 day
sanction)

39 ALL Failed to report to the BEGIN Job Club Prep ..

41 SNCA/SNNC Failed to report to an appointment scheduled by the Job Placement Unit, or

failed to cooperate with efforts to be place on a job or in training. (180 day
sanction)

43 ALL Failed to continue in the BEGIN Job Club Prep.

42* FA/SNFP Voluntary Quit (1st Occurrence) 90 day sanction.

SNCA/SNNC

50* FA/SNFP Voluntary Quit (2nd Occurrence) 150 day sanction.

SNCA/SNNC

51* FA/SNFP Voluntary Quit (3rd Occurrence) 180 day sanction.

SNCA/SNNC

44 ALL Failed to report to the BEGIN Assessment Program.

45 ALL Refused to accept or complete training in the Wildcat Subsidized Employment

Program.

154 ALL Minor absent from the household for 45 consecutive days or more.

283 ALL Failure to Comply With Drug or Alcohol Screening

308 FA Refused Offer Of a Home

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-70
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES - PA IPA: REAS - 331! !cont'd!

CODES USED UNTIL 11/18/02 (CONT'D)

CODE CATGORY REASON

01 ALL Non-Compliance with Outpatient Rehabilitation Program for Alcohol or
Substance Abuse 45 day sanction.

02 (Output Code) 120 day sanction.

03 (Output Code) 180-day sanction.

E2 ALL Failed to participate in BEGIN.

QO ALL Recovery, Lien Assignment: Homestead.

Q1 ALL Recovery, Lien Assignment Homestead.

so FA/SNFP Refuses an Offer of Employment.

SNCA/SNNC

W1 ALL Refused to Provid.e Information: Employer Group Health Plan.

W2 ALL Refused to Enroll in Employer Group Health Insurance Plan

W3 ALL Refused to Provide Information Other than Employer Based Health Insurance
Plan.

W4 ALL Refused to Enroll in Other than Employer Based Health Insurance Plan.

E3 ALL Failed to participate in BEGIN 90-day sanction.

E4 ALL Failed to participate in BEGIN 180-day sanction.

E6 ALL Refused to accept employment or training.

E7 ALL Failed to accept employment or training 90-day sanction.

E8 ALL Refused to accept employment or training 180-day sanction.

E65 ALL Failure to Complete Employment Assessment - Non-Durational.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-71
06/19/2016

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES- PA !PA: REAS- 3311 !cont'd!

CODES USED AFTER 11/18/02

CODE CATGORY REASON .

EY1 ALL Left residential treatment program - whereabouts unknown (45-day sanction).
(Discontinued 10/20/08.)

EY2 ALL Left residential treatment program - whereabouts unknown (120-day

sanction). (Discontinued 10/20/08.)

EY3 ALL Left residential treatment program - whereabouts unknown (180-day

sanction). (Discontinued 10/20/08.)

F12 ALL Failure to apply for SSI (Discontinued 06/21/2010)

F44 ALL Failure to Comply with Drug and/or Alcohol Screening

(Discontinued 02/16/2010)

F45 ALL Failure to Comply with Drug and/or Alcohol Assessment

(Discontinued 02/16/2010)

F46 ALL Failure to Sign or Revoked the Treatment Informational Consent Form
(Discontinued 02/16/2010)

GX1-3 ALL Failure to Take Part In and Complete Rehabilitation Program

(Replaced by PX 1-3 on 02/16/2010)

N42 ALL Voluntary Quit 2nd Occurrence (Discontinued 06/19/2016)

N43 ALL Voluntary Quit 3rd and Subsequent Occurrences (Discontinued 06/19/2016)

WE2 ALL Failure to Comply with Employment Requirements 2nd Occurrence

(Discontinued 06/19/2016)

WE3 ALL Failure to Comply with Employment Requirements 3rd and Subsequent
Occurrences (Discontinued 06/19/2016)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-72
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES- MA !MA: REAS - 3411

CODE CATEGORY VALUE

13 FA/SNFP You failed, without good cause, to provide information
SNCA/SNNC about an absent parent or spouse.
18 NYCRR 369.2, 360-1.2, 370-2

14 FA/SNFP You failed, without good cause, to file a petition requesting

medical support from a legally responsible relative.
18 NYCRR 369.2, 360-1.2

23 FA/SNFP On DATE you failed to report to a scheduled appointment

SNCA/SNNC with the BEGIN Career Planning Program. We have determined
that your action was willful and without god cause.
18 NYCRR 360-1.2, 360-3.3, PART 385
(Note: for FA case other persons in the case must be reclassified)

28 FA/SNFP On DATE you failed to continue attending the BEGIN

SN CA/SN NC Career Planning meetings. We have determined that your action
was willful and without good cause.
18 NYCRR 360-1.2, 360-3.3, PART 385
(Note: For FA, other persons on the case must be reclassified)

30 FA/SNFP You failed to report to an employer to whom

SNCA/SNNC you were referred by the New York State Employment Service.
We have determined that your action was willful and without good cause. You
are disqualified from receiving Medical Assistance for 30 days and until such
time as you are willing to comply with this
requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385 .
(Note: For FA- other persons on the case must be reclassified)

31 FA/SNFP You failed to report to a training program to which you were

SNCA/SNNC referred by the New York State Employment Service.
We have determined that your action was willful and without good
cause. You are disqualified from receiving Medical Assistance for
30 days and until such time as you are willing to comply with this
requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385
(Note: For FA - Other persons on the case must be reclassified)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-73
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES /CONT'D!

SANCTION CODES- MA !MA: REAS - 3411 !cont'd!

CODE CATEGORY VALUE.

40 FA/SNFP You failed to accept an employer's offer to work the New York State
SNCA/SNNC Employment Service. We have determined that your action was willful and
without good cause. You are disqualified from receiving Medical Assistance
for 30 days and until such time you are willing to comply with this requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385
(Note: For ADCU - Other persons on the case must be reclassified)

42 SNCA/SNNC You voluntarily terminated employment or reduced earning capacity and failed
to furnish sufficient information to show that the action taken was for a purpose
other than qualifying for continued or increased Medical Assistance. We have
determined that your action was willful and without good cause. You are
disqualified from receiving Medical Assistance for 75 days and until such time
as you are willing to comply with this requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385

44 FA/SNFP You refused to accept or complete training in the New York State Employment
SNCA/SNNC Service Program. We have determined that your action was willful and without
good cause. You are disqualified from receiving Medical Assistance for 30
days and until such time as you are willing to comply with this requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385
(Note: FA - Other persons on the case must be reclassified)

50 FA/SNFP You voluntarily terminated employment or reduced earnings capacity and

failed to furnish sufficient information to show that action taken was for a
purpose other th<in to qualify for continued or increased Medical Assistance.
We have determined that your action was willful and without good cause. You
are disqualified from receiving Medical Assistance for 30 days and until such·
time as you are willing to comply with this requirement.
18 NYCRR 360-3.3, 360-1.2, PART 385
(Note: For FA - Other persons on the case must be reclassified)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-74
·10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

SANCTION CODES- MA !MA: REAS -341! !cont'd!

CODE CATEGORY VALUE

QO* ALL Assignment of Property
You failed to comply with our policies regarding assignment or utilization of
your non-exempt property.
18 NYCRR 360-4.4

W1 ALL TPHI Resources

You refused to provide information on your employer group health insurance
plan.
18 NYCRR 360-3.2

W2 ALL TPHI Resources

You refused to enroll in an employer group health insurance plan.
18 NYCRR 360-3.2

W3 ALL TPHI Resources

You refused to provide information on other than an employer based group
health insurance plan.
18 NYCRR 360-3.2

W4 ALL TPHI Resources

You refused to enroll in other than an employer based group health insurance
plan.
18 NYCRR 360-3.2

F43 ALL Failure to accept treatment for alcholism and drugs

F44 SNCA/SNNC Failure to Comply With Drug and Alcohol Screening

We will discontinue Medical Assistance effective . This is because the
client did not take part in, or complete the alcohol/substance abuse screening
req uirem en!.
MA: 360-2.6

F45 SNCA/SNNC Failure to Comply With Drug and /Alcohol Assessment

We will discontinue Medical Assistance effective . This is because the
client did not take part in or complete the alcohol/substance abuse
assessment requirement.
MA: 360-2.6

F46 SNCA/SNNC Failure to Sign or Revoked the Treatment Informational Consent Form
We will discontinue Medical Assistance effective . This is because
client did not sign or revoked the consent for the release of treatment
information to this department.
MA: 360-2.6

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-75
10/18/2014

APPENDIX c - OBSOLETE INDIVIDUAL REASON CODES cc;;oNT'Dl

SANCTION CODES- MA IMA: REAS - 3411 (cont'd!

CODE CATEGORY VALUE

GX1 SNCA/SNNC Failure to Take Part in Rehabilitation Program-First Offense
We will discontinue Medical Assistance effective_ _. This is because the
client did not take part in and complete the out-patient rehabilitation program.
The client cannot get assistance for 45 days.
MA: 360-2.2 (d), 370.2

GX2 SNCA/SNNC Failure to Take Part in Rehabilitation Program-Second Offense

We will discontinue Medical Assistance effective_ _. This is because the
client did not take part in and complete the outpatient rehabilitation program.
The client cannot get assistance for 120 days.
MA: 360-2.2 (d), 370.2

GX3 SNCA/SNNC Failure to Take Part in Rehabilitation Program-Third Offense

We will discontinue Medical Assistance effective__ . This is because the
client did not take part in and complete the out-patient rehabilitation program.
The client cannot get assistance for 180 days.
MA: 360-2.2 (d}, 370.2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-76
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D)

SANCTION CODES - SNAP IFS: REAS - 351 I

CODES USED UNTIL 05/08/00

CODES VALUE
OS Sanction Period - 12 Months
359.9

DY Sanction Period - 24 Months

359.9

OF Sanction Period - Forever

359.9

E1 Failure to Comply with the Food Stamp Program's employment and training .
requirements.
387.13

Z1 FS Individual Fraud Sanction

359.9

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-77
10/18/2014

RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-78
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES PA IPA: REAS - 3311

CODES USED UNTIL 12/04/00

CODE CATEGORY REASON

04 FA/SNFP Dependent child has reached 18 and will not graduate High School before his/
her 19th birthday

cs FA/SNFP Not Eligible for CAP. Case is still enrolled in CAP action to be taken on the FS
component of case. This code can only be used in the CAP
Center 017

05 FA/SNFP Only dependent child has reached age 19

06 ALL Dependent child left household

07 ALL An adult left household

10 ALL Failed to keep or reschedule an appointment with Bureau of Client Fraud

Investigation (BCFI).

11 ALL Failed to provide documentation of birth

12 ALL Failed to apply for a social security number

15 SNCA/SNNC Failed to pursue SSI benefits claim and/or fail to cooperate fully with Social
Security Administration's Investigation

16 ALL Failed to comply with policies regarding assignment or utilization of your

property

52 ALL Failed willfully and without good cause to keep rescheduled appointment in
the Income Maintenance/Medical Assistance Center to evaluate employment

53 ALL Refused to provide information on employer group health insurance plan

54 ALL Refused to enroll in employer group health insurance plan

55 ALL Refused to provide information on other than employer based TPHI

56 ALL Refused to enroll in other than employer based TPHI

60 ALL Failed to attend a treatment program for drug addicts or alcoholics.

61 FA/SNFP/ Failed to respond to letter requesting written confirmation of participation in as

SNCA/SNNC appropriated rehabilitation program for drug or alcohol abuse

62 FA/SNFp/ Failed to keep an appointment with the Drug and Alcohol Abuse Referral Unit
SN CA/SN NC to evaluate participation in an appropriate rehabilitation program

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-79
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES (CONT'D!

REMOVAL CODES- PA !PA: REAS - 331! !cont'd!

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

63 ALL Failed to bring in the required permanent identification documents within 30
days.

64 ALL Failed to comply with request to have a medical evaluation

66 ALL Fail to comply with Finger Imaging Requirements - Non-Legally Responsible

Adult

70 ALL Client admitted to a private institution

71 ALL Client admitted to a public institution

72 ALL Client admitted to a penal or correctional institution

73 ALL Receiving assistance in a Shelter Care Program

74 ALL Receiving assistance in a Foster Care Program

75 ALL Receiving assistance from a private agency

76 ALL Receiving in-kind assistance from a private agency

81 ALL Permanently moved to another district within the State

82 ALL Temporarily moved to another district outside the state

83 ALL Permanently moved to another district outside the state

84 ALL Whereabouts are unknown

85 ALL After a field investigation it has been determine that client is not residing at the
address of record

87 ALL Client needs ;;ire included in the grant of another person in the home receiving
the same type of assistance

99 ALL Other reasons

143 ALL In violation of parole or probation, or fleeing to avoid prosecution, custody or

confinement after a felony conviction

144 ALL Client did not take part in or complete the alcohol/substance abuse screening
requirement

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-80
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES- PA IPA: REAS - 3311 lcont'dl

CODES USED UNTIL 12/04/00 (CONT'D)

CODE CATEGORY REASON

145 ALL Client did not take part in or complete the alcohol/substance assessment
requirement

146 ALL Client did not sign or revoked the consent for the release of treatment
information to this department

147 ALL Client is less than 18 years old, unmarried, have a child at least 12 weeks old
and failed to participate in a program to attain a high school diploma or an
alternative education or training program

153 ALL Client fraudulently misrepresented identity or residence to receive multiple

public assistance benefits. Ineligible to receive public assistance and food
stamp benefits for 10 years

155 ALL Client is unmarried, less than 18 years old, pregnant or residing with and
providing care for a minor dependent child. Refused to live in an approved,
suitable housing arrangement.

156 ALL Client is unmarried, less than 18 years old, pregnant or residing with and
providing care for a minor dependent child. Refused to live in an approved,
suitable housing arrangement. Investigated and rejected clients claim that the
home would jeopardize health and safety.

185 ALL Client identified as receiving public assistance in New York State.

186 ALL Client identified as receiving public assistance in New York State (AFIS).

305 ALL Client identified as receiving public assistance in another state.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-81
10/18/2014

APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D\

REMOVAL CODES- PA IPA: REAS - 331\ !cont'd\

CODES USED AFTER 12/04/00

CODE CATEGORY REASON

F35 ALL Fleeing Felon - Probation or Parole Violator. (Discontinued 10/20/08.)

F43 SNCA/SNNC Failure to Complete -In Patient Rehabilitation.

G44 ALL Probation Violator

Client is currently in violation of probation. (Discontinued 10/19/09)
MA continued, FS discontinued
PA: 18 NYCRR 351.2(k)(3)(ii)
G45 ALL Parole Violator
Client is currently in violation of parole. (Discontinued 10/19/09)
MA continued, FS discontinued
PA: 18 NYCRR 351.2(k)(3)(ii)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES ICONT'Dl ·

REMOVAL CODES- MA !MA: REAS - 3411

CODES USED UNTIL 05/08/00

CODE CATEGORY VALUE

01 ALL A dependent child in the household is deceased
18 NYCRR 360-2.6

02 ALL An adult in the household is deceased.

18 NYCRR 360-2.6

04 FA/SNFP Your dependent child has reached age 18 and will not graduate from high
school before his/her 19th birthday. He/she is no longer eligible for assistance
in the Family Assistance category or IVE Adoption Assistance. If still ·1n need,
he/she should apply for Home Relief.
18 NYCRR 30-2.2, 360-2.6

05 FA/SNFP Your only dependent child has reached age 19. Therefore, he/she is no longer
eligible to receive assistance in the Family Assistance category or IVE
Adoption Assistance. If still in need, he/she should apply for SNCA/SNNC
18 NYCRR 360-2

06 ALL A dependent child has left the household.

18 NYCRR 360-2.6

07 ALL An adult has left the household

18 NYCRR 360-2.6

10 ALL You failed to keep or reschedule an appointment with the Bureau of Client
Fraud Investigation
(HRA). 18 NYCRR 360-1.2, PART 351

12 ALL You failed to comply with the Social Security number requirement for_.
18 NYCRR 360-1.2, 360-2.2, 369.2, PART 351

53 ALL You refused to provide information on your employer group health insurance
plan.
18 NYCRR 360-3.2

54 ALL You refused to enroll in your employer group health insurance plan.
18 NYCRR 360-3.2

55 ALL . You refused to provide information on other than employer-based TPHI

18 NYCRR 360-3.2

56 ALL You refused to enroll in other than employer based TPHI.

18 NYCRR 360-3.2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D>

REMOVAL CODES- MA !MA: REAS - 341! !cont'd!

CODES USED UNTIL 05/08/00 (CONT'D)

CODE CATEGORY VALUE

60 ALL You failed to attend a treatment program for drug addicts or alcoholics
18 NYCRR 385.4, 360-1.2

61 ALL You failed to respond to a letter requesting written confirmation of participation

in an appropriate rehabilitation program for drug or alcohol abuse.
18 NYCRR 385.4, 360-1.2

62 ALL You failed to keep appointment with the Drug and Alcohol Abuse Referral Unit,
to evaluate participation in appropriate rehabilitation program.
18 NYCRR 360-3.3, 360-1.2, 360-5 PART 385

64 ALL You failed to comply with our request to have a medical evaluation.
18 NYCRR 385.4, 360-1.2

70 SNCA/SNNC You have been admitted to a private institution.

18 NYCRR 360-1.2, 360-1.3, 360-3.3 PART 352

71 ALL You have been admitted to a private institution.

18 NYCRR 360-3.3, 360-3.4, 360-1.2, PART 352

72 ALL You have been admitted to a penal or correctional institution.

18 NYCRR 360-1.2, 360-1.3, 360-3.3, PART 352

75 SNCA/SNNC You are receiving assistance from a private agency.

18 NYCRR 351.22, 360-3.3, 360-1.2

78 ALL You were granted Medic·a1 Assistance solely for the treatment of a medical
condition which has now expired.
18 NYCRR 360-3.2

81 ALL You have permanently moved to another district within the state.

83 ALL You have permanently moved to another district outside the state.

84 ALL Your present whereabouts are unknown to us.

85 ALL Not residing at the address of record.

91 FA/SNFP You have failed to present medical bills Safety Net families which meet or
exceed your monthly SSI Related surplus/excess income.

94 SSI You are no longer eligible for SSI and have been determined ineligible for MA
SSI.

99 ALL · Other reasons

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D)

REMOVAL CODES- MA !MA: REAS - 341! !cont'd!

CODES USED AFTER 05/08/00

QQDE CATEGORY VALUE

E26 FHP Disc FHP Turning 65, Ineligible for MA Exe Res (NYC)

E27 FHP Disc FHP Turning 65, Ineligible for MA Exe Inc and Res

E82 MA Discontinue Family Planning Services, Excess Income (Discontinued 6/18/12)

Regulation 366(1)(a)(11) and a(11) of the Social Service Law

E94 ALL Receiving SSI

EN1 FHP Failure to Return TPHI Documentation: Verification of Health Insurance and
Coverage

EN2 FHP Failure to Return TPHI Documentation: Verification of Health Insurance

Premiums

EN3 FHP Failure to Return TPHI Documentation: Verification of Health Insurance and
Coverage & Verification of Health Insurance Premiums

F32 MA Excess Income, Child 6 through 18 (Cat Codes 44, 46, 47 or 51 required)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES- MA !MA: REAS - 3411 !cont'd)

CODES USED AFTER 05/08/00 (CONT'D)

CODE CATEGORY VALUE

F55 MA Child age 1-5, Excess Income (Discontinued 2016.1)

F56 MA Child age 1-5, Excess Income and Excess Resourc.e

F68 MA Excess Income and Excess Resources Child 6 Through 18 Above 100%
Federal Poverty Level (Categorical Codes 44, 46,or 51 must be used with this
code)

F75 ALL Absent from Household Without Good Cause

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES- MA !MA: REAS - 3411 !cont'd!

CODES USED AFTER 05/08/00 (CONT'D)

CODE CATEGORY VALUE

F87 FHP FHP Excess Resources

F89 FHP Discontinue FHP Excess Income/Resources (NYC)

FE1 MA Discontinue MA Excess Income, Child Age 6-18 (NYC) (Discontinued 2016.1)

G48 FHP Deny FHP-PAP, ESHI Not Cost Effective, Ineligible for FHP Due to Equivalent
Health Insurance (Discontinued 2016.1)

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES <CONT'D! ·

REMOYAL CODES-.MA !MA: REAS - 3411 !cont'd!

CODES USED AFTER 05/08/00 (CONT'D)

CODE CATEGORY VALUE

H02 FHP Discontinue FHP-Public Employee
A person who is eligible for health care coverage through a federal, state,
county, municipal or school district benefit plan is not eligible for Family Health
Plus. (Discontinued 10/22/12)
Section 369-ee of the SSL and Chapter 5.8 of the Laws of 2005

M97 ALL Receipt of Multiple Benefits

M99 ALL Concurrent Assistance - AFIS Match

Client is already receiving Medical Assistance/Family Health Plus.
1.8 NYCRR 351.9

x40 FHP Discontinued MA Failed to Choose Plan FHP FP (NYC)

X43 FHP Discontinued MA Failed to Choose Plan FHP SCC (NYC)

X44 FHP Discontinued MA Failed to Choose Plan FNP Parent (NYC)

Y.83 ALL Opened in error via Newborn process

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX C - OBSOLETE INDIVIDUAL REASON CODES !CONT'D!

REMOVAL CODES - SNAP IFS: REAS - 3511

CODES USED UNTIL 05/08/00

CODES VALUE
399 Duplicate Assistance Within NYS (This code is used when there has been an
Automated Finger Imaging Match--AFIS)
18 NYCRR 351.2 (a), 351.9

K1 FS Ineligible Student
18 NYCRR 387.9 (a) (3), 387.1 (ee), 387.1 (t) (4) (i)

K2 Ineligible Alien
18 NYCRR 387.9 (a) (2), 387.1 (t) (4) (ii)

K4 Failure to Apply/Provide SSN

18 NYCRR 387.9 (a) (5), 387.1 (t) (4) (iv)

K5 Other FS Closing

K6 Dead
18 NYC RR 387.20 (c) (1)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX c - oasoLETE INDIVIDUAL REASON CODES (CONT'D!

REMOYAL CODES - SNAP IFS: REAS - 351! !cont'd!

CODES USED AFTER 05/08/00

CODES VALUE
F35 Fleeing Felon Probation/Parole Violator. (Discontinued 10/20/08.)
18 NYCRR 387.1

F95 Alien Ineligible for Food Assistance Program

Remove the individual from the case because he/she is an alien who is not eligible to
participate in the Food Assistance Program.
18 NYCRR 388.3

G44 Probation Violator

Client is currently in violation of probation. (Discontinued 10/19/09)
18 NYCRR 351.2(k)(3)(ii)

G45 Parole Violator

Client is currently in violation of parole. (Discontinued 10/19/09)
18 NYCRR 351.2(k)(3)(ii)

M99 Duplicate Assistance - AFIS in NYS

An Automated Finger Imaging match (AFIS) has identified the client as receiving FS
on another case in NYS. (Discontinued 10/22/12)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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RESERVED FOR EXPANSION

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
5.1-91
06/21/2015

APPENDIX D - OTHER OBSOLETE CODES

OBSOLETE SINGLE ISSUANCE CODES

SPECIAL GRANT CODES IPA ISSUANCE CODESI

*COPE TYPE OF ALLOWANCE COMMENTS

32 BIWEEKLY RECURRING BEGIN Discontinued 2007.3 10/22/07
CHILDCARE
53 HR/FS JOB SEARCH EXPENSE Discontinued 2007.3 10/22/07
61 BASIC KITCHEN EQUIPMENT FOR Discontinued 2007.3 10/22/07
PATIENT DISCHARGED
78 LEARNFARE REFUND Discontinued prior to 2007.3 10/22/07
AS SUPPLEMENTAL HSP RENT Discontinued 2007.3 10/22/07
(RECOUPABLE)
A9 HSP RENT SUPPLEMENT (NON- Discontinued 2014.1 02/15/14
RECOUPABLE)
K3 CAP CHILD SUPPORT RECONCILIATION Discontinued prior to 2007.3 10/22/07
K4 CAP CHILDCARE Discontinued prior to 2007.3 10/22/07
K5 CAP GRANT Discontinued prior to 2007.3 10/22/07
N4 BACK TO SCHOOL PAYMENT Discontinued 02/01/10

* NOTE: ALL CODES REQUIRE ONE OF THE FOLLOWING LEVELS OF APPROVAL UNLESS
OTHER LEVELS ARE SPECIFIED ABOVE:
• Up to $999.99 AJOS I/PAA I
• $1000 to $1,999.99 AJOS II/PAA II (Assistant Deputy Director)
• $2,000 and over ADMIN JOS I (Deputy Director)
All special grant code 99's and must have approval from an ADMIN JOS II (Center Director)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX D - OTHER OBSOLETE CODES !CONT'D!

OBSOLETE SINGLE ISSUANCE CODES (CONT'D)

SPECIAL GRANT CODES !SNAP ISSUANCE CODES!

CODE TYPE OF ALLOWANCE COMMENTS

28 REPLACE UNDELIVERED BENEFITS Discontinued 2007.3 10/22/07
30 REPLACE UNDELIVERED BENEFITS Discontinued 2007.3 10/22/07
32 REPLACE COUPONS Discontinued 2007.3 10/22/07
34 REPLACE COUPONS Discontinued 2007.3 10/22/07
41 REPLACE DESTROYED BENEFITS Discontinued 2007.3 10/22/07
43 REPLACE DESTROYED BENEFITS Discontinued 2007.3 10/22/07
45 EXPIRED/MUTILATED/CANCELLED Discontinued 2007.3 10/22/07
BENEFITS
47 REPLACE EXPIRED/MUTILATED/ Discontinued 2007.3 10/22/07
CANCELLED BENEFITS
60 ALTERNATE FOOD STAMPS Discontinued 12/04/00
KG SI CAP FS Discontinued 12/04/00
K9 SI PRE-CAP FS Discontinued 12/04/00

· OBSOLETE ABEL CODES

PA CASE TYPE CODES IPA:TYPEl

ADC (PA Center) Aid to Dependent Children (Replaced by FA)

ADCU (PA Center) Aid to Dependent Children - Unemployed (Replaced by FA)
HR (PA Center) Home Relief (Replaced by SNCA)
HRPG (PA Center) Home Relief Pre Investigation (Clients were evaluated and transferred to one
of the new categories)

FSUT INDICATOR CODES IFSUT: IND!

N Not Eligible for Combined Utility/Phone Standard (Disabled As of 1O/A/04)

PHONE INDICATOR CODES !PHONE: IND!

N Not Eligible for Phone Standard (Disabled as of 1O/A/04)

X Eligible for FS SUA Phone Standard (Disabled as of 10/A/04)

INSTALLATION TYPE CODES !INST: TYPE!

Removed As of 04/A/04

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX D - OTHER OBSOLETE CODES (CONT'D!

OBSOLETE ABEL CODES (CONT'D)

INCOME SOURCE CODES !INCOME/RECURRING: SRCI

03 Work Experience Non-WIN

58 Unearned Earnings from JTPA

SHELTER TYPE CODES CSHELT: TYPE!

20 Emergency Rental Supplement Program

41 Jiggetts-Approved Excess Shelter (Discontinued effective 04/30/10)
51 Congregate Care Level Ill - Enhanced Residential Care (Rest of the State)

INDIVIDUAL SPECIAL NEEDS TYPE CODES CSPEC NOS: TYl

57 Child Care Allowance for Non-PA Non-Legally Responsible Caretaker (Discontinued 2/17/13)

PA ADDITIONAL NEEDS TYPE CODES IPA: ADDL: TYi

42 HSP Shelter Allowance Supplement

43 LTSP Recurring Rent Supplement
44 EIHP Recurring Rent Supplement
48 Shelter Allowance Supplement Adults Only

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX D. OTHER OBSOLETE CODES !CONT'D!

OBSOLETE TAD CODES

OBSOLETE EMERGENCY INDICATORS IEMG: IND!· 270

c Child Assistance Program (CAP) (Discontinued 12/4/2000)

D CAP and EAF Authorization (F) (Discontinued 12/4/2000)
E CAP and Prior Emergency Authorization (P) (Discontinued 12/4/2000)

OBSOLETE STATE/FEDERAL CHARGE CODES !ST/FED CODE! - 307

31 Federal charge unaccompanied refugee minor - Eligible through age 20 if they

entered the country before age 18. (Discontinued 2009.3 10/19/2009)

OBSOLETE STATE/FEDERAL CHARGE DATES !ST/FED DATE! - 325

Charge Code Category Date Limit of State/Federal Charge

31 ALL Date of Entry Indefinite

PA CATEGORICAL CODES !CATI- 372

36 Presumptive Eligibility - Pregnant Woman (Use only with MA coverage codes 13 or 14) [FA/
SNFP/SNNC] (Discontinued 2012.1)
37 Federally Non-Participating (FNP) Alien [FA/SNFP/SNNC] (Discontinued 2011.3)

AFIS EXEMPTION INDICATOR IAFIS EX! - 392

9 Exempted Long Term Care (In-patient) (MA Only)

DOMESTIC VIOLENCE WAIVERS !WAIVERS!

DIA Drug/Alcohol Waiver

IVD IV-D Child Support Waiver
TL Time Limits for Cash Assistance Waiver
OTH Other

SYSTEM GENERATED VALUES may appear in these Domestic Violence Waiver fields to identify
which program requirements have been waived due to a domestic violence situation. These values
are not worker enterable through WMS.

X Waiver status is approved.

P Waiver status is partial (valid for IVD only).
E Waiver status has expired.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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APPENDIX D - OTHER OBSOLETE CODES !CONT'D!

OBSOLETE TAD CODES (CONT'D)

LIFELINE INDICATOR CODES !LFLNl

This field is only valid for FA, SNFP, SNCA, SNNC, and NPA/SNAP case types. (Discontinued 2/17/13)

N Client opts-out of Lifeline Program.

Space Client does not opt-out of Lifeline Program.

LANGUAGE READ CODES !LANG READ! - 281

C Blank Chinese-Mandarin (Discontinued 2015.1)
2 Blank Chinese-Cantonese (Discontinued 2015.1)
3 Blank Chinese-Other (Discontinued 2015.1)
CH Chinese-Toisanese (Discontinued 2015.1)

PA EMPLOYABILITY CODES !EMPl - 375

CODE CATEGORY DEFINITION
77 ALL Non-Exempt from PA Work Requirements/Exempt from SNAP Work
requirements and ABAWD (Discontinued 02/21/2016)
78 ALL Non-Exempt from PA and SNAP Work Requirements/ABAWD Exempt
(Discontinued 02/21/2016)

SNAP EMPLOYMENT CODE IFAPl - 375 (Discontinued 02/21/2016)

WA NPA Work Registration Required/ABAWD Exempt
WE Work Regulations Exempt
WR Work Regulations Required. (Only allowed if individual is aged 18-49 and the case does
not contain any individuals under 18 whose PA or SNAP status is AP, AC, SI, or SN.)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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02/21/2016

APPENDIX D - OTHER OBSOLETE CODES !CONT'D>

OBSOLETE MA CODES

EXPANDED ELIGIBILITY CODE !EEC!

B All Categories (BT's 01 and 05). See P, C and D.

C Child(ren) Calculate Total Net Income. Compares household net income To 133%
of the federal poverty level. (BT's 01 and 05 only). Children ages one through five years of age.
D Child(ren) six (6) through eighteen (18). Compares net income to 100% of the FPL {BT's 01 &
05).
F FHP for 19-20 years old living with their parents and adults living with their child (ren) compare
net income to 150% of federal poverty level.
Infants birth one year. (BT's 01 & 05). Compares household net income to 185% and 200% of the
federal poverty level.
J Medicaid/Family Planning Benefits Program: Income eligibility is at or below 200% of the FPL.
(BT 01,02 and 04).
K Family Planning Benefits Program Only: Income eligibility is at or below 200% of the
FPL. (BT 01,02 and 04).

N FHP for 19-20 years old not living with parents currently 100% of federal poverty level
(Valid on Budget Type 01 & 05 only)
P Pregnant women and Infants. Compares total net income to 200% of the federal poverty level.
(BT's 01 & 05 only).
S FHP for s/cc currently 100% of federal poverty level

RESOURCE CODE ICDl

19 Vehicle (Discontinued 2016.1)

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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CHAPTER 6-
INDICES

ITEM NAME INDEX

Page

ABAWD Ind. Code 1.4-5

Abbreviated CNS Notices (ABBR CNS) 1.2-7

Action Codes 3.1-15

AD EX Indicator 4.2-4

AFIS Exemption Indicator (AFIS EX) 1.4-17

Aged/Disabled Indicator Code (AID) 2.1-6

Alien Citizenship Indicator (ACI} 1.4-14

Alien Reg. Number 1.4-15

Associated Address Codes 3.1-50

Associated Code (ASSOC CD) 1.2-8

Associated Codes

(ASSOC:CD) - NSBL02 2.1-4

(ASSOC:CD) - NSBL06 2.1-10

Birth Verification Indicator (BVI) 1.4-4

Borough/Community District (B/CD) 1.2-1

Budget Source (BUD SRC) 2.1-11

Bureau Of Child Support Indicator (BCS) 1.4-11

Bypass Restriction Indicator 3.1-16

Category Codes

(CATEGORY) - DSS 2921 1.1-1

Case/Suffix Level (CAT) - DSS 3517Sec10 1.2-3

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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ITEM NAME INDEX (CONT'D)

DSS 3575 3.1-13

Individual Level (CAT) - DSS 3575 Sec 15 1.4-1

CBIC Card Codes (CC) 1.4-13

CBIC Card Delivery Codes (CDC) 1.4-13

CHTP Codes 1.4-13

Closing Codes

MA (MA:REAS)

Disaster Relief 4.1-60

Duplicate Assistance 4.1-45
Excess Income And Resources 4.1-30
Failure To Comply With Recertification Procedures 4.1-25
Health Insurance 4.1-53
Living Arrangements 4.1-41
Miscellaneous 4.1-58
Other 4.1-56
PCAP Cases 4.1-62
Spousal Impoverishment 4.1-52
System Generated 4.1-78
System Generated MA Extension Codes 4.1-66

PA (PA:REAS)

60 Month Time Limit 1.3-63

Admission To Private Or Public Institution 1.3-43
Change In Employment, Support or Income 1.3-28
Change In Resources Causing Ineligibility 1.3-47
Client Request 1.3-44
Duplicate Assistance 1.3-49
Failure To Comply With Recertification Procedures 1.3-48
Failure To Provide Verification 1.3-32
Intentional Program Violations 1.3-56

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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02/19/2017

ITEM NAME INDEX (CONT'D)

Investigatory - Eligibility Verification Review 1.3-51

Living Arrangements 1.3-42
Miscellaneous 1.3-60
Moved Or Whereabouts Unknown 1.3-41
Refusal To Comply With Eligibility Requirements 1.3-33

SNAP Only (FS:REAS) 1.3-65

Common Application Form - DSS 2921 1.1-1

Daycare Type Codes (DAYCARE:TYP) 2.1-9

Deduction Type Code (DEDUCTIONS:TYP) 2.1-9

Disability Accommodation Indicator (DAI) 1.4-1

Educational Level (EDUC) 1.4-16

Emergency Indicator (EMG:IND) 1.2-6

Employability Codes (EMP)

MA Only 4.2-4

PA 1.4-5

Employability Status Codes (EMP) 2.1-5

Employer Purchase Indicator (EPI) 4.2-5

External Budgeting Codes 2.1-1

Fair Hearing Codes (AID STATUS) 3.1-50

Fair Hearing Update Data Entry Form - DSS 3722 3.1-50

Frequency Codes (INCOME:FREQ) 2.1-8

FS Single Issuance Authorization Form - DSS 3574 3.1-14

FSUA Indicator Codes (FSUA:IND) 2.1-2

FSUT Indicator Codes (FSUT:IND) 2.1-3

Fuel Indicator Codes (PA:FUEL) 2.1-4

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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02/19/2017

ITEM NAME INDEX (CONT'D)

Heat Type Codes (FSUA:TYPE) 2.1-2

Highest Degree Obtained (HOO) 1.4-16

Hispanic/Latino Code 1.4-15

Homebound Indicator (HMBD) 1.2-6

Household/Suffix Financial Data - Screen NSBL02 2.1-1

Income Exemption Codes (INCOME:CD) 2.1-9

Income Source Codes (INCOME/RECURRING:SRC) 2.1-6

Individual Income/Needs - Screen NSBL06 2.1-5

Individual Reason Codes for MA

Opening Codes (MA:REAS) 4.2-6

Rejection Codes (MA:REAS) 4.2-9

Sanction Codes (MA:REAS) 4.2-31

Individual Reason Codes for PA

Opening Codes (PA:REAS) 1.5-1

Rejection Codes (PA:REAS) 1.5-5

Removal Codes (PA:REAS) 1.5-25

Sanction Codes (PA:REAS) 1.5-15

Individual Reason Codes for SNAP Only

Opening Codes (FS:REAS) 1.5-4

Rejection Codes (FS:REAS) 1.5-12

Removal Codes (FS:REAS) 1.5-31

Sanction Codes (FS:REAS) 1.5-23

Individual Special Needs Type Codes (SPEC NDS:TY) 2.1-10

Insurer Codes 3.1-19

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
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02/19/2017"

ITEM NAME INDEX (CONT'D)

IPV Indicator Flag (IPV) 1.4-17

Issuance Codes 3.1-14

Language Codes

(LANG) : DSS 2921 1.1-2

(LANG) - DSS 3517 1.2-4

Language Read Codes (LANG READ) 1.2-3

M3E Indicator (M3E) 1.2-1

MA Categorical Codes (CAT) 4.2-1

MA Coverage Codes (MA: GOV CD) 4.2-3

MA Coverage Codes (MA:COV CD) 1.4-3

MA Employability Codes (EMP). See Employability Codes (EMP)

MA Responsibility Area Indicator (MA RESP) 4.1-1

MA Responsibility Area Indicators (MA RESP) 1.2-6

MA Restricted/Exception Type 4.2-33

MA Restriction/Exception Record 4.2-33

MA Status Codes

Case/Suffix Level (MA:STAT) - DSS 3517 Sec 10 1.2-7

Individual Level (MA:STAT) - DSS 3517 Sec 15 1.4-2

Marital Status (MAR) 1.4-16

Medicare Savings Program (MSP) 1.4-11

Offense Subtype Codes 3.1-15

Offense Type Codes 3.1-15

Office Of Treatment Monitoring Indicator (OTM) 1.4-14

Opening Codes

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

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02/19/2017

ITEM NAME INDEX (CONT'D)

MA Only (MA:REAS - 241) 4.1-3

PA (PA:REAS) & MA (MA:REAS) 1.3-1

SNAP Only (FS:REAS) 1.3-5

Other Name Codes (CODE) 1.4-17

PA Additional Needs Type Codes (PA:ADDL:TY) 2.1-4

PA Case Type Codes (PA:TYPE) 2.1-3

PA Recoupment Data Entry Form - DSS 3573 3.1-15

PA Routing Codes (PA:ROUT) 1.2-7

PA Single Issuance Authorif'.ation Form - DSS 3575 3.1-1

PA Status Codes

Case/Suffix Level (PA:STAT) - NSBL02 1.2-7

Individual Level (PA:STAT) - NSBL06 1.4-2

Payment Exception Type Codes (PA, MA) 4.2-33

Period Codes (PER) 2.1-2

Pick-Up Codes 3.1-1

Principal Provider Category 4.2-33

Program Indicator Code (PROG) 2.1-8

Race/Ethnic 1.4-15

Race/Ethnic Affiliation Codes 1.1-1

Recertification Source (RCRT SRC) 1.2-2

Recoupment Indicator Code 3.1-13

Rejection Codes

MA Only (MA: REAS - 241) 4.1-10

PA (PA:REAS) 1.3-7

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-7
02/19/2017

ITEM NAME INDEX (CONT'D)

SNAP Only (FS:REAS) 1.3-22

Relationship Code (REL) 1.4-12

Relationship Of Mother To Child (MO CHILD) 1.4-17

Resolution Codes (RES CODE) 3.1-52

Resource Verification Indicator (RVI) 4.1-2

Restricted Indicator 3.1-12

Restriction Type Codes

Case/Suffix Level (RST) - NSBL02 2.1-4

Individual Level (RST) - NSBL06

Restriction/Direct Two Party Indicator 3.1-16

RFI Indicator (RFI IND) 3.1-51

RFI Status (Inquiry Codes) 3.1-52

Safety Net Indicator (SNET IND) 1.2-7

Saved Budgets - Screen NSBL35 2.1-11

Sex Codes (SEX) 1.4-1

Shelter Type Codes

(SHELT:TYPE) - NSBL02 2.1-1

(SHEL TER:TYPE) - DSS 3575 3.1-12

SNAP Categorical Eligibility Codes (CE) 2.1-4

SNAP Eligible Elderly/Disabled Alien Ind 1.4-15

SNAP Employability Code 1.4-5

SNAP Regulatory Citations for Change in Grant 1.6-8

SNAP Report Codes (FR) 2.1-1

SNAP Routing (FS:ROUT) 1.2-7

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-8
02/19/2017

ITEM NAME INDEX (CONT'D)

SNAP Status Codes

Case/Suffix Level (FS:STAT) - DSS 3517 Sec 10 1.2-7

Individual Level (FS:STAT) - DSS 3517 Sec 15 1.4-3

Spanish Indicator (SP IND) 1.2-6, 1.2-7

Special Grant Codes (ISSUANCE CODES) - DSS 3575 3.1-1

Special Needs Type Codes. See Individual Special Needs Type Codes

SSI Indicator (SSI) 1.4-11

State/Federal Charge Codes (ST/FED CODE) 1.4-4

State/Federal Charge Date (ST/FED DATE) 1.4-4

Student ID Code 1.4-13

Teenage Service Act Indicator (TASA) 1.4-5

Third Party Data Sheet Form - DSS 4198 3.1-18

Third Party Health Insurance/Medicare Source Code (TPHl/MCR) 14-11

30+1/3 Indicator (30 1/3) 2.1-5

Time Limit Exemption Indicator (TL-EX) 1.4-17

Trust Indicator (Tl) 1.2-2

Turnaround Document (TAD) - DSS 3517 1.2-1

Usage Codes (INCOME:U) 2.1-8

Utility Guarantee Indicator (UTIL GUAR) 1.2-1

Validate SSN Codes (VALIDATE) 1.4-1

Veteran's Indicator (VET) 1.4-14

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-9
02/19/2017

ITEM NUMBER INDEX

ITEMCODEPAGE

044 Utility Guarantee Indicator 1.2-1

053 M3E Indicator 1.2-1
061 Trust Indicator 1.2-2
063 Recertification Source 1.2-2
209 Category Codes 1.2-3
219 MA Responsibility Area Indicator 4.1-1
219 MA Responsibility Area Indicators 1.2-6
220 Homebound Indicator 1.2-6
221 PA Status Codes 1.2-7
222 PA Reason Codes (Case Closings) 1.3-27
222 PA Reason Codes (Case Denial) 1.3-7
222 PA Reason Codes (Case Opening) 1.3-1
224 PA Routing Codes 1.2-7
230 SNAP Status Codes 1.2-7
231 SNAP Reason yodes (Case Closings) 1.3-65
231 SNAP Reason Codes (Case Denial) 1.3-22
231 SNAP Reason Codes (Case Opening) 1.3-5
233 SNAP Routing 1.2-7
240 MA Status Codes 1.2-7
241 MA Reason Codes (Case Closings) 4.1-24
241 MA Reason Codes (Case Denial) 4.1-10
241 MA.Reason Codes (Case Opening) 4.1-3
249 ·Abbreviated CNS Notices 1.2-7
255 Language Codes 1.2-4
270 Emergency Indicator 1.2-6
273 Spanish Indicator 1.2-6
274 Safety Net Indicator 1.2-7
281 Language Read Codes 1.2-5
282 Resource Verification Indicator 4.1-2
290 Associated Code 1.2-8
304 Teenage Service Act Indicator 1.4-5
307 State/Federal Charge Codes 1.4-4
313 SNAP Eligible Elderly/Disabled Alien Ind 1.4-15
315 Sex Codes 1.4-1
320 SSI Indicator 1.4-11
321 Validate SSN Codes 1.4-1
323 Student ID Code 1.4-13
324 Veteran's Indicator 1.4-14
325 State/Federal Charge Date 1.4-4
328 Bureau Of Child Support Indicator 1.4-11
329 Relationship Code 1.4-12
330 PA Status Codes 1.4-2
331 PA Reason Codes (Individual Denial) 1.5-5
331 PA Reason Codes (Individual Opening) 1.5-1
331 PA Reason Codes (Individual Removal) 1.5-25
331 PA Reason Codes (Individual Sanction) 1.5-15
340 MA Status Codes 1.4-2

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-10
02/19/2017

ITEM NUMBER INDEX (CONT'D)

ITEM CODE PAGE

341 MA Reason Codes (Individual Denial) . 4.2-9

341 MA Reason Codes (Individual Opening) 4.2-6
341 MA Reason Codes (Individual Sanction) 4.2-31
343 MA Coverage Codes 1.4-3
345 Medicare Savings Program 1.4-11
350 SNAP Status Codes 1.4-3
351 SNAP Reason Codes (Individual Denial) 1.5-12
351 SNAP Reason Codes (Individual Opening) 1.5-4
351 SNAP Reason Codes (Individual Removal) 1.5-31
351 SNAP Reason Codes {Individual Sanction) 1.5-23
361 Other Name Codes 1.4-17
366 Birth Verification Indicator 1.4-4
367 Disability Accommodation Indicator 1.4-1
370 SNAP Employability Code 1.4-5
371 ABAWD Ind. Code 1.4-5
372 Categorical Codes 1.4-1
373 Native Hawaiian/Pacific Islander 1.4-15
374 White 1.4-15
375 Employability Codes 1.4-5
375 Employability Codes MA Only 4.2-4
378 Common Benefit Identification Card Code 1.4-13
379 Office Of Treatment Monitoring Indicator 1.4-14
380 Child/Teen Health Program Code 1.4-13
381 Alien Reg. Number 1.4-15
382 Alien Citizenship Indicator 1.4-14
383 CBIC - Card Delivery Codes 1.4-13
387 Marital Status 1.4-16
388 Educational Level 1.4-16
390 Highest Degree Obtained 1.4-16
391 Relationship Of Mother To Child 1.4-17
392 AFIS Exemption Indicator 1.4-17
393 Time Limit Exemption Indicator 1.4-17
394 IPV Indicator Flag 1.4-17
395 Hispanic/Latino 1.4-15
396 American Indian/Alaska Native 1.4-15
397 Asian 1.4-15
398 Black/African American 1.4-15
ITEM ALPHA INDEX

B/CD Borough/Community District 1.2-1

TPHl/MCR Third Party Health Insurance/Medicare Source Code 1.4-11

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-11
02/19/2017

REASON CODE INDEX

CASE (SUFFIX) LEVEL

PA, MA, AND SNAP Opening, Rejection, Sanction, and Closing Codes

vVUC PA PAGE 1v1A PAuc SNAP PAGE

Av RJ vL Av RJ vL Av RJ vL
.A03 4.1-3
AUD . 4.1-3
AU" 4.1-3
A.<U 1.3-1
A.<.. 4.1-3
A.<I) . 4.1-3
A2t 4.1-3
A211 4.1-3
A29 4 ..1....
A3U 1.3-1 1.3-5
A32 1.3-1
A34 1 .3-0
4.1-4
,.....
A41
4.1-4
,...o 1.3-5
A49 1 .3-5
Ali2 4.1-4
A63 4.1-...
A64 4.1-4
Ali7 ........ .

C> 11 1 .3-155
C> I :l 1 .3-o<>
C> 13 1.3-o<>
014 1.3-o<>
C> ,5 1.3-o<>
l:S:lb 1.3-o<>
en 1 4.1-.<u
LJUU 4.1-<>o
LJ.< I .
4.1-0
D22 4.1-5
D23 4.1-5
D24 4.1-5
u:.:5 4.1-0
u".: 4.1-0
u"o 4.1-0
. CU4 4.1-12
c·io . 1.3-7 1.3-22
CTI 4.1-30
c·i2 4.1-25
E18 1.3-0·1
C'I" 1.3-0·1 ·.

E22 4.1-12
E28 1.3-65
E29 ·. 1.3-22 1.3-65
C.>U 1.3-7 1.3-.<o 4.1-12 . 4.1-.>"I 1.3-.<.< 1.3-65
C.>"I 1.3-.<o 4.1-.>"I
C.>.< 1.3-.<o 4.1-.>"I
.
C.>.> 1 .3-.<o 4.1-.>"I
c.>4 1.3-7 1.3-28
c.>5 1.3-7 1.3-28 4.1-12 1.3-22
C.>I> 1.3-.<o 4. 1-.>.<

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-12
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

- . PA PAut: iv1A PAut: ~ .. Al' F"1'UC

Au KJ CL AIJ RJ CL AIJ vL
t:.>il 1.3-29 ""'
C.><> 1.3-.:ll 1.3-o<>
E40 1.3-.:ll 1.3-o<>
t:l>U 1.3-oo
t:l>"I 1.3-oo
E52 1.3-66
E54 1.3-66
Cl>il 4.1-1>.<
Cl>" 4.1-12
cou 1.3-7 1.3-•l"I 4.1-17 4.1-4.<
co·1 1.3-7 1.3-22 1..1-1>1>
E62 4.1-42
E63 1.3-7 4.1-17 4.1-43 1.3-22 1.3-1>1>
co4 1.3-7
CO<> LI-.>.>
coo 1.3-.. ·1 4.1-..,,
co" 1.3-H 1.3-.>.>
E7u 1.3-.<.< 1.3-66
E71 1.3-2Z 1.3-01>
t:7.: 1.J-H 1.J-43 4.1-17 1.3-.<.< 1.3-oo
t:73 1.3-H LS-43 4.1-17 4.1-.. ,,
. t:74 1.3-.<.<
t:75 1.3-.<.<
t:76 1.3-22 1.3-66
t:.77 1.3-Z2 1.3-67
t:/o 1.3-.<.< 1.3-1;7
t:'" 4.1-43
t:il.: 4.1-34
t:il3 4.1-o.:
EB6 1.3-B 1.3-33 1.3-23 1.3-6/
EBB 4, 1-o.>
EB9 4.1-;s.:
t:ll"I 1 ..>-411
E92 1 ..>-.S.S
E93 4.1-o.>
t:ll5 1.3-B 1.3-60 4.1-56 1.3-23 1.3-tl7
EE3 4.1-10
Et:4 4.1-10
EE5 4.1-10
t:I".< 4.1-41
Cl".> 4.1-41
t:l"I> 4.1-41
t:l"7 4.1-41
Cl"il 4.1-41
CIVI" 1 ..>-44
CIVI<> 1 ..>-44
CIVIi 1.3-44
CIVIO 4.1-41
CL"I 1.3-H 1.3-.>.>
CL2 1.3-H 1.3-.>..
CL.> 1.3-H 1.3-.>..
CL't 1.3-H 1.3-.>..

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-13
02/19/2017

REASON CODE INDEX (CONT'pl

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes
.

vUUt: l"'A l"'AuE 1v1" PAe>E :SNAP PAut:

AC RJ vL AC KJ vL AC KJ CL
t:L5 1.3-29
l"Ull 4.1-13 4.1-.>.>
r-·10 1.3-S
,..,., 1.3-ou
r-·1 Z . .. .-1 .... 1
,..,5 1.3-.<.> 1.3-67
,..,, 1.3-S 1.3-34 4.1-20 4.1-47 1.3-67
l""l ll 1.3-.<.> 1.3-67
t".<U 1.3-S 1.3-.>.. 4.1-.<u 4.1-.. ,
,. .<"I 1.3-.<.> 1.3-67
. ,. "" 1.3-67
F26 4.1-1.> 4.1-33
F28 4.1-1.> 4.1-3l>
t".>U 1.3-.<.> 1.3-oo
,. ,,,,
,...,.
1.3-ll 1.3-.<:7
1.3-29
I'".> I .
1 ..>-.<.>
F39 1.3-30
F40 1.3-9 1.3-35 4.1-47
t-43 4.1 ... 0
t-49 1.3-.:.>
t-5u 4.1-.:u
t-51 4.1-.:u
F5;.: 1.3-9
t-53
,...,.
l'"O.<
1.3-1
1.3-9 1.3-35

1 ..>-51

,..,,.
l'"O.> 1.3-ll 1 .., ... ., 4.1-43 1.3-.o<.>
1 ..>-43 4.1-44
F65 1.3-68
F70 1.3-23 1.3-68
F71 1.3-23 1.3-68
F76 1.3-35
1"11"1 1.3-"IU 1.3-35
1"114 1.3-"IU 1.3-35
F85 1.3-68
l"llb 1.3-Z3 1.3-bll
F90 1.3-Z3 1.3-011
t" ll.o< 1.3-10 1.3-ou 4.1-TI 4.1-48 1.3-.:.> 1.3-bll
,.,,,,
,.,,. 1.3-"IU 4.1·TI
.. 1.3-.:.> 1.3-bll
l"llb 1.3-bll
t"ll8 1.3-10 1.3-44
,.,,9 4.1-44
l"t:"I 4.1-14 .

\.:IU"I 1.3-51
u·IO. 1.3-48
\.>Tl 4.1 ......
\.:1"14 4.1-.:o
u·16 1.3·0·1
\.:1"17 1.3-0·1
\.:1"18 4.1-1 ..

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-14
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

vVUC r-" r-""' c 1¥1" '"""'c :SNAI' l'Auc

KJ vL l,;L Al,; KJ
u20 "" 1.3-48
"" "" vL

"'"' I 1.3-o"'
1.3-o"'
"'"'"' 1.3-0:l
"'"'" 1.3-""'
"'"'"
u.c.5 1.3-52
1.3-52
"'"'"
"'"', 1.3-5:t
ULO 1.J-OJ
l:i:lll 1.J-5J
l:i.>U 1.J-u.>
G31 1.3-l)J
l:i32 1.3-l)J
G33 1.3-t>.>
"'"" .
1.3-:.
1.3-48
""" 1.3-48
""'
G39 · 1.3-t>U 4.1-56 1.3-69
u40 1.3-.>u
\:J'l'I 1.3--.u 1.3-30
G46 1.3--.u
U'l7 4:1-4.>
4.1-·1i1
"""
G53 1.3-69
G55 1.3-60
4.1-.<o
""" 4.1--1'1 4.1-.>o
""' 4.1-.<u 4.1-.><>
""" 4.1-.<u 4.1-.>D
"'""
l:i60 1.3-·iu 1.3-53
u61 1.3-41
u62 1.3-41 4.1-44
1.3-.<'I
"'"" 4.1-'lo
"'"" 4.1-44
"'"I
UO 1.3-53
u83 4.1-u.>
u87 1.3-44
uoo 1 ..>-'1'1 4.1-"' I 4.1 ·<>U
uo" 1.3-11 1 .., ......
l:illU 1 ..>-'1'1.
1.3-11 1.J-45
"'""' 4.1-1>3
"'"" 1.J-45
"'""
l:illO 1 ..>-,' 1.J-03
1.J-•. 1.3-46
"'"" 1 ..>-41>
"'",
l:illtl 1.J-41> 4.1-:ll 4.1-at
l:illll 1.3-11 1.3-46
HOS 4.1-21
H-.u 4.1-:..<
M'll 4.1-52

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-15
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

.
vUUC "" PAuE MA l'AUC »NAP PAuc
AC KJ KJ RJ
H"I"
vL
1.3-o.> "" vL
4.1-49
"" vL

4.1-5
""'"'
n.<4 4.1·.<·1 .

n.<5 4.1-H> 4.1-.>D

H2ij 4.1-·10 4.1-.>t
H2ti 4.1-5
n.>.> 4.1-15 4.1-37
4.1-1l> 4.1-.>o
"""' 4.1-1l> 4.1-.>o
"""
n.>o 4.1-1l> 4.1-.>o
4.1-1ij 4.1-.>o
""'
H42 4.1-21
H43 4.1-5
H44 4.1-.>:>
H45 4.1-.i:>
H4ti 4.1-40
H4t 4.1-4U
H4!! 4.1-49
H4ll 4.1-47
nou 4.1-5
r1b1 4.1-oo
no .. 4.1-5
no4 4.1-5
H65 4.1-ti
H66 4.1-ti
Hb7 4.1-b
Hb!! 4.1-b
Hbll 4.1-b
H/U 4.1-b
Hf"I 4.1-6
H/2 . 4.1-6
H/3 4.1-6
H74 4.1-6
H76 4.1-6
.
Ht7 4.1-6
H78 4.1-6
"H79 . 4;1-6 .

H81 4.1-6
no.< 4.1-7
no.> 4.1-7
no4 4.1-7
HOO 4.1-7
.
HOO 4.1-7
H'1"1 4.1-7
4.1-7
"""'
M:>D 4.1-7
n:>o 4.1-7
4.1-7
"""
nn8 4.1-21 4.1-51 .

.
nn9 4.1-22 4.1-0·1
14ij 1.3-47 1.3-D:>
In 1.3-.<.. 1.3-D:>

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES

6.1-16
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

... uDt: ,...,.. PAuE IVI/'\ r/'\Ut: .,,.,..,... l'Al.:iE

,...... KJ IJL AC KJ IJL ,...... vL
.. us ""
LH~4 1.3·o~

IVIU" 4.1-10
1v1u5 4.1-4:.
IVI 13 1.3·TI 1.3-49 4.1-18 1.3-24 1.3-69
IVI I:) 1.3-TI 1.3-35
M:.:U 1.3·1U
M:.:4 4.1-4:1 1.3·1U
IVl:.::J 1.3-1.< 1.3·.)b 4.1-;,:;.: 4.1 ·4:1 1.3·1U
IVl"O 1.3-24 1 ..)·IU
M27 I 1.3-24 1.3-70
M32 4.1-<:<:
IVl.)4 1.3-<:4
IVl.)lJ 1.3·"1"
IVl.)f 1.3·"1"
IVl44 1.3-.>b
1v148 1.3-12 1.3-4Z
M49 1.3-42
1v150 1.3-....
1v153 1.3-70
·IVI05 1.3-U
IVIDD 1.3-U 4.1-111 1.3-.<.. .

IVIDI 1.3-12 4.1-18 1.3-24

IVID<> 1.3-61 4.1-44 1.3-70
IVll"I 1.3-13
1vi7ti 1.3-13
1v177 1.3-13
1vi7H 1.3-13
1v179 1.3-13
IVIO I 1.3-54
IVJO.< 1.3-54
IVIOO 1.3-13 1.3-.;io
IVIO~ 4.1 •<JU
IVl~U 1.3-24 1.3-t u
M91 1.3-24 1.3·t I
M97 1.3-.. ~ 4.1-45 1.3-24 1.3·t I
M98 1.3-14 1.3-4:. 4.1·11:1 4.1-45 1.3-24 1.3-71
1.3-1 .. 1.3-.. ~
···~~
IVI" I 4.1-78
4.1-78
'"""
IVIA1 1.3-14
IVIA" 1.3-14
MJl.3 1.3-14
N1U 1.3-14 1.3-Z4 1.3-f"I
NiZ 1.3·.>D
N"l3 1.3-"l'I .

Ni4 1.3-·1 o 1.3·.>D

N"l5 1.3-·10 1.3-54
N"l6 1.3-·1 o 1.3-36
NH 1.3-·1 o 1.3·.)f
N"l8 1.3-n
N"l9 1.3-15
N.<U 1.3·.) I

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-17
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

vVUC PA PA"'c IVll\ l'A\>E . <>NAt' t'l\\>C

AG RJ vL RJ vL AG RJ Gl
N.<·1 1.3-·1 o
"" ..
N.>l 1.3-Z5
N.>.< 1.3-.<o
N33 1.3-.<o
N41 1.3-31 1.3-71
N4Z 1.3-n ·
N43 1.J-t"
......
N'+O
1.J-.>t
1.J-.> I
NOO 1.J-ou 4.1-'+0 1.J-.<o 1.3-7z
1~01 1.3-ou 4.1-'+0 1.3-72
N70 1.3-54
N71 1.3-54
N7<: 1.3-54
NOO 1.3-37
m:ru 1.3-.<o 1.3-t .<
Nrl . 1.3-.<o ' 1.3-t"
NrL 1.3-<:5 1.3-72
r-LU 1.3-fo
r-.>u 1.3-o<t
r- .> I 1.3-o<t
..... 2 1.3-o<t
t'44 1.3-11> 1.3-37
P45 1.3-16 1.3-37
P46 1,3-16 1.3-38
P47 4.1-7
t'Jl:I 1.3-.>!!
t'A.< 1.3-.>!!
t'A.> 1.3-.>!!
1.3-5
"'"" 1.3-5
"'""
..... o 1.3-oo
R'n 1.3-oo
l'<>lll 4.1-tt> 1.3-.<o
U'1.> 4.1-.<.< 4.1-26
U15 4.1-64
U20 4.1-27
U21 4.1-28
U23 4.1-Z3 4.1-.<!!
U40 1.3,.,., 1.3-47 1.3-25
U41 1.3-·11> 1.3,47 1.3-25 1.3-71
U42 1.3-16 1.3-47
U43 . 1.3-47
U44 1.3-17 1.3-47 1.3-.<o 1.3-t"
U45 1.3-t .>
U54 4_.,_,.u
Uti·1 4.1-.<o
U9t 1.3-t .>
v13 4.1-.<.> 4.1-50
v18 4.1-H>

....,
VLU
1.3-11
1.3-.>L
1.3-Z5 1.3-73

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES

6.1-18
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

1,;uDE t'"A t'"A\>C IVIA PAGE <>NAP PAGE

AC RJ CL AC RJ "'- Al. RJ "'-
V23 1.3-17 1.3-32
v.:4 1.3-17 1.3-.>..
V;<5 1.3-17 1.3-.>..
V;<b 1.3-3Z
vou . 1.3-55
VCl 1.3-.>o
vE2 1.3-.>o
VC.> 1.3-.>o
VV"IU 1.3-H

....,,
VVTI

vv.>5
1.3-17
1.3-H
1.3-·10
1.3-.>o
1.3-32
1.3-61 1.3-<:5 1.3-73
vv40 1.;1-·10 1.3-38

...."
W44

VVVI
1.3-·10
1.3-·10
L!·D I
1.3-01
1.3-.>::7
LS-.:o
1.3-.:o
1.3-73
1.3-73

VVl..< 1.3-.>::7
vvc1 1.3-10 1.3-73
vvc2 1.3-t3
VVC.> 1.3-73
vvri 1.3-.:o
vvr.< 1 ..1-.:o
vvr.> 1 ..1-.<o
VV<>l 1.3-19 1.3-So
W":>2 1.3-19 1.3-50
VV<>.> 1.3-19 1.3-57
vv<>4 1.3-.<u 1.3-57
W':>O 1.3-.<u 1.3-58
VV<>D 1.3-.<u 1.3-58
vv<>7 1.3-;<U 1.3-59
VV<>O 1.3-Z1 1.3-59
VVAl 1.3·.!lj
VVA'+ 1.3-.!lj
.
A'1.< 4.1-5Z
A'1" 4.1-5Z
X50 4.1-53
X51 4.1-0 ..
X52 4.1-oo
Abb 1.3-t ..
l'OZ 4.1-ot
YU.I 4.1-57
no 1.J-74
n2 1.3-26
n4 1.3-61
TH 1.3-5
y·19 1.3-1
,.... 1.3-t't
4.1-ot
y ""
Y26 4.1-57 1.3-74
Y27 4.1-7

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES

6.1-19
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

vUUC . '"" PAuc IVIA ..,."'c SNAP PAuE

Av RJ vL AC RJ vL AG RJ vL
Y29 . 1.3-74
T.>U 4.1-01
T.> I 4.1-57
J ,,, 1.3-1
T.>O 1.3-1

,. ,
T.>'7 1.3-1
.
1.3-1

.
,'"",,
Y45
1.3-;.!
1.3-;.!
1.3-ll
Y4t> 1.3-;.! 1.3-t>
Y47 1.3-2 .

Y50 1.3-.:: I 4.1-23

T <J I 1.3-;.! 1.3-t>
r ""
. 1.3-o I 1.3-74
r ""
4.1-f .

J <>I 4.1-f
Y58 4.1-7
Y59 4.1-7
r65 1.3-:l
r66 1.3-74
Tb7 1.3-:l 4.1-7
Jblj 4.1-7
Y69 4.1-7
Y78 1.3-55
. flj4 4.1-·1:1 4.1 •<JU
Jljb 1.3-55
Jlj/ 1.3-55
T'1.> . 1.3-b'I 1.J-74
Y94 1.3-21 1.3-26
Y95 1.3-21 1.3-b'I
Y96 1.3-b.< .

T'7ij 1.3-b.<
T'7:1 1.3-.t'I 1.3-b.< 4.1-.<.> 4.1-57 1.3-:tb 1.3-74
LTI 1.3-75
U.<:I 1.3-6
Ub4 1.3-6
U:I.> 1.3-4 4.1-9
U:l:I 1.3-6
'IDD 4.1-bb
HO 4.1-0lj
194 4.1-58
198 4.1-58
244 1.3-46
4.1-.<.>
"""
.>.::.:: 4.1-bU
.>.::.> 4.1-bU
,,,,,, 1.3-75
'. 4uu 1.3-1
4u1 1.3-62

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-20
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

1,,uDE r-A PAl.>E IVIA PAl.>C SNAP l'Al.>C

AG RJ '-L AG RJ '-L ,..., RJ vl
414 4.1-9
415 4.HI

...,,
4'16 4.1-DD
4.1-DD
40U 4.1-DD
501 4.1-66
576 4.1-46
DU.< 4.1-ll
DU.> 4.1-DD
ou5 4.1-11
DUD 4.1-01
DUO 4.1-9
DU'1 4.1-8
. DI.> 4.1-ll
Dl't 4.1-ll
4.1-ll
ti "'
DID 4.1-11
620 4.1-06
6.<1 4.1-8 .

DLL 4.1-8
ti31 4.1-5::>
ti3:.! 4.1-9
ti33 . 4.1-9
660 4.1-67
667 4.1-8
bb9 4.1-8
701 4.1-bll
IU..,_ 4.1-bt
7u.> 4.1-bt
7Ub 4.1-67
n4 4.1-67
718 4.1-68
n9 4.1-67
I .<'I 4.1-oo
130 4.1-Do
731 4.1-Do .

732 4.1-Do
736 4.1-Do

,...,
l'IU 4.1-oo
4.1-Do
IOU 4.1-D'1
753 Ll-4
756 4.1-D'1
759 4.1·D'1
701 4.1-tu
ID.> 4.1-tu
llU 4.1-tu
4.1-tu
""' 4.1-70
"" 4.1-70
"" 4.1-t I
""
llD 4.1-t I

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-21
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

liUUt: l"'A l"'Aut: MA PAuE SNAP PAut:

AC KJ CL Ali . RJ liL AC RJ . '-L
777 4.1·1"1
//H 4.1·1"1 .

/Hll .
4.1·1"1
/H1 4.1-72
/HZ 4.1-72
783 4.1-72
784 4.1-72
785 4.1·/ .<
786 . 4.1·/,) .
787 4.1·/,) .

799 4.1·/,)
BOO 1.3-4
806 4.1-8
808 4.1-73
812 4:1=lf
813 4:1=lf
814 4:1=lf
816 4.1-73 .

822 4:1-9
H3U 4.1-:.!3
1!39 1~:>-4
H4U ~
4.1·l>U
!!'ff 4.1-50
842 4.1-50
846 4.1-74
847 4.1-74
850 4.1-74
853 4.1-8
1165 . 4.1-8
1!66 4.1-74
1!67 4.1·/4
11114 4.1-19
!!Ill! 4.1-8
l!U1 1.3-6
l!Ul> 4.1·/l>
911 4.1-75
914 1.3-75
923 4.1-8
""" 1.3-43 4.1-75 1.3-75
943 1.3-:<::<:
944 1.3-75
957 4.1-76
958 4.1-76
959 4.1-76
"hZ 4.1·/I>
"hh 4.1·/I>
"hH . 1.3·/ 0
4.1·1>·1
lJ ' "
976 1.3-75
977 1.3-75
>!HU . 4.1-65
.
"H.1 4.1 """

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-22
02/19/2017

REASON CODE INDEX (CONT'D)

PA, MA, AND SNAP Case Opening, Rejection, Sanction, and Closing Codes

'"'vDE PA PAuc <>Nf\r- PAl>E

..... KJ '"'L
"'"'
"'" PAl>t:
'"'
... L
"'"' '"' ... L
'105 4.1-oa
4.1-ao
"""' 1.3-t"
"""
,,,,4 4.1-29
,,,,5 4.1-29
" 4.1-.<;:>
""'
'1'10 4.1-.. ,,

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-23
02/19/2017

REASON CODE INDEX (CONT'D)

INDIVIDUAL LEVEL
For PA and MA Opening, Rejection (Denial), Sanction and Removal Codes

vVUI:: rtt l'Aut: MA PAGE l>NAI' PAGE

Al.I RJ l>N I.IL AC RJ l>N vL AC RJ l>N vL
uo .. 1.5-3 . 1.0-4
1.:1-J
""
97 1.5-J
·1u·1 1.5-J
.424 4.2 .....
920 4.2-8
9.. 1 1.5-.JU 4.2-8 .·
. 1.5-33
"""
A" 1.5-1 ·
A4 4 ....t;
A5 1.5-1
. A7 4.2-6
'-U 1.5-1
C1 1.5-1
1.5-1
""
..,,, 1.5-1
1,;4 1.5-1
DO 1.5-1
D5 1.5-1
uo 1.5-1
U7 1.5-" .

uo 1.:>-"
t:5 1.5'"
ru 1.:>-2
\.'JU 1.:>-2
1.:>-"
"'"
u6 1.5-:.!
HO 1.5-2
H5 1.5-2 .
.
IU 1.5-2
11 1.5-2
.
1.5-J
'"
,.
13

15
1.5-3
4.2-6
4.2-6
19 4.2-6
JO 4 ... -t;
JI 4.2-6
J" 4.2-6
J,) 4.2-6
J4 4.2-6
JO 4.2-6
LJl 1.5-4
LL 1.o-.
LM 1.0....
L£ 1.o-.
Vt 1.5-3

.
ttU.>
,. ,
A64
4 ...-f
4 ...-f
4 ...-f
.

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-24
02/19/2017

REASON CODE INDEX !CONT'D)

For PA and MA Individual Opening, Rejection (Denial), Sanction and Removal Codes

IJUDt: t'A PAl:iC MA PAGE ::>1'IAP t'Al.:lt:

AC RJ IJL AC RJ SN vL AC RJ »N vL
uuu """ 4.2-.<H
UllO 4.<:-1
o:;u., 4.2-9
E21 1.5-15 4.2-,j"I
t:<:<: 4.2-9
"'" .
t:5ll 4.2-9
4.2-.<u

t:7<: 1.0-1) 1.5-25 4.2-17 4.2-.<b 1.5-u

<:;(,) 1.0-1) 1.0-.<<> 4.<:-11 4.2-.<<>
1.0-1) 1.0-.<<> 1.5-u 1.5-31
"'""
EBB
-=~u 1.0-;;:5 4.<:-.:o
E94 1.5-1> 1.5-25
1:95 1.5-ti 1.5-25 4.2-2B 1.5'12 1.5-31
c~o 1.0-.<;;J 1.5-1.< 1.5-<> I
t:97 1.5-.<<>
EF2 4.2-26
t:r.> 4.<:-.<o
t:r" 4.<:-.<o
er<> 4.<:-.<o
CL"I 1.5-10
CL.< 1.5-15
CL.> 1.0-15
CL" 1.0-10
F09 4.:t-9 4.<:-:.:1
n.< 4.2-32
n5 1.0-1:.: 1.0-.> I
n7 1.0-10 4.:t-31
r·19 1.5-1" 1.5-1:.:
r;.:u 1.5-15 4.2-31 1.5-23
r;.n 1.5-12 1.5·.>·1
1.5-12 1.5-,j"I
r ""
F26 4.2-10 4.2-21
r.<o 4.2-10 4.2-.<"I
r<>u 1.5-12 1.5-J"I
i-4u 1.0-"lb 4.2-32
i-5u 1.0-1 4.2-15
i-51 1.0-1 4.2-15
r<>u 1.0-1 1.5-;.:b 4.2-17 4.2-.<f 1.5-12 1.5-,j"I
r<> I 1.5-;.:b
r<>.> 1.0-1 1.5-.... 4.2-17 4.2-.<I 1.5-13
F64 1.5-26 4.2-27
r<>o 1.0-/ 1.0-.<<> 4.2-lb 4.2-25
i-75 1.0-H 1.5-.... .

1"71> 1.0-H 1.5-....

FB1 4.2-13
ro .. 1.5-10 4.<!-<>.<

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-25
02/19/2017

REASON CODE INDEX (CONT'D)

For PA and MA Individual Opening, Rejection (Denial), Sanction and Removal Codes

vvui:: t'A PAl:it: 1v1" t'Al:it: .,,.,.,.. t'Al:iE

Al,; KJ SN vL AC ....... :>N vL AC KJ :>N l,;L
i-85 U>·13 1.b-31
roo 1.b-13 1.b·.>.<
1""00 1.5-11 1.5-;.:7 .

J-90 1.5-13 1.b·.>.<

,..,,, 1.b-1.> 1.b·.>.<
....... 1.5-11 1.5·.</ 4.;:-13 4.;:.,... 1.5-"I.> 1.b-32
,...,3 1.5-8' 1.5·.</ 4.;:-13 4.2-24 4.;:.,...
,...,4 1.5-13 1.b-32
Ft:1 4.2-11
u57 4.2-11
u82 4.2-24
n14 1.5-27 4.2-.<o
n.:>6 4.2-TI
n.:>7 4.2-12
H38 4.2-22
H42 4.2-13
.
H48 4.2-24 ·.

M49 4.2-28
n1>6 4.2-7
H67 4.2-f
H68 4.2-f
H69 4.2-f
H70 4.2-f
M71 4.2-f
n74 . 4.2-f
H97 4 ..:-t
n98 4.2-f
nH8 4.i-13 4.i-24
4.;:-13 4.2-;:4
"""
In 1.5-13 1.5-23
IVIU.< 4.i-1 ij
MOS 4.2-25
1v113 1.5-8 1.5-27 4.2-19 1.5-13 1.5-32
,.,,,,, 1.5-9 1 .. 5·.</
IVll>I> 4.2-19
M67 4.2-19
1v1 ..1 1.5-9 1.5-.<o 1.5·"1.) 1.5-32
IVllll:I 1.5-9 1.5-<:l:I 4.2-16 4.2-25 1.5-13 1.b-33
M99 1.5-9 1.5-28
MX1 1.5-1t>
MA2 1.5-1t>
IVIA.> 1.5-16
NiU 1.b-16
N31 1.5-9 1.b-14
N32 1.s-1 ..

.....
N33

N4;:
1.5-1t; .
.
1.5-14
1.5-.<.>
1.5-;:3
N43 1.5-23
N44 1.b-9 1.b-.:8
...... 1.5-iu 1.5-.<o .

NEW YORK STATE WELFARE MANAGEMENT SYSTEM

 WORKER'S GUIDE TO CODES
6.1-26
02/19/2017

REASON CODE INDEX (CONT'D)

For PA and MA Individual Opening, Rejection (Denial), Sanction and Removal Codes

vUUI: t'A t'Aut: IVIA t'A ut: SNAP t'Aut:

AC RJ SN IJL Av RJ SN IJL AC RJ SN IJL
N50 1.5-w 1.5-.<u
N66 1.5-10 1.5-.<~ 4.:.:-1 ti 4.:.:-:.:5 1.0-14 1.0•.),)
N90 1.5-14 1.5-J3
Nr-·1 1.5-.<,,
"r" 1.5-:.:3
t'44 1.o-1u 1.0-1 (
t'45 1.o-1u 1.5-17
......, 1.0-11 1.5-17
r'4f 4.:.:-u
.
r-AI 1.5-17
rA.< 1.0-17
r-A.) 1.0-1 (
u44 1.5-11 1.0·.<~

V30 1.l>-11:1
V>J7 4.2-14 4.2-23
vc1 1.0-17
vc,; 1.0-17
vc3 1.0-11
v>/12 1.5-n 1.5-.<>J .
VV.)<J 1.0-11 1.5-"~ 1.5-14 1.5-33
vv4U 1.l>-10
vv44 1.5-11 1.5-.<>J 1.5-14 1.5-,,,,
VV4:> 1.5-11 1.5-.<>J 1.5-14 1.5-,,,,
WC1 1.5-18
vvv2 1.0-18
WE1 1.o-18 1.5-23
WEZ 1.5-24
vvc3 1.o-:.:4
vvF1 1.5-24
Wf 2 1.5-24
VVr.) 1.5-:.:4
VV<ll 1.0-19

...,,,
vv:.2

vv;:,4
1.5-19
1.5-.<u
1.0-.<u .

vv:.5 1.5-21
1.5-21

. ,,,.,
vv::>6
VV;:J/ 1.o-""
1.5-22
Y02 4.2-28
Y48 1.0-J
4.;.(-1!1 4.Z-.<.>
'""
T>J7 . 1.5-30
Y98 1.5-11 1.5-.>u 4.2-19 4.2-28
Y99 1.5-n 1.5-.)U 4.;.:-19 4.;.(-,;o 1.l>-14 1.5.,,,,

NEW YORK STATE WELFARE MANAGEMENT SYSTEM