Form SSA-9584-BK State Mental Instintution Policy Review

Form Approved
OMB No. 0960-0110

REPRESENTATIVE PAYEE ONSITE REVIEW PROGRAM
FOR STATE MENTAL INSTITUTIONS

POLICY REVIEW BOOKLET

(FOR SSA USE ONLY)
Region/State: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Institution:--------------------Reviewers:--------------------

Date:

-----------------------

Form SSA-9584-BK (01-2006) ef(01-2006)

Destroy Prior Editions

PRIVACY ACT

See Revised Privacy Act
Statement

The Social Security Administration (SSA) is authorized to collect information about benefits
you received on behalf of a beneficiary (section 205G) (3) (A) and 1631 (a) (2) (C) of the Social
Security Act). This information is needed to enable Social Security to determine if the
beneficiary's needs are being met. Failure to provide all or part of this information may result in
the selection of another representative payee. The information in this booklet may be disclosed
by SSA to another agency or person for the following purposes: (1) to assist SSA in establishing
the right of a beneficiary to benefits payable under title II and title XVI of the Social Security
Act; (2) to facilitate statistical research and audit activities necessary to assure the integrity and
improvement of Social Security programs; and (3) to comply with laws requiring or authorizing
the exchange of information between SSA and another agency.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies use matching programs to find or determine whether a person qualifies for or
receives benefits paid by the Federal government. The law allows us to do this even if you do
not agree to it.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security offices. If you want to learn more about this, contact
any Social Security office.

See Revised PRA
PAPERWORK REDUCTION ACT: This information collection meets the clearance
requirements of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of
1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take about 60 minutes to
read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED
FORM TO SSA AT THE ADDRESS PROVIDED ON THE LAST PAGE OF THIS
FORM. You may send comments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 2123 5-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Form SSA-9584-BK (01-2006) ef(01-2006)

2

STATE MENTAL INSTITUTION POLICY REVIEW BOOKLET
PART A. IDENTIFYING INFORMATION
1. Date:

-----------------------------

2. Name of Payee/Facility:

----------------------------------------

3. A. Facility Address (Include Number, Street, City, State, and ZIP Code):

B. Mailing Address--if different from 3.A. above. (Include Number, Street,
City, State, and ZIP Code):

4. Area Code and Phone Number: (

-----------------------------------

5. Name and Title of Person Completing this Booklet:

6. Name of Agency or Department:

7. Address--if different from 3.A. or B. above. (Include Number, Street, City,
State, and ZIP Code):

8. Area Code and Phone
9. Facility Population: _____________
• Number receiving Social Security benefits: _____________
• Number receiving SSI benefits: _ _ _ _ _ _ __
• Number receiving both Social Security and SSI benefits: ____________
Form SSA-9584-BK (01-2006) ef(01-2006)

3

10. Medicaid Facility?

DYes

0No

11. Type of Facility:

0

Psychiatric hospital

0

Inpatient facility for developmentally
disabled

0

Facility for both mentally ill
and developmentally disabled

0

Other

---:=--:-:--:--,..---

(Describe)

PART B. CERTIFICATION BY INSTITUTION OF CURRENT POLICIES
Note: If you have not previously completed a SSA-9584-BK, Policy Review
Booklet, or you are not able to locate a copy of the last booklet completed, skip
Part B. and continue with Part C. on page 6.
1. If you have a copy of the SSA-9584-BK, Policy Review Booklet, completed during
the last SSA onsite review, you do not need to complete another booklet at this time.
Simply complete one of the following statements and attach a copy of the last
booklet you completed:

a. I certify that the information in the attached copy of the SSA-9584-BK, Policy Review
Booklet, dated
, is correct.
b. I certify that the information in the attached copy of the SSA-9584-BK, Policy Review
Booklet, dated
, is correct, except for the following changes:
Part _ _

Number _ _

Page _ _

Explanation of Changes:

Part _ _

Number _ _

Page _ _

Explanation of Changes:

Form SSA-9584-BK (01-2006) ef(01-2006)

4

Part _ _ Number

Page _ _

Explanation of Changes:

Part _ _ Number

Page _ _

Explanation of Changes:

2. ADDITIONAL COMMENTS OR REMARKS:

4. TITLE

3. SIGNATURE

After completing Parts A and B above, send these 5 pages along with a copy of the
last SSA-9584-BK, Policy Review Booklet, to SSA at the following address:

Form SSA-9584-BK (01-2006) ef(01-2006)

5

PART C. RATE-SETTING AND REIMBURSEMENT PROCEDURES
Introduction: The following questions apply to institutional/facility and State policies and
practices with regard to Social Security and/or Supplemental Security Income (SSI)
beneficiaries. If the policies and practices differ for these two types of beneficiaries,
please provide a separate explanation for each.
1. What is the maximum amount charged by your institution per day, week, or month?
a. For residents who are not covered by an
assistance program

....:.$_ _ _ _

per _ __

b. For residents who are covered by assistance
programs such as Medicaid (title XIX},
identify the program and charges for each:
~$_ _ _ _ per _ __
~$_ _ _ _ per _ __

_$_ _ _ _ per _ __
2. Because most residents do not have enough income or resources to cover the total
cost of their care, institutions make adjustments to the charges. To determine the
amount a resident will actually be charged for care and maintenance, what factors
do you consider? (Check all that apply.)

D Resident's income and resources D Resident's account balances
D Resident's condition
D Resident's spending patterns or
personal needs
D Amount owed for unpaid care D Income and resources of responsible
and maintenance charges
relatives

D Other. Describe: - - - - - - - - - - - - - - - - - - - - - -

NOTE: If you have a printed rate schedule showing the current amount(s) charged by
your institution, please attach a copy to this booklet.
Form SSA-9584-BK (01-2006) ef(01-2006)

6

3. Is the difference between the established cost of caring for a resident and the amount
he/she actually pays:
D Waived or "forgiven" immediately?

D Considered the resident's liability
forever?

D Waived or "forgiven" periodically
every.__ years?

D Other. Explain.

4. When a resident is permanently discharged, are any of his/her resources ever used
to reduce the accumulated difference between the cost of care and the actual
amount he/she has paid?
DNo.

DYes. Explain.

5. If you receive retroactive (for a period prior to the current month) benefits for a
beneficiary, what, if any, portion of these benefits is used toward the cost of his/her
care? Explain.

6. Are benefits received via direct deposit?
DYes.

D No. Explain.

7. If you serve as payee for children receiving SSI benefits, do you maintain dedicated
accounts for them?
DYes

D No. Explain.

Form SSA-9584-BK (01-2006) ef(01-2006)
7

PART D. RESIDENT ACCOUNTS AND SPENDING PRACTICES
1. Is a standard amount of money allocated monthly for each resident's personal
spending?
0 Yes. How much? Explain.
0 No. Explain.

2. a. Is there a limit on the amount of funds allowed to accumulate in each beneficiary's
personal spending account?

0

Yes. Indicate type and amount of limit.
• SSIIimit of$ _ _ _ __
• Medicaid limit of$ _ _ _ __
• State-established limit of$ _ _ _ _ __
• Institution-established limit of$ _ _ _ _ __

0

No. Skip to Question 3.

b. When the limit is reached, what action is taken? (Check all that apply.)

0 Standard allocation for personal spending is reduced or stopped.
O Personal use funds are "spent-down" by using the excess amount to pay for
care and maintenance charges.

0

Other. Explain.

3. Is there a limit on the amount a beneficiary is permitted to spend?

0No.
0 Yes.

The limit i s $ - - per 0 week,
The limit is $ _ _ per

0

week,

Form SSA-9584-BK (01-2006) ef(01-2006)

8

0

month, or

0

year for

0

month, or

0

year for

(Type of resident)
(Type of resident)

4. How are special medical items such as dentures, glasses, geriatric chairs, hearing aids,
etc. provided?

D Personal funds are used for such purchases

D Dedicated account
D Purchased by institution
D Provided under terms of the Medicaid reimbursement program
D Other. Explain.

5. a. Do you maintain separate burial accounts (or earmark funds for this purpose) for
your residents?

D Yes. All residents.
D No residents. Skip to Question 6.
D Some residents. Explain.

b. Are these burial funds held in interest-bearing accounts?

0No.
DYes. To whom is the interest credited?

c. Are these funds available for the resident if an urgent need arises?

0No.
DYes. Explain.

Form SSA-9584-BK (01-2006) ef(01-2006)

9

d. What happens to these funds if the resident leaves your facility? Explain.

6. a. Do you maintain rehabilitation accounts (or funds earmarked for this purpose) for
your residents?
DYes, all residents.

D No residents. Skip to Question 7.

D Some residents. Explain.

b. Are these rehabilitation funds held in interest-bearing accounts?

0No.
DYes. To whom is the interest credited?

c. What happens to these funds if the resident leaves your facility? Explain.

7. How are personal use funds held?

D Individual interest-bearing savings or checking account or U.S. savings bonds.
How are the accounts or bonds titled?

Form SSA-9584-BK (01-2006) ef(01-2006)
10

D Collective interest-bearing savings or checking account, with interest handled as
shown below:

D Interest prorated to each individual.
D Interest placed in a general fund for the benefit of all residents.
D Other. Explain what is done with the interest.

D Non-interest-bearing collective account. Is there a statutory reason for not
depositing funds in interest-bearing accounts? Explain.

D Other types of investments. Explain.

8. How are the personal needs of those residents who are unable to get to the
canteen or to verbally express their needs provided? Explain.

9. Are staff aware that residents have personal spending funds available and the
amount of these funds?

0No.
DYes. Explain.

Form SSA-9584-BK (01-2006) ef(01-2006)
11

10. When a resident needs clothing, how is it supplied? Please indicate the order (e.g.,
1 = first through 5 = last) in which the sources are used.
_Authorize use of resident's personal funds for the items.
_Ask relatives (or guardians) to supply the items or the necessary funds to
purchase the clothing.
_Provide institutionally purchased clothing.
_Use institution's supply of donated clothing.
_Other. Explain.

11. a. Do any of the residents earn wages for work performed either on or off the facility
premises?
D No. Skip to Question 12.

DYes.

b. Are the resident's earnings from work posted to his/her personal spending
account?
DYes.

DNo.

c. What are the position title(s) of the staff that are responsible for knowing of a
resident's work activity and wages, and for making reports to SSA when
appropriate?

12. In the past year, have group purchases been made for the residents by pooling
their funds?
DYes. Explain.

DNo.

Form SSA-9584-BK {01-2006) ef{01-2006)
12

13. How are remaining conserved/personal spending funds handled when you no
longer serve as representative payee for a beneficiary? Explain.

14. How are remaining conserved/personal spending funds handled when a
beneficiary dies? Explain.

PART E. PLACEMENT PRACTICES
1. How long after a beneficiary leaves your facility without a full discharge do you
ordinarily report the change of physical custody to Social Security?
• Social Security beneficiaries: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
• SSI b e n e f i c i a r i e s : - - - - - - - - - - - - - - - - - - - - 2. When a beneficiary leaves the institution without a full discharge, do you usually
continue to serve as representative payee during a trial period?

D No, usually change payee immediately.

DYes, usual trial period is:

D Other. Explain.

3. How long after a beneficiary leaves the institution with a full discharge do you
ordinarily report the change of physical custody to Social Security?
• Social Security b e n e f i c i a r i e s : - - - - - - - - - - - - - - - - • SSI b e n e f i c i a r i e s : - - - - - - - - - - - - - - - - - - - - -

Form SSA-9584-BK (01-2006) ef(01-2006)

13

4. When a beneficiary leaves the institution with a full discharge, do you usually
continue to serve as representative payee for a short period while evaluating the
success of the discharge?

0

No, usually change payee immediately.

0

Other. Explain.

0

Yes, usual trial period is:

5. What are the position title(s) of the staff responsible for informing SSA of changes
in a beneficiary's custody?

6. How do you handle funds for a beneficiary who resides outside the institution and for
whom you are still serving as representative payee? Check all that apply:

0

Total amount sent to custodian to be used at his/her discretion?

0

Total amount sent to custodian with designated amounts earmarked for specific
purposes?

D Part sent directly to beneficiary and part to custodian?

D Total amount sent to beneficiary (either in a lump sum or installments)?
How are the expenses documented? Explain.

7. When you continue as payee for a beneficiary residing outside the facility, do you
or any other agency arrange for follow-up contacts?

D No.

DYes. Explain.

Form SSA-9584-BK (01-2006) ef(01-2006)
14

8. For those beneficiaries who reside outside of your facility:
a. Describe your procedures for learning about their employment and the amount of
their earnings:

b. Describe your procedures for documenting the earnings and expenses:

c. Describe your procedures for making reports to SSA regarding beneficiaries'
employment and earnings outside the facility.

Form SSA-9584-BK (01-2006) ef(01-2006)

15

PART F. ADDITIONAL INFORMATION
Use this space (or use and attach extra sheet(s) of paper) to expand upon any of the
answers in the previous sections or to provide any additional information.

TITLE:

SIGNATURE:

Return this completed booklet to SSA at the following address:

Form SSA-9584-BK (01-2006) ef(01-2006)
16

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(j) and 1631(a) of the Social Security Act, as amended, authorize us to collect
information about benefits you received on behalf of a beneficiary. We will use the
information you provide on this form to determine if a beneficiary's needs are being met.
Furnishing us this information is voluntary. However, failing to provide us with the requested
information could result in the selection of another representative payee.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0222, entitled, Master Representative
Payee File. Additional information about this and other system of records notices and our
programs is available from our Internet website at www.socialsecurity.gov or at your local Social
Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
60 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.