Form SSA-9584-BK State Mental Instintution Policy Review

Form Approved
OMB No. 0960-0110

Social Security Administration

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 (01-2015) ef (01-2015)
Destroy Prior Editions

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.
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.

Form SSA-9584-BK (01-2015) ef (01-2015)

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):

3. 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 Number:
9. Facility Population:
• Number receiving Social Security benefits:
• Number receiving SSI benefits:
• Number receiving both Social Security and SSI benefits:
Form SSA-9584-BK (01-2015) ef (01-2015)

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10. Medicaid Facility?
Yes
No
11. Type of Facility:
Psychiatric hospital

Inpatient facility for developmentally disabled

Facility for both mentally ill and developmentally disabled
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 to 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 (01-2015) ef (01-2015)

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Part

Number

Page

Explanation of Changes:

Part

Number

Page

Explanation of Changes:

2. ADDITIONAL COMMENTS OR REMARKS:

3. SIGNATURE

4. TITLE

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 (01-2015) ef (01-2015)

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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

$

per

$

per

$

per

b. For residents who are covered by an assistance program
such as Medicaid (Title XIX), identify the program and
charges for each:

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.)
Resident's income and resources

Resident's account balances

Resident's condition

Resident's spending patterns or personal needs

Amount owed for unpaid care and
maintenance charges

Income and resources of responsible relatives

Other. Describe

NOTE: If you have a printed rate schedule showing the current amount(s) charged by your institution, please
attach a copy of this booklet.

Form SSA-9584-BK (01-2015) ef (01-2015)

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3. Is the difference between the established cost of caring for the resident and the amount he/she
actually pays:
Waived or "forgiven" immediately?
Considered the resident's liability forever?
Waived or "forgiven" periodically
every
years?

Other. Explain.

4. When a resident is permanently discharged, are any of his/her resources ever used to reduce the
accumulated different between the cost of care and the actual amount he/she has paid?
No.
Yes. 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?
Yes.

No. Explain.

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

No. Explain.

Form SSA-9584-BK (01-2015) ef (01-2015)

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

Yes. How much? Explain.

2. a. Is there a limit on the amount of funds allowed to accumulate in each beneficiary's personal
spending account?
Yes. Indicate type and amount of limit.
• SSI limit of $
• Medicaid limit of $
• State-established limit of $
• Institution-established limit of $
No. Skip to Question 3.
b. When the limit is reached, what action is taken? (Check all that apply.)
Standard allocation for personal spending is reduced or stopped.
Personal use of funds are "spent-down" by using the excess amount to pay for care and
maintenance charges.
Other. Explain.

3. Is there a limit on the amount a beneficiary is permitted to spend?
No.
Yes. The limit is $

per

week,

month, or

year for

The limit is $

per

week,

month, or

year for

Form SSA-9584-BK (01-2015) ef (01-2015)

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(Type of resident)
(Type of resident)

4. How are special medical items such as dentures, glasses, geriatric chairs, hearing aids, etc. provided?
Personal funds are used for such purchases
Dedicated account
Purchased by institution
Provided under terms of the Medicaid reimbursement program
Other. Explain.

5. a. Do you maintain separate burial accounts (or earmark funds for this purpose) for your residents?
Yes. All residents.
No residents. Skip to Question 6.
Some residents. Explain.

b. Are these burial funds held in interest-bearing accounts?
No.
Yes. To whom is the interest credited?

c. Are these funds available for the resident if an urgent need arises?
No.
Yes. Explain.

Form SSA-9584-BK (01-2015) ef (01-2015)

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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?
Yes. All residents.
No residents. Skip to Question 7.
Some residents. Explain.

b. Are these rehabilitation funds held in interest-bearing accounts?
No.
Yes. 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?
Individual interest-bearing savings or checking account or U.S. savings bonds.
How are the accounts or bonds titled?

Form SSA-9584-BK (01-2015) ef (01-2015)

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Collective interest-bearing savings or checking account, with interest handled as shown below:
Interest prorated to each individual.
Interest placed in a general fund for the benefit of all residents.
Other. Explain what is done with the interest.

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

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?
No.
Yes. Explain.

Form SSA-9584-BK (01-2015) ef (01-2015)

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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?
No. Skip to Question 12.

Yes.

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

No.

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?
No.

Yes. Explain.

Form SSA-9584-BK (01-2015) ef (01-2015)

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13. How are the 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 beneficiaries:
2. When a beneficiary leaves the institution without a full discharge, do you usually continue to serve as
representatives payee during a trial period?
No, usually change payee immediately.
Yes, usual trial period is:
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 beneficiaries:
• SSI beneficiaries:

Form SSA-9584-BK (01-2015) ef (01-2015)

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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?
No, usually change payee immediately.

Yes, usual trial period is:

Other. Explain.

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 of the institution and for whom you are still
serving as representative payee? Check all that apply:
Total amount sent to custodian to be used at his/her discretion?
Total amount sent to custodian with designated amounts earmarked for specific purposes?
Part sent directly to beneficiary and part to custodian?
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?
No.

Yes. Explain.

Form SSA-9584-BK (01-2015) ef (01-2015)

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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 (01-2015) ef (01-2015)

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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.

SIGNATURE:

TITLE:

Return this completed booklet to SSA at the following address:

Form SSA-9584-BK (01-2015) ef (01-2015)

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