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
The Social Security Administration (SSA) is authorized to collect information about benefits you
received on behalf of a beneficiary (section 205(j) (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.

PAPERWORK REDUCTION ACT: This information collection meets the clearance
requirement 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
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

Form SSA-9584-BK (01-2006)

EF (01-2006)
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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 Number: _________________________________________________
9. Facility Population: ____________________
•

Number receiving Social Security benefits ____________________

•

Number receiving SSI benefits ____________________

•

Number receiving both Social Security and SSI benefits ____________________

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Form SSA-9584-BK (01-2006)
10. Medicaid Facility?
□ Yes

EF (01-2006)

□ 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
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:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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Form SSA-9584-BK (01-2006) EF (01-2006)
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:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

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Form SSA-9584-BK (01-2006)

EF (01-2006)

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.)
□ 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 to this booklet.

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Form SSA-9584-BK (01-2006) EF (01-2006)
3. Is the difference between the established cost of caring for a 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 difference 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.

___________________________________________________________________________
___________________________________________________________________________

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Form SSA-9584-BK (01-2006) EF (01-2006)
PART D. RESIDENT ACCOUNTS AND SPENDING PRACTICES
1. Is a standard amount of money allocated monthly for each resident’s personal spending?
□ Yes. How much? Explain.

□ No. 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 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 _________________.
(Type of resident)
The limit is $__________ per □ week, □ month, or □ year for___________________.
(Type of resident)

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Form SSA-9584-BK (01-2006) EF (01-2006)
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.
_________________________________________________________________________
_________________________________________________________________________
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Form SSA-9584-BK (01-2006) EF (01-2006)
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?
_______________________________________________________________________
_______________________________________________________________________

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Form SSA-9584-BK (01-2006) EF (01-2006)
□ 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. _____________________________________________________________
___________________________________________________________________________

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Form SSA-9584-BK (01-2006)

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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.

___________________________________________________________________________
___________________________________________________________________________

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SSA-9584-BK (01-2006)

EF (01-2006)

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 beneficiaries: ____________________________________________________

2. When a beneficiary leaves the institution without a full discharge, do you usually continue to
serve as representative 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: _______________________________________________________

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Form SSA-9584-BK (01-2006) EF (01-2006)
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 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.

___________________________________________________________________________
___________________________________________________________________________

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Form SSA-9584-BK (01-2006)

EF (01-2006)

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.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

SIGNATURE:

TITLE:

__________________________________

_______________________________

Return this completed booklet to SSA at the following address:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

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Form SSA-9584-BK (01-2006)

EF (01-2006)

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