TN 25 (07-06)

GN 00605.531 Description of Information Collected on Form SSA-9584-BK

A. Part A - Identifying Information

Items 1-11 request basic information about an institution and are self-explanatory.

B. Part B – Certification by Institution of Current Policies

NOTE: Part B of Form SSA-9584-BK replaces information previously collected on Form SSA-9584-SUP, which has been obsoleted.

If a copy of Form SSA-9584-BK completed for the last onsite review is available, it is not necessary for the institution to fully complete a new form. By completing Part B, the institution has the option of either certifying that the information on the previous Form SSA-9584-BK is correct or that it is correct except for a couple of changes. There is space available for the institution to indicate the part, item number, and page for each of the items to be corrected, along with space to provide a brief explanation of the necessary changes. The institution will then return completed Parts A and B of the current Form SSA-9584-BK along with a copy of the previously completed form to SSA.

C. Part C - Rate-Setting and Reimbursement Procedures

1. What is the maximum amount charged at your institution per day, week, or month?

This question refers to the maximum charge permitted under State law. The legal maximum charge is generally related to the costs of operation. Charges may vary between patients receiving or not receiving some form of public assistance. Some States set the charges for residents of institutions for the developmentally disabled considerably lower than those set for patients in mental hospitals. Other States make no charge for care of certain types of patients; e.g., developmentally disabled children, the criminally insane, etc. The review team should record any explanations the institution official offers as to the variability in legal charges. If assistance programs are not available to patients in this institution, write “not available” in the appropriate item.

Since most of the beneficiary's funds will be used for current maintenance charges, SSA is interested in how these charges are collected. Some States reclaim part of the funds which were allocated for patient's personal use but not spent. It is important to know under what circumstances this occurs to determine if an institution's method of reimbursement adversely affects meeting the beneficiary's other needs. One fairly common practice is to review account balances periodically and apply to institution charges any

amount above a predetermined maximum balance figure. A variation is to suspend further allocations to the personal account once it has reached a specified level and, in effect, allocate the total benefit to reimbursement of maintenance charges.

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?

This information is used in making a comparison of actual charges to the maximum legal charge. It is essential that any variations be described in as much detail as possible. Otherwise, we may inaccurately report to the State that they have exceeded the legal charge when, in fact, the circumstances of the patient justified the higher charge.

Most patients do not have sufficient income or resources to cover the charges set by State law. Therefore, in most States, an agreement will be made with the patient or his/her representative stating the amount the patient is expected to pay. We need to know what factors are considered in establishing the amount to be charged. Often more than one factor will apply, but the patient's own income is always an important consideration in arriving at an adjusted rate. In some States, the charge is determined by a rate schedule based on individual or family income. If a printed rate schedule is used and was not attached to the completed booklet, the review team should ask for a copy.

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.

“Established cost” refers to the maximum legal charge permitted by State law. In some States, if the patient pays the amount agreed upon, the difference between that amount and the maximum legal charge is waived or “forgiven” immediately, and the patient is not legally liable beyond the amount agreed upon. In other States, the patient is liable for the full amount of the maximum legal charge indefinitely as an unpaid debt owed the State. In such a State, if the patient ever inherits money or has some “windfall,” he/she would be obliged to pay the unpaid debt. In some other States, the patient’s legal liability for the remaining charges is removed after a certain number of years.

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?

In accordance with GN 00603.055—Transfer of Conserved Funds, a representative payee must return conserved funds to SSA for reissuance to either a successor payee or to the beneficiary in direct payment. The institution may say that State law or regulations require certain procedures as to the disposition of funds when unpaid charges are on the books at the time of discharge. These procedures may vary according to the type of account and, in some instances, may allow the institution some option in how much is retained depending on the patient's post-discharge needs. The review team will ascertain from the institution official the basis for their procedures, including any citation of State law, regulation, or policy governing disposition of funds. Copies of any citations made should be obtained and forwarded with the policy questionnaire (Form SSA-9584-BK). The review team should ask enough questions to be sure that the procedures are understood and the written entries and explanations are complete.

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

Instructions in GN 00602.030—Payment of Beneficiary’s Past Due Debts—Claims of Creditors state, “If the beneficiary’s current needs and reasonably foreseeable needs are met, a payee may satisfy a beneficiary’s past debt.” A payee does not need SSA approval to pay a valid past debt unless the payee is also a creditor. A creditor payee must obtain SSA approval prior to using benefits for self-reimbursement.

EXCEPTION: If the creditor payee is a title XIX facility, the payee must allocate 2 month’s personal needs allowance (minimum $60 total) to the beneficiary’s account. The payee then may use any remaining retroactive benefits to pay for past care and maintenance charges without obtaining SSA approval.

6. Are benefits received by direct deposit?

Although receiving benefits by direct deposit is not a requirement for representative payees, if the response to this question is “No,” the review team should use this opportunity to explain the advantages of receiving benefits in this manner. See GN 00605.562.B.6—Direct Deposit for Institutions for additional information.

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

Ensure that the facility understands the law requiring payees to establish and maintain dedicated accounts for certain past-due benefit payments made on or after August 23, 1996 for disabled/blind SSI recipients under age 18. See GN 00602.140—Permitted Expenditures from Dedicated Accounts and SI 02101.010—Past Due Benefits Payable—Individual Under Age 18 with Representative Payee—Dedicated Account Required.

D. Part D – Resident Accounts and Spending Practices

SSA has extended the policy of using the title XVI reduced rate payable to title XVI beneficiaries residing in title XIX facilities only for personal needs to any beneficiary residing in any type of facility; e.g., hospitals, nursing homes, etc. A representative payee must set aside a minimum of $30 per month to be used for the beneficiary’s personal needs or saved on his/her behalf.

Personal needs expenditures are for things not normally provided by the institution but which the patient needs to maintain an interest in life, keep up personal appearances, and to socialize as much as possible. See GN 00602.010.B.3—Examples of Personal Needs Expenditures.

These questions obtain information about how the personal use allocation is determined and what happens to the funds once allocated.


Is a standard amount of money allocated monthly for each resident’s personal spending? How much?

Many States have a fixed amount which is allocated for the patient's personal use each month. In some States, the allocation is discontinued if the patient's spending account balance exceeds a specified amount. In such States, if the patient does not spend the funds allocated, the balance in his/her account will build up to the ceiling and then his/her allowance is discontinued. Thus, the patient is effectively deprived of the use of his/her current funds. In some States, if the beneficiary's balance in the spending account reaches zero, the entire Social Security check will be allocated for personal use until the account has built up.



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


When the limit is reached, what action is taken?

The beneficiary’s personal spending account refers to any account used to handle funds set aside for patient needs not provided by the institution. Frequently, there is a ceiling on the amount of funds a patient may accumulate in his/her account. This is often tied to the receipt of benefits from one of the various assistance programs; for example, for SSI beneficiaries the ceiling should equal the SSI resource limit of $2,000 for an individual or $3,000 for a couple.

The institution may reduce or temporarily stop the standard personal needs allocation once the ceiling is reached. However, a better solution is for the facility to determine whether the patient has unmet needs which could be met with the excess funds. SSA encourages payees to use good judgment in determining appropriate personal expenditures by evaluating the beneficiary’s situation and needs, helping the beneficiary keep in contact with the outside world, and preserve his/her sense of individuality.


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

Institutions which do not have a standard allocation usually have a maximum amount which may be spent during an established period of time; e.g., weekly, monthly, etc. In some institutions where there is no standard allocation, the social service staff in combination with the medical staff will determine the level of spending for each patient. In other institutions, there appears to be a fixed procedure or individualized spending plan, and the beneficiary is permitted withdrawals or expenditures as long as funds are available.


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

In most States, if an institution is certified for Medicaid, it is required to provide many of these items for Medicaid certified patients. When such is the case, the item should be provided by Medicaid rather than using the personal funds of the beneficiary. However, each of these items would be considered acceptable expenditures of the beneficiary's Social Security funds.



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


Are these burial funds held in interest-bearing accounts?


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


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



Do you maintain rehabilitation accounts (or funds earmarked for this purpose) for your residents?


Are these rehabilitation funds held in interest-bearing accounts?


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

For numbers 5 and 6 above, if burial and/or rehabilitation accounts are maintained for some, but not all patients, the review team should determine the criteria for maintaining such account(s). This is an acceptable use of benefits as long as the beneficiary’s personal spending account balance is adequate to meet his/her current and reasonably foreseeable needs.


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?

  • 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.

Personal needs (conserved) funds should be placed in a properly titled interest-bearing savings or checking account or invested in U.S. savings bonds or other types of investments with minimal risk. Any interest earned belongs to the beneficiary and not to the payee. See GN 00603.010—Conserving Benefits in a Savings or Checking Account; GN 00603.030—U.S. Savings Bonds; and GN 00603.040—Investments Other Than U.S. Savings Bonds.

A collective account is acceptable as long as the policies and procedures in GN 00603.020—Collective Savings and Checking Accounts are met. For collective accounts, the interest must be prorated and credited to the individual beneficiaries on the basis of their share of funds in the account. Interest may not be placed in a general fund. In addition, the review team should verify that the account is recorded with the correct eRPS ORG ID in eRPS (currently on the screen—Precedent File—Collective Accounts). (See MS INTRANETERPS 018.001 thru 018.007.)


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

Representative payees must use good judgment in determining appropriate personal expenditures for all beneficiaries. This is especially true for those residents who may be unable to express their wants and needs. In this case the institutional staff should evaluate and recommend appropriate expenditures for the beneficiary.


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

When staff members are aware that a resident has personal funds available, they can recommend or suggest items that the resident may need or want to administrators. In this way purchases can be made to best serve the needs of the resident.


When a resident needs clothing, how is it supplied?

  • Authorize use of residents 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 institutions supply of donated clothing.

  • Other

This question is intended to find out what action the institution takes when it identifies clothing needs for the individual. In any given institution, one or several practices may be followed, depending on circumstances. Some patients may be so disturbed and destructive that only institutional clothing is suitable. Also, severely impaired individuals incapable of attending to any of their own needs are likely to be provided with institutional garments. The answer to this question will help alert the onsite review team as to whether they should expect to find clothing expenditures on the individual account records.

11. a.

Do any of the residents earn wages for work performed on or off the facility premises?

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

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?

All representative payees must report work which could affect a beneficiary’s right to benefits. Because any work by an institutionalized beneficiary may be indicative of medical recovery, the institution should report all work despite the fact that the minimal income earned may not affect the beneficiary’s entitlement to benefits. This question is designed to tell the onsite reviewer if the facility is likely to have any patients who are working in the sample and, if so, how such work is likely to be detected during the review. We are also interested in knowing at what level the responsibility for reporting work is assigned.


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

Pooling the personal funds of several beneficiaries to make group purchases is an acceptable use of benefits provided SSA approval is obtained prior to the purchase. See GN 00602.070—Group Purchases—Beneficiary Resides in an Institution/Nursing Home or Other Group Living Facility.


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

A representative payee who has conserved or invested funds for a beneficiary, but is no longer serving as payee for the beneficiary, must return the funds to SSA for reissuance to either the successor payee or to the beneficiary in direct pay. See GN 00603.055—Transfer of Conserved Funds.


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

When a beneficiary dies, any remaining conserved/personal funds belong to and should be turned over to the legal representative of the deceased beneficiary’s estate for disposition under State law. See POMS GN 00603.100—Entitlement Terminated—Notice to be Given About Conserved Funds.

E. Part E - Placement Practices

  1. 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?

  2. 2. 

    When a beneficiary leaves the institution without a full discharge, do you usually continue as representative payee during a trial period?

  3. 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?

  4. 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?

    The purpose of these questions (E.1-4) is to help us determine the extent to which the State institutional system is fulfilling its payee responsibilities to out-of-hospital patients. In some instances, all the funds are sent to the custodian who may set aside some funds for personal needs. At the time the beneficiary relocates, the institution may retain some funds to cover the charges for the last month the patient resided at the institution. However, it is not proper for the institution to continue to use current benefits to recover charges the patient incurred while in the institution. If this is happening, bring the situation to the attention of the State. Also consider whether a change of payee is needed. If the records show that all funds are being forwarded directly to the patient, a question of whether the beneficiary is capable and should act as his/her own payee is raised.

    In some States, by law, a full discharge accompanies release from an institution even though it is really just a “trial release.” In these cases, the institution may wish to remain payee until it has established that the beneficiary has adjusted to life outside the institution. At that time SSA will need to determine whether the beneficiary is now capable..

  5. 5. 

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

    Determine how the identified staff report changes to SSA; e.g., phone, email, fax, or letter.

  6. 6. 

    How do you handle funds for a beneficiary who resides outside the institution for whom you are still serving as representative payee?

    • 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.

    Sometimes a fixed amount will be mailed directly to the patient; other times, the entire Social Security check will be forwarded to the custodian with the understanding that a specified amount be used for care and maintenance. When a beneficiary is relocated in a nursing home, there is often an immediate Medicaid or State assistance involvement since the patient's own resources are frequently inadequate to meet nursing home costs. Under these circumstances, even though a State mental institution continuing as payee may have little or no authority to earmark SSA funds for any particular use, $30 must be set aside for the beneficiary’s personal needs.

  7. 7. 

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

    Determine how the follow-up contacts are made; e.g., personal visit, phone call, etc.

  8. 8. 

    For those beneficiaries who reside outside of your facility:

    • Describe your procedures for learning about their employment and the amount of their earnings.

    • Describe your procedures for documenting the earnings and expenses.

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

    Representative payees must maintain regular contact with beneficiaries in order to best serve their needs. This is especially true in situations where the payee does not have custody of the beneficiary. The payee must be aware of and ensure that the beneficiary’s current and personal needs are provided for. The review team should emphasize the need for reporting changes in custody so that proper payee determinations can be made in light of the beneficiary’s current whereabouts and circumstances. In addition, when beneficiaries reside outside of a facility, the payee is still responsible for knowing about a beneficiary’s employment, earnings, and expenses and promptly reporting this information to SSA.

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GN 00605.531 - Description of Information Collected on Form SSA-9584-BK - 07/14/2006
Batch run: 05/09/2016