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Supplemental Security Income Exceptional Expense (SSI-E) Handbook Release 10-01 August 25, 2010 |
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Supplemental Security Income Exceptional Expense (SSI-E) Handbook Release 10-01 August 25, 2010 |
6.3.1 Instructions for Application for SSI-E Certification form (F-20818)
6.3.1.1 Instructions Introduction
6.3.1.2 Reporting Instructions
6.3.1.4 Applicant / Representative Signature
6.3.1.6 Relationship to Applicant
6.3.1.7 Distribution of Completed Forms
The F-20818 form is to be used in both natural residential and substitute care settings for certifications, decertifications, and changes of address and/or living arrangement (continues).
The F-20818 form has four copies. In order for the pink (agency) copy to be readable, please:
Place the form on a hard surface.
Press hard with a ball point pen or other "hard point" writing instrument.
Write legibly or type.
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For Certifications: |
Complete numbers 1-21, Signature, Application Date, and Relationship to Applicant. |
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For Decertifications |
Complete numbers 2-4, 5-12, 13-20, Signature, Application Date and Relationship to Applicant. |
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For Change of Address: |
Complete numbers 2-4, 5-12, 14-21, Signature, Application Date and Relationship to Applicant. |
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For Moves From Substitute to Natural Residential Settings or Natural Residential to Substitute Care: |
Complete numbers 2-4, 5-12, 14-21, Signature, Application Date and Relationship to Applicant. |
Enter the address of the Department of Health and Family Services, P.O. Box 6680, Madison, Wisconsin 53716-0680 on forms in which the box marked #1 is blank. Forms with a revision date of 5/99 or later will be pre-addressed.
Check the box for substitute care or natural residential, except: if the person is moving from one to the other, check the box for NRSC or SCNR as appropriate.
If the living arrangement is licensed or certified, it is substitute care.
If the living arrangement is not licensed or certified, it is natural residential.
Both types of living arrangements must meet other criteria to qualify. See complete definitions in the SSI-E Policy.
Check "Start" for new certifications; "Stop" for decertifications; "Continue" for changes of address or movements between substitute care and natural residential settings or vice versa.
Complete this field only for new Certifications; that is, only if "Start" is checked in the ACTION field. If you are unsure of the person’s SSI status, call 800-362-3002 to inquire.
For new certifications: the effective date is always the first of the month following the date you (the worker) complete the form (date in #14).
For all other actions: the effective date is the first of the month following the date you complete the form, except: if a decertification is due to death, the effective date is the date of death.
Enter the last name first. Make sure the spelling is correct. Use full name, not nicknames. Never leave this field blank.
Enter the Social Security Number accurately and legibly. Without the correct number DHFS cannot locate the person’s record in its computer system.
Enter the person’s date of birth in mm/dd/yy format.
Enter the telephone number where the person can be contacted. If the person has a representative payee, enter the payee’s phone number.
Enter the person’s current mailing address.
Enter the person’s county of residence. If the person is being placed out of the county, enter the county of placement.
For new certifications: circle the applicant’s primary disability group or age. Circle only one. All persons age 65 or older should be entered as "Elderly" regardless of the nature of any disability they might have.
For all other actions leave blank.
IF "STOP," DECERTIFICATION REASON - always complete this field when you have indicated "Stop" in Field 3. Circle the one main reason why the person is being decertified for SSI-E.
If the reason isn’t among those listed, then circle "Other" and specify in the space provided.
Enter your (the worker’s) name.
Enter the date form was completed in mm/dd/yy format.
Enter your (the worker’s) phone number, in case the DHFS needs to contact you.
The agency director or his/her designee must sign here for the action to be valid.
If the person has a representative payee, enter his or her name here. Otherwise leave blank.
Enter the complete address of the county agency. The DHFS office will return the green copy to the worker at this address.
If there is a representative payee, enter the payee’s address. If no payee, or address unknown, leave blank.
Enter the date you approve this application for certification.
For new certifications and movement between substitute care and natural residential, enter the person's living arrangement at the time of certification or move. If the person resides in a grandfathered CBRF, name the facility.
For decertifications and changes of address, leave blank.
For new certifications the applicant or a representative must sign the form. The representative can be the person’s guardian, representative payee, spouse, parent, adult child, friend, neighbor, etc.
If the county agency is the person’s representative payee, a staff person may sign for the applicant. For new substitute care certifications only, the county worker completing the form may sign on behalf of the applicant even where the county agency is not the payee.
For decertifications, change of address, moves between natural residential and substitute care or vice versa, leave blank.
For new certifications only enter in mm/dd/yy format. This is the date the person first expresses an intent - in person, by phone, or in writing - to apply for SSI-E.
If someone signed for the applicant, describe that person’s relationship to the applicant (e.g., representative payee, daughter, friend, parent, guardian, etc.).
Send the white and green copies of the F-20818 form to:
DHS
P.O. Box 6680
Madison, WI 53716-0680
Use this address for new certifications, decertifications and change of address or residential setting.
The Assessment Worksheet for Natural Residential Settings is used to document that the E Supplement candidate needs at least 40 hours per month of qualifying services.
The Worksheet establishes need based on an assessment. Complete the Worksheet based on what services the person needs rather than what services the person receives.
However, if the person is currently receiving primary long-term support services, need may be established and the form completed based on hours of qualifying services received and included in the person’s case plan, plus unpaid services and any unmet need.
For a child residing with a parent, count only services needed when the parent is away from the residence for employment.
For a person residing with a spouse, count only services needed when the spouse is away from the residence for employment or which the spouse is physically or mentally unable to provide. See about determining need when a person resides with a spouse before completing the form.
The DDE-817A , the Community Support Program page of the Assessment Worksheet, may be used for persons whose primary disability is chronic mental illness or chronic alcoholism or other drug abuse. It may not be combined with the use of DDE-817.
However, if a person whose primary disability is chronic mental illness, or substance abuse does not meet the 40 hour eligibility threshold using the CSP category, but has a secondary physical or developmental disability, you may attempt to qualify the person using the DDE-817, so long as it is not combined with use of the DDE-817A.
Refer to the definitions at the end of this Appendix for activities that are included in each area of service need. Enter the number of hours needed on the line next to each service area where the person needs assistance. Enter the total hours for each program category.
Two special requirements apply to assessed needs under Supportive Home Care.
First, if two or more persons sharing a household are being assessed, for those tasks included under the CHORE section, the service time should be distributed proportionately or on some other basis reflecting relative benefit, i.e., don’t count the same hour twice.
Second, for On-Site Supervision of the Person (items #11, 21), any number of hours over 20 per month must be accompanied by a narrative explanation of need.
If the person needs a total of 40 or more hours per month of Supportive Home Care plus Daily Living Skills Training Services, the person is eligible for SSI-E, provided the other eligibility conditions are met.
If the person is chronically mentally ill or a chronic alcoholic or other drug abuser and needs 40 hours or more per month of Community Support Program Services, the person is eligible for SSI-E, provided the other eligibility conditions are met.
Supportive Home Care
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EATING MEALS |
Direct assistance in eating, including tube feeding. |
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CHANGING POSITION IN BED |
For people who remain in bed all the time and/or who need help to change positions to avoid bed sores. |
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TRANSFERRING FROM BED OR WHEELCHAIR |
For people who use wheelchairs and/or who need help to get from chair/standing position to bed and back again. |
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USING THE TOILET AND/OR CONTROLLING BLADDER AND BOWEL |
For people who need help transferring to and from the toilet as well as people who use disposable briefs. Count this for children only after they reach age 4. |
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PERSONAL MOBILITY |
For people who need the assistance and/or support of another person in moving about the home, whether direct personal assistance or assistance in using a piece of equipment such as a wheelchair or walker. |
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BATHING, GROOMING, AND DRESSING |
Activities associated with getting up in the morning and of getting ready for bed at night, and includes shopping for clothes and bathing/grooming supplies. |
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MEDICAL SUPPORT |
Physician or nurse supervised. Includes activities such as caring for colostomy, ileostomy or catheters, taking medications by mouth, certain injections (e.g., insulin), taking and recording temperature, pulse, respiratory rates and blood pressure, dressing changes, range of motion exercises, monitoring a special diet, and checking blood and urine for diabetes. |
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LEISURE TIME ACTIVITIES |
Planning and accessing leisure time activities necessary for meeting the goals of normalization and community participation. |
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FINANCES/BILL PAYING |
Assistance in household financial activities performed by a person other than a guardian or representative payee such as making bank deposits, paying bills and household budgeting. |
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ACCESSING MEDICAL CARE |
Accompanying a person to obtain medical diagnosis and treatment. Shopping for medical supplies, equipment and pharmaceutical. |
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ON-SITE SUPERVISION |
Needed to protect health, safety or welfare. For people with Alzheimer’s disease, other irreversible dementia, and others with similar need. Also for persons who are medically fragile or who have severe physical limitations. Includes assistance with using the telephone or specialized communication, adaptive or environmental aids. |
Chores
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GROCERY SHOPPING, FOOD PREPARATION AND CLEAN-UP |
Includes planning meals, cooking and serving food, cleaning-up the dishes, and grocery shopping. |
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HOUSEWORK |
Cleaning activities needed to maintain a clean and safe environment, including laundry activities. |
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YARD WORK, SNOW SHOVELING |
Includes any work done outside the house such as changing storm windows, mowing the lawn, raking leaves, and shoveling snow from the sidewalk and driveway. |
Respite
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RESPITE CARE |
For people whose caregivers need someone to come in and care for the disabled person for a period of time to allow the caregivers time for other activities. |
Other
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OTHER |
Other activities not included elsewhere in section 1 (specify). |
Daily Livings Skills Training
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TRAINING IN PERSONAL HYGIENE, GROOMING, AND DRESSING |
Training for activities defined in bathing, grooming and dressing |
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TRAINING IN PLANNING AND PREPARING FOOD AND CLEAN-UP |
Training for activities defined in food preparation and cleanup |
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TRAINING IN HOUSEKEEPING |
Training for activities defined in housekeeping in |
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TRAINING IN BUDGETING AND/OR USING THE BANKING SYSTEM |
Training for activities such as financial management, making deposits and withdrawals, writing checks, paying bills |
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TRAINING IN PURCHASING NECESSITIES SUCH AS FOOD AND CLOTHING |
Training for activities such as shopping for groceries, clothing, household items. |
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TRAINING IN SOCIALIZATION SKILLS AND DEVELOPING NORMAL LEISURE TIME ACTIVITIES. |
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TRAINING IN DEVELOPING APPROPRIATE SEXUAL BEHAVIORS. |
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TRAINING IN PARENTING SKILLS, FAMILY RELATIONSHIPS |
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TRAINING IN ACCESSING PUBLIC AND PRIVATE TRANSPORTATION |
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TRAINING BY THE BIRTH TO THREE PROGRAM FOR CHILDREN. |
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MEDICAL SUPPORT TRAINING |
Training activities defined in SHC, |
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CONSUMER TRAINING |
Training provided to the consumer supervising care provided by a caregiver and/or functioning as the employer of the Supportive Home Care Worker. |
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OTHER |
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Functional Assessment Worksheet for Natural Residential Settings (DDE-817)
SSI-E Natural Residential Setting Application Checklist (DDE-812).
This page last updated in Release Number: 09-01
Release Date: 04/17/09
Effective Date: 04/17/09