The Kentucky Map 351 form is a Medicaid waiver assessment tool used to evaluate an individual's eligibility for various waiver programs in Kentucky. This form collects essential demographic information, medical history, and details regarding the individual's daily living activities and support needs. Completing the Map 351 form is a crucial step in accessing necessary services, so ensure you fill it out accurately by clicking the button below.
The Kentucky Map 351 form plays a crucial role in the assessment process for Medicaid waiver eligibility in the state of Kentucky. This form is designed to gather comprehensive information about an individual seeking Medicaid services, focusing on their demographics, health status, and daily living capabilities. It consists of several sections that capture essential details, including the member's name, date of birth, Medicaid ID number, and emergency contact information. The form also assesses the individual's eligibility for various waiver programs, such as the Home and Community Based Waiver and the Acquired Brain Injury Waiver. Additionally, it includes an evaluation of the member's abilities in activities of daily living, such as dressing, grooming, and bathing, as well as instrumental activities like meal preparation and managing finances. The assessment further addresses the member's neuro-emotional and behavioral health, ensuring a holistic approach to care. By collecting this information, the Map 351 form aids in determining the level of support and services necessary to enhance the member's quality of life.
MAP 351
Commonwealth of Kentucky
(Rev. 7/08)
Cabinet for Health and Family Services
Department for Medicaid Services
MEDICAID WAIVER ASSESSMENT
SECTION I – MEMBER DEMOGRAPHICS
Name (last, first, middle)
Date of birth (mo., day, yr.)
Medicaid Member ID #
Street address
County code
Sex (check one)
Marital status (check one)
Male
Divorced
Married
Separated
Female
Single
Widowed
City, state and zip code
Emergency contact (name)
Emergency contact (phone #)
Member phone number
Is member able to read and
Member’s height
write
Yes
No
Member’s weight
SECTION II – MEMBER WAIVER ELIGIBILITY
Type of program applied for (CHECK ONE)
Adjudicated
/Nonadjudicated
_____
Home and Community Based Waiver
Type of application (check one)
Acquired Brain Injury Waiver
Certification
Re-certification Re-application
Acquired Brain Injury/Long Term Care Waiver
Supports for Community Living Waiver
Michelle P. Waiver
Consumer Directed Option Blended
Member admitted from (check one)
Certification period (enter dates below)
Home Hospital Nursing facility
ICF/MR/DD
Begin date
End date
Other:
number:
Has member’s freedom of choice been explained and
Has member been informed of the process to make
verified by a signature on the MAP 350 Form Yes
a complaint
No (see instructions)
Physician’s name
Physician’s license number
Physician’s phone number
(enter 5 digit #)
Enter member’s primary diagnosis: HCB (ICD-9 code); SCL (DSM code); ABI (ICD-9 and/or DSM)
Enter all diagnoses including DSM or ICD-9 codes:
Is the member diagnosed with one of the following?
AXIS I: (mental illness)
Mental Retardation/ IQ=
(Date-of-onset
)
Developmental Disability
AXIS II: (MR/DD)
Mental Illness
AXIS III: (Medical)
Brain Injury
Cause of Brain Injury:
Date of Brain Injury:
Rancho Scale
SECTION III – ASSESSMENT PROVIDER INFORMATION
Assessment/Reassessment provider
Provider number
Provider phone number
name:
Provider contact person
Page 1 of 15
NAME (LAST, FIRST)
MEDICAID NUMBER
SECTION IV SELF ASSESSMENT
*For SCL, MP and ABI waivers only
*add additional pages as needed
Community Inclusion (what do you like to do or where would you like to go in the community, where do you go for recreation, do you not get to go somewhere that you would like to)
Relationships (How do you stay in contact with your friends and family, do you need assistance in making or keeping friends, who are your friends)
Rights (do you understand your rights, are any of your rights restricted, do you know what is abuse or neglect)
Dignity and Respect (how are you treated by staff, do you have a place you can go to be with friends or to be alone or have privacy)
Health (who are your doctors ,do you have any health concerns, what medicine do you take, how do they make you feel,)
Lifestyle (do you have a job, do you want to work, do you want to go to school, do you go to the bank, do you have spending money to carry)
Page 2 of 15
Name (LAST, FIRST)
Medicaid Number
SECTION V – ACTIVITIES OF DAILY LIVING
1) Is member independent with
Comments:
dressing/undressing
No(If no, check below all that apply and comment)
Requires supervision or verbal cues
Requires hands-on assistance with upper body
Requires hands-on assistance with lower body
Requires total assistance
2) Is member independent with grooming
Requires hands-on assistance with
oral care
shaving
nail care
hair
3) Is member independent with bed mobility
No (If no, check below all that apply and comment)
Occasionally requires hands-on assistance
Always requires hands-on assistance
Bed-bound
Required bedrails
4) Is member independent with bathing
Requires Peri-Care
5) Is member independent with toileting
Bladder incontinence
Bowel incontinence
Bowel and bladder regimen
6) Is member independent with eating Yes No
(If no, check below all that apply and comment)
Requires assistance cutting meat or arranging food
Partial/occasional help
Totally fed (by mouth)
Tube feeding (type and tube location)
Page 3 of 15
7) Is member independent with ambulation
Dependent on device
Requires aid of one person
Requires aid of two people
History of falls (number of falls, and date of last fall)
8) Is member independent with transferring
Hands-on assistance of one person
Hands-on assistance of two people
Requires mechanical device
Bedfast
SECTION VI - INSTRUMENTAL ACTIVITIES OF DAILY LIVING
1) Is member able to prepare meals
(If no, check below all that apply and explain in the comments)
Arranges for meal preparation
Requires assistance with meal preparation
Requires total meal preparation
2) Is member able to shop independently
Yes No
Arranges for shopping to be done
Requires assistance with shopping
Unable to participate in shopping
3) Is member able to perform light housekeeping
Arranges for light housekeeping duties to be performed
Requires assistance with light housekeeping
Unable to perform any light housekeeping
4) Is member able to perform heavy housework
Arranges for heavy housework to be performed
Requires assistance with heavy housework
Unable to perform any heavy housework
Page 4 of 15
5) Is member able to perform laundry tasks
Arranges for laundry to be done
Requires assistance with laundry tasks
Unable to perform any laundry tasks
6) Is member able to plan/arrange for pick-up,
delivery, or some means of gaining possession of
medication(s) and take them independently
Arranges for medication to be obtained and taken correctly
Requires assistance with obtaining and taking medication
correctly
Unable to obtain medication and take correctly
7) Is member able to handle finances independently
Arranges for someone else to handle finances
Requires assistance with handling finances
Unable to handle finances
8) Is member able to use the telephone independently
Requires adaptive device to use telephone
Requires assistance when using telephone
Unable to use telephone
SECTION VII-NEURO/EMOTIONAL/BEHAVIORAL
1) Does member exhibit behavior problems
No (If yes, check below all that apply and explain
Date of functional analysis:
and/or
the frequency in comments)
Date of behavior support plan:
Disruptive behavior
Agitated behavior
Assaultive behavior
Self-injurious behavior
Self-neglecting behavior
Page 5 of 15
2) Is member oriented to person, place, time
Yes No (If no, check below all that apply and comment)
Forgetful
Confused
Unresponsive
Impaired Judgment
3) Has member experienced a major change or
Description:
crisis within the past twelve months
(If yes, describe)
4) Is the member actively participating in social
and/or community activities Yes
5) Is the member experiencing any of the following
(For each checked, explain the frequency and details in the
comments section)
Difficulty recognizing others
Loneliness
Sleeping problems
Anxiousness
Irritability
Lack of interest
Short-term memory loss
Long-term memory loss
Hopelessness
Suicidal behavior
Medication abuse
Substance abuse
Alcohol Abuse
Page 6 of 15
6) Cognitive functioning (Participant’s current
level of alertness, orientation, comprehension,
concentration, and immediate memory for simple
commands)
Alert/oriented, able to focus and shift
attention, comprehends and recalls task
directions independently.
Requires prompting (cueing, repetition,
reminders) only under stressful or unfamiliar
conditions.
Requires assistance and some direction in
specific situations (e.g., on all tasks
involving shifting of attention), or
consistently requires low stimulus
environment due to distractibility.
Required considerable assistance in routine
situations. Is not alert and oriented or is
unable to shift attention and recall directions
more than half the time.
Totally dependent due to disturbances such
as constant disorientation, coma, persistent
vegetative state, or delirium.
7) When Confused (Reported or Observed):
Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not
constantly
Constantly
NA (non-responsive)
8) When Anxious (Reported or Observed):
None of the time
Less often than daily
Daily, but not constantly
All of the time
9) Depressive Feelings (Reported or Observed):
Depressed mood (e.g., feeling sad, tearful)
Sense of failure or self-reproach
Recurrent thoughts of death
Thoughts of suicide
None of the above feelings reported or
observed
Page 7 of 15
10) Member Behaviors (Reported or Observed):
Indecisiveness, lack of concentration
Diminished interest in most activities
Sleep disturbances
Recent changes in appetite or weight
Agitation
Suicide attempt
None of the above behaviors observed or
reported
11) Behaviors Demonstrated at Least Once a
Week:
Memory deficit: failure to recognize
familiar persons/places, inability to recall
events of past 24-hours, significant memory
loss so that supervision is required.
Impaired decision-making: failure to
perform usual ADL’s, inability to
inappropriately stop activities, jeopardizes
safety through actions.
Verbal disruption: yelling, threatening,
excessive profanity, sexual references, etc.
Physical aggression: aggressive or
combative to self and others (e.g. hits self,
throws objects, punches, dangerous
maneuvers with wheelchair or other
objects).
Disruptive, infantile, or socially
inappropriate behavior (excludes verbal
actions).
Delusional, hallucinatory, or paranoid
behavior.
None of the above behaviors demonstrated.
12 ) Frequency of Behavior Problems (Reported or
Observed) such as wandering episodes, self abuse,
verbal disruption, physical aggression, etc.:
Less than once a month
Once a month
Several times each month
Several times a week
At least daily
Page 8 of 15
13)
Mental Status:
Oriented
Depressed
Disoriented
Lethargic
Agitated
Other
14) Is this member receiving Psychiatric Nursing
Services at home provided by a qualified psychiatric
nurse?
SECTION VIII-CLINICAL INFORMATION
1) Is member’s vision adequate (with or without
glasses)
Undetermined
Difficulty seeing print
Difficulty seeing objects
No useful vision
2) Is member’s hearing adequate (with or without
hearing aid)
(If no, check below all that apply, and comment)
Difficulty with conversation level
Only hears loud sounds
No useful hearing
3) Is member able to communicate needs
Speaks with difficulty but can be understood
Uses sign language and/or gestures/communication device
Inappropriate context
Unable to communicate
4) Does member maintain an adequate diet
No (If no, check all that apply and comment)
Uses dietary supplements
Requires special diet (low salt, low fat, etc.)
Refuses to eat
Forgets to eat
Tube feeding required (Explain the brand, amount, and
frequency in the comments section)
Other dietary considerations (PICA, Prader-Willie, etc.)
Page 9 of 15
Filling out the Kentucky Map 351 form is an important step in the Medicaid waiver assessment process. This form collects essential information about the member's demographics, eligibility, assessment, and daily living activities. Completing it accurately ensures that the member receives the appropriate services and support they need.
The Kentucky Map 351 form serves as a Medicaid Waiver Assessment tool. It collects essential information about individuals applying for various Medicaid waiver programs. These programs are designed to provide support and services to individuals with specific health needs, allowing them to live in their communities rather than in institutional settings.
The form must be completed for individuals seeking eligibility for Medicaid waiver programs in Kentucky. This includes individuals with conditions such as acquired brain injuries, developmental disabilities, or those requiring long-term care. It is typically filled out by the member or their representative, in collaboration with healthcare providers.
The Map 351 form requests a variety of information, including:
This comprehensive data helps determine the level of care and services needed for the individual.
The assessment process begins with the completion of the Map 351 form. Once submitted, a qualified assessor reviews the information and may conduct interviews or further evaluations. This process ensures that the individual's needs are accurately identified and that they receive appropriate services. The assessment results will guide decisions about eligibility and the type of support available through Medicaid waivers.
If you have questions about the Map 351 form, it is advisable to contact the Kentucky Cabinet for Health and Family Services or your local Medicaid office. They can provide guidance on completing the form, understanding the assessment process, and addressing any specific concerns related to Medicaid waivers. Additionally, healthcare providers involved in the assessment may also offer assistance.
Incomplete Personal Information: Many individuals forget to fill in all required fields, such as the member's full name, date of birth, and Medicaid Member ID number. Omitting any of these details can delay the processing of the application.
Incorrect Program Selection: Applicants sometimes select the wrong type of program or application. It is crucial to check the correct box for the program being applied for, such as Home and Community Based Waiver or Acquired Brain Injury Waiver.
Missing Signatures: Failing to obtain necessary signatures can lead to complications. The form requires signatures to confirm that the member's freedom of choice has been explained and that they have been informed about the complaint process.
Inaccurate Diagnosis Information: Providing incorrect or incomplete diagnosis details is a common mistake. It is important to accurately enter all relevant diagnoses, including the appropriate ICD-9 or DSM codes.
Neglecting to Review the Form: Many applicants do not review the completed form before submission. Taking a moment to check for errors or omissions can prevent unnecessary delays in processing.
The Kentucky Map 351 form is a crucial document used in the Medicaid waiver assessment process. It collects essential information about the member's demographics, eligibility, and needs. However, several other forms and documents are often utilized in conjunction with this form to ensure a comprehensive assessment and facilitate the Medicaid application process. Below is a list of these related documents.
Understanding these documents is vital for a smooth Medicaid waiver application process. Each form plays a specific role, contributing to a comprehensive understanding of the member's needs and ensuring that they receive the appropriate services and support.
The Kentucky Map 351 form is similar to the Medicare Health Outcomes Survey (HOS), which assesses the health status and functional abilities of Medicare beneficiaries. Both documents aim to gather comprehensive information about an individual's health and daily living skills. While the Map 351 focuses on Medicaid waiver eligibility and specific care needs, the HOS evaluates overall health outcomes and quality of life. Each form serves to ensure that individuals receive appropriate support and services tailored to their unique circumstances.
Another comparable document is the Uniform Assessment Instrument (UAI) used in various states for assessing long-term care needs. Like the Map 351, the UAI collects demographic information, medical history, and functional abilities. It is designed to determine eligibility for state-funded long-term care services. Both forms facilitate a standardized approach to evaluating an individual's care requirements, ensuring that necessary resources are allocated efficiently.
The Functional Independence Measure (FIM) is also similar to the Kentucky Map 351 form. This document assesses an individual's level of disability and functional independence across various activities of daily living. Both instruments provide valuable insights into a person's capabilities and needs, allowing healthcare providers to create personalized care plans. The FIM, however, is often used in rehabilitation settings, while the Map 351 specifically addresses Medicaid waiver eligibility.
The Comprehensive Assessment and Review for Long-Term Care Services (CARES) is another document that shares similarities with the Map 351. CARES evaluates individuals seeking long-term care services through a comprehensive assessment process. Both forms require detailed information about medical conditions and functional abilities. They help determine the appropriate level of care and services needed to support individuals in their daily lives.
The Personal Care Assessment Tool (PCAT) is a similar document that assesses individuals’ needs for personal care services. Like the Map 351, the PCAT evaluates the ability to perform daily activities and identifies areas where assistance is required. Both forms aim to ensure that individuals receive the necessary support to maintain their independence and quality of life.
The Long-Term Care Facility Resident Assessment Instrument (RAI) is another comparable document. The RAI is used to assess residents in long-term care facilities, focusing on their medical, psychological, and functional needs. Similar to the Map 351, it collects essential information to develop individualized care plans. Both instruments emphasize the importance of understanding an individual's unique needs to provide effective care.
The Community Health Assessment (CHA) is also relevant, as it gathers data on the health and wellness of a population. While the Map 351 focuses on individual assessments for Medicaid waivers, the CHA looks at broader community health trends. Both documents aim to identify health needs and gaps in services, ultimately guiding resource allocation and program development.
The Health Risk Assessment (HRA) is another document that shares similarities with the Kentucky Map 351 form. An HRA evaluates an individual's health risks and lifestyle factors that could impact their overall well-being. Both assessments provide valuable insights into health status and help identify areas where intervention may be necessary. While the Map 351 is specifically tailored for Medicaid waiver eligibility, the HRA can be used across various healthcare settings.
The Assessment of Living Skills and Resources (ALSR) is another document that resembles the Map 351. The ALSR focuses on evaluating an individual's living skills and available resources, similar to the daily living activities assessed in the Map 351. Both forms aim to identify the level of support needed for individuals to thrive in their environments, ensuring they receive appropriate assistance.
Lastly, the Individualized Support Plan (ISP) is akin to the Kentucky Map 351 form. The ISP outlines the specific support and services required for individuals with disabilities. Like the Map 351, it takes into account the individual's preferences, strengths, and needs. Both documents are instrumental in creating tailored care plans that enhance the quality of life for those receiving assistance.
When filling out the Kentucky Map 351 form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are seven things to do and avoid while completing the form:
Following these guidelines can help streamline the process and ensure that all necessary information is provided for the member's assessment.
Misconceptions about the Kentucky Map 351 form can lead to confusion and errors in the application process. Here are eight common misconceptions along with clarifications:
This form is also used for re-certifications and re-applications, not just for new applications.
Filling out the form does not ensure approval. Eligibility is determined by specific criteria that must be met.
While healthcare professionals often assist, the member or their family can also provide the necessary information.
Some sections may not apply to every member. Incomplete sections do not automatically invalidate the form.
The Map 351 form also addresses daily living activities, emotional and behavioral issues, and community inclusion.
A signature is often needed to confirm that the member understands their rights and the application process.
Members can request changes or updates to the information after submission if necessary.
This form applies to individuals of all ages who are seeking Medicaid waiver services.
When completing the Kentucky Map 351 form, it is essential to ensure accuracy and thoroughness. Here are four key takeaways regarding the form: