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Blank Kentucky Map 351 Form

The Kentucky Map 351 form is a crucial document used for Medicaid waiver assessments in Kentucky. It gathers essential information about a member's demographics, health status, and daily living activities. This form helps determine eligibility for various Medicaid waiver programs, ensuring that individuals receive the appropriate support they need.

Outline

The Kentucky Map 351 form serves as a critical tool in the Medicaid Waiver assessment process, designed to gather essential information about individuals seeking access to various waiver programs. This comprehensive document encompasses several sections that detail member demographics, eligibility criteria, and assessment of daily living activities. The first section collects basic personal information, including the member's name, date of birth, and Medicaid ID, along with emergency contact details. Following this, the form delves into the specific waiver eligibility, allowing applicants to indicate the type of program they are applying for, such as Home and Community-Based Waivers or the Acquired Brain Injury Waiver. The assessment also addresses the member’s abilities in daily activities, ranging from personal care tasks like dressing and grooming to instrumental activities such as meal preparation and managing finances. Furthermore, the form includes a section dedicated to neuro/emotional and behavioral assessments, ensuring a holistic view of the member’s needs and challenges. By meticulously documenting this information, the Kentucky Map 351 form plays a vital role in determining the appropriate level of support and services for individuals with varying needs, ultimately facilitating their access to essential resources.

Sample - Kentucky Map 351 Form

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

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:

Certification

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

Yes

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)

(Date-of-onset

)

Mental Illness

(Date-of-onset

)

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:

Street address

City, state and zip code

Provider contact person

Page 1 of 15

MAP 351		Commonwealth of Kentucky
(Rev. 7/08)		Cabinet for Health and Family Services
		Department for Medicaid Services
		MEDICAID WAIVER ASSESSMENT

	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

MAP 351			Commonwealth of Kentucky
(Rev. 7/08)			Cabinet for Health and Family Services
			Department for Medicaid Services
			MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)				Medicaid Number

			SECTION V – ACTIVITIES OF DAILY LIVING
	1) Is member independent with			Comments:
	dressing/undressing
	Yes	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			Comments:
	Yes	No(If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Requires hands-on assistance with
	oral care		shaving
	nail care		hair
	Requires total assistance

	3) Is member independent with bed mobility			Comments:
	Yes	No (If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Occasionally requires hands-on assistance
	Always requires hands-on assistance
	Bed-bound
	Required bedrails

	4) Is member independent with bathing			Comments:
	Yes	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 Peri-Care
	Requires total assistance

	5) Is member independent with toileting			Comments:
	Yes	No (If no, check below all that apply and comment)
	Bladder incontinence
	Bowel incontinence
	Occasionally requires hands-on assistance
	Always requires hands-on assistance
	Requires total assistance
	Bowel and bladder regimen

	6) Is member independent with eating Yes No			Comments:
	(If no, check below all that apply and comment)
	Requires supervision or verbal cues
	Requires assistance cutting meat or arranging food
	Partial/occasional help
	Totally fed (by mouth)
	Tube feeding (type and tube location)

Page 3 of 15

MAP 351				Commonwealth of Kentucky
(Rev. 7/08)				Cabinet for Health and Family Services
				Department for Medicaid Services
				MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)					Medicaid Number

	7) Is member independent with ambulation					Comments:
	Yes	No (If no, check below all that apply and comment)
	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					Comments:
	Yes	No (If no, check below all that apply and comment)
	Requires supervision or verbal cues
	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			Yes	No		Comments:
	(If no, check below all that apply and explain in the comments)
	Arranges for meal preparation
	Requires supervision or verbal cues
	Requires assistance with meal preparation
	Requires total meal preparation
	2) Is member able to shop independently				Yes No		Comments:
	(If no, check below all that apply and explain in the comments)
	Arranges for shopping to be done
	Requires supervision or verbal cues
	Requires assistance with shopping
	Unable to participate in shopping

	3) Is member able to perform light housekeeping						Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for light housekeeping duties to be performed
	Requires supervision or verbal cues
	Requires assistance with light housekeeping
	Unable to perform any light housekeeping

	4) Is member able to perform heavy housework						Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for heavy housework to be performed
	Requires supervision or verbal cues
	Requires assistance with heavy housework
	Unable to perform any heavy housework

Page 4 of 15

MAP 351			Commonwealth of Kentucky
(Rev. 7/08)			Cabinet for Health and Family Services
			Department for Medicaid Services
			MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)				Medicaid Number

	5) Is member able to perform laundry tasks				Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for laundry to be done
	Requires supervision or verbal cues
	Requires assistance with laundry tasks
	Unable to perform any laundry tasks

	6) Is member able to plan/arrange for pick-up,				Comments:
	delivery, or some means of gaining possession of
	medication(s) and take them independently
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for medication to be obtained and taken correctly
	Requires supervision or verbal cues
	Requires assistance with obtaining and taking medication
	correctly
	Unable to obtain medication and take correctly

	7) Is member able to handle finances independently				Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Arranges for someone else to handle finances
	Requires supervision or verbal cues
	Requires assistance with handling finances
	Unable to handle finances

	8) Is member able to use the telephone independently				Comments:
	Yes	No
	(If no, check below all that apply and explain in the comments)
	Requires adaptive device to use telephone
	Requires supervision or verbal cues
	Requires assistance when using telephone
	Unable to use telephone
		SECTION VII-NEURO/EMOTIONAL/BEHAVIORAL
	1) Does member exhibit behavior problems			Comments:
	Yes	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:
	the frequency in comments)
	Disruptive behavior
	Disruptive behavior
	Agitated behavior
	Assaultive behavior
	Self-injurious behavior
	Self-neglecting behavior

Page 5 of 15

MAP 351	Commonwealth of Kentucky
(Rev. 7/08)	Cabinet for Health and Family Services
	Department for Medicaid Services
	MEDICAID WAIVER ASSESSMENT

Name (LAST, FIRST)		Medicaid Number

2) Is member oriented to person, place, time		Comments:
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	Yes No
(If yes, describe)

4) Is the member actively participating in social		Description:
and/or community activities Yes	No
(If yes, describe)

5) Is the member experiencing any of the following		Comments:
(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

MAP 351	Commonwealth of Kentucky
(Rev. 7/08)	Cabinet for Health and Family Services
	Department for Medicaid Services
	MEDICAID WAIVER ASSESSMENT

Name (LAST, FIRST)		Medicaid Number

6) Cognitive functioning (Participant’s current		Comments:
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):		Comments:
	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):		Comments:
	None of the time
	Less often than daily
	Daily, but not constantly
	All of the time
	NA (non-responsive)

9) Depressive Feelings (Reported or Observed):		Comments:
	Depressed mood (e.g., feeling sad, tearful)
	Sense of failure or self-reproach
	Hopelessness
	Recurrent thoughts of death
	Thoughts of suicide
	None of the above feelings reported or
observed

Page 7 of 15

MAP 351	Commonwealth of Kentucky
(Rev. 7/08)	Cabinet for Health and Family Services
	Department for Medicaid Services
	MEDICAID WAIVER ASSESSMENT

Name (LAST, FIRST)		Medicaid Number

10) Member Behaviors (Reported or Observed):		Comments:
	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		Comments:
Week:	Memory deficit: failure to recognize
	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		Comments:
Observed) such as wandering episodes, self abuse,
verbal disruption, physical aggression, etc.:
	Never
	Less than once a month
	Once a month
	Several times each month
	Several times a week
	At least daily

Page 8 of 15

MAP 351				Commonwealth of Kentucky
(Rev. 7/08)				Cabinet for Health and Family Services
				Department for Medicaid Services
				MEDICAID WAIVER ASSESSMENT

	Name (LAST, FIRST)				Medicaid Number

13)		Mental Status:			Comments:
			Oriented
			Forgetful
			Depressed
			Disoriented
			Lethargic
			Agitated
			Other

	14) Is this member receiving Psychiatric Nursing				Comments:
	Services at home provided by a qualified psychiatric
	nurse?		Yes	No

				SECTION VIII-CLINICAL INFORMATION
	1) Is member’s vision adequate (with or without				Comments:
	glasses)
	Yes	No	Undetermined
	(If no, check below all that apply and comment)
	Difficulty seeing print
	Difficulty seeing objects
	No useful vision

	2) Is member’s hearing adequate (with or without				Comments:
	hearing aid)
	Yes	No	Undetermined
	(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				Comments:
	Yes	No (If no, check below all that apply and comment)
	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				Comments:
	Yes	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

Click for PDF

Form Information

Fact Name	Description
Form Title	Kentucky Map 351 - Medicaid Waiver Assessment
Governing Body	Cabinet for Health and Family Services, Department for Medicaid Services
Revision Date	Revised in July 2008
Member Demographics	Includes name, date of birth, Medicaid ID, address, and emergency contact information.
Waiver Eligibility	Determines eligibility for various Medicaid waiver programs such as Home and Community Based Waiver.
Assessment Provider Information	Captures details about the assessment provider, including name and contact information.
Activities of Daily Living	Assesses the member's independence in daily activities like dressing, grooming, and eating.
Instrumental Activities of Daily Living	Evaluates the member's ability to perform tasks such as meal preparation and managing finances.
Behavioral Assessment	Identifies any behavioral issues and includes a functional analysis date and behavior support plan date.

Detailed Guide for Filling Out Kentucky Map 351

Once you have the Kentucky Map 351 form in front of you, it’s time to fill it out accurately. This process requires attention to detail to ensure that all necessary information is provided. Here are the steps to complete the form:

Start with Section I – Member Demographics. Fill in the member’s Name, Date of Birth, and Medicaid Member ID #.
Provide the Street Address, County Code, City, State, and Zip Code.
Indicate the member’s Sex and Marital Status by checking the appropriate boxes.
List the Emergency Contact Name and Phone Number, along with the Member Phone Number.
State whether the member is able to read and write by checking Yes or No.
Enter the member’s Height and Weight.
Proceed to Section II – Member Waiver Eligibility. Check the type of program applied for.
Specify the Type of Application by checking one of the options provided.
Indicate where the member was admitted from by checking the appropriate box.
Fill in the Certification Period dates and the Certification Number.
Confirm if the member’s freedom of choice has been explained and verified by a signature on the MAP 350 Form.
Provide the Physician’s Name, License Number, and Phone Number.
Enter the member’s primary diagnosis along with all relevant diagnoses, including codes.
Answer the questions regarding the member’s diagnosis and provide any necessary details.
In Section III, fill out the Assessment Provider Information including the provider’s name, number, and contact details.
Complete Section IV – Self Assessment by answering the questions about community inclusion, relationships, rights, dignity, respect, health, and lifestyle.
In Section V, assess the member’s independence in Activities of Daily Living by answering each question and providing comments as needed.
Move to Section VI and evaluate the member’s ability to perform Instrumental Activities of Daily Living, answering each question and adding comments where applicable.
Finally, complete Section VII by noting any neuro/emotional/behavioral issues, including any behavior problems and relevant details.

Obtain Answers on Kentucky Map 351

What is the Kentucky Map 351 form?

The Kentucky Map 351 form is a Medicaid Waiver Assessment used to determine eligibility for various Medicaid waiver programs in Kentucky. It collects important information about the member, including demographics, health status, and daily living activities. The form is essential for assessing the needs of individuals who require assistance due to disabilities or other health conditions.
Who needs to fill out the Map 351 form?

The form must be completed for individuals applying for or renewing their eligibility for Medicaid waiver programs. This includes those seeking support through Home and Community Based Waivers, Acquired Brain Injury Waivers, and others. It is typically filled out by the member or their representative, with input from healthcare providers as needed.
What information is required on the Map 351 form?

The form requires a variety of information, including:
- Member demographics (name, date of birth, address, etc.)
- Medicaid Member ID
- Type of program applied for
- Details about the member’s health conditions and diagnoses
- Assessment of daily living activities and independence levels
- Emergency contact information
How does the assessment process work?

The assessment process involves evaluating the member’s needs and capabilities. After completing the Map 351 form, a qualified provider will review the information and may conduct an in-person assessment. This assessment helps to determine the level of care and support the member requires. The results will influence the approval of the waiver application.
What happens after submitting the Map 351 form?

Once the Map 351 form is submitted, the relevant Medicaid authority will review the application. If additional information is needed, they may contact the member or their representative. After the review, a determination will be made regarding eligibility for the requested waiver program. Members will be notified of the decision, and if approved, they will receive further instructions on accessing services.

Common mistakes

Filling out the Kentucky Map 351 form can be a daunting task, and mistakes are common. One of the most frequent errors occurs when individuals fail to provide complete and accurate demographic information. Missing details such as the member’s full name, date of birth, or Medicaid Member ID can lead to significant delays in processing. Ensuring that all fields are filled out correctly is essential to avoid unnecessary complications.

Another common mistake is neglecting to check the appropriate boxes for the member’s marital status and sex. This seemingly minor oversight can create confusion during the eligibility assessment. It’s important to double-check these sections to ensure that the information aligns with the member’s current status.

Many people also overlook the importance of providing a primary diagnosis and additional diagnoses with the correct codes. This information is crucial for determining eligibility for specific waivers. Without accurate diagnosis codes, the assessment may not reflect the member’s true needs, which can impact their access to necessary services.

In Section II, a common error is failing to indicate whether the member's freedom of choice has been explained and verified. This is a critical requirement, and neglecting to sign off on this can result in the application being rejected. It’s essential to ensure that all necessary signatures are obtained and documented properly.

When it comes to the assessment of daily living activities, individuals often misinterpret the instructions. For example, when answering whether the member is independent with activities like dressing or bathing, it’s vital to provide honest and detailed comments. Misrepresenting the level of assistance needed can lead to inappropriate service allocation.

Another frequent mistake is not providing enough detail in the self-assessment section. This area allows members to express their preferences and needs, and vague responses can hinder the assessment process. Specific examples of community involvement or relationships can help assessors understand the member’s situation better.

In the instrumental activities of daily living section, many people fail to indicate whether the member can handle finances or use the telephone independently. These skills are essential for assessing overall independence. Providing clear comments about the member’s capabilities can significantly influence their eligibility and the services they receive.

Additionally, some applicants do not keep track of important dates, such as the date of brain injury or the last functional analysis. This information is crucial for evaluating the member’s needs and ensuring that the assessment is up-to-date. Keeping thorough records can prevent complications later in the process.

Lastly, individuals sometimes submit the form without reviewing it for completeness. A final check can catch errors that might have been overlooked during the initial filling out of the form. Taking a moment to ensure that all sections are complete and accurate can save time and frustration in the long run.

By being aware of these common mistakes, applicants can improve their chances of a smooth and successful application process. Attention to detail and thoroughness are key when completing the Kentucky Map 351 form.

Documents used along the form

The Kentucky Map 351 form serves as a vital component in the Medicaid waiver assessment process. However, it is often accompanied by several other forms and documents that help create a comprehensive profile for individuals seeking assistance. Each of these documents plays a unique role in ensuring that the assessment process is thorough and effective.

MAP 350 Form: This form is essential for documenting a member's freedom of choice and the process for making complaints. It verifies that the member understands their rights and the options available to them.
Physician's Order: A signed document from a healthcare provider that outlines the medical necessity for the services requested through the waiver. This order is crucial for establishing eligibility based on medical needs.
Assessment Tool: This tool is used by assessors to evaluate the individual's needs and capabilities. It often includes questions about daily living activities, health status, and social interactions.
Personal Care Plan: A customized plan that outlines the specific services and supports required by the individual. It takes into account their preferences and needs, ensuring that care is person-centered.
Eligibility Determination Form: This form is used to formally assess whether the individual meets the criteria for Medicaid waiver services. It includes details about income, resources, and other eligibility factors.
Consent Forms: These documents are necessary for obtaining permission from the member or their legal representative to share information with providers and other entities involved in their care.
Service Provider Agreement: A contract between the member and the service provider that outlines the responsibilities of both parties. It ensures clarity regarding the services to be provided and the expectations involved.
Incident Report Forms: These forms document any incidents or issues that arise during the provision of services. They are important for maintaining accountability and ensuring the safety of the member.
Financial Assessment Form: This form evaluates the member's financial situation to determine their ability to contribute to the cost of care, if applicable. It helps in planning the financial aspects of their services.

In summary, the Kentucky Map 351 form, while significant, is part of a larger framework of documentation that ensures individuals receive the appropriate support and care they need. Each accompanying document contributes to a holistic understanding of the member's situation, facilitating a smoother and more effective assessment process.

Similar forms

Medicaid Application Form: Similar to the Kentucky Map 351 form, the Medicaid Application Form collects essential demographic information and medical history to determine eligibility for Medicaid services. Both forms require personal details, including name, date of birth, and Medicaid ID.
Medicaid Renewal Form: This document is used to renew Medicaid eligibility. Like the Map 351, it requires updated information about the member's status, including income and living situation, ensuring that the information is current for continued benefits.
Long-Term Care Assessment Form: This form evaluates the needs of individuals seeking long-term care services. It shares similarities with the Map 351 in that it assesses daily living activities and health conditions to determine the level of care required.
Personal Care Assessment Form: Used to assess an individual’s need for personal care services, this form, like the Map 351, focuses on daily living activities and the assistance required by the member.
Home and Community-Based Services (HCBS) Eligibility Form: This document determines eligibility for HCBS programs. It parallels the Map 351 by collecting information on the member’s health, living situation, and support needs.
Disability Determination Form: This form assesses an individual's disability status for various benefits. Similar to the Map 351, it requires detailed medical information and evaluations to support the determination of eligibility.
Caregiver Assessment Form: This document gathers information about the caregiver’s ability to support the member. Like the Map 351, it assesses the member's needs and the level of support required from caregivers to ensure adequate care.

Dos and Don'ts

When filling out the Kentucky Map 351 form, it’s important to follow specific guidelines to ensure accuracy and completeness. Here’s a list of things you should and shouldn’t do:

Do read the instructions carefully before starting.
Do fill in all required fields with accurate information.
Do double-check the Medicaid Member ID number for correctness.
Do use clear handwriting or type the information if possible.
Do provide emergency contact details, including a phone number.
Don’t leave any sections blank unless specified.
Don’t use abbreviations that may cause confusion.
Don’t provide incomplete diagnoses or omit important medical history.
Don’t forget to sign and date the form where required.
Don’t submit the form without reviewing it for errors.

Misconceptions

Here are nine common misconceptions about the Kentucky Map 351 form, along with clarifications to help you understand its purpose and requirements.

Misconception 1: The Map 351 form is only for new Medicaid applicants.

This form is also used for re-certifications and re-applications, making it essential for ongoing Medicaid eligibility.

Misconception 2: You don’t need to provide detailed medical information.

In fact, the form requires comprehensive medical history, including diagnoses and treatment details, to assess eligibility accurately.

Misconception 3: The form can be filled out by anyone.

Only authorized individuals, such as healthcare providers or case managers, should complete the form to ensure accuracy and compliance.

Misconception 4: The Map 351 form is the only document required for Medicaid Waiver eligibility.

Additional documentation may be needed, including the MAP 350 form, which verifies the member’s freedom of choice and complaint process.

Misconception 5: The form is straightforward and easy to complete.

While it may seem simple, the form has multiple sections that require careful attention to detail. Incomplete or incorrect information can delay processing.

Misconception 6: You can submit the form without a physician's signature.

A physician's signature is essential to validate the medical information provided and confirm the member’s diagnosis.

Misconception 7: The Map 351 form is only for individuals with severe disabilities.

This form is applicable to a range of individuals who may require various levels of support, not just those with severe disabilities.

Misconception 8: Once submitted, the form is processed immediately.

Processing times can vary significantly based on the completeness of the application and the current workload of the Medicaid office.

Misconception 9: You cannot appeal if your application is denied.

There is a process for appeals, and understanding your rights and options is crucial if you receive a denial.

Key takeaways

Filling out the Kentucky Map 351 form is an important step in the Medicaid waiver assessment process. Here are key takeaways to consider:

The form is used to assess eligibility for various Medicaid waivers in Kentucky, including Home and Community Based Waiver and Acquired Brain Injury Waiver.
Accurate member demographics must be provided in Section I, including name, date of birth, and Medicaid Member ID.
Emergency contact information is essential. Include the name and phone number of someone who can be reached in case of an emergency.
Section II focuses on the type of waiver applied for and the member's eligibility. Be sure to check the appropriate boxes for program type and application type.
It is crucial to document all diagnoses clearly, including ICD-9 or DSM codes, to facilitate the assessment process.
Section IV requires a self-assessment. This section allows the member to express their preferences and needs regarding community inclusion, relationships, rights, dignity, respect, health, and lifestyle.
Activities of Daily Living (ADLs) are evaluated in Section V. Note the level of independence for each activity, such as dressing, grooming, and bathing.
Instrumental Activities of Daily Living (IADLs) are assessed in Section VI. This includes tasks like meal preparation, shopping, and handling finances.
Behavioral concerns should be documented in Section VII. If the member exhibits any behavior problems, provide detailed comments and dates of any functional analyses or behavior support plans.
Ensure all sections are filled out completely and accurately. Incomplete forms may delay the assessment process.

By following these guidelines, you can help ensure that the Kentucky Map 351 form is completed correctly, facilitating a smoother assessment process for Medicaid waivers.