Fill in Your Kentucky Map 351 Form

The Kentucky Map 351 form is an essential document designed by the Commonwealth of Kentucky, specifically within the Cabinet for Health and Family Services Department for Medicaid Services. It serves as a Medicaid Waiver Assessment tool that captures comprehensive information regarding an individual’s demographics, membership waiver eligibility, their needs for daily and instrumental activities, as well as an assessment of their neuro/emotional/behavioral status. Understanding and accurately completing this form is crucial for individuals seeking to apply for Medicaid waivers, such as the Home and Community Based Waiver, Acquired Brain Injury Waiver, and others, as it determines their eligibility and the extent of services they may require. Ensure you fill out the form correctly by clicking the button below.

Open Kentucky Map 351 Editor Here

The Kentucky Map 351 form serves as a comprehensive assessment tool designed to evaluate individuals who are seeking or currently receiving Medicaid Waiver services in the state of Kentucky. Updated in July 2008, this form is an integral document within the Cabinet for Health and Family Services Department for Medicaid Services. It meticulously gathers member demographics, including personal information such as name, date of birth, Medicaid Member ID, and contact details, to ensure a personalized approach to Medicaid Waiver eligibility and services. The form is structured to assess the candidate's eligibility under various waiver programs like the Home and Community Based Waiver, Acquired Brain Injury Waiver, and others, taking into account the individual's medical condition, living situation, and the desired program. Furthermore, it delves deeply into the member's ability to perform daily and instrumental activities, thereby evaluating the extent of support needed. The assessment also considers the provider's information, self-assessment concerning community inclusion, relationships, rights, and other personal aspects that affect quality of life. By encompassing detailed sections on Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and Neuro/Emotional/Behavioral assessments, the Kentucky Map 351 form captures a holistic picture of the member's health and social needs, facilitating tailored Medicaid Waiver services that aim to enhance their well-being and autonomy.

Kentucky Map 351 Example

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

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) Does member require respiratory care and/or			Comments:
equipment
Yes	No (If yes, check all that apply and comment)
Oxygen therapy (Liters per minute and delivery device)
Nebulizer (Breathing treatments)
Management of respiratory infection
Nasopharyngeal airway
Tracheostomy care
Aspiration precautions
Suctioning
Pulse oximetry
Ventilator (list settings)

6) Does member have history of a stroke(s)			Comments:
Yes	No (If yes, check all that apply and comment)
Residual physical injury(ies)
Swallowing impairments
Functional limitations (Number of limbs affected)

7) Does member’s skin require additional,			Comments:
specialized care		Yes No
(If yes, check all that apply and comment)
Requires additional ointments/lotions
Requires simple dressing changes (i.e. band-aids,
occlusive dressings)
Requires complex dressing changes (i.e. sterile dressing)
Wounds requiring “packing” and/or measurements
Contagious skin infections
Ostomy care
8) Does member require routine lab work			Comments:
Yes	No (If yes, what type and how often)

9) Does member require specialized genital and/or			Comments:
urinary care Yes		No
(If yes, check all that apply and comment)
Management of reoccurring urinary tract infection
In-dwelling catheter
Bladder irrigation
In and out catheterization

10) Does member require specific, physician-			Comments:
ordered vital signs evaluation necessary in the
management of a condition(s) Yes No (If yes,
explain in the comments section)
11) Does member have total or partial paralysis			Comments:
Yes	No (If yes, list limbs affected and comment)

Page 10 of 15

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Form Data

Fact Name	Detail
Form Purpose	The Kentucky MAP 351 form is designed to assess eligibility for Medicaid waiver services, detailing the applicant's demographics, waiver eligibility, and required care level.
Sections Covered	It covers multiple sections including Member Demographics, Member Waiver Eligibility, Assessment Provider Information, Self Assessment, Activities of Daily Living, Instrumental Activities of Daily Living, and Neuro/Emotional/Behavioral.
Governing Body	The form is governed by the Commonwealth of Kentucky Cabinet for Health and Family Services Department for Medicaid Services.
Revision Date	This version of the form was revised in July 2008.

How to Fill Out Kentucky Map 351

Filling out the Kentucky MAP 351 form is essential for accessing Medicaid waiver services, serving as a comprehensive overview of an individual's need for support and living conditions. The document is divided into seven sections, each designed to gather critical information from demographic details to the type of assistance required daily. Its thorough completion ensures that health professionals can effectively assess and address the specific needs of Medicaid members. Follow these step-by-step instructions to accurately fill out the form:

Begin with Section I - MEMBER DEMOGRAPHICS. Enter the member's full name, date of birth, Medicaid Member ID number, street address, county code, and city, state, and zip code. Indicate the member's sex, marital status, emergency contact information, if the member can read and write, and the member’s height and weight.
Move on to Section II - MEMBER WAIVER ELIGIBILITY. Here, check the appropriate boxes to define the type of program applied for and the type of application. You must also provide details on where the member was admitted from, the certification period dates, if the MAP 350 form has been signed, the contact details of the physician, the member’s primary diagnosis, and any additional diagnoses.
In Section III – ASSESSMENT PROVIDER INFORMATION, record the name, provider number, phone number, address, and contact person of the assessment or reassessment provider.
Section IV - SELF ASSESSMENT requires input on community inclusion, relationships, rights, dignity and respect, health, and lifestyle. Add any additional pages as necessary.
For Section V – ACTIVITIES OF DAILY LIVING, check the appropriate boxes to indicate the member's level of independence in various activities such as dressing, grooming, bed mobility, bathing, toileting, eating, ambulation, and transferring, providing detailed comments as needed.
Section VI - INSTRUMENTal ACTIVITIES OF DAILY LIVING similarly asks for details about the member's ability to perform tasks such as meal preparation, shopping, housekeeping, laundry, handling finances, and using the telephone, with a space for comments on each.
Finally, Section VII - NEURO/EMOTIONal/BEHAVIORal inquires about any behavior problems, specifying the need for a functional analysis and a behavior support plan if applicable.

Upon completing these steps, ensure that all provided information is accurate and reflective of the member's current needs and circumstances. Proper completion of the Kentucky MAP 131 form is pivotal for accessing suitable Medicaid waiver programs that cater to the individual's specific health and living requirements.

Crucial Queries on This Form

What is the Kentucky MAP 351 form?

The Kentucky MAP 351 form is a document used by the Commonwealth of Kentucky's Cabinet for Health and Family Services, specifically within the Department for Medicaid Services. Its main purpose is to assess individuals applying for or currently receiving Medicaid waivers. These waivers are designed to provide services to support individuals living in their community instead of a nursing facility or hospital. The form includes sections on member demographics, member waiver eligibility, a self-assessment, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and neuro/emotional/behavioral assessments. It is a comprehensive tool used to capture the needs, abilities, and preferences of the Medicaid member.
Who needs to complete the MAP 351 form?

This form is for individuals in Kentucky applying for, or currently enrolled in, one of the Medicaid Waiver Programs such as the Home and Community Based Waiver, Acquired Brain Injury Waiver, Supports for Community Living Waiver, or Michelle P. Waiver, among others. It must be filled out by the applicant, caregivers, or healthcare providers who can accurately report on the individual's condition and needs. The assessment provider, typically a healthcare professional, also completes parts of the form based on their evaluation of the member.
How is the MAP 351 form used in determining waiver eligibility?

The MAP 351 form plays a crucial role in the waiver application and eligibility determination process. It provides a standardized method for assessing an individual's need for services covered by Medicaid Waivers. By evaluating the applicant's abilities in various areas such as ADLs, IADLs, and their medical and behavioral health status, the Department for Medicaid Services can determine the most appropriate type of support and services. The form's data helps ensure that individuals receive care tailored to their specific needs, enhancing their ability to live more independently in their community.
What happens after the MAP 351 form is submitted?

After submission, the MAP 351 form is reviewed by the Department for Medicaid Services or an affiliated agency. The individual's eligibility for the requested waiver program is determined based on the completed assessment and any required supporting documentation. If eligible, the department will develop a plan of care outlining the approved services, such as personal care, respite, or environmental modifications, which aim to support the individual's needs identified in the MAP 351 assessment. The applicant or their guardian will be notified of the decision and informed about the next steps. In cases of denial or if the individual disagrees with the assessment outcomes, information about the process to make a complaint or appeal the decision will also be provided.

Common mistakes

Filling out the Kentucky Map 351 form correctly is crucial for Medicaid Waiver Assessment, yet common pitfalls can hinder the accuracy and completeness of the application. Let's delve into some of the frequent mistakes people make when completing this vital document.

Not providing complete member demographics: The form starts with the basics like the individual's name, date of birth, Medicaid Member ID number, and contact information. An often-observed error is leaving fields blank or incompletely filled, which can cause delays in processing the application.
Overlooking to indicate the type of waiver program applied for: The form requires indicating the specific Medicaid Waiver program being applied for, such as Home and Community-Based Waiver or Acquired Brain Injury Waiver, etc. Failing to mark the appropriate box could lead to incorrect processing of the application.
Failing to document member waiver eligibility clearly: Section II requires detailed information about the member’s eligibility and current living situation. Missteps often occur when applicants do not accurately report the member's status, leading to potential issues in service provision.
Incorrectly reporting the medical and diagnostic information: Accurately entering diagnoses, including ICD-9 and DSM codes in the dedicated section, is essential. Errors or omissions in this section can affect the services the member is eligible to receive.
Glossing over the member’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This part of the application requires a detailed assessment of the individual's capabilities and needs, which is critical for tailoring their care plan. Inaccuracies or incomplete answers here can lead to inadequate support for the individual’s requirements.
Omitting emergency contact information: It is important to provide an up-to-date emergency contact. This oversight could lead to difficulties in reaching an appropriate contact in urgent situations.
Missing signatures and dates: The form requires signatures to confirm the information provided and to acknowledge the understanding of the member's rights and complaint procedures. Neglecting to provide these signatures can invalidate the application or delay its processing.
Neglecting to attach required additional information or documentation: Participants sometimes forget to include additional necessary pages or documents that support the application, such as medical records or proof of residency.

To avoid these mistakes, applicants are encouraged to review each section of the form carefully and to consult with a healthcare professional or case manager if any questions arise during the completion process. Ensuring accuracy and completeness at every step can significantly smooth the pathway to obtaining needed Medicaid services.

Documents used along the form

The Kentucky MAP 351 form is a comprehensive document used by the Cabinet for Health and Family Services Department for Medicaid Services. It assesses eligibility for Medicaid Waiver programs. To ensure a thorough evaluation and seamless process, several supplementary documents and forms are often utilized alongside the MAP 351.

MAP 350 Form - Freedom of Choice Statement: This form is crucial for documenting that the individual has been informed of the available service options and acknowledges their right to select a provider freely.
Comprehensive Needs Assessment (CNA): While not a predefined form, a Comprehensive Needs Assessment report complements the MAP 351 by providing detailed information about the medical, behavioral, and social needs of the individual. This assessment helps in identifying the most appropriate services and supports.
Physician’s Statement: A form completed by the individual’s healthcare provider that outlines the medical conditions, diagnoses, and recommendations for care. This document supports the eligibility determination process.
Individual Service Plan (ISP): Following the assessment, an ISP is developed to outline the specific services, goals, and outcomes expected for the individual. It draws from the information gathered in the MAP 351 and any additional assessments conducted.

Together, these documents ensure a holistic approach to determining an individual's eligibility and need for services under the Medicaid Waiver programs in Kentucky. The integration of information from various sources provides a robust foundation for tailoring services to meet the unique needs of each individual.

Similar forms

The Kentucky MAP 351 form, designed for Medicaid Waiver Assessment, shares similarities with other essential documents used within the health and family services sectors. These documents facilitate comprehensive assessment, planning, and support coordination for individuals requiring various types of assistance.

One comparable document is the Personal Care Plan (PCP), which, like the MAP 351, collects detailed information about an individual's health status, personal care needs, and preferences. The PCP focuses on creating a tailored care plan that addresses the person's specific requirements for daily living, much like how the MAP 351 helps to determine eligibility for certain Medicaid Waiver programs based on an individual's functional and medical needs.

Another related document is the Individual Service Plan (ISP) often found in settings providing services for people with developmental disabilities or long-term care needs. The ISP and the MAP 351 both aim to capture a holistic view of the person, including their abilities, desires, and necessary medical and personal care services, ensuring that the individual's comprehensive needs are met in a coordinated manner.

The Functional Needs Assessment (FNA) is also closely related to the MAP 351 form. The FNA is used to evaluate an individual’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), similar to sections IV and VI of the MAP 351. This parallel underscores their shared goal of determining the level of support and services required to allow individuals to live as independently as possible.

Last, the Comprehensive Assessment and Review for Long-Term Care Services (CARES) document parallels the MAP 351 by providing an extensive evaluation of an individual's need for long-term care services, whether in a facility or in a community-based setting. Both documents play a critical role in ensuring that individuals receive appropriate levels of care tailored to their specific health and personal care needs, facilitating better healthcare outcomes and quality of life.

Dos and Don'ts

When you're tasked with completing the Kentucky Map 351 form, precision and clarity are your best friends. This document is vital for Medicaid Waiver Assessment process in Kentucky, ensuring individuals receive the appropriate support and services. Here are some essential dos and don'ts to guide you through the form filling process:

Do double-check the form version you have is the most current one by comparing it with the version available on the Kentucky Cabinet for Health and Family Services website.
Do ensure you have all the necessary information at hand before starting, including Medicaid Member ID, physician contact details, and any diagnoses with respective codes.
Do read each section carefully to ensure you understand what is being asked, as some sections may require detailed responses or checking specific boxes.
Do use black or blue ink if you are filling out the form by hand to ensure legibility.
Do provide accurate and complete information for every section, especially in sections concerning medical diagnoses and member waiver eligibility.
Do
Do make a copy of the completed form for your records before submitting it.

Don't rush through the form. Take your time to fill out each section detailedly to avoid mistakes or omissions.

Don't leave any sections blank unless the instructions specifically say it is optional. If a section does not apply, mark it as "N/A" (not applicable).

Don't hesitate to contact the Kentucky Cabinet for Health and Family Services if you have any questions or need clarification on how to correctly fill out the form.

By following these guidelines, you can ensure the form is completed accurately and efficiently, helping to expedite the assessment process for the member in question. Remember, the clarity of your information can significantly impact the services provided to the member, making it crucial to approach this task with diligence and care.

Misconceptions

Understanding the Kentucky MAP 351 form is crucial for anyone involved in the Medicaid Waiver Assessment process in Kentucky. However, there are several misconceptions surrounding this form that can lead to confusion. Below is a list of ten common misconceptions and the facts that dispel them:

Only for the elderly: The form is not solely for ageing individuals. It's designed for all qualifying Medicaid members who need waiver services, regardless of age.

Self-completion: It's often believed that the form can be completed by the member alone. In truth, the process usually requires assistance from a healthcare provider or a caregiver to ensure accuracy.

One-time process: The assessment isn't a one-time event. Regular reassessments are necessary to ensure the member’s needs are accurately captured over time, especially if their condition changes.

Eligibility guarantee: Completing the MAP 351 does not guarantee Medicaid waiver eligibility. It's a part of the assessment process, but approval depends on meeting specific criteria.

Immediate processing: The belief that forms are processed immediately after submission is incorrect. Processing times can vary, potentially delaying the start of services.

Only for medical services: The form isn’t limited to assessing needs for medical services. It also evaluates the necessity for community and support services, aiming to provide a comprehensive care plan.

Filled out at the Medicaid office: Contrary to this belief, the form can be completed in various settings, including the member's home or a healthcare facility, to accommodate the member's condition.

Renewal is automatic: Members must go through a re-evaluation process for waiver services before the end of their certification period. Renewal is not automatic.

No need for updates if no changes: Any change in a member's condition, address, or care needs should prompt an update to the form. Ongoing accuracy is crucial.

Only for physical disabilities: The assessment covers individuals with mental, neurological, and developmental disabilities, in addition to physical disabilities, ensuring a wide range of beneficiaries.

Dispel these misconceptions to better understand how the Kentucky MAP 351 form plays a critical role in the Medicaid Waiver Assessment process. By doing so, members and their families can navigate the system more effectively, ensuring those in need receive the appropriate supports and services.

Key takeaways

Filling out the Kentucky MAP 351 form is a critical step toward accessing certain Medicaid waiver programs for those who need them. This form, serving as both an assessment and a gateway, aids in determining eligibility for support services that can profoundly impact the quality of life for Kentucky residents. Here are five key takeaways to guide you through the process:

Complete Section I Carefully: This section captures essential demographic information about the member, including their name, date of birth, Medicaid ID number, contact details, and basic personal information. Accuracy here is paramount as this information is used to identify the applicant in the system.

Understand Eligibility Requirements: Section II focuses on member waiver eligibility and requires the applicant to specify the type of program they are applying for. It’s important to review the options and eligibility criteria ahead of time to ensure the correct selection, which may include Home and Community Based Waiver, Acquired Brain Injury Waiver, among others.

Medical and Diagnosis Information is Crucial: Providing accurate medical diagnosis and physician information is critical. This includes the primary diagnosis with appropriate codes (ICD-9, DSM), which helps in determining the specific needs and eligibility for certain waiver programs. Don’t forget to complete details regarding the physician who is familiar with the member's medical condition.

Don’t Overlook the Self-Assessment and Living Skills Sections: Sections IV and V ask for a detailed overview of the member's daily living abilities and needs, ranging from community inclusion to activities of daily living (ADLs) like dressing, grooming, eating, and mobility. These sections are vital for assessing what level of assistance the member requires.

Behavioral Assessments Matter: Section VII requires information on any behavioral issues, which can play a significant role in determining the need for specialized services or supports. Be candid and detailed in describing any behavior that might affect the member's care.

Overall, completing the Kentucky MAP 351 form is a comprehensive process that entails providing detailed information about the member's demographics, medical condition, daily living capabilities, and behavior. The accuracy and detail of the information provided can significantly influence the services and support the member is eligible for. It’s advisable to gather all necessary information and consult healthcare or social work professionals if needed before starting the application process.

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