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Special Assistance

TitleTypeFormatSize 
Appendix G SAIH Slot Request Formpdf15 KB
DAAS 20201 Special Assistance Second Party Review Form APPLICATIONSdocx34 KB
DAAS 20202 Special Assistance Second Party Review Form RECERTIFICATIONSdocx32 KB
DHHS-AS-0011 Adult and Family Service Plan HWdocx44 KB
DHHS-AS-0011_Adult_and_Family_Service_Plan _Elecdocx48 KB
DHHS-AS-0016 Consent for Release of Information HWdocx38 KB
DHHS-AS-6219 Adult Services Face Sheet Elec 3.2024docx35 KB
DHHS-AS-6223 Interim or Quarterly Review Elec 2024pdf110 KB
DHHS-AS-6225 Case Closing Summary Elec 3.2024docx30 KB
DHHS-AS-6225 Case Closing Summary HW 3 2024docx24 KB
DSS_5027_SIS_Client_Entry_Formpdf1,014 KB
DSS-0031 SAIH Program Interagency Referral Formpdf141 KB
DSS-0032 SAIH Signature Attestation Formpdf107 KB
DSS-0033: Appendix E, Supplement 1pdf136 KB
DSS-0034: Appendix E, Supplement 2pdf126 KB
DSS-3000 Appointment Follow-up Letter Regarding SA Assistance Requestpdf56 KB
DSS-3001: Notice of County of Residence Reassignment/Transferpdf30 KB
DSS-3001sp Notificación sobre reasignación o transferenciapdf32 KB
DSS-3002 Agreement to Sellpdf73 KB
DSS-3002sp Compromiso de ventapdf75 KB
DSS-3003 Important Information About Your Special Assistance and Your Resourcespdf22 KB
DSS-3004 Referral to SSA for Waiver or Reduction of Overpayment Recoupmentpdf57 KB
DSS-3005 Documentation Regarding Continuation of Special Assistance When the LOC Is Upgraded, But No Bed Is Availablepdf53 KB
DSS-3006 Medical Care Special / Medical Expense Formpdf57 KB
DSS-8190 SSI/Non-SSI Application Workbookpdf800 KB
DSS-8190A SSI/Non-SSI Application Workbook Appendix Apdf118 KB
DSS-8191 Special Assistance Re-enrollment Information Noticepdf554 KB
TitleTypeFormatSize 
Administrative Letter 18-03 Important: Systematic Alien Verification for Entitlements (SAVE) Paperless Verification Processingpdf186 KB
Administrative Letter No. 09-07 – Economic Recovery Payment’s Effect on Special Assistance Adult Care Home (SA/ACH) and Special Assistance In-Home (SA/IH) Eligibility (Economic recovery payments were made only in 2009 and were no longer excluded as a resource after March 1, 2010)pdf16 KB
Administrative Letter No. 13-07 – Instructions for Special Assistance In-Home Approvals for Individuals with Verified Supported Housing Slotspdf101 KB
Administrative Letter No. 13-11 – Electronic Benefit Issuancepdf98 KB
Administrative Letter No. 13-11 – Electronic Benefit Issuancepdf98 KB
Administrative Letter No. 14-02 – Effect of 2014 Social Security Cost of Living Adjustment and New 2014 Federal Poverty Level on SA/IH Casespdf113 KB
Administrative Letter No. 14-04, Revised Timeframe for Replacement of Special Assistance Checkspdf25 KB
Administrative Letter No. 14-11 Addendum , Appropriations Act of 2014: Policy for Resources for SA IHpdf24 KB
Administrative Letter No. 14-11 Addendum, Appropriations Act of 2014: Policy for Resources for SA IHpdf24 KB
Administrative Letter No. 14-11, Appropriations Act of 2014: Changes to the Special Assistance Programpdf20 KB
Administrative Letter No. 14-13, Social Security Cost-of-Living Adjustment (COLA 2015) and VA Cost-of- Living Adjustment (COLA 2015) for Special Assistance (SA) in a Facilitypdf60 KB
Administrative Letter No. 15-07, Special Assistance Redeterminations/Recertifications Amendedpdf39 KB
Administrative Letter No. 17-03, Social Security Cost-of-Living Adjustment (COLA) and VA COLA for Special Assistance In-Home (SA_IH)Beneficiariespdf31 KB
Administrative Letter No. 17-03, Social Security Cost-of-Living Adjustment (COLA)and VA COLA for Special Assistance In-Home (SA-IH) Beneficiariespdf31 KB
Administrative Letter No. 17-08, Social Security Cost-of-Living Adjustment (COLA 2018) and VA Cost-of-Living Adjustment (COLA 2018) for Special Assistance (SA) in a Facilitypdf288 KB
Administrative Letter No. 18-02 Social Security Cost-of-Living (COLA 2018) and Veteran’s Assistance (VA) Cost-of-Living Adjustment for Special Assistance In-Home (SA-IH) Beneficiariespdf112 KB
Administrative Letter No. 18-08, Social Security Cost-of-Living Adjustment (COLA 2019) and VA Cost-of-Living Adjustment (COLA 2019 for Special Assistance (SA) in a Facility.pdf852 KB
Administrative Letter No. 19-03, Social Security Cost-of-Living Adjustment (COLA 2019) and VA Cost-of-Living Adjustment for Special Assistance In-Home (SA-IH) Beneficiaries.pdf453 KB
Administrative Letter No. 19-10, Social Security Cost-of-Living Adjustment (COLA 2020) and VA Cost-of-Living Adjustment for Special Assistance In-Home (SA-IH) Beneficiariespdf32 KB
Administrative Letter No. DAAS 16-12 COLA 2017pdf39 KB
Administrative Letter No. DAAS-07-10 – Social Security Administration Data Accesspdf24 KB
Administrative Letter No. DAAS-07-16 – Veteran‚Äôs Affairs Matchpdf547 KB
Administrative Letter No. DAAS-07-20 – Interstate Matchpdf274 KB
Administrative Letter No. DAAS-08-04 – Economic Stimulus Act Payments (Stimulus payments were received in 2008 only)pdf81 KB
Administrative Letter No. DAAS-08-15 – Applying the 2009 Social Security Cost of Living Adjustment (COLA) Disregard to Special Assistance In-Home (SA/IH) Cases Onlypdf49 KB
DAAS ADMINISTRATIVE LETTER NO: 13-02 DMA ADMINISTRATIVE LETTER NO: 01-13, MEDICAID TERMINATION FOR ALL SPECIAL ASSISTANCE BENEFICIARIES IN AN INSTITUTION FOR MENTAL DISEASE (IMD)pdf230 KB
DAAS ADMINISTRATIVE LETTER NO. 09-24, CITIZENSHIP DOCUMENTATION, DMA ADMINISTRATIVE LETTER NO. 08-09, ECONOMIC AND FAMILY SERVICES EFS_WF_AL-11-2009pdf426 KB
DMA ADMINISTRATIVE LETTER NO: 03-10, DSS ADMINISTRATIVE LETTER PERFORMANCE MANAGEMENT/REPORTING AND EVALUATION MANAGEMENT PM-REM-AL-02-10, DAAS ADMINISTRATIVE LETTER NO: 10-07pdf32 KB
DMA ADMINISTRATIVE LETTER NO: 07-10, DSS ADMINISTRATIVE LETTER PERFORMANCE MANAGEMENT/REPORTING AND EVALUATION MANAGEMENT PM-REM-AL-07-10, DAAS ADMINISTRATIVE LETTER NO: 10-14, AUTHORIZED REPRESENTATIVE SCREENpdf9 MB
DMA ADMINISTRATIVE LETTER NO. 08-09, DAAS ADMINISTRATIVE LETTER NO. 09-24 ECONOMIC AND FAMILY SERVICES EFS_WF_AL-11-2009 ADDENDUM 1, (CITIZENSHIP DOCUMENTATION)pdf46 KB
DSS ADMINISTRATIVE LETTER PERFORMANCE MANAGEMENT/REPORTING AND EVALUATION MANAGEMENT PM-REM-AL-06-10, DMA ADMINISTRATIVE LETTER NO: 05-10, DAAS ADMINISTRATIVE LETTER NO: 10-11pdf223 KB
Performance Management/Reporting and Evaluation Management, PM-REM AL-02-2013, DMA ADMINISTRATIVE LETTER NO: 03-2013, DAAS ADMINISTRATIVE LETTER NO: 2013-05, DSS ECONOMIC AND FAMILY SERVICES ADMINISTRATIVE LETTER NO: 03-2013, DCDEE ADMINISTRATIVE LETTER NO: 01-2013, ONLINE VERIFICATION (OLV) ENHANCEMENTSpdf291 KB
Special Assistance Administrative Letter No. 17-08 Social Security Cost-of-Living Adjustment (COLA 2018) and VA Cost-of-Living Adjustment (COLA 2018) for Special Assistance (SA) in a Facilitypdf288 KB
TitleTypeFormatSize 
CHANGE NO: 01-06, VERIFICATION OF CITIZENSHIP AND IDENTITY FOR SPECIAL ASSISTANCEpdf48 KB
CHANGE NO: 01-07, SPECIAL ASSISTANCE ADULT PROGRAM MANUAL UPDATESpdf48 KB
CHANGE NO: 02-02, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATEpdf23 KB
CHANGE NO: 02-03, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESdoc34 KB
CHANGE NO: 02-07, SPECIAL ASSISTANCE ADULT PROGRAM MANUAL UPDATESpdf26 KB
CHANGE NO: 03-02, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf15 KB
CHANGE NO: 04-02, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf15 KB
CHANGE NO: 05-02, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf11 KB
CHANGE NO: 06-02, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf9 KB
CHANGE NO: 07-02, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf10 KB
CHANGE NO. 01-04, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf29 KB
CHANGE NO. 01-08, SPECIAL ASSISTANCE FOR ADULTS PROGRAM MANUAL UPDATESpdf46 KB
CHANGE NO. 01-09, SPECIAL ASSISTANCE FOR ADULTS (SA/ACH) PROGRAM MANUAL UPDATESpdf36 KB
CHANGE NO. 01-10, SPECIAL ASSISTANCE FOR ADULTS PROGRAM MANUAL UPDATESpdf46 KB
CHANGE NO. 01-11, FIGURE CHANGE TO FORM AND CLARIFICATIONSpdf36 KB
CHANGE No. 01-12, Federal Poverty Guidelinespdf26 KB
CHANGE NO. 01-13, SSI 2013 FEDERAL BENEFIT RATE (FBR) UPDATES IN THE SPECIAL ASSISTANCE MANUALpdf31 KB
CHANGE NO. 01-15, SA MANUALpdf21 KB
CHANGE NO. 01-2017, SA ELIGIBILITY MANUAL AND FORM REVISIONSpdf20 KB
CHANGE No. 02-06pdf42 KB
CHANGE NO. 02-08, SPECIAL ASSISTANCE FOR ADULTS PROGRAM MANUAL UPDATESpdf29 KB
CHANGE NO. 02-09, SPECIAL ASSISTANCE FOR ADULTS PROGRAM MANUAL UPDATES – RESOURCESpdf37 KB
CHANGE No. 02-10, Special Assistance for Adults In-Home (SA/IH) Program Manual Updatespdf27 KB
CHANGE No. 02-11, Federal Poverty Guidelinespdf27 KB
CHANGE NO. 02-12, CONVERSION OF FIGURES TO FORMSpdf40 KB
CHANGE No. 02-13, Federal Poverty Level UPDATE TO SA-IH MANUALdoc32 KB
CHANGE NO. 02-14, SPECIAL ASSISTANCE TO THE CERTAIN DISABLED (SCD)pdf20 KB
CHANGE No. 02-2017: State/County Special Assistance In-Home (Eligibility)pdf19 KB
CHANGE NO. 03-08, SPECIAL ASSISTANCE FOR ADULTS PROGRAM MANUAL UPDATESpdf54 KB
CHANGE NO. 03-10, SPECIAL ASSISTANCE FOR ADULTS PROGRAM MANUAL UPDATESpdf27 KB
CHANGE No. 03-11 Removal Of SA-5600 and SA-5700pdf22 KB
CHANGE No. 03-12: Changes in the SA/IH PROGRAMpdf39 KB
CHANGE NO. 03-14, RESIDENCY REQUIREMENT CHANGESpdf53 KB
CHANGE NO. 03-2017, SA ELIGIBILITY REDETERMINATIONSpdf86 KB
CHANGE No. 04-08, Special Assistance In-Home Program Manual Updatespdf33 KB
CHANGE NO. 04-10, SPECIAL ASSISTANCE PROGRAM MANUAL UPDATESpdf70 KB
CHANGE NO. 04-11, SA-3110 FIGURES TO FORMSpdf29 KB
CHANGE NO. 04-2017, SA APPLICATION PROCESSpdf127 KB
CHANGE NO. 05-10, SPECIAL REVIEW CODES AND OVERPAYMENT RECOUPMENT ADJUSTMENT REQUESTSpdf36 KB
CHANGE NO. 05-11, SSI 2012 FEDERAL BENEFIT RATE (FBR) UPDATES IN THE SPECIAL ASSISTANCE MANUALpdf30 KB
CHANGE No. 06-10, Special Review Codespdf38 KB
CHANGE No. 06-11, SSI 2012 Federal Benefit Rate (FBR) Updates in the Special Assistance In-Home Manualpdf25 KB
CHANGE No. 1-14: 2014 FPL and IEMpdf24 KB
SAIH CASE MANAGEMENT MANUAL CHANGE NOTICEpdf253 KB

Special Assistance Manual State/County Special Assistance (SA) is a Supplemental Security Income (SSI) state supplement that pays cash benefits to eligible beneficiaries who reside in licensed facilities authorized to receive SA payments. The SA payment is funded by 50% county dollars and 50% state dollars. SA beneficiaries are automatically eligible for Medicaid.

TitleTypeFormatSize 
Special Assistance In Home Program Manualpdf616 KB
Special Assistance Manualpdf3 MB
State/County Special Assistance In-Home Case Management Manualpdf479 KB

Appendix A Forms

DSS-1473 Request for State Appeal
DSS-1656 Refund Receipt (Collection of Overpayment)
DMA-2041 Third Party Health and Accident Resources Information
DMA-2043 Third Party Liability Accident Information Report
DSS-2216 Request for Record
DSS-3431 Request for Financial Information
DMA-5010 Referral for Inpatient Hospital and Intermediate Care Facilities
DMA-5022 Retroactive Eligibility Checks/ID Cards
DSS-8108 Notice of Benefits
DSS-8109 “Your Application For Benefits Is Being Denied Or Withdrawn”
DSS-8110 “Your Benefits Are Changing” (Timely/Adequate Notice)
DSS-8113 Wage Verification
DSS-8129 Request for Replacement Check and Affidavit
DSS-8176 Contribution Report
DSS-8189 Appointment Notice
DSS-8194 Income Maintenance Transmittal Form
DMA-372-124-ach-ia Adult Care Home FL2 Form
DMA-5001 Notice on the Use of Social Security Numbers
DMA-5049 Referral to Local Social Security Office
DMA-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice
DMA-5094 Notice of Your Right to Apply for Benefits
DMA-5095 Medicaid/Work First Notice of Inquiry
DMA-5097 Request for Information
DMA-5155 Verification of Cash Value of Life Insurance
DMA-5202C Designation of Authorized Representative – Appendix C
DSS-1464: Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964
DSS-5023: Direct Deposit Enrollment Authorization Form
DSS-6969: Consent for Release of Information
DSS-8201: County Responsible Overpayment
DSB-2202: DSB/Report of Eye Examination