55 Pa. Code § 255.3 - Requirements
(a)
General. In cases of suspected overpayment the information
must be verified. The client must consent to the county office obtaining the
needed verification or face the alternative of ineligibility for continued
assistance. If the client refuses to consent, the county office will proceed in
obtaining the necessary verifications without client consent on active or
inactive cases.
(b)
Criteria
for distinguishing between suspected fraud and nonfraud. The
determining factor in distinguishing between fraud and nonfraud will be the
intent of the client. Intent will be established by examining and evaluating
pertinent objective facts, including the following:
(1)
Actions and attitudes of the
client. The answers to the following questions will be employed in
determining the actions and attitudes of the client:
(i) Did the client deny the fact that caused
the overpayment?
(ii) Did the
client provide information that was misleading or incorrect?
(iii) Were the actions of the client directed
to concealing information? For example, did he deface or alter documents or
arrange appointments with the caseworker so as to conceal other
activities?
(iv) What was the
reaction of the client to the fact of the overpayment? What did he see as the
cause?
(2)
Nature
of the overpayment. The answers to the following questions will be
employed in determining the nature of the overpayment:
(i) Was the overpayment in an amount that the
client could not have failed to realize that his assistance payment was
incorrect?
(ii) Did the period of
overpayment extend over a period of time that the client had repeated
opportunities to report?
(iii) Were
there previous overpayments for related reasons?
(3)
The ability of the client to
comprehend requirements. The answers to the following questions will
be employed in determining the ability of the client to comprehend
requirements:
(i) Are there physical
disabilities, such as advanced age, defective hearing or vision or illness
which affect the ability of the client to understand the requirements and his
responsibilities in connection with them?
(ii) Are there mental limitations, such as
emotional or psychiatric disturbances or mental retardation which affect the
client's understanding of what is expected of him?
(iii) Does the client have any social
handicaps, such as illiteracy, language barriers or lack of education which
affect his comprehension of requirements?
(iv) Were there social factors at the time of
the overpayment such as death, accident, serious illness, desertion and the
like that so involved the client that comprehension of the importance of
meeting reporting requirements was affected?
(4)
Quality of worker's job with the
client. The answers to the following questions will be employed in
determining the quality of the worker's job with the client:
(i) Does the case record indicate that the
pertinent regulations were explained in terms suited to the capacity of the
client?
(ii) Were appropriate
reporting plans worked out with the client?
(iii) Were redeterminations of eligibility
made as frequently as appropriate to the situation?
(iv) Has the method of working with the
client been such as to demonstrate to him the importance of reporting changes
in his circumstances? Has the capacity of the client for carrying
responsibility been evaluated realistically?
(c)
Overpayment pending hearing
decision. Restitution will be required for overpayments which occur
when assistance is continued pending a hearing decision.
(d)
Closure. The county
office will have the basic responsibility for determining ineligibility as well
as eligibility for assistance. When a closure is requested, information must be
obtained from the client concerning the reasons for closure to determine
whether the closing is timely or whether overpayment has occurred. When the
closing is due to income from employment, support and the like, follow-up will
be needed to establish the amount and the date the income began. If overpayment
has occurred and repayment is to be sought, referral to claims settlement must
be submitted before the case record is disposed of. When the specific reasons
for a closure are not provided by the client and reasonable efforts to obtain
the information fail, the county should make a notation as a last entry in the
case record so that at subsequent reapplications, intake will be alerted that
the situation must be cleared by taking the following actions:
(1) Verifying that a resource precipitating
closure no longer exists.
(2)
Exploring possible overpayment.
(3)
Reviewing the credibility of the client and reliability in reporting.
(e)
[Reserved].
Notes
The provisions of this § 255.3 issued under sections 201(2) and 403(b) of the Public Welfare Code (62 P. S. §§ 201(2) and 403(b)).
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