55 Pa. Code § 275.5

Current through Register Vol. 54, No. 44, November 2, 2024

Section 275.5 - Settling appeals and paying retroactive benefits-statement of policy

(a) This statement of policy provides a means for CAOs, and other administering agencies, to settle appeals in cases where verification provided to the CAO subsequent to its adverse action on the case shows that the appellant, in fact, met the substantive conditions of eligibility during the period of time at issue in the appeal. The question on appeal, therefore, is not whether the CAO or administering agency acted properly based upon the information then available, but whether the appellant was eligible for the period of time at issue based upon evidence of eligibility the client is able to provide at or before the hearing.

(b) When a client files a timely appeal from an adverse Departmental action, the CAO shall determine whether the appellant subsequently provided acceptable verification of eligibility relating back to the effective date of the adverse action. If this requirement is met, the CAO shall restore benefits retroactive to the effective date of termination, denial, reduction or suspension of benefits. In the case of a denial of assistance, benefits will be restored retroactive to the date by which an eligibility determination should have been made if the actual date of the decision to deny benefits was delayed more than 15 days from the date of application, as specified in § 125.21(b) (relating to policy).

(c) If the verification subsequently provided by the appellant does not relate all the way back to the effective date of adverse action, but does establish eligibility as of a later date, the CAO shall restore assistance to the date on which the eligibility factor at issue in the appeal was met.

(d) The following examples are provided to illustrate how this statement of policy is to be applied:

Example No. 1

Mary Jones was sent a PA/FS 162-A Notice dated January 5, 1989, advising her that her assistance would be terminated effective January 20, 1989, based upon her failure to attend a scheduled reapplication interview and to provide verification of her household's continued eligibility for AFDC, food stamps and MA. On January 25, 1989, Ms. Jones filed a timely appeal.

On February 1, 1989, prior to the hearing, Ms. Jones provided the CAO with acceptable verification establishing her household's continued eligibility for Public Assistance.

Since the verification established that Ms. Jones was eligible for AFDC, food stamps and Medical Assistance as of the date the assistance was terminated, the CAO would rescind its January 5, 1989, termination action and restore benefits to Ms. Jones retroactive to January 20, 1989. In this case, the verification provided by Ms. Jones subsequent to the closing action proved her eligibility for the period of time at issue in the appeal.

Example No. 2

Sam Smith applied for assistance on February 2, 1989, but was unable to obtain documentary proof that the market value of his car was actually less than the book value, which exceeded the $1,500 equity limit. (None of the excess value could be applied to the general resource limit, because Mr. Smith has other resources which equal the resource limit.) On February 10, 1989, the CAO issued a notice denying Mr. Smith's application.

On February 28, 1989, Mr. Smith filed a timely appeal. Prior to the hearing, Mr. Smith provided the CAO with a statement from a mechanic showing that his car was worth only $1,000 when the mechanic last saw it on February 1, 1989. Upon receipt of this verification, and assuming Mr. Smith met the other conditions of eligibility, the CAO would promptly authorize assistance retroactive to February 10, 1989.

If the statement submitted by Mr. Smith had indicated that the mechanic first saw the car on February 27, 1989, and estimated its value at $1,000, the CAO would authorize assistance retroactive to February 27, 1989, the date when Mr. Smith first met the eligibility condition at issue in the appeal.

Example No. 3

Maria Mendez moved from Puerto Rico to Pennsylvania in February 1989 and on March 3, 1989, applied for assistance for herself and her three children. By notice dated March 10, 1989, the CAO denied Ms. Mendez's application based upon information that her Public Assistance case in Puerto Rico was still open.

Ms. Mendez filed a timely appeal on March 25, 1989, and subsequently provided the CAO with acceptable verification that she had not received any assistance benefits from Puerto Rico since she moved to Pennsylvania. Upon receipt of this verification, and assuming Ms. Mendez and her children met the other conditions of eligibility, the CAO would immediately authorize assistance retroactive to March 10, 1989.

Example No. 4

Bill Brown applied for GA benefits on January 5, 1989, after his unemployment compensation benefits ran out. At his prescreen interview, a CAO worker explained to Mr. Brown that if he could prove a work history of 48 months out of the last 8 years, he would qualify for Chronically Needy GA benefits based upon exhaustion of his unemployment compensation. The worker further explained what verification Mr. Brown would need to prove his work history and informed him that the CAO would help him obtain this information should he require help.

Mr. Brown did not submit verification of his work history. On January 20, 1989, his application for assistance was denied. Mr. Brown received 90 days of Transitionally Needy GA benefits within the year preceding his application.

Mr. Brown filed a timely appeal on January 22, 1989, and on January 25, 1989, he provided the CAO with acceptable verification of his work history. Upon receipt of this information, and assuming that Mr. Brown met the other conditions of eligibility, the CAO would authorize CN benefits effective January 20, 1989.

55 Pa. Code § 275.5

The provisions of this §275.5 adopted July 7, 1989, effective 7/8/1989, 19 Pa.B. 2959.