« PreviousContinue »
(2) The agency promptly informs the a fair hearing, except where the claimclaimant in writing if assistance will be ant requests a delay in the hearing. discontinued, based on the State agency's (12) The claimant will be notified of determination.
the decision, in writing, in the name of (6) Alternatively, the State may pro- the State agency and, to the extent it vide for continuing assistance in all is available to him, of his right to judicases.
cial review. In cases in which a fair hearing is re
(13) When the hearing decision is quested after expiration of the advance
favorable to the claimant, or when the notice period, the State may provide for agency decides in favor of the claimant an additional period during which time prior to the hearing, the agency will the request for a hearing will result in make corrective payments retroactively reinstatement of assistance to be con
to the date the incorrect action was tinued until the fair hearing decision.
taken or such earlier date as is provided (6) Information and referral services
under State policy. are provided to help claimants make use
(14) Recommendations of the hearof any legal services available in the ing officer or panel shall be based excommunity that can provide legal rep
clusively on evidence and other material resentation at the hearing.
introduced at the hearing. The verbatim (7) The hearing will be conducted at
transcript of testimony and exhibits, or a time, date and place convenient to the an official report containing the subclaimant, and adequate preliminary
stance of what transpired at the hearwritten notice will be given.
ing, together with all papers and re(8) The hearings will be conducted by
quests filed in the proceeding, and the an impartial official (or officials) of the recommendations of the hearing officer State agency. Under this requirement, or panel will constitute the exclusive the hearing official must not have been record for decision by the hearing auinvolved in any way with the action in
thority and will be available to the question.
claimant at a place accessible to him (9) When the hearing involves medical or his representative at any reasonable issues such as those concerning a diag
time. nosis, or an examining physician's re
(15) Decisions by the hearing authorport, or the medical review team's deci- ity, rendered in the name of the State sion, a medical assessment other than agency, shall specify the reasons for that of the person or persons involved in the decision and identify the supporting making the original decision will be evidence. They shall be binding on the obtained at agency expense from a
State and local agency. Under this source satisfactory to the claimant and requirement: made part of the record if the hearing (i) No person who participated in the officer or the appellant considers it
local decision being appealed will parnecessary.
ticipate in a final administrative deci(10) The claimant, or his representa
sion on such a case; tive, will have adequate opportunity:
(ii) The State agency is responsible (i) To examine all documents and for seeing that the decision is carried records used at the hearing at a reason
out promptly. able time before the date of the hearing (16) The State agency will establish as well as during the hearing;
and maintain a method for informing, at (ii) At his option, to present his case least in summary form, all local agencies himself or with the aid of others includ- of all fair hearing decisions by the hearing legal counsel;
ing authority and the decisions will be (iii) To bring witnesses;
accessible to the public (subject to provi(iv) To establish all pertinent facts sions of safeguarding public assistance and circumstances;
information). (v) To advance any arguments with- (17) In respect to title XIX, when the out undue interference;
appeal has been taken on the basis of (vi) To question or refute any testi- eligibility determination, the agency remony or evidence, including opportunity sponsible for the determination of eligito confront and cross-examine adverse bility for medical assistance, if different witnesses.
from the single State agency administer(11) Prompt, definitive, and final ad- ing the medical assistance plan, shall ministrative action will be taken within participate in the conduct of the fair 60 days from the date of the request for hearing.
(b) Federal financial participation. State plan for OAA, AFDC, AB, APTD, Federal financial participation is avail- AABD, and MA must provide that: able for the following items:
(1) Effective no later than July 1, (1) Payments of assistance continued 1969, a simplified method for the deterpending a hearing decision;
mination of eligibility must be used on a (2) Payments of assistance made to test basis in selected local units encomcarry out hearing decisions, or to take passing a significant percentage of the corrective action after an appeal but caseload, representative of the existing prior to hearing, or to extend he benefit State public assistance programs from of a hearing decision or court order to the standpoint of staff, applicants and others in the same situation as those di- recipients, and other significant characrectly affected by the decision or order.
teristics which will assure an adequate Such payments may be retroactive in demonstration of the method. At least accordance with applicable Federal poli
one of the local units will be an urban cies on corrective payments.
area. (3) Payments of assistance within the
(2) Effective July 1, 1970, with rescope of Federally aided public assistance
spect to OAA, AB, APTD, and AABD: programs made in accordance with a (i) The simplified method for detercourt order.
mination of eligibility will be used for (4) Service costs incurred by the
applications for and redeterminations of
assistance. agency, at the applicable matching rates, for:
(ii) The State will use the simplified (i) Providing legal counsel to repre
method on a progressive basis and will sent clients at hearings or in judicial re
increase the number of areas in the State view;
using the system on a planned schedule
which will achieve State-wide operation (ii) Providing transportation for the
no later than July 1, 1971. claimant, his representative and wit
(ii) The State will develop a plan to nesses to and from the place of the hearing;
be carried out over a period ending July (iii) Meeting other expenditures in
1, 1973, which shall be directed to: curred by the client in connection with
(a) Simplification of eligibility and the hearing.
procedural requirements. (5) Administrative costs incurred by
(6) Simplification of forms. the agency in carrying out the hearing
(c) Modernization of the payment procedures, including expenses of obtain
mechanism. ing an additional medical assessment.
(d) Appropriate training and utiliza
tion of staff. (36 F.R. 3034, Feb. 13, 1971)
(e) Use of the State Technical Con§ 205.20 Methods for determination of
sultation Panel. eligibility.
A regulation will be issued, with proUnder the Social Security Act, State
spective effective date, regarding Stateplans for public assistance must provide
wide use of the simplified method in such methods of administration as are
AFDC and MA, when the Secretary defound by the Secretary to be necessary
termines that the results from the test for the proper and efficient operation of
in those programs support the overall the plan. In determinations and redeter
effectiveness of the method on & ininations of eligibility for assistance,
permanent basis. and for the amount of assistance, this
(3) When under the simplified methrequires methods directed to the follow
od, statements of the applicant or reing objectives: Payment of assistance to all individuals who are eligible and de
cipient are incomplete, unclear, or innial of assistance to all individuals who
consistent, or where other circumstances are not eligible; procedures which are
in the particular case indicate to a pru
dent person that further inquiry should simple, efficient and economical, allowing the most effective use of limited per
be made, and the individual cannot clarisonnel; and full respect for the rights
fy the situation, the State agency will
be required to obtain additional substanand dignity of applicants for, and re
tiation or verification. In such instances, cipients of assistance. The regulations
verification is obtained from the indi. in this section are directed to these
vidual or the agency's records or from purposes.
the public records, or with the individ(a) Requirements for State plans. A ual's knowledge and consent, from another source. The simplified method does (1) Use of a simplified form for apnot apply to eligibility factors for which plication and redetermination which: Federal law or policies require procedures (i) Will provide for the information beyond obtaining a client's statement, necessary for the determination of eligisuch as requirements for a professional bility and extent of entitlement under examination to determine whether an the State plan; individual is blind, for a professional de- (ii) Will contain appropriate and termination regarding permanent and conspicuous notice to applicants and retotal disability, for a determination of cipients, informing them of the penalties whether training or employment was re- for fraud; fused for "good cause." The simplified (iii) Will be reviewed and approved as method does not exclude the use of data specified by the Department of Health, exchange for information about receipt Education, and Welfare after the pretest of social security with the Social Security and at the time of any significant Administration.
revision; (4) Procedures are adopted which are (2) A testing of the simplified form designed to assure that recipients make for initial and redetermination of eligitimely and accurate reports of any bility prior to full implemetation. The change in circumstances which affect testing includes an item-by-item review their eligibility for assistance or its designed to discover and correct ambigamount.
uous language, to ensure that the in(5) When there is evidence that fraud formation requested is relevant, and to has been practiced in order to obtain ensure that the form has logical seassistance, the case must be referred to quence. The pretest should show whether the appropriate law enforcement official, applicants and recipients understand in accordance with Federal requirements. what information is being sought and The agency's method of investigating in- why. stances of suspected fraud must respect (3) Validation which relates to the the legal rights of individuals.
procedures adopted in the initial testing (6) An initial progress report shall be of the correctness of the eligibility desubmitted to the Department of Health, cisions. The validation process consists Education, and Welfare at the end of of a full field review of samples of local the first quarter. This report shall pro- agency case actions made under the simvide information as requested on the plified method, to determine how reliable progress of the demonstration or imple- the entire method is in actual operation. mentation of the method including find- (4) Establishment of a State Techings on eligibility, ineligibility and extent nical Consultation Panel consisting of of entitlement. (For continuing reports, interested individuals, including persons see definitions, paragraph (c) (5) (11) of from business, labor, universities and asthis section.)
sistance recipients. The Panel will carry (b) Evaluation. The Secretary of out a continuous and periodic evaluation Health, Education, and Welfare shall ap- of the method, to assure that the method point a National Evaluation Committee is consistent with proper and efficient composed of prominent citizens repre- administration and contributes to senting industry, education, labor, wel- achievement of the objectives of the fare recipients, and other groups who program. shall review, periodically, results of the (5) A method of continuing review on operation of the system and recommend a sampling basis (Quality Control) deto the Secretary any changes consid- signed to operate as an effective measered necessary to improve the method urement of the accuracy of decisions on and to assure proper and efficient eligibility and extent of entitlement. The administration.
sampling design in the simplified method (c) Definitions. The simplified meth- required by the Department of Health, od means an organized method by which Education, and Welfare will: the agency accepts the statements of the (i) Be of sufficient size to identify applicant for, or recipient of assistance, weaknesses which need correction and to about facts that are within his know- obtain reliable statistical measures of inledge and competence (all facts except correct eligibility decisions in total State those specified in paragraph (a) (3) of caseloads as well as in the caseloads of this section) as a basis for decisions re- large urban agencies within the State. garding his eligibility and extent of To facilitate these objectives, the field entitlement. The method includes:
investigation in the sample cases is
provide for identical information as a minimum;
(3) Field investigations, including a personal interview in all cases which fall within the sample of the active caseload and, as necessary, with persons who have been denied assistance or whose assistance has been terminated;
(4) Use of qualified staff under appropriate direction;
(5) Reporting to the Federal Government as prescribed.
(b) The State agency must submit to the Social and Rehabilitation Service, in accordance with Federal instructions:
(1) A brief description of the State's sampling plan including the system of selecting the sample;
(2) The State's plan for use of staff;
pursued to the point where findings related to eligibility or ineligibility are definitively concluded by independent verification. Each factor of eligibility is substantiated by documentary or other appropriate evidence as correct.
(ii) Provide for reporting controls in which rate of incorrect eligibility decisions and extent of entitlement are reported to the Federal agency at quarterly intervals. Alternate quarterly reports will also include an analysis of the findings of the previous six (6) month period together with appropriate corrective action taken or to be taken.
(iii) Provide for a 3 percent tolerance level on incorrect eligibility decisions. When it is determined that the rate of incorrect eligibility decisions exceeds a 3 percent tolerance level, the State and or large urban agency must conduct a 100 percent verification on those specific factors of eligibility identified as causing the unacceptable incorrect decision rate. This more intensive investigation on specific factors of eligibility will be continued until the Federal agency and the State assess the situation and work out a solution. The system contemplates periodic review and monitoring of operations by the Department of Health, Education, and Welfare. [34 F.R. 1145, Jan. 24, 1969, as amended at 35 F.R. 8366, May 28, 1970] § 205.30 Methods of administration.
State plan requirements: A State plan under title I, IV-A, X, XIV, XVI, or XIX of the Social Security Act must provide for such methods of administration as are found by the Secretary to be necessary for the proper and efficient operation of the plan. [36 F.R. 3860, Feb. 27, 1971] § 205.40 Quality control system.
State plan requirements: A State plan under title I, IV-A, X, XIV, XVI, or XIX of the Social Security Act must provide for a system of quality control in accordance with Federal specifications. Under this requirement:
(a) The State agency's system of quality control must be implemented through:
(1) Application of one of the sampling methods prescribed by the Social and Rehabilitation Service;
(2) Use of federally prescribed schedules and instructions, or schedules which
(3) The plan for analysis of and action on findings. [36 F.R. 3860, Feb. 27, 1971) $ 205.50 Safeguarding information.
(a) State plan requirements. A State plan under title I, IV-A, X, XIV, XVI, or XIX of the Social Security Act, except as provided in paragraph (b) of this section, must provide that:
(1) Pursuant to State statute which imposes legal sanctions:
(i) The use or disclosure of information concerning applicants and recipients will be limited to purposes directly connected with the administration of the program. Such purposes include establishing eligibility, determining amount of assistance, and providing services for applicants and recipients.
(ii) The State agency has authority to implement and enforce the provisions for safeguarding information about applicants and recipients;
(iii) Publication of lists or names of applicants and recipients will be prohibited.
(2) The agency will have clearly defined criteria which govern the types of information that are safeguarded and the conditions under which such information may be released or used. Under this requirement:
(i) Types of information to be safeguarded include but are not limited to:
(a) The names and addresses of applicants and recipients and amounts of assistance provided (unless excepted under paragraph (b) of this section);
(b) Information related to the social and economic conditions or circumstances of a particular individual;
(c) Agency evaluation of information about a particular individual;
(d) Medical data, including diagnosis and past history of disease or disability, concerning a particular individual.
(ii) The release or use of information concerning individuals applying for or receiving financial or medical assistance is restricted to persons or agency representatives who are subject to standards of confidentiality which are comparable to those of the agency administering the financial and medical assistance programs.
(iii) The family or individual is informed whenever possble of a request for information from an outside source, and permission is obtained to meet the request. In an emergency situation when the individual's consent for the release of information cannot be obtained, he will be notified immediately thereafter.
(iv) In the event of the issuance of a subpoena for the case record or for any agency representative to testify concerning an applicant or recipient, the court's attention is called, through proper channels to the statutory provisions and the policies or rules and regulations against disclosure of information.
(v) The same policies are applied to requests for information from a governmental authority, the courts, or a law enforcement official as from any other outside source.
(3) The agency will publicize provisions governing the confidential nature of information about applicants and recipients, including the legal sanctions imposed for improper disclosure and use, and will make such provisions available to applicants and recipients and to other persons and agencies to whom information is disclosed.
(4) All materials sent or distributed to applicants, recipients, or medical vendors, including material enclosed in envelopes containing checks, will be limited to those which are directly related to the administration of the program and will not have political implications. Under this requirement:
(i) Specifically excluded from mailing or distribution are materials such as “holiday” greetings, general public announcements, voting information, alien registration notices;
(ii) Not prohibited from such mailing or distribution are materials in the im
mediate interest of the health and welfare of applicants and recipients, such as announcements of free medical examinations, availability of surplus food, and consumer protection information;
(iii) Only the names of persons directly connected with the administration of the program are contained in material sent or distributed to applicants, recipients, and vendors, and such persons are identified only in their official capacity with the State or local agency.
(b) Exception. In respect to a State plan under title I, IV-A, X, XIV, or XVI of the Social Security Act, exception to the requirements of paragraph (a) of this section may be made by reason of the enactment or enforcement of State legislation, prescribing any conditions under which public access may be had to records of the disbursement of funds or payments under such titles within the State, if such legislation prohibits the use of any list or names obtained through such access to such records for commercial or political purposes. [36 F.R. 3860, Feb. 27, 1971] § 205.60 Reports and maintenance of
records. State plan requirements: A State plan under title I, IV-A, X, XIV, XVI, or XIX of the Social Security Act must provide that:
(a) The State agency will maintain or supervise the maintenance of records necessary for the proper and efficient operation of the plan, including records regarding applications, determination of eligibility, the provision of financial or medical assistance or social services, and administrative cost; and statistical, fiscal and other records necessary for reporting and accountability required by the Secretary; and will retain such records for such periods as are prescribed by the Secretary. Under this requirement, individual records are kept which contain pertinent facts about each applicant and recipient and include information as to the date of application and date and basis of its disposition; facts essential to determination of initial and continuing eligibility, need for, and provision of financial or medical assistance or social services, and basis for discontinuing assistance or services.
(b) The State agency will make such reports in such form and containing such information, as the Secretary may from time to time require, and comply with