The CAO will decide what information needs to be confirmed from:
The information on the application.
Prior case information.
Statements made by the individual.
Information from automated sources. (See Section 378.6, Automated Sources.) 55 Pa. Code § 201.1
Sometimes it may be impossible to get proof beyond the applicant’s statement on certain eligibility factors. The caseworker must use his or her judgment and make a decision using the proof on hand. The caseworker must consider how creditable the individual is and how reliable the sources of proof are. As long as the applicant cooperates in getting proof, the CAO must approve MA within 30 calendar days from the date when the application is received. If all other conditions of eligibility for MA are met except proof of citizenship or identity, and the individual is cooperating with CAO staff in getting the proof, MA must not be denied or stopped while waiting for proof. 55 Pa. Code § 201.4(1)(iii) 55 Pa. Code § 125.21(b)
NOTE: The applicant/recipient does not need to come to the CAO to show proof of citizenship or identity. Once proof has been provided, it will be copied or scanned and placed in the case record.
If the proof the individual uses is not appropriate, not complete, or not consistent with other information, the caseworker will tell the individual, in a language that the individual understands, that more proof is needed. The caseworker and the individual must decide what other proof can be used. If the proof the individual provides is still unacceptable, the caseworker will make a collateral contact, using a copy of the PA 4 when it is needed. 55 Pa. Code § 201.4(1)(iv)
The CAO will set up a plan with the individual for obtaining the needed proof within the following time limits: 55 Pa. Code § 201.4(1)(iv) 55 Pa. Code § 201.3
At application, thirty calendar days from the date the CAO asks for the proof. 55 Pa. Code § 125.21(b)
NOTE: It is the CAO’s duty to get the needed proof before approving benefits.
Fifteen working days from the date a complete renewal is due. 55 Pa. Code § 133.23(a)(3)(i)
Exception: Proof of an incapacity is needed so that an eligibility determination can be made within thirty calendar days. Information about medical resources is needed within thirty calendar days after the renewal.
Thirty calendar days from the date a partial renewal is due. 55 Pa. Code § 133.84(d)
Thirty calendar days from the date the CAO finds out about a change that needs proof. 55 Pa. Code § 133.84(d)
Reminder: The CAO will clearly identify and explain to the applicant what proof is needed to determine eligibility for MA. Approval of MA must not be delayed while waiting for proof for Cash Assistance or SNAP.
If the applicant has cooperated but is still unable to provide acceptable evidence, the CAO must make a collateral contact. (See Section 378.4, Collateral Contacts.) 55 Pa. Code § 201.4(1)(i)
If the individual does not cooperate in obtaining proof, the CAO will send a PA 162 Not Eligible notice to applicant if the individual is an applicant or a PA 162 Advance Notice if the individual is a recipient. These notices include the following:
A list of information that was not provided or action that was not taken.
The policy citation stating the information or action that was needed.
NOTE: See Chapter 377, Notices, for complete information about client notices.
The record must clearly show eligibility or ineligibility. The CAO will explain in the record any decision to ask for more sources of proof or proof of inconsistent information.
The CAO will ask for proof of conditions of eligibility at application. 55 Pa Code § 201.3
Reminder: For a child under age 21, the following items will be obtained from the parent’s or caretaker’s statement: Social Security Number, age and date of birth, and who is in the household. If the family notes on the CHIP application there is third-party insurance, contact the family and get the information.
Items that must be proven include the following:
Gross income, including income to be deemed (see Chapter 350, Income, and Chapter 355, Deeming Income and Resources). 55 Pa Code § 181.3
Income expense deductions (see Chapter 360, NMP Deductions, and Chapter 361, MNO Deductions). 55 Pa Code § 181.3
Child support the household gets.
Resources, unless the applicant, the applicant’s spouse, or the applicant’s children or stepchildren who are living in the household are under age 21 or the applicant has care and control of a child under age 21 living in the household (see Chapter 340, Resources). 55 Pa Code § 178.3
The equity value and ownership of resources, unless the applicant, the applicant’s spouse, or the applicant’s children or stepchildren who are living in the household are under age 21 or the applicant has care and control of a child under age 21 living in the household (see Chapter 340, Resources).
Health insurance or other third-party resources that can be used to pay medical expenses (see Supplemental Handbook, Chapter 980, Third-Party Resources). 55 Pa Code § 178.6
Citizenship or Alien status (see Chapter 322, Citizen/Noncitizen). 55 Pa Code § 150.1
Residence (see Chapter 323, Residence). 55 Pa Code § 148.1
Identity of the applicant (see Chapter 320, Identity). 55 Pa Code § 125.1(b)
The following must be proven if part of the case record:
The relationship of the specified relative to the child, if the CAO has reason to question the applicant’s statement (see Chapter 327, Specified Relatives). 55 Pa Code § 178.11(4) (ii) 55 Pa Code § 178.12(5) (ii)
Deprivation of a TANF dependent child, if the CAO has reason to question the applicant’s statement (see Chapter 329, Deprivation).
For GA-related MA only, the need to obey a summons or bench warrant to appear as a defendant at a criminal court case (see Chapter 304, Appendix C). 62 P.S. 481.1
Pregnancy.
Disability.
Medical Expenses.
Dependent Care Expenses.
Student Status.
Child Support paid to someone outside the household (for deeming computations).
For MAWD: Need to prove employment.
Note: Proof of employment includes, but is not limited to, pay stubs, tax records, and letters from employers.
For category PD, proof of GA-related eligibility. 55 Pa Code § 141.61(c) (1)
If a case record already has proof of information that is not likely to change (for example, birth date, citizenship, identity, health insurance, address, or Social Security number), the CAO must not require proof again unless information does not match up.
As long as the applicant cooperates in getting proof, the CAO will approve MA within thirty calendar days from the date of application. If the CAO cannot make a decision in thirty days, they may extend the period to forty-five calendar days, as long as the applicant is told the following in a letter:
Why there is a delay.
The expected date of decision.
The right to a fair hearing.
If the CAO approves MA while waiting for proof, they will allow thirty more calendar days after the approval date for proof to be provided. As long as the applicant cooperates and the delay is caused by a third party, the CAO will continue benefits for thirty more calendar days. The CAO will allow more thirty-day periods if they are needed due to a third party delay. 55 Pa Code § 125.21(b) (2)
If the applicant refuses to cooperate in getting proof, the CAO will deny benefits. 55 Pa Code § 201.1
Past management is considered when an individual states how he or she has been living or who is the source of the income used to meet the individual’s needs.
If proof of the individual’s past management is needed, the individual must give the name and most recently known address of the source. The individual will be asked to give written or other proof, including a letter from the source, of how much is currently available. If, however, the individual is afraid of physical danger, emotional upset, or is not willing to contact the former source, the individual can give the name and most recently known address of the source to the CAO. The caseworker may then go ahead and contact the source to find out whether the individual can get more money.
Past management, like the other factors,will be discussed only as much as is necessary to understand the individual’s present situation and to find out how much money is still available. 55 Pa Code § 125.24(c) (7) (ii)
When handling a complete renewal, the CAO will get proof of the following: 55 Pa Code § 133.73 55 Pa Code § 133.83
Citizenship or nationality, if the information is not already in the case record.
Noncitizen status, if the information that the individual gives does not match up with other information.
Identity, if the information is not already in the case record.
NOTE: MA and CHIP applications will go through a Master Client Index (MCI) interface with the SSA. The interface will match an individual on demographic information and return a positive response if the individual is a U.S. citizen. The interface may fail if there is a mismatch or if the SSA has no record of the individual's citizenship information. If the SSA match is successful for both citizenship and identity, there is no further action required by the CAO. If the SSA match is unsuccessful, the CAO will need to reach out to the individual to obtain identity and citizenship verification. In a situation where the SSN match is unsuccessful, a SSN is not acceptable verification of identity.
Reminder: Processing of a referral received from Pennsylvania Insurance Department (PID) will not be delayed due to lack of citizenship or identity documentation as long as the household is cooperating in providing these documents.
Gross, nonexempt income, including deemed income.
Individuals can provide a single pay stub (weekly, bi-weekly or monthly) that is representative of the income received and the information will be used in the eligibility determination, either at application or renewal. Pay stubs for a full month's income is not required.
It is acceptable verification for individuals to provide a single pay stub received within a 60-day period prior to the date the application or renewal is received by the CAO.
Example: John Smith is applying for MA for his pregnant wife and two children, ages 3 and 8. Mr. Smith provides a pay stub date 02/17/2012 with a gross income of $613.75. He is paid bi-weekly. the caseworker will use this single pay stub to make the MA determination by converting the income to a monthly amount.
NOTE:This policy does not eliminate the requirements for the caseworker to verify income when another source of income does not support the determination made based on the single pay stub or income that was received within the 60 day period prior to application or renewal.
Example: Caseworker gets an IEVS hit for the third quarter that shows the individual received $7,500 wages from John Public Construction but the pay stub that was presented for this company stated $300 a week which converts to $1,200 a month. Since there appears to be a discrepancy, the caseworker must confirm the individuals past and present income to establish past and future eligibility.
Child support that the household gets.
Income expense deductions.
Resources, unless the applicant, the applicant’s spouse, or the applicant’s children or stepchildren who are living in the household are under age 21 or the applicant is taking care of and in charge of a child under age 21 living in the household (see Chapter 340, Resources)
The following things must be proven if they are part of the case record:
Medical Expenses.
Disability.
Dependent Care Expenses.
Age.
GA-related eligibility for NMP category PD and MNO category TD.
Pregnancy.
For GA-related MA only, the need to obey a summons or bench warrant to appear as a defendant at a criminal court case (see Chapter 304, Appendix C). 62 P.S. 481.1
Student Status.
Child Support paid to someone outside the household.
Other eligibility factors for which a change has taken place or for which information about it does not match up with the facts or the available proof.
At a Partial Renewal for Breast and Cervical Cancer Prevention and Treatment (BCCPT), the need for continued treatment must be proven. The CAO will be notified by a fax from OMAP of the continued need for treatment, less treatment, or the stopping of treatment because (a) the treatment is no longer medically necessary or (b) because the individual has not provided proof of the need for treatment. Public Law 106-354
When processing a complete renewal for the BCCPT program, the continued need for treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix must be proven. If credible coverage is shown on the renewal papers, it must also be proven. Public Law 106-354
If a case record already has proof of information that is not likely to change (for example, birth date, citizenship, identity, health insurance, address, or Social Security Number), the CAO will not ask for proof again unless information does not match.
The CAO will allow the recipient fifteen working days from the date of the renewal to provide any needed proof. If all other conditions of eligibility for MA are met except proof of citizenship or identity, and the individual is cooperating with CAO staff in getting the proof, MA must not be denied or stopped while waiting for proof. 55 Pa Code § 133.23(a) (3) (i)
If the recipient cooperates but cannot meet the fifteen-day deadline because of a third party, then the CAO will continue MA and allow more time for proof to be provided. The CAO will review cooperation every thirty days. 55 Pa Code § 133.23(a) (3) (i) 55 Pa Code § 125.21 (b)
Exception: Proof of incapacity is needed for an eligibility determination to be made within thirty calendar days.
If the recipient does not cooperate in giving proof, the CAO will send an Advance Notice that benefits will end. The notice must tell the recipient what proof is needed for continued eligibility for MA. 55 Pa Code § 201.1 (1)
The CAO will confirm conditions of eligibility, income, and resources when there is a change that affects eligibility.
55 Pa Code § 125.74 55 Pa Code § 133.84(d) (3)
When the CAO learns of a change, they must review the applicant/recipient group’s eligibility for continued benefits. The CAO will get proof of the changed information. The recipient must provide the proof no later than thirty calendar days after the date when the CAO learns of the change. If the recipient is cooperating but cannot get the proof because of a delay caused by a third party, MA will continue until proof is received. The CAO will review progress every thirty days. 55 Pa Code § 125.21 (b)
When a recipient asks the CAO to close his or her case, the CAO will find out why. If it is because the individual has income, the CAO will confirm when the individual received it and the gross amount. If the reason for the closing is unknown or cannot be confirmed, the CAO will narrate the information in the case record. If the individual applies for MA again, the CAO will verify the information that was unknown and find out whether any resources at closing are still available
An individual who files a timely appeal of adverse action may submit new or extra proof of eligibility at any time up to and including the fair hearing. If proof shows that the individual was eligible for MA, he or she can get retroactive benefits. 55 Pa. Code § 275.4(a)(3)
The individual does not need to show that the CAO made a mistake in stopping, denying, or reducing benefits.
When the individual provides the needed proof, the CAO will:
Decide whether proof confirms eligibility factors at issue in the appeal.
Decide what date the eligibility factor at issue in the appeal was met.
If proof shows the individual needed MA and was eligible in a retroactive month, approve benefits for that month.
If proof shows the individual was eligible on the date of application or the date when benefits were stopped, denied, or changed, approve benefits back to that date. All other eligibility factors must be met.
If proof shows the individual was eligible at a later date, approve benefits back to that date. All other eligibility factors must be met.
Example: Mr. Landry submitted an MA application on February 2. Both Mr. Landry and his wife applied for benefits. On February 8, he sent unpaid hospital bills from December to the CAO. Mrs. Landry had a life insurance policy with a face value of $5,000. The CAO calculates that the cash value of the insurance policy plus other resources puts the couple over the resource limit. The Landrys met all other eligibility factors. On February 19, the CAO issued a notice denying the Landrys’ application for MA.
On February 28, Mr. Landry files an appeal. Before the hearing, he gives the CAO a statement from his wife's insurance company saying that the cash value of her life insurance policy had been lowered because she borrowed against it several years ago. This proves that the couple’s total resources are less than the limit now and in December.
The CAO approves continuing MA effective February 2 and retroactive MA for the month of December.
Updated February 14, 2012, Replacing October 29, 2008