PCA-20312-870 Interim Assistance (IA) Benefit Notices (Published February 4, 2021)
PMA-19966-870 Medical Assistance (MA) Appeal Adjudications and Maintaining Eligibility During the Coronavirus (COVID-19) Emergency (Published May 28, 2020)
Each applicant and recipient has the right to ask for a hearing to appeal a decision or failure to act which affects his benefits, such as cash assistance, medical assistance, Supplemental Nutrition Assistance Program (SNAP, the new name for the food stamp program), Low Income Home Energy Assistance (LIHEAP), State Blind Pension (SBP), Refugee Assistance, and services. The client may appeal decisions of the County Assistance Office (CAO), the Department of Human Services (DHS), and any agency which provides services under contract with the Department.
55 Pa. Code § 275.1(a) 7 CFR 273.15(a)
The CAO, agency, or provider is responsible for helping the client with the hearing request and may not limit or interfere with the right to appeal in any way.
55 Pa. Code § 275.1(a)(1) 55 Pa. Code § 275.4(a)(1) 7 CFR 273.15(h) 7 CFR 273.15(i)
An explanation of the right to appeal appears on client notices, such as, but not limited to, the Notice to Applicant, Advance Notice, Confirming Notice, the PA/NH 162 series forms for level of care in a nursing home, Application for Benefits, Semiannual Reporting Form (PA 564) and Late/Incomplete Notice (PA 564-A). The CAO will explain the client's right to appeal at each application, redetermination, and recertification.
An appeal and fair hearing:
gives the client a chance for an impartial, objective review of decisions, actions, or failure to act;
55 Pa. Code § 275.1(b) 7 CFR 273.15(a)
settles issues and clearly defines the decision on issues raised by the client;
helps DHS apply regulations consistently;
gives the client an opportunity to challenge the evidence or basis for the agency’s decision; and
identifies regulations which are unfair, wrong, or not in agreement with the law.
The Bureau of Hearings and Appeals (BHA) will designate an Administrative Law Judge (ALJ) who has the authority to make a decision on an appeal. The Director of BHA will affirm, amend, reverse, or remand the decision. The CAO, administering agency, or provider agency is bound by the decision, but may request reconsideration by the Secretary of Human Services, with the exception of SNAP issues. Only the client has the right to appeal to Commonwealth Court.
55 Pa. Code § 275.4(h) 7 CFR 273.15(m) 7 CFR 273.15(v)
ALJs must interpret, but may not invalidate or modify regulations. A hearing decision is restricted to the case at issue.
An individual may appeal decisions including but not limited to the following:
Denial, suspension, or discontinuance of benefits.
Change in the type or amount of a benefit.
The SNAP allotment at any time during their recertification period
Their category.
DHS’s failure to act.
CAO decision to issue a restricted or protective payment.
The amount of restored benefits.
Denial, suspension, discontinuance, or reduction of a special items allowance or special allowance for supportive services.
NOTE: The client may continue to receive SNAP, cash assistance, medical assistance, etc. if the appeal is filed within 15 days of the notice. The CAO or agency must explain to the client that if benefits continue and the client loses the appeal, an overpayment may occur.
Delay in making a change in a benefit, a decision on an application, or acting on a request for a service.
Overpayment and reimbursement claims, including the amount of the claim and collection procedures.
Assignment or reassignment of support orders and reimbursement of delayed support payments or arrearages.
Denial of a payment for a medical service or item.
Denial of a request to correct or delete information in the case record.
The deduction from income allowed for support of a community spouse for a long- term care client.
An increase in the amount a client is required to pay toward his cost for long-term care.
Requirement to participate in semiannual reporting.
Decision based on a Quality Control finding.
55 Pa. Code § 275.1(a) 55 Pa. Code § 275.4(a) 7 CFR 273.15(a)
A client may not appeal the following decisions:
Denial or discontinuance of a protective or vendor payment.
Change in the method of payment for special allowances for supportive services.
A decision to deny payment to a provider for improper billing.
Initiation of prosecution proceedings.
Automatic mass changes in the cash assistance payment unless there is a mathematical error in the computation.
NOTE: The client may appeal a SNAP mass change.
55 Pa. Code § 275.1(a) 7 CFR 273.15(a)
Recoupment for a case which has been prosecuted.
Disqualification. The Office of Inspector General (OIG) initiates disqualification proceedings.
Exception: The client may appeal the identity of the individual who is disqualified, the length of the disqualification period, and the amount of benefits authorized for the remaining family members.
Overpayment claims for benefits received pending an appeal decision. The amount of such claim may be appealed.
Exception: Interim assistance will not be subject to restitution except in the case of deliberate misrepresentation of facts by the appellant.
If the CAO or other agency has taken an action, or proposed to take an action, the client must request a hearing within the following time limits:
SNAP - For applicants, the household must appeal within 90 days beginning with the date of the Notice to Applicant. For recipients, the 90 day period begins with the effective date of the change in benefits.
55 Pa. Code § 275.3(b)(4) 7 CFR 273.15(a)
A household may appeal at any time during the certification period if it believes that the amount of the current allotment is incorrect.
A household may also appeal the denial of a request for lost benefits if the loss occurred less than one year prior to the request.
Cash Assistance, Refugee Assistance, State Blind Pension, LIHEAP, Medical Assistance, and Services - The client must appeal within 30 days from the date of the written notice of a CAO decision or action.
The client may appeal within 60 days from the date of a CAO decision or action when the CAO did not send a written notice because a written notice was not required.
The client may also appeal within 60 days from the CAO's failure to act on a request or an application.
For all types of benefits, the client also may appeal in writing for a period of six months from the date of an action or failure to act, if the CAO or other agency:
failed to send a required written notice of the action;
failed to inform the client of his right to appeal;
was in error;
caused ongoing delay; or
failed to take corrective action that should have been taken.
After six months from the date of an action or failure to act, the client may appeal providing he submits, with the written appeal, an affidavit stating that he:
did not know of the right of appeal;
believed that the CAO was resolving the problem;
believed that the CAO erred in its actions; and
is making the appeal in good faith.
The CAO must forward the appeal to BHA regardless of whether the appeal is or is not timely filed.
The CAO/agency will offer the client and his representative the opportunity to have a prehearing conference. This conference may be by telephone or face-to face.
NOTE: The CAO will not schedule a prehearing conference with a represented client without offering the representative(s) the opportunity to attend either by telephone or in person.
A prehearing conference is an effort to resolve an issue between the client and the CAO/agency before going to a hearing. If the issue can be resolved at the prehearing conference, the work and expense of an appeal hearing can be eliminated. The prehearing conference does not affect the client's right to have a hearing and it does not affect the requirements for submitting requests timely to BHA.
The CAO will schedule a prehearing conference as follows:
Give the client and his representative, if known, a Notice of Prehearing Conference. If the notice is mailed, include a return envelope. See Appendix A.
Provide a supervisor to monitor all prehearing conferences.
If the complaint involves a denial of expedited service for SNAP, schedule the conference within two working days unless the household requests a postponement.
Advise the client that the agency conference is optional and that it will not delay or replace the fair hearing process.
If the complaint is resolved, have the client sign a request for withdrawal. Include the client's name, case number, and date of the hearing request. Send a copy of the withdrawal request to BHA.
The Prehearing Conference Letter may be used by the appellant to withdraw the appeal. Ensure the appellant checks the box to withdraw the appeal, signs and dates the form. Forward a copy to BHA.
NOTE: The complaint is not resolved until all necessary steps have been taken to implement the changes agreed upon with the appellant and his/her representative.
NOTE: If the appeal is not withdrawn by the client, a hearing is held.
Keep a log of prehearing conferences which indicates:
date of the hearing request;
client's name;
case record number;
method of conference;
result; and
whether a notice was sent to BHA.
Never attempt to convince the client to withdraw his request. If the client decides to withdraw the request after it has been sent to BHA, notify BHA immediately and send a copy of the date-stamped withdrawal.
Reissued September 27, 2012, replacing March 16, 2012; reviewed July 25, 2013