1. (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.

2. (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. (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:

      1. (i) Did the client deny the fact that caused the overpayment?
      2. (ii) Did the client provide information that was misleading or incorrect?
      3. (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?
      4. (iv) What was the reaction of the client to the fact of the overpayment? What did he see as the cause?

   2. (2) Nature of the overpayment. The answers to the following questions will be employed in determining the nature of the overpayment:

      1. (i) Was the overpayment in an amount that the client could not have failed to realize that his assistance payment was incorrect?
      2. (ii) Did the period of overpayment extend over a period of time that the client had repeated opportunities to report?
      3. (iii) Were there previous overpayments for related reasons?

   3. (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:

      1. (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?
      2. (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?
      3. (iii) Does the client have any social handicaps, such as illiteracy, language barriers or lack of education which affect his comprehension of requirements?
      4. (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. (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:

      1. (i) Does the case record indicate that the pertinent regulations were explained in terms suited to the capacity of the client?
      2. (ii) Were appropriate reporting plans worked out with the client?
      3. (iii) Were redeterminations of eligibility made as frequently as appropriate to the situation?
      4. (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?
3. (c) Overpayment pending hearing decision. Restitution will be required for overpayments which occur when assistance is continued pending a hearing decision.

4. (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. (1) Verifying that a resource precipitating closure no longer exists.
   2. (2) Exploring possible overpayment.
   3. (3) Reviewing the credibility of the client and reliability in reporting.
5. (e) [Reserved].

Authority

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)).

Source

The provisions of this § 255.3 adopted August 4, 1977, effective August 5, 1977, 7 Pa.B. 2180; amended January 13, 1983, effective January 15, 1983, 13 Pa.B. 464. Immediately preceding text appears at serial page (74966).

Notes of Decisions

Overpayments paid to an illiterate recipient who was receiving Social Security payments in addition to AFDC benefits were not due solely to administrative error, since the recipient admitted that she knew that when she received the Social Security payments she would be ineligible for AFDC payments. Sease v. Department of Public Welfare, 399 A.2d 1175 (Pa. Cmwlth. 1979).

Even though there was a five-month delay in reporting one spouse’s employment, there was no intent to commit fraud within the guidelines of 55 Pa. Code § 255.3(b) (relating to requirements), since no specific procedures existed for reporting employment, there was no evidence of secretive or evasive behavior and the recipients eventually did inform the Department fully and accurately of the terms of the employment of the spouse. Commonwealth v. Luther, 403 A.2d 1329 (Pa. Super. 1979) (dissenting opinion).

Given the determination that the recipient was capable of reporting his unemployment compensation income and was obligated to do so, it cannot be said that the Department erred in not promptly investigating his pending unemployment compensation claim. Schofield v. Department of Public Welfare, 408 A.2d 588 (Pa. Super. 1979).

Since the provisions of § 255.3 (relating to requirements) require restitution for overpayments which occur when assistance is continued pending a hearing decision, a case did not become moot where appellant continued to receive payments during pendency of her departmental appeal and subsequently continued to receive payments because the disqualifying factor no longer existed. Fritsch v. Wohlgemuth, 378 A.2d 849 (Pa. 1977).

Cross References

This section cited in 55 Pa. Code § 255.2 (relating to definitions); and 55 Pa. Code § 255.83 (relating to requirements).