reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 255 - RESTITUTION › MA RESTITUTION PROVISIONS FOR THE MEDICALLY NEEDY › Section 255.83 - Requirements

Current through Register Vol. 54, No. 28, July 13, 2024
Restitution will be waived on client overpayments that
						meet the criteria specified in §
											255.3 (relating to requirements).
						In addition restitution will be waived on client overpayments that are $50 or
						less because of the cost of handling claims.
This section cited in 55 Pa. Code §
													255.71 (relating to policy); 55
						  Pa. Code §
													255.81 (relating to policy); and
						  55 Pa. Code §
													255.82 (relating to
						  definitions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 255 - RESTITUTION › MA RESTITUTION PROVISIONS FOR THE MEDICALLY NEEDY › Section 255.84 - Procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Negligence action (third party liability).
If medical care is
					 due to an accident or injury for which there is a negligence action or a
					 potential one, the County Assistance Office, provided that the hospital or
					 other provider has not taken an assignment, will approve payment, and refer the
					 situation to claim settlement as specified in §
											177.83(reserved).
					 If the hospital takes a subrogation or assignment for damages against the third
					 party to the extent of the hospital bill, the client will not be eligible for
					 Medical Assistance payment of the bill.
(b)
Administrative error.
Action taken regarding administrative error will be as follows:
(1) If the County Assistance Office
					 erroneously authorizes payments on an invoice when the client is not eligible,
					 and if the facts to determine eligibility were known to the CAO, it will be
					 administrative error. The overpayment will be referred for collection action
					 only if the client had been clearly notified of his ineligibility for Medical
					 Assistance before making the application for coverage represented by the
					 bill.
(2) If a patient was eligible
					 for both Medicare and Medical Assistance and the former was not billed first,
					 an administrative error will exist.
(3) In negligence cases, if the third party
					 was billed on the interim
per diem
Medical Assistance rate and
					 not the actual charge, an administrative error will exist.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 257 - REIMBURSEMENT › AFDC/GA REIMBURSEMENT PROVISIONS › Section 257.21 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General.
AFDC/GA reimbursement policy in general is as
					 follows:
(1) There are two closely related
					 reasons for reimbursement. The first rests on the basic principle that public
					 assistance supplements resources and that whenever assistance is granted in
					 lieu of the utilization of certain resources, the assistance should be repaid
					 whenever these resources become available. The second reason relates to the
					 financing of the program. Reimbursement results in a recovery of money that is
					 then available for redistribution as assistance, thereby reducing to this
					 extent the need for additional tax revenues.
(2) Requiring reimbursement from persons who
					 receive assistance in lieu of the utilization of certain resources will insure
					 that they are treated equitably with other persons who have the same kind of
					 resources but who use their resources instead of seeking public assistance.
					 Inherent in this concept is a further saving of tax moneys, since persons will
					 thereby be encouraged to find ways of remaining independent of public
					 assistance.
(3) The obligation of
					 reimbursement has always been inherent in the receiving of public assistance in
					 the Commonwealth. The Supreme Court emphasized this and recognized the right of
					 the Commonwealth to repayment under the common law when it decided in
Waits' Estate,
336 Pa. 151, that "there is an implied duty on
					 the part of a recipient of public assistance, or his estate, to make
					 reimbursement." The Support Law (see
					 62
					 P. S. §§
													1971-1977) sets forth
					 certain conditions pertaining to reimbursement. The rules and regulations of
					 the Department which have been developed with the advice of the Attorney
					 General implement the common law and the Support Law (62 P. S.
					 §§
													1971-1977) by establishing the
					 limits of liability specifically.
(4) Protection and collection of the
					 Commonwealth's claim for reimbursement are mandatory, and the interests of the
					 Commonwealth are best protected by providing that property owners pledge
					 property which is liable for reimbursement as security for future reimbursement
					 of assistance received by them or by persons for whom they are held
					 responsible.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 257 - REIMBURSEMENT › AFDC/GA REIMBURSEMENT PROVISIONS › Section 257.22 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
						have the following meanings, unless the context clearly indicates
						otherwise:
Adult
-One who is 21 years of age or
						older.
Lien
-A legal claim on property as
						security for debt. The lien obtained by filing a DPA 9 is similar to one
						obtained if the Department sued the person liable for reimbursement and the
						court gave judgment in favor of the Department.
Living with
-Using the same family living
						quarters. Temporary absences while hospitalized, in detention, working
						elsewhere and the like will not be considered to interrupt the
						arrangement.
Minor child
-One who is under 21 years of
						age.
Obligor
-The owner of real or personal
						property subject to reimbursement.
Ownership of property
-In accordance with
						the Support Law (62 P. S. §§
												1971-1977), only property owned or to which
						there was a right of ownership at the time the assistance was received will be
						held liable. Reimbursement will be based on the property, not on property
						acquired after discontinuance of assistance. A right to ownership will exist
						when there is a resource of which actual possession is delayed because of legal
						processes or other reason.
Property which is liable for
						reimbursement
-Generally, that which is not immediately converted into
						cash and used for current maintenance. Resident property, frozen assets,
						interests in or rights to real property, benefits, compensation, damages or
						other assets whose conversion into cash is delayed are examples of resources
						from which reimbursement will be required. A more complete list is given in
						§
											257.23 (relating to
						requirements).
Reimbursement
-The repayment of
						assistance granted to a person or certain of his relatives while he has
						ownership or the right to ownership of property. Repayment of assistance for
						which the recipient was not eligible is termed restitution, as set forth in
						Chapter 255 (relating to restitution).
Unemancipated minor child
-One who is
						under 21 years of age, not married and in the care and control of his
						parents.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 257 - REIMBURSEMENT › AFDC/GA REIMBURSEMENT PROVISIONS › Section 257.23 - Requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Ownership rights and reimbursement actions affected.
Ownership
					 rights and reimbursement actions are affected by the following:
(1) Reimbursement is based on the rights to
					 ownership of property while assistance is being received. Both of these factors
					 are variable and the determination of the correct reimbursement action to take
					 to assure acknowledgment of liability for reimbursement is dependent on the
					 following:
(i) The category, period and
					 relationships involved in the granting of assistance, as provided in subsection
					 (b).
(ii) The type of property, as
					 described in subsection (c).
(iii)
					 The way property is owned, as provided in subsection (b).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 257 - REIMBURSEMENT › AFDC/GA REIMBURSEMENT PROVISIONS › Section 257.24 - Procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Acknowledgment of liability.
Acknowledgment of liability will
					 be as follows:
(1)
General.
Liability for reimbursement will be as follows:
(i) Liability for reimbursement will not be
					 dependent upon agreement by the debtor. Action to protect or collect could be
					 delayed until the obligor leaves the assistance rolls or the asset is
					 converted. This delay, however, would increase the amount of the claim by
					 adding cost of the court suit and the like. In addition, the Commonwealth would
					 collect fewer claims because the assets could be spent before collection, and
					 uniformity of treatment could not be assured.
(ii) To avoid the publicity and additional
					 costs imposed on a former recipient or his estate by court action, and to
					 assure equal treatment, persons who are liable for reimbursement will be
					 required to acknowledge in writing at the time of application their liability
					 for reimbursement. If property is real estate, this acknowledgment will be
					 recorded at the courthouse and become a lien against the real estate owned by
					 the signers. If the property owned is personal, the acknowledgment may transfer
					 the title to the Commonwealth.
(iii) Only owners of property which is liable
					 for reimbursement will be required to sign acknowledgments of liability. The
					 liability of the property may be for assistance to the owner, to his relatives,
					 or both, in accordance with §
													257.21 (relating to policy). If
					 property which is liable because assistance was received by the owner or his
					 relatives, is sold or transferred, the new owner may be asked to acknowledge
					 the liability of the former owner or he may be asked to agree to have his name
					 included as a judgment debtor if settlement of the claim is to be postponed.
					 Other actions will be possible when owners change and the county office should
					 notify the area office when it learns of the transfer of property which is
					 liable for reimbursement. The area office will take any action
					 necessary.
(iv) Although there will
					 be no liability for reimbursement of Blind Pension, a blind pensioner who is
					 liable for repayment of AFDC or GA received by his relatives in accordance with
					 §
													257.21 will be required to
					 acknowledge the liability of his property in the same way as a nonapplicant
					 obligor.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This chapter
				  applies to the estates of individuals who received MA for nursing facility
				  services, home and community based services or related hospital and
				  prescription drug services, who were 55 years of age or older at the time that
				  MA was received, who died on or after August 15, 1994, and who received MA on
				  or after August 15, 1994. This chapter does not apply to individuals who
				  received MA before reaching 55 years of age and whose MA eligibility terminated
				  before reaching 55 years of age.
(b) The estate of a an individual who was 55
				  years or older at the time that MA was received is liable to repay the
				  Department for the amount of MA paid for all nursing facility services, home
				  and community based services and related hospital and prescription drug
				  services provided from the time the individual was 55 years of age and
				  thereafter. Only MA services provided on or after August 15, 1994, are subject
				  to estate recovery.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.4 - Request for statement of claim

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The personal representative has a duty to
				  ascertain whether the decedent received MA services during the 5 years
				  preceding death and, if so, give notice to the Department requesting a
				  statement of claim. The 5-year time frame is for notification purposes only and
				  does not limit the Department's claim. Effective August 15, 1994, the amount of
				  MA paid for services rendered after August 15, 1994, to an individual 55 years
				  of age or older is subject to the Department's claim. The notice shall be sent
				  by certified mail return receipt, facsimile machine or electronic mail to the
				  address of the Department specified in §
										258.14 (relating to service on the
				  Department). The notice shall include the following:
(1) A statement that the personal
				  representative is requesting a statement of claim against the estate of the
				  decedent.
(2) The decedent's
				  name.
(3) The decedent's last
				  address.
(4) The decedent's date of
				  birth.
(5) The decedent's date of
				  death.
(6) The decedent's Social
				  Security Number.
(7) The personal
				  representative's name, address and telephone number.
(8) Written documentation of the gross value
				  of the decedent's estate.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.5 - Computation of claim

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department's claim with respect to a decedent shall consist of the total of all
				  MA payments made with respect to the decedent for nursing facility services,
				  home and community based services and related hospital and prescription drug
				  services rendered on or after August 15, 1994.
(b) Premium payments and cost-sharing for
				  decedents who were qualified Medicare beneficiaries shall be included in the
				  statement of claim for the period of time the decedent received nursing
				  facility services, home and community based services or related hospital and
				  prescription drug services rendered on or after August 15, 1994. A qualified
				  Medicare beneficiary is an individual whose Medicare copayments, premiums or
				  deductibles only are paid by the MA program.
(c) With respect to a claim for the costs of
				  MA services delivered through a Managed Care Organization (MCO) contract, the
				  Department's claim will be based on the amount the Department paid to the MCO
				  on behalf of the decedent.
(d) The
				  Department will not reduce its claim on account of attorneys' fees or other
				  costs incurred by the estate to obtain or liquidate assets. These costs may be
				  treated as expenses of administration of the estate.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.6 - Priority of the Department's claim

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department's claim is entitled to
				  priority under
				  20 Pa.C.S. §
											3392(3) (relating to
				  classification and order of payment) to the extent it includes payment for
				  services rendered within 6 months of death. Otherwise, the Department's claim
				  shall be paid under
				  20 Pa.C.S. §
											3392(6).
(b) The Department's claim against deposit
				  accounts and patient care accounts subject to
				  20 Pa.C.S. §
											3101
				  (relating to payments to family and funeral directors) is subordinate to
				  reasonable funeral expenses and to those claims of creditors having priority
				  over the Department under
				  20 Pa.C.S. §
											3392.
(c) The Department's claim against assets
				  subject to
				  20 Pa.C.S. §
											3101
				  shall be superior to that of family members and any person receiving money
				  under that provision of law shall be answerable to the Department.
(d) The Department's claim is subordinate to
				  the family exemption and to perfected liens on specific property. A family
				  exemption is the exemption provided by
				  20 Pa.C.S. §
											3121
				  (relating to when available).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.7 - Postponement of collection

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will postpone collection of its claim until the last of one of the
				  following occurs:
(1) The death of any
				  surviving spouse.
(2) The death of
				  any child who is blind or totally and permanently disabled, as determined under
				  the standards of the Supplemental Security Income (SSI) program in the Social
				  Security Act. See 42
				  U.S.C.A. §
												1382.
(3) The date any surviving child is 21 years
				  of age.
(4) The death of, property
				  transfer by or vacating of the property by a sibling who has an equity interest
				  in the property and who has been living in the home for at least 1 year prior
				  to the death of the decedent.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.8 - Liability of personal representative

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The personal representative has a duty to
				  insure that the Department's claim is adequately presented to the court and,
				  unless the Department's claim is postponed, to pay the Department's claim after
				  payment of all superior claims of creditors.
(b) The personal representative is personally
				  liable to pay the Department's claim if property subject to the Department's
				  claim, and not subject to postponement of collection, is transferred without
				  valuable and adequate consideration to an heir or other person having a lower
				  priority claim of a creditor, without satisfaction of the Department's
				  claim.
(c) When the Department's
				  claim is postponed, the personal representative is personally liable if
				  property subject to the Department's claim is transferred without valuable and
				  adequate consideration to an heir or other person having a lower priority claim
				  of a creditor, without protecting the Department's claim.
(d) A decree of distribution will discharge
				  the liability of the personal representative to the Department only if the
				  following conditions are met:
(1) The
				  Department is served with a copy of the proposed distribution at least 30 days
				  in advance of court approval.
(2)
				  The court records show that the personal representative made the inquiry
				  required by §
											258.4 (relating to request for
				  statement of claim) and obtained a statement of claim, if
				  appropriate.
(3) The court records
				  show that any claim of the Department was presented to the court and paid, or
				  that there were insufficient assets to pay the Department's claim.
(4) The Department is served with a copy of
				  the final distribution order and paid all amounts that it is due.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.9 - Liability of transferees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  transferee is liable to pay the Department's claim when he receives property
				  subject to the Department's claim for which he did not pay fair market value.
				  The transferee's liability is limited to the difference between the fair market
				  value of the property that was not protected and the amount of money received
				  by the estate in exchange for the transfer, if any.
(b) When the Department's claim is postponed,
				  a transferee is personally liable to pay the Department's claim if the
				  transferee receives property subject to the Department's claim and the
				  transferee fails to protect the Department's claim during the postponement
				  period. The transferee's liability is limited to the fair market value of the
				  property that was not protected.
(c) The arms length sale of the decedent's
				  real property at fair market value by the personal representative to a party
				  unrelated to the decedent or the personal representative shall be deemed to be
				  supported by valuable and adequate consideration.
This section cited in 55 Pa. Code §
												258.12 (relating to administrative
						enforcement).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.10 - Undue hardship waivers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will waive its claim in cases of undue hardship.
(b) The Department will find undue hardship
				  and will permanently waive its claim with respect to the primary residence of a
				  decedent if the person requesting the undue hardship waiver meets all of the
				  following conditions:
(1) The person has
				  continuously resided in the primary residence of the decedent for at least 2
				  years immediately preceding the decedent's receipt of nursing facility
				  services, or, for at least 2 years during the period of time which
				  Medicaid-funded home and community based services were received.
(2) The person has no other alternative
				  permanent residence.
(3) The person
				  has provided care or support to the decedent for at least 2 years during the
				  period of time that Medicaid-funded home and community based services were
				  received by the decedent, or for at least 2 years prior to the decedent's
				  receipt of nursing home services during which time the decedent needed care or
				  support to remain at home
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.11 - Unadministered estates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will provide information regarding unadministered estates to the
				  probate and estate section of local county bar associations so that those
				  estates can be administered by willing attorneys under the sponsorship of the
				  bar association as a public service and under the authority of
				  20 Pa.C.S. §
											3155(b)(5) (relating to
				  persons entitled). When appropriate, the Department will authorize a member of
				  this local county bar association to obtain letters of administration on the
				  Department's behalf under
				  20 Pa.C.S. §
											3155(b)(4). A reasonable
				  administrator's commission and attorney's fee may be charged to the estate as
				  expenses of administration, but may not exceed a combined fee of $1,000, or 6%
				  of the gross assets of the estate, whichever is greater.
(b) The Department may cause one of its
				  employees to administer an estate if no administrator has been appointed and
				  assets may exist to pay the Department's claim.
(c) The Department's Office of Legal Counsel
				  may provide legal services to an estate if a Departmental employee has been
				  designated to administer the estate. Alternatively, the administrator may
				  employ private counsel.
(d) The
				  Department will charge the estate a reasonable administrator's commission and
				  attorney's fee as expenses of administration not to exceed a combined fee of
				  $1,000, or 6% of the gross assets of the estate, whichever is greater, if
				  administrative or attorney services are provided to the estate by Commonwealth
				  employees.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.12 - Administrative enforcement

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
				  addition to any other remedies allowed by law, the Department may
				  administratively assess liability upon a personal representative or transferee
				  in accordance with §§
										258.8 and
				  258.9 (relating to liability of
				  personal representative; and liability of transferrees) under section 1412 of
				  the Public Welfare Code (62 P. S. §
											1412(a.1)(1) and (2)). A personal
				  representative or transferee will be notified in writing of the assessment of
				  liability and the right to appeal this decision in accordance with §
										258.13 (relating to appeals and
				  jurisdiction).
(b) A final
				  administrative order in any proceeding to assess liability against a personal
				  representative or transferee shall be binding upon the parties in any
				  subsequent judicial proceeding to enforce the administrative order.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.13 - Appeals and jurisdiction

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  personal representative, transferee or family member adversely affected by a
				  decision of the Department under this chapter may appeal to the Department's
				  Bureau of Hearing and Appeals in accordance with Chapter 275 (relating to
				  appeal and fair hearing and administrative disqualification hearings), within
				  30 days of the date the affected person is notified of the decision.
(b) An appeal shall be mailed to the Bureau
				  of Hearings and Appeals, Department of Human Services, Post Office Box 2675,
				  Harrisburg, Pennsylvania 17105.
(c)
				  The Bureau of Hearings and Appeals has exclusive jurisdiction over disputes
				  involving a request for waiver, compromise or postponement of collection.
				  Appeals involving the exercise of the Department's discretion shall be reviewed
				  by the Bureau of Hearings and Appeals under an abuse of discretion standard,
				  otherwise the Bureau of Hearings and Appeals shall review the matter de
				  novo.
(d) The Bureau of Hearings
				  and Appeals has concurrent jurisdiction with the courts of common pleas over
				  disputes involving the computation of the Department's claim or assessment of
				  liability against a personal representative or transferee. The Bureau's
				  decision is binding upon all parties participating before the Bureau of Hearing
				  and Appeals, subject to the Secretary's reconsideration and appellate
				  review.
This section cited in 55 Pa. Code §
												258.12 (relating to administrative
						enforcement).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 258 - MEDICAL ASSISTANCE ESTATE RECOVERY › Section 258.14 - Service on the Department

Current through Register Vol. 54, No. 28, July 13, 2024
The address for requesting a statement of claim or for
					 serving legal papers on the Department is: Third Party Liability Section,
					 Department of Human Services, Estate Recovery Program, Post Office Box 8486,
					 Harrisburg, Pennsylvania 17105-8486.
This section cited in 55 Pa. Code §
												258.4 (relating to request for
						statement of claim).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 259 - THIRD-PARTY LIABILITY › Section 259.1 - Statement of claim; managed care organizations-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) With respect to
				  claims against third parties for the costs of Medical Assistance (MA) services
				  delivered through a Managed Care Organization (MCO) contract, the Department
				  will recover the actual payment to the hospital or other medical provider for
				  the service. If no specific payment is earmarked by the MCO for the service,
				  such as in the example of a capitated payment to physicians, the Department
				  will recover its fee schedule amount for the service.
(b) If the MCO fails to provide the
				  Department with information necessary to compute the statement of claim within
				  contractual deadlines, the Department will use the amount of the capitation
				  payments made to the MCO since the date of the injury as its claim against the
				  third party until sufficient information is provided to compute a statement of
				  claim in accordance with subsection (a). When the Department is forced to use
				  the capitation payment to compute its statement of claim, the MCO will be
				  liable to the Department for the amount of the Department's diminished recovery
				  in accordance with the terms of the MCO's contract with the
				  Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 259 - THIRD-PARTY LIABILITY › Section 259.2 - Claims against moneys for which third parties are liable as a result of a tort claim allocation of tort proceeds in actions filed before September 2, 2008-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) With
				  respect to claims asserted by the MA Program against moneys owed by third
				  parties as a result of tort claims asserted by a beneficiary of MA benefits,
				  the Department will only recover from that portion of a tort recovery which
				  represents payment for medical care by the third party. The term "beneficiary"
				  includes both present and former recipients of MA benefits, and includes
				  individuals receiving benefits through an MA managed care
				  organization.
(b) In determining
				  the portion of a tort recovery that represents payment for medical care by a
				  third party, the Department will apply the following interpretations:
(1) Unless the Department intervenes in a
				  lawsuit or sues separately, beneficiaries, including beneficiaries who are
				  minors, are vested with the right to recover injury related medical expenses
				  paid by the MA Program as part of their cause of action for other damages, and
				  absent an express court order to the contrary are deemed to recover medical
				  expenses as part of any tort recovery.
(2) In the absence of a court order
				  allocating tort proceeds among categories of damages, 1/2 of the net proceeds
				  are allocated by law to be available to repay injury-related MA expenses. The
				  amount of net proceeds is computed by deducting from the gross proceeds the
				  attorney's fees, litigation costs and medical expenses relating to the injury
				  that were paid for by the beneficiary prior to the settlement of the injured
				  beneficary's action or claim.
(3)
				  If the beneficiary or other party seeks to obtain a court order limiting the
				  portion of the tort recovery from which MA reimbursement may be paid to an
				  amount less than 1/2 of net proceeds, or excluding amounts paid by the MA
				  Program from the recovery, the Department shall be given fair notice and an
				  opportunity to protect its interest.
(4) Failure to provide the Department with
				  fair notice and an opportunity to protect its interest, prior to obtaining a
				  court order limiting the portion of a tort recovery from which MA reimbursement
				  may be paid, constitutes a violation of section 1408(a)(1) of the Public
				  Welfare Code (62 P. S. §
												1408(a)(1)).
(5) The Department is not bound by a private
				  agreement between the parties to a tort claim regarding allocation of the
				  proceeds.
(6) The Department's
				  claims against third parties for reimbursement of MA cannot be released by a
				  beneficiary without the Department's express consent in writing.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 259 - THIRD-PARTY LIABILITY › Section 259.3 - Claims against moneys for which third-parties are liable as a result of a tort claim allocation of tort proceeds in actions filed on or after September 2, 2008-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) With respect to claims asserted by the MA
				  Program against moneys owed by third parties as a result of tort claims
				  asserted by a beneficiary of MA benefits, the Department will only recover from
				  that portion of a tort recovery which represents payment for medical care by
				  the third party. The beneficiary has the burden of informing the Department
				  that its claim must be limited under this subsection and showing not all
				  medical expenses paid by MA were recovered. For purposes of this section, the
				  term "beneficiary" includes both present and former adult and minor recipients
				  of MA benefits, and includes individuals receiving benefits through an MA
				  managed care organization.
(b) If a
				  beneficiary elects not to recover expenses for which medical assistance is
				  provided under section 1409(b)(5) of the Public Welfare Code (62 P. S. §
											1409(b)(5)) then:
(1) The Department will pursue its claim
				  directly against the liable third-party or insurer if it is cost-effective to
				  do so.
(2) The Department will not
				  reduce its claim on account of attorney fees or costs incurred by the
				  beneficiary regardless of any indirect benefit that the Department receives
				  from the beneficiary's prosecution of his claim.
(3) The beneficiary is prohibited from
				  attempting to recover past or future medical expenses that will be paid by
				  MA.
(4) Notice of settlement under
				  section 1409(b)(5)(iv) of the Public Welfare Code shall be provided to the
				  Department.
(5) The election not to
				  recover expenses paid by MA may be revoked by the beneficiary only with the
				  consent of the Department in writing.
(6) The beneficiary shall disclose to the
				  liable third party or insurer that the beneficiary has elected not to recover
				  expenses paid by MA and that the third-party or insurer will remain liable to
				  the Department on the claim.
(7)
				  The beneficiary shall cooperate with the Department's efforts to obtain payment
				  of medical care from any liable third-party or insurer as a condition of
				  eligibility for MA in accordance with §
											259.5 (relating to cooperation in
				  obtaining payment from third-parties-statement of policy)
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 259 - THIRD-PARTY LIABILITY › Section 259.4 - Settlements without litigation-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) With respect to claims asserted by the MA
				  Program against moneys owed by third parties as a result of tort claims
				  asserted by a beneficiary of MA benefits, the Department will only recover from
				  that portion of a tort settlement which represents payment for medical care by
				  the third party. The beneficiary has the burden of informing the Department
				  that its claim must be limited under this subsection and showing not all
				  medical expenses paid by MA were recovered. For purposes of this section, the
				  term "beneficiary" includes both present and former adult and minor recipients
				  of MA benefits, and includes individuals receiving benefits through an MA
				  managed care organization.
(b) If a
				  beneficiary settles a tort claim without litigation, the settlement includes
				  medical expenses paid by MA unless one of the following applies:
(1) The case involves a minor or
				  incapacitated individual and a court enters an order expressly adjudicating the
				  Department's claim after the Department has been given notice and an
				  opportunity to be heard.
(2) The
				  beneficiary is legally incapable of recovering the medical expenses paid by
				  MA.
(3) The beneficiary notifies
				  both the Department and the third party or insurer that the beneficiary's claim
				  does not include medical expenses paid by MA prior to settling the
				  claim.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 259 - THIRD-PARTY LIABILITY › Section 259.5 - Cooperation in obtaining payment from third parties-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A beneficiary
				  has a duty to cooperate with the Department in obtaining payment from third
				  parties and insurers as a condition of eligibility for MA.
(b) If a beneficiary does not cooperate with
				  the Department's efforts to obtain payment of medical care from any third party
				  or insurer, then the Department will determine the beneficiary to be ineligible
				  for MA and pursue an overpayment of MA received after the date of
				  noncooperation. The Department is not limited to recovering from the medical
				  portion of a tort recovery when an overpayment is established.
(c) Cooperation with the Department's efforts
				  to obtain payment of medical care from any third party or insurer includes the
				  following:
(1) Disclosing to the Department
				  that a claim was filed against an insurer or third party.
(2) Identifying and providing information to
				  assist the Department in pursuing a third party who may be liable to pay for
				  medical care and services.
(3)
				  Consenting to the Department's intervention into the beneficiary's pending
				  lawsuit.
(4) Consenting to a
				  reasonable extension of time requested by Department counsel in the
				  case.
(5) Providing Department
				  counsel copies of discovery documents and legal papers filed in the lawsuit
				  upon request.
(6) Disclosing to the
				  liable third party or insurer that the beneficiary has elected not to pursue
				  recovery of expenses paid by MA and the third party or insurer will remain
				  liable to the Department on the claim.
(7) Not agreeing to indemnify or release the
				  liable third party or insurer from the Department's claims.
(8) Providing testimony and evidence in
				  support of the Department's claim.
(9) Providing notices required under section
				  1409(b)(5) of the Public Welfare Code (62 P. S. §
												1409(b)(5) in compliance
				  with this section.
(10) Including
				  medical expenses paid by MA in a claim or lawsuit if requested to do so by the
				  Department.
(11) Taking any other
				  action requested by the Department that is necessary to pursue a claim against
				  a third party.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart G - Restitution and Reimbursement › Chapter 259 - THIRD-PARTY LIABILITY › Section 259.6 - Civil money penalties-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department may impose a civil money
				  penalty of up to $5,000 per violation upon a person who willfully fails to
				  comply with the obligations imposed under section 1409 of the Public Welfare
				  Code (62 P. S. §
											1409).
(b) The Department may impose a civil money
				  penalty of up to $1,000 per violation upon a person who willfully fails to
				  disclose a material fact regarding third party liability for a beneficiary's
				  injuries.
(c) Persons who are
				  required to disclose information regarding third-party liability to the
				  Department include the beneficiary, any representative of the beneficiary, and
				  any liable third-party or insurer in possession of that information.
(d) "Willfully" means that the person acted
				  intentionally in the sense that the person intended to do the act and was aware
				  of what the person was doing. Proof of evil motive or intent or knowledge that
				  the person's conduct violated the law is not required.
(e) The Bureau of Hearings and Appeals has
				  jurisdiction to hear appeals from the assessment of civil money penalties by
				  the Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart H - Appeal and Fair Hearing › Chapter 275 - APPEAL AND FAIR HEARING AND ADMINISTRATIVE DISQUALIFICATION HEARINGS › Subchapter A - APPEAL AND FAIR HEARING › GENERAL PROVISIONS › Section 275.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and forms, when used in this
						  chapter, have the following meanings, unless the context clearly indicates
						  otherwise:
Appellant
-The applicant or recipient
						  who has requested the hearing and signed the appeal.
Hearing request
-An expression, oral or
						  written, by the client or the person acting for him, such as his legal
						  representative, relative or friend, to the effect that he wants an opportunity
						  to present his case to higher authority.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart H - Appeal and Fair Hearing › Chapter 275 - APPEAL AND FAIR HEARING AND ADMINISTRATIVE DISQUALIFICATION HEARINGS › Subchapter A - APPEAL AND FAIR HEARING › GENERAL PROVISIONS › Section 275.4 - Procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Requesting a hearing.
The following procedures will be
						employed in requesting a hearing:
(1)
Aid to clients making appeals.
The County Assistance Office or
						administering or provider agency will provide whatever help the
						applicant/recipient needs in requesting a hearing. This may include the
						following:
(i) Clearly explaining the basis
						for questioned decisions or actions.
(ii) Explaining the rights and fair hearing
						proceedings of the applicant/recipient.
(iii) Providing the necessary forms and
						explaining to the applicant/ recipient how to file his appeal and, if
						necessary, how to fill out the forms.
(iv) Advising the applicant/recipient that he
						may be represented by an attorney, relative, friend or other spokesman and
						explaining that he may contact his local bar association to locate the legal
						services available in the county.
(v) For food stamps, upon request, making
						available without charge case record materials relevant to the decision or
						action of the agency which are necessary for a household or its representative
						to determine whether a hearing should be requested or to prepare for a hearing.
						If the individual making the request speaks a language other than English and
						requires an interpreter pursuant to
						7 CFR
						272.4(c)(3), the agency
						shall provide bilingual staff or interpreters to explain the hearing procedures
						in that language.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart H - Appeal and Fair Hearing › Chapter 275 - APPEAL AND FAIR HEARING AND ADMINISTRATIVE DISQUALIFICATION HEARINGS › Subchapter B - ADMINISTRATIVE DISQUALIFICATION HEARINGS › GENERAL PROVISIONS › Section 275.11 - General policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Office
						of Hearings and Appeals is responsible for conducting administrative
						disqualification hearings for individuals alleged to have committed an
						intentional program violation as defined under §§
												255.2 and
						501.1 (relating to definitions;
						and general provisions), which incorporates
						7 CFR
						273.16(c) (relating to
						disqualification for intentional program violation), when one of the following
						exists:
(1) The Office of Inspector General
						did not refer the case to the criminal court system.
(2) The Office of Inspector General referred
						the case to the criminal court system and the district attorney declined to
						prosecute.
(3) The Office of
						Inspector General referred the case to the criminal court system and the court
						took no action within a reasonable period, resulting in case withdrawal by the
						Office of Inspector General.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart H - Appeal and Fair Hearing › Chapter 275 - APPEAL AND FAIR HEARING AND ADMINISTRATIVE DISQUALIFICATION HEARINGS › Subchapter B - ADMINISTRATIVE DISQUALIFICATION HEARINGS › GENERAL PROVISIONS › Section 275.12 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this
						  subchapter, have the following meanings, unless the context clearly indicates
						  otherwise:
Director
-The head of the Office of
						  Hearings and Appeals who will affirm, amend, reverse or remand the hearing
						  officer's decision in an administrative disqualification hearing.
Good cause
-The term includes serious
						  illness, accident, death or physical or mental handicap making it unreasonable
						  for the individual to be present at the hearing.
Hearing officer
-A person designated by
						  the Department to conduct administrative disqualification hearings and render
						  decisions.
Hearing record
-An official record
						  containing the testimony recorded at the proceeding, and the exhibits, papers
						  and requests filed in the proceeding.
Individual
-A person alleged to have
						  committed an intentional program violation.
Intentional program violation
-An
						  action by an individual as defined under §§
												255.2 and
						  501.1 (relating to definitions;
						  and general provisions) which incorporates
						  7 CFR
						  273.16(c) (relating to
						  disqualification for intentional program violation).
Office of Inspector General
-The agency
						  within the Executive Office of the Governor designated to pursue cases of
						  intentional program violations.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart H - Appeal and Fair Hearing › Chapter 275 - APPEAL AND FAIR HEARING AND ADMINISTRATIVE DISQUALIFICATION HEARINGS › Subchapter B - ADMINISTRATIVE DISQUALIFICATION HEARINGS › HEARING REQUIREMENTS › Section 275.22 - Combining a fair hearing and an administrative disqualification hearing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
						may combine a fair hearing, as described under Subchapter A (relating to appeal
						and fair hearing), and an administrative disqualification hearing into one
						hearing if the issues originate from the same or related circumstances. The
						budget group/household will receive at least 30 days notice that the Department
						will combine the hearings.
(b) The
						Department will apply the regulations under this subchapter when the hearings
						are combined.
(c) If the Department
						combines the hearings to adjudicate the claim amount and to adjudicate whether
						an intentional program violation occurred, the budget group/household will not
						be entitled to a subsequent fair hearing on the claim amount.
(d) One hearing officer, as designated by the
						Office of Hearings and Appeals, may preside over the combined fair and
						administrative disqualification hearing.