Page images
PDF
EPUB

is remanded, the Secretary may thereupon make new or modified findings of fact, and may modify his previous determination. The Secretary shall certify to the court the transcript and record of the further proceedings. The judgment of the court is subject to review by the Supreme Court of the United States upon certiorari or certification as provided in 28 U.S.C. 1254.

Subpart B-Review and Audits

§ 201.10 Review of State and local administration.

(a) In order to provide a basis for determining that State agencies are adhering to Federal requirements and to the substantive legal and administrative provisions of their approved plans, the Service conducts a review of State and local public assistance administration. This review includes analysis of procedures and policies of State and local agencies and examination of case records of individual recipients.

(b) Each State agency is required to carry out a continuing quality control program primarily covering determination of eligibility in statistically selected samples of individual cases. The Service conducts a continuing observation of these State systems.

(c) Adherence to other Federal requirements set forth in the pertinent titles of the Act and the regulations in this title is evaluated through review of selected case records and aspects of agency operations. § 201.11

Personnel merit system review.

A personnel merit system review is carried out by the Office of State Merit Systems of the Office of the Assistant Secretary for Administration of the Department. The purpose of the review is to evaluate the effectiveness of the State merit system relating to the public assistance programs and to determine whether there is compliance with Federal requirements in the administration of the merit system plan. See Part 70 of this title.

[blocks in formation]

audits are made to determine whether the State agency is being operated in a manner that

(1) Encourages prudent use of program funds, and

(2) Provides a reasonable degree of assurance that funds are being properly expended, and for the purposes for which appropriated and provided for under the related Act and State plan, including State laws and regulations.

(b) Reports of these audits are released by the Audit Agency simultaneously to program officials of the Department, and to the cognizant State officials. These audit reports relate the opinion of the Audit Agency on the practices reviewed and the allowability of costs audited at the State agency. Final determinations as to actions required on all matters reported are made by cognizant officials of the Department.

§ 201.13 Action on audit and review findings.

(a) If the audit results in no exceptions, the State agency is advised by letter of this result. The general course for the disposition of proposed exceptions resulting from audits involves the submittal of details of these exceptions to the State agency which then has an opportunity to concur in the proposed exceptions or to assemble and submit additional facts for purposes of clearance. Provision is made for the State agency to appeal proposed audit exceptions in which it has not concurred and which have not been deleted on the basis of clearance material. After consideration of a State agency's appeal by the Administrator, the Service advises the State agency of any expenditures in which the Federal Government may not participate and requests it to include the amount as adjustments in a subsequent statement of expenditures. Expenditures in which it is found the Federal Government may not participate and which are not properly adjusted through the State's claim will be deducted from subsequent grants made to the State agency.

(b) If the Federal or State reviews reveal serious problems with respect to compliance with any Federal requirement, the State agency is required to correct its practice so that there will be no recurrence of the problem in the future.

PART 202-[RESERVED]

PART 203-DEPRIVATION OF PARENTAL SUPPORT OR CARE § 203.1 Condition of plan approval; bases for determining eligibility of a child.

(a) A State plan for aid and services to needy families with children under part A of title IV of the Social Security Act, to be approved under section 402 of such Act (42 U.S.C. 602), must provide that the determination whether a child has been deprived of parental support or care by reason of the death, continued absence from the home, or physical or mental incapacity of a parent, or (if the State plan includes such cases) the unemployment of his father, will be made only in relation to the child's natural or adoptive parent, or in relation to a child's stepparent who is ceremonially married to the child's natural or adoptive parent and is legally obligated to support the child under State law of general applicability which requires stepparents to support stepchildren to the same extent that natural or adoptive parents are required to support their children.

(b) The inclusion in the family, or the presence in the home, of a "substitute parent" or "man-in-the-house" or any individual other than one described in paragraph (a) of this section is not an acceptable basis for a finding of ineligibility or for assuming the availability of income by the State. As provided in Interim Policy Statement No. 4 (33 F.R. 10230, July 17, 1968), items 3.C.2 (i) and (iii), and 6(ii), in the consideration of all income and resources in establishing financial eligibility and the amount of the assistance payment, only such net income as is actually available for current use on a regular basis will be considered, and the income only of the parent described in paragraph (a) of this section will be considered available for children in the household in absence of proof of actual contributions.

(c) Any State whose past policies and procedures with respect to the determination referred to in paragraph (a) of this section have been inconsistent with the provisions in paragraph (a) or (b) of this section must provide effective methods for giving notice of its present policies

and procedures to former and potential applicants for and recipients of AFDC and to other interested persons. The methods which the State agency proposes to meet this notice requirement must be submitted to and be approved by the Regional Commissioner, SRS, DHEW. In addition, where the records of the State agency permit identification of persons whose cases have been terminated or applications denied at any time within the past 2 years by reason of such inconsistent policies or procedures, the State agency must give prompt written notification to such persons concerning the change in such policies or procedures. Such notification must be given within 90 days of publication of the regulations in this part and must explain clearly the rights which such persons have under the regulations in this part.

(Sec. 1102, 49 Stat. 647, sec. 402, 49 Stat. 627; 42 US.C. 1302, 602) [38 FR. 11290, Aug. 8, 1968]

[blocks in formation]

(b) Federal financial participation. Federal financial participation is available in:

(1) Cost for services of lawyers, under the adult categories to represent welfare clients in fair hearings, at the 75 percent rate, if the State has an approved services plan for the adult categories. The 50 percent rate would be applicable if the State has no approved plan for services in the adult categories.

(2) Cost for services of lawyers, under Title IV, Part A, to represent clients in fair hearings, at the 85 percent rate to July 1, 1969, and at the 75 percent rate thereafter.

(

(3) Cost for legal services at the applicable rate for clients pursuing judicial review of a fair hearing decision.

[84 FR. 1144, Jan. 24, 1969, as amended at 35 F.R. 10591, June 30, 1970]

§ 205.20 Methods for determination of eligibility.

Under the Social Security Act, State plans for public assistance must provide such methods of administration as are found by the Secretary to be necessary for the proper and efficient operation of the plan. In determinations and redeterminations of eligibility for assistance, and for the amount of assistance, this requires methods directed to the following objectives: Payment of assistance to all individuals who are eligible and denial of assistance to all individuals who are not eligible; procedures which are simple, efficient and economical, allowing the most effective use of limited personnel; and full respect for the rights and dignity of applicants for, and recipients of assistance. The regulations in this section are directed to these purposes.

(a) Requirements for State plans. A State plan for OAA, AFDC, AB, APTD, AABD, and MA must provide that:

(1) Effective no later than July 1, 1969, a simplified method for the determination of eligibility must be used on a test basis in selected local units encompassing a significant percentage of the caseload, representative of the existing State public assistance programs from the standpoint of staff, applicants and recipients, and other significant characteristics which will assure an adequate demonstration of the method. At least one of the local units will be an urban area.

(2) Effective July 1, 1970, with respect to OAA, AB, APTD, and AABD:

(i) The simplified method for determination of eligibility will be used for applications for and redeterminations of assistance.

(ii) The State will use the simplified method on a progressive basis and will increase the number of areas in the State using the system on a planned schedule which will achieve State-wide operation no later than July 1, 1971.

(iii) The State will develop a plan to be carried out over a period ending July 1, 1973, which shall be directed to:

(a) Simplification of eligibility and procedural requirements.

(b) Simplification of forms.

(c) Modernization of the payment mechanism.

(d) Appropriate training and utilization of staff.

(e) Use of the State Technical Consultation Panel.

A regulation will be issued, with prospective effective date, regarding Statewide use of the simplified method in AFDC and MA, when the Secretary determines that the results from the test in those programs support the overall effectiveness of the method on permanent basis.

(3) When under the simplified method, statements of the applicant or recipient are incomplete, unclear, or inconsistent, or where other circumstances in the particular case indicate to a prudent person that further inquiry should be made, and the individual cannot clarify the situation, the State agency will be required to obtain additional substantiation or verification. In such instances, verification is obtained from the individual or the agency's records or from the public records, or with the individual's knowledge and consent, from another source. The simplified method does not apply to eligibility factors for which Federal law or policies require procedures beyond obtaining a client's statement, such as requirements for a professional examination to determine whether an individual is blind, for a professional determination regarding permanent and total disability, for a determination of whether training or employment was refused for "good cause." The simplified method does not exclude the use of data exchange for information about receipt of social security with the Social Security Administration.

(4) Procedures are adopted which are designed to assure that recipients make timely and accurate reports of any change in circumstances which affect their eligibility for assistance or its amount.

(5) When there is evidence that fraud has been practiced in order to obtain assistance, the case must be referred to the appropriate law enforcement official, in accordance with Federal requirements. The agency's method of investigating in

stances of suspected fraud must respect the legal rights of individuals.

(6) An initial progress report shall be submitted to the Department of Health, Education, and Welfare at the end of the first quarter. This report shall provide information as requested on the progress of the demonstration or implementation of the method including findings on eligibility, ineligibility and extent of entitlement. (For continuing reports, see definitions, paragraph (c) (5) (ii) of this section.)

(b) Evaluation. The Secretary of Health, Education, and Welfare shall appoint a National Evaluation Committee composed of prominent citizens representing industry, education, labor, welfare recipients, and other groups who shall review, periodically, results of the operation of the system and recommend to the Secretary any changes considered necessary to improve the method and to assure proper and efficient administration.

(c) Definitions. The simplified method means an organized method by which the agency accepts the statements of the applicant for, or recipient of assistance, about facts that are within his knowledge and competence (all facts except those specified in paragraph (a)(3) of this section) as a basis for decisions regarding his eligibility and extent of entitlement. The method includes:

(1) Use of a simplified form for application and redetermination which:

(i) Will provide for the information necessary for the determination of eligibility and extent of entitlement under the State plan;

(ii) Will contain appropriate and conspicuous notice to applicants and recipients, informing them of the penalties for fraud;

(iii) Will be reviewed and approved as specified by the Department of Health, Education, and Welfare after the pretest and at the time of any significant revision;

(2) A testing of the simplified form for initial and redetermination of eligibility prior to full implemetation. The testing includes an item-by-item review designed to discover and correct ambiguous language, to ensure that the information requested is relevant, and to ensure that the form has logical sequence. The pretest should show whether

applicants and recipients understand what information is being sought and why.

(3) Validation which relates to the procedures adopted in the initial testing of the correctness of the eligibility decisions. The validation process consists of a full field review of samples of local agency case actions made under the simplified method, to determine how reliable the entire method is in actual operation.

(4) Establishment of a State Technical Consultation Panel consisting of interested individuals, including persons from business, labor, universities and assistance recipients. The Panel will carry out a continuous and periodic evaluation of the method, to assure that the method is consistent with proper and efficient administration and contributes to achievement of the objectives of the program.

(5) A method of continuing review on a sampling basis (Quality Control) designed to operate as an effective measurement of the accuracy of decisions on eligibility and extent of entitlement. The sampling design in the simplified method required by the Department of Health, Education, and Welfare will:

(i) Be of sufficient size to identify weaknesses which need correction and to obtain reliable statistical measures of incorrect eligibility decisions in total State caseloads as well as in the caseloads of large urban agencies within the State. To facilitate these objectives, the field investigation in the sample cases is 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

50-100-71

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]

§ 205.70 Availability of agency program manuals.

State plan requirements. A State plan under title I, IV-A, IV-B, X, XIV, XVI, or XIX of the Social Security Act must provide that:

(a) Program manuals and other policy issuances which affect the public, including the State agency's rules and regulations governing eligibility, need and amount of assistance, recipient rights and responsibilities, and services offered by the agency, will be maintained in the State office and in each local and district office for examination on regular workdays during regular office hours by individuals, upon request for review, study, or reproduction by the individual.

(b) (1) A current copy of such material will be made available without charge for access by the public through custodians who (i) request the material for this purpose, (ii) are centrally located and publicly accessible to a substantial number of the recipient population they serve, and (iii) agree to accept responsibility for filing all amendments and changes forwarded by the agency.

(2) Under this requirement the material, if requested, must be made available without charge to public or university libraries, the local or district offices of the Bureau of Indian Affairs, and welfare or legal services offices or organizations. The material may also be made available, with or without charge, to other groups and to individuals. Wide availability of agency policy materials is recommended.

(c) Upon request, the agency will reproduce without charge the specific policy materials necessary for an applicant or recipient, or his representative, to determine whether a fair hearing should be requested or to prepare for a fair hearing; and will establish policies for reproducing policy materials without charge, or at a charge related to cost,

[blocks in formation]

§ 211.1

General definitions.

When used in this part:

(a) "Act" means Public Law 86-571, approved July 5, 1960, 74 Stat. 308, entitled "An Act to provide for the hospitalization, at Saint Elizabeths Hospital in the District of Columbia or elsewhere, of certain nationals of the United States adjudged insane or otherwise found mentally ill in foreign countries, and for other purposes";

(b) The term "Secretary" means the Secretary of Health, Education, and Welfare;

(c) The term "Department" means the Department of Health, Education, and Welfare;

(d) The term "Director" means the Director of the Bureau of Family Services of the Welfare Administration, Department of Health, Education, and Welfare;

« PreviousContinue »