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Pennsylvania Code



101.1.    Policy.
101.2.    Definitions.
101.5.    Forms.

Cross References

   This chapter cited in 55 Pa. Code §  121.1 (relating to policy).

§ 101.1. Policy.

 (a)  Scope. The policies, procedures and standards for determining eligibility, the amount of the grant and for making payments for all types of assistance administered by the Department are included in this part. The types of assistance are TANF, General Assistance and State Blind Pension. Social services in Public Assistance, medical care, including nursing home care, burial and employment are also included.

   (1)  Although the TANF Program replaces the AFDC Program, most of the rules and procedures under which the Department administered AFDC, including those for the job opportunities and Basic Skills (JOBS) Training Program, will continue in effect as part of the new TANF Program.

   (2)  The references to AFDC found within this title are to be read and considered as applicable to the TANF Program or to a TANF applicant or recipient, unless doing so would be inconsistent with the TANF requirements or with this section.

 (b)  County Assistance Office informational responsibilities. The County Assistance Office (CAO) will provide information on public assistance services and programs, ongoing, new and revised, to public assistance client groups and individuals, and the community of which they are a part. Feasible methods of communication will be used to carry out this informational function effectively.

 (c)  Purpose of the welfare system. The purposes of the welfare system are as follows:

   (1)  The broad general purpose of the Office of Income Maintenance of the Department, as set forth in Article IV of the Public Welfare Code (62 P. S. § §  401—488), is to provide assistance to the needy and distressed, to enable them to maintain for themselves and their dependents a decent and healthful standard of living, and to do this in such a way as to promote self-respect, rehabilitation, and, if possible, self-dependency.

   (2)  The main purpose of the system is as follows:

     (i)   To improve delivery of social services and financial assistance to eligible persons.

     (ii)   To assure the right of a person to claim and receive assistance, without any conditions, implied or specified, beyond established eligibility requirements.

     (iii)   To make the best possible use of staff, time, skills, money and other resources to implement the mandates, philosophy, programs and functions of the Department.

     (iv)   To provide access to responsive social and rehabilitative services, to prevent the breakdown of individual and family functioning, to help solve the problems of troubled and dependent families and individuals and when possible to help restore these persons to independent living.

     (v)   To enable the local welfare administration to provide strong leadership to the community in identifying the causes and effects of dependency, ill health and maladjustments, in identifying unmet human needs and in stimulating community action toward solution of the problems.

     (vi)   To demonstrate respect for the ability of the client to communicate information about his needs, resources and other eligibility factors, when given a reasonable opportunity.

     (vii)   To implement the belief of the Department in the dignity, rights, freedoms and entitlements of the client.

 (d)  Purpose of TANF. TANF has the following purposes:

   (1)  TANF is intended to provide money for dependent children who are in need because support from the usual source, parents, is not available. The money will be provided so that these children may live in family homes with their own parents, or with certain relatives who take the place of parents. Thus, it is the purpose of the TANF Program to prevent a child from being forced to be away from his own family for economic reasons alone. TANF recognizes the importance to a child of his own home and family relationships.

   (2)  TANF is a time-limited money payment to an adult on behalf of children because the program recognizes the child needs an adult to look after him. The parents are the persons who have the right and obligation to rear, care for, support and make major decisions for the child. Usually, it is a parent who applies for assistance. Whichever one applies, both share responsibility for the child, and the other parent should, if possible and advisable, have some part in the decision on going through with an application for assistance. For parents who are living together, this means a joint application. For other parents, this means clarifying the role of the absent parent in support and care of the child.

   (3)  If a relative other than a parent applies, the reasons for the shift in parental responsibility need to be explored. There must be clarity as to who will be responsible for the child in his every-day living, and who will take responsibility for deciding on his living arrangements. Unless a parent is dead, his whereabouts unknown, or other circumstances make it inadvisable, he should always have some part in an application for assistance.

 (e)  Medical care programs. The following provisions shall apply to medical care programs:

   (1)  Persons in need of assistance are those persons who have applied for and have been found eligible for a money payment from the Office of Income Maintenance, and those persons who have been financially eligible but are not eligible for a money payment because they do not meet State regulations. However, under Title XIX of the Social Security Act (42 U.S.C.A. § §  1396—1396q) these persons are eligible for the same vendor payments for the medical care that is provided persons actually receiving a money payment.

   (2)  The Department will have responsibility for establishing the scope, standards, regulations, procedures and fees for medical care provided for the following:

     (i)   Categorically needy persons who are eligible for the full medical program, that is, for persons financially eligible who do or do not receive money payments depending on whether or not they meet other points of eligibility.

     (ii)   Medically needy persons who receive limited medical assistance because their incomes are insufficient to pay for major medical expenses although sufficient for their everyday necessities.

   (3)  The purpose of medical care programs for school children is to meet the cost of treatment a child needs for a condition recorded in the school health record of the child, and for which the parents or guardian of the child are unable, according to law and regulations, to pay.

   (4)  The County Assistance Office will have responsibility for administering the medical care programs on the local level within Departmental regulations, and subject to review and supervision by the State Office.

   (5)  In accordance with public assistance regulations and fee schedules, the Department will make direct payments to practitioners and vendors for services, medications and medical supplies provided. This system is necessary because medical needs are extremely varied and unpredictable, requiring an individualized and flexible way of meeting these needs. The practitioner and vendor shall send bills to the Office of Medical Assistance for services provided.

   (6)  Payment for health items as the usual household medicine chest supplies and items of personal care will not be included in the system of practitioner and vendor payments because these items constitute a common, predictable, continuing need. Therefore, an amount of money to meet this need will be included in the money payment to the recipient, in the determination of eligibility of the need amount to the nonmoney payment recipient, and in the evaluation of resources of a medically needy school child.

 (f)  Medical care programs and the State Office. The following provisions relate to the relationship between the State Office and medical care programs:

   (1)  In the administration of the medical programs, the responsibilities of the State Office are will be follows:

     (i)   To establish standards, regulations and fees governing medical care of a quality acceptable to competent authorities in their respective medical fields.

     (ii)   To obtain maximum cooperation from practitioners in providing quality services for assistance recipients and other medically needy persons, as economically as possible with due regard for essential needs of the patients and a fair return to the practitioner.

     (iii)   To make maximum use of existing medical and allied re-sources available to medically needy persons.

     (iv)   To promote coordination of the medical programs with other Statewide health programs.

     (v)   To secure the advice of the health professions through the public assistance medical care committee, and encourage each County Assistance Office to establish a county medical committee.

   (2)  The State Office of Medical Assistance, undertaking to provide medical care for eligible persons through a system of direct payments to practitioners and vendors, is in effect a nonmedical agency purchasing the services of individual members of medical and allied professions throughout this Commonwealth.

   (3)  In administering the medical care program, circumstances occasionally arise indicating that certain practitioners may not be observing the regulations of the Department on giving services or invoicing for services, or may possibly be providing inferior, inadequate or incorrect medical care. Under such circumstances, an investigation will be initiated and, if the facts warrant, consideration will be given to disciplinary action against the practitioner.

 (g)  County medical and dental consultants. County medical and dental consultants shall conform with the following:

   (1)  To supplement and enhance the professional help available from the county medical care committee, the County Assistance Office has on its staff a medical and a dental consultant. These consultants do not substitute for or replace the committee. They may or may not be members of the committee, but it is desirable that the functions of the members of the committee, who are advisers on broad policies, be kept separate from the functions of the consultants.

   (2)  The primary function of the consultant is to provide professional advice on individual cases as needed. He shall work directly with staff on services to individual clients, on specific medical or dental problems, and the like. The consultant shall also have functions in staff development and in liaison with medical, dental and allied professions.

   (3)  The consultant shall act in an advisory or consultative capacity to the county assistance administration; he shall not administer the public assistance medical or dental programs. The county assistance administration retains authority for accepting or rejecting the recommendations of the consultant, for the agency is legally responsible for final administrative decisions.

   (4)  The consultants are under the general administrative direction of the County Assistance Office. The medical consultant is under the professional direction of the medical director of the Office of Public Assistance. The dental consultant is under the professional direction of the State Office Bureau of Medical Services which has a Dental Consultant.


   The provisions of this §  101.1 amended under sections 201(2) and 403 of the Public Welfare Code (62 P. S. § §  201(2) and 403).


   The provisions of this §  101.1 (as amended by PRWORA) amended July 28, 2000, effective retroactive to March 3, 1997, 30 Pa.B. 3779. Immediately preceding text appears at serial pages (247229) to (247233).

Notes of Decisions

   The denial of benefits to an applicant because of her failure to apply for the railroad retirement benefits of her late husband serves to further the purpose of the welfare system, since the applicant is not a ‘‘needy’’ person which the program is designed to assist, and assistance is intended to supplement, not to replace, the resources of an individual. Armlovich v. Department of Public Welfare, 411 A.2d 893 (Pa. Cmwlth. 1980).

§ 101.2. Definitions.

 The following words and terms, when used in this part, have the following meanings, unless the context clearly indicates otherwise:

   AAA—Area Agency for the Aging.

   AC—Application Control.

   ACE—Active Corps of Executives.

   AD—Assistance Disbursement.

   AFDC—The Aid to Families with Dependent Children Program, replaced by the TANF Program effective March 3, 1997.

   AII—Aged Individual.

   ARA—Area Redevelopment Administration (AR)—Occupational Training.

   ASC—Aged Spouse.

   BDP—Bureau of Data Processing.

   BES—Bureau of Employment Security.

   BII—Blind Individual.

   BP—Blind Pension.

   BP-B—State Blind Pension.

   BSC—Blind Spouse.

   BVR—Bureau of Vocational Rehabilitation.

   CAO—County Assistance Office.

   CBA—County Board of Assistance.

   CETA—Comprehensive Employment and Training Act.

   CF—Aid to Families with Dependent Children—Foster Care.

   CHAMPUS—Civilian Health and Medical Program of the UniformedServices.

   CID—County Institution District.

   CRS—Catholic Relief Services.

   CS—Claim Settlement.

   CSB—Claim Settlement Bureau.

   CU—Unemployed Father.

   CWS—Child Welfare Service.

   CWT—Community Work and Training Act.

   DC—Domiciliary Care.

   DCF—Disabled Child with Father.

   DCM—Disabled Child with Mother.

   DCP—Disabled Child with Parents.

   DDS—Direct Delivery System.

   DHS—Department of Human Services.

   DII—Disabled Individual.

   DRO—Domestic Relations Office.

   DSC—Disabled Spouse.

   Department—Department of Human Services.

   EA—Emergency Assistance.

   ETP—Employment and Training Program.

   FCI—Food, Clothing, and Incidentals Program.

   FNS—Food Nutrition Service.

   FSBP—Federal State Blind Pension.

   GA—General Assistance.

   GC—General Control.

   GED—General Educational Development.

   HEW—Federal Department of Health, Education and Welfare.

   HMO—Health Maintenance Organization.



   IM—Income Maintenance.

   IMU—Income Maintenance Unit.

   INS—Immigration and Naturalization Service.

   IRS—Internal Revenue Service.

   JS—Job Service.

   LIAB—Life Insurance Adjustment Bureau.

   LRR—Legally Responsible Relative.

   MA—Medical Assistance.

   MH/MR—Mental Health/Mental Retardation.

   MIL—Minimum Income Level.

   MNO—Medically Needy Only.

   NCE—Noncontinuous Eligibility.

   NCWC—National Catholic Welfare Conference.

   NHC—Nursing Home Care.

   NMP—Nonmoney Payment.

   OAA—Old Age Assistance.

   OASDI—Old Age Survivors and Disability Insurance.

   OES—Office of Employment Security.

   OFS—Office of Family Services.

   OJT—On the Job Training.

   OTI—Out-of-Town Inquiries.

   PA—Public Assistance.

   PC—Aid to Families with Dependent Children—Nonmoney Payment.

   PD—General Assistance—Nonmoney Payment.

   PE—Presumptive Eligibility.

   PJ—Aid to Disabled—Nonmoney Payment.

   PK—Nonmoney Payment—Transitionally Needy.

   PM—Aid to Blind—Nonmoney Payment.

   PSE—Public Service Employment.

   PSES—Pennsylvania State Employment Services.

   QC—Quality Control.

   RR—Railroad Retirement.

   RSDI—Retirement, Survivor’s and Disability Insurance.

   RWP—Relief Works Project.

   SAU—Separate Administrative Unit.

   SBP—State Blind Pension.

   SCORE—Service Corps of Retired Executives.

   SDX—State Data Exchange System.

   SR—Specified Relative.

   SSA—Social Services Administration.

   SSI—Supplemental Security Income.

   SSN—Social Security Number.

   SUB—Supplemental Unemployment Benefits.

   Secretary—Secretary of Human Services.

   TA—Old Age—Medically Needy Only.

   TANF—The Temporary Assistance for Needy Families Program.

   TB—Aid to Blind—Medically Needy Only.

   TC—Aid to Dependent Children—Medically Needy Only.

   TD—General Assistance—Medically Needy Only.

   TJ—Aid to Disabled—Medically Needy Only.

   TK—Medically Needy Only—Transitionally Needy.

   UC—Unemployment Compensation.

   UHIAS—United Hebrew Immigrant Aid Society.

   UMWA—United Mine Workers of America.

   VISTA—Volunteers in Service throughout America.

   VR—Vocational Rehabilitation.

   WIN—Work Incentive Program.


   The provisions of this §  101.4 amended under 201(2) and 403(b) of the Public Welfare Code (62 P. S. § §  201(2) and 403(b)).


   The provisions of this §  101.2 amended October 2, 1992, effective upon publication and apply retroactively to October 1, 1989, 22 Pa.B. 4875; amended July 28, 2000, effective July 29, 2000, 30 Pa.B. 3779. Immediately preceding text appears at serial pages (247233) to (247235).

§ 101.5. Forms.

 (a)  Forms used in the administration of the public assistance program, including those which may be revised or renumbered are available from the Department of Human Services, Management Services, Post Office Box 2675, Harrisburg, Pennsylvania 17105.

 (b)  The following is a list of several forms referred to on this part and their corresponding official designations:

   A-3—Treasury Investigation Form.

   A-4—Treasury Investigation Report Form.

   AG-1—Notice of Exception.

   AG-1 Part I—Identification Factors.

   AG-1 Part II—Eligibility Factors.

   AG-1 Part III—Explanation of Exception.

   CY 931—Certificate of Subsidized Adoption.

   DP 207—Request for Treasury Investigation.

   DHS 6190—Authorization to Sign Document.

   ES 1—Referral and Placement Report.

   ES 350—Applicants’ Record Card.

   IM-2—IM Referral to Vocational Rehabilitation.

   IM-3—Referral for WIN Registration.

   IM-6—AFDC WIN Change Notice.

   IM-9—AFDC WIN Grant Reduction Record.

   MA S-95—WIN Registration Record.

   MA 5-96—WIN Certification Record.

   MA 5-97—WIN Status Change Notice.

   MA 57—Hospital Admission Certification.

   MA 62—Social Information for Permanent and Total Disability.

   MA 215—Letter-Disability Review.

   OA-132—Accounting for Appropriation Advancement Voucher Transmittal.

   OA 275—Authorization of Signature Card.

   PA 1—Application for Assistance.

   PA 1-M—Application-Medical Assistance.

   PA 1-MS—Supplemental Application for Medical Assistance.

   PA 1-S—Supplemental Application for Medical Assistance.

   PA 1-SP—Application for Participation in Food Stamp Program.

   PA 3-R—Property Lien Notice.

   PA 4—Authorization for Information on Resources.

   PA 4-M—Medical Assistance Physician’s Prescription.

   PA 5A—Medical Identification Card (White).

   PA 5-A—Medical Identification Card (Blue).

   PA 5-B—Medical Identification Card (Pink).

   PA 5-C—Medical Identification Card (Green).

   PA 5-M—Certification-Medical Care.

   PA 6-F—Assignment of Insurance.

   PA 6-G—Distribution of Insurance Benefits.

   PA 6-K—Assurance as to Nonchange of Beneficiary.

   PA 6-M—Hospital Admission Certification.

   PA 9—Reimbursement Agreement.

   PA 13—Reference Card and Registration Report.

   PA 21—Face Sheet.

   PA 21-B—Blind Pension Authorization Sheet.

   PA 21-BI—Computation Sheet.

   PA 21-BN—Federal-State Blind Pension Authorization Sheet.

   PA 21-F—Legally Responsible Relatives.

   PA 21-H—Insurance—Burial Resources.

   PA 21-I—BP Property.

   PA 21-M—Computation of Resources Medical Assistance.

   PA 21-MR—Benefit Period Record.

   PA 21-MU—Medical Assistance Verification Summary.

   PA 21-N—NHC Authorization Sheet.

   PA 21-P—Authorization Sheet.

   PA 21-PF—Foster Care Authorization Sheet.

   PA 28—Analysis of Employment Information.

   PA 28-S—Employable Index Card.

   PA 40—Report of Epthamological Examination.

   PA 41—Report of Medical Examination.

   PA 41-D—Report of Medical Examination—Domiciliary Care.

   PA 41-S—Medical Supplement.

   PA 44—Burial Reserve Agreement.

   PA 48—Authorization for Services and Supplies.

   PA 50—Request for Appointment of Guardian, Representative, or Trustee.

   PA 50-P—Agreement (Public Nursing Home Care Program).

   PA 51—Request and Report State Mental Institutions.

   PA 52—Application-Foster Child Care.

   PA 52-C—Notice of Change in Eligibility for Foster Care Payment.

   PA 52-F—Child Welfare Service Agreement.

   PA 52-R—Annual Report-Foster Child Care.

   PA 53—PA Foster Home and Institutional Care Payment Report.

   PA 53-S—Summary Invoice for Foster Home and Institutional Care Payment Report.

   PA 54—Clearance of Mismatches-Enumeration Process.

   PA 57—Institution Agreement.

   PA 60-P—Medical Report Pulmonary.

   PA 61-S—Social Information Supplement.

   PA 62—Social Information for Aid to the Disabled Assistance.

   PA 72—Missing Relative Summary.

   PA 73—Request for Information.

   PA 75—Employer’s File Card.

   PA 76—Request for Financial Information.

   PA 78—Request for Confidential Employment Information.

   PA 79—Request for Legal Information.

   PA 83-Z—Request for Insurance Data.

   PA 84—Request for Information from Unemployment Records.

   PA 84-M—Request for Information Bureau of Motor Vehicles.

   PA 84-R—Authorization and Request for Information Railroad Retirement Board.

   PA 84-V—Request for Verification of Birth.

   PA 84-W—Request for Workmen’s Compensation Information.

   PA 85—Case Message.

   PA 87—Alphabetical Index Card.

   PA 88—Geographical Index File Card.

   PA 89—Cross Reference Card.

   PA 90—Application Control Card.

   PA 90-M—Medical Application Control Card.

   PA 91—Master Index File Information Only Card.

   PA 93—Sample Data Report on Medical Assistance.

   PA 94—Case Record Request.

   PA 95—Caseworker Notice.

   PA 95-N—General Control Notice.

   PA 96—Quality Control Card.

   PA 96-S—Quality Control Card Supplement.

   PA 117—Monthly Report on Medical Exams and Hearing to Determine Exempt Status.

   PA 118—Burial Request-Invoice.

   PA 122—Authorization for Assistance.

   PA 122-E—CBA Disbursement Authorization.

   PA 122-N—Authorization for Nursing Home Care.

   PA 122-PC—Petty Cash Voucher.

   PA 122-R—Authorization to Vendor.

   PA 122 Turnaround—Authorization for Assistance.

   PA 123-E—County Disbursement Notice of Credit.

   PA 124—NMP Authorization Card.

   PA 124-C—NMP Closing Card.

   PA 127—Report of Applications Other than MA (T).

   PA 127-M—Report of Applications Medical Assistance.

   PA 128—Report of Employable Persons.

   PA 153-A—Temporary Recording Sheet.

   PA 157—Report of Exception-County Reply.

   PA 162—Notice to Applicant.

   PA 162-A—Advance Notice.

   PA 162-C—Confirming Notice.

   PA 162-D—Notice to Applicant for Domiciliary Care.

   PA 162-M—Eligibility-Medical Assistance.

   PA 162-S—Discontinuance Authorization.

   PA 163—Request for Address and/or Amount of Assistance.

   PA 173-B—Referral for Support Action.

   PA 173-C—Application for Unadjusted Assistance Grant and Authorization to Pay Support Order Payments to the Department of Human Services.

   PA 173-D—Stipulation to Change Beneficiary.

   PA 173-E—Authorization to Change Beneficiary and to Pay Order and Arrearages to DHS.

   PA 173-F—Notice of Support Referral.

   PA 173-K—Agreement and Authorization to Pay Claim.

   PA 173-M—Medical Assistance Referral for Court Action.

   PA 173-S—Reimbursement Referral.

   PA 176-K—Agreement and Authorization to Pay Claim.

   PA 176-KM—Agreement and Authorization to Pay Medical Assistance Claim.

   PA 176-S—Reimbursement Authorization.

   PA 176-U—Agreement to Pay Claim—Delayed UC Checks.

   PA 184-S—Suggestion of Non-Payment.

   PA 189—Overpayment Referral.

   PA 189-A—Suspected Grant Referral Disposition Notice.

   PA 189-R—Claim Settlement Report on Referral.

   PA 189-X—Overpayment Investigation Control.

   PA 198—Assignment Receipt.

   PA 198-S—Assignment of Interest in Decedent’s Estate.

   PA 205—Notice of Returned Check.

   PA 205-S—Notice of Suspension.

   PA 207—Request for: Investigation of Check and/or Waiver of Investigation of Check.

   PA 207-DP—Authorization Correction Notice.

   PA 210—Referral to County Administrator.

   PA 212—Notice of Appointment with County Administrator.

   PA 213—Progress Report.

   PA 214—Monthly Report of Advancements, Expenditures and Balances Emergency Fund.

   PA 258-N—Request for NHC Payment.

   PA 259—Standard Medical Invoice.

   PA 259-C—Request for Correction of Payment Medical Assistance.

   PA 250-NS—Nursing Invoice.

   PA 259-P—Institutional Care Invoice Certification.

   PA 259-S—Invoice Transmittal.

   PA 260-F—Recommendation by County Review Team.

   PA 293—Child Support Action Notice.

   PA 295—School Medical Referral.

   PA 296—Social Security Number Consent Statement.

   PA 340—Application for Assistance.

   PA 364—Retirement Check Transmittal.

   PA 408—Verification of Social Security Number.

   PA 409—Enumeration—Clerical Control Sheet.

   PA 430—Medical Eligibility Authorization.

   PA 451—Report of Personal Interview.

   PA 653—Notice of Caseworker Change.

   PA 740—Face Sheet.

   PA 742—Income/Change Sheet.

   PA 743—Eligibility Form.

   PA 743-C—Eligibility Form.

   PA 743-R—Eligibility Form.

   PA 743-RE—Eligibility Form.

   PA 743-S—Rights and Responsibilities.

   PA 745—Domiciliary Care Redetermination Report.

   PA 746—Termination State Supplement for Domiciliary Care.

   PA 747—Authorization State Supplement for Domiciliary Care.

   PW 361—Standard Transmittal.

   PW 361-S—Standard Transmittal Supplement.

   PW-SS 205—SSA referral and disposition of services.

   SAU-2—IMU Allowance Request.

   SAU-3—Monthly Referral/Registration Activity.

   SAU-4—SAU Certification Record.

   SRS117A—WIN Certification Report.

   SRS 117B—AFDC WIN Grant Reductions Report.

   SS-5—Application for a Social Security Number.

   SSA-5—Application for Social Security Number.

   SSA 1610—Request for Information from SSA.

   SSA 8036—Notice of SSI Eligibility.

   SSA 8220—SSA State SSI Information Exchange Form.

   UC-46—Status of Overpayment.


   The provisions of this §  101.5 amended July 11, 1986, effective July 12, 1986, 16 Pa.B. 2524. Immediately preceding text appears at serial pages (28853) to (28857) and (96061).



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