135.01 Administrative Appeal Requests and the ANP (AAM)

135.01 Administrative Appeal Requests and the ANP (AAM)

SR 13-12 Dated 9/13 Previous Policy

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If an individual requests an administrative appeal within *15 days from the date on the notice of the termination of APTD cash assistance , continue assistance at the pre-change level pending the appeal decision. If an individual requests an administrative appeal after the *15 days expire, or if there is no advance notice period (ANP), the termination or decrease takes effect on schedule.

Any benefits received during pending appeals is subject to recoupment if the Administrative Appeals Unit (AAU) does not find in favor of the individual.

Exception: Individuals whose APTD cash assistance was denied or terminated because the individual was denied Social Security Administration (SSA)-related benefits because the individual did not meet SSA medical criteria, can only continue to receive cash assistance at the pre-change level pending the AAU decision when the following criteria are met:

• The request for continued receipt of APTD cash assistance pending the appeal is received within 15 days from the date on the notice of the termination of APTD cash assistance; and

• Within that same 15-day period, the individual provides documentation signed and dated by a physician, physician’s assistant (PA), advanced practice registered nurse (APRN), or psychologist which in cludes the printed name of the health professional, the specialty of the health professional, and the address and phone number of the health professional, and states:

- that the individual’s medical condition has increased in severity during the 12 months prior to the date the individual requested the administrative appeal; or

- that the medical condition for which the SSA based the decision to deny the individual SSA benefits is unrelated to the medical information upon which the Disability Determination Unit (DDU) based the decision to approve the individual for APTD benefits.

Note : The statement from the physician, PA, APRN, or psychologist regarding a medical condition increasing in severity must specify the increase happened at some point within the last 12 months prior to the date the individual requested an administrative appeal. If the increasing severity of the medical condition happened over a period of time longer than 12 months, or at some point prior to 12 months, the individual cannot receive continued benefits while pending the appeal.

EXAMPLES : A physician, PA, APRN, or psychologist’s statement indicates that an individual’s medical condition has increased in severity:

• due to an incident which happened 13 months prior to the date the individual filed the administrative appeal. This individual would not be eligible for continued receipt of APTD cash benefits while the individual is waiting for the AAU decision because the incident happened more than 12 months prior to the date the individual filed the administrative appeal.

• over the course of the individual’s illness, which they have been suffering from over the past 5 years. This individual would not be eligible for continued receipt of APTD cash benefits while the individual is waiting for the AAU decision because the increase in severity happened over a period of time longer than 12 months prior to the date the individual filed the administrative appeal.

• 2 days prior to the individual’s submission of the request for an administrative appeal. This individual would be eligible for continued receipt of APTD cash benefits while the individual is waiting for the AAU decision because the incident happened less than 12 months prior to the date the individual filed the administrative appeal.

If the individual fails to provide the documentation above, or the documentation provided does not demonstrate that the requirements have been met, the individual is not eligibility for continued receipt of APTD cash assistance pending the appeal.

If the termination of APTD cash assistance is ultimately overturned at the appeals hearing:

• due to the individual’s medical condition having increased in severity during the 12 months prior to the date the individual requested the administrative appeal, provide the individual 30 days from the date the District Office receives the AAU decision to verify that the individual:

- has appealed the SSA denial; and

- has sent SSA the documentation regarding the increased severity of their medical condition.

• because the medical condition for which the SSA denied SSA benefits is not the medical condition for which the individual was approved APTD cash assistance, provide the individual 30 days from the date the District Office receives the AAU decision to verify that the individual:

- has reapplied for SSA benefits; and

- that the medical condition for which the individual has reapplied for SSA benefits is the same medical condition for which DDU approved the individual for APTD cash assistance.

If the individual fails to provide verification within 30 days, and APTD is then terminated, do not continue APTD cash assistance pending the appeal decision.

Any benefits received during pending appeals is subject to recoupment if the AAU does not find in favor of the individual.