Pennsylvania, PA
 


Rights & Responsibilities
 
Rights & Responsibilities
 
  • I understand that information available through the Income Eligibility Verification System (IEVS) will be requested, used and may be verified through collateral contacts when discrepancies are found by the State agency, and that such information may affect the household’s eligibility and level of benefits. Information from other state and federal agencies will be used to verify the information I give them. If I misrepresent, hide or withhold facts which may affect my eligibility for benefits, I may be required to repay my benefits and I may be prosecuted and disqualified from receiving certain future benefits.
  • I understand that I can designate an authorized representative by completing the Authorized Representative section and submitting it with this application.
  • I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is being submitted by someone acting on my behalf.
  • I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.
  • I understand that the information entered in this application will be kept confidential and only to administer benefits. I authorize the release of personal, financial and medical information for the purpose of determining eligibility.
  • I understand that any changes I am required to report must be reported within the first 10 days of the month following the month of change.
  • I understand that I will receive a written notice explaining the benefits. If benefits are denied, changed, suspended or stopped, the written notice will explain why.
  • I understand that I will have 30 days (90 days for SNAP (food stamp) benefits) from the date of the notice to request a hearing if I do not agree with the decision made on this application.
  • I understand that my situation is subject to verification from employers, financial sources and other third parties.
  • I understand that applicants must provide their Social Security number or apply for one if they do not have one. This number may be used to check the information on this application.
  • I understand that I must use the Electronic Benefit Transfer (EBT) or the PA ACCESS Card only during the period I am eligible. I must use the EBT or the PA ACCESS Card only for the person who is eligible and may get only the benefits that are needed and reasonable.
  • I understand that I may not use TANF funds issued through my PA ACCESS card to make EBT transactions in liquor stores, casinos (gambling casinos, gaming establishments), or places for adult entertainment.
  • I understand that I do not have to provide a Social Security number for anyone who is not applying for assistance. If I do provide their Social Security number, it may be used to check the information on this application.
  • I certify that all information that has been entered is true under penalty of perjury.
  • I understand that I have the right to a certificate of creditable coverage to verify my medical coverage. Federal law limits when health care coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition clause, I can get credit for the time I received Medical Assistance.
  • If I receive cash benefits, I will cooperate with the requirements of the child support enforcement program as directed by the Department. I give the Department and the Domestic Relations Section the right to pursue and collect cash and/or medical support for me and others for whom I am applying.
  • I understand that if I report and provide proof of the household expenses, I will get the maximum amount of SNAP (food stamp) benefits allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproved expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Notice 6-99, issued January 4, 1999).
  • I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (food stamps) certification period.
  • I understand that I have the right to ask the county assistance office (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for confirmation if I am having trouble getting proof of anything
  • I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for CHIP. If this is the case, I authorize the Department of Human Services to give my name and information on this application to a CHIP contractor.
  • I understand that if some or all of the individuals applying do not qualify for health care through the department, that they may be eligible for federal benefits and/or explore private health care options through the Health Insurance Marketplace. If this is the case, I authorize the department to give my name and information on this application to the Marketplace.
Prohibitions and Penalties  Read about your responsibilities:
IF THIS HAPPENS WITHOUT GOOD CAUSE THIS MAY HAPPEN (PENALTY)
ALL BENEFITS
SNAP
CASH
HEALTH CARE
Misuse Electronic Benefits Transfer (EBT) Card or PA ACCESS Card. Fine, prison, or both.
Do not report changes, as required. Benefits cut or stopped.
On purpose, give information that is false, incorrect or incomplete, or not report changes. Fine, disqualification and/or jail time for Welfare Fraud, disqualification for administrative hearing proceedings.
Not eligible for cash:
  • First time - 6 months.
  • Second time - 12 months.
  • Third time - forever.
Not eligible for SNAP:
  • First time - 12 months.
  • Second time - 24 months.
  • Third time - forever.
Trade, sell or attempt to trade, sell, buy or use another person’s ACCESS Card. Not eligible:
  • All court convictions - 12 months.
SNAP On purpose, misuse SNAP benefits, for example, trade, sell, or buy EBT Card or SNAP benefits; convert benefits; or dump containers purchased with SNAP benefits to receive deposits – or buy things not covered by SNAP, such as alcohol or tobacco – or use SNAP benefits to pay for food already received or food on credit. Not eligible:
  • First time - 12 months.
  • Second time - 24 months.
  • Third time - forever.
  • First time court conviction over $500 - forever.
Purchase a product with SNAP benefits with the intent of obtaining cash or consideration other than eligible food by reselling the product in exchange for cash or consideration other than eligible food.
On purpose, purchase products originally purchased with SNAP benefits in exchange for cash or consideration other than eligible food.
Use/receive SNAP benefits to buy drugs or controlled substances.

Not eligible:

  • First time - 24 months.
  • Second time - forever.
Use/receive SNAP benefits in sale of firearms, ammunition, or explosives. First time - not eligible forever.
Be convicted for buying, selling or trading SNAP benefits for total of $500 or more. Not eligible forever.
Lie about who you are or where you live to receive more than one SNAP benefit. Not eligible for 10 years.
Flee to avoid prosecution, custody, or confinement because of a felony/attempted felony – or flee because of breaking probation or parole. Not eligible until you do what the law says.
CASH Do not comply with your court penalty, including payment of fines, for a felony or misdemeanor. Not eligible until you comply with your penalty.
Lie about where you live to receive cash in two or more states. Not eligible for 10 years.
Flee to avoid prosecution, custody, or confinement because of a felony conviction/attempted felony; fail to appear as a defendant at a criminal court proceeding when issued a summons or a bench warrant for a summary offense, felony or misdemeanor; flee because of breaking probation/parole; or have any active warrant against you. Not eligible until you do what the law says.
SNAP WORK RULES For household members – physically and mentally fit – over age 15 and under 60 – not otherwise exempt or with good cause. Not eligible:
  • First time - one month and until you do what is required.
  • Second time - three months and until you do what is required.
  • Three or more times - six months each time and until you do what is required.
Refuse to:
  • Participate in approved work/training program.
  • Accept a job.
  • Tell CAO about work status and job availability.
On purpose, take action to:
  • Quit a job.
  • Cut work hours to less than 30 per week (unless another job already meets work requirements).
CASH WORK RULES Do not meet cash work requirements on purpose, as written on the Agreement of Mutual Responsibility (AMR). Not eligible:
  • First time - You will be ineligible for at least 30 days and until you demonstrate and maintain compliance for at least one week. If you are disqualified for 90 days, your entire family will be disqualified until you demonstrate and maintain compliance for at least one week.
  • Second time - You will be ineligible for at least 60 days and until you demonstrate and maintain compliance for at least one week. If you are disqualified for 60 days, your entire family will be disqualified until you demonstrate and maintain compliance for at least one week.
  • Third time - Forever.
CHIP
 
You have a right to:
  • Confidentiality — All information on this application will be kept confidential. This application will be shared only with the government programs for which you apply and/or may be eligible, such as Medical Assistance and Health Insurance Marketplace premium assistance
  • Designate a Personal Representative - You may select another person to receive health related information regarding you or your minor child(ren) by completing a Personal Representative Designation form.
  • Certificate of Creditable Coverage - When you leave the program, you will receive a certificate of creditable coverage to verify medical coverage, if you are eligible.
  • Written Notice - You will be given a written notice explaining your eligibility.
  • Appeal - You may request an impartial review if you do not agree with any decision made regarding this application, if the request is made within 30 days of the decision.
You have a responsibility to:
  • Read and fully understand this application.
  • Provide true, correct and complete information, understanding that there are penalties for knowingly giving false information: it is a serious offense and considered criminal insurance fraud.
  • Help with the review of this application, which may include interviews and reviewing health records.
  • Be aware that certain information may be subject to verification from employers, financial sources and other third parties.
  • Provide proof of identity and U.S. citizenship if that information is not obtained through this application process.
  • Provide proof of legal immigration status by presenting documentation from the U.S. Citizenship and Immigration Services if you are applying for someone who is not a U.S. Citizen.
  • Report all changes regarding your household including income, address and telephone number as soon as they occur.
I understand:
  • If some or all of the individuals applying do not qualify for CHIP, that they may be eligible for Medical Assistance. If this is the case, I authorize the CHIP Contractor to give any and all information found on this application to the Department of Human Services. I understand my rights and responsibilities under Medical Assistance.
  • If some or all of the individuals applying do not qualify for CHIP, that they may be eligible for federal benefits and/or explore private health care options through the Health Insurance Marketplace. If this is the case, I authorize the Department to give any and all information on this application to the Marketplace. I understand my rights and responsibilities under the Health Insurance Marketplace.
  • If it is determined that my child is eligible for or enrolled in state employees’ health care benefits from a public agency and the agency would pay even a small portion of the benefit or premium cost, then my child is not eligible for CHIP. If this is the case and my child has been receiving CHIP benefits, my child’s CHIP benefits may be retroactively terminated.
Health Insurance Marketplace
 
  • I certify that all information that has been entered is true under penalty of perjury. I know that I may be subject to penalties under federal law if I knowingly provide false and/or untrue information.
  • I know that I must tell the Health Insurance Marketplace if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household.
  • I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting hhs.gov
  • I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed).
  • Renewal of coverage in future years: To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.
All Health Care Programs
 
  • I certify that, to the best of my knowledge, I understand my rights and responsibilities and that the information included in this application is complete and true under penalty of perjury. I also certify that knowingly providing false or incomplete information on this application is insurance fraud.
  • I understand that I can designate an authorized representative by completing the Authorized Representative section and submitting it with this application.
  • I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is submitted by someone acting on my behalf.
  • I understand that all individuals applying will be provided access to coverage under the program for which they are eligible, if they are found eligible for Medical Assistance, CHIP or federal benefits through the Health Insurance Marketplace premium assistance.
  • I will allow the Department of Human Services to give my name and information on this application to the CHIP contractor if any applicants may be eligible for CHIP.
  • I will allow the CHIP Contractor to give any and all information found on this application to the Department of Human Services if any applicants may be eligible for Medical Assistance.
  • I understand that I do not have to provide a Social Security number for anyone who is not applying for assistance. If I do provide their Social Security number, it may be used to check the information on this application..
  • I certify that all information that has been entered is true under penalty of perjury.
  • I certify that the person(s) I am applying for are U.S. citizens or aliens in lawful immigration status.
Supplemental Nutrition Assistance Program (Food Stamps) Rights & Responsibilities
 
  • I understand that if I report and provide proof of the household expenses, I will get the maximum amount of SNAP (Food Stamps) benefit allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproven expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Note 6-99, issued January 4, 1999).
  • I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (Food Stamps) certification period.
  • I understand that I have the right to ask the County Assistance Office (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for confirmation if I am having trouble getting proof of anything.
  • In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
Long Term Care and Home and Community-Based Services Rights & Responsibilities
 
  • If I am age 55 or older and receive Medical Assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, it will be required that my probate estate be used to repay the cost of these services.
  • If I do not report changes as required, my benefits may be reduced or stopped. If I purposely fail to give correct information or report changes, I may be fined and/or put in jail.
Low-Income Home Energy Assistance Program (LIHEAP) Rights & Responsibilities
 
  • My signature on this application gives my permission to the Department of Human Services or its authorized agent to: (a) check any information I give about where I live, my jobs, income, resources, energy supply and energy supplier; (b) share information with my energy supplier and receive information from my energy supplier to allow DHS to obtain a record of my annual energy consumption, cost and billing information for purposes of program evaluation, operation, or reporting; and (c) complete any survey in connection with energy assistance.
  • I authorize the release of LIHEAP eligibility information to and from my energy suppliers or weatherization agencies and allow them to seek assistance for which I may be eligible. The assistance may include LIHEAP Cash, Crisis, or Weatherization benefits.
  • I understand I have the right to appeal any decision or undue delay in decision which I consider improper regarding this application.
  • I affirm that Pennsylvania is my legal residence.
  • I understand any Social Security number(s) given will be used in the administration of this program, including cross matches with other programs.
  • I understand that I will be sent a notice of eligibility or ineligibility and, if eligible, the notice will state the amount of my benefit.
  • I further understand that if my household is eligible for a LIHEAP cash benefit, it must be sent directly to my utility company or fuel dealer unless I am a renter and my heat is included in my rent or my fuel is supplied by a fuel dealer who does not accept vendor payment.
  • I certify that, subject to penalties provided by law, the information I gave is true, correct and complete to the best of my knowledge.
  • I know that if I give false information, I can be penalized by fine and/or imprisonment.
  • I understand by signing this application, I may not qualify because LIHEAP money has run out.
National School Lunch Program Rights & Responsibilities
 
  • I understand that an incomplete application cannot be approved for benefits. Be sure to fill out all required information.
  • I understand that my income may be verified (checked).
  • I certify that all the information is true and accurate.
  • I understand that if I purposely give false information, my children may lose meal benefits.
  • I understand that I may be fined and/or imprisoned for providing false information.
  • I may apply for meal benefits at any time throughout the school year.
  • I may ask for a hearing if I do not agree with the school's decision regarding the school meals application.
  • I understand that this information is to be kept confidential and used only for the purposes intended (School Meals, Title I, PSSA tests, certain NCLB reports, etc.) unless confidentiality is waived.
Child Care Works Rights & Responsibilities
 
I understand that:
  • The information in this form will be kept confidential.
  • I may pick any eligible child care provider for my children. An eligible provider meets the requirements of the Subsidized Child Care Program and agrees to follow the Department of Human Services's rules.
  • I may need to pick another provider if my provider is not eligible to participate in the Subsidized Child Care Program.
  • I will be told in writing when a change causes my family to lose help in paying for child care and that I may ask for a hearing if I disagree with a decision that the CCIS agency has made.
  • I must give the CCIS agency true and complete information and proof of information as requested.
  • I must report the following to the CCIS agency within ten days of the change:
  • Loss of work including layoffs or strikes
  • Number of days or hours my child needs care
  • Telephone Number
  • Marital Status
  • Who is providing child care for my child(ren)
  • Decrease in hours of work, education or training below an average of 20 hours a week
  • Number of people who live in the house with the child(ren)
  • Address
  • Maternity leave status
  • I must pay back the cost of any child care I receive during a period of time when I am not eligible.
After the CCIS has determined you eligible for child care and funds for child care are available to enroll your child(ren) in care, you need to know the following:
  • You must pay a co-payment to your provider every week. The co-payment is due to the provider on the first day of the week that your child(ren) attend(s). It is important that you pay your co-payment on time, or you may lose the CCIS agency's help in paying for your child care.
  • Unless your child is ill, your child must attend the child care program on all the days that you said he/she needed care. If you need to make a change due to your work, education or training schedule, you must call the CCIS. You could lose the CCIS agency's help in paying for your child care costs if your child is absent for 5 days in a row for a reason other than:
  • Illness, injury or hospitalization of the child or another family member.
  • Family/maternity leave.
  • Visitation with a parent who does not live with the child(ren).
  • A break in the parent’s work, education or training.
  • If your child is absent for more than 25 enrollment days in the State's fiscal year (July 1st - June 30th), you will be responsible to pay the provider the daily rate for each day of absence beginning with the 26th absence. You must pay the provider's daily rate in addition to your weekly co-payment. For example, if your co-payment is $20/week and the daily rate is $20, you must pay $40 for the week that includes your child's 26th day of absence.
  • The CCIS will pay a child care center, family child care home or a group child care home for up to 15 days when the facility is not open to care for your child.
    The CCIS is unable to pay an alternate child care provider during these 15 days when your provider is not open to care for your child.
  • If the CCIS sends you a Notice of Adverse Action, it means there may be a change in your eligibility for subsidized child care. If you do not understand what is written in the notice, you should contact the CCIS agency immediately. If you disagree with a decision that the CCIS agency has made, you may ask for a hearing to review the decision. You must inform the CCIS that you do not agree with the decision by doing one of the following:
  • Fill out the bottom part of your notice or write a letter and then mail, fax or take the information to the CCIS.
  • Call the CCIS to discuss the reason you do not agree with the decision and follow-up by putting your concerns in writing within 7 days following the date of your telephone call with the CCIS.
If you want the CCIS to continue to help pay for your child care during this process, you must mail, fax or take the bottom part of your notice or the letter that you wrote to the CCIS or call the CCIS on or before the date on the Notice of Adverse Action.    
 
  • You may choose a new provider at any time. However, you must tell the CCIS agency before your child begins child care with a different provider. The CCIS agency will authorize the transfer and continue to help in paying for your child care after the transfer if: your family co-payments are up-to-date AND you continue to be eligible for the CCIS agency's help in paying for your child care AND the new provider that you choose meets the requirements of the Subsidized Child Care Program. The new provider must also agree to follow the Department of Human Services's rules. If the CCIS does not authorize the transfer, you will be responsible for paying the total cost of child care at the new provider.
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