Part 348 - REQUIREMENTS APPLICABLE TO FRAUD CASES

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Statutory Authority: 
Social Services Law, Sections 20, 34

Section 348.1 - Fraud defined.

Section 348.1 Fraud defined. For the purposes of section 145 of the Social Services Law and the regulations herein, fraud shall be deemed to exist when a person knowingly obtains, or attempts to obtain, or aids or abets another person to obtain, public assistance or care to which he is not entitled by means of a false statement, deliberate concealment of a material fact or other dishonest act.

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Section 348.2 - Required district procedure.

348.2 Required district procedure. Each social services district shall take these measures designed to prevent, detect and report fraud:

(a) Establish and maintain clear and adequate policies, procedures and controls in order to effectively handle cases of suspected fraud in the administration of public assistance and care.

(b) Make an agreement with the appropriate district attorney or other prosecuting official establishing the procedures for referral to such official of all cases wherein reasonable grounds exist to believe that fraud was committed.

(c) File with the department a copy or a statement of the agreement with the prosecuting official.

(d) Designate a person, either of administrative or supervisory responsibility or in a consultative capacity to the local district such as a welfare attorney, or establish a unit which shall consist of persons of similar responsibility, to which all cases of known or suspected fraud shall be referred, to perform the following functions:

(1) review district material referred, including any that may be legal evidence;

(2) determine whether that material indicates that reasonable grounds exist to believe that fraud was committed by the applicant or recipient and/or others;

(3) in cases of suspected fraud, when the material referred and reviewed does not indicate that reasonable grounds exist to believe that fraud was committed, but when such material is insufficient to erase suspicion of fraud, decide whether further investigation may produce evidence necessary to determine that reasonable grounds exist or erase the suspicion, and conduct the investigation;

(4) determine the existence of any mitigating facts or circumstances;

(5) promptly refer to the appropriate district attorney or other prosecuting official all cases wherein reasonable grounds exist to believe that fraud was committed, in accordance with such procedures as may be developed locally between the social services official and district attorney or other prosecuting official, which procedures may, to avoid duplication of referrals, merely require the social services department to identify cases already referred to the district attorney by the inspector general with the knowledge of that office and to transmit to the district attorney on a continuing basis, all material pertinent to the prosecution of such cases which may supplement the material already transmitted by the inspector general. Any existing mitigating facts or circumstances known to the department shall be included in the referral;

(6) maintain liaison with such appropriate district attorney or other prosecuting official and endeavor to secure reports of actions taken with respect to cases referred;

(7) promptly advise the appropriate district attorney or other prosecuting official whenever restitution, or arrangements for restitution of fraudulently received public assistance funds has been made, or is being made.

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Section 348.3 - Investigations of fraud.

348.3 Investigations of fraud. Investigations of fraud shall be promptly made, but shall be conducted by lawful means only, without infringing upon the civil rights of individuals. Under no circumstances, shall force, threat of force or false statements be used to obtain entry into a household or to obtain evidence of any nature.

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Section 348.4 - Recovery of assistance wrongfully obtained by an applicant or

348.4 Recovery of assistance wrongfully obtained by an applicant or recipient. In a case of suspected fraud which was or should have been referred by a local social services department to a district attorney or other prosecuting official pursuant to the provisions of the regulations of this department, and in which case there is evidence, in the judgment of the social services official of such local department, which clearly establishes that the applicant or recipient of public assistance and care willfully withheld from such local social services department at the time of his application for public assistance and care, or any time thereafter, information about his income or resources, and as a result of withholding such information from the local social services department, the applicant or recipient has received grants, of public assistance, or care at public expense to which he was not entitled in whole or part, the social services official shall recover the amount of the public assistance granted or the cost of care provided to the applicant or recipient to which he was not entitled in accordance with subdivision

(d) of section 352.31 of this Title.

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Section 348.5 - Records required to be maintained.

348.5 Records required to be maintained. Each local social services department shall keep a record of all cases referred to the designated person or unit for review, which record shall include:

(a) the names, case number and other identifying information;

(b) a brief description of the facts constituting the grounds for suspecting fraud;

(c) the estimated amount of overpayment;

(d) the duration of such overpayment;

(e) whether the case was referred to the appropriate district attorney or other prosecuting official:

(1) if a case is not referred, the reasons for such action shall be stated;

(2) if a case is referred, the record shall include:

(i) date of such referral;

(ii) disposition of such referral; and

(iii) the amount of any sum of money recovered.

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Section 348.6 - Reports to department.

348.6 Reports to department. Each local social services department shall report to the State Department of Social Services such information as the latter may require.

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Section 348.7 - Front end detection system (FEDS).

348.7 Front end detection system (FEDS).

(a) Each social services district must take actions to ensure the integrity of the public assistance (PA) caseload and the correctness of PA eligibility determinations and establish procedures to identify and refer for investigation potential cases of fraud, misrepresentation or questionable documentation prior to determining applicants' eligibility for PA.

(b) The procedures established by each district must not delay the determination of eligibility for PA or the provision of emergency assistance beyond the timeframes established in this Title.

(c) Each social services district must submit a plan to the department for approval, describing the procedures required by subdivision (a) of this section, in such form and at such times as the department may require. The plan must include, but need not be limited to:

(1) a description of the circumstances under which referral to the FEDS investigative unit will be made.

(i) The referral indicators must include the following circumstances:

(a) where the applicant states that the household's stated expenses exceed the stated income or the current grant without a reasonable explanation of how the applicant met those expenses;

(b) where the applicant states that the ability to meet the household's expenses in the past was the result of receiving income which was not declared to the appropriate tax authorities;

(c) where the applicant states that the ability to meet the household's expenses in the past was the result of loans or gifts received from family or friends;

(d) where the application contains information about the applicant which is inconsistent with prior case information maintained by the district; and

(e) where the applicant has a history of previous denials of applications for assistance, case closings, or overpayments or recoupments which resulted from investigations by a social services district.

(ii) The referral indicators also may include specific circumstances relating to the income/resources, residence and identity of the applicant as follows:

(a) where the applicant is self-employed but does not have adequate business records to support assertions about the applicant's finances made in the application;

(b) where the applicant has no documentation to verify his or her identity or the documentation of identity provided is questionable;

(c) where the applicant is an alien, has no documentation to substantiate his or her immigration status or the documentation of immigration status is questionable;

(d) where the applicant provides documentation or information which is inconsistent with the information contained in the application, such as when a different name is used for a signature or when an invalid social security number is used;

(e) where a post office box is used as a mailing address without a reasonable explanation;

(f) where the applicant's landlord does not verify the household's composition or provides information inconsistent with the information contained in the application;

(g) where the applicant is the primary tenant but has no utility bills in his or her name;

(h) where the application states that there are children in the household under the age of six and no birth certificates for the children are provided;

(i) where the applicant provides no information concerning an absent parent or the information provided is inconsistent with information contained in the application; or

(j) where the applicant is unsure of his or her own address.

(2) procedures to be used by income maintenance eligibility determination personnel and the FEDS investigators for receiving, monitoring and investigating referrals;

(3) timeframes within which the FEDS investigative unit must report the results of its investigation to the eligibility determination personnel; and

(4) a designation of the social services district's contact person responsible for FEDS and for the submission of FEDS reports requested by the Department from time to time.

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