11/03/1975 Agreement / t A
i
'
i\V„"Ft STATE OF FLORIDA Rt��
Pi -' DEPARTMENT OF Reubin O'D Askew,Governor
Id Health & Rehabilitative Services
•
Li 5920 ARLINGTON EXPRESSWAY P.O. BOX 2050 JACKSONVILLE, FLORIDA 32203
January 13, 1976 SES-03A
Ms. Vi Papp, Director
Monroe County Social Services
Public Service Building
Wing II, Room 205
Key West, Florida 33040
Dear Ms. Papp:
Please find enclosed your agreement with HEW (Social Security) and the State of
Florida to provide interim assistance to applicants of SSI.
Please review the agreement and notice that Appendix D has been developed for
your County from correspondence with you. As we discussed in the Orlando
meeting, SSA will be ready February 1, 1976, but will notify their local offices
as each county contract is executed. Please have the appropriate county official::
sign the second page of Appendix B. In most cases this will be the county corn-
missioner. When this agreement is signed, please return it to my attention at
the address shown above, and I will have Doctor Alford sign it in behalf of the
Department of HRS.
When all signatures are present, a photocopy of the agreement will be made and
sent to you. The copy with the original signatures must remain with the Office of
Social and Economic Services.
We are working on the questions raised at the Orlando meeting about specific sere
vices. I will write to each county when the answers have been determined.
Please return the agreement as soon as you can. Thank you.
Sincerely,
/„SY2'12- ---,„6_e, ' '0...--2 --I-1.
William E. Brattain
Public Assistance Program Supervisor
WEB:ra
End.asure
i
•
S
•
SUPPLEMENTAL SECURITY INCOME FOR THE
•
AGED, BLIND AND DISABLED
Agreement
• Between
The Secretary of Health, Education, and Welfare
And
The State of Florida
The Secretary of Health, Education, and Welfare, hereinafter referred to as the Secretary,
and the Department of Health and Rehabilitative Services, hereinafter referred to as the
State, for the purpose of assuring the availability of assistance to meet basic needs of
applicants for benefits under Title XVI of the Social Security Act pending determinations of
their eligibility, hereby agree to the following:
Article I
DEFINITIONS
For purposes of this agreement --
A. The term "Secretary" means the Secretary of Health, Education, and Welfare, or his
delegate.
B. The term "State" means the Department of Health and Rehabilitative Services including
any local counties as specified in Appendix A of this agreement.
C. The term "Act" means the Social Security Act.
D. The term "interim assistance" means assistance furnished to or on behalf of the individual
financed totally from State and/or local funds for meeting basic needs and furnished during the
period beginning with the month in which the individual filed an application for benefits and for
which such individual was eligible.
E. The term "initial payment" means the amount of benefits determined by the Secretary to
be payable to an eligible individual (including retroactive amounts, if any) at the time such
individual is first determined to be eligible under Title XVI of the Act but does not include any
emergency advance payment authorized under section 1631(a)(4)(A) of the Social Security Act.
F. The term "benefits" means supplemental security income benefits under. Title XVI of the
Act and any State supplementary payments under section 1616 thereof or mandatory minimum
supplements under section 212 of P.L. 93-66, and P. L. 93-233 which the Secretary makes on
behalf of the State.(or political subdivision thereof).
G. Tne term "Supplemental Security Income Program" means Title XVI of the Social Security
Act as in effect on the date of the execution of this agreement.
•
•
•
Article II
FUNCTIONS TO BE PERFORMED BY THE SECRETARY
The Secretary shall:
A. Send to the State the initial payment for any such individual for whom a copy of the
agreement described in article III-A has been received by the Secretary prior to the date
of determination of eligibility and payment under Title XVI.
B. Provide information to the State in order to assist the State in complying with the terms
of this agreement.
C. Accept, for purposes of protecting such individual's filing date, the date of mailing or
delivery to the Secretary a signed copy of the agreement described in article III, paragraph A,
of this agreement, provided such copy is mailed or delivered promptly.
D. Perform such other functions as may be required by the terms of this agreement.
Article. III
FUNCTIONS TO BE PERFORMED BY THE STATE
The State shall be a "contractual intermediary" between the Secretary and participating County
who shall:
A. In the case of any individual who has or will receive assistance financed totally from State
or local funds for meeting basic needs and who has been referred to apply for supplemental
security income, obtain a written agreement, the terms of which shall provide that in consider-
ation of the prompt payment of interim assistance by the State, the amount of such individual's
initial payment shall be paid to the State for purposes of providing reimbursement for such
interim assistance, and furnish a copy of each such agreement to the Secretary.
B. Deduct from the initial payment received from the Secretary, with respect to any individual,
the amount necessary as reimbursement for interim assistance made on behalf of such individual,
provide to the individual an explanation of the apportionment, and pay the balance to that individ-
ual within 10 working days from the date that the State receives the initial payment.
C. Provide to any individual notice and an opportunity for hearing with respect to disputes
arising from the action taken by the State pursuant to the implementation of this agreement
with respect to the apportionment of such individual's initial payment between the State and
the eligible individual.
D. Maintain adequate records of all transactions relating to interim assistance and the ap-
portionment of the individual's initial payment.
E. Perform such other functions as may be required by the terms of this agreement.
F. Nothing contained in this contract shall create a duty upon the State, or upon any County
thereof, to provide emergency assistance, assistance or interim assistance to any person,
or to create an assistance program.
•
•
Article IV
ACCOUNTING REPORTS
A. As soon as possible after the close of the fiscal year ending June 30, the State shall submit
a report for that fiscal year accounting to the Secretary for the total interim assistance paid,
the total amount of initial payments received by the State, and the total apportionments thereof.
B. If the Secretary and the State are unable to agree upon any item in dispute, an official
designated by the Commissioner of Social Security shall make an initial determination and
inform the State, in writing, of his determination with a full explanation thereof. This deter-
mination shall be final and conclusive unless, within 30 days the State request the Commissioner
of Social Security to reconsider this initial decision, whereupon the Commissioner will recon-
sider the initial determination and inform the State, in writing, of his determination with a full
explanation thereof. This determination shall be final and conclusive unless the State files a
written appeal to the Secretary within 30 days. If the State appeals the Commissioner's deter-
mination, the Secretary will review the reconsideration and, on the basis of the evidence
obtained or submitted to the Secretary, he shall render a decision, affirming, modifying, or
reversing such determination. In notifying the State of his decision, the Secretary shall state
the basis thereof. In connection with the Commissioner's or Secretary's review, the State shall
be afforded an opportunity to be heard and to offer evidence in support of its position. Pending
the decision of the Secretary, the State and the Secretary shall proceed diligently with the per-
formance of this agreement. The delegate of the Secretary who makes the decision shall not
be the Commissioner of Social Security or any subordinate of the Commissioner of Social
Security. Nothing in this agreement shall be construed to waive the State's right to seek judicial
review by a court of the competent jurisdiction of both findings of fact and conclusions of law
contained in the Secretary's decision.
C. After the final determination referred to in this article, either by mutual agreement between
the Secretary and the State, or after application of the provisions of paragraph B of this article,
the Secretary and the State shall promptly make such fiscal adjustments as may be necessary in
order to carry out the provisions of this agreement. It is understood that in no event shall
interest be charged or payable by either party to the other with respect to any such adjustments
required by this article.
Article V
ADMINISTRATIVE COSTS
Neither the State nor the Secretary, in performing their functions and duties under this agree-
ment, shall pay to the other any costs of administration incurred by the other.
Article VI
EXAMINATION OF RECORDS
The State agrees that the Secretary and the Comptroller General of the United States (including
their duly authorized representatives) have access to and the right to examine any directly
pertinent books, documents, papers, and records of the State for purposes of verifying trans-
actions with respect to matters covered by this agreement.
•
•
•
•
•
•
Article VII
CONFIDENTIAL NATURE AND LIMITATION ON USE
OF INFORMATION AND RECORDS
The Secretary and the State shall adopt policies and procedures to ensure that information
contained in respective records and obtained from the Secretary or from others in carrying
out their functions under this agreement shall be used by them and disclosed solely as pro-
vided in section 1106 of the Act and the regulations promulgated thereunder.
Article VIII
TERM OF AGREEMENT
This agreement shall begin on , and end on June 30, 1976. It
will automatically be renewed for a period of one year unless the State or the Secretary gives
written notice not to renew at least 30 days before the end of the current period.
Article IX
TERMINATION AND MODIFICATION OF AGREEMENT
A. The State or the Secretary may terminate this agreement at any time upon 30 days
written notice to the other party.
•
B. This agreement may be modified in writing at any time by mutual consent of the parties
hereto.
C. If this agreement is terminated by the State in any manner (including nonrenewal), the .
accounting requirements provided for in this agreement shall apply.
D. If this agreement is terminated by either party, the Secretary and the State agree that all
cases for which the State has obtained the agreement called for by article III-A shall be pro-
cessed in accordance with this agreement.
Article X
APPENDIX
Appendix A (List of Counties) attached hereto is included as part of this agreement.
Appendix B (agreement between the State and participating County) attached hereto is included
as part of this agreement,
Appendix C (itemized list of reimbursable services) attached hereto is included as part of this
agreement.
Appendix D shall include each participating county's procedure for conducting a fair hearing.
•
•
In Witness Whereof, the parties hereby execute this agreement this
day of /Via4- e. •II l�-L�_.,_.� , 1975.
THE SECRETARY OF HEALTH,
- . ' EDUCATION, AND WELFARE .
47 . ,n •
• . .BY. .,,,,,, e-Z,A. 1,( //f. i'(69-"Alf.17(../e--/.. C— •
Regional Commissioner
Social Security Administration
(Title) •
•
(State) •� � .
. • - BY ... -17-../..gt.„.,_ .....c...YA.._ . .
•
'Secretary, Department of Health &
•
(Title)
Rehabilitative Services
1323 Winewood Boulevard
• Tallahassee, Florida
(Address)
•
I•,.,721-7v,- .- /7%/,'/ ,7:,z..•,:,. , certify that I am the Attorney General* of the State of
}
/ :-. e)ii i' '(/) ; that k /i i".41,9 �7, 7'.
/�� , •.: r-, who sided this agreement
on behalf of the State was thence. r),f7/. -/.•,,/;;; ,-,c•,,/f;_ 4 of said State; and-that he is
authorized to enter into agreements of this nature on behalf of the State and that there is
authority under the laws of the State of 7,.47.,. (/,) -- to carry out all functions
to be performed by the State as provided herein and comply with the terms of this agreement.
. r .
•
. . 0 (-, ,.....1.,_..._,.... ..).-2) /1-1.\(......A....-1„,• .. .
Signature of Counsel
*or legal counsel for ,
• the State Agency .
•
•
•
•
•
AUTHORIZATION
By
(Your Name) • (Social Security Number)
, And
•
(Spouse, if any) (Social Security Number)
FOR AN IN CONSIDERATION of the prompt payment of State interim assistance
(assistance furnished to or on behalf of applicants for supplemental security
income financed from State or local funds for basic needs during the period in
which applications are pending), I/We hereby authorize the Secretary of Health,
• Education, and Welfare to make the first payment of supplemental security
income benefits to which I/We are determined to be eligible to receive, for and
on my/our behalf, to the State of Florida for County
I/We further authorize the County to deduct from such first payment an amount
sufficient as reimbursement for interim assistance paid to me/us; and after
making such deduction, the County shall promptly pay the balance, if any, to
me/us. It is understood that in the event of disagreement, I/We shall have the
right to a hearing from the County with respect to such apportionment of such
first payment.
Signature
•
Signature
•
a_ .
• Appendix A
County - Mailing Address
Pinellas. 1: Dept of Social Services
2: Dept of Social Services
• 3: 601 Court St
• • 0 4: Clearwater FL
. 5:.
• 6: 33516
. 7: 10510
Orange 1: Dept of Social Services
• 2: Dept of Social Services
•
3: 86 W Underwood St
• 4: Orlando FL
5:
• 6: 32806
•
7: 10470
•
Palm Beach 1: Palm Bch Cty Welf Dept
• ' 2: Palm Bch Cty Welf Dept
• 3: 826 Evernia St
• 4: W Palm Bch FL
5: •
6: 33401
7: 10490
•
Broward 1: Broward Cty Soc Srvcs
2: Broward Cry Soc Srvcs
• 3: 605 SW 26 St
4: Ft Lauderdale FL
• 5:
• • • 6: 33315 •
• 7: 10050
Alachua 1: Alachua Cty Soc Srvcs
2: Alachua Cty Soc Srvcs.
3: P. O. Pox 353
• 4: Gainesville FL
5:
• 6: 32602
7: 10000
•
•
•
•
•
County Mailing Address
Monroe 1: Monroe Cty Soc Srvcs
2: Monroe Cty Soc Srvcs
3: Public Srvcs Building
• 4: Stock Island
5: Key West F.L
• 6: 33040
7: 10430
Hillsborough 1: Hillsborough Cty Welf
2: Hillsborough Cty Welf
• 3: 1403 Tampa St
4: Tampa FL
•
5:
• 6: 33602
•
• 7: 10280
Brevard 1: Brevard Cry Well
2: Hlth & Soc Srvcs Div .
• 3: 2575 N Courtenay Pkwy
4: Merritt Island FL
• • 5:
6: 32952
- 7: 10040
•
Duval - • I.: City Welfare Division
2: Jax Welfare Dept
3: 962 Main St
4: Jacksonville FL
• 5:
• 6: 32202
7: 10150
Polk • • 1: Div Soc Srvcs & Rehab
2: Div Soc Srvcs & Rehab
3: PO Box 158
4: 2010 E Georgia St
5: Bartow FL
6: 33830
20520 •
Dade 1: Dade Cty Welf Dept
2: Dade Cty Welf Dept
3: 1425 NW 10th Ave
4: Miami FL
• 5:
6: 33136
7: 10120
•
•
1 •
•
•
•
•
•
APPENDIX B
1. It is the intent and purpose of this contract that the State shall be a "contractual
intermediary" between the Secretary and participating County, Monroe.
2. Nothing contained in this contract shall create a duty upon the State, or upon any
County thereof, to provide emergency assistance, assistance or interim assistance to any
person, or to create an assistance program.
3. The County shall•adopt and ratify the contract, appended hereto, between the State
and the Secretary and the County shall assume the rights, duties and responsibilities delegated
to the State set forth in Articles III, IV, V, VI and VII of this contract, except those specified
herein, and in addition shall:
(a) • As provided in Article IV, A, of the appended contract, the County shall submit
a monthly report to the State Office, Post Office Box 2050., Jacksonville, Florida 32203. The
report shall reflect the name of the individual, address, Social Security number, amount of
emergency assistance, date of receipt of initial payment, date payment to recipient, amount
of the warrant received from SSI, amount reimbursed to the individual (if SSI amount is
greater than the emergency payment, the amount disbursed by the County); and the type of
assistance provided for which reimbursement is claimed (if more than one type was provided,
itemize amount by type of assistance). The report shall be furnished on a form provided by
the State. Said report shall be submitted monthly no later than ten (10) days after the end of
month.
(b) The County shall maintain adequate accounting records of the transaction referred
to in paragraph (a) above. The State, or its assigns, shall have the right to inspect and audit
all records of the County regarding payment of emergency assistance, reimbursement, hear-
ings and all other records material to this contract.
4. The County agrees to abide by any regulations for distribution, accounting, reporting,
or hearings currently or hereafter promulgated by the State or the Secretary.
5. The County shall pay to the State, for transmittal to the Secretary, such amounts that
the Secretary or the State, after an accounting or hearing or an appeal as provided for in
Article IV of the attached contract, determines is owed by the County. The County agrees to
hold harmless the State from any amounts which the Secretary, after an accounting or hearing
or appeal, determines is owed by the State on behalf of said County.
6. . Prior to the signing of this contract by the County and as an appendix thereto, the
County shall submit to the State the proposed procedure for conducting a fair hearing pursuant
to Article III, C, of the contract, which procedure shall be approved by the State prior to the
signing of this contract. The procedure shall include (a) method of advising the client of the
right to a fair hearing, and (b) the procedure to be utilized by the County if the client requests
a fair hearing. The hearing procedure shall be annexed hereto as Appendix D of this contract,
•
•
•
•
•
7. The County may be reimbursed for emergency assistance furnished to its residents
under the following terms and conditions:
(a) Proper and complete accounting records are maintained by the County of each
transaction.
(b) The Secretary or SSA is to be the sole authority for the determination of the
type of emergency assistance for which the County may claim reimbursement pursuant
to this contract.
8. This contract may be terminated by the State or by the County upon thirty (30) days
written notice to either party. Said contract may be terminated with or without cause.
DATED this day of DATED this day of
, A.D. 1976. , A.D. 1976 .
STATE OF FLORIDA, DEPARTMENT BOARD OF COUNTY COMMISSIONERS
OF HEALTH AND REHABILITATIVE OF COUNTY
SERVICES BY
Chairman
Attested by: (Corporate
James A. Alford, M.D. Seal)
Assistant Secretary for Program
Planning and Development
Clerk, Board of County Commissioners
E. D. Endsley, Staff Director
. Social and Economic Serv' s
Program Office
•
•
•
•
•
•
,
APPENDIX C
This Appendix shall include an itemized list of the services provided by the County to the
recipient, which are considered reimbursable by SSA. The SSA shall be the sole authority
as to which services shall be reimbursable.
The guide to use in determining which services are considered reimbursable is that the
approved services would be those for which the County would not make payment if the in-
dividual were receiving SSI. Such services will generally fall within the following categories:
I. Shelter:
Rent
Mortgage payment in lieu of rent
Room and Board
II. Food:
Cash for food and/or food vouchers (to purchase food or food stamps)
III. Utilities:
Electricity
Heating and/or cooking fuel
Garbage pick up
Water
Sewage
Gas -
.
IV. Medical needs not covered under Medicaid/Medicare and not available without charge
in the County:
Physician's fee
Out-patient clinic care
Diagnostic exams
Medicine
Denture
Hearing Aids
Glasses
Other medical apparatus (walker, wheelchair, hospital bed, catheters, etc.)
Nursing home care
In-patient hospital care
Telephone service on request of a physician
Ambulance service
V. Other:
Housekeeping services (necessary for life support)
Household incidentals (cleaning material, light bulbs, etc.)
Personal incidentals (soap, shaving gear, deodorant, etc.)
Insurance premiums
Emergency transportation
•
•
APPENDIX D
This appendix shall include the procedure to be utilized by Monroe County in the '
event the client requests a fair hearing relative to action taken in the interim/
emergency assistance program.
•
'Fair Hearing Procedure
Within ten days after a complaint is received from a client, a hearing will be
held in the County Social Service Office. The purpose of this hearing will be
to allow the client a fair opportunity to voice his/her complaint before a Hearings
Committee. This Committee will consist of the County Social Worker assigned
to the case, the Director of Monroe County Social Services Department, and
County Commissioner.
• The final decision.will be reached by the Hearings Committee in accord with
the Florida Statutes and the County Resolution governing the County Social •
Services Department. •