Current through 2024-38, September 18, 2024
Section 9.1
Intentional Program Violation means that a recipient, applicant,
or any other individual in the "Assistance Unit" has intentionally
misrepresented facts (including, but not limited to such facts as living
arrangement, income, or assets) in order to receive MaineCare, and the
recipient, applicant, or any other individual in the Assistance Unit would not
have been eligible for MaineCare if the Department had been notified of the
correct facts, or of a material change in facts. This includes, but is not
limited to:
A. False or misleading statements
or misrepresentations, concealment, or withholding of facts, or
B. An act intended to mislead, misrepresent,
conceal, or withhold facts or propound a falsity.
Section 9.2
Determining the
Overpayment. "Overpayment" means program benefits that exceed the amount
of program benefits, if any, for which an individual or assistance unit is
actually eligible when the department or a court has determined that the
benefits were provided as a result of an Intentional Program Violation by the
individual. Overpayments are calculated as follows:
A. For excess assets, the amount subject to
recovery is the lesser of:
a. The amount of
the payment made on behalf of the individual; or
b. The difference between the actual amount
of countable resources and the applicable resource limit.
B. For excess income, the amount subject to
recovery is the total amount of program benefits made on behalf of the
individual during the months of the overpayment period.
C. For combinations of excess assets and
excess income, the amount subject to recovery is the greater of either A. or B.
in this Section.
D. For
misrepresentation of circumstances other than income and assets, the amount
subject to recovery is the total amount of payments made on behalf of the
individual during the months of the overpayment period.
E. For Medically-Needy cases, as described in
Part 10 of 10-144 CMR Chapter 332, the amount subject to recovery is the lesser
of:
a. The amount of program benefits made on
behalf of the individual; or
b. The
difference between the amount of the deductible in effect during the
overpayment period and the correct amount of the deductible.
F. Situations involving
individuals receiving long-term care and waiver services:
a. Excess Income -
i. If the individual should not have been
made eligible for MaineCare, the amount subject to recovery is the amount of
program benefits made on behalf of the individual.
ii. If the individual was correctly made
eligible for MaineCare but the cost of care was incorrectly calculated, the
amount subject to recovery is the difference between the amount of the correct
cost of care and the cost of care that was in effect during the overpayment
period.
b. Excess
Resources -
i. The amount subject to recovery
is the difference between the actual amount of countable resources and the
applicable resource limit.
ii. The
individual may choose to make a payment of a lump sum to the long term care
facility if the increase will reduce the resources to the appropriate limit.
The reduction in resources shall be completed in one calendar month.
Section 9.3
Notice of Overpayment/IPV. The eligibility office in cooperation
with the Office of MaineCare Services shall provide the following information
to the individual and/or assistance unit:
A.
a detailed explanation of the misrepresentation and the effect it had on
eligibility.
B. a claims history
indicating the services that should not have been paid.
C. a request that the applicant contact the
Office for Family Independence (OFI) within 10-days to discuss repayment of the
benefits issued.
D. deadlines and
methods for requesting an administrative hearing.
E. closings, denials, and eligibility notices
will be handled according to Part 2 Sections 14 and 15.
Section 9.4
Administrative
Hearing - the Department will provide instructions on how to request an
Administrative Hearing consistent with Part 1 Section 7 above.
Section 9.5
Referral to Fraud
Investigation & Recovery Unit (FIRU) for recovery of overpayments described
in Section 9.2
The OFI will send a copy of the above-referenced notice of
over-payment to the Fraud Investigation and Recovery Unit:
A. if the individual or assistance unit does
not appeal the department's findings; or
B. the final written decision by the
Administrative Hearing Officer finds in favor of the department and the
individual does not request a judicial review; or
C. judicial review finds in favor of the
department.
