Current through Register Vol. 35, No. 18, September 24, 2024
The department shall take action to establish a claim against
any eligibility determination group that received more benefits than it was
entitled to receive, including LIHEAP benefits paid to a vendor on behalf of
the eligibility determination group, whether or not the overpayment occurred
because of an IHE, an AE, or an IPV.
A.
Claim recovery:
(1) All adult eligibility determination group
members will be jointly liable for any overpayment of benefits to the
eligibility determination group.
(2) A claim will be established against any
or all of the adult members of an eligibility determination group at the time
an overpayment occurred.
(3) A
claim will be established against any eligibility determination group that
contains an adult member who was an adult member of another eligibility
determination group that received more benefits than it was entitled to
receive.
(4) The earned income
deduction of twenty percent (20%) is not allowed when determining an
overpayment due to the failure of an eligibility determination group to report
earned income in a timely manner.
B.
Types of claims for all
programs:
(1)
IHE claims:
(a) A claim will be handled as an IHE claim
if the overpayment was caused by:
(i) the
misunderstanding or unintended error on the part of the eligibility
determination group; or
(ii) the
misunderstanding or unintended error on the part of a categorically eligible
eligibility determination group, provided that a claim can be calculated based
on a change in the eligibility determination group's net income, eligibility
determination group size, or both; or
(iii) a social security administration
action, or failure to take action, resulting in an eligibility determination
group becoming or continuing categorical eligibility, provided that a claim can
be calculated based on a change in net income, eligibility determination group
size, or both.
(b)
Instances of IHE's that may result in a claim include, but are not limited to,
the following:
(i) eligibility determination
group unintentionally failed to provide the department with correct or complete
information; or
(ii) eligibility
determination group unintentionally failed to report changes in its
circumstances; or
(iii) eligibility
determination group unintentionally received benefits or received more benefits
than it was entitled to receive pending a fair hearing decision because the
eligibility determination group requested a continuation of benefits based on
the mistaken belief it was entitled to them; or
(iv) eligibility determination group received
benefits solely because of categorical eligibility, but was later determined
ineligible for cash assistance; or
(v) social security administration took
action or failed to take appropriate action, resulting in the eligibility
determination group improperly receiving supplemental security income
(SSI).
(2)
Administrative or agency errors:
(a) A claim will be handled as an AE claim if
the overpayment was caused by the department's action or failure to take
action.
(b) In the case of a SNAP
categorical eligibility, a claim will be handled as an AE if action by an
agency of the state or local government resulted in the eligibility
determination group's improper eligibility for cash assistance.
C.
IPV claims
established for SNAP:
(1) A claim will
be handled as an IPV claim only if:
(a) an
administrative disqualification hearing official or a court of appropriate
jurisdiction has determined that an eligibility determination group member
committed an IPV; or
(b) an
individual is disqualified as a result of signing a waiver of disqualification
hearing in a case referred for prosecution; or
(c) an individual has signed a
disqualification consent agreement in a case of deferred adjudication;
or
(d) an individual has signed a
waiver of an administrative disqualification hearing in a case referred for
disqualification.
(2)
Before the determination of an IPV or the signing of either the waiver of right
to a disqualification hearing or a disqualification consent agreement, the
claim against an eligibility determination group is handled as an IHE
claim.
D.
Claims
for medical assistance benefits: Upon a determination that the
individual is not eligible for the category of assistance in which they were
enrolled, the department shall determine if the individual is eligible for any
category of assistance. If the individual is ineligible for any category, the
department shall determine which months the individual was not eligible and
forward the documentation to the medical assistance division for the
determination of repayment of fee for service payments or the capitation
payments made to the health maintenance organization on behalf of the
individual for months the individual was not eligible for the category of
assistance. The department will pursue the repayment of capitation amounts paid
to the health maintenance organization for the months the individual was
ineligible for any medical assistance programs and received medical
services.
E.
Development of
information: When quality control review findings, or information
reported or received indicate, that benefits may have been issued incorrectly;
the department shall attempt to obtain and verify whether benefits were
provided in error.
F.
When
claims are not established: Overpayment claims shall not be established
for administrative or IHE's, if an over-issuance occurred because the
department did not ensure that the following procedural requirements were
fulfilled:
(1) an application form was signed;
or
(2) appropriate work
registration code was entered.
G.
Claim establishment
threshold: Claims for SNAP, cash assistance and LIHEAP will not be
established when the cumulative amount of the claim is less than the
establishment thresholds.
(1) Claims for all
programs resulting from an administrative error will not be established if the
cumulative claim is less than five hundred dollars ($500).
(2) Claims resulting from an IHE will not be
established if the cumulative error is less than two hundred fifty dollars
($250).
(3) Claims resulting from
fraud or an IPV will always be established for the full amount of the
overpayment.
