New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 100 - GENERAL PROVISIONS FOR PUBLIC ASSISTANCE PROGRAMS
Part 640 - RESTORATION AND CLAIMS
Section 8.100.640.12 - CALCULATING THE AMOUNT OF THE ERROR (CALCULATING CLAIMS)
Universal Citation: 8 NM Admin Code 8.100.640.12
Current through Register Vol. 35, No. 18, September 24, 2024
A. SNAP:
(1)
Calculating the claim for an IHE
and AE: For each month that benefits have been over-issued to an
eligibility determination group because of an IHE or AE, the department shall
determine the correct benefit amount the eligibility determination group was
entitled to receive.
(a) The total amount of
the claim is calculated, based at a minimum, on the monthly overpayment amount
which occurred during the twelve (12) months preceding the date the overpayment
was discovered.
(b) The department
shall calculate the amount of the claim back to the month the error occurred
regardless of the length of time that elapsed until the error was
discovered.
(c) The department
shall not include in the calculation any overpayment amount that occurred in a
month more than six (6) years before the date the overpayment was
discovered.
(2)
Calculating the claim for an IPV:
(a)
For each month that benefits have been over-issued to an eligibility
determination group because of an IPV, the department shall determine the
correct amount of benefits the eligibility determination group was entitled to
receive.
(b) The amount of the IPV
claim will be calculated back to the month the IPV occurred, regardless of the
length of time that elapsed until the determination of an IPV was
made.
(c) The department may not
include in the calculation any amount of the overpayment that occurred in a
month more than six (6) years prior to the date the overpayment was
discovered.
(d) If an eligibility
determination group member is determined to have committed an IPV by
intentionally failing to report a change in eligibility determination group
circumstances, the first month affected by the failure to report will be the
first month in which the change would have been effective if it had been timely
reported.
(e) In no event shall the
department determine as the first month that the change would have been
effective any month later than two (2) months after the month that the change
in eligibility determination group circumstances occurred.
(f) If an eligibility determination group
received a larger benefit amount than it was entitled to receive, a claim will
be established against the eligibility determination group equal to the
difference between the benefit amount the eligibility determination group
received and the amount the eligibility determination group should have
received.
(g)
Earned income
deduction penalty: When determining the amount of benefits the
eligibility determination group should have received, the twenty percent (20%)
earned income deduction is not applied to that portion of earned income that
the eligibility determination group intentionally failed to report. A claim
must be recomputed if it was initially handled as an IHE claim.
(3)
Offsetting the
claim: Once the amount of the claim for IPV, IHE, and AE is established,
the department may offset the amount of the claim against any benefit amount
not yet restored to the eligibility determination group. Action must be taken
to initiate collection of the remaining balance, if any.
B. Cash assistance programs:
(1)
Claims for administrative and
client caused errors: Claims are established when the department issues
more than the eligibility determination group was eligible to receive due to an
AE or if the eligibility determination group fails, either intentionally or
unintentionally, to report correct information at application or while
receiving benefits.
(a) For each month of
eligibility, the grant determinations are made using the standard of need, case
information and policy in effect for that month.
(b) The department shall recover all cash
assistance overpayments, including overpayments resulting from an AE, and any
assistance paid while pending a fair hearing decision.
(c) An historical change that results in a
lower payment than was originally issued, results in an overpayment and the
establishment of a claim if it exceeds the claims establishment thresholds
listed in Subsection G of 8.100.640.11 NMAC.
(d) If a change occurs that makes the
eligibility determination group eligible for a lower benefit payment for a
month, the adult member(s) of the eligibility benefit group is responsible for
paying the difference back to the department.
(e) If a change occurs that lowers the
standard of need for which the eligibility determination group is eligible, the
eligibility determination group shall be allowed the amount that they were
eligible on the first day of the month.
(2)
Overpayments to sponsored
aliens:
(a) Aliens and sponsors are
jointly liable for overpayments caused by failure of the sponsor to provide
correct information, unless the sponsor is without fault or has good cause.
"Without fault" or "good cause" exists when:
(i) the agency failed to request information
from the sponsor; or
(ii) the
sponsor can show that the sponsor provided all information available to the
sponsor at the time the information was provided;
(iii) the alien provided incorrect
information without the knowledge of the sponsor; or
(iv) the sponsor can show that the giving of
incorrect information was not intentional on the part of the sponsor.
(b) If good cause is found to
exist, the alien has sole responsibility for repayment.
(3)
Developing substantiating
information:
(a) Upon receiving
indication that a possible error exists, the department shall investigate
whether an erroneous payment has occurred. Pertinent information shall be
requested from the participant. Because this information may be used to
prosecute the participant for fraud, the participant shall not be required to
provide such information; however, if the participant declines to provide
information crucial to the determination of overpayment, the participant shall
be ineligible for the period in question because of failure or refusal to
provide information.
(b) The same
standards shall be used in determining erroneous payments as are used to
determine initial and ongoing eligibility and payment.
(c) The participant must be periodically
reminded of the reporting responsibilities and must indicate, no less
frequently than at every certification, that the participant understands these
requirements. This requirement is met by the use of a department form that
reminds participants at each certification of their reporting responsibilities.
This form also serves as the participant's statement that the participant
understands the reporting responsibilities. If it is determined that a
participant may have difficulty understanding the reporting responsibilities
because of language, literacy, or mental or emotional problems, the department
shall supplement the written notice with an oral explanation. All such oral
explanations must be documented in the case record.
(d) The participant shall become ineligible
on a continuing basis if there is a continuing failure to provide information
affecting the participant's current eligibility.
(4)
Offsetting the claim: Once
the amount of the claim for IPV, IHE and AE is established, any restoration the
eligibility determination group is eligible to receive is reduced or offset by
the amount of the claim. Action must be taken to initiate collection of the
remaining balance, if any.
C. LIHEAP:
(1) A claim shall be established for LIHEAP
benefits that have been overpaid regardless of the reason of the
overpayment.
(2) The department may
establish a claim that exceeds the claim establishment threshold, as identified
in Subsection G of 8.100.640.11 NMAC, for LIHEAP benefits overpaid up to six
(6) years prior to the date the overpayment occurred.
(3)
Offsetting the claim: A
benefit amount may be offset during the issuance process in order to recover a
LIHEAP overpayment. The amount that is offset shall be conveyed to the
restitutions bureau to be applied to the eligibility determination group's
overpayment.
D. Claims involving reported changes: In cases involving reported changes, the department shall determine the first month the overpayment occurred.
(1)
Inadvertent household
error: If caused by an inadvertent error on the part of the eligibility
determination group (failure to report a change in circumstances within the
required time frames), the first month affected by the eligibility
determination group's failure to report is the first month in which the change
would have been effective if it had been reported timely. In no event will the
department determine as the first month in which the change would have been
effective any month later than two (2) months from the month in which the
change in eligibility determination group's circumstances occurred.
(2)
Agency error: If an
eligibility determination group reported a change timely but the department did
not act on the change within the required time frame, the change should have
taken effect the first month following the reported change, if it had been
acted upon within the time frame. In no event shall the department determine as
the first month in which the change would have been effective any month later
than two (2) months from the month in which the change in eligibility
determination group circumstances occurred. If an adverse action notice was
required but was not provided, the department shall assume for the purpose of
calculating the claim that the maximum advance notice period would have expired
without the eligibility determination group requesting a fair
hearing.
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