Current through Register Vol. 63, No. 9, September 1, 2024
This rule specifies how the Department calculates an
overpayment (see OAR
461-195-0501).
(1) The Department calculates an
overpayment by determining the amount the individual received,
or the payment made by the Department on behalf of the individual that exceeds
the amount for which the individual was eligible.
(2) When a filing group (see
OAR 461-110-0310, 461-196-0020 and
OAR 414-175-0015), HSD
medical programs (see OAR
461-001-0000)
eligibility determination group (see OAR
410-200-0015), ineligible
student, or authorized representative (see OAR
461-115-0090 and OAR
410-200-0015) fails to report
income, the Department establishes, calculates and determines the
overpayment by assigning unreported income to the applicable
budget month without averaging the unreported income, except:
(a) An individual's earned income reported
quarterly from the Employment Department is considered received by the
individual in equal amounts during the months identified in the
report.
(b) In the Employment
Related Day Care (ERDC), Refugee Assistance (REF), Summer EBT (SEBT),
Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for
Needy Families (TANF) programs, an individual's actual self-employment income
is annualized retrospectively to calculate the
overpayment.
(c)
In the HSD medical programs, if actual income is not available
for the months in which an overpayment occurred, an
individual's actual self-employment income (see OAR
410-200-0015) received during
the year when an overpayment occurred is annualized to
calculate an overpayment.
(d) In all programs, if verification of
self-employment income is not provided to the Department following the issuance
of a subpoena, or is not yet available to the individual, self-employment
income from a prior year is annualized prospectively to calculate an
overpayment. There is a rebuttable presumption that self-employment income from
the prior year is representative of actual self-employment income for the time
of overpayment. The presumption may be rebutted only by clear and convincing
evidence.
(3) The
Department establishes, calculates, and determines an administrative
error overpayment (see OAR 461 195 0501) based on information
initially provided by a filing group, ineligible student, or authorized
representative. The Department may calculate the administrative error
overpayment by using any of the following:
(a) Correct prospective budgeting (see OAR
division 461-150 and OAR
414-175-0040) based on
information initially provided; or if it results in a lower overpayment
amount;
(b) Actual income;
or
(c) Averaging an individual's
earned income reported quarterly from the Employment Department.
(4) When using prospective
budgeting (see OAR division 461-150 or OAR
414-175-0040) and the actual
income differs from the amount determined under OAR
461-150-0020(2)
or OAR 414-175-0040, there may be a
client error overpayment (see OAR
461-195-0501) only when the
filing group, ineligible student, or authorized representative
withheld information, failed to report a change, or provided inaccurate
information. In such a case, the Department uses the actual income to determine
the amount of an overpayment.
(5) The Department uses actual income to
determine the amount of a medical assistance overpayment
caused by possible fraud.
(6) When
a filing group, ineligible student, or authorized
representative fails to report all earned income within the reporting
time frame, the earned income deduction (see OAR
461-160-0160, 461-160-0190,
461-160-0430,
461-160-0550, or
461-160-0552) is applied as
follows:
(a) In the Oregon Supplemental
Income Program (OSIP), Oregon Supplemental Income Program Medical (OSIPM),
Qualified Medicare Beneficiaries (QMB), and Refugee Assistance Medical (REFM)
programs, the Department allows the earned income deduction.
(b) In the REF and TANF programs, the
Department allows the earned income deduction when good cause
(see section (7) of this rule) exists.
(c) In the SNAP program, no deduction is
applied to earned income if the amount or source of income was not timely
reported.
(7) For the
purposes of OAR 461-195-0501 to
461-195-0561, "good cause" means
circumstances beyond the individual's reasonable control that caused the
individual to be unable to report income timely and accurately.
(8) When support is retained:
(a) In the TANF program, the amount of
support (other than cash medical support) the Department of Justice retains as
a current reimbursement each month is added to other income to determine
eligibility (see OAR
461-001-0000). When an
individual is not eligible for TANF program benefits, the
overpayment is offset by the support the Department of Justice
retains as a current reimbursement.
(b) For medical assistance, the amount of the
cash medical support the Department retains each month is excluded income and
not used to determine eligibility. When an individual has
incurred a medical assistance overpayment, the
overpayment is offset by the amount of the cash medical
support the Department retains during each month of the
overpayment.
(9) In the REF and TANF programs, when an
individual directly receives support used to determine
eligibility or calculate benefits, the
overpayment is:
(a) If still
eligible for REF or TANF program benefits, the amount of support the individual
received directly; or
(b) If no
longer eligible for REF or TANF program benefits, the amount of program
benefits the individual received.
(10) When an overpayment
occurs due to the failure of an individual to reimburse the Department, when
required by law to do so, for benefits or services (including cash medical
support) provided for a need for which that individual is compensated by
another source, the overpayment is limited to the lesser of
the following:
(a) The amount of the payment
from the Department;
(b) Cash
medical support; or
(c) The amount
by which the total of all payments exceeds the amount payable for such a need
under the Department's rules.
(11) Benefits paid during a required
notice period (see OAR
461-175-0050, OAR
410-200-0120, or
414-175-0055) are included in
the calculation of the overpayment when:
(a) The filing group, HSD medical programs
eligibility determination group, ineligible student, or
authorized representative (see OAR
461-115-0090, OAR
410-200-0015, and OAR
414-175-0002) failed to report a
change within the reporting time frame under OAR
461-170-0011, OAR
410-200-0235, or OAR
414-175-0060; and
(b) Sufficient time existed for the
Department to adjust the benefits to prevent the overpayment
if the filing group, HSD medical programs eligibility determination
group, ineligible student, or authorized
representative had reported the change at any time within the
reporting time frame.
(12) In the SNAP program, if the
benefit group (see OAR
461-110-0750) was categorically
eligible under OAR 461-135-0505, there is no
overpayment based on resources.
(13) In the OSIP and OSIPM programs, when a
individual does not pay their share of the cost of services (see OAR
461-160-0610) or the Oregon
Supplemental Income Program-Employed Persons with Disabilities (OSIP-EPD) or
Oregon Supplemental Income Program Medical-Employed Persons with Disabilities
(OSIPM-EPD) program participant fee (see OAR
461-160-0800) in the month in
which it is due, an overpayment is calculated as follows:
(a) All payments made by the Department on
behalf of the individual during the month in question are totaled, including
but not limited to any payment for:
(A)
Capitation;
(B) Long term care
services;
(C) Medical expenses for
the month in question;
(D) Medicare
buy-in (when not concurrently eligible for an MSP);
(E) Medicare Part D;
(F) Mileage reimbursement;
(G) Special needs under OAR
461-155-0500 to
461-155-0710; and
(H)
Home and community-based
care (see OAR
461-001-0030), including home
delivered meals and non-medical transportation.
(b) Any partial or late liability payment
made by an individual receiving home and community-based care
in-home services or participant fee paid by an OSIP-EPD or
OSIPM-EPD program participant is subtracted from the total calculated under
subsection (a) of this section. The remainder, if any, is the amount of the
overpayment.
(14) When an individual's liability is
unreduced pending the outcome of a contested case hearing about that liability
the overpayment is the difference between the liability amount
determined in the final order and the amount, if any, the individual has
repaid.
(15) For medical
assistance, if the individual was not eligible for one program, but during the
period in question was eligible for another program with the same benefit
level, there is no overpayment.
(16) Credit against an
overpayment is allowed as follows:
(a) In the General Assistance (GA), REF, and
TANF programs, a credit is allowed for an individual's payment for medical
assistance made during the period covered by the overpayment,
in an amount not to exceed the Department fee schedule for the service, but
credit is not allowed for an elective procedure unless the Department
authorized the procedure prior to its completion.
(b) In the SNAP program, if the
overpayment was caused by unreported earned income, verified
child care costs are allowed as a credit to the extent the costs would have
been deductible under OAR
461-160-0040 and
461-160-0430.
(c) In all programs, for an underpayment of
benefits in the program in which the overpayment
occurred.
(17) In the
REF program, when an individual used or accessed cash benefits in violation of
OAR 461-165-0010(8)(a),
the amount of the overpayment is the amount of cash benefits
the individual used or accessed.
(18) In the State Family Pre-SSI/SSDI (SFPSS)
and TANF programs, when an individual used or accessed cash benefits in
violation of OAR 461-165-0010(9)(a),
the amount of the overpayment is the amount of cash benefits
the individual used or accessed.
Statutory/Other Authority: ORS
329A.500,
413.085,
414.685, ORS
409.050,
411.060,
411.070,
411.404,
411.660,
411.706,
411.816,
412.014,
412.049,
412.124 &
414.231
Statutes/Other Implemented: ORS
329A.500,
411.060,
411.070,
411.404,
411.660,
411.706,
411.816,
412.014,
412.049,
412.124,
414.231, ORS
409.010,
411.620,
411.630,
411.635,
411.640,
411.690 &
416.350
