OAR 461-195-0501
Definitions and Categories of Overpayments
(1)
“Overpayment” means:(a)
A benefit or service received by or on behalf of a client, or a payment made by the Department on behalf of a client, that exceeds the amount for which the client is eligible.(b)
A payment made by the Department and designated for a specific purpose which is spent by a person on an expense not approved by the Department.(A)
In the REF program, there is a rebuttable presumption that the full amount of cash benefits was improperly spent in violation of OAR 461-165-0010 (Legal Status of Benefit Payments)(8)(a) when cash benefits are used or accessed in Oregon, outside of Oregon, or on tribal lands at:(i)
Any liquor store (see OAR 461-165-0010 (Legal Status of Benefit Payments));(ii)
Any casino, gambling casino, or gaming establishment (see OAR 461-165-0010 (Legal Status of Benefit Payments));(iii)
Any retail establishment that provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment; or(iv)
Any marijuana dispensary.(B)
In the SFPSS and TANF programs, there is a rebuttable presumption that the full amount of cash benefits was improperly spent in violation of OAR 461-165-0010 (Legal Status of Benefit Payments)(9)(a) when cash benefits are used or accessed in Oregon, outside of Oregon, or on tribal lands at:(i)
Any liquor store;(ii)
Any casino, gambling casino, or gaming establishment;(iii)
Any retail establishment that provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment; or(iv)
Any marijuana dispensary.(C)
The rebuttable presumptions in paragraphs (A) and (B) of this section also apply when an individual in a location covered in paragraphs (A) or (B) uses or accesses cash benefits from a private bank account.(c)
A payment for child care made by the Department to, or on behalf of, a client that:(A)
Is paid to an ineligible provider;(B)
Exceeds the amount for which a provider is eligible;(C)
Is paid when the client was not engaged in an activity that made the client eligible for child care, such as an activity of the JOBS program (see OAR 461-001-0025 (Definitions of Terms, Components, and Activities; JOBS, Pre-TANF, TANF) and 461-190-0151 (Case Planning; JOBS, Pre-TANF, REP, SFPSS, TA-DVS) to 461-190-0401 (Applicability));(D)
Is paid when the client was not eligible for child care benefits; or(E)
Has given an electronic benefit transfer (EBT) card, card number, or personal identification number (PIN) to a provider for the purpose of checking a child (see OAR 461-001-0000 (Definitions for Chapter 461)) in or out from the provider’s child care.(d)
A misappropriated payment when a person cashes and retains the proceeds of a check from the Department on which that person is not the payee and the check has not been lawfully endorsed or assigned to the person.(e)
A benefit or service provided for a need when that person is compensated by another source for the same need and the person fails to reimburse the Department when required to do so by law.(f)
A cash benefit received by an individual in the GA or SFPSS programs for each month for which the client receives a retroactive SSI lump sum payment.(g)
In the TA-DVS program, a payment made by the Department to an individual or on behalf of an individual when the individual intentionally and without intimidation or coercion by an abuser:(A)
Makes a false or misleading statement or misrepresents, conceals, or withholds information for the purpose of establishing eligibility (see OAR 461-001-0000 (Definitions for Chapter 461)) for or receiving a benefit from the TA-DVS program; or(B)
Commits any act intended to mislead or misrepresent, conceal, or withhold information for the purpose of establishing eligibility for or receiving a benefit from the TA-DVS program.(2)
The Department may establish an overpayment for the initial month (see OAR 461-001-0000 (Definitions for Chapter 461)) of eligibility under circumstances including, but not limited to:(a)
The filing group (see OAR 461-110-0310 (Filing Group; Overview)), ineligible student, or authorized representative (see OAR 461-115-0090 (Authorized Representatives; General)) withheld information;(b)
The filing group, ineligible student, or authorized representative provided inaccurate information;(c)
The Department failed to use income reported as received or anticipated in determining the benefits of the filing group; or(d)
The error was due to an error in computation or processing by the Department.(3)
In the HSD medical programs (see OAR 461-001-0000 (Definitions for Chapter 461)), the Department may establish an overpayment for the budget month (see OAR 410-200-0015 (General Definitions)) when the HSD medical programs eligibility determination group (see OAR 410-200-0015 (General Definitions)) or authorized representative (see OAR 410-200-0015 (General Definitions)) withheld or provided inaccurate information.(4)
Overpayments are categorized as follows:(a)
An administrative error overpayment is an overpayment caused by any of the following circumstances:(A)
The Department fails to reduce, suspend, or end benefits after timely reporting by the filing group, HSD medical programs eligibility determination group, ineligible student, or authorized representative (see OAR 461-115-0090 (Authorized Representatives; General) and 410-200-0015 (General Definitions)) of a change covered under OAR 461-170-0011 (Changes That Must Be Reported) or 410-200-0235 (Changes That Must Be Reported) and that reported change requires the Department to reduce, suspend, or end benefits;(B)
The Department fails to use the correct benefit standard;(C)
The Department fails to compute or process a payment correctly based on accurate information timely provided by the filing group, HSD medical programs eligibility determination group, ineligible student, or authorized representative;(D)
In the GA and SFPSS programs, the Department fails to require a client to complete an interim assistance agreement; or(E)
The Department commits a procedural error that was no fault of the filing group, HSD medical programs eligibility determination group, ineligible student, or authorized representative.(b)
A client error overpayment is any of the following:(A)
An overpayment caused by the failure of a filing group, HSD medical programs eligibility determination group, ineligible student, or authorized representative to declare or report information or a change in circumstances as required under OAR 461-170-0011 (Changes That Must Be Reported) or 410-200-0235 (Changes That Must Be Reported), including information available to the Department, that affects the client’s eligibility to receive benefits or the amount of benefits.(B)
A client’s unreduced liability or receipt of unreduced benefits pending a contested case hearing decision or other final order favorable to the Department.(C)
A client’s failure to return a benefit known by the client to exceed the correct amount.(D)
A client’s use of a JOBS or SFPSS program support payment (see OAR 461-190-0211 (Case Plan Activities and Standards for Support Service Payments; JOBS, Pre-TANF, REF, REP, SFPSS, TANF)) for other than the intended purpose.(E)
A payment for child care when the client was not engaged in an activity that made the client eligible for child care, such as an activity of the JOBS program (see OAR 461-001-0025 (Definitions of Terms, Components, and Activities; JOBS, Pre-TANF, TANF) and OAR 461-190-0151 (Case Planning; JOBS, Pre-TANF, REP, SFPSS, TA-DVS) to OAR 461-190-0401 (Applicability)).(F)
A payment for child care when the client was not eligible for child care benefits.(G)
The failure of a client to pay their entire share of the cost of services or the participant fee (see OAR 461-160-0610 (Client Liability; OSIPM (except OSIPM-EPD)) and 461-160-0800 (Determining Participant Fee; OSIP-EPD, OSIPM-EPD (Including In-Home Services))) in the month in which it is due.(H)
An overpayment caused by a client giving an electronic benefit transfer (EBT) card, card number, or personal identification number (PIN) to a provider for the purpose of checking a child in or out from the provider’s child care.(I)
In the REF, SFPSS, and TANF programs, an overpayment caused by the client using or accessing cash benefits in any electronic benefit transaction in any liquor store; casino, gambling, or gaming establishment; retail establishment that provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment; or marijuana dispensary (see OAR 461-165-0010 (Legal Status of Benefit Payments)).(c)
A fraud overpayment is an overpayment determined to be an intentional program violation (see OAR 461-195-0601 (Intentional Program Violations; Defined) and 461-195-0611 (Intentional Program Violations; Establishment and Appeal)) or substantiated through a criminal prosecution.(d)
In the SNAP program, a provider error overpayment is an overpayment made to a drug or alcohol treatment center or residential care facility that acted as a client’s authorized representative.(e)
In the child care program, a provider error overpayment is a payment made by the Department on behalf of a client to a child care provider when:(A)
Paid to an ineligible provider; or(B)
The payment exceeds the amount for which a provider is eligible.(5)
When an overpayment is caused by both an administrative and client error in the same month, the Department determines the primary cause of the overpayment and assigns as either an administrative or client error overpayment.(6)
In the TANF and TA-DVS programs, when an overpayment puts the client at greater risk of domestic violence (see OAR 461-001-0000 (Definitions for Chapter 461)), the overpayment is waived (see OAR 461-135-1200 (Specific Requirements; TA-DVS)).(7)
Except as provided in section (8) of this rule, the Department establishes an overpayment when the following thresholds are exceeded:(a)
Administrative error overpayments concerning:(A)
Cash and child care programs, when the amount is greater than $200;(B)
SNAP open case, when the amount is greater than $100; and(C)
SNAP closed case, when the amount is greater than $200.(b)
Client error overpayments in:(A)
Cash and child care programs, when the amount is greater than $200;(B)
SNAP open case, when the amount is greater than $100;(C)
SNAP closed case, when the amount is greater than $200;(D)
Medical programs, when the amount is greater than $750.(c)
Provider error overpayments in:(A)
Cash and child care programs, when the amount is greater than $200;(B)
SNAP open case, when the amount is greater than $100;(C)
SNAP closed case, when the amount is greater than $200.(8)
There are no overpayment thresholds in all of the following situations:(a)
In SNAP program, if the overpayment was identified in a quality control review.(b)
In all programs, if the overpayment was caused by a client’s receipt of continuing benefits in a contested case.(c)
In all programs, if the overpayment was caused by possible fraud by a client or provider.
Source:
Rule 461-195-0501 — Definitions and Categories of Overpayments, https://secure.sos.state.or.us/oard/view.action?ruleNumber=461-195-0501.