OAR 461-195-0521
Calculation of Overpayments
(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, HSD medical programs (see OAR 461-001-0000 (Definitions for Chapter 461)) eligibility determination group (see OAR 410-200-0015 (General Definitions)), ineligible student, or authorized representative (see OAR 461-115-0090 (Authorized Representatives; General) and OAR 410-200-0015 (General Definitions)) 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 ERDC, REF, SNAP, and 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 (General Definitions)) 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, HSD medical programs eligibility determination 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 division 410-200) 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) and the actual income differs from the amount determined under OAR 461-150-0020 (Prospective Eligibility and Budgeting)(2), there may be a client error overpayment (see OAR 461-195-0501 (Definitions and Categories of Overpayments)) 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)
When using anticipated income for the HSD medical programs and the actual income differs from the amount determined under OAR 410-200-0310 (Eligibility and Budgeting; MAGI Medicaid/CHIP), there may be a client error overpayment only when the HSD medical programs eligibility determination group or authorized representative (see OAR 410-200-0015 (General Definitions)) knowingly 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.(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 (Earned Income Deduction; REF, REFM, and TANF), 461-160-0190, 461-160-0430 (Income Deductions; SNAP), 461-160-0550 (Income Deductions; Non-SSI OSIP (except OSIP-EPD) and OSIPM (except OSIPM-EPD) in the Community When There Are No Children in the Household Group), and 461-160-0552 (Income Deductions; Qualified Medicare Beneficiaries Programs)) is applied as follows:(a)
In the OSIP, OSIPM, QMB, and 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 (6) of this rule) exists.(7)
For the purposes of OAR 461-195-0501 (Definitions and Categories of Overpayments) to 461-195-0561 (Compromise of an Overpayment Claim), “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 (Definitions for Chapter 461)). 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)
In the medical programs, the amount of the cash medical support the Department retains each month is excluded income and not used to determine eligibility for medical program benefits. When an individual has incurred a medical program 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:(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 (Notice Period), OAR 410-200-0120 (Notices)) 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 (Authorized Representatives; General) and OAR 410-200-0015 (General Definitions)) failed to report a change within the reporting time frame under OAR 461-170-0011 (Changes That Must Be Reported) or OAR 410-200-0235 (Changes That Must Be Reported); 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 (see OAR 461-115-0090 (Authorized Representatives; General) and OAR 410-200-0015 (General Definitions)) 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 (Benefit Group)) was categorically eligible under OAR 461-135-0505 (Categorical Eligibility for SNAP), 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 (Client Liability; OSIPM (except OSIPM-EPD))) or the OSIP-EPD or OSIPM-EPD program participant fee (see OAR 461-160-0800 (Determining Participant Fee; OSIP-EPD, OSIPM-EPD (Including In-Home Services))) 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 (Special Needs; Overview) to 461-155-0710 (Special Need; Diversion Services; OSIP and OSIPM); and(H)
Home and community-based care (see OAR 461-001-0030 (Definitions; OSIP, OSIPM Long-Term Care or Home and Community-Based Care)), 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.(15)
In the HSD medical programs, OSIPM, QMB, and REFM programs if the individual was not eligible for one program, but during the period in question was eligible for another program:(a)
With the same benefit level, there is no overpayment.(b)
With a lesser benefit level, the overpayment is the amount of medical program benefit payments made on behalf of the individual exceeding the amount for which the individual was eligible.(16)
When an overpayment is caused by administrative error (see OAR 461-195-0501 (Definitions and Categories of Overpayments)), any overpayment of GA, OSIP, REF, SFPSS, or TANF program benefits is not counted as income when determining eligibility for the HSD medical programs, OSIPM, and REFM programs.(17)
Credit against an overpayment is allowed as follows:(a)
In the GA, REF, and TANF programs, a credit is allowed for an individual’s payment for medical services 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 (Dependent Care Costs; Deduction and Coverage) and 461-160-0430 (Income Deductions; SNAP).(c)
In all programs, for an underpayment of benefits in the program in which the overpayment occurred.(18)
In the REF program, when an individual used or accessed cash benefits in violation of OAR 461-165-0010 (Legal Status of Benefit Payments)(8)(a), the amount of the overpayment is the amount of cash benefits the individual used or accessed.(19)
In the SFPSS and TANF programs, when an individual used or accessed cash benefits in violation of OAR 461-165-0010 (Legal Status of Benefit Payments)(9)(a), the amount of the overpayment is the amount of cash benefits the individual used or accessed.
Source:
Rule 461-195-0521 — Calculation of Overpayments, https://secure.sos.state.or.us/oard/view.action?ruleNumber=461-195-0521.