Or. Admin. Code § 461-195-0501
Current through Register Vol. 63, No. 12, December 1, 2024
Section 461-195-0501 - [Effective 2/18/2025] Definitions and Categories of OverpaymentsThis rule applies to benefits and services delivered under chapters 410, 411, 414, and 461 of the Oregon Administrative Rules.
(1) "Overpayment" means: (a) A benefit or service received by or on behalf of a recipient (see OAR 461-195-0301), or a payment made by the Department (see OAR 461-195-0301) on behalf of a recipient, that exceeds the amount for which the recipient 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 Refugee Assistance (REF) program, there is a rebuttable presumption that the full amount of cash benefits was improperly spent in violation of OAR 461-165-0010(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);(ii) Any casino, gambling casino, or gaming establishment (see OAR 461-165-0010);(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 State Family Pre-SSI/SSDI (SFPSS) and Temporary Assistance for Needy Families (TANF) programs, there is a rebuttable presumption that the full amount of cash benefits was improperly spent in violation of OAR 461-165-0010(9)(a) when cash benefits are used or accessed in Oregon, outside of Oregon, or on Tribal lands at:(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 recipient that: (A) Is paid to an ineligible provider;(B) Exceeds the amount for which a provider is eligible;(C) Is paid when the recipient was not engaged in an activity that made the recipient eligible for child care, such as an activity of the Job Opportunity and Basic Skills (JOBS) program (see OAR 461-001-0025 and OAR 461-190-0151 to OAR 461-190-0401); or(D) Is paid when the recipient was not eligible for child care benefits.(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 recipient receives a retroactive Supplemental Security Income (SSI) lump sum payment.(g) In the Temporary Assistance for Domestic Violence Survivors (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) 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) of eligibility under circumstances including, but not limited to: (a) The filing group (see OAR 461-110-0310 and 414-175-0015), ineligible student, or authorized representative (see OAR 461-115-0090 and 414-175-0002) 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) Retroactively effective April 21, 2021, for medical assistance the Department:(a) Shall not establish an administrative error overpayment,(b) Shall not establish a client error overpayment unless an individual received unreduced liability or unreduced benefits pending a contested case hearing decision or other final order favorable to the Department, and(c) May establish a fraud overpayment when a court determines the individual made a false or misleading statement or misrepresented, concealed, or withheld a fact for the purpose of establishing or maintaining eligibility.(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, ineligible student, or authorized representative of a change covered under OAR 461-170-0011 or 414-175-0060 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, ineligible student, or authorized representative;(D) In the General Assistance (GA) and SFPSS programs, the Department fails to require a recipient to complete an interim assistance agreement; or(E) The Department commits a procedural error that was no fault of the filing 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, ineligible student, or authorized representative to declare or report information or a change in circumstances as required under OAR 461-170-0011 or 414-175-0060, including information available to the Department, that affects the recipient's eligibility to receive benefits or the amount of benefits.(B) A recipient's unreduced liability or receipt of unreduced benefits pending a contested case hearing decision or other final order favorable to the Department.(C) A recipient's failure to return a benefit known by the recipient to exceed the correct amount.(D) A recipient's use of a JOBS or SFPSS program support payment (see OAR 461-190-0211) for other than the intended purpose.(E) A payment for child care when the recipient was not eligible for child care benefits.(F) The failure of a recipient to pay their entire share of the cost of services or the participant fee (see OAR 461-160-0610 and 461-160-0800) in the month in which it is due.(G) In the REF, SFPSS, and TANF programs, an overpayment caused by the recipient 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).(c) A fraud overpayment is an overpayment determined to be an intentional program violation (see OAR 461-195-0601 and 461-195-0611) or substantiated through a court determining the individual made a false or misleading statement or misrepresented, concealed, or withheld a fact for the purpose of establishing or maintaining eligibility.(d) In the Supplemental Nutrition Assistance Program (SNAP), a provider error overpayment is an overpayment made to a drug or alcohol treatment center or residential care facility that acted as a recipient's authorized representative.(e) In a child care program, a provider error overpayment is a payment made by the Department on behalf of a recipient 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 recipient at greater risk of domestic violence (see OAR 461-001-0000), the overpayment is waived (see OAR 461-135-1200).(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; and(C) SNAP closed case, when the amount is greater than $200.(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 recipient's receipt of continuing benefits in a contested case.(c) In all programs except Summer EBT (SEBT), if the overpayment was caused by possible fraud by a recipient or provider.(9) In the SEBT program, the Department (see 461-196-0020) establishes an overpayment when OAR 461-196-0160 subsections (1)(a) through (1)(c) are true.Or. Admin. Code § 461-195-0501
AFS 3-2000, f. 1-31-00, cert. ef. 2-1-00; AFS 7-2001(Temp), f. & cert. ef. 4-4-01 thru 6-30-01; AFS 12-2001, f. 6-29-01, cert. ef. 7-1-01; SSP 33-2003, f. 12-31-03, cert. ef. 1-4-04; SSP 14-2005, f. 9-30-05, cert. ef. 10-1-05; SSP 11-2007(Temp), f. & cert. ef. 10-1-07 thru 3-29-08; SSP 14-2007, f. 12-31-07, cert. ef. 1-1-08; SSP 15-2007(Temp), f. 12-31-07, cert. ef. 1-1-08 thru 3-29-08; SSP 5-2008, f. 2-29-08, cert. ef. 3-1-08; SSP 13-2009, f. & cert. ef. 7-1-09; SSP 38-2009, f. 12-31-09, cert. ef. 1-1-10; SSP 25-2011, f. 9-30-11, cert. ef. 10-1-11; SSP 7-2013(Temp), f. & cert. ef. 3-25-13 thru 9-21-13; SSP 23-2013, f. & cert. ef. 9-20-13; SSP 36-2013(Temp), f. & cert. ef. 11-1-13 thru 4-30-14; SSP 9-2014, f. & cert. ef. 4-1-14; SSP 19-2015, f. & cert. ef. 7/1/2015; SSP 23-2016, f. 6-28-16, cert. ef. 7/1/2016; SSP 45-2016, f. 12-20-16, cert. ef. 1/1/2017; SSP 27-2021, amend filed 03/24/2021, effective 4/1/2021; SSP 46-2021, temporary amend filed 09/10/2021, effective 9/10/2021 through 3/8/2022; SSP 29-2022, amend filed 02/24/2022, effective 3/1/2022; SSP 20-2023, amend filed 06/22/2023, effective 7/1/2023; SSP 31-2024, minor correction filed 04/25/2024, effective 4/25/2024; SSP 47-2024, temporary amend filed 08/23/2024, effective 8/23/2024 through 2/18/2025; SSP 58-2024, amend filed 11/27/2024, effective 12/1/2024Statutory/Other Authority: ORS 409.050, 411.060, 411.070, 411.081, 411.404, 411.816, 412.001, 412.014, 412.049 & HB 2089 (2013 Section 10)
Statutes/Other Implemented: 411.060, 411.070, 411.081, 411.404, 411.816, 412.001, 412.014, 412.049, ORS 409.010, 411.620, 411.640, 411.690, 411.892, 414.025, 416.350, 7 CFR 273.18, 42 U.S.C. 608 & 412.072