Or. Admin. Code § 461-195-0521

Current through Register Vol. 63, No. 12, December 1, 2024

Section 461-195-0521 - [Effective until 2/18/2025] Calculation of Overpayments

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.

Or. Admin. Code § 461-195-0521

AFS 3-2000, f. 1-31-00, cert. ef. 2-1-00; AFS 25-2000, f. 9-29-00, cert. ef. 10-1-00; AFS 6-2001, f. 3-30-01, cert. ef. 4-1-01; AFS 27-2001, f. 12-21-01, cert. ef. 1-1-02; AFS 22-2002, f. 12-31-02, cert ef. 1-1-03; SSP 23-2003, f. & cert. ef. 10-1-03; SSP 4-2005, f. & cert. ef. 4-1-05; SSP 10-2006, f. 6-30-06, cert. ef. 7-1-06; SSP 20-2003, f. & cert. ef. 8-15-03; SSP 7-2007, f. 6-29-07, cert. ef. 7-1-07; SSP 14-2007, f. 12-31-07, cert. ef. 1-1-08; SSP 8-2008, f. & cert. ef. 4-1-08; SSP 6-2009(Temp), f. & cert. ef. 4-1-09 thru 9-28-09; SSP 13-2009, f. & cert. ef. 7-1-09; SSP 28-2009, f. & cert. ef. 10-1-09; SSP 38-2009, f. 12-31-09, cert. ef. 1-1-10; SSP 17-2011, f. & cert. ef. 7-1-11; SSP 25-2011, f. 9-30-11, cert. ef. 10-1-11; SSP 13-2013, f. & cert. ef. 7-1-13; SSP 17-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SSP 26-2013, f. & cert. ef. 10-1-13; 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 2-2016, f. & cert. ef. 1/1/2016; SSP 25-2016(Temp), f. 6-30-16, cert. ef. 7-1-16 thru 12-27-16; SSP 31-2016, f. & cert. ef. 9/1/2016; SSP 5-2019, temporary amend filed 02/27/2019, effective 03/01/2019 through 06/30/2019; SSP 15-2019, amend filed 06/11/2019, effective 7/1/2019; 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 47-2024, temporary amend filed 08/23/2024, effective 8/23/2024 through 2/18/2025

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