Or. Admin. R. 461-195-0501 - Definitions and Categories of Overpayments
This rule applies to benefits and services delivered under chapters 410, 411, and 461 of the Oregon Administrative Rules.
(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(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 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(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 and 461-190-0151 to
461-190-0401);
(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) 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) 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),
ineligible student, or authorized representative (see OAR 461-115-0090)
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 (see OAR 461-115-0090) of a
change covered under OAR 461-170-0011 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 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, 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, 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) 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 and OAR 461-190-0151 to OAR 461-190-0401).
(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 and 461-160-0800) 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).
(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 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 a 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), 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 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.
Notes
Statutory/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: ORS 409.010, 411.060, 411.070, 411.081, 411.117, 411.404, 411.620, 411.640, 411.690, 411.816, 411.892, 412.001, 412.014, 412.049, 414.025 & 416.350
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