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.
When a filing group, HSD medical
(see OAR 461-001-0000
) eligibility determination
(see OAR 410-200-0015
), ineligible student, or
(see OAR 461-115-0090
) 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
(b) In the ERDC, REF, SNAP,
and TANF programs, an individual's actual self-employment income is annualized
retrospectively to calculate the overpayment.
In the HSD medical
, if actual income is not available for the months in which an
occurred, an individual's actual self-employment
income (see OAR 410-200-0015
) received during the year when an
occurred is annualized to calculate an
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.
The Department establishes, calculates,
and determines an administrative error overpayment
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
(a) Correct prospective budgeting
(see OAR division 461-150) 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.
When using prospective budgeting (see OAR
division 461-150) and the actual income differs from the amount determined
under OAR 461-150-0020
(2), there may be a client error
(see OAR 461-195-0501
) only when the filing group,
ineligible student, or authorized representative
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
(5) The Department uses actual income to
determine the amount of a medical assistance overpayment
caused by possible fraud.
a filing group, ineligible student, or authorized
fails to report all earned income within the reporting
time frame, the earned income deduction (see OAR 461-160-0160
, and 461-160-0552
) 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.
(c) In the SNAP program, no deduction is
applied to earned income if the amount or source of income was not timely
purposes of OAR 461-195-0501
, "good cause" means circumstances
beyond the individual's reasonable control that caused the individual to be
unable to report income timely and accurately.
When support is retained:
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
(see OAR 461-001-0000
). When an individual is not
eligible for TANF program benefits, the overpayment
by the support the Department of Justice retains as a current
(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.
In the REF and TANF programs, when an
individual directly receives support used to determine
or calculate benefits, the
(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.
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
(a) The amount of the payment
from the Department;
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.
Benefits paid during a required
(see OAR 461-175-0050
, OAR 410-200-0120
included in the calculation of the overpayment
The filing group, HSD medical programs
eligibility determination group
, ineligible student, or
(see OAR 461-115-0090
) failed to report a change within the reporting time frame under
or OAR 410-200-0235
Sufficient time existed for the
Department to adjust the benefits to prevent the overpayment
if the filing group, HSD medical programs eligibility determination
, ineligible student, or authorized
(see OAR 461-115-0090
and OAR 410-200-0015
reported the change at any time within the reporting time frame.
In the SNAP program, if the
(see OAR 461-110-0750
) was categorically
eligible under OAR 461-135-0505
, there is no overpayment
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 OSIP-EPD or OSIPM-EPD program
(see OAR 461-160-0800
) in the month in which
it is due, an overpayment
is calculated as follows:
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:
(B) Long term care
(C) Medical expenses for
the month in question;
buy-in (when not concurrently eligible for an MSP);
(E) Medicare Part D;
(F) Mileage reimbursement;
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
(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
(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.
Credit against an
is allowed as follows:
(a) In the 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.
In the SNAP program, if the
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
(c) In all programs, for an underpayment of
benefits in the program in which the overpayment
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
is the amount of cash benefits the individual used
In the 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
the amount of cash benefits the individual used or accessed.
Or. Admin. R.
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;
19-2015, f. & cert. ef.
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;
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;
15-2019, amend filed 06/11/2019, effective
27-2021, amend filed 03/24/2021, effective
46-2021, temporary amend filed 09/10/2021, effective
9/10/2021 through 3/8/2022;
29-2022, amend filed 02/24/2022, effective
To view tables referenced in rule text,
click here to view
Statutory/Other Authority: ORS
Statutes/Other Implemented: ORS