The CAO will take the following actions upon discovery of a possible overpayment: enter the overpayment data into the Automated Restitution and Referral and Computation (ARRC) system; explore the facts that caused the overpayment; obtain verification to decide if an overpayment did or did not occur; determine the type of error that caused the overpayment; update the ARRC system and refer the overpayment to the OIG. If for any reason the overpayment can't be entered into ARRC, the CAO must complete the OIG 189 to refer the overpayment.
NOTE: A completed OIG 189 has to be completed for Cash Assistance, but the Cash computations sheet does not need to be completed.
The CAO will take the above actions, except referring the overpayment through ARRC for Buy-in, LTC, LIHEAP and SSP cases. Instead of entering information into ARRC, the CAO must complete the OIG 189. See Appendix A.
When the CAO discovers information that may lead to a possible Cash Assistance, MA, or Diversion benefit overpayment, the CAO will complete an Overpayment Referral Data Input Form and enter the data into the ARRC system within 30 workdays from the date the information was verified.
When the CAO discovers a possible SNAP overpayment, the CAO will enter the data into the ARRC system within 10 workdays from the date the overpayment was identified.
The ARRC system will track and monitor the potential overpayment, generate verification request forms, create alerts for follow-up actions, establish the overpayment and calculate the claim amount (excluding MA) when verification is received, and refer the overpayment to the OIG for recovery.
MA claim amount calculations are completed outside of ARRC according to instructions in Appendix A. The claim amount is then entered on the ARRC ARCAFA screen.
NOTE: Data on possible overpayments caused by wages that are discovered through a review of an IEVS match will be automatically entered from IEVS into the ARRC system for tracking and monitoring purposes. The automated entry of a possible overpayment on the ARRC system will occur when the worker requests verification through IEVS.
NOTE: For manual referrals, enter the claim in ARRC and answer question #1 on the ARCAFQ screen with “M” indicating manual referral (paper OIG 189 completed).
The CAO will explore a possible overpayment in the same way as any other determination of eligibility. The CAO will use methods appropriate to each situation and to different eligibility factors.
When investigating possible overpayments, the CAO will neither infringe on the civil liberties of individuals, nor interfere with or violate due process of law. The CAO will not:
forcibly enter a home;
search a home;
enter a home under false pretenses;
question an individual based on a presumption of guilt;
use any other method which violates personal dignity or privacy or that constitutes harassment of the individual; or
make home visits during normal sleeping hours, generally 10 p.m. to 7 a.m. The CAO will not visit the individual outside of normal working hours or on weekends unless the visits were previously scheduled with the individual.
Whenever possible, the CAO will discuss the finding of a possible overpayment with the individual and inform him that an overpayment will be referred to the OIG for appropriate action.
The CAO has four weeks from the date that a possible overpayment was first identified to secure verification of the overpayment. Verification is a document that shows the income or resources, or the change(s) in circumstances that caused the overpayment. For possible overpayments that the CAO does not refer through the ARRC system, the date the information which caused the overpayment was first identified and the date a verification request was sent to a third party must be noted in the case record.
NOTE: For a possible overpayment caused by wages and identified through a review of an IEVS match, the date the information which caused the overpayment was identified and the date a verification request was sent to an employer is automatically recorded in and monitored by the ARRC system. If the employer fails to respond to the first request, it will be necessary for the CAO to verify the employer address before regenerating the second PA 78. If the CAO is unable to verify the address, there is no overpayment referred. If the address is correct or an address correction has been entered, the ARRC system will generate a second request. If the employer fails to respond to the second request, there will be no overpayment.
NOTE: For employers, who specifically state they will not cooperate, the CAO Executive Director should provide the OIG BFPP Bureau Director with written details via a memo of their attempts at obtaining the information from the employer as well as who they spoke with at the employer and exactly what the employer said about refusing to return the information. The CAO should not regenerate another PA 78.
Sources of verification include, but are not limited to, the individual, the case record, banks, doctors, employers, law enforcement agencies, school administrators, and reliable third party sources familiar with the event or reason that caused the overpayment.
Written verification may be in the form of any document that identifies the source and beginning date of the change in circumstances or the resource that caused the overpayment. If the cause of the overpayment is financial, the verification document must provide amounts and receipt dates. An overpayment will not be referred to the OIG without written verification of the overpayment.
The following items are examples of acceptable verification documents:
Pay stubs;
PA 73 – US Civil Service Information;
PA 76 – Request for Financial Information form – Bank, savings & loan, credit union information;
PA 78 – Request for Employment Information form – Earned income, employer medical insurance, employer sick benefit information;
PA 79 – Real property, court house information;
PA 83-Z – Insurance information;
PA 84-M – Motor vehicle information;
PA 84-R – Railroad Retirement information;
PA 84-W – Workers’ Compensation information;
PA 176-NR – Nonresident property agreement;
SSA 1610 – Social Security, SSI, and Black Lung benefit information;
Bank records, public records, or letters from a landlord, employer, school, or other public or private agency. If the verification is from a third party source, the CAO will note in the case record or on the document the name and title of the person who provided the information and the date it was received; and
Contacting employer by telephone and narrating the contact name and telephone number.
Insufficient wage information from employers occurs when a returned Request for Employment Information Form does not provide wage data broken down on a payday-by-payday basis for the time period requested. Summary reports of quarterly or semiannual wage data cannot be substituted for payday-by-payday data or used as verification that an overpayment occurred. The CAO should attempt to obtain payday-by-payday wage data through alternative means.
The following are examples of acceptable alternative means of obtaining wage data:
obtain all individual pay stubs or wage records from the individual;
attempt additional contact with the employer, the Personnel or Payroll Office, to obtain the information;
determine if the employer can provide the data by another means, e.g., hourly rate of pay and number of hours worked; or
work number of employer.
If the attempt to obtain payday-by-payday wage data is unsuccessful, the CAO will not refer the overpayment to the OIG. If the proper wage data is received within five years from the date the overpayment was first identified, the CAO will refer the overpayment to the OIG.
PO-17659-910; Individual and Administrative Errors and Overpayments; 8/17/2015
The CAO will review the facts to determine the type of error that caused the overpayment. The types of error are: administrative error; and individual error. Individual error overpayments occur when an individual takes an action or fails to take an action causing any individual to receive benefits for which that individual is not eligible.
Administrative errors occur when DHS takes an action or fails to take an action causing an individual to receive benefits for which that individual is not eligible.
NOTE: For MA, Buy-In and LIHEAP only, overpayments caused by administrative error are not referred to the OIG. All overpayments caused by individual error, intentional or unintentional are referred.
For SNAP and Cash Assistance, all overpayments without regard to type of error are referred to the OIG.
Situations when the overpayment is caused by administrative error include but are not limited to the following:
The CAO failed to obtain signature(s) or correct signature(s) on the application form;
The CAO failed to act in the required timeframe on a reported change;
The CAO computed income or deductions incorrectly
The CAO misapplied regulations;
The CAO issued a benefit, or Pennsylvania ACCESS card incorrectly;
The CAO issued a duplicate benefit or one-time issuance (OTI);
The CAO continued SNAP benefits after the certification expired and without renewal;
The CAO failed to secure or act on information;
The CAO failed to reduce SNAP benefits because of a change in a cash assistance payment; or
The CAO failed to disqualify an individual timely from the cash/SNAP program.
The CAO failed to close an SSP-Only budget timely (according to information provided by the SSP Central Unit) resulting in the issuance of an SSP-Only benefit for which the individual was not eligible.
Situations when the overpayment is caused by individual error include but are not limited to the following:
An individual misunderstood the responsibility to provide the CAO with information;
An individual failed to disclose information or facts without intent to receive benefits the individual is not otherwise entitled to receive;
An individual failed to meet usual reporting requirements due to circumstances beyond the individual’s control, such as serious illness, death, or accident;
An individual failed to provide correct or complete information with good cause;
An individual received benefits, or more benefits than the individual is entitled to receive, pending a fair hearing decision in favor of the CAO;
An individual received benefits due to prospective ineligibility; or
An individual received TANF cash assistance for a period covered by a diversion benefit.
An individual intentionally made a false or misleading statement
An individual misrepresented, concealed, or withheld a fact;
An individual acted to mislead about, misrepresent, conceal, lie about, or withhold a material fact;
An individual deliberately failed to report a change in circumstances;
An individual used the Pennsylvania ACCESS or managed care plan identification card after the effective date of ineligibility for MA program benefits;
An individual traded or sold SNAP benefits;
An individual used SNAP benefits to buy ineligible items such as alcoholic drinks or tobacco;
An individual used SNAP benefits to buy illegal drugs, firearms, ammunition, or explosives;
An individual used another household’s SNAP benefits;
An individual secured forged prescriptions for drugs;
An individual allowed other persons to use the Pennsylvania ACCESS or managed care plan card; or
An individual “shopped” by obtaining the same prescription from different doctors;
An individual reported untimely or failed to report a change in circumstances to the SSA that subsequently causes an SSI individual to be ineligible for the SSP.
The CAO determines if the overpayment appears to be caused by the individual’s willful withholding of information.
The CAO must have told the individual what information is required and the course of action or lack of action and the individual must have understood.
The CAO will consider the following factors in making its recommendation:
Actions and attitudes of the individual
Did the individual deny the facts that caused the overpayment?
Did the individual provide information that was misleading or incorrect?
Were any of the individual’s actions directed to hiding information?
Example: Defacing or altering documents, or arranging appointments with the CAO so as to conceal other activities would be considered hiding information.
How did the individual react? What did the individual see as the cause?
Nature of the overpayment
Was the overpayment in such an amount that the individual could not have failed to realize that the assistance payment amount was not correct?
Did the overpayment cover such a long period of time that the individual had repeated opportunities to report?
Were there previous overpayments for related reasons?
Ability of the individual to understand requirements
Does the individual have any physical disabilities or illness which affects his/her ability to understand the requirements and his/her responsibilities?
Examples: Advanced age, defective hearing, or poor vision.
Does the individual have any mental limitations that affect his/her understanding of his/her responsibilities?
Examples: Emotional or psychiatric disturbances or mental retardation.
Does the individual have any social handicaps that affect his/her understanding of the requirements?
Examples: Illiteracy, language barriers, or lack of education.
Was the individual so involved in a serious situation at the time of the overpayment that his/her understanding of the importance of meeting reporting requirements was affected?
Examples: Death of a family member, accident, serious illness, or desertion.
County Assistance Office actions
Does the case record show that the CAO explained the pertinent regulations in a manner that the individual could understand?
Did the CAO work out appropriate reporting plans with the individual?
Did the CAO complete redeterminations of eligibility as often as appropriate to the situation?
Did the CAO realistically evaluate the individual’s ability to understand and work with the individual in such a way as to show the individual the importance of reporting changes in circumstances?
NOTE: When the overpayment is referred to the OIG, the CAO must detail, in case comments, the circumstances leading to the overpayment including factors which may indicate that an individual error was intentional or unintentional. The OIG will determine whether prosecution is indicated.
NOTE: Ensure all verifications are scanned into the county record for the OIG to review.
If a SNAP overpayment occurs due to incorrect information from an alien's sponsor, the CAO will determine whether the sponsor had good cause for not providing the correct information.
Good cause exists when:
circumstances beyond the control of the sponsor, such as serious illness, death, or accident, make it impossible to meet the full reporting requirements; or
the sponsor acted reasonably and prudently but unknowingly gave incorrect information.
If good cause does not exist, the OIG will decide whether the sponsor, alien, or both should be held liable for repayment.
The sponsor is entitled to a fair hearing to question either the amount of the claim or the determination that he/she was at fault when he/she gave incorrect information.
The ARRC system may compute up to 30 months of the claim period prior to the overpayment discovery date for Cash Assistance and SNAP claims. The OIG will compute the portion of a Cash Assistance claim period that exceeds the ARRC system computation limits. The CAO will, upon request from the OIG, compute the portion of a SNAP claim period that exceeds the ARRC system computation limits. The OIG will compute LTC overpayment claims and manual cash overpayments.
NOTE: The CAO will compute MA claims according to instructions found in Appendix A.
The OIG will notify the CAO if a SNAP overpayment claim period needs to be calculated past the ARRC system computation limits. These claims are marked for prosecution or administrative disqualification hearings. The CAO will compute the portion of the claim for the months identified by the OIG. These claims are not entitled to the earned income deductions.
When the overpaid budget group contains only mandatory budget group members, the claim is a total liability claim. The ARRC system will consider all of the assistance the budget group received during the overpayment period to compute the total liability claim amount.
When the overpaid budget group contains both mandatory and non-mandatory budget group members, the claim is a non-total liability claim. The ARRC system will use only the assistance received during the overpayment period, by the member who caused the overpayment and his/her dependents, to compute the non-total liability claim amount. The portion of assistance received by the overpaid members of a non-total liability claim is the incremental share of assistance. The incremental share is the difference between:
the family size allowance of the budget group with the overpaid individual and the overpaid individual’s legally responsible relatives in the budget group; and
the family size allowance of the budget group without the overpaid individual and the overpaid individual’s legally responsible relatives.
The ARRC system will apply the prospective determination and prospective budgeting principles of Chapter 167 in the Cash Assistance Handbook to determine the claim period.
For income overpayments that begin on or after May 27, 2003 but before August 1, 2005, the claim period begins with the first assistance payment authorized, 10 days from the date following the receipt of the unreported, late reported, or partially reported income
For income overpayments that begin on or after August 1, 2005, ARRC will begin the overpayment with the first benefit issued on or after the eleventh day of the month following the month the income was received. The claim period ends with the date prior to the assistance date where the income is adjusted to the budget; or the date prior to case closure; or the date prior to the assistance date that would have last been affected by the income.
The ARRC system will not allow the same budgeting disregards, work expense deductions, and income incentives the CAO allows in determining eligibility in computing the overpayment claim.
55 Pa. Code § 255.4(d)(1)(iii)
See Appendix E for ARRC Semi-Annual Reporting (SAR) cash claim computation methodology.
Budgeting disregards, work expense deductions, and income incentives are not deducted from earned income if the Cash Assistance individual failed, without good cause, to report earnings on a timely basis.
55 Pa. Code § 255.4(d)(1)(iii)(B)
The amount of the overpayment claim is the:
amount of unreported gross earned income, if that amount is less than the amount of assistance received during the overpayment period; or the amount of assistance received during the overpayment period, if the unreported gross earned income is greater
total amount of assistance received during the period of the overpayment when the overpayment was due to the failure to report a change in a condition of eligibility or was caused by resources that exceeded the resource limit; or
difference between the assistance received during an overpayment caused by an unreported decrease or overstatement of the family size, or the ineligibility of one or more but not all of the family unit members; and the assistance that the CAO would have authorized if the CAO knew the correct circumstances for the same period; or
difference between the amount of the special allowance received during the period of an overpayment caused by an unreported decrease or overstatement of special need, and the amount of the special allowance that would have been authorized if the decrease in need was reported timely or the true amount for a special need was known during the same time period.
The ARRC system (for electronic referrals) or the CAO (for paper referrals) will:
1. Determine when the overpayment began:
If the household failed to provide correct information at application, the overpayment begins the date benefits were issued.
If the individual or CAO did not act timely, the overpayment begins the first month in which the allotment would have been adjusted if the individual or CAO was timely. Allow 10 days for the individual to report a change and 10 days for the CAO to act. If an Advance Notice is required, assume the advance notice period expired without a request for a fair hearing.
NOTE: The first month in which the change would have been effective can never be more than two months from the month of the change.
For an employment and training special allowance, the overpayment begins the date the special allowance was issued.
2. Determine when to begin calculating the overpayment claim:
For agency error, count 12 months prior to the date of the identification. Use the first month of overissuance within the 12-month period as the claim period start date.
Example 1: Sally K. begins working April 2006 and reports her income timely. The CAO does not adjust her income until October 2008. The overissuance begins April 2006; however, the overpayment calculation begins November 2007, which is 12 months prior to the date of overpayment discovery.
Example 2: Suzie B. begins working June 2008 and reports her income timely. The CAO does not adjust her income until December 2008. The overissuance begins June 2008, which is within the 12-month time period. The overpayment calculation begins June 2008.
For individual error claims, count 24 months prior to the date of identification and use the first month of overissuance within the 24-month period as the claim period start date.
Example 1: Sally K. begins working October 2006 and does not report her income. The CAO discovers her income October 2009. The overissuance begins October 2006; however, the overpayment calculation begins November 2007, which is 24 months prior to the date of overpayment discovery.
Example 2: Suzie B. begins working December 2008 and does not report her income. The CAO discovers her income October 2009. The overissuance begins December 2008, which is within the 24-month time period. The overpayment calculation begins December 2008.
The CAO will:
1. Determine the SNAP budgeting method by entering (A= Application month, R=Re-certification month, W=Within the budget period and either a SAR code 1=SAR household (130% of the FPIG), or SAR code 6=non-SAR household ($125 threshold)) for the SNAP overpayment claim and enter the codes on the overpayment referral data input form or on the reverse side of the request for employment information form.
2. Promptly, upon request and as identified by the OIG, calculate the portion of a claim period that exceeds the ARRC claim calculation limits. Complete a SNAP Overissuance Computation Sheet for the claim period. See Appendix C, for instructions on completing the SNAP Overissuance Computation Sheet, OIG 711C.
NOTE: Do not allow the earned income deduction when calculating the claim amount for an overpayment claim where the individual did not report earned income timely. Use other allowable expenses and the appropriate budgeting methodology. Annual or quarterly summary reports on wages that were earned weekly or monthly are not averaged to arrive at a weekly or monthly figure.
If an underpayment occurred for any month(s) during the period of overpayment, the household is eligible for restored benefits. Complete an Offsetting Overissuance Against Restored Benefits form and attach it to the Overpayment Referral. The OIG will offset the restored benefits against the claim. See SNAP Handbook Chapter 581, Restoring Benefits.
3. Promptly, upon request by the OIG, recalculate any supplemental benefits issued during the overpayment period to exclude the earned work deduction.
See Appendix E for ARRC Semi-Annual Reporting (SAR) SNAP claim computation methodology.
The Office of Medical Assistance Programs (OMAP) computes claims and collects overpayments caused by provider error and fraud. The OIG computes LTC and waiver overpayments and collects all non-provider MA claims. OIM computes all other non-provider MA claims. Claims are determined based on services paid for through the Health Care Benefit Package the individual was assigned to during the period of the overpayment, less the services of the Health Care Benefit Package the individual would have been assigned to if the facts regarding the overpayment were known.
Reminder: The CAO only calculates and refers overpayments for individuals who were ineligible for all categories of MA except LTC and Buy-In.
A provider causes an overpayment by:
billing for services that were not provided or used for the individual;
billing for services, medicine, etc., that were unsuitable for the individual’s needs, or insufficient or lacking in quality;
billing for uncovered or nonchargeable services or supplies disguised as covered items;
billing for services without regard to results, the ailments of the individual, or the orders of the physician;
overcharging or under filling of prescriptions;
failing to adhere to the eligibility dates on the Pennsylvania ACCESS card; or
failing to assure the identity of the individual.
Examples of manual SSI/SSP calculations of overpayment amounts:
Duplicate issuance.
CIS automatically opens a case on 02/29/12 with an eligibility begin date of 01/01/12. A payment also is issued to the client for the period 01/01/12 to 02/28/12 in the amount of $44.20. The client contacts the CAO on 03/05/12 and states no payment was received. An OTI is issued by the county for the period 01/01/12 to 03/31/12. Since the client is SSI eligible, the CAO issues $22.10 for each month for a total of $66.30. Upon review of the case, it is determined that the March benefit was the only monthly benefit not paid to the client. The overpayment would be for 2 months x $22.10 = $44.20.
Total ineligibility due to untimely reporting by the client to SSA.
The CAO receives alert to close an SSI/SSP case as the client is no longer eligible and the 60-day waiting period elapsed. Upon further review and contact with SSA, the CAO receives complete information regarding an overpayment processed by SSA. SSA provides the caseworker with the months of complete ineligibility, which include 11/11, 12/11, 01/12, and 02/12. Using this information, the caseworker calculates the overpayment to be 4 months x $22.10= $88.40.
NOTE: There are no direct means by which the county will be able to determine that an overpayment was processed by SSA. However, if the CAO becomes aware of such a case and documents the situation in the case record, an overpayment must be filed for the SSP.
Examples of manual SSP-Only calculations of overpayment amounts:
Duplicate issuance.
The caseworker receives a call from the client stating that no payment of SSP was received for 01/12 or 02/12 . The caseworker proceeds to issue an OTI for both months totaling $44.20. After issuance, the client calls and states that he/she now received not only the OTI, but also the original payments in the correct amount of $22.10 for each month. He/she also refuses to return any of the money to be redeposited by Treasury. The caseworker calculates the overpayment to be $44.20 or the total amount of the OTI.
Untimely closing of SSP-Only budget.
The Central Unit completes a reapplication on an SSP-Only case receiving $18.40 per month. It is determined that the client is no longer eligible for SSP. A referral is sent to the county on 06/10/12 requesting closure of the case for 07/31/12 . The referral is not received by the caseworker and no action is taken. On 08/01/12 , the SSP liaison contacts the Central Unit regarding the now overdue reapplication. A duplicate referral is provided to the liaison. The case is closed with a date of 08/31/12 . The amount of the overpayment is 1 month x $18.40 = $18.40.
Reissued: August 20, 2015 , replacing August 13, 2013