910.1 General Policy

PCAPMA19269910 Processing Overpayments Within 30 Calendar Days after the CAO Verifies the Overpayment March 28, 2019

OPS180402 Family Planning Services (FPS) Eligibility and Medical Assistance (MA) Overpayment Determinations April 30, 2018

OPS120404    Medical Assistance (MA) Program – Overpayment Referrals  April 13, 2012

PO17680910   MA Overpayment and Family planning Services (FPS)  September 4,  2015

An overpayment exists when an individual/household receives assistance for which they are ineligible.

The cause of an overpayment may be classified as:

• Fraudulent misrepresentation by an individual. A suspicion of fraud exists when an individual is believed to have knowingly and deliberately withheld information or provided incorrect information to obtain assistance for which he/she would otherwise be ineligible.

• Error by a County Assistance Office (CAO) or an individual. Error may result from an individual’s misunderstanding of eligibility requirements or failure to provide information; an individual’s innocent concealment of facts; or CAO omission or administrative error in securing or acting on information.

55 Pa. Code § 255.2

The Department of Human Services (DHS) is responsible by law to identify overpayments and recover overpayments from individuals.

55 Pa. Code § 255.4(a)

The Office of Inspector General (OIG) conducts welfare fraud investigations and recovers overpayments for the DHS.

The overpayment recovery guidelines set forth in this chapter apply to the following assistance programs:

55 Pa. Code § 255.1(a)

• Temporary Assistance for Needy Families (TANF);

• General Assistance (GA);

• Supplemental Nutrition Assistance Program (SNAP);

• Medical Assistance (MA) and all MA benefit package services, including Long Term Care (LTC), regardless of the method of delivery;

• State Blind Pension (SBP), except where modified by SBP regulations. See Chapter 700, State Blind Pension;

• Low-Income Home Energy Assistance Program (LIHEAP);

• Special Allowances;

• Disaster Assistance;

• Diversion Benefit; and

• State Supplementary Payment (SSP) program.

The guidelines in this chapter do not apply to overpayments resulting from the replacement of assistance benefits, duplicate receipt of assistance benefits, or altered assistance benefits. The Pennsylvania Treasury Department investigates and prosecutes cases involving overpayments caused by the mishandling of benefits. The Treasury Department may refer these cases to the OIG for recovery activity. See Chapter 180 of the Cash Assistance Handbook, “Issuing Benefits.”

55 Pa. Code § 255.4(a)(4)

The OIG may refer an overpayment case for criminal prosecution if there is evidence of fraud.

55 Pa. Code § 231.2

55 Pa. Code § 255.4(e)(2)

The OIG may refer an individual applying for or receiving TANF, GA, or SNAP for an administrative disqualification hearing (ADH) if there is evidence of an intentional program violation.

55 Pa. Code § 231.2

55 Pa. Code § 255.1(c)

910.11 Responsibilities of the CAO

The CAO is responsible for determining the eligibility and ineligibility of individuals for assistance.

55 Pa. Code § 255.4(a)

The CAO is responsible for:

• determining if a budget group or SNAP household has been overpaid in active or closed cases;

• determining overpayments on active and closed cases for recipients of TANF, GA, MA, SNAP, Disaster, LIHEAP, Special Allowance, and SSP programs;

• determining the cause of the overpayment;

55 Pa. Code § 255.4(a)(1)(iii)

• calculating the amount of all manual overpayments, with the exception of cash and LTC;

• discussing the overpayment with the individual;

55 Pa. Code § 255.4(b)(4)

• defining a specific reporting plan with the individual, and recording the plan in the case record;

• explaining that any overpayments will be recovered;

• obtaining verification of the income or resource and documenting the circumstances which caused the overpayment;

• retaining overpayment verification documents in the case record for the life of the overpayment or for 10 years if documents are scanned;

• attaching overpayment verification documents to all Manual Overpayment Referrals;

55 Pa. Code § 255.4(c)(2)(ii)

• furnishing the OIG with any current information which may affect action on the overpayment;

• referring the overpayment to the OIG;

55 Pa. Code § 255.4(c)

• attending and representing the DHS at fair hearings when an individual appeals a program overpayment claim;

55 Pa. Code § 255.4(e)(2)(i)

• testifying before district justices, judges, juries, and grand juries in cases referred for criminal prosecution, and before hearing officers at fair hearings or administrative disqualification hearings;

• accepting payments “on account.” See Section 910.6, Collection of Overpayments; and

55 Pa. Code § 255.4(e)(1)(ii)

Exception: The CAO will not accept a payment if prosecution is being considered.

• imposing disqualifications in active TANF, GA, or SNAP cases.

• completing and sending the OIG 189 (manual Overpayment Referral) to the OIG. See Appendix A, Completing the Overpayment Referral Data Input Form (PA 189), ARRC Claim Change Form (PA 1001), and Overpayment Referral (OIG 189).

910.12 Responsibilities of the OIG

The OIG is responsible for:

• determining whether an overpayment is either a suspected fraud or non-fraud case;

55 Pa. Code § 255.4(c)(2)(i)

• referring suspected fraud overpayments to the appropriate judicial authority;

• computing the amount of manual cash overpayments and LTC overpayments;

55 Pa. Code § 255.4(d)

55 Pa. Code § 255.81(d)

• collecting and settling overpayment claims;

55 Pa. Code § 255.4(e)(1)(i)

• investigating and initiating legal action to prosecute in suspected fraud cases;

55 Pa. Code § 255.4(e)(2)(i)

• notifying the CAO of prosecution, disqualification, and recoupment activity;

55 Pa. Code § 255.4(e)(2)(i)

• referring overpayment claims to the Bureau of Hearings and Appeals for an Administrative Disqualification Hearing if the cause of the overpayment is a suspected intentional program violation;

55 Pa. Code § 275.11(b)

• initiating and controlling recoupment;

• imposing disqualifications in inactive TANF, GA, or SNAP cases.

Updated August 21, 2018 , replacing December 29, 2016