Situations when an overpayment exists and the CAO will complete an overpayment referral include but are not limited to the following:
ESA 16542-135 Sanctions and SPAL Overpayments (Linked February 25, 2013)
The individual used assistance benefits and received assistance he/she was not eligible to receive. The CAO should establish an overpayment. The OSIG will determine if it is referred for collections or prosecution. The CAO should not accept any payments from recipients to repay a prosecution claim;
NOTE: If a cash assistance recipient is found to be totally ineligible for cash assistance for a period the household was ineligible, a manual determination of MA eligibility for each individual must be completed before completing an MA overpayment.
Exception: If a LIHEAP or MA overpayment is caused by an Administrative error, it cannot be collected and will not be referred to the OSIG. LIHEAP and MA overpayments will only be referred to the OSIG if they are caused by an individual error.
Reminder: MA Includes Buy-In and LTC unless otherwise noted.
NOTE: If there is an LIHEAP overpayment caused by an individual error, DHS will refer the overpayment for collection to the OSIG by completing an OSIG-189 form. The CAO will keep one copy in the LIHEAP record and send all other copies to the OSIG. See Appendix A. If the person or agency that received the funds returns an uncashed check, there is no overpayment and an OSIG-189 is not required.
The individual used an electronic authorization card [Electronic Benefit Transfer (EBT) or ACCESS card] to receive assistance for which he/she was not eligible;
The Cash Assistance or SNAP individual received a special allowance which was not used for its intended purpose;
Example: A special allowance is issued to an individual for car repairs to obtain employment. The individual does not have the car repaired and uses the special allowance for another purpose.
Exception: An overpayment does not exist when a special allowance is issued to an individual for a service which the individual obtained, but the individual did not use the allowance to pay the service provider. (See Section 910.22).
Example: A special allowance is issued to an individual for car repairs to obtain employment. The repairs are completed; however, the individual does not use the special allowance to pay for the repairs. (See Section 910.22).
The Cash Assistance or SNAP individual received a special allowance for a specific activity, the activity ended, and the need no longer existed.
Example: When an individual receives books to attend vocational education then stops attending half-way through the semester because she lost interest in the program, the CAO may process an overpayment for 50% of the cost of the books.
The RESET participant did not participate in or comply with RESET, including meeting hourly and other work and work-related requirements as specified on the AMR or EDP.
Example: An individual received a monthly bus pass to attend a training program, but dropped out after one week, thereby, did not fulfil the requirement of the AMR. The CAO may process an overpayment for the cost of the unused portion of the bus pass.
Exception: An individual stops attending school due to illness, hospitalization, homelessness or similar circumstance which meets good cause or exemption criteria, the CAO would not process an overpayment. (See Section 910.22).
The RESET participant or provider of supportive service, or both, did not provide verification that some or all of the supportive services requested were obtained using the special allowance payment within the 14 day timeframe.
The TANF individual used the special allowance for its intended purpose but was later found ineligible for TANF benefits in the month the special allowance was issued;
The actual cost of a service was less than the estimated cost of the service for which a special allowance was issued.
The individual provided falsified documentation to obtain a special allowance;
The individual received an ongoing special allowance when the need no longer existed;
The individual obtained MA Program Services, including LTC, for which he/she was not eligible except when the receipt of these services is caused by an administrative error;
NOTE: An overpayment for MA exists only if an individual received MA during a period the individual was ineligible for any category of MA except TA/TJ 65/67 for a period the individual received MA. MA overpayments are determined on an individual basis for each recipient in a household.
Exception: Beginning April 30, 2018, FPS will only be used to negate an MA overpayment if the individual was open in FPS at the time. If the individual is receiving the Family Planning Services at the time of the overpayment the FPS income limit of 215% FPIG would be used.
Example: An individual intentionally failed to report a change in circumstances to the CAO which caused an individual receiving MA to be ineligible for any category of MA except Family Planning Services, or TA/TJ 67.
Example: Sam (age six) is a tax dependent of his father, Larry, and they are both open in MA MAGI budgets. Sam has zero income and Larry has unreported wages that exceed 215% FPIG, which makes the family ineligible for MA and FPS. At application, Larry and Sam requested MA and FPS. Even though Sam has no income, the FPS income limit would not be used for an MA overpayment determination. In this case, both Sam and Larry would be considered for an MA overpayment based on the MA MAGI income limits.
Example: Kendra (age 45), is open FPS as a single adult. At application, Kendra applied for both MA and FPS and did not report that she was married and living with her husband, James, and their child. An address match alerts the CAO of the household composition and James’ income. When determining if an FPS overpayment exists, we would use the FPS income limit of 215% FPIG for a three-person household.
The individual received MA in a category that included buy-in for which the individual was ineligible for any category. This results in an overpayment for MA as well as a separate manual overpayment for the amount of Medicare premiums paid by the Commonwealth of PA.
Example: An individual receiving PH 80 benefits was subsequently determined to have been ineligible for any category of MA. The CAO must complete an overpayment for PH, as well as a manual overpayment for Buy-In payments.
The individual loaned his/her Pennsylvania ACCESS card to a person who was not eligible to use it;
The individual received TANF cash assistance for a period covered by a diversion benefit;
An individual receives a check inadvertently sent due to a systems error to make payment to a child care provider who is enrolled in OIM Direct Pay and the individual fails to make payment to the provider, the CAO will make direct payment to a provider. An overpayment exists and a referral will be submitted for the payment received by the individual;
There is a duplicate issuance of the SSP benefit by the Pennsylvania Treasury Department (Treasury);
The SSP individual was ineligible for Supplemental Security Income (SSI) and, consequently, the SSP;
The individual was found to be ineligible for SSP-Only payments.
NOTE: For overpayments caused by the receipt of assigned support payments beginning the second month of assistance. (See Cash Assistance Handbook Chapter 131) There are no SNAP overpayments in these situations.
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 non-chargeable 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.
Situations when an overpayment will not be established or referred include, but are not limited to, the following:
The CAO did not require the SNAP individual to sign the Application for Benefits;
The CAO did not certify the individual for SNAP in the correct county;
A SNAP individual did not provide a Social Security Number (SSN) because the CAO failed to advise the individual of the SSN requirement for all household members;
When a SNAP employment and training special allowance is used for its intended purpose, even if the individual is later found ineligible for the SNAP benefits in the month of authorization; and
A special allowance issued to an individual for a service which the individual obtained but the individual did not use the allowance to pay the service provider.
Example: An individual was determined eligible for a childcare allowance, took the children to the babysitter, but did not pay the babysitter for the service.
Exception: If there is an error in the system and a check is inadvertently sent to an individual to make payment to a child care provider who is enrolled in OIM Direct Pay and the individual fails to make payment to the provider, the CAO will make direct payment to a provider. An overpayment exists and a referral will be submitted for the payment received by the individual. (See Cash Assistance Handbook Section, 183.8 and Supplemental Handbook section 910.21).
A Medical Assistance or LIHEAP overpayment is caused by an administrative error See Section 910.45 for the definition of administrative error.
NOTE: If an overpayment is caused by individual error, intentional or unintentional, the overpayment is not administrative and will be referred to the OSIG.
A special allowance issued to an individual for an AMR/EDP activity discontinued the activity for a reason meeting good cause or exemption criteria.
Example: An individual stopped attending school due to illness, hospitalization, homelessness or similar circumstance which met good cause or exemption criteria.
An individual is eligible for any category of MA except TA/TJ 65/67 or Family Planning Services (if the individual is not receiving Family Planning Services).
Updated February 29, 2024, replacing March 24, 2021