910.4 What Actions Follow the Discovery of a Possible Overpayment

The CAO will take the following actions upon discovery of a possible overpayment:

NOTE: If for any reason the overpayment can't be entered into the ARRC system, the CAO must complete the Overpayment Referral with Codes Form, OSIG 189, to refer the overpayment.

NOTE: A completed OSIG 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 the ARRC system for Buy-in, LTC, LIHEAP and SSP cases. Instead of entering information into the ARRC system, the CAO must complete the OSIG 189. See Appendix A.

55 Pa. Code § 255.4(b)(2)

55 Pa. Code § 255.84(b)

 

910.41 Overpayment Data – the ARRC System Input

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 calendar days from the date the information was verified. The CAO must initiate the overpayment before the 30th calendar day to be timely.

NOTE: For MA, regulation requires an overpayment be referred to OSIG within 30 days of receipt of verification that establishes an overpayment. The CAO must not exceed the 30-day window to submit the overpayment referral. However, if due to unforeseen circumstances the overpayment is not filed timely, the CAO should continue to file it as they normally would.

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. See Appendix A and Using ARRC.

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 OSIG for recovery.

The CAO will complete MA claim amount calculations outside of the ARRC system according to instructions in SH 910.473. The claim amount is then entered on the ARRC system.

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, the CAO enter the claim in the ARRC system and answer question #1 on the ARCAFQ screen with “M” indicating manual referral (paper OSIG 189 completed).

55 Pa. Code § 255.4(c)(2)

 

910.42 Exploring a Possible Overpayment

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.

55 Pa. Code § 255.4(b)(2)

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:

55 Pa. Code § 255.4(b)(1)(i)

 

55 Pa. Code § 255.4(b)(ii)

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 OSIG for appropriate action.

55 Pa. Code § 255.4(b)(4)

 

910.43 Verification

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.

55 Pa. Code § 255.4(a)(1)(iv)

 

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, the CAO will 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.

See Using ARRC.

NOTE: For employers, who specifically state they will not cooperate, the CAO Executive Director will provide the OSIG Bureau of Fraud Prevention and Prosecution (BFPP) 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.

55 Pa. Code § 255.4(b)(2)

 

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 OSIG without written verification of the overpayment.

The following items are examples of acceptable verification documents:

 

910.44 Insufficient Wage Information from Employers

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 will attempt to obtain payday-by-payday wage data through alternative means.

55 Pa. Code § 255.4(a)(1)(iv)

 

The following are examples of acceptable alternative means of obtaining wage data:

If the attempt to obtain payday-by-payday wage data is unsuccessful, the CAO will not refer the overpayment to the OSIG. 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 OSIG.

 

910.45 Determining the Type of Error

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.

NOTE: For MA (not including LTC services), Buy-In and LIHEAP only, overpayments caused by administrative error are not referred to the OSIG. 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 OSIG.

55 Pa. Code § 255.3(b)(3)

 

Situations when the overpayment is caused by administrative error include but are not limited to the following:

 

Situations when the overpayment is caused by individual error include but are not limited to the following:

55 Pa. Code § 255.2

 

55 Pa. Code § 255.81(b)

 

7 CFR § 273.16(c)

 

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:

Example: Defacing documents, altering documents, or arranging appointments with the CAO so as to conceal other activities would be considered hiding information.

Examples: Advanced age, defective hearing, or poor vision.

Examples: Emotional or psychiatric disturbances or developmental disability.

Examples: Illiteracy, language barriers, or lack of education.

Examples: Death of a family member, accident, serious illness, or desertion.

55 Pa. Code § 255.3(b)

 

 

NOTE: When the overpayment is referred to the OSIG, 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 OSIG will determine whether prosecution is indicated.

NOTE: Ensure all verifications are scanned into the county record for the OSIG to review.

55 Pa. Code § 255.3(b)

910.46 SNAP Overpayment Due to Incorrect Sponsor Information

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.

7 CFR § 273.11(j)(8)

 

Good cause exists when:

If good cause does not exist, the OSIG 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.

 

910.47 Computing Claims

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 OSIG will compute the portion of a Cash Assistance claim period that exceeds the ARRC system computation limits. The CAO will, upon request from the OSIG, compute the portion of a SNAP claim period that exceeds the ARRC system computation limits.  The OSIG will compute LTC overpayment claims and manual cash overpayments.

55 Pa. Code § 255.4(d)

NOTE: The CAO will compute MA claims according to instructions found in Appendix A.

 

The OSIG 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 OSIG. These claims are not entitled to the earned income deductions.

 

910.471 Computing Cash Claims

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.

55 Pa. Code § 255.4(d)(1)

 

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 ARRC system will apply the prospective determination and prospective budgeting principles to determine the claim period. See Cash Assistance Handbook Chapter 167.

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, the ARRC system 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.

55 Pa. Code § 255.4(d)(1)(i)

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 the ARRC system 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:

55 Pa. Code § 255.4(d)(1)(iv)

 

55 Pa. Code § 255.4(d)(1)(v)

55 Pa. Code § 255.4(d)(1)(v)

 

910.472 Computing SNAP Claims

The ARRC system (for electronic referrals) or the CAO (for paper referrals) will:

1. Determine when the overpayment began:

7 CFR § 273.18(c)

 

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.

2. Determine when to begin calculating the overpayment claim:

55 Pa. Code § 501.12(b)

Example:  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:  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.

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.

55 Pa. Code § 501.12(b)

 

7 CFR § 273.18(c)(1)(i)

 

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.

NOTE: All SNAP overpayments are processed and input into the ARRC system. If the overpayment amount of a nonparticipating household is under the $125 threshold and not discovered by a Quality Control (QC) review, the ARRC system will not pass the overpayment on to OARS for a SNAP budget that is closed.

 

NOTE: When the SNAP budget is in the process to close, CAOs will process an overpayment after the SNAP budget is in closed status unless the SNAP overpayment was discovered in a QC review.

7CFR § 273.18(e)(2)(ii)

2. Promptly, upon request and as identified by the OSIG, calculate the portion of a claim period that exceeds the ARRC system 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.

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.

7 CFR § 273.18(c)(ii)(B)

 

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 OSIG will offset the restored benefits against the claim. See SNAP Handbook Chapter 581.

3. Promptly, upon request by the OSIG, recalculate any supplemental benefits issued during the overpayment period to exclude the earned work deduction.

See Appendix E for the ARRC system Semi-Annual Reporting (SAR) SNAP claim computation methodology.

 

910.473 Computing Medical Assistance Claims

The Office of Medical Assistance Programs (OMAP) computes claims and collects overpayments caused by provider error and fraud. The OSIG 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. The Family Planning Services income limit is only used to negate the overpayment if the individual was open in FPS during the period of the overpayment.

55 Pa. Code § 255.81(d)

55 Pa. Code § 255.84(d)(3)

 

Overpayment for MA begins the first month in which the individual(s) no longer qualified for MA (excluding Family Planning, Buy-In and LTC).

The overpayment begin date is determined by when the individual was required to report the change.  The County Assistance Office (CAO) must establish at which point the individual no longer qualified for MA and consider timeframes for reporting requirements and the individual’s right to an advanced notice for adverse action.

Per MAEH 370.1, all changes that impact eligibility must be reported by the tenth day of the month following the change.  The CAO then has 10 days to conduct a case review (MAEH 370.5).  MA budgets that are closing are given a 15-day advance notice (MAEH 377.3).  The overpayment begins the month following the actual budget closure date, in which the individual would have zero days of MA eligibility.

Example:  CAO discovers in December that an individual began employment and received income in April which exceeded MA limits.  They were required to report this information by May 10.  The CAO had 10 days to act upon the information (May 20), and the budget would have closed 15 days after the record was updated (June 4).  Since MA coverage extends through the end of the month in which the budget is closed, the first month of ineligibility and overpayment start date is July.

 

 The CAO will complete the PA 189 for MA overpayment referrals made electronically in the ARRC system following instructions in Appendix A.

Each CAO will select an Income Maintenance Caseworker Supervisor or Manager and an alternate to be responsible for researching MA claim information in the Data Warehouse. The CAO must develop a process for caseworkers to follow when requesting claim information from the office designee.

The overpayment for Buy-In begins in the month the individual is no longer eligible for Buy-In. All Buy-In Overpayment referrals for collection to OSIG require completion of the OSIG 189.

Individuals enrolled in the Health Insurance Premium Payment (HIPP) program are subject to overpayment referrals. To identify a HIPP MA case, review the TPL Summary in the Standalone TPL module.  If the indicator in the HIPP column is “Yes”, then the individual is enrolled in HIPP. 

If it is determined that an MA overpayment exists, a HIPP program representative will determine if a HIPP overpayment exists and the dollar amount of the overpayment.  To obtain a determination of the HIPP overpayment:

 

1.     A Supervisor or Manager designated by the CAO will email the Regional HIPP Office with the case information, period of MA eligibility, and the affected individuals, requesting they determine if there is an overpayment and the amount. 

 

The HIPP Regional Office addresses, email addresses, and the counties which each office serves are located in MA Handbook Chapter 317, Appendix F.

 

2.     If the HIPP Regional Office determines there is an overpayment, process the overpayment using the information provided by the HIPP Regional Office.

 

NOTE:  It may take up to 30 days for the HIPP Regional Office to determine the MA overpayment and email the CAO.

 

Once a response from the HIPP Regional Office is received, the CAO will follow the current procedure for filing an overpayment outlined above.  The CAO will also collect fee-for-service claim information as individuals enrolled in HIPP may have fee-for-service claims.

55 Pa. Code § 255.81(c)

55 Pa.Code § 255.84 (d)(3)

 

 

910.474 Computing SSI/SSP and SSP-Only Claims

Examples of manual SSI/SSP calculations of overpayment amounts:

eCIS 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.

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:

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.

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.

 

 

Updated March 1, 2024, replacing February 29, 2024