Benefit Errors - Cash and Medical Assistance Overpayment Descriptions
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Benefit Errors - Cash and Medical Assistance Overpayment Descriptions

Revised May 22, 2012

Purpose:
WAC 388-410-0001What is a cash / medical assistance overpayment?
WAC 388-410-0005Cash and medical assistance overpayment amount and liability

What is a cash / medical assistance overpayment?

WAC 388-410-0001

WAC 388-410-0001

Effective June 1, 2005

WAC 388-410-0001 What is a cash / medical assistance overpayment?

  1. An overpayment is any cash or medical assistance paid that is more than the assistance unit was eligible to receive.

  2. There are two types of cash/medical overpayments: 

    1. Intentional overpayments, presumed to exist if you willfully or knowingly:

      1. Fail to report a change you must tell us about under WAC 388-418-0005 within the timeframes under WAC 388-418-0007; or

      2. Misstate or fail to reveal a fact affecting eligibility as specified in 388-446-0001.

    2. Unintentional overpayments, which includes all other client-caused and all department-caused overpayments.

  3. If you request a fair hearing and the fair hearing decision is in favor of the department, then:

    1. Some or all of the continued assistance you get before the fair hearing decision must be paid back to the department (see WAC 388-418-0020); and

    2. The amount of assistance you must pay back will be limited to sixty days of assistance, starting with the day after the department receives your hearing request.

  4. If you receive child support payments directly from the noncustodial parent, you must turn these payments over to the division of child support (DCS). These payments are not cash assistance overpayments.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

1.    Intentional overpayment: 

An intentional overpayment is the result of the client's willful knowing concealment of information or failure to reveal information resulting in an overpayment.

2.     Unintentional overpayment: 

a.   An unintentional client error overpayment is based on the condition that although caused by the client, there was no intent to obtain or retain assistance for which the client knew they were not eligible.

b.   An unintentional department error overpayment is the direct result of omission, neglect or error by the department in taking action on information affecting the amount of benefits for which a client is eligible.

c.   An unintentional technical error is an overpayment not directly caused by department error or client error. These types of overpayments are due to effective dates and procedural requirements. Following are examples of technical errors:

i.     Administrative Hearings:  Continued assistance pending a fair hearing results in an overpayment when the decision of the Department is upheld.  Continued assistance overpayments cannot be established for more than 60 days' worth of benefits from the date the administrative hearing was requested.

ii.   Ten-Day  Advance Notice:  When advance notice requirements for termination or reduction result in a payment of benefits for which the client is not eligible, the resulting One-Time Payment is an overpayment.

3.   Strikers:

Prior to July 1, 1999, an overpayment exists for any month in which a member of a TANF/SFA household is on strike on the last day of that month.  Starting with July 1999 benefits, there are no overpayments based solely on a member of the TANF/SFA assistance unit being on strike.

4.    Prospective budgeting:

An overpayment exists when a client intentionally understates his or her estimated income for the first 2 months of eligibility.  See WAC 388-450-0215.

5.    When someone fails to report a change in circumstances required for cash only:

When someone does not report a change in circumstances required under WAC 388-418-0005, we determine if a client has an overpayment for each program based on that program’s reporting requirements.

If the person was not required to report a change for Basic Food or medical benefits, we do not set up an overpayment for these programs based on the unreported change. This is true even if we would have reduced benefits if the household reported the change.


EXAMPLE

Julie, Spencer, and their two children receive TANF and Basic Food. They fail to report that Spencer got a job Earning $900 monthly. Spencer received his first paycheck on August 25th. We discover this information in November.

TANF:

The family was required to report getting a job for TANF. We determine amount of TANF benefits the family was eligible for if they reported the change timely on September 10th and set up an overpayment for October and November.

Basic Food:

The new job did not cause the family to go over the gross income limit for a family of four. Since they did not have to report this change for Basic Food, we do not set up an overpayment.


  1. ABD cash grants that are subsequently duplicated by receipt of SSI benefits for the same period are considered an unintentional overpayment and are subject to recovery. See WAC 388-474-0020.

WORKER RESPONSIBILITIES

  1. Do not establish an intentional overpayment when the overpayment is directly due to any omission, neglect or error by the department, unless:
    1. The client kept the assistance; and
    2. Knew or had reason to believe he/she was not eligible for the assistance.
  2. Establish an intentional overpayment for funds that were authorized to replace lost, unendorsed warrants when it is later determined the claimed loss was false. See WAC 388-412-0035.

Cash and medical assistance overpayment amount and liability.

WAC 388-410-0005

WAC 388-410-0005

Effective September 1, 1998

WAC 388-410-0005 Cash and medical assistance overpayment amount and liability

  1. The amount of overpayment for cash and medical assistance households is determined by the amount of assistance received to which the assistance unit was not entitled.

  2. Cash and medical assistance overpayments are recovered from: 

    1. Any individual member of an overpaid assistance unit, whether or not the member is currently a recipient; or

    2. Any assistance unit of which a member of the overpaid assistance unit has subsequently become a member.

  3. A cash or medical assistance overpayment is not recovered from:

    1. A nonneedy caretaker relative or guardian who received no financial benefit from the payment of assistance; or

    2. A person not receiving assistance when an unintentional overpayment of less than thirty-five dollars is discovered and/or computed.

  4. Overpayments resulting from incorrectly received cash assistance are reduced by:

    1. Cash assistance a household would have been eligible to receive from any other category of cash assistance during the period of ineligibility; and

    2. Child support the department collected for the month of overpayment in excess of the amount specified in (a) of this subsection; or

    3. Any existing grant underpayments.

  5. A cash assistance overpayment cannot be reduced by a medical or food assistance underpayment.

  6. A medical assistance overpayment cannot be reduced by a cash or food assistance underpayment.

  7. An underpayment from one assistance unit cannot be credited to another assistance unit to offset an overpayment.

  8. All overpayments occurring after January 1, 1982 are required to be repaid by mandatory grant deduction except where recovery is inequitable as specified in WAC 388-410-0010.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. All members of an assistance unit, including children, are responsible for overpayments incurred after January 1, 1982 provided they were actually members of the assistance unit at the time of the overpayment.
  2. The amount of an overpayment can be reduced by the amount of any unpaid underpayments in any period prior to the month in which the overpayment is computed.

WORKER RESPONSIBILITIES

Verification of Overpayment

  1. The department will attempt to verify all pertinent information when an overpayment has occurred.
  2. If the verification obtained is incomplete, the department will contact the recipient to obtain an explanation of the circumstances to clarify the overpayment.
  3. If the recipient fails to cooperate, the department will make an independent determination based on all available information and initiate recovery of the overpayment.
    1. If an employer does not respond to a request for a statement of earnings in a timely manner the department may file a Subpoena Request without a FRED or DFI referral.

Invalid Overpayment

  1. When the department determines that it has mistakenly charged an assistance unit with an overpayment, the department will cancel the overpayment account and credit any amount paid to any other outstanding debt obligation.
  2. The client will be notified of the error and of the amount credited to any existing debt obligation. If any balance remains from the amount paid by the client the department will refund the balance to the assistance unit.
  3. If the department determines that an assistance unit’s overpayment amount needs to be modified because of an error, the worker should refer to the ACES manual, Benefit Error Group (BEG) - Modify a BEG - Overpayment or Underpayment.

Establishing Overpayments

  1. Once an overpayment is verified, determine the assistance program involved in the cash, medical or food assistance overpayment. Determine the amount of the overpayment using the following criteria:
    1. Reconstruct eligibility in cases where the client failed to report information or where reported information was not acted upon.
    2. Consider the change as it would have been considered if reported and acted upon timely.
  2. If all criteria specified in WAC 388-410-0005 (3) (a)&(b) are met do not refer cases to Office of Financial Recovery.

Eligibility for Other Programs

  1. Financial assistance:  Reduce the amount of an overpayment by the amount of cash assistance a client would have received if eligible for another cash program during the period of the overpayment.
  2. Medical assistance:
    1. Redetermine eligibility for medical assistance beginning the first of the month in which ineligibility occurs.
    2. If the assistance unit was ineligible for any medical assistance, all medical expenses paid by the Health Care Authority (HCA) for the period of ineligibility are an overpayment.
    3. If the assistance unit was eligible for the Medically Needy Program the overpayment is:
      1. The amount the assistance unit would have been required to spend-down before medical expenses would have been paid for the overpayment period.
      2. The difference between those medical payments covered by the CN program and those covered by the MN program.
      3. Scope of care determinations are referred to HCA.
    4. If the assistance unit was eligible for the Psychiatric Indigent Inpatient Program (PII), the overpayment is:
      1. The amount paid by HCA up to the deductible; plus
      2. Any additional amount the assistance unit would have been required to spend down; plus
      3. The difference between medical payments covered by the CN program and those covered under the PII program.

ACES PROCEDURES

See Benefit Error Group (BEG) - Confirm a BEG Overpayment.

See Benefit Error Group (BEG) - Modify a BEG –  Overpayment or Underpayment

Modification Date: May 22, 2012