11000 Incorrect Benefits and Fraud Determination

11120 Overpayments and Claims - An overpayment is assistance that is over the amount to which the client is entitled.

One or several months of overpayment become a claim when the cause of the overpayment(s) are due to the same or related causes. See 11121 . A claim shall be established against any household that has received more assistance than it is entitled to receive, except as outlined in 11122 .

For food assistance, all adult household members shall be jointly and separately liable for the amount of any overpayment of benefits to the household. For cash (including the Work Incentive payment), any or all of the adult members of an assistance family group in which an overpayment occurred are liable for the overpayment and recovery efforts can be established on any of these adult members. For non-refugee non-citizens, both the non-citizen's sponsor and the non-citizen are liable for any overpayment made to the non-citizen.

11121 Criteria For Establishing Types of Claims - Claims are classified according to the error cause as follows:

11121.1 Agency Error - Instances of agency error which may result in a claim include, but are not limited to, the following:

Prompt action was not taken on a change reported by the household;

The household's income or deductions were incorrectly computed or the household was otherwise assigned an incorrect allotment;

Benefits continued to be provided to a household after its review period had expired without benefit of a reapplication determination; or

Misapplication of policy.

11121.2 Client Error - Instances of client error which may result in a claim include, but are not limited to, the following:

Non-willful withholding of information from a one-time failure on the part of a client to report a change timely (see 9121 or 9122 ), which affects eligibility and/or the amount of assistance when: The worker has reason to believe that the client did not understand his responsibility; and There was no oral or written misstatement by the client, or

Willful withholding of information such as: Misstatement (oral or written) made by the client in response to oral or written questions from the agency; Failure by the client to report a change timely (see 9121 or 9122), which affects eligibility and/or amount of assistance; Failure by the client to report the receipt of a payment which he knows, or should know, represents an incorrect benefit;

11121.3 Fraud Error - A fraud error is a willful client error which has been found to be fraud in accordance with the provisions in 11200 . An individual shall be considered to have committed fraud for TANF (including the Work Incentive payment), Child Care, and Food Assistance:

When the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction;

By the individual signing a disqualification consent agreement for cases in deferred adjudication;

When the individual has been established as having committed fraud through an Administrative Disqualification Hearing; or

By the individual signing a Waiver of Administrative Disqualification Hearing form.

Fraud error status is not established if a court's resolution to a willful error situation is to place the person on diversion unless the person has signed a disqualification consent agreement. Potential fraud claims are initially established as a recovery account with a status reason of ‘Pending Fraud Prosecution.’ Also see 11125 .

See 11220 for penalties applicable to fraud determinations.

NOTE: The proper classification of cash overpayments is critical for determining the correct amount of Food Assistance benefits when reduction is being made from a cash assistance payment for overpayment recovery. See 6410 .

11122 Instances Not Requiring a Claim - A claim shall not be established if an overpayment occurred as a result of the agency failing to insure that the household fulfilled the following procedural requirement :

Signed the application;

Other instances when a claim should not be established include:

Assistance granted in accordance with the treatment of income policies or the inability to act on available information due solely to issuance cutoff dates and/or timely notice requirements do not constitute an incorrect payment.

Eligibility errors related to citizenship or non-citizen status will not cause incorrect payments in the following situations: eligibility was based on verification of satisfactory immigration status by the Immigration and Naturalization Service (INS); eligibility was approved to meet timely processing guidelines, but no INS response to a request for verification of immigration status has been received; or eligibility was approved to meet timely processing guidelines, but the reasonable opportunity period allowed for non-citizen applicants to provide documentation of their non-citizen status had not expired. "Reasonable opportunity" shall be defined as 10 calendar days from the date of request.

Overpayments that occur as a result of the household not reporting a change in household circumstances that they were not required to report. See 9121 or 9122 .

Work Program payments are unconditional and unrestricted and are not considered overpayments if used by the client for purposes other than those intended.

11123 Time Frames and Limits for Establishing Claims - The date of discovery for purposes of tracking timely claims establishment (based on the following time frames) shall be the date the case is first identified as potentially having an overpayment either by the worker, quality control or by other means.

Time Frames For agency and client overpayments, the EES Unit is required to prepare the claim and initiate recovery or attempt to initiate recovery by the end of the calendar quarter following the calendar quarter in which the overpayment is first identified. For fraud overpayments, the Fraud Unit is required to prepare the claim and initiate a referral for the Administrative Disqualification Hearing by the end of the calendar quarter following the calendar quarter in which the overpayment is first identified.

Note: Failure to establish a claim within the time frames identified does not negate the responsibility of agency to establish or collect on the claim, or of the client to repay any benefits they received but were not entitled to.

Time Limits - (Food Assistance Program Only) - Claims shall be established for any overpayment which has occurred in the three years (36 months) prior to the month the overpayment was discovered. Claims may be established for any overpayment which occurred prior to the three years (36 months) provided the claim does not go back farther than 6 years (72 months) and the agency has sufficient information to document the claim. NOTE: Fraud overpayment claims for Food Assistance must be calculated back to the month the first act occurred, but no more than six years (72 months).