OVERPAYMENTS (CLAIMS AGAINST ELIGIBILITY DETERMINATION GROUPS):

(a) A claim will be handled as an IHE claim if the overpayment was caused by:

(i) the misunderstanding or unintended error on the part of the eligibility determination group; or

(ii) the misunderstanding or unintended error on the part of a categorically eligible eligibility determination group, provided that a claim can be calculated based on a change in the eligibility determination group's net income, eligibility determination group size, or both; or

(iii) a social security administration action, or failure to take action, resulting in an eligibility determination group becoming or continuing categorical eligibility, provided that a claim can be calculated based on a change in net income, eligibility determination group size, or both.

(b) Instances of IHE’s that may result in a claim include, but are not limited to, the following:

(i) eligibility determination group unintentionally failed to provide the department with correct or complete information; or

(ii) eligibility determination group unintentionally failed to report changes in its circumstances; or

(iii) eligibility determination group unintentionally received benefits or received more benefits than it was entitled to receive pending a fair hearing decision because the eligibility determination group requested a continuation of benefits based on the mistaken belief it was entitled to them; or

(iv) eligibility determination group received benefits solely because of categorical eligibility, but was later determined ineligible for cash assistance; or

(v) social security administration took action or failed to take appropriate action, resulting in the eligibility determination group improperly receiving supplemental security income (SSI).

(2) Administrative or agency errors:

(a) A claim will be handled as an AE claim if the overpayment was caused by the department’s action or failure to take action.

(b) In the case of a SNAP categorical eligibility, a claim will be handled as an AE if action by an agency of the state or local government resulted in the eligibility determination group's improper eligibility for cash assistance.

C. IPV claims established for SNAP:

(1) A claim will be handled as an IPV claim only if:

(a) an administrative disqualification hearing official or a court of appropriate jurisdiction has determined that an eligibility determination group member committed an IPV; or

(b) an individual is disqualified as a result of signing a waiver of disqualification hearing in a case referred for prosecution; or

(c) an individual has signed a disqualification consent agreement in a case of deferred adjudication; or

(d) an individual has signed a waiver of an administrative disqualification hearing in a case referred for disqualification.

(2) Before the determination of an IPV or the signing of either the waiver of right to a disqualification hearing or a disqualification consent agreement, the claim against an eligibility determination group is handled as an IHE claim.

D. Claims for medical assistance benefits: Upon a determination that the individual is not eligible for the category of assistance in which they were enrolled, the department shall determine if the individual is eligible for any category of assistance. If the individual is ineligible for any category, the department shall determine which months the individual was not eligible and forward the documentation to the medical assistance division for the determination of repayment of fee for service payments or the capitation payments made to the health maintenance organization on behalf of the individual for months the individual was not eligible for the category of assistance. The department will pursue the repayment of capitation amounts paid to the health maintenance organization for the months the individual was ineligible for any medical assistance programs and received medical services.

E. Development of information: When quality control review findings, or information reported or received indicate, that benefits may have been issued incorrectly; the department shall attempt to obtain and verify whether benefits were provided in error.

F. When claims are not established: Overpayment c laims shall not be established for administrative or IHE’s, if an over-issuance occurred because the department did not ensure that the following procedural requirements were fulfilled:

(1) an application form was signed; or

(2) appropriate work registration code was entered.

G. Claim establishment threshold: Claims for SNAP, cash assistance and LIHEAP will not be established when the cumulative amount of the claim is less than the establishment thresholds.

(1) Claims for all programs resulting from an administrative error will not be established if the cumulative claim is less than five hundred dollars ($500).

(2) Claims resulting from an IHE will not be established if the cumulative error is less than two hundred fifty dollars ($250).

(3) Claims resulting from fraud or an IPV will always be established for the full amount of the overpayment.

[8.100.640.11 NMAC - N, 09/30/2013]