Notice of Medical Overpayment and Planned Action



|[pic] |SHARED SERVICES |[pic] |

| |Office of Payment Accuracy and Recovery | |

| |Overpayment Writing Unit | |

|Program: |Branch: |Case number: |Worker ID: |Date of notice: |

|      |      |      |      |      |

|Case name: |Program that has overpayment: |

|      |      |

|      |Notice of Medical Overpayment |

| |and Planned Action |

1. We found that from   /  /     to   /  /     you received $       more in medical benefits than you should have received. During this time period you may have months where you received the correct amount of benefits or services. Attached calculation forms show the exact months when the overpayment occurred, explain how the overpayment was calculated and are expressly incorporated into this notice. Contact your worker if you want copies of additional records.

The reason for this overpayment is      .

We reviewed the medical assistance programs of the Oregon Health Authority (OHA) and the Department of Human Services (DHS). For each program below, you did not meet one or more of the financial, non-financial or general requirements during the overpayment time frame.

Breast and Cervical Cancer medical (BCCTP):

No one was found to need treatment following a screening through the Breast and Cervical Cancer Screening Program. [ORS 414.534, OAR 461-135-1060(2)

OAR 410- 200- 0400]

Other:      

Continued Eligibility for Medicaid (CEM):

      is 19 years or older. [OAR 461-135-1149(1), 410-200-0510]

      did not meet citizen or alien status requirements. [OAR 461-135-1149(7), 461-120-0125(4), 410-200-0510]

Other:      

Continued Eligibility for Children’s Health Insurance Program (CHIP) Pregnant Women (CEC):

      was over age 20. [OAR 461-135-1149(3), 410-200-0510]

      was not pregnant. [OAR 461-135-1149(3), 410-200-0510]

      did not meet citizen or alien status requirements. [OAR 461-135-1149(3), 461-120-0125(4), 410-200-0510]

Other:      

Medical coverage for children in substitute or adoptive care:

      is over age 21 and was not institutionalized and either determined to be blind or to have a disability before turning 21. [OAR 461-120-0510(14),

461-135-0150, 461-135-0950(7)]

      is under 21 but not residing in a state psychiatric hospital, substitute care, foster care or adoptive care; or receiving independent living payments from the state. [OAR 461-135-0150]

Other:      

Medical Assistance Assumed (MAA) and Medical Assistance to

Families (MAF):

Your household income exceeded the standard. [OAR 461-155-0040,

461-160-0100]

No one was caring for a dependent child who was related and lived

in the household. [OAR 461-110-0330(1), 461-125-0010, 461-135-0070,

410-200-0510]

Other for MAA:      

Other for MAF:      

Extended Medical Assistance (EXT):

No one was properly receiving medical benefits through the MAA or MAF programs and no one lost eligibility for these programs because of increased earnings or child support. [OAR 461-135-0095, 410-200-0510]

Other:      

Oregon Supplemental Income Program Medical (OSIPM):

      was not blind, was under age 65, and did not have a disability that met Social Security Standards. [OAR 461-125-0310, 461-125-0330, 461-125-0350, 461-125-0370]

Your household income exceeded the standard. [461-155-0250]      

Other:      

OSIPM-EPD:

      did not have a disability that met Social Security standards.

[461-135-0725(1)]

      did not have employment. [461-135-0725(1)]

Other:      

Oregon Health Plan (OHP) and Healthy KidsConnect (HKC):

Your household income exceeded the standard for all OHP and HKC programs. [OAR 461-155-0225(1), 461-160-0700]

Your household income exceeded the standard for the OHP standard program (OPU). There is no eligibility for other OHP or HKC programs because:

      was not pregnant or a newborn child, and was over age 6 and age 19. To qualify for the OPP program, an individual must be pregnant or a baby born to a mother who was properly receiving Medicaid. To qualify for the OP6 program, a child must be under age 6. To be eligible for other OHP programs for children (OPC and CHIP) or the HKC program, a child must be under age 19. [OAR 461-135-1100(4), (5), (6) and (7), 461-135-1101(1), 461-155-0225(1), 461-160-0700, 410-200-0510]

Your household income exceeded the standard for all OHP programs except CHIP and HKC.       is covered by private major medical health insurance so does not qualify for CHIP or HKC. [OAR 461-135-1100(7), 461-135-1101(1), 461-155-0225(1), 461-160-0700, 410-200-0510]

Other:      

Refugee assistance medical:

No one met the alien status requirements for these programs.

[OAR 461-120-0110, 461-135-0930, 461-135- 0900]

Office of Client and Community Services (HSD) Medical programs: MAGI Parent or Other Caretaker Relative, MAGI Pregnant Woman, MAGI Child, MAGI Adult , MAGI CHIP, MAGI SAC, Former Foster Care Youth, Extended Medical Assistance programs:

Your household income exceeded the standard for all HSD Medical

Programs. [OAR 410-200-0315]

MAGI Parent or Other Caretaker Relative Program:

You household income exceeded the standard for the MAGI Parent or Other

Caretaker Relative program.

No one was caring for a dependent child. [OAR 410- 200- 0420]

MAGI Child, MAGI Adult Program, and MAGI Pregnant Woman Programs:

Your household income exceeded the standard for the MAGI Child and MAGI

Adult Program [OAR 410- 200- 0415, 410- 200- 0435].There is no eligibility for

MAGI Pregnant Woman program because:

      was not pregnant or a child under age 1. To qualify for the MAGI

Pregnant Woman Program or MAGI Child Program under 185% of the

federal poverty level, an individual must be pregnant or a child under age 1.

[OAR 410- 200- 0425, 410- 200- 0415]

MAGI CHIP Program:

Your household income exceeded the standard for all HSD Medical Programs except MAGI CHIP.       is covered by accessible minimum essential coverage so does not qualify for MAGI CHIP. [OAR 410- 200- 0410]

Extended Medical Assistance Program:

No one was properly receiving medical benefits through the MAA, MAF,

MAGI Parent or Other Caretaker Relative or MAGI Child programs and no

one lost eligibility for these programs because of increased earned income.

[OAR 410- 200- 0440]

No one was receiving medical benefits through MAGI Pregnant Woman

program and lost eligibility to the increase of earned income or spousal

support. [OAR 410- 200- 0440]

MAGI SAC Program:

      was under age 21, but did not live in an intermediate psychiatric

care facility [OAR 410- 200- 0405] and had household income at or below

income standard.

Former Foster Care Youth Medical Program:

      was not age 18 or older, but under age 26 and was not living in

foster care receiving Medicaid upon the age at which the state’s or tribe’s

foster care assistance ended. [OAR 410- 200- 0406]

Other:      

Citizen/Alien-Waived Emergent Medical:

No one was ineligible for HSD Medical Programs solely because of their citizen or alien status. [410- 200- 0240]

Other:      

Medicare savings programs (Qualified Medicare Beneficiary (QMB), Supplementary Medical Insurance Benefit (SMB) and SMF):

      does not receive benefits under Part A of Medicare.

[OAR 461-135-0010, 461-135-0730]

Your household income exceeded the standard. [OAR 461-155-0290,

461-155-0291, 461-155-0295]

Other:      

Retroactive medical:

No one was found eligible for one of the medical programs required for this benefit. [OAR 461-135-0875(1), OAR 410- 200- 0130]

You must pay back this overpayment even if it was not your fault or you did not know you were being overpaid. The overpayment amount may go up if we find additional medical benefits you received to which you were not entitled. If this happens, you will receive another notice.

[Oregon Administrative Rules 410-120-0006, 461-195-0501, 461-195-0521,

461-195-0541, 461-195-0551, and      ]

2. How overpayments are collected: If you do not contact the Overpayment Recovery Unit (ORU) to repay the debt in full within 15 days, you will receive a Payment Plan Agreement from ORU. The repayment plan will include a monthly payment amount due and the due date.

The following actions may occur if you do not pay the claim in full:

• We may take your Oregon state tax refunds.

• For SNAP overpayments, we will refer the claim to the Federal Treasury Offset Program. This means the Treasury Department will take the money you owe from your federal payments including your federal tax refunds.

• We may issue a "distraint warrant". This allows us to garnish your wages and bank accounts.

• We may put a lien on property you own.

• We may turn the debt over to a private collection agency.

• We may add extra collection fees to the amount you owe if you are overdue in paying your overpayment.

Send payment to: DHS Overpayment Recovery Unit

PO Box 14150

Salem, OR 97309-0430

If you have questions about repaying your overpayment, contact ORU at 503-373-7772 in Salem or toll-free at 800-273-0548.

3. If you do not agree with this overpayment: You have the right to ask for a hearing if you do not agree with this overpayment. You also have the right to talk with a person in charge. You may ask for a meeting by contacting your local branch office. The time limits for requesting a hearing do not change. If you want a hearing, you must request it in time, whether you want to talk to a manager or not.

At a meeting or hearing, you can explain why you do not agree with the overpayment. You can also have people testify for you. You can have a lawyer or someone from a non-profit legal service represent you. We cannot pay the costs of witnesses or a lawyer. You may call the Public Benefits Hotline (a program of Legal Aid Services of Oregon) at 1-800-520-5292 for advice and possible representation. The laws about your hearing rights and the hearing process are at OAR 137-003-0501 to 0700, 461-025-0300 to 0375, ORS 183.411 to 183.470, and ORS 411.703.

If you want a hearing, you must ask for one within 90 days from the date of

this notice.

You can ask for a hearing on MSC 0443 form, by phone, in writing or by asking a DHS employee in person.

In some cases, you do not have a right to a hearing on the overpayment.

These include:

• When you've already had a hearing on the same issue;

• When you've signed legal papers admitting you received this overpayment;

• When a court has decided that you received this overpayment; or

• When you didn't ask for a hearing within 90 days after the date of an earlier notice about this overpayment.

You can put off paying us back until the hearing decision is made.

If you do not ask for a hearing on time, or if you withdraw the hearing request or miss your hearing, you may lose your right to have one. This notice will be the final Department of Human Services (DHS) and Oregon Health Authority (OHA) decision (called a "final order by default"). You will not get a separate final order by default. The case file, along with any materials you submitted in this matter, is the record. The record is used to support the DHS|OHA decision upon default. You may appeal the final order by default by filing a petition in the Oregon Court of Appeals

(ORS 183.482). If you do not ask for a hearing, this appeal must be filed within 60 days of the date this notice becomes a final order by default. If you withdraw a hearing request or miss your hearing, the appeal deadline is set out in the dismissal order.

Note to military personnel: Active duty service members have a right to stay these proceedings under the federal Servicemembers Civil Relief Act (SCRA). For more information you may contact the Oregon State Bar (800-452-8260), the Oregon Military Department (800-452-7500) or the nearest legal assistance office at: .

|      | |      |

|( agency representative) (Branch office) |

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2.

You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. To file a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at:

Governor’s Advocacy Office

500 Summer Street NE, E17

Salem, OR 97301

Fax: 503-378-6532

Email: @state.or.us

“Equal opportunity is the law!”

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1SNAP clients are protected against political belief discrimination.

2Sexual orientation is protected by the State of Oregon, but not federal laws.

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