11120 Overstated Eligibility and Claims - Overstated eligibility occurs when an individual receives more coverage than they are entitled to receive. Eligibility staff shall document how the overstated eligibility was determined and the reason case correction was required. All overstated eligibility must be promptly resolved.
11121 Types of Claims - There are three types of claims. The type of claim will determine action to be taken in recovery efforts.
11121.1 Agency Error - Instances of agency error which may result in a claim include, but are not limited to, the following:
1. Prompt action was not taken on a change reported by the household.
2. Household income or allowable deductions were incorrectly computed.
3. Coverage continued after the review period expired without benefit of a required redetermination of eligibility.
4. Policy was misallied.
11121.2 Client Error - Instances of client error which may result in a claim include, but are not limited to, the following:
1. Nonwillful withholding of information from a one-time failure on the part of a client to report a change timely (see 9121), which affects eligibility when:
a. The worker has reason to believe that the client did not understand his/her responsibility; and
b. There was no oral or written misstatement by the client, or
2. Willful withholding of information such as:
a. Misstatement (oral or written) made by the client in response to oral or written questions from the agency;
b. Failure by the client to report a change timely (see 9121), which affects eligibility;
c. Failure by the client to report the receipt of a medical coverage payment which he/she knows, or should know, is incorrect.
11121.3 Fraud Error - A fraudulent error occurs when the client intentionally:
1. Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility; or
2. Misuses medical benefits, including selling, sharing or trading the medical I.D. number for money or other renumeration, signing for services that were not provided to the recipient, or other misuse as determined by the agency.
An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim.
A finding of fraud under these provisions may result in criminal penalty, including fines and imprisonment, but may only result in a period of ineligibility if so ordered by the court. Fraud error status is not established if the court’s resolution to the willful client error is to place the individual on diversion.
11122 Claim Not Required - Even though a technical overstatement of eligibility may have occurred, a claim shall not be established in the following instances.
1. The agency failed to ensure the application used to approve eligibility was signed.
2. Coverage granted in accordance with the treatment of income policies or the inability of the agency to act on available information due solely to system cutoff dates. Assistance provided under these circumstances does not constitute incorrect coverage.
3. Overstatement of eligibility that occurred as the result of the household failing to report a change in circumstances they were not required to report. See 9121.
4. The overstated eligibility was the result of agency error and the recipient did not receive any medical services within the month, even if capitation payments have been made on their benefit.
5. An eligibility error related to citizenship or alien status is not considered overstated eligibility when:
a. Eligibility was based on verification of satisfactory immigration status by the Immigration and Naturalization Service (INS).
b. Eligibility was approved to meet timely processing guidelines, but no INS response to a request for verification of immigration status has been received.
c. Eligibility was approved to meet timely processing guidelines, but the reasonable opportunity period for alien applicants to provide documentation of their alien status had not expired.
6. A previously met spenddown is increased within the base period due to a change in income and the new spenddown amount is not met.
11123 Time Frames - The date of discovery for purposes of tracking timely claims shall be the date the case is first identified as potentially having overstated eligibility by the worker, quality assurance, or by other means.
1. For agency and client errors (see 11121.1 and 11121.2), the agency is required to prepare the claim and initiate recovery or attempt to initiate recovery by the end of the calendar quarter in which the overstated eligibility is first identified.
2. For fraud errors (see 11121.3), the agency is required to prepare the claim and initiate referral to KDHE-DHCF Legal Division for prosecution by the end of the calendar quarter following the calendar in which the overstated eligibility is first identified.
Note: Failure to establish a claim within the time frames identified above does not negate the responsibility of the agency to establish or collect on the claim, or of the client to repay any valid overstated eligibility.