Section 144-332-1-9 - PROGRAM INTEGRITYSection 9.1Intentional Program Violation means that a recipient, applicant, or any other individual in the "Assistance Unit" has intentionally misrepresented facts (including, but not limited to such facts as living arrangement, income, or assets) in order to receive MaineCare, and the recipient, applicant, or any other individual in the Assistance Unit would not have been eligible for MaineCare if the Department had been notified of the correct facts, or of a material change in facts. This includes, but is not limited to: A. False or misleading statements or misrepresentations, concealment, or withholding of facts, orB. An act intended to mislead, misrepresent, conceal, or withhold facts or propound a falsity.Section 9.2Determining the Overpayment. "Overpayment" means program benefits that exceed the amount of program benefits, if any, for which an individual or assistance unit is actually eligible when the department or a court has determined that the benefits were provided as a result of an Intentional Program Violation by the individual. Overpayments are calculated as follows: A. For excess assets, the amount subject to recovery is the lesser of: a. The amount of the payment made on behalf of the individual; orb. The difference between the actual amount of countable resources and the applicable resource limit.B. For excess income, the amount subject to recovery is the total amount of program benefits made on behalf of the individual during the months of the overpayment period.C. For combinations of excess assets and excess income, the amount subject to recovery is the greater of either A. or B. in this Section.D. For misrepresentation of circumstances other than income and assets, the amount subject to recovery is the total amount of payments made on behalf of the individual during the months of the overpayment period.E. For Medically-Needy cases, as described in Part 10 of 10-144 CMR Chapter 332, the amount subject to recovery is the lesser of:a. The amount of program benefits made on behalf of the individual; orb. The difference between the amount of the deductible in effect during the overpayment period and the correct amount of the deductible.F. Situations involving individuals receiving long-term care and waiver services: a. Excess Income - i. If the individual should not have been made eligible for MaineCare, the amount subject to recovery is the amount of program benefits made on behalf of the individual.ii. If the individual was correctly made eligible for MaineCare but the cost of care was incorrectly calculated, the amount subject to recovery is the difference between the amount of the correct cost of care and the cost of care that was in effect during the overpayment period.b. Excess Resources -i. The amount subject to recovery is the difference between the actual amount of countable resources and the applicable resource limit.ii. The individual may choose to make a payment of a lump sum to the long term care facility if the increase will reduce the resources to the appropriate limit. The reduction in resources shall be completed in one calendar month.Section 9.3Notice of Overpayment/IPV. The eligibility office in cooperation with the Office of MaineCare Services shall provide the following information to the individual and/or assistance unit: A. a detailed explanation of the misrepresentation and the effect it had on eligibility.B. a claims history indicating the services that should not have been paid.C. a request that the applicant contact the Office for Family Independence (OFI) within 10-days to discuss repayment of the benefits issued.D. deadlines and methods for requesting an administrative hearing.E. closings, denials, and eligibility notices will be handled according to Part 2 Sections 14 and 15. Section 9.4Administrative Hearing - the Department will provide instructions on how to request an Administrative Hearing consistent with Part 1 Section 7 above.Section 9.5Referral to Fraud Investigation & Recovery Unit (FIRU) for recovery of overpayments described in Section 9.2The OFI will send a copy of the above-referenced notice of over-payment to the Fraud Investigation and Recovery Unit:
A. if the individual or assistance unit does not appeal the department's findings; orB. the final written decision by the Administrative Hearing Officer finds in favor of the department and the individual does not request a judicial review; orC. judicial review finds in favor of the department.10- 144 C.M.R. ch. 332, § 1-9