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H-8310 Restitution Defined
Revision 12-4; Effective December 1, 2012
Restitution is securing payment from a recipient when fraud is not indicated or pursued and when the recipient has been undercharged co-payment because of previously unreported or under-reported monthly income or resources that do not involve income averaging.
Restitution applies only to recipients in intermediate and skilled nursing facilities and in community-based ICF/IID facilities. The department does not seek restitution from recipients or recipients' authorized representatives for vendor payments made to state supported living centers or state centers. The department does not seek restitution from recipients or recipients' authorized representatives on home and community based waiver cases, including those living in assisted living facilities.
H-8320 Restitution Procedures
Revision 12-1; Effective March 1, 2012
Recipients or responsible relatives for recipients must notify the department within 10 calendar days of changes in income, resources and other circumstances that affect the amount of benefits received. Any department employee who receives or obtains information from or about a recipient is responsible for relaying the information immediately to the appropriate eligibility specialist. If a recipient has been undercharged co-payment because of previously unreported or under-reported monthly income or resources that do not involve income averaging, and fraud is not indicated, pursue voluntary restitution. Discuss the situation with the recipient and send Form H1225, Restitution. Record restitution requests in case comments.
Calculate the amount of restitution based on the difference between the correct daily co-payment and the previously collected daily co-payment. Multiply this amount by the number of days the recipient was in the facility. For months in which a recipient was ineligible, the amount of restitution sought is the total amount of vendor payments made by the department for those months. Include the reason for the restitution request on Form H1225.
With the following exception, do not request restitution for the current month until the month is over. If ineligibility is a result of resources on hand and the recipient will be ineligible until resources are reduced, restitution may be requested for a current month.
Overpayments of restitution are refundable from Fiscal Management Services.
H-8330 Overpayments Considered for Restitution
Revision 13-1; Effective March 1, 2013
HHSC pursues restitution for MEPD and SSI cases if the overpayment is not the result of department error or income averaging and any of the following situations occur:
- Actual income received in any month varies by $5 or more from budgeted income.
- Fraud is suspected and cumulative vendor payment does not exceed $100.
Note: If the difference between the actual and projected income is the result of income averaging and you are submitting Form H1259, Correction of Applied Income, do not pursue restitution. However, if the budget must be corrected for both income averaging and a lump-sum payment, reconcile the averaged income and seek restitution for the lump-sum payment.
- Changes in income were not reported within 10 days from receipt. Restitution is requested beginning with the month the increased income was received.
- A lump-sum payment (including income excluded for eligibility as irregular or infrequent income) raises income more than $5 for any month.
- Initial payment plan (co-payment) for an SSI recipient is understated by $5 or more.
- A recipient is advised about the correct amount of co-payment on the appropriate notification form, but a lower amount appears on the Patient Status Payment Plan Notice because of a processing or coding error.
- A recipient is determined to be ineligible for the month because of unreported or under-reported resources that exceed program limits.
- ICF, SNF or ICF/IID vendor payments have been continued for a denied recipient pending an appeal, and the hearing officer upholds the denial. Seek restitution for the total amount of the vendor payment made between the initial denial effective date and the date payment stops after the hearing decision. If payments are discontinued because the recipient is denied a level of care, the department requests restitution for vendor payments made after the original level-of-care denial date (as shown on Texas Department of State Health Services Form X-27).
- Co-payment has been continued at a lower level pending an appeal of an increase, and the hearing officer sustains the increase. Seek restitution for the difference between the old and new co-payment amounts for the period from the effective date of the original increase until the date of the appeal decision.
- Income tax refunds are subject to restitution policy (in the month of receipt) for co-payment purposes to the extent that withholding tax was excluded in the co-payment budget.
H-8340 Overpayments Not Considered for Restitution
Revision 09-4; Effective December 1, 2009
HHSC does not seek restitution for MEPD and SSI cases in any of the following situations:
- Cumulative overpayment is $5 or less (for any month).
- Overpayment of over $100 is referred for fraud.
- Overpayment is the result of the department's computation error or failure to act on available information.
- A change in regular monthly income (not lump-sum payment) is reported within 10 days of receipt. The department does not seek restitution for the month of receipt or for the subsequent month if the 10-day advance notice period extends beyond the department's computer cutoff date for that month.
- Income is incorrect as a result of an automated across-the-board adjustment.
- The resource limitation was met on the first day of the month. If a recipient's resources exceed the limit during the month, the department does not collect restitution for partial months.
- Co-payment is based on income averaging.
H-8350 Steps for Submitting Restitution Payment
Revision 19-4; Effective December 1, 2019
| Step | Procedure |
|---|---|
| 1 | Obtain the recipient's cashier's check, money order or personal check in whole dollar amounts. |
| 2 | Give the recipient the original Form H4100, Money Receipt. |
| 3 | Attach the first copy of Form H4100 to the payment, and send to: Texas Health and Human Services Commission Fiscal Management Services ARTS Billing P.O. Box 149055 Austin, TX 78714-9055 |
| 4 | Record the payment on the worksheet. Note: Submit payments to Fiscal Management Services on the day of receipt. |
Related Policy
Restitution Defined, H-8310
Restitution Procedures, H-8320
H-8360 Steps for Requesting a Refund of Restitution Overpayment
Revision 19-4; Effective December 1, 2019
Recipients can request a refund if an incorrect amount of restitution is collected because the recipient was not in the facility for the full month and the refund amount is greater than $1.00.
To request a refund:
| Step | Procedure |
|---|---|
| 1 | Determine and document the amount of the refund on the worksheet. |
| 2 | Send a memo to: Texas Health and Human Services Commission Fiscal Management Services ARTS Billing P.O. Box 149055 Austin, TX 78714-9055
|