5101:4-8-03 Food assistance: restoration and entitlement of lost benefits.

(A) What is restoration of food assistance benefits?

Restoration of benefits is when an assistance group is issued benefits because they have been determined eligible, and additional benefits are due to them because an incorrect amount was issued.

(B) Who is eligible for a restoration of benefits?

Assistance groups who:

(1) Have lost benefits due an agency error.

(2) Were determined to have committed an intentional program violation that has been reversed.

(a) An individual would not be entitled to restoration of lost benefits for the period of disqualification based solely on the fact that a criminal conviction could not be obtained, unless the individual successfully challenged the disqualification period imposed by an administrative disqualification in a separate court action. Participation in an administrative disqualification hearing in which the assistance group contests the county agency assertion of intentional program violation shall be considered notification that the assistance group is requesting restored benefits.

(b) For each month the individual was disqualified, not to exceed twelve months prior to county agency notification, the amount to be restored, if any, shall be determined by comparing the allotment the assistance group received with the allotment the assistance group would have received had the disqualified member been allowed to participate. If the assistance group received a smaller allotment than it should have received, the difference equals the amount to be restored.

(3) Receive a judicial action determining benefits were wrongfully withheld. When the assistance group's situation has been reviewed and determined through the judicial process that the benefits have been wrongfully withheld, the county agency shall restore the assistance group's benefits. If the judicial action is the first action the recipient has taken to obtain restoration of lost benefits, the benefits shall be restored for a period of no more than twelve months from the date the court action was initiated. When the judicial action is a review of a county agency action, the benefits shall be restored for a period of no more than twelve months from the first of the following dates.

(a) The date the county agency receives a request for restoration; or

(b) If no request for restoration is received, the date the fair hearing action was initiated; but never more than one year from when the county agency is notified of, or discovers, the loss.

(4) Have gained categorical eligibility. Assistance groups who gain categorical eligibility are entitled to restored benefits back to the date of the original food assistance application, the date it gained categorical eligibility, or the date categorical eligibility for the specific type of assistance group was created, whichever is later. To determine the prior months of eligibility and the date when restored benefits should begin, consult rule 5101:4-4-27 of the Administrative Code.

(5) Have been found to be eligible for a restoration of benefits which was discovered by the agency. The county agency shall automatically take the necessary action to restore the benefits. No action by the assistance group is necessary. Benefits shall not be restored if the benefits were lost more than twelve months prior to the month the loss was discovered by the county agency in the normal course of business, or were lost more than twelve months prior to the month the county agency was notified in writing or orally of a possible loss to a specific assistance group.

The county agency shall notify the assistance group of its:

(a) Entitlement;

(b) Amount of benefits to be restored;

(c) Any offsetting that was done;

(d) The method of restoration; and

(e) The right to appeal through the fair hearing process.

(C) What are the specific timeframes for making a restoration?

(1) County agencies shall issue restored benefits within thirty days from the date the lost benefits were discovered.

(2) Restored benefits due under rule 5101:4-2-02 of the Administrative Code shall be restored to assistance groups that are categorically eligible within ten days after the discovery date.

(3) If a restoration is ordered through a compliance as a result of a fair hearing decision, it must be completed in accordance with division 5101:6 of the Administrative Code.

(D) When can a restoration be made?

Benefits can only be restored up to twelve months prior to whichever occurs first:

(1) The date the county agency receives the request for a restoration from the assistance group; or

(2) The date the county agency is notified or otherwise discovers that a loss to an assistance group has occurred.

(E) How are restorations tracked?

(1) Each county shall maintain an accounting system for documenting an assistance group's eligibility for restored benefits and calculating the balance. At a minimum, the county agency shall use the JFS 07424, "Report of Claim Determination/Lost Benefits" (rev. 08/01) in the case record.

(2) The calculation of the restored benefit should also be documented and stored in the case record.

(3) The county agency shall have a system in place that readily identifies outstanding claims against assistance groups so they can be offset against the restored benefit amount prior to issuing the restoration.

(F) How is eligibility determined for lost benefits?

The county agency shall determine if the assistance group was actually eligible for the month the loss occurred. In cases where there is insufficient information in the assistance group's case the county agency shall advise the assistance group of what must be provided to demonstrate eligibility for these months. For each month the assistance cannot provide the necessary information to demonstrate its eligibility, the assistance group shall be considered ineligible.

(G) How is the amount of the restoration determined?

After correcting the loss for future months and excluding those months for which benefits may have been lost prior to the twelve-month time limits, the county agency shall calculate the amount to be restored as follows:

(1) Incorrect allotment - if the assistance group was eligible but received an incorrect allotment, the loss of benefits shall be calculated only for those months the assistance group participated.

(a) Under issuance - if the assistance group received a smaller allotment than it was eligible to receive, the difference between the actual and correct allotments equals the amount to be restored.

(b) Offsetting claims - if a claim against an assistance group is unpaid or terminated as provided in rule 5101:4-8-19 of the Administrative Code, the amount to be restored shall be offset against the amount due on the claim before the balance, if any, is restored to the assistance group. At the point in time the assistance group is certified and receives an initial allotment, the initial allotment shall not be reduced to offset claims, even if the initial allotment is paid retroactively.

(2) Delay, denial, or termination - if the loss was caused by an incorrect delay, denial, or termination of benefits, the months affected by the loss shall be calculated as follows:

(a) Incorrect denial: if an eligible assistance group's application was incorrectly denied, the month the loss initially occurred shall be the month of application, or for an eligible assistance group filing a timely reapplication, the month following the expiration of its certification period.

(b) Incorrect delay: if an eligible assistance group's application was delayed, the months for which benefits may be lost shall be calculated in accordance with procedures in rule 5101:4-2-01 of the Administrative Code.

(c) Incorrect termination: if an assistance group's benefits were incorrectly terminated, the month the loss initially occurred shall be the first month benefits were not received as a result of the erroneous action.

(H) What are the payment methods of restoration?

There are two ways to issue a restoration of benefits:

(1) Lump sum - the county agency shall restore lost benefits to an assistance group by issuing an allotment equal to the amount of benefits that were lost. The amount restored shall be issued in addition to the allotment the assistance group is currently eligible to receive.

(2) Monthly installment - the county agency shall honor reasonable requests by assistance groups to restore lost benefits in monthly installments if, for example, the assistance groups fears the excess benefits may be stolen or that the amount to be restored is more than it can use in a reasonable period of time.

(I) What if the assistance group make up is different than when the benefit loss occurred?

When lost benefits are owed to an assistance group and the assistance group's membership has changed, the county agency shall restore the lost benefits to the assistance group containing a majority of the individuals who were assistance group members at the time the loss occurred. If the county agency cannot locate or determine the assistance group which contains a majority of assistance group members, the county agency shall restore the lost benefits to the assistance group containing the individual who was head of the assistance group at the time the error occurred.

(J) What happens if the assistance group disagrees with the determination of the restoration request or benefit amount?

If the assistance group does not agree with the county agency's decision regarding the lost benefits or with the amount of lost benefits computed by the county agency the following procedures apply:

(1) If the assistance group does not agree with the amount to be restored as calculated by the county agency or any other action taken by the county agency to restore lost benefits, the assistance group may request a fair hearing within ninety days from the date the assistance group is notified of its entitlement to restoration of lost benefits. If a fair hearing is requested prior to or during the time lost benefits are being restored, the assistance group shall receive the lost benefits as determined by the county agency pending the results of the fair hearing. If the fair hearing decision is favorable to the assistance group, the county agency shall restore the lost benefits in accordance with that decision.

(2) If an assistance group believes it is entitled to restoration of lost benefits, but the county agency does not agree, the assistance group has ninety days from the date of the county agency determination to request a fair hearing. The county agency shall restore lost benefits to the assistance group only if the fair hearing decision is favorable to the assistance group. Benefits lost more than twelve months prior to the date the county agency was initially informed of the assistance group's possible entitlement to lost benefits shall not be restored.

Replaces: 5101:4-8-03

Effective: 02/10/2011
R.C. 119.032 review dates: 11/01/2015
Promulgated Under: 111.15
Statutory Authority: 5101.54
Rule Amplifies: 329.04 , 329.042 , 5101.54
Prior Effective Dates: 6/2/80, 1/22/82, 3/20/83, 7/1/83 (Temp.), 8/19/83, 9/24/83 (Temp.), 11/11/83, 4/10/84 (Emer.), 8/1/84 (Emer.), 10/20/84, 1/16/87 (Emer.), 4/6/87, 6/22/87, 4/1/89, 1/5/90 (Emer.), 3/22/90, 10/1/90, 8/1/92 (Emer.), 10/30/92, 8/1/95, 10/1/96, 5/1/99, 10/1/01 (Emer.), 10/11/01, 12/01/05