Form NA1282 "Notice of Action in-Home Supportive Services (Ihss) Overpayment - Advance Pay" - California

What Is Form NA1282?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NA1282 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form NA1282 "Notice of Action in-Home Supportive Services (Ihss) Overpayment - Advance Pay" - California

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State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION
IN-HOME SUPPORTIVE SERVICES (IHSS)
OVERPAYMENT - ADVANCE PAY
County of:
(ADDRESSEE)
Notice Date:
Case Name:
Case Number:
Worker Name:
Worker Telephone:
Worker Address:
Questions? Contact your worker.
NOTE: THIS NOTICE ONLY RELATES TO YOUR IN-HOME SUPPORTIVE
SERVICES. IT DOES NOT AFFECT YOUR RECEIPT OF SSI/SSP, SOCIAL
SECURITY, OR MEDI-CAL.
KEEP THIS NOTICE WITH YOUR IMPORTANT PAPERS.
OVERPAYMENT INFORMATION:
This notice is to inform you that you were overpaid for authorized In-Home
Supportive Services (IHSS) for the period of _____________ to _____________,
totaling _____ months. During this period your monthly IHSS payment amount was
________________. Thus, the amount of the overpayment is $________, or _____
months x $________ per month.
You are required to repay the total overpayment amount of $ _____________ (amount
unreconciled, which is the total amount of Advance Pay you received for which
timesheets were not submitted).
REASON FOR OVERPAYMENT:
The reason you were overpaid is because you failed to submit the required signed
timesheet(s) for reconciliation after you were issued your advance payment(s) as
required by program rules, and as a result, it cannot be verified that the advance
payment(s) were spent on IHSS (Welfare and Institutions Code (WIC) §12301.25). If
you think additional facts or circumstances should be considered regarding the
unreconciled timesheets, contact your social worker.
NA 1282 (12/19)
Page 1 of 4
State of California – Health and Human Services Agency
California Department of Social Services
NOTICE OF ACTION
IN-HOME SUPPORTIVE SERVICES (IHSS)
OVERPAYMENT - ADVANCE PAY
County of:
(ADDRESSEE)
Notice Date:
Case Name:
Case Number:
Worker Name:
Worker Telephone:
Worker Address:
Questions? Contact your worker.
NOTE: THIS NOTICE ONLY RELATES TO YOUR IN-HOME SUPPORTIVE
SERVICES. IT DOES NOT AFFECT YOUR RECEIPT OF SSI/SSP, SOCIAL
SECURITY, OR MEDI-CAL.
KEEP THIS NOTICE WITH YOUR IMPORTANT PAPERS.
OVERPAYMENT INFORMATION:
This notice is to inform you that you were overpaid for authorized In-Home
Supportive Services (IHSS) for the period of _____________ to _____________,
totaling _____ months. During this period your monthly IHSS payment amount was
________________. Thus, the amount of the overpayment is $________, or _____
months x $________ per month.
You are required to repay the total overpayment amount of $ _____________ (amount
unreconciled, which is the total amount of Advance Pay you received for which
timesheets were not submitted).
REASON FOR OVERPAYMENT:
The reason you were overpaid is because you failed to submit the required signed
timesheet(s) for reconciliation after you were issued your advance payment(s) as
required by program rules, and as a result, it cannot be verified that the advance
payment(s) were spent on IHSS (Welfare and Institutions Code (WIC) §12301.25). If
you think additional facts or circumstances should be considered regarding the
unreconciled timesheets, contact your social worker.
NA 1282 (12/19)
Page 1 of 4
State of California – Health and Human Services Agency
California Department of Social Services
METHOD OF REPAYMENT:
Consistent with State law, your monthly IHSS Advance Pay payment will be adjusted
resulting in a reduction of 10% until the overpayment is repaid. At the current pay rate,
your IHSS Advance Pay payment amount will be reduced by $ _____________. The
reduction will take effect _____________ through _____________. You must continue
to pay your Individual Provider(s) in full for all Authorized IHSS services provided.
You also have the option of repaying the full amount, or making additional payments
in addition to the reduction described above to shorten the repayment time. If you
choose either of these options, please make checks/money orders payable to:
(COUNTY DEPARTMENT)
ADDITIONAL INFORMATION:
Please note, if Advance Pay timesheets are not submitted for reconciliation 90 days
from the date you were last issued payment, the county may change your Advance
Payment method to payment in arrears. This means your IHSS provider(s) will be paid
directly by the state (instead of by you) after you approve each timesheet (Manual of
Policies and Procedures (MPP) §30-767.133(b) and 30-769.737).
You must immediately report any changes that might affect your eligibility or
need for IHSS, such as changes in income, property, living arrangement, medical
condition or ability to work.
LAWS AND RULES:
These laws and rules apply: WIC §10950, 12300(a), 12301.25, 12303.4, 12304 and
California Department of Social Services’ MPP §30-767.133, 30-767.133(a) and (b),
30-769.737, you may review them at your county welfare office.
STATE HEARING: YOU HAVE THE RIGHT TO FILE A WRITTEN OR ORAL
REQUEST FOR A STATE HEARING. PLEASE SEE REVERSE SIDE OF THIS
NOTICE FOR FURTHER DETAILS.
NA 1282 (12/19)
Page 2 of 4
YOUR HEARING RIGHTS
1. You have the right to ask for a conference
7. If you do not want to go to the hearing
with the county to talk about this action. At
alone, you can bring a relative, friend, or
the conference you can speak for yourself,
other person with you.
or someone else (a lawyer, relative, friend,
or other person) can speak for you. If you
8. You can review the regulations about
want a conference, contact the county.
hearings at your local IHSS office.
2. Whether or not you ask for a conference,
9. Information Practices: The information
you also have the right to ask for a hearing
you give to ask for a hearing is required
if you disagree with any county action. You
to process your request according to state
have only 90 days to ask for a hearing. The
law. A case file will be made up for the
90 days started the day after the county
hearing and you have the right to look at
gave or mailed you this notice.
the information in the file. Any information
you give may be shared with the county
3. If you ask for a hearing before an action on
or the United States Department of Health
your In-Home Supportive Services (IHSS)
and Human Services.
takes place, your services will continue
until the hearing. If you make your request
TO ASK FOR A HEARING:
in good faith, you will not have to repay any
Fill out this page.
money you receive for services you get
Make a copy of the front and back of this
pending the hearing, even if the hearing
page for your records. If you ask, your
decision says the county’s action was right.
worker will get you a copy of this page.
Send this page to:
4. You can ask for a hearing in person or in
writing. You have to say that you want a
California Department of Social Services
hearing and tell the reason(s) you want
State Hearings Division
one.
P.O. Box 944243
Mail Station 8-16-50
5. You can ask for a hearing on your own
Sacramento, CA 94244-2430
or you can ask the county for assistance.
Either way, you should tell your worker as
OR Call toll free:
soon as possible.
1-800-952-5253 or for hearing or speech
impaired who use TDD, 1-800-952-8349.
6. At a hearing, you can speak for yourself,
or someone else (a lawyer, relative, friend,
or other person) can speak for you. You
can get free legal help at your local legal
aid or welfare rights office. For a legal aid
referral, call the toll-free number listed on
this page.
NA BACK IHSS (3/15) - REQUIRED FORM - NO SUBSTITUTE PERMITTED
REQUEST FOR HEARING:
I want a hearing because I disagree with
… I want the person named below to
the action of the county regarding my social
represent me at this hearing. I give my
services. Here’s why:
permission for this person to see my
___________________________________
records and/or go to the hearing for me.
___________________________________
(This person can be a friend or relative but
___________________________________
this person cannot interpret for you.)
___________________________________
____________________________________
___________________________________
Name
___________________________________
____________________________________
Telephone
… If you need more space, check box and
____________________________________
add a page.
Street Address
… I need the state to provide me with an
____________________________________
interpreter at no cost to me. (A relative
City
State
Zip Code
or friend cannot interpret for you at the
hearing.) My language or dialect is:
______________________
_____________________________________________
PERSON WHOSE SOCIAL SERVICES
WERE DENIED,CHANGED OR STOPPED
___________________________________
Telephone
Birthdate
___________________________________
Street Address
___________________________________
City
State
Zip Code
___________________________________
Signature
Date
___________________________________
NAME OF PERSON COMPLETING THIS
FORM
NA BACK IHSS (3/15) - REQUIRED FORM - NO SUBSTITUTE PERMITTED
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