ORDERS:
ORDER
STATEMENT OF THE CASE
This matter is before the Administrative Law Judge Division (ALJD or Division) pursuant to
S.C. Code Ann. § 44-6-190 (2002) and S.C. Code Ann. §§ 1-23-310 et seq. (1986 & Supp. 2002).
Appellant Boag M. Smith seeks review of a decision of the South Carolina Department of Health and
Human Services (DHHS or Department) that affirmed the denial of his application for Medicaid
benefits by the Marlboro County Department of Health and Human Services. In particular, the
Department determined that, while he met the financial eligibility requirements of the Aged, Blind or
Disabled (ABD) Medicaid program, Appellant was not “disabled” so as to qualify for Medicaid
benefits under the program. On appeal, Appellant contends that he is, in fact, disabled, and that his
disability is such that he is eligible for benefits under South Carolina’s ABD program. Upon careful
consideration of the record, the briefs filed,
and the applicable law, I find that the Department’s
decision to deny Appellant Medicaid benefits must be affirmed.
BACKGROUND
On May 10, 2002, Appellant sustained significant injuries from a gunshot wound to his right
hip that shattered his right femoral neck. As a consequence of this injury to his femur, Appellant’s
right leg is shortened and externally rotated and he suffers pain in his right hip with dynamic weight-bearing activity. Further, this injury to his right leg has affected Appellant’s strength and endurance
in that leg and his overall gait and balance.
Prior to his injury, Appellant worked as a forklift driver and warehouseman with duties that
required climbing, lifting, and carrying materials. In addition to his prior work experience, Appellant
has earned his high school diploma and attended college for one year. At the time of the DHHS
hearing, Appellant was thirty-four years old.
On May 31, 2002, Appellant filed an application for ABD Medicaid benefits with the
Marlboro County DHHS. The Marlboro County DHHS determined that Appellant met the financial
eligibility requirements of the program and referred the application to the South Carolina Department
of Vocational Rehabilitation (VR) for an independent disability determination. In its report, the VR
found that, while Appellant’s condition was severe enough to prevent him from working at the time
of the evaluation, his condition would improve within the year such that his impairment would not
prevent him from working for a continuous period of twelve months. Based upon this finding that
Appellant did not meet the disability criteria for ABD benefits, the Marlboro County DHHS denied
Appellant’s Medicaid application.
Appellant challenged that denial at a “fair hearing” held before a DHHS hearing officer on
January 7, 2003. In a decision issued on January 9, 2003, the DHHS hearing officer found that
Appellant’s impairment was severe enough to prevent him from resuming his past work for a
continuous period of more than twelve months, but further concluded that Appellant’s residual
functional capacity, when considered with his education, age, and previous work experience, allowed
him to find and perform other work. Therefore, having determined that Appellant was “not disabled”
as defined under the ABD eligibility criteria, the hearing officer affirmed the denial of Appellant’s
application for Medicaid benefits. Appellant appealed that decision to this tribunal on February 4,
2003.
STANDARD OF REVIEW
When sitting in its appellate capacity, the ALJD reviews agency decisions under the standard
of review set up in S.C. Code Ann. § 1-23-380(A)(6) (Supp. 2002). Under that standard, this
tribunal is not entitled to “substitute its judgment for that of the agency as to the weight of the
evidence on questions of fact.” Id. However, this tribunal may reverse or modify the agency’s
decision if substantial rights of the appellant have been prejudiced because
the administrative findings, inferences, conclusions or decisions are:
(a) in violation of constitutional or statutory provisions;
(b) in excess of the statutory authority of the agency;
(c) made upon unlawful procedure;
(d) affected by other error of law;
(e) clearly erroneous in view of the reliable, probative and substantial evidence on the whole record; or
(f) arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.
Id. “Substantial evidence” as used under this standard of review “is not a mere scintilla of evidence
nor the evidence viewed blindly from one side of the case, but is evidence which, considering the
record as a whole, would allow reasonable minds to reach the conclusion that the administrative
agency reached or must have reached in order to justify its action.” Lark v. Bi-Lo, Inc., 276 S.C.
130, 135, 276 S.E.2d 304, 306 (1981). This substantial evidence “is something less than the weight
of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does
not prevent an administrative agency’s finding from being supported by substantial evidence.” Id. at
136, 276 S.E.2d at 306. Accordingly, “[t]he findings of an administrative agency are presumed
correct and will be set aside only if unsupported by substantial evidence.” Rodney v. Michelin Tire
Co., 320 S.C. 515, 519, 466 S.E.2d 357, 359 (1996). Further, the party challenging an agency action
has the burden of proving convincingly that the agency’s decision is unsupported by substantial
evidence. Waters v. S.C. Land Res. Conservation Comm’n, 321 S.C. 219, 226, 467 S.E.2d 913, 917
(1996).
DISCUSSION
The Medicaid program is a joint venture between the federal government and the states to
provide medical and other assistance to persons meeting the relevant eligibility criteria. In South
Carolina, the Medicaid program is administered by DHHS. While the federal government requires
that individuals meeting certain federal criteria be eligible for Medicaid, at their option, states may
extend Medicaid coverage to other individuals and may also offer additional services to individuals.
South Carolina affords such optional coverage to a class of individuals meeting the criteria of the
Aged, Blind, or Disabled (ABD) program.
In order to be eligible for Medicaid assistance under the ABD program, an individual must:
(a) meet[] SSI[
] criteria for either aged, disability or blindness;
(b) ha[ve] countable income, as determined in accordance with Title XIX of the
Social Security Act and federal regulations promulgated in accordance therewith,
which is below 100 percent of the federal poverty level (or as otherwise specified in
the Title XIX State Plan);
(c) ha[ve] countable resources, as determined in accordance with Title XIX of the
Social Security Act and federal regulations promulgated in accordance therewith,
which is below the level specified in the Title XIX State Plan; and
(d) meet[] all non-financial criteria required by Title XIX of the Social Security Act
and federal regulations promulgated in accordance therewith.
27 S.C. Code Ann. Regs. 126-365(M)(1) (1992). In the case at hand, both parties agree that
Appellant satisfies the asset and income limitations of the federal Social Security regulations and that
Appellant is neither blind nor aged as defined by federal regulation. Further, the parties agree that
Appellant meets the other non-financial criteria, such as citizenship, referenced in Subsection (d) of
Regulation 126-365(M)(1). Therefore, the sole issue in this matter is whether Appellant is “disabled”
as defined by the SSI regulations such that he is entitled to assistance under South Carolina’s ABD
Medicaid program. (Hr’g Tr. at 3-4.)
In making an independent determination of disability, see 42 C.F.R. § 435.541(c) (2002),
the
Department, through the VR, applies the SSI evaluation of disability criteria found at 20 C.F.R. §§
416.901 et seq. (2002). See 42 C.F.R. § 435.541(d) (2002). Under those regulations, a disability
is defined as “the inability to do any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to result in death or which has
lasted or can be expected to last for a continuous period of not less than 12 months.” 20 C.F.R. §
416.905(a) (2002). In order to meet this definition, an applicant “must have a severe impairment,
which makes [him] unable to do [his] previous work or any other substantial gainful activity which
exists in the national economy.” Id. And, to determine whether an applicant is able to do other work,
the evaluating agency looks to the applicant’s “residual functional capacity and [his] age, education,
and work experience.” Id. To elaborate upon these basic disability criteria, 20 C.F.R. § 416.920
(2002) sets forth the specific steps to be taken in evaluating an applicant’s claim of disability.
As noted above, in evaluating Appellant’s disability, the VR found that, while Appellant’s
impairment was “severe enough to prevent him from working at this time,” his condition was “not
expected to prevent him from working for a continuous period of 12 months.” (Disability Rationale,
Medicaid Disability Determination, Sept. 5, 2002.) Therefore, the VR recommended that Appellant’s
Medicaid claim be denied as his disability did not meet the duration requirements of the federal
regulations. See 20 C.F.R. § 416.905(a), § 416.909 (2002). Contrary to the VR’s findings, the
DHHS hearing officer concluded not only that Appellant’s medically determined physical impairment
was severe, but also that this impairment was expected to last for a continuous period of at least
twelve months. The hearing officer further found that Appellant’s condition precluded him from
returning to any of his previous jobs, all of which required medium or heavy work, and that Appellant
was limited to a residual functional capacity of sedentary work.
Having reached these conclusions, the hearing officer was required to determine whether,
given his residual functional capacity and his age, education, and work experience, Appellant could
perform work other than the work he has done in the past. See 20 C.F.R. § 416.920(f)(1) (2002).
This inquiry into Appellant’s capacity to perform other work is governed by the guidelines set forth
at 20 C.F.R. Part 404, Subpart P, Appendix 2, Table 1 (2002). See 20 C.F.R. § 416.969 (2002).
These guidelines provide a table for determining whether, based on the individual’s age, level of
education, and type of work experience, an individual limited to sedentary work by a severe
impairment can perform other work, thereby determining whether the individual should be considered
disabled or not. In applying these guidelines in light of Appellant’s residual functional capacity, his
age, and his background, the hearing officer concluded that Appellant’s education (high school
diploma and some college), age (34), and previous work (skilled and semi-skilled with non-transferable skills) dictated a vocational finding of not disabled under the regulatory standards.
Therefore, the hearing officer affirmed the denial of Appellant’s Medicaid claim.
This decision is supported by substantial evidence. The medical evidence in the record and
the testimony taken at the hearing plainly support the hearing officer’s conclusions that, while
Appellant’s impairment to his right leg was severe and was expected to last for at least a year, his
condition was not a per se disability and that, because he has no limitation on the functioning of his
upper extremities, Appellant has a residual functional capacity to perform sedentary work despite his
condition. Further, it is uncontroverted that Appellant is thirty-four years old, that he graduated from
high school and has attended some college, and that he has skilled and semi-skilled previous work
experience, although those skills are not transferable to other work. Under the federal guidelines, an
individual who is limited to a residual functional capacity of sedentary work as a result of a severe
medically determinable impairment and who is between eighteen and forty-four years old, has a high
school education or more, and has skilled or semi-skilled work experience, even if those skills are
non-transferrable, is not considered to be disabled. See 20 C.F.R. Part 404, Appendix 2, Table 1,
Section 201.28 (2002); 20 C.F.R. § 416.969 (2002). Therefore, as the DHHS hearing officer’s
findings regarding the extent of Appellant’s impairment are supported by substantial evidence, and
the hearing officer’s application of the federal disability guidelines to those findings was correct, the
Department’s decision to deny Appellant’s application for ABD Medicaid benefits must be sustained.
This tribunal understands and is sympathetic to Appellant’s concerns regarding his ability to
find and sustain gainful employment. Nevertheless, this tribunal cannot substitute its judgment for
that of the Department except where a “manifest or gross error of law has been committed by the
administrative agency.” Lark v. Bi-Lo, Inc., 276 S.C. 130, 134, 276 S.E.2d 304, 307 (1981). No
such error has been established here, as Appellant has not adequately substantiated his claim to
Medicaid disability benefits. Rather, the record supports the hearing officer’s findings of fact and
conclusions of law. Quite simply, the federal regulations do not consider a person with Appellant’s
injuries and of Appellant’s age, educational background, and work experience to be disabled, even
where the individual cannot perform his prior work and is limited to performing sedentary work.
Accordingly, DHHS properly determined that Appellant is not disabled so as to qualify for benefits
under the ABD program.
ORDER
Based upon the record and applicable state and federal law,
IT IS HEREBY ORDERED that the Department’s decision to deny Appellant’s application
for Medicaid benefits under the Aged, Blind or Disabled program is AFFIRMED.
AND IT IS SO ORDERED.
______________________________
JOHN D. GEATHERS
Administrative Law Judge
June 9, 2003
Columbia, South Carolina |
