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SC Administrative Law Court Decisions

CAPTION:
Boag M. Smith vs. South Carolina Department of Health and Human Services

AGENCY:
South Carolina Department of Health and Human Services

PARTIES:
Appellant:
Boag M. Smith

Respondent:
South Carolina Department of Health and Human Services
 
DOCKET NUMBER:
03-ALJ-08-0064-AP

APPEARANCES:
n/a
 

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, Footnote 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[ Footnote ] 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), Footnote 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. Footnote

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. Footnote 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. Footnote

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


Brown Bldg.

 

 

 

 

 

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