ORDERS:
ORDER
STATEMENT OF THE CASE
This matter is before the Administrative Law Judge Division (ALJD) pursuant to S.C. Code Ann. § 44-6-190 (Supp. 2000)
and S.C. Code Ann. §§ 1-23-310 et seq. (1986 & Supp. 2000). Appellant Henry C. Hayes, III, seeks review of a decision of
the Department of Health and Human Services (DHHS or Department) denying his application for disability benefits under
the Aged, Blind or Disabled (ABD) Medicaid program. Upon careful consideration of the record, the briefs filed, (1) and the
applicable law, I find that the Department's decision to deny Appellant's application for Medicaid benefits must be
affirmed.
BACKGROUND
Appellant applied for Medicaid disability benefits under the ABD program on September 6, 2001. Appellant had
previously applied to the Social Security Administration (SSA) for cash assistance payments under the Supplemental
Security Income Program (SSI) based on the same disability. Finding that Appellant was "not disabled," the SSA denied
Appellant's SSI claim on March 22, 2001. Bound by the prior SSA determination that Appellant was not disabled, the
South Carolina Department of Social Services (DSS), with whom DHHS contracts to conduct disability evaluations, found
that Appellant was not disabled and therefore denied his application for ABD Medicaid benefits on September 28, 2001.
Appellant appealed this Medicaid denial to DHHS. The DHHS hearing officer found that the Department was bound by
the prior SSA disability determination and that Appellant's only avenue of relief was to appeal that determination through
the federal administrative appeals process. Accordingly, the hearing officer dismissed Appellant's case on October 18,
2001. This appeal followed.
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. 2000). 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.
DISCUSSION
The sole ground upon which Appellant brings this appeal is his contention that the SSA relied upon erroneous facts in
reaching its determination that he was not disabled. However, because this ground for appeal seeks to re-litigate the merits
of his federal SSI claim and does not allege a cognizable ground for appeal related to the Medicaid decision reached by
DHHS, this appeal must be denied.
As noted above, "[i]n reviewing a final decision of an administrative agency under § 1-23-380, [this tribunal] essentially
sits as an appellate court to review alleged errors committed by the agency." Kiawah Resort Assocs. v. S.C. Tax Comm'n,
318 S.C. 502, 505, 458 S.E.2d 542, 544 (1995). Accordingly, a petition for appellate review of an agency decision must
specify particular errors committed by the deciding agency to afford the reviewing tribunal a sufficient basis from which to
conduct its inquiry. See Pringle v. Builders Transp., 298 S.C. 494, 495, 381 S.E.2d 731, 732 (1989) ("A petition for . . .
review pursuant to the Administrative Procedures Act (APA) must direct the court's attention to the abuse allegedly
committed below, including a distinct and specific statement of the rulings of which appellant complains."); Smith v. S.C.
Dep't of Soc. Servs., 284 S.C. 469, 470, 327 S.E.2d 348, 349 (1985) ("[A] petition which will suffice legally must be one
which will direct the court's attention to the abuse or abuses allegedly committed below through a distinct and specific
statement of the ruling complained of."). In short, a petition for appellate review of an agency decision under the APA is
insufficient unless there is at least some "allegation which would explain why [the appellant] believes the agency decision
was wrong." Id. at 471, 327 S.E.2d at 349.
Here, neither Appellant's Notice of Appeal nor his appellate brief contain such an allegation. While Appellant does
contend that several errors were made by the SSA in its denial of his application for federal SSI disability benefits, he does
not allege that DHHS committed any particular error in holding that the SSA's disability determination was binding upon
DHHS and thus required the dismissal of his ABD Medicaid claim. And it is the decision of DHHS, not the SSA, that is
the subject of this appeal. Appellant has framed his appeal as a challenge to the factual merits of the disability
determination made by the SSA, not as a petition for appellate review of the legal decision reached by DHHS. Put simply,
he has not made an allegation which would explain why he believes the Department's decision was wrong. Because
Appellant has failed to direct this tribunal's attention to an abuse allegedly committed by DHHS through a distinct and
specific statement of the ruling complained of, this appeal must be denied for his failure to set forth any cognizable grounds
for appellate review.
Further, even if Appellant had articulated a sufficient allegation of error on the part of DHHS, his appeal would have failed.
Federal law requires state Medicaid programs to adopt a Social Security disability determination if that determination
involved the same disabling factors alleged in the Medicaid application and was made within the prescribed time period of
the Medicaid application. 42 C.F.R. § 435.541 (2001). Thus, DHHS was correct in holding that the SSA's determination
that Appellant was not disabled so as to qualify for SSI benefits was binding upon DHHS when evaluating Appellant's
ABD Medicaid application. See id.; see also Disabled Rights Union v. Kizer, 744 F. Supp. 221, 225 (C.D. Cal. 1990)
(upholding the policy that SSA disability determinations supersede Medicaid disability determinations and noting that
"when the SSA determines nondisability against the applicant, it should be binding for Medicaid purposes") (emphasis in
original); Preamble, Medicaid Program, Eligibility Determinations Based on Disability, 54 Fed. Reg. 50,755, 50,756 (Dec.
11, 1989) (to be codified at 42 C.F.R. pts. 435 & 436) ("[A] finding by SSA that an individual is not disabled controls for
purposes of any applications for Medicaid based upon an allegation of disability for essentially the same condition and time
periods.").
ORDER
IT IS THEREFORE ORDERED that the decision of the Department of Health and Human Services to deny Appellant's
application for disability benefits under the ABD Medicaid program is AFFIRMED.
AND IT IS SO ORDERED.
______________________________
JOHN D. GEATHERS
Administrative Law Judge
Post Office Box 11667
Columbia, South Carolina 29211-1667
January 8, 2002
Columbia, South Carolina
1. Pursuant to the discretion granted under ALJD Rule 39, this tribunal determined that it was not necessary to hear oral
arguments in this appeal. |
