South Carolina              
Administrative Law Court
Edgar A. Brown building 1205 Pendleton St., Suite 224 Columbia, SC 29201 Voice: (803) 734-0550

SC Administrative Law Court Decisions

CAPTION:
Donna Roach vs. SCDHHS

AGENCY:
South Carolina Department of Health and Human Services

PARTIES:
Appellant:
Donna Roach

Respondents:
South Carolina Department of Health and Human Services
 
DOCKET NUMBER:
97-ALJ-08-0340-AP

APPEARANCES:
Donna Roach, Pro Se

Charles M. Black, Jr., Esquire, for Respondent
 

ORDERS:

ORDER AND DECISION
AFFIRMED

STATEMENT OF THE CASE

This is an appeal of the June 11, 1997 decision of a hearing officer of the South Carolina Department of Health and Human Services (Department). The Department dismissed Appellant's appeal of her denial of Medicaid benefits on the ground that the Social Security Administration determined that Appellant is not disabled. A hearing was conducted before the Administrative Law Judge Division in Columbia, South Carolina, on October 13, 1997, at which time oral arguments were heard on the merits of the appeal. For the reasons stated herein, the decision of the Department's hearing officer is affirmed.

The Department is the state agency charged with administering the Medicaid Program, which is a joint venture between the states and federal government to provide medical assistance to individuals meeting certain criteria. Appellant applied for Medicaid benefits under the ABD (aged, blind or disabled) coverage group, which includes those persons who are over 65 years of age, blind or disabled. Appellant applied under the disability provision on January 31, 1997. Appellant also applied for Social Security benefits from the Social Security Administration (SSA) claiming disability. Appellant's application for Social Security benefits was denied on May 6, 1997, on the grounds that Appellant was not disabled. Based on that finding, the Department denied Medicaid benefits to Appellant on May 15, 1997. Appellant filed a timely appeal and a hearing officer for the Department dismissed the appeal on June 11, 1997, on the grounds that federal law mandates the Department follow the determination by the SSA that Appellant is not disabled.

Appellant has subsequently requested a reconsideration of the SSA determination and filed additional medical reports during oral arguments in the present action. The Department stated that it would honor a new disability determination by the SSA if one is made in that case.

ISSUE

Did the Department err in dismissing Appellant's appeal of denial of Medicaid benefits?

STANDARD OF REVIEW

In reviewing the findings and conclusions of an agency, the Administrative Law Judge Division is limited to determining whether substantial rights of the Appellant have been prejudiced because the administrative findings, inferences, conclusions, or decisions are in violation of constitutional or statutory provisions, in excess of agency authority, made upon unlawful procedure, affected by error of law, clearly erroneous in view of the substantial evidence on the record or arbitrary or capricious or an abuse of discretion. S.C. Code Ann. § 1-23-380(A)(6)(a)-(f) (Supp. 1996).

DISCUSSION

In this case, the hearing officer concluded that the Department acted properly in determining that Appellant's application for Medicaid benefits be denied. I find that this determination is correct in applying the statutory provisions of the law.

The criteria used by the Department to determine disability are identical to those used by the SSA. 42 C.F.R. § 435.540(a) (1996). To ensure consistency and eliminate unnecessary, duplicative efforts, federal law requires the states to adopt a Social Security disability determination if the Social Security determination considered the same alleged disabling factors that have been raised in the Medicaid application and the Social Security determination was made within certain time limits.

42 C.F.R. § 435.541(a)(2) (1996).

In South Carolina, the Department and the SSA have both contracted with the South Carolina Department of Vocational Rehabilitation (VR) to perform disability determinations for the respective programs. Therefore, when an individual applies to either the Medicaid program or the for Social Security disability benefits, VR evaluates the case based on the federal disability criteria acting on behalf of either the Department or the SSA, respectfully.

Appellant was referred to the VR twice - once for the Medicaid application through the Department and once through the SSA for Social Security benefits. VR made a determination regarding the SSA application, and applying the federal criteria denied benefits for disability. Once a Social Security determination is made that meets the two requirements, that decision is binding on the Department until the determination is changed by the SSA. 42 C.F.R. § 435.541 (b)(1)(i) (1996).

The application for aid by Appellant to the Department and to the SSA both arose from the same allegations of the cause of disability, and were made within the permitted time constraints. Therefore, as a matter of law, the Department could not make an independent determination of aid. It was bound by federal law to follow the disability determination made by the SSA to dismiss Appellant's request for review.

I therefore find that the decision of the hearing officer is correct in view of the evidence and applicable law of this case and was not arbitrary or capricious.

Should the Social Security Administration reverse their decision regarding Appellant's disability status, under federal regulations the Appellant's status is also reversed with the Department. 42 C.F.R. § 435.541 (b)(1)(ii) (1996).

ORDER

IT IS THEREFORE ORDERED that the decision of the Department to deny the Appellant Medicaid is AFFIRMED.



___________________________________

STEPHEN P. BATES

ADMINISTRATIVE LAW JUDGE

November 19, 1997

Columbia, South Carolina


Brown Bldg.

 

 

 

 

 

Copyright © 2022 South Carolina Administrative Law Court