SC Administrative Law Court Decisions

This is an appeal from a final decision of the South Carolina Department of Health and Human Services (DHHS) Division of Appeals and Hearings dated October 27, 1998. Appellant challenges the decision of the DHHS Hearing Officer, which affirmed the determination of the Horry County Department of Social Services (DSS), rejecting his application for Medicaid benefits through the Aged, Blind and Disabled Program (ABD). Calculations prepared by DSS showed that Appellant's countable monthly income exceeded the allowable limit for ABD benefits. These calculations were verified by the Hearing Officer. A Notice of Appeal was filed November 24, 1998 and briefs were filed by each party in accordance with the relevant rules of procedure. Pursuant to Rule 39 of the Rules of Procedure for the Administrative Law Judge Division, no oral arguments were heard.

The Administrative Procedure Act, S.C. Code Ann. §§ 1-23-310 et seq. (Rev. 1986 and Supp. 1997) (APA) sets out the standard of review to be used on appeal of an agency's decision. Accordingly, 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 clearly erroneous in view of the reliable, probative and substantial evidence on the whole record. S.C. Code Ann. § 1-23-380 (A)(6)(e) (Supp. 1997). In accordance with the foregoing provision, the Hearing Officer's decision may only be set aside if unsupported by "substantial evidence."

"Substantial evidence" 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, 134, 276 S.E.2d 304, 306 (1981).

Appellant became disabled on January 5, 1998, according to the Social Security Administration Office Disability and International Operations. He applied for Retirement, Survivors and Disability Insurance from that same entity. Appellant was allotted $765 per month in Social Security benefits beginning July, 1998. On August 7, 1998, Appellant applied for Medicaid benefits under the Aged, Blind or Disabled (ABD) program with the Horry County Department of Social Services. When computing income eligibility for ABD, Respondent must compute earned and unearned income and may disregard up to $20.00 from gross income. This computation identified Appellant's countable income as $745.00. On August 10, 1998, Respondent notified Appellant that his application for ABD benefits was denied due to an income in excess of the Medicaid poverty level of $671 for an individual.

An applicant who disagrees with the determination of DSS may request a "fair" hearing before the DHHS Division of Appeals and Hearings.⁽¹⁾ Appellant participated in a "fair" hearing on October 6, 1998, in Conway, South Carolina. DSS's decision was upheld. The Hearing Officer found that Petitioner has extensive medical expenses, but ABD guidelines do not permit taking these expenses into account when determining eligibility. Based on his letter filed with this tribunal on January 12, 1999, Appellant generally challenges being denied Medicaid benefits, especially in light of his costly medical expenses incurred each month.

Appellant did not allege any error of law by either DHHS in its conduct of the initial appeal or by DSS in the underlying eligibility determination. In determining the applicant's countable earned and unearned income for purposes of ABD eligibility, DSS used the following formula:

Gross Monthly Unearned Income $765.00

General SSI disregard - $ 20.00

Countable Monthly Unearned Income $745.00

In order to be eligible, an individual's countable monthly income cannot exceed $671.00. Appellant's Medicaid benefits were denied because his countable monthly income was determined to be $745.00 which exceeded the ABD limit.

Appellant contends that he needs the Medicaid assistance to supplement his medical expenses. Appellant suffers from rheumatoid arthritis. He included in his Request for Appeal copies of various medical bills and communications with doctors regarding his condition. While it is not disputed that Appellant suffers from this illness which generates substantial medication costs, no provision is made to consider these costs in the ABD eligibility calculation.⁽²⁾

This tribunal understands and is sympathetic to the high cost of Appellant's monthly medications. However, this tribunal will not substitute its judgment for that of the agency 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. Further, the record supports the Hearing Officer's findings of fact and conclusions of law.

Based upon the record and the applicable law, the Order and Decision of the Hearing Officer is AFFIRMED.

AND IT IS SO ORDERED.

_____________________________

JOHN D. GEATHERS

Administrative Law Judge

February 22, 1999

Columbia, South Carolina

1. DHHS administers the Medicaid program in South Carolina. Under contract with DHHS, the Department of Social Services (DSS) acts as DHHS's agent in processing applications for Medicaid eligibility and rendering eligibility determinations.

2. Pursuant to 42 U.S.C. § 1396a(a)(17), a state may elect to provide medical benefits to the "medically needy", defined as persons who meet the nonfinancial eligibility requirements but exceed the financial eligibility standards under AFDC or SSI. Atkins v. Rivera, 477 U.S. 154, 159 (U.S.Mass. 1986). The record does not indicate that South Carolina has elected to participate in this program.