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Administrative Law Court
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SC Administrative Law Court Decisions

CAPTION:
Janis J. Baughman vs. SCDHHS

AGENCY:
South Carolina Department of Health and Human Services

PARTIES:
Petitioners:
Janis J. Baughman

Respondents:
South Carolina Department of Health and Human Services
 
DOCKET NUMBER:
99-ALJ-08-0186-AP

APPEARANCES:
n/a
 

ORDERS:

ORDER

This case is before the Administrative Law Judge Division (ALJD) as an appeal of a decision rendered by a Hearing Officer of the Department of Health and Human Services (DHHS).

STATEMENT OF THE CASE

Ms. Baughman applied for Medicaid benefits on April 15, 1998, under the "Aged, Blind, and Disabled" (ABD) eligibility category. Her application for Medicaid was denied on September 19, 1998. That initial denial was based on a determination by the South Carolina Department of Vocational Rehabilitation that Ms. Baughman was not "disabled" because she did not have a "severe impairment."

Ms. Baughman appealed this Medicaid denial to the DHHS Division of Appeals and Hearings. During the pendency of that appeal, DHHS discovered that Ms. Baughman had applied for benefits from the federal Social Security Administration (SSA) on September 30, 1998, alleging that she was disabled. This September SSA application included the same ailment(s) alleged in her April Medicaid application. As the result of the pending SSA application, the Hearing Officer postponed the fair hearing in the Medicaid appeal in order to await the outcome of the SSA disability determination.

On March 22, 1999, the SSA claim was denied on the basis that Ms. Baughman was not "disabled." The SSA determination that Ms. Baughman was not disabled was automatically adopted by the Medicaid Program. Ruling that the Medicaid Program remains bound by the SSA decision until it is changed by SSA, the DHHS Hearing Officer dismissed Ms. Baughman's Medicaid appeal and advised her to pursue an appeal of the SSA decision through the federal administrative appeals process. The Hearing Officer issued her Order of Dismissal on March 29, 1999.

By letter dated April 7, 1999, Ms. Baughman filed an appeal with the Administrative Law Judge Division (ALJD), challenging the Hearing Officer's dismissal of her case.

PROCEDURAL POSTURE OF THIS APPEAL

A postcard from the Petitioner dated June 6, 1999 -- along with her initial letter requesting the appeal -- was accepted by the ALJD as Ms. Baughman's Brief. The Department responded with its Brief, which was filed with the ALJD on June 11, 1999. A "Notice of Hearing" was issued on June 10, 1999 advising that the action on this appeal would be heard at 2:00 p.m. on Tuesday, September 28, 1999. An acceptance card on file at the ALJD indicates that Ms. Baughman received this "Notice of Hearing" via certified mail.

On September 28, 1999, neither Ms. Baughman nor anyone purporting to represent her appeared, despite the court's decision to wait for an additional ten (10) minutes past the scheduled time for the commencement of the hearing,. The ALJD received no communication from Ms. Baughman concerning her failure to attend the hearing, nor did she provide the ALJD with any prior explanation of any conflicts or other difficulties that would impair her ability to be present individually or through a designated representative.

Charles M. Black, Jr., Assistant General Counsel for the Department, did appear at the appointed hearing time. Mr. Black had previously indicated the Department's willingness to submit to a decision based upon the briefs and other materials filed in this matter. In light of Petitioner's failure to appear at the scheduled hearing, and because the issue presented in this matter is sufficiently straightforward to be evaluated without oral argument, I find that this case is appropriate for disposition without oral argument as authorized by ALJD Rule 39.

DISCUSSION

The Medicaid Program is a joint venture between the states and the federal government to provide medical assistance to individuals meeting certain financial and other criteria. The federal government provides the majority of funding for Medicaid, although the states are required to provide "matching funds" that contribute to meeting the costs of Medicaid. The eligibility category under which Ms. Baughman applied to Medicaid -- ABD -- is an optional coverage group that the State of South Carolina has chosen to include in its Medicaid Program. In order to qualify under this category, an individual must meet financial criteria that require assets and monthly income to be below certain limits. In addition, the applicant must also be "aged" (over 65), "blind" (according to the Social Security Administration's definition of blindness) or "disabled."(1)

Federal criteria established in regulations issued by the Social Security Administration are used to determine whether an applicant is "disabled." These criteria are the same as those used by the Social Security Administration in determining whether an individual qualifies for certain Social Security benefit programs (e.g. cash assistance payments of the Supplemental Security Income Program).

In order to receive both cash assistance and coverage for medical expenses, applicants often apply for Social Security benefits and Medicaid. To ensure consistency, and in an effort to eliminate unnecessarily duplicative efforts, federal law requires the states to adopt a Social Security disability determination if: (1) the Social Security determination considered the same alleged disabling factors that have been raised in the Medicaid application; and (2) the Social Security determination was made within certain time limits. (42 CFR 435.541.) Once a Social Security determination is made that meets these two requirements, that decision remains binding upon the Medicaid Program until the determination is changed by the Social Security Administration. (42 CFR 435.541(b)(1)(i).)

Ms. Baughman applied for both Social Security benefits (under Title XVI) and for Medicaid, so her case was twice referred to the South Carolina Department of Vocational Rehabilitation (VR) -- once by the Medicaid Program, and later by the Social Security Administration.

On August 13, 1998, VR made a determination on the Medicaid application that Ms. Baughman did not meet the Social Security disability requirements, and therefore did not qualify for Medicaid. Because an independent disability determination made on behalf of the state (i.e., the Medicaid Program) is not binding upon SSA, VR was required to make a second determination for Ms. Baughman for the purposes of her later application for Social Security disability benefits. This determination was issued on March 22, 1999, and again found that Ms. Baughman did not meet the Social Security requirements to be considered "disabled." Once this March 22 decision was made on behalf of SSA that included the same alleged basis of disability that had been made for the Medicaid application, the state was required to adopt that SSA decision and remains bound by it until it is changed by SSA.

In light of the binding nature of the SSA's disability determination on March 22, the DHHS hearing officer's decision to dismiss the appeal was proper. Ms. Baughman has not proven convincingly that the decision of DHHS requires reversal.

As noted by the DHHS Hearing Officer in her order of dismissal, Ms. Baughman should utilize the appellate process of SSA, which includes a hearing before a federal administrative law judge, to challenge the SSA disability determination. If Ms. Baughman is successful in a federal appeal through the SSA and is able to have the SSA disability determination reversed, then that reversal would also be adopted by DHHS for purposes of Medicaid eligibility.

ORDER

For the reasons stated above, the March 29, 1999 decision of the DHHS Hearing Officer to dismiss the Petitioner's Medicaid appeal is affirmed. Any additional grounds for appeal raised by the Petitioner that are not specifically discussed in this Order are denied.

AND IT IS SO ORDERED.



Ralph King Anderson, III

Administrative Law Judge





October 15, 1999

Columbia, South Carolina

1. Ms. Baughman's application was made on the basis of her allegations of disability. She did not allege blindness, and she is under age 65.


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