ORDERS:
FINAL ORDER AND DECISION
This matter comes before me upon Appellant William A. Dunbar's appeal of a determination by the South Carolina
Department of Health and Human Services (DHHS) that he is not eligible for benefits under the Medicaid Aged, Blind, or
Disabled (ABD) Program because he is not "disabled."(1) DHHS has opposed the appeal on the grounds that federal law
requires South Carolina's Medicaid Program to adopt a prior determination of the federal Social Security Administration
(SSA) that Mr. Dunbar is not "disabled." DHHS has informed Appellant that his proper recourse is to challenge the SSA
determination through the federal appellate process, which includes federal administrative court.
Pursuant to the authority provided under ALJD Rule 39, I find that oral argument is not required in this matter. Further,
after reviewing the record on appeal and considering the briefs submitted by both parties, I find that the decision of DHHS
must be affirmed.
STATEMENT OF THE CASE
On May 17, 1999, Mr. Dunbar applied for Medicaid benefits under the ABD Program based on an alleged disability. See
DHHS Administrative Decision of July 22, 1999. DHHS referred Mr. Dunbar's case to the S.C. Vocational Rehabilitation
Department (VR) to determine whether Mr. Dunbar was "disabled," as defined under the federal SSA criteria applicable to
the federal Supplemental Security Income (SSI) program. Mr. Dunbar had previously applied for benefits under the SSI
program but was denied benefits because SSA had determined that Mr. Dunbar was not "disabled." On June 25, 1999, VR
automatically adopted the prior SSA determination that Mr. Dunbar was not "disabled." For this reason, on July 1, 1999,
DHHS denied Mr. Dunbar's application for Medicaid. By Letter dated July 7, 1999, Mr. Dunbar appealed the DHHS
determination to the DHHS Division of Appeals and Hearings. See Letter from Mr. Dunbar dated July 7, 1999.
A DHHS Hearing Officer, Vastine G. Crouch, dismissed the appeal and advised Mr. Dunbar to pursue an appeal of the SSA
determination through the federal administrative appeals process. See DHHS Administrative Decision dated July 22, 1999.
By letter dated July 29, 1999, Mr. Dunbar appealed the DHHS decision to the ALJD. See Letter of William Dunbar dated
July 29, 1999. His letter states that he was injured in an accident at work on August 10, 1998, he has been unable to work
since the accident, and he was unable to obtain Worker's Compensation, unemployment or SSI benefits. According to his
July 29 letter, Mr. Dunbar suffers from a pinched nerve, severe headaches and seizures.
STANDARD OF REVIEW
The Administrative Procedures Act, S.C. Code Ann. §§ 1-23-310 et seq. (Rev.1986 and Supp.1998) establishes the
standard of review for appeals of agency decisions. Lark v. Bi-Lo. Inc., 276 S.C. 130, 276 S.E.2d 304 (1981). In reviewing
the evidence in an appeal of a contested case, the ALJD is limited to determining whether 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.
S.C. Code Ann. § 1-23-380 (A)(6)(e) (Supp.1998). The burden is on the appellant to show convincingly that the decision of
DHHS requires reversal. See Hamm v. AT & T, 302 S.C. 210, 394 S.E.2d 842 (1990). In this instance, the Appellant, Mr.
Dunbar, has not proven convincingly that the decision of DHHS requires reversal.
ANALYSIS
In order to invoke the jurisdiction of the ALJD in an appeal of an agency decision, a notice stating the specific grounds for
the appeal must be filed within thirty days of the receipt of the decision being appealed. S.C. Code Ann. § 1-23-380
(Supp.1998); see ALJD Rule 33. Mr. Dunbar has complied with the notice requirements, and this tribunal has jurisdiction
over this matter.
The Medicaid Program is a joint venture between the federal government and the States to provide medical and other
assistance to persons meeting certain criteria. In South Carolina, DHHS administers the Medicaid Program. 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 criteria of the "Aged, Blind and Disabled" Program.
Under the ABD Program, an applicant must establish that (1) the applicant's assets and income fall below certain limits; and
(2) the applicant is "aged" (over 65), "blind" (as determined under SSA regulations) or "disabled" (as determined under SSA
regulations). The federal government has established specific criteria that are used by the SSA to determine when an
applicant is "disabled" under the ABD program. Since applicants may concurrently apply for both federal SSI benefits and
Medicaid benefits, federal law streamlines the application process by requiring that the States adopt a prior SSA disability
determination if the following three requirements are met: (1) SSA's determination considers the same alleged disabling
factors that have been raised in the Medicaid application; (2) SSA's determination covers the same alleged period of
disability presented to DHHS in the Medicaid application; and (3) SSA's determination is was made within certain time
limits. 42 C.F.R. § 435.541. When these three requirements are met, the SSA determination remains binding for purposes
of the Medicaid Program until the determination is changed by SSA. 42 C.F.R. § 435.541(b)(1)(I).
Both DHHS and the federal government have contracted with VR to conduct disability determinations for their respective
programs. VR evaluates the case based on federal disability criteria and determines whether the applicant is "disabled."
When VR evaluates an SSI application, it acts on behalf of the federal government. When VR evaluates a Medicaid
application, it acts on behalf of South Carolina.
Mr. Dunbar applied for SSI benefits and later Medicaid benefits; consequently, his case was referred to VR twice. On behalf
of the federal government regarding the application for SSI benefits, VR determined that Mr. Dunbar was not "disabled."
On behalf of the State of South Carolina for Medicaid benefits, VR automatically adopted the prior determination that Mr.
Dunbar is not "disabled." According to the record on appeal, (1) SSA's disability determination considered the same
alleged disabling factors that were raised in the Medicaid application; (2) SSA's disability determination covered the same
alleged period of disability presented to DHHS in the Medicaid application; and (3) SSA's disability determination was made
within the proper time limits. See 42 C.F.R. § 435.541; see also Armstrong v. Palmer, 879 F.2d 437 (8th Cir. 1989);
Disabled Rights Union v. Kizer, 744 F. Supp. 221 (C.D. Cal. 1990). For this reason, the SSA determination was binding on
DHHS. In light of the binding nature of SSA's disability determination, DHHS's decision to dismiss the appeal was proper.
Mr. Dunbar has not proven convincingly that the decision of DHHS requires reversal.
As DHHS's Administrative Decision dated July 22, 1999 advises, Mr. Dunbar should utilize the appellate process of SSA,
which includes a hearing before a federal administrative law judge, to challenge the SSA disability determination. If Mr.
Dunbar's appeal results in a reversal of the SSA disability determination, he can then seek a determination from DHHS that
he is "disabled" and eligible for Medicaid benefits. Also, Mr. Dunbar may then be eligible for Medicaid benefits retroactive
to his initial date of application. See 27 S.C. Code Ann.Regs. 126-360 (B)(1) (1976).
This tribunal may rule on this matter without oral argument. ALJD Rule 39 provides that:
[t]he Clerk of the Division shall provide at least twenty (20) days notice of oral argument. The oral argument shall follow
the procedure in Rule 218, SCACR. In the discretion of the administrative law judge, oral argument may not be
required.
Pursuant to the authority provided in Rule 39, I find that oral argument is not required.
ORDER
IT IS THEREFORE ORDERED that 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
Post Office Box 11667
Columbia, South Carolina 29211-1667
October 1, 1999
Columbia, South Carolina
1. Mr. Dunbar claims that he is "disabled," rather than "aged" or "blind." |
