State Hearing Decision - Hearing Decisions and Administrative ...

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES
BUREAU OF STATE HEARINGS
In the matter of:
JFS 04005 (Rev. 6/2002)
Case Number: County:
5075670108 FRANKLIN
Appeal: Program: Disposition:
1621027
FS
OVERRULED
1621028
MED
OVERRULED
1621029
DFA
OVERRULED
No Compliance Required
Decision Date:
Request Date:
Hearing Officer:
State Hearing Decision
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04/27/2011
11/04/2010
BETSY WEST SUVER
ISSUE SECTION
Appeal #1621028 (Medicaid) and #1621029 (DFA):
The issue on appeal is whether the Disability Determination Area (DDA) correctly denied the
Appellant’s disability claims to support the denials of Medicaid for the Disable and Disability
Financial Assistance (DFA) by the Franklin County Department of Job and Family Services
(Agency).
After careful consideration of the evidence and regulations that apply, I find the denial of
disability by DDA was correct, therefore, the denials of Medicaid and DFA are correct as well.
Thus, these appeals should be overruled.
Appeal #1621027; Food Assistance:
The Appellant did not have a food assistance issue, therefore, this appeal should be overruled.
PROCEDURAL MATTERS
On 11-4-10 the Appellant requested a state hearing. The hearing was originally scheduled for 2-
1-11 but was rescheduled for and duly conducted on 4-11-11 at the Franklin County North
Opportunity Center. The Appellant was present and represented himself. Neither DDA, nor the
Agency had a representative present, but the DDA did submit an appeal summary on its behalf.
An oath was administered and taken by the Appellant.
FINDINGS OF FACT
1. The Appellant applied for Medicaid and DFA claiming to be disabled due to mental
health issues (the referral listed anxiety, hallucinations, and depression), and high blood
pressure.
2. The Appellant had an alcohol and crack cocaine addiction but has not used any
substances since April 2010. He has been receiving mental health services from
Southeast Inc. for several months.
3. The DDA denied the disability claims because high blood pressure is not a disabling
condition by itself. As for the mental health issue, the DDA indicated that his cocaine

STATE HEARING DECISION CONTINUATION
addition is in early full remission, and the substance-induced mood and psychotic
disorders were also in remission. DDA compared the conditions to social security listing
12.08 (personality disorders) and 12.09 (substance addiction disorders). DDA found he
did not meet the criteria for either listing, then determined his residual functional
capacity. It found that with his mental health issues he could still do some light work in
the national economy such as janitorial work after hours.
4. The Mental Functional Capacity Assessment completed on 7-14-10 indicated he had no
marked or extremely marked limitations. The mental status exam found no obvious
indications of perceptual disturbances, and reasoning abilities and other cognitive
processes did not seem overtly compromised.
5. The Appellant has a history as laborer at Value City Distribution from 1999 to 2004.
6. He does not have a high school diploma or GED.
7. The Appellant is several medications for his high blood pressure, medication for his
depression and schizophrenia and insomnia. He currently has prescriptions for 10
different medications.
CONCLUSIONS OF POLICY
In order to be eligible for Medicaid for the Disabled (MA-D) the individual must have a physical
or mental impairment that limits her ability to work as determined by the Disability
Determination Unit. The impairment must result from anatomical, physiological, or
psychological abnormalities which can be shown by medically acceptable clinical and laboratory
diagnostic techniques. A physical or mental impairment must be established by medical evidence
consisting of signs, symptoms, and laboratory findings, not only by a statement of symptoms. 20
CFR 416.908 (1991).
The determination of disability by DDA is based upon the SSI requirements specified in 20 Code
of Federal Regulations § 416.901 to 416.998. The regulations define “disability” as the inability
to do any substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months. If the individual’s severe impairment
does not meet or medically equal a listing in appendix 1 to subpart P of part 404 of this chapter,
the individual’s residual functional capacity is assessed to see if past relevant work or other work
in the national economy can be done. In other words, the individual must have a severe
impairment that makes her unable to do her past relevant work or any other substantial gainful
work that exists in the national economy. 20 CFR § 416.905 (2003). Work may be substantial
even if it is done on a part-time basis or if the individual does less, is paid less, or has less
responsibility than when he or she worked before.
Listing 12.04 (Schizophrenic Disorders) is characterized by the onset of psychotic features with
deterioration from a previous level of functioning.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied, or when the requirements in C are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one or more
of the following:
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STATE HEARING DECISION CONTINUATION
1. Delusions or hallucinations; or
2. Catatonic or other grossly disorganized behavior; or
3. Incoherence, loosening of associations, illogical thinking, or poverty of content of
speech if associated with one of the following:
OR
a. Blunt affect; or
b. Flat affect; or
c. Inappropriate affect;
4. Emotional withdrawal and/or isolation;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration;
OR
C. Medically documented history of a chronic schizophrenic, paranoid, or other psychotic
disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to
do basic work activities, with symptoms or signs currently attenuated by medication or
psychosocial support, and one of the following:
1. Repeated episodes of decompensation, each of extended duration; or
2. A residual disease process that has resulted in such marginal adjustment that even a
minimal increase in mental demands or change in the environment would be predicted to
cause the individual to decompensate; or
3. Current history of 1 or more years' inability to function outside a highly supportive
living arrangement, with an indication of continued need for such an arrangement.
Listing 12.08(personality disorder) exists when personality traits are inflexible and maladaptive
and cause either significant impairment in social or occupational functioning or subjective
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STATE HEARING DECISION CONTINUATION
distress. Characteristic features are typical of the individual's long-term functioning and are not
limited to discrete episodes of illness.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Deeply ingrained, maladaptive patterns of behavior associated with one of the
following:
AND
1. Seclusiveness or autistic thinking; or
2. Pathologically inappropriate suspiciousness or hostility; or
3. Oddities of thought, perception, speech and behavior; or
4. Persistent disturbances of mood or affect; or
5. Pathological dependence, passivity, or aggressivity; or
6. Intense and unstable interpersonal relationships and impulsive and damaging
behavior;
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
“Episodes of decompensation” are exacerbations or temporary increases in symptoms or signs
accompanied by a loss of adaptive functioning, as manifested by difficulties in performing
activities of daily living, maintaining social relationships, or maintaining concentration,
persistence, or pace. Episodes of decompensation may be demonstrated by an exacerbation in
symptoms or signs that would ordinarily require increased treatment or a less stressful situation
(or a combination of the two). Episodes of decompensation may be inferred from medical
records showing significant alteration in medication; or documentation of the need for a more
structured psychological support system (e.g., hospitalizations, placement in a halfway house, or
a highly structured and directing household); or other relevant information in the record about
the existence, severity, and duration of the episode.
Although the Agency only determined whether the Appellant met the criteria for listing 12.08,
the evidence shows he does not meet the criteria for 12.04 either. The psychologist who
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STATE HEARING DECISION CONTINUATION
completed the Mental Functional Capacity Assessment found no marked restrictions, to meet
part B of both listings. The DDA appeal summary stated the medical evidence found no inability
to function outside the home or repeated episodes of decompensation to meet Part C. The
Appellant did not report an inability to function outside the home either and testified that he
could do some janitorial work between the hours of 3pm and 8pm. He explained that he hears
voices in his head which led him to use drugs and alcohol. The Appellant does not meet the
social security listing for either 12.04 or 12.08.
The next step in the evaluation is the Appellant’s residual functional capacity assessment. The
residual functional capacity is the most an individual can still do despite his or her limitations. If
DDA finds that he or she cannot do his or her past relevant work (or he or she does not have any
past relevant work), DDA will use the same assessment of the individual’s residual functional
capacity at step five of the sequential evaluation process to decide if he or she can make an
adjustment to any other work that exists in the national economy. 20 C.F.R. § 416.945. At this
step, DDA will not use the assessment of the residual functional capacity alone to decide if the
individual is disabled. DDA will consider the residual functional capacity assessment together
with the information about the individual’s vocational background to make the disability
determination or decision. 20 C.F.R. § 416.945.
When DDA assess an individual’s physical abilities, it must first assess the nature and extent of
his or her physical limitations and then determine his or her residual functional capacity for work
activity on a regular and continuing basis. A limited ability to perform certain physical demands
of work activity, such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other
physical functions (including manipulative or postural functions, such as reaching, handling,
stooping or crouching), may reduce his or her ability to do past work and other work. 20 C.F.R. §
416.945.
DDA found that his conditions only cause moderate limitations, and would still allow him to do
routine tasks with minimal interpersonal contact. DDA found he could do some work in the
national economy, such as janitorial work that does light cleaning and empties trash after hours
when everyone is gone. The Appellant agreed that he could do this kind of job from 3pm to 8pm.
He explained he would not be able to do early morning work because he is taking medicines to
help him sleep and he is too groggy in the morning, and then he takes the medicines again at
8pm. He also indicated he is interested in taking computer classes because he does not know how
to operate one. Based on the Appellant’s testimony, I find the DDA correctly determined he has
the residual functional capacity to do light work in the national economy.
As for the high blood pressure disability allegation, DDA was correct to deny this claim as it is
not a disabling condition under social security. Although the Appellant experiences the affects of
high blood pressure, such as headaches, it is not a disabling condition in and of itself.
In conclusion, DDA correctly denied the Appellant’s disability claims because he did not meet
the social security listings criteria, and he has the residual functional capacity assessment to do
some light work in the national economy. Since the Appellant is not disabled, he is not eligible
for Medicaid for the Disabled or DFA and the Agency correctly denied the applications.
Therefore, these appeals should be overruled.
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STATE HEARING DECISION CONTINUATION
HEARING OFFICER'S RECOMMENDATION
Based on the record and Agency policy before me, I recommend that appeal #1621028, 1621029
and 1621027 be overruled.
FINAL ADMINISTRATIVE DECISION AND ORDER
Since I find that the Hearing Officer's recommendation is supported by policy and the evidence, I
hereby adopt the recommendation. Thus, appeal #1621028, 1621029 and 1621027 be overruled.
Hearing Authority
April 27, 2011
Notice to Appellant
This is the official report of your hearing and is to inform you of the decision and order in your case. All papers and materials
introduced at the hearing or otherwise filed in the proceeding make up the hearing record. The hearing record will be maintained
by the Ohio Department of Job and Family Services. If you would like a copy of the official record, please telephone the hearing
supervisor at the COLUMBUS District hearing section at 1-866-635-3748.
If you believe this state hearing decision is wrong, you may request an administrative appeal by writing to: Ohio Department of
Job and Family Services, Bureau of State Hearings, P.O.BOX 182825, Columbus, OH 43218-2825 or fax: (614) 728-9574.
Your request should include a copy of this hearing decision and an explanation of why you think it is wrong. Your written
request must be received by the Bureau of State Hearings within 15 calendar days from the date this decision is issued. (If the
15th day falls on a weekend or holiday, this deadline is extended to the next work day.) During the 15-day administrative appeal
period you may request a free copy of the tape recording of the hearing by contacting the district hearings section.
If you want information on free legal services but don't know the number of your local legal aid office, you can call the Ohio
State Legal Services Association, toll free, at 1-800-589-5888, for the local number.
Aviso a la Apelante
Esta es la decisión estatal administrativa de su caso. Todos los documentos y materiales presentados como prueba en la vista o de
otra manera radicados componen el récord administrativo. El récord administrativo será mantenido por el Ohio Department of
Job and Family Services.
Si usted cree que esta decisión estatal administrativa es erronea, usted puede solicitar una apelación administrativa escribiendo al:
Ohio Department of Job and Family Services, Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825 o
facsímil (614) 728-9574. Su solicitud debe indicar por qué usted piensa que la decisión administrativa es erronea. Usted puede
completar la solicitud de apelación incluida con esta decisión. Su solicitud escrita o formulario de apelación tiene que ser
recibido por el Bureau of State Hearings dentro de los 15 días calendario desde la fecha en que esta decisión es expedida. (Si el
15to. día recae sobre un fin de semana o un día feriado, esta fecha límite es extendida al próximo día laborable). Durante el
período de 15 días de apelación administrativa, usted o su representante pueden solicitar una copia gratuita del récord
administrativo y de la grabación de la vista llamando al Bureau of State Hearings al 1-866-635-3748 (seleccione la opción 1 del
menú principal).
Si usted quiere información sobre servicios legales gratuitos pero no sabe el número de su oficina local de servicios legales, usted
puede llamar al Ohio State Legal Services Association, gratuitamente, al 1-800-589-5888, para el número local.
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STATE HEARING DECISION CONTINUATION
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EXHIBITS
STATE HEARING DECISION CONTINUATION
Appendix
DDA:
1. Referral to DDA
2. Social Summary Report
3. Mental Functional Capacity Assessment
4. Objective Medical Documentation (3 pages)
5. Five Step Sequential Evaluation Process
Appellant:
A. Prescription Medication List
B. State Hearing Request
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