MD Court of Special Appeals rules ALJ must determine eligibility for

Administrative law judges should render a final determination as to whether applicants for medical assistance are in fact eligible for such benefits, even when faced with new evidence that was not considered by the reviewing body below, the Court of Special Appeals has ruled.The intermediate appellate court held that an ALJ erred in remanding the case of a man referred to as Albert S. back to a State Review Team for a determination of disability. According to the opinion, Administrative Law Judge Marc Nachman reasoned that since the members of the SRT are the proper persons to make disability determinations, they should have had the opportunity to review updated information - such as medical report forms and emergency room records - that had not been available when they decided to deny benefits.Without a final decision from the ALJ, Albert S. failed to get the fair hearing that he was entitled to under federal and state regulations, the appellate court concluded.[O]nce an applicant contests the determination of the SRT, it is the ALJ's responsibility to render a final decision in the matter, assuming the sufficiency of the evidence, Judge Ellen L. Hollander wrote last week for the court.Sandra T. Brushart of the Legal Aid Bureau Inc. said yesterday she has been waiting for an appellate decision on this issue.ALJs were taking the position that they could not review the new medical evidence that might be introduced at the hearing and make a disability determination on their own, she said. They don't like looking at the new evidence.While ALJs may remand such a case back to the SRT if there is insufficient evidence before them, it is illegal for them to do so otherwise, Brushart said.Usually we present pretty substantial medical evidence, but the judge could still not make a decision, she noted, calling ALJ responses on the issue spotty and unpredictable. We're hoping this decision will mean some of the hurdles will be broken down. Disabled?Albert S., who suffers from ailments including hand and ankle injuries, hypertension, diabetes and arthritis, applied for Medicaid benefits in October 2002. The SRT - a body of physicians and disability specialists who assist local departments of social services in determining eligibility - concluded he was not disabled, and his request was denied. Albert appealed and received an ALJ hearing in August 2003. At the hearing, a representative of the Baltimore County Department of Social Services testified that it had received updated information and that the SRT was reconsidering the case.The ALJ accordingly remanded the case to the SRT, which again found Albert was not disabled.A review board of the Department of Mental Health and Hygiene affirmed the ALJ in 2004, but by then, Albert S. had reapplied for Medicaid benefits and was deemed eligible. An appeal of the board's decision to the Baltimore County Circuit Court was dismissed on mootness grounds.Though it agreed that the case was moot, the Court of Special Appeals seized the opportunity to address the merits of what it recognized as an important matter. Clearly, in addressing the issue, our opinion will help to educate counsel as well as ALJs, Hollander noted. Carolyn Johnson of the Public Justice Center - which filed an amicus brief in the case with other groups including AARP and the Maryland Disability Law Center - said that ALJ remands in such cases have resulted in very poor and very sick applicants going longer without medical care.It's a universal practice as far as we have seen, she said. DHMH was telling the Office of Administrative Hearings to hear these cases and decide these cases on the merits, and they continued not to do so. Brushart said the majority of remands occurred in cases like this one, where new evidence was presented at the time of the ALJ hearing.But Wayne Brooks, an ALJ and deputy director of operations for the Office of Administrative Hearings, said he was not aware of any ongoing problem.We've read and understood the decision and will certainly abide by it, he said yesterday.Counsel for the Department of Health and Mental Hygiene, which conceded that the ALJ erred but argued the case was moot, did not return a call for comment yesterday. WHAT THE COURT HELDCase:Albert S. v. Dept. of Health and Mental Hygiene, CSA No. 2465, Sept. Term 2004. Reported. Opinion by Hollander, J. Filed Feb. 6, 2006.Issue:Did an ALJ err in remanding a medical assistance benefits case to a state review team where there was evidence presented at the administrative hearing that the review team had not had an opportunity to examine? Holding:Yes; judgment dismissing case as moot reversed. The case was of sufficient public concern for the court to consider it; federal and state regulations require that an ALJ must render a final decision as to a person's eligibility for Medicaid. Counsel:Sandra T. Brushart for appellant; Daniel R. Malone for appellee.

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