Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter. Sincerely,

Transcription

1 STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF INSPECTOR GENERAL Earl Ray Tomblin BOARD OF REVIEW Karen L. Bowling Governor 2699 Park Avenue, Suite 100 Cabinet Secretary Huntington, WV February 18, 2014 RE: v. WVDHHR ACTION NO.: 13-BOR-1995 Dear : Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter. In arriving at a decision, the State Hearing Officer is governed by the Public Welfare Laws of West Virginia and the rules and regulations established by the Department of Health and Human Resources. These same laws and regulations are used in all cases to assure that all persons are treated alike. You will find attached an explanation of possible actions you may take if you disagree with the decision reached in this matter. Sincerely, Todd Thornton State Hearing Officer Member, State Board of Review Encl: Claimant s Recourse to Hearing Decision Form IG-BR-29 cc: Erika Young, Chairman, State Board of Review April Goebel, APS Healthcare Linda Workman, PC&A

2 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BOARD OF REVIEW, Claimant, v. Action Number: 13-BOR-1995 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES, Respondent. DECISION OF STATE HEARING OFFICER INTRODUCTION This is the decision of the State Hearing Officer resulting from a fair hearing for. This hearing was held in accordance with the provisions found in Chapter 700 of the West Virginia Department of Health and Human Resources Common Chapters Manual. This fair hearing was convened on February 6, 2014, on an appeal filed August 26, The matter before the Hearing Officer arises from the March 19, 2013 decision by the Respondent to deny the Claimant medical eligibility for the Intellectual Disabilities and Developmental Disabilities (I/DD) Waiver Program. At the hearing, the Respondent appeared by Linda Workman. The Claimant appeared pro se. Appearing as witnesses for the Claimant were,,, and. All witnesses were sworn and the following documents were admitted into evidence. Department's Exhibits: D-1 Notice of denial, dated March 19, 2013 D-2 Bureau for Medical Services Provider Manual, Chapter 513: I/DD Waiver Services (excerpt) D-3 Independent Psychological Evaluation (IPE) of Claimant, evaluation date November 30, 2012 D-4 Addendum to Claimant s IPE, dated March 15, 2013 D-5 Child Fact Sheet for Claimant, dated January 12, 2012 D-6 Comprehensive Biopsychosocial Psychiatric Reevaluation of Claimant, evaluation date October 12, BOR-1995 Page 1

3 After a review of the record, including testimony, exhibits, and stipulations admitted into evidence at the hearing, and after assessing the credibility of all witnesses and weighing the evidence in consideration of the same, the Hearing Officer sets forth the following Findings of Fact. FINDINGS OF FACT 1) The Claimant was an applicant for I/DD Waiver Program services. 2) The Respondent, through its Bureau for Medical Services, contracts with Psychological Consultation & Assessment (PC&A) to perform functions related to the I/DD Waiver Program, including eligibility determination. Linda Workman, a licensed psychologist and licensed school psychologist with PC&A, made the eligibility determination regarding the Claimant. 3) Ms. Workman has been in private practice as a psychologist since 1981 and has extensive experience conducting psychological evaluations over the course of her career. 4) The Respondent denied the Claimant s application based on unmet medical eligibility and issued a notice (Exhibit D-1) dated March 19, 2013, advising the Claimant of the basis for denial. The notice states, in pertinent part: While it is noted that the psychologist who performed the most current IPE for [Claimant] has diagnosed Mild Intellectual Disability, it is also noted that her scores actually fall in the Borderline range of intellectual ability with her verbal ability extending into the Low Average range. [Claimant s] intellectual impairment is not within the range which typically results in the need for an institutional level of care such as that provided in an ICF/IID facility. While her Axis II diagnosis may be in dispute, there is a long and well documented history of serious mental illness, which has resulted in the need for psychiatric hospitalizations and residential placement. It appears that [Claimant s] primary handicapping condition is serious mental illness. Services and interventions she has received to date have been designed to address her Axis I conditions and it appears that adaptive functioning is also impacted by her mental illness. Individuals whose primary diagnosis is mental illness are specifically excluded from participation in the I/DD Waiver program. 5) The independent psychological evaluation (IPE) of the Claimant (Exhibit D-3) noted the Claimant s test results on previous psychological evaluations. The Claimant was administered the Wechsler Intelligence Scale for Children in September 2003, and received a Full Scale IQ result of 62, a Verbal IQ of 69, and a Performance IQ of 72. Additionally, the Claimant was administered the Wechsler Adult Intelligence Scale (WAIS) in November 2010, with a Full Scale IQ result of 57. Ms. Workman testified 13-BOR-1995 Page 2

4 that the score of 69 was in the upper limit of mild mental retardation, the score of 72 was in the borderline range, and the score of 57 indicated the Claimant was not performing to the full extent of her ability when that test was given. 6) Exhibit D-3 additionally included the Claimant s results on the WAIS administered on the evaluation date of November 30, The Claimant s standard scores on all scales of the WAIS ranged from 71 to 81. Ms. Workman testified that eligible scores for this instrument would result in percentile ranks of 1 or less, and the Claimant presented standard scores with percentile ranks between 3 and 10. Ms. Workman testified that standard scores between 70 and 79 on this instrument indicates borderline functioning and does not meet the program requirements for such test results. 7) Exhibit D-3 provided diagnoses for the Claimant including Bipolar II Disorder, with Psychotic Features; and Mild Intellectual Disability. Ms. Workman testified that the Claimant s diagnosis of Mild Intellectual Disability was inconsistent with the Claimant s test scores. For this reason, clarification was requested of the evaluating psychologist. This clarification came in the form of an addendum (Exhibit D-4) to the IPE of the Claimant. The evaluating psychologist replied that some IQ scores for the Claimant fell in the borderline range, but that others (the Full Scale IQ scores of 62 and 57 noted above), coupled with deficits in adaptive behaviors, continue to support a Mild Mental Retardation diagnosis. 8) The November 30, 2012 IPE of the Claimant (Exhibit D-3) noted the Claimant s history of mental illness, as well as services and interventions intended to address mental illness, as follows in pertinent part: [Claimant] was in a number of residential placements including a psychiatric hospital in in, for psychotic symptoms in January She was involuntarily hospitalized in November 2011 at given psychotic symptoms 9) The Child Fact Sheet (Exhibit D-5) for the Claimant provided a section regarding her adaptive living skills. In this section, the Claimant is described as able to independently ambulate, independent in all transfers, independent with eating, independent with dressing, independent with toileting, and independent with her grooming skills. In some of these areas the Claimant was noted to require encouragement and monitoring. Ms. Workman testified that part of the purpose of the I/DD Waiver program is to help individuals become more independent in these areas. 10) A Comprehensive Biopsychosocial Psychiatric Reevaluation of the Claimant conducted on October 12, 2010 (Exhibit D-6), noted exacerbations of the Claimant s mental illness as follows, in pertinent part: 13-BOR-1995 Page 3

5 [Claimant] continues her interactions with imaginary friends and immerses herself into the fantasy world of her favorite cartoon. She is constantly talking to nobody and appears to others to be responding to internal stimuli. [Claimant] also reports that she can see the future as well as dead people. 11) is an employee with the West Virginia Department of Health and Human Resources who provides guardianship services for the Claimant. She testified that the Claimant requires assistance with money management, doctor s appointments, and has a poor concept of safety. She agreed that the Claimant suffers from severe mental illness, but contended that the I/DD Waiver Program is the Claimant s shot at independent living. 12) is a Behavioral Support Professional who has provided services to the Claimant for over a year. She testified the Claimant has problems with processing and impulse control. She testified the Claimant is unable to maintain safety or adequate hygiene on her own. 13) provides services to the Claimant as a Service Coordination Supervisor for West Virginia. She testified the Claimant has problems with impulse control and safety, requires supervision for doctor s appointments, and that the Claimant requires 24-hour protective oversight. 14), a registered nurse who administers services to the Claimant, testified that the Claimant has safety issues, poor judgment, makes poor eating choices and refuses her medications. APPLICABLE POLICY The policy regarding initial medical eligibility for the I/DD Waiver Program is located in Bureau for Medical Services Provider Manual, Chapter 513: I/DD Waiver Services, at This policy requires applicants to meet medical eligibility criteria in each of the following categories: diagnosis, functionality, and the need for active treatment. The policy regarding diagnostic eligibility is located at , and requires applicants to have a diagnosis of mental retardation with concurrent substantial deficits manifested prior to age 22, or a related condition which constitutes a severe and chronic disability with concurrent substantial deficits manifested prior to age 22. Policy provides a list of examples of related conditions which specifically excludes mental illness, stating Any condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires services similar to those required for persons with mental retardation. 13-BOR-1995 Page 4

6 DISCUSSION The medical eligibility component under dispute for the Claimant is diagnostic. The expert witness for the Department testified that the Claimant s test scores did not support a diagnosis of mental retardation. Additionally, the Department s expert witness testified that a related condition diagnosis of the Claimant must be excluded because it is rooted in severe mental illness and such conditions are specifically excluded by policy. The IPE and the addendum to the IPE of the Claimant cannot be given the same weight as the in-person testimony of the Department s expert witness. Without the diagnostic component, medical eligibility for the I/DD Waiver Program cannot be established for the Claimant. CONCLUSIONS OF LAW 1) Policy for the I/DD Waiver Program requires an eligible diagnosis. Because the Claimant does not have a diagnosis of mental retardation or a related condition as defined by policy, the Claimant does not meet the diagnostic component of medical eligibility. 2) Because the diagnostic component could not be established, medical eligibility as a whole for the program could not be established and the Claimant s application must be denied. DECISION It is the decision of the State Hearing Officer to uphold Respondent s denial of Claimant s application for services under the I/DD Waiver Program. ENTERED this Day of February Todd Thornton State Hearing Officer 13-BOR-1995 Page 5