Public benefits cases prove difficult

The Office of Clients’ Rights Advocacy (OCRA) handles cases for regional center consumers in many areas of the law. Though many of OCRA’s cases involve special education and regional center services, some of the most compelling and difficult involve public benefits.

Agency procedures differ

Each agency that administers public benefits has its own due process procedures. Learning how to navigate those procedures in all those agencies is one the greatest challenges for clients’ rights advocates (CRAs). Though the agencies have some requirements in common — such as written notice of denials to applicants — each agency also has its own procedures and time lines.

A CRA’s objective is to get the benefit for the consumer in the least amount of time with the least amount of stress for the consumer and the family. The following cases show just how large the challenge can be.

SSI appeal is successful

FM is a client of East Los Angeles Regional Center. She applied for Supplemental Security Income (SSI) under the diagnosis of mental retardation. When the agency turned her down, she filed an appeal. With help from the regional center service coordinator, FM contacted Matt Pope, the CRA for East Los Angeles Regional Center.

Pope’s investigation and review of FM’s medical records showed that she had an additional mental health diagnosis. He agreed to represent FM at her hearing, and submitted a brief with documentation of the second diagnosis. The administrative law judge ruled from the bench in FM’s favor.

Client gets funds from Indian account

OCRA learned two years ago, from a group home manager, that DA had been notified by the Office of Trust Funds Management in the Department of the Interior that he had some money in an individual Indian money account. He only had to have his notarized signature on a document to get the money. But a local notary would not perform the service because she did not believe DA was competent to sign the form.

Frank Broadhead, the CRA at Redwood Coast Regional Center, took care of that problem. DA called him again when no money came from the Office of Trust Funds Management. He just got various reasons and excuses for the delay. Finally, after two years of phone calls, letters, and arguments, the Office of Trust Funds Management sent DA his $3,900.

Request for in-home nursing granted

BL is 11 years old. He has many medical complications from encephalitis and a seizure disorder. To continue living at home, BL needs a minimum of 171 hours a month of in-home care from a licensed vocational nurse (LVN). He also needs at least five hours a month of supervision from a registered nurse (RN). BL was eligible for services from his private insurance, from Medi-Cal through institutional deeming, from California Children’s Services (CCS), from In-Home Supportive Services, and from the regional center. Having so many agencies involved in his care resulted in a lack of coordination. BL and his parents could not figure out which agency was responsible for the in-home nursing hours he needs.

For over a year, BL’s mother tried to get Medi-Cal or CCS to cover the in-home nursing care. Even after she got denials from both Medi-Cal and CCS, the regional center refused to be the payor of last resort.

On reviewing the records, Eva Casas-Sarmiento, the CRA for Regional Center of Orange County, and the assistant CRA, Lupe Moriel, found that CCS should cover the service. They asked for a hearing against CCS and helped BL’s mother submit a more comprehensive Treatment Authorization Request (TAR).

Meanwhile, Casas-Sarmiento tried to get the regional center to pay for in-home nursing services pending the CCS appeal. The regional center refused to provide gap funding, so she filed a request for hearing against them as well.

Representatives from CCS and the regional center then agreed to meet and talk about the request for in-home nursing services. The result was a decision from CCS to approve BL’s initial request. He now gets 171 hours of LVN in-home care with five hours of RN supervision per month.