Down's Syndrome Case

The Appellant appealed the Department’s decision to deny her request for HCBS because they determined she does not meet eligibility criteria for any waiver program they administer. The appeal was untimely filed by the Appellant’s Representative due to her failure to be notified of the Department’s denial. The Appellant’s Representative clarified that she is only appealing the timely filing due to non-receipt of notice and the denial of the OBRA and Independence waivers.

The Department’s Position

JD, the PA IEB Representative, testified that the Appellant’s representative was not listed in their system as an authorized representative; therefore she was not issued notification of the denial for HCBS. JD testified that due to HIPAA, the Appellant
The Appellant’s primary diagnosis is Down’s syndrome. The services provided through the Independence HCBS waiver would require the Appellant to have three (3) or more limitations in daily living, self-care, mobility, communication, or self-direction however, an eligible applicant would require hands on care, since the waiver does not provide supervision services. The Appellant requires supervision services, which are offered from the waiver programs through the ODP. JD testified that there are waivers specific to consumers with a Down’s syndrome diagnosis; therefore OLTL denied the Appellant’s application for
CK testified that the Appellant also suffers from uncontrolled hypothyroidism and obesity. CK argued that the Down’s syndrome is a developmental disorder, but she is not certain why it took as long as it did to render a decision of ineligibility based upon that diagnosis. OBRA Waiver offers personal care for developmental disorders for those in a facility, but the Appellant has help from her brother and mother whom she resides with; so she only needs hands on care when they are not present. CK testified that the OBRA waiver offers her everything that the Appellant requires, so she is not in agreement with the decision to make her apply for another waiver. CK testified that the process is time consuming, but the Appellant completed all that was requested of her in a month; it was the other parties that did not complete their parts timely. CK’s priority is to help the Appellant get the needed services without prolonging the process any further. CK argued that if the LCD states that the Appellant is NFCE, she should qualify for Independence Waiver services; if the PC states the Appellant is eligible for the OBRA Waiver, she should be eligible. CK concluded that the Department should not make a decision to deny her, however choose between the two eligible