Lawsuit targets New Mexico Medicaid evaluation procedures

Graphic of the state flag of New Mexico.  The shape of New Mexico in deep yello with a red cross with a circle.
New Mexico

Disability Rights New Mexico and the Arc of New Mexico filed a lawsuit in federal court January 15, challenging a new evaluation system for determining eligibility for its Medicaid-funded Home and Community Based Waiver program.

To reduce the program’s costs, the New Mexico Human Services Department implemented a new evaluation system, using a “Supports Intensity Scale,” in November 2012. Under this system, people eligible for the program are placed in one of seven categories, labeled A to G, with people in Category A requiring the fewest services.

The state currently has 4,200 individuals receiving services through the program, as well an additional 6,000 people on its waiting list.

“We are not opposed to use of the SIS as an assessment tool. It is a highly regarded, national model for assessing client needs,” the advocacy groups stated in a news release. “[However] it was not intended to be a tool for establishing budgets, or for dictating how much of a particular therapy a person needs or should receive.”

In the lawsuit, the advocacy groups argue that the evaluation system violates federal Medicaid law by using standards that are “vague” and “arbitrary,” resulting in the elimination and reduction of services previously deemed to be “medically necessary.”

“Due Process requires an individualized process where the needs of a participant are taken into account before the allocation of services, rather than the arbitrary system of caps and reductions mandated by the contested regulations and employed by defendants,” the lawsuit states.

As explained in the lawsuit, the state is also allegedly violating Medicaid’s fair hearing requirement by denying an appeals process for certain service changes, as well as by failing to make public its evaluation procedures. Federal Medicaid law requires states to provide a mechanism so recipients can “meaningfully contest reductions in their services.”

The advocacy groups are seeking a preliminary injunction to halt the state’s use of the evaluation system, while the parties seek to either modify the program or continue litigation.

Disability Rights New Mexico is the federally funded protection and advocacy system in New Mexico, and a member of the National Disability Rights Network.