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The SIS Process in New Mexico
Randy CostalesExecutive Director, The Arc of New Mexico
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Designed to assist in the service planning process for the individual, parents, family members, and service providers. Outlines the type and intensity of support the individual would benefit from to participate and be successful in his or her community. Best applied in combination with person-centered planning to achieve the desired outcome in creating individual goals.
SIS Profile Information
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SIS Score used to assign individuals to budget categories with caps
Some individuals were denied services that they needed simply based on the scores they get through the assessment instrument
Reductions or denials of services based simply on SIS test scores and assigned budget categories put the health and safety of some individuals at risk.
However, in NM…
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Pre- Assessment Issues – Information, Scheduling, etc. SIS AssessmentVerification ProcessAlgorithm (Developed by HSRI)Standard ScoreGroup Assignment (Developed by NM DOH/DDSD)Case ManagerIndividual/Guardian/Parent
NM SIS Process
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Base Budget – Case management, living arrangement, day services including employment and customized community supports.
Professional Services Budget – Physical, Speech, Occupational and Behavioral Therapies
Other (need prior authorization)
Budget Components
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A. Mild support needs and low to moderate behavioral challenges
B. Low to moderate support needs and behavioral challenges
Note: Budgets for Groups A and B do not include living arrangements
Budget Groups
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C. Mild to above average support needs and moderate to above average behavioral challenges
D. Above average support needs and low to moderate behavioral challenges
E. High support needs and mild to above average behavioral challenges
Groups (Cont.)
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F. Extraordinary medical challenges
G. Extraordinary behavioral challenges
H Policy - Purpose of policy is to allow individuals who have extenuating circumstances or extremely complex needs to receive authorized services beyond the service package option that corresponds with their Group assignment.
Groups (Cont.)
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State restricted the ability of clients and families to appeal decisions that affect the services they receive.
State imposed restrictions on what can be appealed and when it can be appealed violate federal law governing Medicaid.
The Unfair Hearing Process
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Filed by eight individuals/families, The Arc of NM and Disability Rights NM
To stop state from using SIS to arbitrarily deny people with developmental disabilities the essential services they need and putting their health and safety at risk.
Challenged state regulations, policies, standards, and practices that deny DD Waiver participants due process of law and that otherwise violate federal law
January 15, 2014 Lawsuit
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To prohibit further implementation of recent state regulations, policies and practices until such time as the state can fix the problems identified in the complaint.
To restore services to individuals that had been cut as a result of the new system, and prohibit any further service reductions until the violations of federal law have been corrected
Preliminary Injunction Requested
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August 18-19, 2014 - Hearing held in Federal District Court
March 10, 2015 – Judge issued preliminary injunction in plaintiff’s favor
Defendants and plaintiffs are currently working together to settle the case
Legal Proceedings
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Not opposed to use of the SIS as an assessment tool. It is a highly regarded, national model for assessing individual’s needs.
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.
Position Statement
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Service plans should be individualized and take into account not only test scores but past experience and the independent judgment of the multi-disciplinary team that works with the individual.
Some individuals may be determined to need a lesser amount of services than previously received.
Everyone who is facing a reduction in services is entitled to appeal the decision, to make sure that it is appropriate in their circumstances and that the rules were followed.
The Right Way
