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Horizon NJ Health
Managed Long Term Services and
Supports (MLTSS)
Care Management Program Overview
December 2, 2014
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Horizon NJ Health
Goal MLTSS
• Is to help people get the support they need to remain in their home or in
less costly community settings, rather than nursing homes.
• Provide services and supports to adults and children to help them
perform activities of daily living such as bathing, dressing, eating and
toileting, as well as supportive activities such as making meals,
shopping, cleaning and laundry.
• Assist members to transition from a Nursing Facility back to the
Community or Community to Nursing Facility
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Horizon NJ Health
Qualifying for MLTSS
• To qualify for MLTSS individuals must be Medicaid eligible and must meet
Nursing Facility level of care (LOC) criteria.
• Home Care Assessment
• The Clinical Level of Care is determined by the New Jersey Choice Assessment
• This assessment measures a member’s ability to perform basic activities of daily
living including bathing, dressing, feeding, meal preparation, shopping and
cleaning.
Office of Community Choice Options (OCCO) renders all MLTSS
eligibility determinations.
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Horizon NJ Health
MLTSS Care Management
Horizon NJ Health members who are eligible for MLTSS will be assigned
a RN/SW or BH Care Manager.
Care managers perform face-to-face visits with each member to initiate
care planning.
• Initial Face to Face visit
• 30 day/90 day visit
• Change in condition visits
The care manager and member create a plan of care that is specific to the
physical, social, behavioral and long term care needs of the member
.
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Horizon NJ Health
Community Services
PT/OT/ST Therapists
County Services
Primary Care
Physicians
Legal System Support
Educational Services
Medical Supply
Companies
In-Home Caregivers
Mental Health
Specialty Practices
Hospitals& Clinics
Religious/Spiritual
Support
Coordination
Family
Member
Care Notes
Care Plan
Discussions
Notifications
Scheduling
Files
Roles & Rosters
What Care Coordination Looks Like at HNJH:
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Horizon NJ Health
Traditional Benefits
HNJH responsible for authorization and payment for:
Chiropractor Services Inpatient Hospital
Dental Services Inpatient Skilled and Rehab
DME & Assistive Technology Devices Laboratory Services
EPSDT Nursing facility (1st 30 days)
Hearing Aid Optometrist Services
Home Health Agencies Outpatient Hospital
Hospice Services Personal Care Assistance/PPP
Radiology Services Preventive Health
Medical Transportation (Logisticare) Medical Day Care
* When indicated by and Individual Health Assessment and/or Complex Needs Assessment
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Horizon NJ Health
Community Alternative Residential Settings
• Adult Family Care
• Assisted Living Residence
• Community Personal Care Homes
• Assisted Living Program
• Community Residential Services (TBI)
Nursing Facility
Private Duty Nursing (Adult)
Caregiver/Participant Training
Chore Services
Traumatic Brain Injury
• Behavioral Management
• Cognitive Rehabilitation Therapy
• Structured Day Program
• Supported Day Services
Respite (up to 30 days per year)
Community Transition (from NH) Services
Home-Based Supportive Care
Home Delivered Meals
Medication Dispensing Device
Non-Medical Transportation
Personal Emergency Response System
Residential Modifications
Vehicle Modifications
Social Adult Day Care
Adult Medical Day
Personal Care Assistance (PCA)
Personal Preference Consumer Directed
Non-Traditional MLTSS Services
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Horizon NJ Health
Dedicated MLTSS Member Services
•1-844-444-4410
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Horizon NJ Health
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Horizon NJ Health
Questions?
Beverly Roberts, [email protected]
Director, Mainstreaming Medical Care
The Arc of New Jersey
December 2, 2014
MLTSS and
PERSONS WITH I/DD
Medicaid MCOs Providing MLTSS
Services in NJ
MLTSS: Managed Long Term Services & Supports
Aetna Better Health of New Jersey (new as of
Dec. 1, 2014)
Amerigroup, New Jersey
Horizon NJ Health
United Healthcare Community Plan
WellCare Health Plans of New Jersey
Persons on 4 Medicaid Waivers
Transitioned into MLTSS, 7-1-14 Community Resources for Persons with Disabilities
(CRPD)
Traumatic Brain Injury (TBI)
ACCAP (AIDS waiver)
Global Options (GO waiver)
************
No more waiver “slots”
However, per person maximum budget amounts
may be a problem for people with high level of
need
Case Example of Bethany, a Child
Who Needs PDN
Bethany, a child who is medically fragile and
requires private duty nursing (PDN).
Bethany’s parents are viewed as “middle class.”
Dad works full-time; family is covered by his
employer’s health insurance.
Mom works part-time.
Family’s health insurance does not cover PDN.
Bethany received PDN from CRPD waiver; now
receives MLTSS services, and receives PDN
through the Medicaid benefit.
Bethany’s Diagnoses
Bethany is 21 years old and will finish school in June.
Diagnosed with Trisomy 18, also known as Edwards
syndrome (caused by an error in cell division).
Unlike Down syndrome, children with Trisomy 18 have
severe medical complications that are potentially life-
threatening.
Typical characteristics of Trisomy 18 include:
- Heart defects
- Kidney problems
- Part of the intestinal tract is outside the stomach
- The esophagus doesn’t connect to the stomach
- Pocket of fluid on the brain
- Delayed growth and severe developmental delays
Approved for Medicaid Waiver
at Age Two Bethany was approved for the CRPD Medicaid
waiver many years ago.
Has received 16 hours PDN daily for many years.
Family income is too high for Medicaid. When
Bethany was a young child and approved for
Medicaid waiver, it was due to her medically
fragile condition.
Bethany transitioned to the MLTSS waiver on
July 1, 2014.
What will Happen to Bethany in June
when School Ends?
Other 21-year-olds will receive DDD services.
Problem due to needing to continue private
duty nursing (PDN)
Limited options: currently cannot have DDD and
MLTSS services simultaneously!
Requesting permission from CMS
Special Child Health and
Early Intervention Services
These are NJ Dept. of Health programs.
Early Intervention System serves children up to
age 3 who have developmental delays or
disabilities.
Case Management Units serve children of all
ages (up to 21) with complex medical
conditions such as: autism, cerebral palsy, cleft
lip/palate, intellectual disability, hemophilia, HIV
& AIDS, PKU, sickle cell disease.
Special Child Health Services (SCHS)
cont.
Each of the State’s 21 counties has a SCHS case
management unit.
SCHS case managers, with parental consent,
work with the child’s parents and the physician
to evaluate the affected child’s strengths and
needs; and develop an individual service plan
for the child and family.
http://nj.gov/health/fhs/sch/index.shtml
NJ’s Catastrophic Illness in Children
Relief Fund Program
This program provides eligible families with financial
assistance to help cover medical expenses,
previously incurred because their child was
catastrophically ill or injured.
Covered expenses include special ambulatory care,
acute or specialized in- or out-patient hospital care,
medical equipment, medically related home
modifications, home health care, and medical
transportation.
For further information, call 1-800-335-3863 or
609-292-0600, 8:00 am to 5:00 pm Mon. thru Fri.
Case Example of an Adult
Joe has Down syndrome and is 54 years old. Lives with widowed mother. Never had DDD services.
He worked at a grocery store when he was younger, but he cannot work any longer. Recently diagnosed with dementia.
Very forgetful; previously used bus transportation to get to his job, but that skill has been lost.
Has anger outbursts that he never had before. Had his first seizure recently.
Wants to wear clothing not appropriate to the weather, e.g., wearing bathing suit in 40 degree weather. Needs constant reminders to brush his teeth and take a shower.
Income: $1,150/month from SSD.
He never had SSI. Had WorkAbility when he was working, but since he’s no longer working, no WorkAbility.
Process for DDD Client Who May
Need MLTSS Services
Person with I/DD may need MLTSS services and
stay in the community, or
Person with I/DD may need placement in a
nursing home (through MLTSS).
The key issue is whether the person is able to
benefit from DDD specialized services or not.
Cannot have DDD and MLTSS services
simultaneously.
Some people with I/DD are not DDD clients
because don’t have Medicaid.
Some people – referred for MLTSS in error!
If a Person Currently has DDD
Services & Medicaid Contact DDD case manager to discuss the
individual’s needs. Can DDD meet those needs?
If nursing home placement may be needed: first
step is PASRR process – Preadmission Screening and
Resident Review – by DDD nurse.
PASRR is not required for admission to assisted living
facility – but contact DDD anyway.
Remember: cannot have MLTSS services unless DDD
services are ended!
Contact Beverly Roberts at [email protected] if DDD case manager cannot help.
If a Person Does Not Have Medicaid
and Needs MLTSS Services
If no Medicaid: Start the process with outreach
to Aging and Disability Resource Center (ADRC)
Income threshold for “institutional” MLTSS
services is higher than for community Medicaid!
Maximum monthly income for 2014 is $2,163.
Starting Jan. 1, 2015, maximum monthly income-
$2,199.
Miller Trust possible, if income is higher than
above. See attorney.
New Information on Setting Up
a Miller Trust Account
At the end of November 2014, NJ Medicaid allowed
a person who is eligible for MLTSS services but has
income above the limit ($2,163 for 2014) to set up an
irrevocable Miller trust account at a bank.
All income above $2,163/month goes into that trust
account.
Withdrawals allowed for qualified living expenses
and for the portion of their care that individuals can
afford.
Medicaid will pay for the rest of their care – at
home, in assisted living, or nursing home.
ADRC/AAA CONTACT INFORMATIONNationwide Toll-Free Telephone Number 1-877-222-3737
NORTHERN NEW JERSEY OFFICES:
Bergen(201-336-7400)Bergen County Division of Senior ServicesOne Bergen County Plaza, 2nd FloorHackensack, NJ 07601-7076
Essex(973-395-8375)Essex County Division of Senior Services900 Bloomfield AvenueVerona, NJ 07044
Hudson
(201-369-4313)Hudson County Office on Aging595 County Avenue, Building 2Secaucus, NJ 07094
Morris(973-285-6848)
Morris County Division on Aging, Disabilities and Veterans340 West Hanover AvenuePO Box 900Morristown, NJ 07963-0900
Passaic(973-569-4060)Passaic County Department of Senior Services, Disabilities and Veterans' Affairs930 Riverview Drive, Suite 200Totowa, NJ 07512
Sussex(973-579-0555)Sussex County Division of Senior ServicesSussex County Administration Building
1 Spring Street, 2nd FloorNewton, NJ 07860
Warren(908-475-6591)Warren County Division of Aging & Disability ServicesWayne Dumont Jr. Admin. Bldg.165 County Road, Suite 245Route 519 SouthBelvidere, NJ 07823-1949
ADRC/AAA CONTACT INFORMATIONNationwide Toll-Free Telephone Number 1-877-222-3737
CENTRAL NEW JERSEY OFFICES:
Hunterdon(908-788-1361/1362/1363)Hunterdon County Division of Senior, Disabilities and Veterans' Services4 Gauntt Place, Building 1PO Box 2900
Flemington, NJ 08822-2900
Mercer(609-989-6661/6662)Mercer County Office on Aging640 S. Broad StreetPO Box 8068Trenton, NJ 08650
Middlesex(732-745-3295)Middlesex County Office of Aging and Disabled Services75 Bayard Street, 5th FloorNew Brunswick, NJ 08901
Monmouth(732-431-7450)Monmouth County Division of Aging, Disabilities and Veterans Services3000 Kozloski RoadFreehold, NJ 07728
Ocean
(732-929-2091)Ocean County Office of Senior Services1027 Hooper Avenue, Building #2PO Box 2191Toms River, NJ 08754-2191
Somerset
(908-704-6346)Somerset County Office on Aging and Disability Services27 Warren Street, 1st FloorPO Box 3000Somerville, NJ 08876
Union(908-527-4870 or toll-free 888-280-8226)Union County Division on AgingAdministration BuildingElizabeth, NJ 07207
ADRC/AAA CONTACT INFORMATIONNationwide Toll-Free Telephone Number 1-877-222-3737
SOUTHERN NEW JERSEY OFFICES:
Atlantic(1-888-426-9243 or 609-645-5965)Atlantic County Division of Intergenerational Services
Shoreview Building, Office 222101 South Shore RoadNorthfield, NJ 08225
Burlington(609-265-5069)Burlington County Office on Aging49 Rancocas RoadPO Box 6000Mount Holly, NJ 08060
Camden(856-858-3220)Camden County Division of Senior & Disabled Services512 Lakeland Avenue, 4th FloorBlackwood, NJ 08012
Cape May(609-886-2784/2785)Cape May County Department of Aging and Disability ServicesSocial Services Building4005 Route 9, SouthRio Grande, NJ 08242
Cumberland(856-453-2220/ 2221)
Cumberland County Office on Aging and DisabledAdministration Building800 East Commerce StreetBridgeton, NJ 08302
Gloucester(856-384-6900)Gloucester County Division of Senior Services115 Budd Blvd.West Deptford, NJ 08096
Salem(856-339-8622)Salem County Office on Aging98 Market Street
Salem, NJ 08079
Eligibility for the Community Care
Waiver (CCW)
Eligible for DDD services, and
Meet clinical eligibility for ICF/ID level of care, and
Determined to be in need of and use a monthly
waiver service, and
Determined to be blind or disabled by either the
Social Security Admin, or NJ Medicaid, and
Resident of NJ, and
U.S. citizen or national, and
$2,163 monthly income limit and $2,000 limit in
resources
Application Process for CCW
Initial contact is made through the DDD case
manager.
He/she makes the referral to initiate Medicaid
financial application for the CCW.
Medicaid financial packet is submitted to
Institutional Services Section (ISS) of Medicaid for
financial eligibility determination.
5-year look-back on all finances.
Services Available Through CCW
(Draft Amendments Sent to CMS) CCW does not provide private duty nursing (PDN).
Note: Housing is available through CCW, but emphasis is on
the services needed, not just getting housing!!
CCW services DDD is requesting in renewal application to CMS:
Assistive Technology
Behavioral Management
Career Planning
Case Management
Community Transition Services
Day Habilitation
Environmental Modifications
Individual Supports
Draft of Services – CCW (cont)
Occupational Therapy
Personal Emergency Response System (PERS)
Physical Therapy
Prevocational Training
Respite
Speech, Language and Hearing Therapy
Support Coordination
Supported Employment
Transportation
Vehicle modifications
QUESTIONS?
