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Many states are changing their long-term care Medicaid programs by replacing their HCBS Waivers with Medicaid Managed Care Organizations (MCO). For the elderly, this means they work with a single administering organization for all their health care services and personal care needs.
One of the goals of the switch is to allow for an expansion of the number of people served and to work towards the elimination of the enrollment caps and waiting lists for those wishing to receive care and services outside of nursing homes.
Medicaid Managed Long Term Services and Supports or MLTSS is an assistance program for low income, New Jersey seniors in which participants receive all their medical and non-medical care services from one state-authorized organization. This can include assistance as diverse as personal care, assisted living, home modifications, and/or assistive technology.
In 2014, to improve the quality of care and to better control costs, the New Jersey Department of Health absorbed the Global Options (GO) for Long Term Supports Waiver into the new managed care program, MLTSS. All existing beneficiaries were transferred to the managed care system. In addition, all new qualified applicants are enrolled in this program.
This switch has positives and minuses for New Jersey seniors. On a positive note, participants are no long subject to enrollment caps and/or waiting lists for community and home based services as they were under the old system. By reducing the number of programs and service providers, managed care simplifies services for long term care participants. However, some outside observers cite concerns about diminished consumer choice when it comes to service providers and caregivers under managed care.
One area in which MLTSS has maintained consumer choice, is in Home-Based Supportive Care (HBSC). HBSC includes supports such as shopping, housekeeping, chore services and non-medical transportation. MLTSS preserves the choice of providers by allowing participants to choose their own providers for these services as these supports do not require any special training. This option is formally referred to as Personal Employer Provider (PEP). Certain family members are permitted to be hired to serve in these roles and will be compensated by the state at a program-determined hourly rate (estimated at $15/ hr).
NJ FamilyCare is the name of the state Medicaid program. MLTSS is a program specifically for seniors within NJ Medicaid. The Comprehensive Medicaid Waiver is an administrative name from the federal government under which these changes are authorized.
Two exceptions to mandatory enrollment exist for seniors in the new MLTSS program. In seven New Jersey counties, the Program of All-inclusive Care for the Elderly (PACE / LIFE) represents an alternative for residents who are at least 55 years old, require the level of care typically provided in nursing homes, and are eligible for either Medicare or Medicaid and live within specific zip codes. The NJ counties with PACE services are Mercer, Burlington, Camden, Hudson, Cumberland, Gloucester and Salem counties.
The second exception is for nursing home residents who are already on regular Medicaid. These individuals will continue to receive their benefits outside of the managed Medicaid system.
To enroll in the MLTSS, a resident New Jersey elder must qualify for NJ Medicaid. To do so, the individual's age, medical and financial criteria are considered. Financial criteria vary dependent on marital status and whether or not both spouses are applying.
Age - Participants must be either 65 years or older or, if younger, disabled as defined by the Social Security Administration.
Functional Ability - To qualify an applicant as medically eligible, one must show that the applicant requires nursing home level of help or that they need assistance from another person in order to do any two or more of the activities of daily living (ADL).
Financial - In 2018, an unmarried or widowed applicant can have monthly income up to $2,250. A married couple with both spouses applying can have up to $4,500 per month in combined wages. A married couple with a single applicant is more complex. The non-applicant is permitted to absorb some of the applicant’s income as a living allowance, up to $3,090 in 2018.
"Countable assets" are also considered. Countable assets do not include one's home provided their home equity does not exceed $858,000 in value. An unmarried or widowed applicant can have $2,000 in countable assets. Couples, with both spouses applying, can have $3,000. Couples, with a single spouse applying, are permitted to shift up to $123,600 in assets to the non-applicant spouse.
Medicaid will investigate applicants' past assets transfers for up to 60 months preceding their date of application to ensure they did not simply give away assets to qualify. Having done so will not necessarily prohibit one from receiving Medicaid, but may limit or delay some benefits.
MLTSS is a comprehensive health care plan for participating individuals. The program includes both medical coverage and also home care and personal care services. Because state rules had previously restricted the number of qualified elderly Medicaid participants who could receive Home and Community Based Services, elders who wanted to receive their care outside of a nursing home often had to put their name on a waiting list, this is no longer the case.
In addition to the emergency and primary medical services that are provided through the Managed Care Organization, participating individuals in New Jersey may be able to receive these non-medical services:
To learn more about the MLTSS program, readers can go to the state website.
Individuals who meet the eligibility rules and are ready to make an application should contact their local area agency on aging.
Those uncertain of the Medicaid eligibility status should contact a Medicaid planner prior to applying to prepare their resources.