What is Medicaid Managed Care?
Many states are changing their long-term care Medicaid programs by replacing their Home and Community Based Services (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. MCOs 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 personal emergency response systems.
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 preparing meals. 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). Family members, including spouses, 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/ hour).
For persons who are not receiving HBSC through PEP, there is also the Personal Preference Program (PPP). This is a consumer directed delivery option for personal care assistance. For this option, Medicaid recipients receive a personal care needs assessment from their managed care company, which is sent to the state for review. Based on the assessment, the state provides a monthly allowance to spend on personal care assistance.
FamilyCare vs. MLTSS vs. Comprehensive Medicaid Waiver
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 10 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, 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, Monmouth, Atlantic, Cape May, 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 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 three or more of the activities of daily living (ADL).
Financial – In 2022, an unmarried or widowed applicant can have monthly income up to $2,523. A married couple with both spouses applying can have up to $5,046 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 $3,435 / month in 2022. This is also called a monthly maintenance needs allowance.
“Countable assets” are also considered. Countable assets do not include one’s home provided their home equity does not exceed $955,000 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 $137,400 in assets to the non-applicant spouse. This is known as a community spouse resource allowance.
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. Learn more here.
When Finances Exceed the Limits
If a family or individual has income or assets that exceed NJ Medicaid’s limits, they might still gain access to assistance by working with a professional Medicaid planner, using Qualifying Income Trusts or being “Medically Needy”. Learn more.
Benefits and Services
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:
- Adult day care
- Assisted living care / adult family care
- Behavioral health services
- Care management
- Home & auto modifications
- Home care
- Mental health / addiction services
- Nursing home care
- Personal assistance
- Personal Emergency Response Services (PERS)
- Prepared meals brought to the residence
- Respite Care
How to Apply / Learn More
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 their Medicaid eligibility status should contact a Medicaid planner prior to applying to prepare their resources. Persons who are currently enrolled in New Jersey Medicaid and are interested in enrolling in the MLTSS program should contact their Managed Care Organization.
New Jersey nursing home residents might be interested in the Choose Home NJ Program, which aids persons with the move back into their homes from nursing homes. Another option is the Congregate Housing Program, which is similar to assisted living.