Managed Long-Term Services and Supports and Program of All-Inclusive Care for the Elderly – Begley Report
by: Begley Law Group
By: Marianne Johnston, Esquire
MANAGED LONG-TERM SERVICES AND SUPPORTS
As of July 1, 2014, what was formerly known as Global Options for Long-Term Care (GO) is now known as Managed Long-Term Services and Supports (MLTSS). Individuals previously receiving benefits under AIDS Community Care Alternatives Program (ACCAP), Community Resources for People with Disabilities (CRPD) and Traumatic Brain Injury (TBI) were automatically enrolled in the MLTSS program. The MLTSS program was designed to permit individuals to live in the community for as long as possible with services and support.
The change from GO to the MLTSS program has reduced the number of programs and service providers and has simplified the services provided. There are no longer enrollment caps and waiting lists for community and home-based services, as existed under the above-mentioned waiver programs.
The MLTSS program is for individuals who require services and support that are living at home, in an assisted living facility, in community residential services, as well as those in a nursing home. MLTSS participants must meet income and asset requirements, as well as be determined clinically eligible. An MLTSS participant must meet a nursing home level of care, which means that he or she requires limited assistance with a minimum of three activities of daily living (ADL) or the individual has cognitive deficits and requires assistance with more than three ADL areas. MLTSS strives to assist participants to live as independently as possible for as long as possible while focusing on the individual’s care needs.
A care manager will work with each individual to create a plan specific to their needs. The care manager will create a Plan of Care, as well as assist in selecting and arranging such services and ensuring that all medical visits take place. With the help of the care manager, the participant is able to determine which services he or she needs, select providers of the needed services and ensure that those services are, in fact, implemented.
To be eligible for MLTSS, an individual must meet all of the following criteria:
- Resident of New Jersey;
- 65 years of age or older, or under age 65 and determined to be blind or disabled under the Social Security Administration or the Division of Medical Assistance and Health Services;
- Qualify for Medicaid financially, this includes monthly income, as well as total liquid assets:
- Income can be equal to or less than $2,523 per month (2022).
- If an individual’s income exceeds $2,523 then a Miller Trust, also known as a Qualified Income Trust (QIT) will be required.
- Resources must be at or below $2,000 for an individual and $3,000 for a couple, where both individuals are applying for services.
- Couples, where only one spouse is applying, may keep up to $137,400 in assets, known as the Community Spouse Resource Allowance (CSRA) (2022).
- Clinically eligible for a nursing home level of care, meaning that the individual requires assistance with activities of daily living. A clinical assessment will be performed before an individual enters the MLTSS program.
The MLTSS program uses NJ Family Care managed care organizations to coordinate all services provided under the program. Each participant is provided with an individualized Plan of Care (POC). This assessment is continually reviewed and updated at least annually.
♦ Description of Services Provided. MLTSS services include the following:
- Personal Care;
- Care Management;
- Home and Vehicle Modifications;
- Home Delivered Meals;
- Personal Emergency Response Systems;
- Mental Health and Addiction Services;
- Assisted Living;
- Community Residential Services;
- Nursing Home Care; and
♦ Description of Service Providers.
- Managed Care Organization (MCO). Under an MCO an individual will need to enroll in one of the following:
- Amerigroup New Jersey, Inc.
- HealthFirst Health Plan of New Jersey, Inc.
- Horizon NJ Health
- UnitedHealth Care Community Plan
- WellCare Health Plans of New Jersey
The county welfare agency will determine the cost share for individuals residing in a facility. The cost share will be based on his or her monthly income.
MLTSS is a voluntary program so participants can withdraw at any time. Alternately, a participant may be disenrolled for a variety of reasons, including if he or she no longer meets the financial or clinical eligibility criteria or if he or she moves out of New Jersey.
An MLTSS participant has the right to request a fair hearing provided by the Office of Administrative Law if he or she is determined ineligible or denied services, or if services are suspended, reduced, or terminated. The state will provide 30 days notice of termination of benefits unless the reason for disenrollment is that the participant has moved out of the state. Once provided written notice of the action, the participant must request a fair hearing within 20 days of the date of the letter. Medicaid benefits may continue until a hearing decision is reached; however, if the hearing decision is not in the participant’s favor, the participant may be required to repay the cost of benefits that he or she was not entitled to receive.
PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY
The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare program that provides individuals with medical and social services coordinated and provided by a team of professionals in a community-based center and in their homes. The goal of the program is to assist program participants in delaying or avoiding long-term nursing home care.
To be eligible for PACE, an individual must meet all of the following criteria:
- An individual must be age 55 or older;
- The individual must be in need of a nursing home level of care, but able to live in the community; and
- The individual must reside in a PACE service area.
There are currently six PACE organizations in nine counties in New Jersey:
- LIFE (Living Independently for Elders) St. Francis, operated by St. Francis Medical Center. This program services Mercer and many zip codes in Burlington County.
- Trinity Health LIFE, located in Pennsauken NJ. This program services most of Camden County and several zip codes in Burlington County.
- Lutheran Senior LIFE, located at Jersey City Medical Center. This program services most of Hudson County.
- Inspira LIFE, operated by Inspira Health Network. This program services portions of Cumberland, Gloucester and Salem Counties.
- Beacon of LIFE, located in Oceanport. This program serves all of Monmouth County.
- AtlaniCare LIFE Connection, located in Atlantic City. This program services Atlantic and Cape May Counties.
Through the PACE program, an individual receives the same services provided by Medicare and Medicaid, without the same limitations. PACE may also provide additional services determined to be necessary for a particular individual, in order to help keep that individual in the community. PACE services include, but are not limited to:
- Primary care;
- Prescription drugs;
- Adult day health care;
- Home and personal care services;
- Nutrition services;
- Hospital care; or
- Nursing home care if and when needed.
An interdisciplinary team of professionals working at the PACE centers provide participants with a customized plan of care that is reevaluated on a regular basis.
If a program participant is eligible for both Medicare and Medicaid, PACE services are completely covered and there are no out-of-pocket expenses. If a participant is eligible for Medicare but not Medicaid, there are co-pays the participant must pay out-of-pocket. These co-pays may be high. Participants who are not eligible for Medicaid or Medicare must pay for PACE services out-of-pocket.
Participants of the PACE program may elect to disenroll from the program at any time and return to their former health care coverage.