Managed Long-Term Services and Supports and Program of All-Inclusive Care for the Elderly – Begley Report

By: Thomas D. Begley, Jr., Esquire, CELA and Marianne Johnston, Esquire

MANAGED LONG-TERM SERVICES AND SUPPORTS

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 need a nursing home level of care, but the care need not be received in a nursing home. 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.

Eligibility

To be eligible for MLTSS, an individual must meet all of the following criteria:

• S. citizen or qualified alien.
• 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 limits on monthly income, as well as total liquid assets:
  • Income can be equal to or less than $2,829 per month (2024).
  • If an individual’s income exceeds $2,829 then a Miller Trust, also known as a Qualified Income Trust (QIT), will be required.
  • Countable 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, the healthy spouse may keep one-half of the couple’s assets up to a maximum of $154,140 in assets, known as the Community Spouse Resource Allowance (CSRA) (2024).
• Qualify for Medicaid clinically which means the individual requires 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.  A clinical assessment will be performed before an individual enters the MLTSS program.

 

Services

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;
• Respite;
• 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
• Transportation

♦ Description of Service Providers.  To participate in the MLTSS program, an individual will need to enroll in one of the following Managed Care Organizations (MCOs):

• Amerigroup New Jersey, Inc.
• Horizon NJ Health
• UnitedHealth Care Community Plan
• WellCare Health Plans of New Jersey
• Aetna

Cost Share

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.

Disenrollment

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.

Recourse

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.

PERSONAL PREFERENCE PROGRAM

The Personal Preference Program (PPP) is available through Managed Long-Term Services and Supports (MLTSS).  The program allows individuals to remain in their home and receive personal care services from trusted relatives, friends and neighbors.

The program provides a monthly budget for self-directed home care services and employs spouses, parents, friends, relatives, and/or neighbors as personal care workers.  The program does not require use of a home health care agency. The individual’s managed care organization determines the hours of personal care services authorized per week. The program calculates the monthly budget based on the number of hours authorized for certain home care services converted into a dollar amount using the current reimbursement rate for 2024 of up to $25 per hour.  The program also provides fiscal management services which include the handling of payroll responsibilities, acting as a bookkeeping service, processing time sheets and issuing paychecks to the workers.

A PPP participant may use their monthly budget for:

• Employment of individuals, including family members to provide personal assistance with the activities of daily living, which include bathing, dressing, feeding, toileting, and transferring;
• Cleaning services from private companies to clean your home’s personal areas, including bedroom, bathroom, kitchen;
• Errand services to assist with banking, shopping and other routine tasks;
• Laundry service from a laundromat or other provider;
• Services from a home health agency;
• Equipment, small appliance, technology or other items that increase independence (e.g., microwave oven); and
• Supplies and equipment that promote or enhance independence that are not covered by Medicaid.

Eligibility requirements for the PPP include the same income and asset limits as MLTSS. There is also a transfer of asset penalty with a five-year lookback. The individual must live in a community-based residence (including a private home) where personal care is not provided.