WellCare of New Jersey. Managed Long Term Services and Supports (MLTSS) Booklet

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1 WellCare of New Jersey Managed Long Term Services and Supports (MLTSS) Booklet

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3 Welcome to WellCare of New Jersey Managed Long Term Services and Supports (MLTSS) Welcome to your new MLTSS health plan! We re excited to have you as a member and look forward to serving you. We want you to take an active role in your care. As our member, you ll partner with a Care Manager who will help you manage your care and make sure you get the services you need. Together, we ll plan and coordinate services to enhance your quality of life. We encourage you to read through this entire booklet. You will find very important information about your health plan, including care and services just for MLTSS members. Because these services are offered in addition to those available through NJ FamilyCare, you should keep this booklet with your member handbook. In your member handbook, you ll find information about: Your available NJ FamilyCare benefits; Advance directives; Details about the complaint process for our members (we call these grievances and appeals); How we protect your privacy; and Preventive health. If you have questions, call our Customer Service Department toll-free at (TTY ). newjersey.wellcare.com

4 Table of Contents Important Phone Numbers Your MLTSS Identification (ID) Card Get to Know Your Care Manager Contact Us Member Representative Moving Back Home from a Nursing Facility: The Money Follows the Person Program (MFP) Participant Direction (Self-Direction) MLTSS Cost-Sharing MLTSS Services Covered by WellCare Member Rights and Responsibilities newjersey.wellcare.com

5 Important Phone Numbers MLTSS Customer Service TTY MLTSS Member Representative Hour Behavioral Health Crisis Line Care Manager Keep these numbers near your phone. You can call toll-free any time you need help. newjersey.wellcare.com 3

6 Your MLTSS Identification (ID) Card You ll get your WellCare ID card in the mail. If you don t receive it, call your Care Manager or call our Customer Service Department toll-free at (TTY ) and we ll send you another one. You can also order a new one through our website: newjersey.wellcare.com. When your WellCare ID card arrives, keep it with you at all times. You ll need to show it to receive care or services. Before you put your ID card in your wallet or purse, look it over to make sure the information on it is correct. Managed Long Term Services and Supports (MLTSS) Member ID #: < > Member: <First MI. Last Name> Effective Date: <XX/XX/XXXX> Issue Date: <XX/XX/XXXX> Primary Care Provider: <Dr. First Last Name> <Group Name> <XXXX Main Street> <Suite XXXX> <City, ST XXXXX> Phone: <XXX-XXX-XXXX> <PLAN NAME> Medicaid ID #: < > <CO-PAY INFORMATION> <Dental. $<5/10>> <Emergency $<10/35>> <PCP... $<5/5>> <Pharmacy $<1/5 5/10>> <Specialist $<5/5>> Customer Service: (TTY ) Members: Present this card to receive services from network providers. For benefits, provider network or general information, call Customer Service. If you have a medical emergency, dial 911 or go to the nearest emergency room and call your PCP within 48 hours. Prior authorization is not required. Servicio al Cliente: (TTY ) Miembros: Presente esta tarjeta para recibir servicios de los proveedores de la red. Para información sobre beneficios, la red de proveedores o información general, llame a Servicio al Cliente. Si usted tiene una emergencia médica, marque al 911 o vaya a la sala de emergencias más cercana y llame a su PCP dentro de las 48 horas. No se requiere autorización previa. Medical claims are to be mailed to: Las reclamaciones médicas deben ser enviadas a: WellCare P.O. Box Tampa, FL newjersey.wellcare.com Rx Bin: Rx PCN: Rx GRP: Don t hesitate to ask your Care Manager any questions about your ID card. newjersey.wellcare.com 4

7 Get to Know Your Care Manager As a member of our MLTSS health plan, you ll work with a Care Manager. He or she is a licensed nurse, social worker or qualified health care professional, and will be your partner. Your Care Manager will work with you and your medical and behavioral health providers to make sure you get the care you need. To do this, he or she will: Meet with you face-to-face in your home, hospital or nursing home to get familiar with your health (within 10 days of your enrollment in our health plan); Work with you, your primary care provider (PCP) and other providers to create a plan of care and update it regularly or as your health changes; Coordinate with your PCP and other providers to make sure you re getting the right care; Help you make the transition when you leave a nursing facility and return home, or when you move from your home to a nursing facility; Monitor your overall care; and Answer any questions you or your family may have about your health. My Care Manager: Phone Number: Write in your Care Manager s name and phone number. Be sure to keep this handy! You should stay in touch with your Care Manager and let him or her know of any changes in your health. newjersey.wellcare.com 5

8 Call your Care Manager if: Your health changes, for better or worse (so you can increase or decrease your level of service); Your caregiver is not able to provide care to you that s in your plan of care (for example, if your caregiver gets sick and can t make it to your home); You go to the hospital or emergency room; Any of your medications change; You plan to leave our service area for a long period of time (for example, if you plan to move south for the winter or stay with family); Your Medicaid eligibility changes or you get any letters or calls from NJ Medicaid; or You re moving. If you have an urgent need to talk with a Care Manager after hours, call our Customer Service Department toll-free at (TTY ). newjersey.wellcare.com 6

9 Contact Us Call or write us with any questions you have. We re happy to answer them for you. Customer Service Toll-free: (TTY ) WellCare of New Jersey MLTSS 550 Broad Street, 12th Floor Newark, NJ You can call us any time you need help with: Getting a replacement ID card; Finding and choosing a provider; Making an appointment with a provider; Updating your contact information, such as your mailing address and phone number; and Filing a grievance or an appeal. We want you to be comfortable when working with us and your providers. If you speak a different language or need information in Braille, large print or audio, we can provide translations and alternative formats at no cost to you. To obtain information in alternate formats, call our Customer Service Department toll-free at (TTY ). newjersey.wellcare.com 7

10 Member Representative In addition to your Care Manager, we have a Member Representative within our company who will act as your MLTSS advocate. He or she will work with our different departments to: Ensure our members best interests are represented when planning for quality improvement programs; Oversee the education of our members, their family and providers with regards to MLTSS issues; and Work on ways to improve our MLTSS health plan for our members and their providers. Our Member Representative will also: Be another resource for members and their families to go to for any questions they may have; Help make sure our MLTSS members know how to get the most from our health plan ; Make sure members get in touch with the right staff members within our plan; and Provide help with getting any issues or problems resolved. To get in touch with our Member Representative, call or write: Customer Service Toll-free: WellCare of New Jersey MLTSS Attn: Member Representative 550 Broad Street, 12th Floor Newark, NJ newjersey.wellcare.com 8

11 Moving Back Home from a Nursing Facility: The Money Follows the Person Program (MFP) If your health improves enough for you to leave a nursing facility, we ll help you make the move back home and cover the cost. This is called community transition. There are a few things that need to happen to help this move occur: 1. Your Care Manager will meet with you to discuss the move. 2. He or she will need to complete paperwork. 3. Once you re approved to move, your Care Manager will meet with your providers to make sure your move goes smoothly. 4. Your Care Manager will get any prior authorizations for services you ll need. This will be done before you leave the nursing facility. 5. Your Care Manager will talk with you within 3 business days of your move date to agree and complete the design of your plan of care. Your plan of care must be signed before you leave the nursing facility. 6. You and your Care Manager will also meet face-to-face within 10 business days of your return home. Remember, if your health changes at any time, call your Care Manager. Once you re home, your Care Manager will call you at least once a month to check in and see how you re doing. He or she will also stop by to see you at least every 3 months. If any changes need to be made to your plan of care, you can work on them together. newjersey.wellcare.com 9

12 Participant Direction (Self-Direction) If you re getting care in your own home, you can choose participant direction. (Also called self-direction.) You can choose who you want to hire to provide certain care for you. You ll be given the training and guidance you need to make the right decisions about your care. You ll work with the people you hire to meet the goals in your plan of care. The goal of participant direction is to give you the freedom to choose how best to manage your care. It empowers you to choose: What kind of care you want and need; When and where to get your care; and Who will provide your care. Ask about participant direction when you meet with your Care Manager. Together you can decide if this would be a good option for you. You may decide at some point that participant direction is not for you. If so, you can choose to end it at any time. You can choose a family member to manage your participant direction. He or she will be your representative. Please note: a family member cannot be your self-direction representative and provide personal attendant services at the same time. MLTSS Cost-Sharing If you re in a nursing home or assisted living facility, you are responsible for patient payment liability. This is simply your portion of the cost of care. The County Welfare Agency (CWA) will review your income to figure out your portion to pay and will provide this information to you. This cost is in addition to your NJ FamilyCare co-pays (for these co-pays, please see your member handbook). You ll pay this directly to your nursing home/assisted living facility. If you don t make your payments, you could lose your WellCare benefits. newjersey.wellcare.com 10

13 MLTSS Services Covered by WellCare In addition to the NJ FamilyCare services we ll provide to you, we also cover the following MLTSS services. If you have any questions, call your Care Manager or call our Customer Service Department toll-free at (TTY ). Service Description/Limits This services allows you to live with up to 2 nonfamily members in the home of a trained caregiver. The caregiver helps with: Adult Family Care (AFC) Errands Giving medications Housekeeping Laundry Meal preparation Personal care Recreational and social activities Supervision (up to 24 hours if needed) Transportation Watching over your finances (at your request) You cannot receive this service at the same time as Personal Care Assistant services, Chore Services, Home-Delivered meals, Home-Based Supportive Care, Caregiver/Participant Training or Assisted Living Services. newjersey.wellcare.com 11

14 Service Description/Limits These services are available if you re in a publicly subsidized assisted living facility, and include: Assisted Living Program (ALP) Chore Services Managing and giving medications Homemaker Services Personal Care services 24-hour on-site staff who will - Meet your needs in a way that allows for respect, dignity and independence - Provide supervision, safety and security You re responsible for paying your monthly rent payments and utility bills, as well as for your own meals and other household items. You cannot receive this service at the same time as: - Adult Family Care (AFC) - Assisted Living Services - Caregiver/Participant Training - Chore Services - Home Based Supportive Care (HBSC) These services are available if you re in an assisted living facility, and include: Assisted Living Services Assisted Living Residence Chore services Homemaker services Managing and giving medications Personal care services Recreational and social activities and programs 24-hour on-site staff who will - Meet your needs in a way that allows for respect, dignity and independence - Provide supervision, safety and security newjersey.wellcare.com 12

15 Service Description/Limits An Assisted Living Residence (ALR) is a facility that s approved by the Department of Health to provide: Apartment-style housing Assisted living services Group dining Each apartment-style unit includes a/an: Front door that can be locked from inside Private bathroom Small kitchen (kitchenette) Unfurnished bedroom Assisted Living Services Assisted Living Residence In an ALR, you can get to your own apartment kitchen and the facility s pantry at any time to get food and drinks. You cannot receive this service at the same time as: Adult Day Health services Adult Family Care (AFC) services Assisted Living Program (ALP) Attendant Care Caregiver/Participant Training Chore Services Home Based Supportive Care (HBSC) Home-Delivered meals Personal Emergency Response System (PERS) Residential Modifications Respite care Social Adult Day Care (SADC): Social and recreational activities in a group newjersey.wellcare.com 13

16 Service Description/Limits A Comprehensive Personal Care Home (CPCH) is a facility that s approved by the Department of Health to provide: Assisted Living Services Room and board Arrange for resident transportation to and from health care services In a CPCH: Assisted Living Services Comprehensive Personal Care Home The stove in the kitchen can be removed if it s a safety hazard There s a front door that can be locked from inside You can get to your own apartment kitchen at any time to get food and drinks You may share a unit with another person (no more than 1) You cannot receive this service at the same time as: Adult Day Health services Adult Family Care (AFC) services Assisted Living Program (ALP) Attendant Care Caregiver/Participant Training Chore Services Home Based Supportive Care (HBSC) Home-Delivered meals Personal Emergency Response System (PERS) Residential Modifications Respite care Social Adult Day Care (SADC) newjersey.wellcare.com 14

17 Service Description/Limits This service provides training and counseling to those who provide care to you. Caregiver/ Participant Training The training can be provided in a one-on-one or group setting and can include seminars. The training needs must be listed in your plan of care. Limited to 1 training session a day. You cannot receive this service at the same time as Adult Family Care, Assisted Living Program or Assisted Living Services. The following services involve tasks and maintenance to keep your home clean and safe. They go beyond the tasks of day-to-day living such as housekeeping and laundry. These chore services are available when you, a relative or landlord cannot do them because of physical or financial reasons: Chore Services Changing screens/storm windows, weather stripping around doors and caulking windows for seasonal weather Cleaning appliances Cleaning and securing rugs and carpets Cleaning attics and basements to remove fire and health hazards Clearing walkways of ice, snow and leaves and trimming overhanging tree branches Installing safety equipment Replacing door locks and window catches Replacing fuses, light bulbs, electric plugs and bad cords Washing walls, windows and scrubbing floors You cannot receive this service at the same time as Adult Family Care, Assisted Living Program or Assisted Living Services. newjersey.wellcare.com 15

18 Service Description/Limits This is treatment you can get if you ve had a traumatic brain injury (TBI) or have been in a TBI waiver program. The treatment is to help maintain and prevent worsening of your ability to: Cognitive Therapy (Group and Individual) Make decisions for yourself Pay attention and focus Remember things Solve problems What kinds of therapy and how often you get them are decided by: A first-time and on going assessments you ll receive Your plan of care Therapy can be provided in your home, a rehabilitation center or residential program. These services are offered if you ve had a traumatic brain injury (TBI) or have been in a TBI waiver program. The services are given in your home, and include: Community Residential Services (CRS) Chore Services Companion Services Night supervision Personal care Recreational activities Transportation Your CRS provider will arrange these services for you. newjersey.wellcare.com 16

19 Service Description/Limits This is financial aid to help cover the costs you may face when setting up your home after moving out of a medical institution and cannot afford them on your own. Covered expenses include: Community Transition Services Any fees for arranging and managing your move Installation of things to help you get around in your home (for example, a ramp or grab bars) Moving costs Necessary household items like furniture, food preparation tools and bed linens Pest control and cleaning (one-time, when you first move in) Security deposits to lease an apartment or house Set-up fees for utilities (for example, electricity and phone) Your financial aid needs must be listed in your plan of care. Service limits include: Does not cover vehicle modification Financial aid cannot be used to buy TVs or other recreational items Monthly rent/mortgage payments and utility bills are not covered This service can only be used once in your lifetime Total expenses cannot be more than $5,000 newjersey.wellcare.com 17

20 Service Description/Limits These services help you with your Instrumental Activities of Daily Living (IADL) needs so you can stay in your home and be as independent as possible. Home Based Supportive Care (HBSC) Services include, but aren t limited to: Grocery shopping Laundry Light housework Meal preparation Watching over your finances You cannot use this service at the same time as Assisted Living Services. You can have meals delivered to your home if you do not live in a medical facility, are unable to shop for and/or prepare food without help, or do not have a caregiver to make meals for you. The meals are high in nutrition and provide 1/3 of the Recommended Dietary Allowance (RDA). Home-Delivered Meals Meals from a restaurant, cafeteria or caterer may be substituted if: They re to be delivered outside of a normal day/time You have special dietary needs You live in a hard-to-reach area Limited to 1 meal each day. You cannot use this service at the same time as Adult Family Care (AFC) and Assisted Living Services since meals are already included in these. newjersey.wellcare.com 18

21 Service Description/Limits This service is to help you remember to take your medication on time and as instructed if you live alone or are alone for long periods of time during the day. Here s how the service works: Medication Dispensing Device The device automatically dispenses your medication as the prescription requires (amount and timing) Once your medication is dispensed, you ll need to get it within a certain period of time; if you don t, the machine will give you reminders If you don t get to your medication by the last reminder, an automatic phone call will be made to you, your emergency contact and your Care Manager until someone answers If there s no answer, the machine will lock your missed medication Includes installation of the device and service. This service must be medically necessary. Nursing Facility Services (Custodial Care) Occupational Therapy (Group and Individual) Services are to meet your medical, nursing, dietary and psychosocial needs in a setting that provides continuous medical supervision and nursing care. The NJ Department of Human Services, Office of Community Choice Options or their designee decides if you need this kind of care. Services are to help keep you from relapsing and losing any more daily living functions that have been re-gained through rehabilitation. This service must be medically necessary. newjersey.wellcare.com 19

22 Service Description/Limits These are devices that enable you to get help in an emergency and are available if you: Live alone Need regular supervision and are alone for a long period of time during the day Personal Emergency Response System (PERS) These devices: Are connected to your phone. Send a signal to a response center when you press the Help button. Are also available as portable Help buttons, which allow you to move around your house and still be able to call for help when needed. Includes installation of the PERS and service. This service must be medically necessary. Physical Therapy (Group and Individual) Services are to help keep you from relapsing and losing any more bodily functions (movement and mobility) that have been re-gained through rehabilitation. This service must be medically necessary. This is one-on-one, on going nursing care that s provided to you in your home by a registered nurse (RN) or licensed practical nurse (LPN). Private-Duty Nursing (for adults age 21 and older) Limits include: This service is not available if you re an inpatient at a hospital or in a nursing facility. Up to 16 hours of service are approved in a 24-hour period (the remaining time should be provided by an adult caregiver living in your home). This service must be medically necessary. Prior authorization is required. newjersey.wellcare.com 20

23 Service Description/Limits These are special changes made to your home to help you live on your own (without these changes, you would have to move to a nursing facility). Changes to your home must be: Needed for your care, as well as for your health and safety Meet state and local building codes Changes can include: Installing a ramp and grab bars Widening doorways Residential Modifications Changes or improvements for general use are not covered, such as: Carpeting Central air conditioning Changes that increase the total square footage of your home Roof repair Limits include: Total expenses cannot be more than $5,000 each calendar year or $10,000 in your lifetime You cannot use this service if you live in an assisted living residence or assisted living program Changes to a rental unit must be approved in advance by the landlord, and you must continue to live in the unit for at least 1 year after the changes are completed newjersey.wellcare.com 21

24 Service Description/Limits These services ensure you receive care for short periods when your regular caregivers are absent. The services are: Respite Care Available to you if you re unable to care for yourself Provided in your home or a Medicaid-licensed nursing facility Not meant to take the place of care usually provided by a nurse or therapist Services are limited to 30 days each calendar year. This group program offers different health, social and related support services if you have a functional impairment. It is designed to meet non-medical needs. Social Adult Day Care (SADC) The program involves going to a supervised adult day care center on a regular basis for several hours and taking part in recreational and social activities. Limits include: You cannot use this service if you re in an Assisted Living Facility. You cannot use this service at the same time as Adult Day Health Services. Speech, Language and Hearing Therapy (Group and Individual) Services are meant to help you keep the speech, language and hearing functions that you have re-gained through rehabilitation. These services must be medically necessary. newjersey.wellcare.com 22

25 Service Description/Limits These services are offered if you ve had a traumatic brain injury (TBI) or have been in a TBI waiver program. Services are provided outside of your home in a one-on-one or group setting. Structured Day Program The program will provide activities to help you become more independent and get back into your community. Activities are aimed at improving your: Attention skills Completing tasks Problem solving ability Managing finances Safety awareness These services are offered if you ve had a traumatic brain injury (TBI) or have been in a TBI waiver program. Supported Day Services Services are aimed to get you active in your community through: Recreational activities Shopping Volunteering A plan of care will be created for you that includes these types of activities, and you ll do them with a health care professional one-on-one. newjersey.wellcare.com 23

26 Service Description/Limits These services are offered if you ve had a traumatic brain injury (TBI) or have been in a TBI waiver program, and are experiencing severe anxiety or aggressive behavior that s dangerous to yourself or others. Traumatic Brain Injury (TBI) Behavior Management (Group and Individual) Services are provided in your home or a group setting with the goal of treating the behaviors and getting you back to an improved state. To do this: A first-time and ongoing assessments will be done by a psychiatrist, neuropsychologist or neuropsychiatrist A behavioral modification plan will be created and followed This service must be medically necessary. Services include: Vehicle Modifications Changes to a vehicle that would help you to be more independent at home and in your community, while keeping you safe Examples include mechanical lifts and electronic monitoring systems The need for these changes must be identified in your plan of care. Service Limitations: You or your authorized representative must own the car and it must be registered in NJ. Changes/Modifications must follow NJ motor vehicle codes. newjersey.wellcare.com 24

27 Member Rights and Responsibilities You have the right to: Ask for and receive information about the services available to you Have access to and choice of qualified service providers Be informed of your rights before getting selected and approved services Receive services without regard to race, religion, color, creed, gender, national origin, political beliefs, sexual orientation, marital status or disability Have access to appropriate services that support your health and welfare To make decisions concerning your care needs To choose between a nursing facility and a Home Based Supportive Care (HBSC), whichever meets your needs To assume risk after being fully informed and able to understand the risks and consequences of your decisions Participate in the development of and make changes to your plan of care Request changes in services at any time, including to add, increase, decrease or discontinue services Ask for and receive from your Care Manager a list of names and duties of any person(s) assigned to provide services to you under your plan of care Receive help and guidance from your Care Manager to resolve concerns about your care needs and/or complaints about services or providers Be informed of and receive in writing facility-specific resident rights upon admission to an institutional or residential setting Be informed of all the covered/required services you are entitled to, required by and/or offered by the institutional or residential setting, and any charges not covered by our health plan while in the facility newjersey.wellcare.com 25

28 Member Rights and Responsibilities Not to be transferred or discharged out of a facility except for medical necessity - To protect your physical welfare and safety or the welfare and safety of other residents, or - After reasonable notice, you fail to make payments to the facility that are based on your statement of available income for Medicaid payment Have us protect and promote your ability to exercise all the rights identified in this document Have all rights and responsibilities mentioned here passed on to your authorized representative or court-appointed legal guardian You have the responsibility to: Provide all health and treatment-related information, including but not limited to medication, circumstances, living arrangements, informal and formal supports to your Care Manager in order to identify care needs and develop a plan of care Understand your health care needs and work with your Care Manager to develop or change goals and services Work with your Care Manager to develop and/or change your plan of care to facilitate timely authorization and implementation of services Ask questions when you don t understand something Understand the risks associated with your decisions about care Report any significant changes to your health condition, medication, circumstances, living arrangements, informal and formal supports to your Care Manager Let your Care Manager know if any problems occur or you re not happy with the services being provided Follow our rules and/or those rules in an institutional or residential setting newjersey.wellcare.com 26

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32 Customer Service: (TTY/TDD ) newjersey.wellcare.com NJ025328_CAD_BKT_ENG State Approved WellCare 2014 NJ_01_ NJCADBKT58410E 58410