Update on Managed Long Term Services and Supports (MLTSS): DHS Services and the NJ Comprehensive Medicaid Waiver

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1 Update on Managed Long Term Services and Supports (MLTSS): DHS Services and the NJ Comprehensive Medicaid Waiver New Jersey Foundation for Aging June 11, 2014 Nancy Day, Deputy Director, Division of Aging Services Carol Grant, Chief, Office of Managed Care, Division of Medical Assistance and Health Services Department of Human Services 1

2 Backdrop for Move to MLTSS Medicaid managed care was introduced in NJ to improve quality, health outcomes and contain costs for Medicaid and NJ FamilyCare clients. While the program grew in enrollment, the full advantages of the managed care system were not realized with major services excluded from the benefit package. Home and community based services (HCBS) and facilitybased long term care stayed in the Fee For Service (FFS) system NJ spent $3.5 billion+ on LTC services for seniors and people with disabilities under the current FFS system. Most of State s spending was for nursing home care, instead of preferable and often less costly HCBS.

3 NJ s Comprehensive Medicaid Waiver 1115(a) 3 Allows NJ to develop Medicaid programs that differ from the standard federal Medicaid program. Enables NJ to expand Medicaid eligibility and coverage options for people who needed home and community based services but were not eligible for Medicaid due to income. Gives NJ broad authority to modify rules for efficiency while providing quality care. Combines four existing Home and Community Based waivers (all services remain, provided by MLTSS): 1. Global Option (GO) for Long Term Care; 2. AIDS Community Care Alternatives Program (ACCAP); 3. Traumatic Brain Injury (TBI); and 4. Community Resources for People with Disabilities (CRPD). Protects consumer choice and independence.

4 Rationale for MLTSS 4 July-October 2011 The aged, blind and disabled populations, and duals (individuals with both Medicare and Medicaid benefits) were mandated to move into managed care for Medicaid benefits. Services considered long term supports (Medical Day Care and Personal Care Assistant services) were also moved in managed care. This shift to managed care did not include their facilitybased long term care or HCBS which remained Medicaid fee-for-service. Families prefer to be given the options: access to HCBS, or services in a nursing facility (NF). Coordinates primary, acute, behavioral and long term services and supports.

5 NJ s Medicaid Program = NJ FamilyCare 5 NJ FamilyCare managed care delivers coordinated health care services and supports through a network of providers. Managed care works like a health care supermarket to deliver all of an individual s Medicaid benefits through one organization. NJ has chosen to provide MLTSS through NJ Family Care. PACE programs, which also manages physical and long term service needs, remains an option. This is called NJ FamilyCare Managed Long Term Services and Supports (MLTSS).

6 MLTSS Policy and Philosophy 6 A MCO-managed care delivery system MLTSS will coordinate long term services and supports for eligible Medicaid beneficiaries. Provides a comprehensive menu of service options across beneficiary groups or care settings; whether in the home, an alternate community setting like assisted living or in a nursing facility. Coordination of providers and community based services and supports. Enhances the ability of beneficiaries to live as independently as long as possible in the community.

7 MLTSS Means 7 Access to more services Delay or discontinue need for care in a facility Preservation of independence Medically appropriate care Better coordination of care (reduced duplication of services) Focus on preventive and in-home care No slot limitations/no waiting lists due to new Medicaid HCBS eligibility

8 NJ FamilyCare MLTSS 8 As of July 1, NJ FamilyCare MLTSS will: Include the home and community based services; now provided by DoAS/DDS Medicaid waivers, and care in a nursing home when needed. Access To: o Health care providers and services within the managed care network to meet needs; and o A care manager to help coordinate medical, long term services and supports, behavioral health services and NJ FamilyCare State Plan services, i.e., medical day care and personal care assistance, through an individualized plan of care.

9 Array of Services under MLTSS 9 Specific Services: o Respite o Personal Emergency Response System (PERS); o Home and Vehicle Modifications; o Home Delivered Meals; o Assisted Living; o Behavioral Health Services; o Community Residential Services; and o Nursing home care.

10 Exclusions to MLTSS on July 1, Division of Developmental Disabilities CCW (Community Care Waiver) or Supports Program beneficiaries People with Pervasive Developmental Disabilities (DD) Intellectual/DD Beneficiaries in out-of-state HCBS settings Persons receiving inpatient services for intellectual or developmental disability and mental health illness in a psychiatric hospital PACE Program beneficiaries Persons enrolled in Dual Eligible Special Needs Plans (D- SNP) Continued.

11 Exclusions to MLTSS on July 1, Fee-for-service (FFS) Medicaid beneficiaries who are in custodial nursing home care on or before July 1, 2014 Medicaid beneficiaries living in Special Care Nursing Facilities (SCNFs) as of July 1, 2014 will remain in the current fee-for-service environment for two years (until July 1, 2016)

12 Policy Cornerstones for Phase-in of Nursing Facility (NF) Residents into MLTSS 12 Once an individual is enrolled in managed care, the individual will always remain in managed care and outside of FFS system regardless of placement. Effective 7/1/14, for new Medicaid beneficiaries with NF Custodial Care triggers MCO enrollment and MLTSS eligibility for NJ FamilyCare eligible individuals in a NF. NJ FamilyCare State Plan Services are available on a FFS basis during the gap between the determination of an individual s NJ FamilyCare eligibility and his/her enrollment in an MCO.

13 Triggers Effective 7/1/14 for Managed Care MLTSS Enrollment for Individuals Currently Living in a NF/SCNF 1) Change in Level of Care 2) Change in NF/SCNF Provider (new Plan of Care, MDS and Admission Records Required) 3) New Admission to MLTSS (NF or Community Placement) 4) New Individual to NJ FamilyCare and Eligible for MLTSS 5) Change from Rehabilitation to Custodial Care after 7/1/14 (regardless of when admission to the NF occurred) 13

14 Not Eligible for Managed Care/MLTSS Enrollment for Individuals Currently Residing in a NF/SCNF Effective 7/1/ ) Temporary admission to the hospital a) Individual returns to the same NF after hospitalization regardless of the length of the hospital stay under FFS 2) Non-IMD psychiatric treatment facility stay of less than 30 days a) Individual returns to the same NF after treatment under FFS

15 Medicaid FFS Individuals in a NF Seeking Transition to the Community 15 1) NJ FamilyCare MCO enrollment occurs upon discharge to the community a) NJ FamilyCare MCO, which is selected by the individual, is responsible for participating in the Transition Planning IDT and establishing/authorizing Transitional Services before enrollment in the MCO

16 Dual Eligible Special Needs Plans (D-SNP) 16 D-SNP coordinates an individual s Medicare and Medicaid services through one MCO. The D-SNP covers all of the following services: o o o o o ALL Medicare Part A services (hospital insurance); ALL Medicare Part B services (medical insurance); Additional benefits not covered by original Medicare (varies by MCO); ALL Medicare Part D prescription drugs; and ALL Medicaid managed care services not covered by Medicare.

17 Dual Eligible Special Needs Plans (D-SNP) 17 Beginning July 1, 2014, members who are eligible for MLTSS and wish to receive these benefits must disenroll from their D-SNP. Here are their options: o o o o o Return to original Medicare and a Medicare Part D Drug Plan, with NJ FamilyCare services handled by the same MCO that offered their D-SNP coverage; Return to original Medicare and a Part D Drug Plan, with NJ FamilyCare services handled by another MCO; Enroll in a Medicare Advantage plan with drug coverage, with NJ FamilyCare services handled by the same MCO that offered their D-SNP coverage; Enroll in a Medicare Advantage plan with drug coverage, with NJ FamilyCare services handled by another MCO; or Enrollment in a PACE program.

18 Dual Eligible Special Needs Plans (D-SNP) 18 Amerigroup New Jersey = Amerivantage Specialty + Rx (HMO-SNP) serving Bergen, Burlington, Essex, Hudson, Middlesex, Monmouth, Ocean, Somerset and Union counties. Healthfirst Health Plan of New Jersey = Healthfirst NJ Maximum Plan -- Serving Bergen, Essex, Hudson, Middlesex, Passaic, Somerset and Union counties. Horizon NJ Health = Horizon Medicare Blue TotalCare (HMO-SNP) -- Serving all 21 counties.

19 Qualifications for MLTSS Eligibility 19 Categorical Eligibility o Aged 65 years old or older. o Blind or Disabled Under 65 years of age and determined blind or disabled by the Social Security Administration or the State of New Jersey. Clinical Eligibility o An individual must meet clinical eligibility criteria, established by the State of New Jersey, based upon an assessment of what the individual can and can t do for his or her self.

20 Financial Qualifications 20 Income o Income for one person can be equal to or less than $2,163* per month (2014). o Income for a couple can be equal to or less than $4,326* per month (2014). o All income is based on the gross amount. Resources o Resources must be at or below $2,000 for an individual and $3,000 for a couple. * Subject to annual change ¹Note that for children applying for MLTSS and who meet the nursing home level of care, parental income and resources are not counted in determining financial eligibility.

21 No Wrong Door/Single Entry Point 21 New Jersey has a standardized process by which potential new enrollees enter the MLTSS system: o contact local Aging and Disability Resource Connection (ADRC) for information, assistance and screening o contact County Welfare Agency (CWA) to apply for Medicaid For NJ FamilyCare eligibility, you must apply at County Boards of Social Services, also known as County Welfare Agencies.

22 MLTSS Enrollment Process 22 Beginning July 1, 2014, consumers will have two options: 1. Receive MLTSS through Managed Care Organization (MCO); OR 2. PACE Program (based on an individual s zipcode) o Apply through one of the four PACE organizations operating in seven NJ counties. NJ FamilyCare financial eligibility is also required through the County Welfare Agencies.

23 NJ FamilyCare MLTSS MCOs 23 Amerigroup New Jersey -- Serving all counties except Salem Healthfirst Health Plan of New Jersey -- Serving 12 counties: (Atlantic, Bergen; Essex; Hudson; Mercer; Middlesex; Morris; Passaic; Somerset; Sussex, Union and Warren.) Horizon NJ Health -- Serving all counties UnitedHealthcare Community Plan -- Serving all counties WellCare Health Plans of New Jersey -- Serving five counties: (Essex, Hudson, Middlesex, Passaic and Union)

24 Program of All-Inclusive Care for the Elderly (PACE) The PACE organization coordinates and provides ALL services including nursing facility care, if needed. An individual must be 55 or older, able to live safely in the community at the time of enrollment and have care needs at the nursing home level. Four PACE organizations now are in seven counties. An individual must live in the PACE provider service area to be eligible to enroll. 24

25 PACE in NJ 25 LIFE at Lourdes o Serving most of Camden County Lutheran Senior LIFE o Serving parts of Hudson County LIFE St. Francis o Serving Mercer County and parts of northern Burlington County Inspira LIFE o Serving Cumberland and parts of Gloucester and parts of Salem counties

26 Crosswalk of Care Management Before and After MLTSS Begins 26 Population Prior to Implementation of Comprehensive Waiver and MLTSS New Care Coordination Entity Global Option (GO) Waiver Division of Aging Services (DoAS) MCO AIDS Community Care Alternatives Program (ACCAP) Waiver Traumatic Brain Injury (TBI) Waiver Division of Disability Services Division of Disability Services MCO MCO Community Resources for People with Disabilities (CRPD) Waiver Division of Disability Services MCO CCW Division of Developmental Disability No change PACE PACE program PACE program

27 Care Management (CM) Transition for GO 27 MCOs completed GO CM Training 1/14 Division of Aging Services (DoAS) trained Office of Community Choice Options (OCCO)/ADRC Assessors and Area Agency on Aging (AAA) Information Specialists on counseling new LTSS eligible enrollees to select a LTSS option Managed Care or PACE and if managed care is chosen how to select the MCO for MLTSS completed 1/14. MCOs assumed CM for all newly enrolled GO participants and transfer cases as of 2/1 DoAS sponsors weekly conference calls with each MCO to identify and address issues, concerns, and provide technical assistance in the development of their MLTSS policies and procedures.

28 Care Management (CM) Transition for Medicaid Waiver Participants 28 Training for new MCO CMs still on-going Sessions held on about 20 different MLTSS, DoAS/DDS LTC topics with select ones videotaped/posted on the DHS website Waiver care management meetings finished with last one held on 5/21/14

29 GO Care Management Enrollments 29 Number of new GO enrollments since February 1, 2014 = 729 To date, the number of GO cases which have transferred from their current CMOs to the MCOs = 1,500 (about 12,000 total)

30 Provider Readiness for MLTSS 30 Claims testing for MLTSS services began in April with MCOs providing updates as part of their readiness process for MLTSS Provider manuals have been updated by the MCOs to include MLTSS specific information DMAHS MLTSS newsletter will be mailed to all current Medicaid Waiver providers

31 Provider Training for MLTSS 31 MLTSS Training Subcommittee met in July 2013 and created sub-groups by provider category to address needs of individual provider types. DHS received comments on FAQs and training documents. DHS posted MLTSS resources for stakeholders and providers on its website. As part of MLTSS readiness, the MCOs also are requested to post provider training schedules. In-depth training currently is taking place. Provider associations also are working individually with the MCOs and DMAHS to request providerspecific trainings.

32 MLTSS Participant Rights 32 Consumer has right to change his/her Medicare Health or Drug Plan or NJ FamilyCare MCO at any time during the year: Consumer can change his/her NJ FamilyCare MCO as follows: o Within 90 days of new enrollment ; o During the annual Open Enrollment Period, which takes place every year from October 1 to November 15; or o For good cause.

33 For More Information on MLTSS 33 NJ FamilyCare Hotline (for consumers and providers) The NJ State Health Insurance Assistance Program (SHIP) at for assistance with MLTSS enrollment for D-SNP participants