What is Medicaid MLTSS?

Horizon NJ Health 210 Silvia Street West Trenton, NJ 08628 Phone: (609) 718-9001 www.horizonnjhealth.com What is Medicaid MLTSS? MLTSS is a managed care delivery system that coordinates long term services and supports for eligible Medicaid beneficiaries. MLTSS includes but is not limited to services such as: Chore Services; Community Alternative Residential Settings; Community Residential Services; Home and Vehicle Modifications; Home Delivered Meals; Nursing Home; and Respite MLTSS is part of a comprehensive package of health care services delivered through a managed care plan. To receive MLTSS eligible beneficiaries must join a managed care plan. Objectives of MLTSS: Help individual to live as independently and as long as possible in the community, but provide care in a nursing home, if needed. Focus on comprehensive care needs in the community Use public funds in the most efficient manner. Non-Traditional Provider Application Parameters: Part 1 and 2 of the Application represents uniform requirements for New Jersey Medicaid/NJFamily Care Health Plans. Part 3 includes additional Health Plan-specific information that may be required. Part 1 Administrative Documents: All applicants must submit the administrative documents identified in this section of the Application. Part 2 Service Specific Requirements: Complete the Service Submission Requirements based on services the nontraditional provider applicant wants to provide as a participating network provider of the health plan to which they are applying. NJ Medicaid MLTSS Non-Traditional Provider Application 1 August 2013

Table of Contents I. Part 1: Administrative Documents 3-7 Page II. Part 2: Service Specific Requirements 8-14 Service Specific Requirements Reference Table 8 Service Summary Documents 10-14 III. State of New Jersey MLTSS Reference Information 15 IV. Part 3: Health Plan (HMO) Specific Information 16 NJ Medicaid MLTSS Non-Traditional Provider Application 2 August 2013

PART 1: ADMINISTRATIVE DOCUMENTS 1. Provider Identification Information 2. Attestation and Information Release 3. Disclosure Statement of Ownership and Control, Interest, Related Business Transactions and Persons Convicted of Crime 4. W-9 Tax Form 5. State of NJ Business Registration 6. Business Entity Information (New Jersey Tax Certification or Trade Name Registration) 7. Process for Addressing Individual Complaints and/or Grievances NJ Medicaid MLTSS Non-Traditional Provider Application 3 August 2013

If entry is not applicable please enter N/A (not applicable). Part 1: Administrative Documents 1. Provider Identification Information: Legal Business Name: Doing Business As: Owner/Manager Name: Owner/Manager direct telephone number: ID Number Information National Provider Identifier # (if applicable) : Medicaid Provider ID Servicing (if applicable) : Medicaid Provider ID Billing (if applicable): Medicare Provider ID (if applicable): Tax ID#: Social Security Number: Administrative Information Primary Contact Name: Alternate Contact Name: Credentialing Contact: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Website Address: Payment Information (attach copy of W-9) Contact Person: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Billing Company Name (if applicable): Contact Person: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: NJ Medicaid MLTSS Non-Traditional Provider Application 4 August 2013

2. ATTESTATION BY OWNER OR AUTHORIZED REPRESENTATIVE ANY ALTERATION OR FAILURE TO SIGN AND DATE THIS FORM WILL RESULT IN THE DELAY OF PROCESSING THIS APPLICATION By signing below, I attest that I am the duly authorized representative of (business), and that all information on this Application pertains to the above-named business, (business), and that all information provided in this application is current, complete and correct. Signature is required to complete this application. Stamped signatures are NOT acceptable. Business Name: Authorized Representative Name : Title: Signature: Date: NJ Medicaid MLTSS Non-Traditional Provider Application 5 August 2013

3. DISCLOSURE STATEMENT OF OWNERSHIP DISCLOSURE STATEMENT OF OWNERSHIP AND CONTROL INTEREST, RELATED BUSINESS TRANSACTIONS AND PERSONS CONVICTED OF A CRIME. This form shall be submitted to the HMO annually and upon request. For definitions, procedures and requirements refer to 42 CFR 455.100-106 (copy attached). ATTACH SEPARATE SHEETS I. Identifying Information of Disclosing Entity (Name of Disclosing Entity and D/B/A) Street Address City County State Zip Code Telephone No. II. Ownership and Control Interest A. Please complete the information: 1. NAME ADDRESS RELATIONSHIP % OWNERSHIP IRS ID/OTHER TAX ID (FOR CORPORATIONS) DATE OF BIRTH (FOR INDIVIDUALS) SSN (FOR INDIVIDUALS) 2. NAME ADDRESS RELATIONSHIP % OWNERSHIP IRS ID/OTHER TAX ID (FOR CORPORATIONS) DATE OF BIRTH (FOR INDIVIDUALS) SSN (FOR INDIVIDUALS) 3. NAME ADDRESS RELATIONSHIP % OWNERSHIP IRS ID/OTHER TAX ID (FOR CORPORATIONS) DATE OF BIRTH (FOR INDIVIDUALS) SSN (FOR INDIVIDUALS) B. Please complete the information below: The name of any other disclosing entity (or fiscal agent or) in which a person with an ownership or control interest in the business (disclosing entity) also has an ownership or control interest. ) NAME ADDRESS NAME ADDRESS NJ Medicaid MLTSS Non-Traditional Provider Application 6 August 2013

C. Please list the name, address, date of birth, and Social Security Number of any managing employee.) 1. NAME ADDRESS DATE OF BIRTH SSN 2. NAME ADDRESS DATE OF BIRTH SSN 3. NAME ADDRESS DATE OF BIRTH SSN III. Information related to business transactions. Provide ownership information of (1) Any subcontractor with whom the contractor has had business transactions totaling more than $ 25,000 during the 12- month period ending on the date of the request; and (2) Any significant business transactions between the contractor and any wholly owned supplier, or between the Contractor and any subcontractor, during the 5-year period ending on the date of the request. NAME ADDRESS OWNERSHIP Disclose information on types of transactions with a "party in interest" as defined in Section 1318(b) of the Public Health Service Act (Section 1903(m)(4)(A) of the Social Security Act). IV. Disclosure of Information on persons convicted of crimes. Identity of any person who has ownership or control interest in the provider organization, or is an agent or managing employee of the provider organization; and has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or the Title XX services program since the inception of those programs. Are there any directors, officers, agents, or managing employees of the provider organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX? If yes list names and addresses of individuals or corporations. WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. Name of Authorized Representative (Typed), Title Signature, Date REMARKS: NJ Medicaid MLTSS Non-Traditional Provider Application 7 August 2013

Part 2: Service Specific Requirements Service Reference for Credential/ License Entity Insurance Page Caregiver Participant Training Chore Services Community Transition Services Home Delivered Meals Appropriate license and or certification as per Department of Community Affairs guidelines Complete Statement of Intent for Community-Based Supportive Care Services Copy of General and/or Professional Liability as required by business license and/or required by health plan 10 Residential Modification See the NJ Business Action Center http://www.nj.gov/njbusiness/pdfs/licce rt.pdf for a list of the appropriate licenses/certificates required for the contracted service Copy of General and/or Professional Liability as required by business license and/or required by health plan 11 Vehicle Modifications Medication Dispensing Device (MDD) Set- up and Monthly Monitoring Appropriate license and or certificate as per the National Highway Traffic Safety Administration See the NJ Business Action Center http://www.nj.gov/njbusiness/pdfs/licce rt.pdf for a list of the appropriate licenses/certificates required for the contracted service Copy of General and/or Professional Liability as required by business license and/or required by health plan Copy of General and/or Professional Liability as required by business license and/or required by health plan 12 13 Personal Emergency Response System (PERS) Set-Up and Monitoring See the NJ Business Action Center http://www.nj.gov/njbusiness/pdfs/licce rt.pdf for a list of the appropriate licenses/certificates required for the contracted service Copy of General and/or Professional Liability as required by business license and/or required by health plan 14 New Jersey Business Action Center: 1. Main Phone: 866-534-7789 2. Email: http://www.state.nj.us/njbusiness/pdfs/liccert.pdf NJ Medicaid MLTSS Non-Traditional Provider Application 8 August 2013

Community-Based Support Services: Description of Applicant Responsibilities: (Reference: MLTSS Service Descriptions): Caregiver Participant Training: Provide instruction to a client and/or caregiver in either a one-to-one or group situation to teach a variety of skills necessary for independent living, including but not limited to: coping skills to assist the individual in dealing with disability; coping skills for the caretaker to deal with supporting someone with long term care needs; skills to deal with care providers and attendants. Examples include, seminars on supporting someone with dementia, seminars to support someone mobility difficulties. Training needs must be identified through the comprehensive evaluation, re-evaluation, or in a professional evaluation and must be identified in the approved Plan of Care as a required service. Chore Services: Provide services needed to maintain the home in a clean, sanitary and safe environment. The chores are non-continuous, non-routine heavy household maintenance tasks intended to increase the safety of the individual. Chore services include cleaning appliances, cleaning and securing rugs and carpets, washing walls, windows, and scrubbing floors, cleaning attics and basements to remove fire and health hazards, clearing walkways of ice, snow, leaves, trimming overhanging tree branches, replacing fuses, light bulbs, electric plugs, frayed cords, replacing door locks, window catches, replacing faucet washers, installing safety equipment, seasonal changes of screens and storm windows, weather stripping around doors, and caulking windows. Community Transition Services: Assist members with coordination of transition from an institutional setting to his/her own home in the community through coordination of non-recurring transitional expenses (i.e. moving expenses; necessary accessibility adaptations to promote safety and independence; and activities to assess need, arrange for and procure needed resources). This service is provided to support the health, safety and welfare of the participant. Home-Delivered Meals: Deliver nutritionally balanced meals to a member s home when this meal provision is more cost effective than having a personal care provider prepare the meal. These meals do not constitute a full nutritional regimen, but each meal shall provide at least 1/3 of the current Recommended Dietary Allowance (RDA) established by the Food & Nutrition Board of the National Academy of Sciences, and National Research Council. NJ Medicaid MLTSS Non-Traditional Provider Application 9 August 2013

Service Summary Documents: Community-Based Support Services: It is the intention of (Enter Corporate Name) to be a provider of Community-Based Support Services for the New Jersey Medicaid Program via a Health Plan Contract. The organization intends to become a provider for the following Managed Long Term Community-Based Support Services: (Please check all that apply) Caregiver Participant Training Chore Services: Cleaning Maintenance Community Transition Services Home Delivered Meals 1. Please include a copy of applicable licenses, certifications and/or accreditation to provide the selected services. 2. Copy of General and/or Professional Liability as required by business license and/or required by health plan Address of Locations Location #1: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Hours of Operation: Languages Spoken: Location #2: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Hours of Operation: Languages Spoken: Counties Served: Statewide: Yes No If no, check all of the counties where your company would like to provide services. Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Special Populations: Please include narrative describing experience the organization, its employees, and/or subcontractors have working with individuals receiving Long Term Services and Supports. NJ Medicaid MLTSS Non-Traditional Provider Application 10 August 2013

Service Summary Documents: Residential Modifications Residential Modifications (Eligible for MFP 25%): Those physical modifications/adaptations to a participant s private primary residence required by his/her plan of care which are necessary to ensure the health, welfare and safety of the individual, or which enable him/her to function with greater independence in the home or community and without which the individual would require institutionalization. Such adaptations may include the installation of ramps and grab bars, widening of doorways, modifications of bathrooms, or installation of specialized electrical or plumbing systems that are necessary to accommodate the medical equipment and supplies which are needed for the health, safety and welfare of the individual. Service Limitations: Residential Modifications are limited to $5,000 per calendar year, $10,000 lifetime. Provider applicant must provide: 1. Copy of applicable license required by New Jersey law. See the NJ Business Action Center http://www.nj.gov/njbusiness/pdfs/liccert.pdf for a list of the appropriate licenses/certificates required for the contracted service 2. Copy of General and/or Professional Liability as required by business license and/or required by health plan Address of Location: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Hours of Operation: Languages Spoken: Counties Served: Statewide: Yes No If no, check all of the counties where your company would like to provide services: Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Special Populations: Please include narrative describing experience the organization, its employees, and/or subcontractors have working with individuals receiving Long Term Services and Supports. NJ Medicaid MLTSS Non-Traditional Provider Application 11 August 2013

Service Summary Documents: Vehicle Modifications Vehicle Modifications (Eligible for MFP 25%) The services includes needed vehicle modification (such as electronic monitoring systems to enhance beneficiary safety, mechanical lifts to make access possible) to a participant or family vehicle as defined in an approved plan of care. Modifications must be needed to ensure the health, welfare and safety of a participant or which enable the individual to function more independently in the home or community. All services shall be provided in accordance with applicable State motor vehicle codes. Service Limitations: The vehicle must be owned by the participant or their authorized representative. The vehicle must be registered in NJ. Provider applicant must provide: 1. Appropriate license and or certificate as per the National Highway Traffic Safety Administration 2. Copy of accreditation from National Mobility Equipment Dealers Association 3. Copy of General and/or Professional Liability as required by business license and/or required by health plan Address of Location: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Hours of Operation: Languages Spoken: Counties Served: Statewide: Yes No If no, check all of the counties where your company would like to provide services. Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Special Populations: Please include narrative describing experience the organization, its employees, and/or subcontractors have working with individuals receiving Long Term Services and Supports. NJ Medicaid MLTSS Non-Traditional Provider Application 12 August 2013

Service Summary Documents: Medication Dispensing Device (MDD) Set- up and Monthly Monitoring (Eligible for MFP 25%) This may include an electronic medication-dispensing device that allows for a set amount of medications to be dispensed as per the dosage instructions. If the medication is not removed from the unit in a timely manner the unit will lock that dosage, not allowing the participant access to the missed medication. Before locking, the unit will use a series of verbal and/or auditory reminders that the participant is to take his or her medication. If there is no response, a telephone call will be made to the participant, participant s contact person, and case management site in that order until a live person is reached. Installation, upkeep and maintenance of device/systems are provided. Service Limitations: Per Medical Necessity as defined in the MCO contract. Medication Dispensing Device is for an individual who lives alone or who is alone for significant amounts of time per the plan of care. Individuals might not have a regular care giver for extended periods of time or would require extensive routine supervision. Provider applicant must provide: 1. Copy of applicable license required by New Jersey law 2. Copy of General and/or Professional Liability as required by business license and/or required by health plan Address of Location: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Hours of Operation: Languages Spoken: Counties Served: Statewide: Yes No If no, check all of the counties where your company would like to provide services. Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Special Populations: Please include narrative describing experience the organization, its employees, and/or subcontractors have working with individuals receiving Long Term Services and Supports. NJ Medicaid MLTSS Non-Traditional Provider Application 13 August 2013

Service Summary Documents: Personal Emergency Response System (PERS) Set-up and Monitoring (Eligible for MFP 25%) PERS is an electronic device which enables participants at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable help button to allow for mobility. The system is connected to the person s phone and is programmed to signal a response center once a help button is activated. The response center is staffed by trained professionals. The service consists of two components both of which are managed by the PERS contractor; first is the initial installation of the equipment and the second is the monitoring of the service by staff at the response center. The addition of the fiscal intermediary is the modification to the provider specifications. Previously the provider of the specific service was required to execute a purchase agreement with the case management agency; now that agreement is between the fiscal intermediary and the service provider. Service Limitations: Per Medical Necessity as defined in the MCO contract. PERS is for an individual who lives alone for a significant amounts of time per the plan of care. Individual might not have a regular care giver for extended periods of time or would require extensive routine supervision. Provider applicant must provide: 1. Copy of applicable license required by New Jersey law See the NJ Business Action Center http://www.nj.gov/njbusiness/pdfs/liccert.pdf for a list of the appropriate licenses/certificates required for the contracted service 2. Copy of General and/or Professional Liability as required by business license and/or required by health plan Address of Location: Address Line 1: Address Line 2: City: State: Zip: Phone Number: Fax Number: Email Address: Hours of Operation: Languages Spoken: Counties Served: Statewide: Yes No If no, check all of the counties where your company would like to provide services. Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Special Populations: Please include narrative describing experience the organization, its employees, and/or subcontractors have working with individuals receiving Long Term Services and Supports. NJ Medicaid MLTSS Non-Traditional Provider Application 14 August 2013

State of New Jersey MLTSS References New Jersey Department of Human Services: Division of Aging Services: Provider Hotline: 866-854-1596 Medicaid Hotline: 800-356-1561 Medicaid Office of Managed Health Care, Managed Provider Relations Unit Main Phone: 609-588-3826 E-mail: MAHS.MCProviderInquiries@dhs.state.nj.us Health Plan Contract: http://www.state.nj.us/humanservices/dmahs/info/resources/care/ (MLTSS Contract documents which include the MLTSS Service Dictionary will be posted when MLTSS is implemented.) New Jersey Business Action Center: 3. Main Phone: 866-534-7789 4. Email: http://www.state.nj.us/njbusiness/pdfs/liccert.pdf Health Plan Provider Relations Telephone Numbers 1. Amerigroup New Jersey: 800-454-3730 2. Healthfirst Health Plan of NJ, Inc.: 888-464-4365 3. Horizon NJ Health: 877-765-4325 4. UnitedHealthcare Community Plan: 888-362-3368 NJ Medicaid MLTSS Non-Traditional Provider Application 15 August 2013

Part 3: Horizon NJ Health Liability Insurance Coverage (Minimum coverage of 1 Million per service) Name of Current Professional Liability Insurance Carrier: Address City State Zip Policy No. Period of Coverage Amount of Coverage per occurrence Amount of Coverage per aggregate Non English Languages Spoken (Staff): Arabic ASL Cantonese Chinese Danish Dutch Farsi Filipino French German Greek Hebrew Hindi Hungarian Indian Iranian Italian Japanese Korean Mandarin Pakistani Persian Polish Portuguese Romanian Russian Spanish Swedish Tagalog Thai Turkish Ukrainian Urdu Vietnamese Yugoslavian Criminal Background/Civil History Attestation Complete and on file for all Employees and updated annually. If driving a motor vehicle is a job requirement for your employees, you are required to have on file a driving history report for all employees who drive company or personal vehicles for business. Motor Vehicle Reports (MVRs) must provide a comprehensive review of individual driving records, including offenses and citations and must be updated annually and kept on file for audit purposes. NJ Medicaid MLTSS Non-Traditional Provider Application 16 August 2013

Criminal Background Check Attestation: I attest that all staff members who provide services for Horizon NJ Health members have received the required criminal history background check. Additionally, I attest that I have received and reviewed original copies of the criminal background check via the State vendor and will keep on file for audit purposes and updated yearly. The following questions should also be completed for each employee and kept on file for audit purposes and updated yearly: 1. Have you ever been convicted of, pled guilty to or pled nolo contendere to any felony in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional? 2. Have you ever been convicted of, pled guilty to or pled nolo contendere to any felony in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is that alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? 3. Have you ever been indicted in any civil or criminal suit? 4. Have you ever been court martialed for actions related to your duties as a medical professional? 5. Are you currently engaged in the illegal use of drugs? ( Currently means sufficiently recent to justify a reasonable belief that the use of drugs any have an ongoing impact on one s ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of an application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. Illegal use of drugs refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 USC section 812.2. It does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other pro vision of Federal law. The term does include, however, the unlawful use of prescription controlled Substances.) 6. Do you use any chemical substances that would in any way impair or limit your ability to perform the functions of your job with reasonable skill and safety? 7. Do you have any reason to believe that you would pose a risk to the safety or well-being of your clients? By signing below, I attest that I am the duly authorized representative of Click here to enter text. (Business), and that all information on this Attestation pertains to the above-named business employees, and that all information provided in this application is current, complete and correct. Signature is required to complete this application. Stamped signatures are NOT acceptable. Business Name: Authorized Representative Name and Title: Authorized Representative Signature: Applicant Signature: Date: Date: NJ Medicaid MLTSS Non-Traditional Provider Application 17 August 2013