Managed Long Term Services and Supports (MLTSS) is a critical program within New Jersey Medicaid’s NJ FamilyCare, designed to deliver comprehensive long-term care services. This program emphasizes expanding access to home and community-based services, promoting community inclusion, and ensuring both quality and efficiency in care delivery. Understanding the administrative guidelines that govern MLTSS is crucial for both recipients and providers to navigate this system effectively. While specific guidelines evolve, the 2017-2018 period represents a significant phase in the program’s development and implementation.
What is MLTSS and its Core Objectives?
MLTSS fundamentally shifts the approach to long-term care by operating under the NJ FamilyCare managed care umbrella. This means that managed care organizations (MCOs), also known as health plans or HMOs, are central to coordinating all aspects of care. Whether an individual requires support at home, in assisted living, within community residential services, or in a nursing home, MLTSS aims to provide comprehensive and coordinated services. The overarching goal is to create a system that is not only efficient but also prioritizes the individual’s needs and preferences for community-based living.
Key Services Covered Under MLTSS
The breadth of services covered by MLTSS is designed to be extensive, addressing a wide spectrum of needs for individuals requiring long-term support. These services include:
- Access to NJ FamilyCare Plan A Benefits: This foundational benefit ensures access to a broad range of healthcare services.
- Care Management: A cornerstone of MLTSS, care management ensures coordinated and personalized care plans.
- Home and Vehicle Modifications: Essential for enabling individuals to live safely and comfortably in their homes and communities.
- Home Delivered Meals: Providing nutritional support for those who have difficulty preparing meals.
- Respite Care: Offering temporary relief for caregivers, recognizing the vital role they play.
- Personal Emergency Response Systems (PERS): Enhancing safety and independence at home through rapid access to help in emergencies.
- Mental Health and Addiction Services: Addressing the holistic health needs of individuals, including behavioral health.
- Assisted Living: Providing a supportive residential setting for those needing assistance with daily living.
- Community Residential Services: Offering various community-based living options tailored to individual needs.
- Nursing Home Care: Covering long-term custodial care in nursing facilities when community-based options are not sufficient.
Nursing Home Care and MLTSS Integration
Nursing home care within MLTSS is carefully structured. For new NJ FamilyCare enrollees entering a nursing facility (NF) or special care nursing facility (SCNF), the MCOs manage their acute and primary healthcare from the outset. Short-term rehabilitation in these facilities is a standard NJ FamilyCare Plan A benefit. Following rehabilitation, MCOs assess individuals to determine if they meet MLTSS criteria for long-term custodial care. If MLTSS eligibility is confirmed, the Division of Aging Services (DoAS) conducts a clinical assessment to finalize eligibility.
Individuals already in or seeking placement in a NF/SCNF and are pending or newly eligible for NJ FamilyCare Plan A are directed to the DoAS Office of Community Options (OCCO) for MLTSS clinical eligibility assessment. Upon both financial and clinical approval for Medicaid, enrollment in MLTSS and an MCO follows. It’s important to note that residents in NF/SCNF who were receiving custodial care through Medicaid prior to July 1, 2014, remain in the NJ FamilyCare fee-for-service system for the duration of their stay.
Qualifying for MLTSS: Eligibility Requirements
Eligibility for MLTSS is based on meeting specific Medicaid criteria, encompassing both financial and clinical needs.
Financial Requirements: These consider both monthly income and total liquid assets. Detailed information regarding Medicaid financial eligibility is available here.
Clinical Requirements:
For individuals 21 years and older, clinical eligibility is met under the following conditions:
- Requiring Nursing Facility Level of Care: This involves needing hands-on assistance with at least three Activities of Daily Living (ADLs) such as bathing, dressing, toileting, locomotion, transfers, eating, and bed mobility. Alternatively, individuals with cognitive deficits requiring supervision and cueing with three or more ADLs also qualify.
For children ages birth through 20, clinical eligibility is determined by:
- Functional Limitations: Identified as developmental delays or functional limitations in age-appropriate ADLs. These children must require nursing care that goes beyond routine parenting.
- Skilled Nursing Care Needs: Meeting criteria for skilled nursing care that demands complex interventions 24/7.
- Technology Dependence: Requiring medical and/or intense therapeutic services as technology-dependent children who rely on life-supporting or life-sustaining devices. The use of these devices necessitates ongoing skilled nursing intervention around the clock.
Age and/or Disability Requirements:
- Age: Individuals must be 65 years or older.
- Disability: For those under 65, they must be determined blind or disabled by the Social Security Administration or the State of New Jersey.
Note for children applying for MLTSS: Parental income and resources are not considered when determining financial eligibility for children meeting Pediatric Clinical Eligibility as per the Comprehensive Waiver approved in August 2017. This reflects a commitment to ensuring children with significant needs can access necessary services regardless of parental financial status.
Application Process for MLTSS
The application process varies slightly depending on age:
For individuals 21 and older, the first step is to contact the local County Area Agency on Aging (AAA) – Aging and Disability Resource Connection (ADRC). These agencies provide information on local services and resources and conduct the initial clinical screening for MLTSS eligibility.
For children birth through 20 years old, contact the Division of Disabilities Services (DDS) at 1-888-285-3036 (press 2 then 1 as prompted) to speak with an Information and Referral Specialist.
Another avenue for accessing comprehensive care is the Program of All-Inclusive Care for the Elderly (PACE). Eligibility for PACE requires living within a PACE provider service area. Currently, six PACE organizations serve parts of ten counties in New Jersey. More information about PACE is available here.
For specific inquiries about MLTSS, email questions can be directed here.
The Significance of 2017-2018 Administrative Guidelines
The administrative guidelines in the 2017-2018 period were crucial in shaping the operational framework of the MLTSS program. These guidelines provided the detailed instructions and rules for MCOs, providers, and beneficiaries on how the program should function daily. They likely covered aspects such as care coordination protocols, service authorization processes, quality monitoring, and beneficiary rights and responsibilities. While specific publicly accessible documents titled “2017-2018 Patient Care Program Administrative Guidelines” might be internal or not broadly circulated, the principles and directives from this period would have been foundational for the ongoing delivery of MLTSS. Understanding the intent and direction set during this period is valuable for stakeholders seeking to comprehend the program’s evolution and its commitment to person-centered, community-based long-term care.
Conclusion
Managed Long Term Services and Supports (MLTSS) represents a significant commitment by New Jersey Medicaid to provide coordinated, community-focused long-term care. By understanding the program’s structure, covered services, eligibility criteria, and application processes, individuals and their families can effectively access the support they need. While the specific administrative guidelines from 2017-2018 may be detailed and technical, their underlying purpose was to ensure the effective and equitable delivery of patient care within the MLTSS framework. For those seeking long-term care solutions in New Jersey, MLTSS offers a comprehensive and valuable resource.
