New Jersey Launches MLTSS
July 15, 2014 08:48 AM
On July 1, New Jersey launched its managed care long-term services and supports (MLTSS) program. Details of the transition are discussed below, as analyzed by NAHC’s affiliated National Council on Medicaid Home Care.
Two entry points. Enrollees can gain access to MLTSS either through one of five MCOs, or one of four PACE organizations through the state’s PACE program. For details, see pages 13-16, here. For a recent Council brief on PACE, click here.
Included waivers. MLTSS will encompass home and community based services previously available under waivers. These waivers include the AIDS Community Care Alternatives Program (ACCAP), Community Resources for People with Disabilities (CRPD), Global Options for Long-Term Care (GO), and the Traumatic Brain Injury (TBI) waivers. Enrollees in these waivers will automatically be enrolled in the MCOs.
Developmentally disabled. The services of the developmentally disabled population not in the above four waivers will not be affected by the transition to MLTSS.
D-SNPs. Those enrolled in dual eligible special needs plans (D-SNPs) can voluntarily enroll in MLTSS, but must first disenroll from their D-SNP plans. For details, see page 7, here.
MLTSS in New Jersey now includes: assisted living, care management, community residential services, home and vehicle modifications, home delivered meals, mental health and addiction services, nursing home care, personal care, personal emergency response systems (PERS), and respite. A care manager will help coordinate LTSS with behavioral and medical services.
Private Duty Nursing. For beneficiaries up to age 21, private duty nursing (PDN) is included as a NJ FamilyCare benefit. After age 21, PDN in MLTSS is based on a beneficiary’s needs as assessed by the managed care plan. For those receiving PDN services under the current NJ FamilyCare waiver, these services may continue based on needs as assessed by the MCOs.
The MCO contracts will have “any willing provider” and “any willing plan” contract provisions for two years with assisted living providers, community residential services (CRS) providers for residents with traumatic brain injury (TBI), nursing facilities, and special care nursing facilities. Personal care providers are not included in these provisions. Providers not in the MCO networks must contact these MCOs to request joining the networks.
Enrollment and Care Transitions
Enrollees of the four included waivers described above will be automatically enrolled in MLTSS through their current MCOs. Enrollees will also be given information on how to change their MCO if they would like to do so.
Others interested in enrolling in MLTSS must meet financial, clinical, and age and/or disability requirements, and must contact their local County Area Agency on Aging (AAA) or County Welfare Agency (Board of Social Services).
Providers administering services prior to the MLTSS transition can continue to do so past June 30th until the MCO has established a new plan of care for the beneficiaries, and the MCO has notified the provider of this. The MCO will then either continue to allow the provider to provide services, albeit under MLTSS, or will terminate services of that provider. It is unclear through publically available documents what, if any, obligation of notice is required for MCOs to terminate services in these circumstances.
Universal billing forms. Providers will have universal billing forms for MLTSS services, both in paper and electronic forms. For details, see page 21 and 22, here.
Claims processing. According to the MCO contracts, the MCOs must process each MLTSS service claim within 15 days of a clean submission. For non-MLTSS services, the MCOs must process these claims within 30 days of a clean submission.
Claims resubmissions. The MCOs may deny claims for a variety of reasons. The most common re-submissions types are for: bundled claims, corrected claims, and prior notification/prior authorization information.
For details of New Jersey’s move to MLTSS, click here.
Chrissy Buteas, President & CEO of the Home Care Association of New Jersey, commented on the recent shift to MLTSS. “With the launch of MLTSS, we look forward to continued dialogue with the State and MCOs to ensure that, together, we create a landscape where patients receive the high quality services they deserve and agencies receive appropriate reimbursement levels for the essential role they play in the success of the initiative," said Buteas.
NAHC’s affiliated National Council on Medicaid Home Care expresses a couple of concerns on the launch to MLTSS, specifically:
Any willing provider. In some states, health plans will contract with any willing provider, as Texas required MCOs to do during the early years of MLTSS. Further, Centene incorporates “any willing provider” language into its contracts in Florida, and has supported “any willing provider” legislation in Kansas. New Jersey’s MLTSS to date does not have any willing provider provisions for personal care companies. The Council calls on New Jersey to move forward with “any willing provider” contracts for personal care companies. The Council continues to advocate for such provisions across all states that are transitioning to MLTSS. For details on the Council’s support of “any willing provider” provisions in home care generally, see page 47 of our 2014 policy blueprint, here.
Transition to MLTSS rates creates uncertainty. Unfortunately, New Jersey did not set any defined times for maintaining fee-for-service (FFS) rates. Essentially, the rates paid to providers can’t change until the MCOs sends in their clinicians to do an assessment. Once the MCOs conduct their assessments and make plans, then the payment to the provider adjusts from FFS to the managed care contract rate, which in the past has often been lower than FFS in New Jersey. The time it takes for the MCOs to conduct assessments varies widely (they can take anywhere from two days to two months or more), so providers have no real way to plan for when the rates will adjust.
The Council will soon have results from its July survey on MLTSS that was sent to both Forum of State Associations and home care agencies alike. Home care providers are encouraged to keep abreast of managed care transitions in their states, advocate on a state level, and to contact the Council with any questions or concerns.