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NJ Medicaid Waivers Transition to Managed Care Effective 7/1/14!

on Sat, 06/28/2014 - 20:53

Families of children (and adults) with disabilities need to know that New Jersey’s Medicaid waivers are moving to managed care effective 7/1/14.  This factsheet will help explain the new process and how to address concerns.  Please note:  The Medicaid Community Care Waiver (CCW) is not changing.  Everyone who has been receiving services through the CCW will continue to receive those services.

What will change for individuals currently receiving services through these Medicaid waivers?

The four NJ Medicaid programs, Global Options for Long-Term Care (GO), AIDS Community Care Alternatives Program (ACCAP), Community Resources for People with Disabilities (CRPD), and Traumatic Brain Injury (TBI) Waiver are moving to a streamlined system of managed care starting 7/1/14.  This system is called “Managed Long Term Services and Supports (MLTSS).  Letters were sent to families whose children are currently on these waivers on 4/1/14.  After July 1, 2014, the state will be using a standardized assessment tool to determine the level of care needed.  There will be NO changes in current services until the Medicaid Health Maintenance Organization (HMO) does an evaluation. Families will probably be assigned a new HMO care manager in the MLTSS system.  There will also be a new general MLTSS phone number for each HMO -- operational 24 hours a day -- for urgent problems.  This phone number should always be used when a problem arises, rather than calling the general HMO member services number.

What will change for individuals who need to apply for these specialized Medicaid services?

For new families, the Division of Disability Services (DDS) will be screening for services, the NJ Office of Community Choice Options will determine eligibility, and then if determined to be eligible refer them to a Managed Care Organization.  The process will usually take 6 weeks but OCCO can triage urgent cases.  If the application was completed 5/16 or later, it will be automatically transitioned to the new MLTSS system.  DDS will handle MLTSS referrals in the same way that they would make a referral to any other program that they don't  run, and will take on an ombudsperson function for the families who need it.   In many cases this may be prepping a parent to have a good call with their care manager by explaining terminology, process and jargon, and by helping them to be good question askers.

What do families need to know?

Children who receive services from the Division of Developmental Disabilities (DDD) can still get those services.  However, if the family moves to MLTSS they may lose some DDD services such as transition services, so they need to decide which program better fits the needs of their child.  See resources below for whom families should reach out to for help in making the decision.

An Interdisciplinary Team (IDT) evaluation occurs for complex cases to examine the cost of care at home vs. facility care, though the goal is to remain in the community.  If needed, a risk agreement will be developed to provide a percentage of the cost of care at home vs. facility care.  This means that the family makes the decision on placement and may pay the rest of the cost of care.

Families can Appeal if an HMO Reduces or Denies Medically Necessary Services

Staff from DDS Information and Referral, Medicaid Quality Assurance, and Medical Assistance Consumer Centers will still be available to help families. There will still be 3 levels of appeal as well as a Medicaid fair hearing , which provides an opportunity for the HMO and the family (sometimes with assistance from an attorney) to present the facts to an administrative law judge.  All of these appeal rights are listed in the HMO’s member handbook.  If a family is appealing a reduction or denial of a medically necessary service that was previously authorized, it is very important that families request a “continuation of benefits” throughout the appeal process.  As long as this request is made in a timely manner, (and this request may need to be repeated as different levels of appeal and/or a Medicaid fair hearing are requested) the previously authorized services will continue.

Medical documentation and the appeals process

When submitting an appeal, it is important to have sufficient medical documentation.  For example, if private duty nursing (PDN) has been denied or the hours reduced, the pediatrician and/or pediatric specialist(s) can document the necessity for the skilled nursing services that the child requires in addition to writing a prescription.  It is also important to note that home nursing could prevent hospitalization, which is cost saving and also effective care, often resulting in best outcomes. 

Resources:

v  Main website on MLTSS  http://www.state.nj.us/humanservices/dmahs/home/mltss.html

v  Frequently Asked Questions on MLTSS http://www.state.nj.us/humanservices/dmahs/home/Consumer_FAQs.pdf

v  Letter to families currently in waiver programs http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Consumer_Communications.pdf.

Helpful Contacts:

Ø  NJ Division of Disability Services http://nj.gov/humanservices/dds/home/ or call (888)285-3036

Ø  Special Child Health Services http://www.nj.gov/health/fhs/sch/sccase.shtml

Ø  Medical Assistance Consumer Centers  http://www.state.nj.us/humanservices/dmahs/info/resources/macc/

Ø  Statewide Parent Advocacy Network www.spanadvocacy.org or (800)654-SPANThe Arc of NJ http://www.arcnj.org/programs/mainstreaming_medical.html or (732)246-2525

Ø  The Arc of NJ http://www.arcnj.org/programs/mainstreaming_medical.html or (732)246-2525

Families of individuals with complex needs on Medicaid waivers need to know what options are available, and how to continue services, to get the best care for their child. 

 
Note:  This factsheet is current as of 7/1/14 - for updates please see http://www.state.nj.us/humanservices/dmahs/home/mltss.html