New Jersey Medicaid (FamilyCare) Managed Long Term Services and Supports (MLTSS)

Last updated: June 02, 2021

 

Overview of the Managed Long Term Services and Supports Program

Via New Jersey’s Medicaid (NJ FamilyCare) Managed Long Term Services and Supports (MLTSS) Program, elderly New Jersey residents can receive medical, behavioral health, and nursing home care, as well as a variety of home and community based services (HCBS). Intended for those who require a nursing home level of care, HCBS allow program beneficiaries to reside in their own home, the home of a loved one, an adult family care home (adult foster care), a comprehensive personal care home, or an assisted living facility rather than be admitted to a nursing home.

The exact long term care benefits a program participant receives is specific to their needs and circumstances. As an example, a person who lives alone might receive home delivered meals, a personal emergency response system, and assistance with personal care tasks and housekeeping to promote independent living. On the other hand, an individual who lives with an informal family caregiver might be eligible for adult day health care and respite care to supplement the care already being provided.

MLTSS program participants receive their long-term care benefits (and other benefits) via a single Medicaid (NJ FamilyCare) health plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. MLTSS program participants have several long-term care managed care health plans from which to choose.

There is some flexibility of providers for persons receiving care services via the MLTSS Program, as some benefits, such as home-based supportive care (chore services, light housecleaning, laundry, etc.), may be participant directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. Relatives, including spouses and adult children, can be hired. A financial management services agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.

The MLTSS Program is an entitlement program. This means meeting eligibility requirements equates to immediate receipt of program benefits. Put differently, the program does not limit the number of participant enrollment slots and there is not a waitlist for program participation.

NJ’s Managed Long Term Services and Supports Program operates under the New Jersey Comprehensive Waiver (NJCW), which is a 1115 demonstration waiver through which managed care is provided. NJCW was previously called the New Jersey Comprehensive Waiver. MLTSS operates under this waiver. Furthermore, several Medicaid Waiver programs were consolidated into MLTSS and includes Global Options for Long Term Care (GO), Community Resources for People with Disabilities (CRPD), the Traumatic Brain Injury Waiver (TBI), and the AIDS Community Care Alternatives Program (ACCAP). Medicaid in New Jersey is called NJ FamilyCare and programs specific to seniors and disabled individuals are called Aged, Blind, Disabled Programs.

 What is Medicaid Managed Care?
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.

 

Benefits of the Managed Long Term Services and Supports Program

In addition to medical benefits, such as doctor’s appointments, laboratory services, x-rays, and hospitalization, and behavioral health benefits, a variety of home and community based services are available via MLTSS. An individual care plan will determine which services and supports a program participant will receive.

– Adult Day Care – non-medical daytime care and supervision in a community group setting
– Adult Family Care / Adult Foster Care – personal care assistance, supervision, housekeeping, laundry, meals, etc. for up to 3 unrelated persons in a caregiver’s home
– Assisted Living Program – assisted living services (see below) in specific subsidized housing buildings
– Assisted Living Services – personal care assistance, health services, medication oversight / administration in an assisted living residence or a comprehensive personal care home
– Care Management
– Chore Services – window washing, snow / ice removal, replacing door locks, changing light bulbs, etc.
– Community Residential Services – in-home personal care assistance, chore services, nighttime supervision, etc.
– Community Transition Services – covered one-time expenses to assist with transitioning from a nursing to community living (i.e., security deposit, utility deposits, essential home furnishings, etc.)
– Home Modifications – for safety and accessibility (i.e., grab bars, wheelchair ramps, and widening doorways)
– Home-Based Supportive Care – assistance with housecleaning, laundry, shopping for groceries, preparing meals, etc.
– Home Meal Delivery – refrigerated / frozen meals
– Nursing Facility Care
– Medication Dispensing Device
– Non-Medical Transportation
– Personal Emergency Response Systems (PERS)
– Private Duty Nursing
– Respite Care – in-home and out-of-home short-term care to alleviate a primary caregiver
– Skills Training – for program participants / caregivers to promote independent living
– Vehicle Modifications – for safety and accessibility (i.e., mechanical life and electronic monitoring system)

While program participants can reside in an adult family care home, comprehensive personal care home, or an assisted living facility, MLTSS does not cover the cost of room and board.

 

Eligibility Requirements for Managed Long Term Services and Supports Program

 The American Council on Aging provides a quick and easy NJ Medicaid eligibility test for seniors. Start here

The MLTSS Program is for New Jersey residents of all ages who meet the eligibility criteria. However, the criteria below is specific for persons who are Aged (65+ years old), Blind, and Disabled (ABD).

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. There is a minimum income allowance, set at $2,155 / month (effective July 2020 – June 2021), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.

  Another program through which New Jersey seniors can receive their Medicaid (NJ FamilyCare) Long Term Services and Supports is PACE (Program of All-Inclusive Care for the Elderly). While most program participants are “dual eligible”, this is not a requirement. “Dual eligible” means eligible for both Medicaid and Medicare.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a New Jersey Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $906,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a minor, blind, or disabled child living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the MLTSS Program, this means an applicant must require hands on assistance with at least three activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, bathing, dressing). Cognitive deficits, which are common in persons with Alzheimer’s Disease or a related dementia, are also taken into account. If cognitive deficits are present, hands on assistance is not required. Instead, supervision and prompting with a minimum of three activities of daily living, will meet the NFLOC requirement. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC

 For more information about long-term care Medicaid in New Jersey, click here.

 

Qualifying When Over the Limits

Having income and / or assets over NJ FamilyCare’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on medical bills, household furnishings and appliances, or even a vacation. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of New Jersey to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program, preserving them for family as inheritance. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, such as the Modern Half a Loaf Strategy, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the Managed Long Term Services and Supports Program

Before You Apply

Prior to applying for the MLTSS Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To enroll in the MLTSS Program, persons must be eligible and enrolled in Medicaid (NJ FamilyCare). An application for the NJ FamilyCare Aged, Blind, Disabled Program can be downloaded here. To apply and request a functional assessment for MLTSS, one should contact their local County Board of Social Services office. Contact information can be found here. Alternatively, one can contact their local Area Agency on Aging (AAA) / Aging and Disability Resource Connection (ADRC). County specific information can be found here.

Those already enrolled in NJ FamilyCare, should contact their MCO to request a functional assessment for MLTSS. A list of current MCO’s / NJ FamilyCare Health Plans can be found here.

Additional information about the Medicaid Managed Long Term Services and Supports Program can be found here. Persons can also contact NJ FamilyCare at 1-800-701-0710.

The State of New Jersey’s Department of Human Services’ (DHS) Division of Medical Assistance & Health Services (DMAHS) administers the MLTSS Program. The local County Boards of Social Services determines financial eligibility, and the Division of Aging Services (DoAS) determines functional / medical eligibility.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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