Navigating the landscape of long-term care can be complex, especially when considering the crucial aspect of mental health services. Many individuals and families seek clarity on whether managed long-term care programs extend their coverage to include mental health support. In New Jersey, the answer is yes, through the Medicaid Managed Long Term Services and Supports (MLTSS) program. This program is specifically designed to deliver comprehensive long-term services, ensuring that mental health is an integral part of the care provided.
What is Managed Long Term Services and Supports (MLTSS)?
Managed Long Term Services and Supports (MLTSS) is New Jersey Medicaid’s initiative to provide long-term care services through its NJ FamilyCare managed care program. The core aim of MLTSS is to broaden the availability of home and community-based services, foster community engagement, and maintain high standards of care and operational efficiency. Instead of the traditional fee-for-service model, MLTSS utilizes NJ FamilyCare Managed Care Organizations (MCOs), also known as HMOs or health plans, to oversee and coordinate all aspects of care. This integrated approach ensures that individuals receive comprehensive support tailored to their needs, whether they are at home, in assisted living, within community residential settings, or in a nursing home.
What Services are Covered Under MLTSS?
MLTSS is designed to be comprehensive, covering a wide array of services to support individuals’ long-term care needs. Importantly, mental health and addiction services are explicitly included within the MLTSS coverage. Beyond mental health support, MLTSS encompasses:
- Access to all NJ FamilyCare Plan A Benefits, which forms the foundation of healthcare coverage.
- Care Management services to coordinate and personalize care plans.
- Home and Vehicle Modifications to enhance accessibility and safety at home.
- Home Delivered Meals to ensure nutritional needs are met.
- Respite care to provide temporary relief for caregivers.
- Personal Emergency Response Systems for immediate help in emergencies.
- Assisted Living services for those needing support in a residential setting.
- Community Residential Services offering care within community-based homes.
- Nursing Home Care for individuals requiring skilled nursing facilities.
This broad spectrum of services ensures that MLTSS participants receive holistic care, addressing both their physical and mental well-being. The inclusion of mental health services underscores the program’s commitment to treating the whole person, recognizing the vital role of mental health in overall health and quality of life.
MLTSS Coverage for Nursing Home Care
For individuals entering a nursing facility (NF) or special care nursing facility (SCNF) under NJ FamilyCare for the first time, MLTSS plays a crucial role in managing their care. Initially, NJ FamilyCare Managed Care Organizations (MCOs) handle their acute and primary healthcare needs, including short-term rehabilitation within the NF/SCNF, which is a standard NJ FamilyCare Plan A benefit.
Upon completion of rehabilitation, the MCO assesses the individual to determine if they meet MLTSS criteria. If long-term custodial care is needed, whether in a nursing facility or community setting, the MCO conducts a clinical assessment for MLTSS. The Division of Aging Services (DoAS) then makes the final determination on clinical eligibility. Individuals who are new to NJ FamilyCare Plan A and require NF/SCNF placement are directly referred to the DoAS Office of Community Options (OCCO) for an MLTSS clinical eligibility assessment. If approved for Medicaid both financially and clinically, enrollment in MLTSS and an MCO follows. It’s important to note that NF/SCNF residents receiving custodial care under Medicaid before July 1, 2014, remain in the NJ FamilyCare fee-for-service system for the duration of their stay.
Eligibility for MLTSS
Qualifying for MLTSS involves meeting specific Medicaid requirements, both financial and clinical.
Financial Requirements: These are based on monthly income and total liquid assets. Detailed information on Medicaid financial eligibility can be found here.
Clinical Requirements:
For individuals aged 21 and older, clinical eligibility is met if they require a Nursing Facility level of care. This is defined as 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 for three or more ADLs also meet the criteria.
For children from birth through age 20, clinical eligibility is determined by functional limitations related to developmental delays or limitations in age-appropriate ADLs. This includes children who need nursing care beyond routine parenting, requiring complex skilled nursing interventions 24/7. It also encompasses technology-dependent children needing medical or intense therapeutic services, relying on life-sustaining devices that necessitate continuous skilled nursing intervention. Notably, for children applying for MLTSS who meet Pediatric Clinical Eligibility as per the Comprehensive Waiver approved in August 2017, parental income and resources are not considered for financial eligibility determination.
Age and/or Disability Requirements: Applicants must be either 65 years or older, or under 65 and determined blind or disabled by the Social Security Administration or the State of New Jersey.
How to Apply for MLTSS
The application process for MLTSS differs slightly based on age:
For individuals aged 21 and older, the first step is to contact the local County Area Agency on Aging (AAA) – Aging and Disability Resource Connection (ADRC). They provide information on local services and resources and conduct the clinical screening for MLTSS.
For children from birth through 20 years old, contact the Division of Disabilities Services (DDS) at 1-888-285-3036 (press 2, then 1) to speak with an Information and Referral Specialist.
Additional Options: PACE Program
Another avenue to consider is the Program of All-Inclusive Care for the Elderly (PACE). Eligibility for PACE requires residence within a PACE provider service area. Currently, six PACE organizations serve parts of ten counties in New Jersey. More information about PACE can be found here.
For any further inquiries about MLTSS, you can Click Here to E-mail Questions about MLTSS.
In conclusion, New Jersey’s MLTSS program is a vital resource for individuals needing long-term care, and it definitively includes mental health services as part of its comprehensive coverage. By understanding the scope of MLTSS, eligibility criteria, and application processes, individuals and families can access the support they need to ensure both physical and mental well-being are addressed in their long-term care journey.
