Recently, the state of New Jersey changed the manner in which Medicaid services are delivered to its residents. New Jersey switched to a method of delivering services to Medicaid beneficiaries known as Medicaid Managed Long Term Services and Support. Because the phrase Medicaid Managed Long Term Services and Support is such an unwieldy name, most people who work with the program simply call it MLTSS.
Medicaid is a federal and state health insurance program for needy individuals. Unlike most health insurance programs, Medicaid will pay for long-term care costs, such as care in a nursing home or an assisted living residence.
The federal agency responsible for administering the Medicaid program describes MLTSS as follows:
“Managed Long Term Services and Supports (MLTSS) refers to the delivery of long term services and supports through capitated Medicaid managed care programs. Increasing numbers of States are using MLTSS as a strategy for expanding home- and community-based services, promoting community inclusion, ensuring quality and increasing efficiency. The number of States with MLTSS programs increased from 8 in 2004 to 16 in 2012, and CMS has experienced increasing interest from States in the form of concept papers, waiver applications and requests for technical assistance.”
In order to qualify for Medicaid services, an individual must have a very limited amount of countable resources and insufficient income to pay for his care. Various techniques exist for qualifying a person who would not otherwise qualify for benefits, and elder law attorneys assist people with these techniques. This practice is commonly known as Medicaid planning.
In my opinion, MLTSS will benefit the needy citizens of New Jersey; however, I also think MLTSS will cause many bumps in the road to the delivery of Medicaid benefits and many more individuals may require the assistance of an attorney in order to ensure that they receive the appropriate level of services.
For instance, Medicaid will pay for long-term care services at home, such as the services of a home health aide. Before the implementation of MLTSS, a person living at home who qualified for benefits would receive approximately four to five hours of services from a home health aide on a daily basis. After MLTSS, what services this person will receive are very much up for grabs.
Because MLTSS is a managed system, the insurance administrator has an incentive to cut services that are delivered to a Medicaid beneficiary because the insurance company makes more money for itself by cutting services to beneficiaries. The more efficient the management company, the better they are perceived to be, but efficient is really just a euphemism for a reduction of services.
The managed system of MLTSS opens up a new need for advocacy on the part of elder law attorneys. For instance, I work with physicians and social workers who can be called upon to assess a person’s needs and, when appropriate, appeal the decision of the MLTSS as to the services it is willing to provide to a Medicaid beneficiary. I believe that when challenged, an opportunity exists to expand substantially the services being provided to Medicaid beneficiaries.
Staying compliant with Medicaid rules involves more than qualifying once. Ongoing management helps prevent disruptions in coverage and care.
Medicaid planning does not end once benefits are approved. Changes in income, assets, living arrangements, and care needs can all affect continued eligibility. Understanding those responsibilities can help families avoid unnecessary interruptions in benefits.