The State of New Jersey has not yet proposed new regulations covering the details of its NJ FamilyCare MLTSS Medicaid program. However, the details can be found by reading the Contract which must be signed by a participating Contractor to the program. The Contract is 118 pages long. It does cross-reference certain federal and state regulations. Of course, an applicant first has to become financially eligible, something I’ve written about elsewhere on this blog and on our website. However, the assessment of clinical eligibility is just as important a component, for without a PAS, the person will receive no MLTSS services at all.
The basic process is that someone contacts the Office of Community Choice Options (OCCO) on behalf of the applicant — it could be their family representative, it could be the nursing home administrator — to request a PAS (Pre-Application Screening). This process is conducted by a nurse or social worker who is certified by the State of New Jersey who visits the applicant and utilizes a tool called the NJ Choice Tool. The tool is an 8-page document containing subparts in which the applicant is given a score concerning many different aspects of their needs for assistance. These encompass everything from decision-making capability to issues such as gait instability, frequency of falls within the last 90 days, number of medications taken, hearing and vision, behavior disruptions, recent health crises, safety of the premises, awareness of safety problems, and so on. The ability of the person to perform Activities of Daily Living ADLs) with or without assistance is being measured. You would think that it would take a full hour to perform an adequate assessment. You would also expect that if the assessment is being done in a facility, that the assessor would look at the chart.
I believe that it is vital that an applicant have a designated person (friend, family or professional) to be at their side as their advocate from the start of the clinical assessment process. A person with memory impairment may provide wholly inaccurate self-reports about their daily needs (“I don’t take medication” “I do my own shopping” “I only need someone to do this or that for me.”). A person with no cognitive impairment, but who is laboring under the stress of an imminent hospital discharge or who is living in the community with a patchwork of inadequate services simply may be too overwhelmed to recall everything in answer to the many questions they’re being asked. The State Medicaid Manual already allows an applicant to have a relative serve as their “authorized representative,” see N.J.A.C. 10:71-2.5(c), and practice has evolved that have enabled applicants to sign a document that specifically appoints someone as their designated representative. In fact, the provider Contract includes provisions that enable an applicant or recipient to have their representatives included — such as when meetings are being conducted to discuss the actual PoC (Plan of Care) and any needed Risk Management Agreement.
The designated representative should coordinate the home visits, handle the phone calls, and be present during the assessment with relevant medical records and notes on a detailed recent history covering the issues that will be covered by the assessment. If the applicant is unreliable in answering the telephone for whatever reason, the representative can give their own phone number as the contact (at a certain point I had to do that with all of my mother’s doctor’s as her memory got unreliable). The goal is to have the applicant approved for the maximum amount of services available so as to best ensure safety and minimize the hazard of remaining at home. The representative’s loyalty is to the applicant, then, and can protect their interests. Then once the case is approved (PAS is issued), it is time to develop the Plan of Care.
The PoC is developed by the assigned Care Manager “with the Member and/or authorized representative, based on the Member’s assessed needs pursuant to program requirements. This shall include unmet needs, personal goals, risk factors, and Back-Up Plans.” (Contract, section 9.6.3.F). The Contract requires at section 9.6.3.A. that the Plan use a Person-Centered Approach, “taking into account not only covered services, but also formal and informal support services as applicable.” Once the Plan of Care is developed, it gets signed by the member and/or the representative. So it is clear that such a person can be involved at all levels to help the applicant.
Next time … more on services available for the Plan of Care.
Call for representation on Medicaid eligibility … 732-382-6070