Applicants need an advocate during Clinical Assessment for NJ Medicaid Services

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


Applying for NJ MLTSS? Here are the acronyms you need to know

You probably know by now that NJ Medicaid’s Home and Community Based Services are now being administered NJ FamilyCare and that the State’s Comprehensive Medicaid Waiver has created a whole new landscape that is centered around managed care. When applying for these services you will encounter a lot of code words. For example, when your low-income or low-asset loved one is being discharged from the hospital, you might be told  that “as soon as he’s eligible financially for MLTSS, you need to contact the ADRC, request a referral to OCCO for a PAS, then file an application at the CWA and then if they meet LOC, you’ll  receive a PoC that includes HBSC and PCA, but you could choose the PPP instead, and you’ll have to sign off on the PoP and select an MCO.”  Aagh!  So  I thought I’d help out by listing them here:

DHS – NJ Department of Human Services

DAS – Division of Aging Services

DMAHS – Division of Medical Assistance and Health Services (administers NJ Family Care)

ADRC – Aging & Disabiality Resource Connection – or AAA – Area Agency on Aging  ( a county-based portal of entry for people seeking referrals for governmental programs)

DDS – Division of Disability Services (makes clinical determinations)

CWA – County Welfare Agency, sometimes called a Board or Division of Social Services (this is where the Medicaid application is filed and processed)

OCCO – Office of Community Choice Options (sends out the person to perform the clinical PAS, and decides whether to issue the PAS)

PAS – Pre-Admission Screening (required to establish clinical eligibility for Medicaid services)

LOC – Level of Care ( as in “she does not meet the level of care to receive services”)

HCBS – Home and Community Based Services (its an umbrella for many waiver services)

LTC – Long Term Care (nursing home care)

TBI – Traumatic Brain Injury Program ( a waiver program)

GO – Global Options (an older HCBS program waiver program under secn. 1915(c))

MFP – Money follows the Person, ( a federal mandate for funds to follow a person who is leaving a nursing home and going back to the community with services)

MCO – Managed Care Organization (all new Medicaid  recipients must select an MCO to manage their care)

PoC – Plan of Care (must be developed by the Care Manager from the MCO before services are started)

There are a variety of types of services that can be incorporated into a PoC. These include HBSC – Home-Based Supportive Care (non-medical, such as help with chores); PCA – Personal Care Assistant; PERS – personal Emergency Response System (phone button or necklace); PDN  – Private Duty Nursing (required for specific medical needs, up to 16 hours per day);

PPP – Personal Preference Program (Medicaid recipient becomes the employer and controls the terms and conditions of employment of their caregiving team)

IDT – Interdisciplinary Team review (done to assess costs and risks of the PoC)

ACT – Annual Cost Threshold (all services in the PoC are measured in comparison to this per-person capitation rate)


Next time … thoughts on the level-of-care assessment process.

Call us for legal advice on Medicaid eligibility …  732-382-6070


Understanding Alzheimers Disease and Creating a safe environment for aging

I just came across a great article in the Journal of Family Practice (January 2015) by Marisa Mendola PhD and Barry D. Weiss, MD, called “Addressing Alzheimers: A pragmatic approach.”       JFP_06401_Article1   The article is, of course, addressed to physicians who may be noticing signs of cognitive impairment in their patients or who have been alerted that “there seems to be something going on,” “something’s changing,” “he is getting confused.”The article has lots of practical advice that can be useful for non-physicians as well.

I have observed over the years in my clients that the progression of the disease may be slow at first and can then periodically seem to speed up. A person with Alzheimer’s (called “AD” in the article) may withdraw or may make jokes in ways that could seem to mask the deeper degree of genuine confusion that is present. They may remain capable in certain simple domains of daily living but become unable to make decisions when faced with multiple choices, or may become unable to remember new information. Along with getting a good assessment of what may be going on, the caring family members need to start dealing with the impact of this disease on the person’s ability to safely manage their daily life.

The broad issues can be sorted into medical, legal, residential and social. From the legal standpoint, once it is apparent that dementia is developing, it is crucial to make sure that the patient appoints a health care representative (called a “proxy” or “agent”) before it’s too late. The “proxy” will be authorized to make the medical decisions when the person is no longer capable. Similarly, it is crucial that there be a financial surrogate, whether that be an agent under power of attorney, or the trustee of a revocable living trust. This person would manage the assets, sign contracts, pay the bills, file the tax returns, pursue any necessary lawsuits, hire and fire caregivers, and so on. See my previous posts about these planning arrangements. If there’s no Will, the patient needs to meet with his or her attorney and get one in place, again before it’s too late to make the decisions and understand what they are signing. I have had so many clients with early stage dementia who told me that now they felt more secure, knowing they had put a plan in place.

On the home front, once a diagnosis of dementia or Alzheimer’s has been made, it will probably be necessary to increase the frequency of visits by family members in order to really stay aware of how things are changing and make sure the home is cared for. Is the mail piling up? Is the checkbook being overdrawn? Is the laundry being done? Is the house clean? Is spoiled food being thrown out? Is mom eating regularly? Family meetings may be needed. The person with dementia may be losing their ability to cope with pain or recognize symptoms of a medical problem. There may be disagreements among the family members about the scope of the problem. But safety first has to be the prime consideration.

You need to look at the home from the vantage point of whether a person with some confusion will be at risk of falls. Injury caused by falling is one of the major causes of people having to leave the comfort of their homes before they want to.You may need to get a companion in the home at a time that your loved one feels they need no help. These are delicate issues, but I like to say that we respect our elders by arranging for their care and safety. Keeping out of the way so that your loved one with dementia can “stay independent” for the sake of independence can result in compromised safety or even financial loss. A person with dementia can easily be preyed on and send money to strangers without understanding why.  As these problems start to develop, a person with dementia needs their family to step up to the plate and do what’s needed to preserve their safety and quality of life.

When I needed to step in to help my mother overcome her own reluctance to accept the need for home care, and to stop driving, and to have someone  go with her to every doctor’s appointment, and someone to oversee all of her medication,  she was very mad at me. “Linda, I feel that I am being managed,” she said. To which I replied, “You are, Mom, because I worry about you and I love you and you raised me to be here.” She was still mad, but she did get over it.

Call us for advice on developing your elder care plan and for estate planning … 732-382-6070



State of NJ issues MedCom to Medicaid Supervisors on use of Qualified Income trusts (QITs)

On December 19th, 2014, the NJ Division of Medical Assistance and Health Services (DMAHS) issued Medicaid Communication No. 14-15  to the County Welfare (CWA) Directors, explaining the necessity for certain higher-income Medicaid applicants to divert their excess income into a Qualified Income Trust (QIT) before they can apply for MLTSS Medicaid services to pay for nursing home, assisted living or community care. I’ve blogged about this previously – check my October and November posts. According to the Med-Com at page 1, the purpose of the QIT is “to disregard an individual’s income above 300% of the Federal Benefit Rate (FBR). In order for [it] to be disregarded, it must be deposited into the QIT bank account.”  Here is the pdf:


In 2015, if the monthly income is in excess of $2,199.00, it has to be diverted through a QIT.

Keep in mind that the Trust has to be set up before the date you want eligibility for. So you may need a few months to finish up the Medicaid “spend-down” and to set up this Trust at the bank. Many banks are still not familiar with this structure. Once the application is filed, and the CWA caseworker determines that there is eligibility, s/he will prepare a Medicaid Patient Responsibility (PR) form to be used by the Trustee as the guide for the monthly allocation of the income for the Medicaid recipient’s required expenses.The income has to be spent in this order each month: (1) Personal Needs Allowance or home maintenance allowance, (2) Spousal and family member maintenance allowance (calculated by the CWA based on the regulations), (3) unreimbursed state-approved medical expenses, (4) health insurance premiums, and (5) the mandatory cost share to the facility.

At ever step of the way there can be legal disputes that arise based on how the regulations apply to your particular case. Call us for advice and representation with Medicaid applications, MLTSS and QIT’s … 732-382-6070.

The 1.7% COLA increase in Social Security will be disregarded by SSI

Some people who are disabled receive a modest amount of Social Security Disability benefits and also receive Supplemental Security income (SSI). To be eligible for SSI, the total countable income in a given month must not exceed certain amounts that are set annually. If one receives at least a dollar of SSI, s/he can receive Medicaid for health insurance.

Effective January 1, 2015, the Social Security Administration gave a 1.7% increase in monthly benefit as a COLA (cost of living adjustment) . This increased income could put a person “over the top” and cause them to have income in excess of the limits for SSI. That could mean they’d lose their Medicaid benefit as well.

The State of New Jersey issued  MedCom No. 15-01 (Medicaid Communication memo) on January 13th, 2015 which clarifies that such individuals will NOT lose their eligibility and the excess income due to a COLA increase is to be disregarded when determining continuing as well as initial eligibility. 15-01_SSI_Ineligibles_COLA_2015

This class of individuals is sometimes referred  to as “Pickle People” because the original federal law protecting them from the unintended loss of SSI by a COLA increase in Social Security was an amendment sponsored by U.S. COngressman J.J. Pickle (D-Texas).

This issue is of particular importance to people with special needs disabilities who participate in DDD programs and receive Social Security Disability benefits based on the earnings record of their retired or deceased parent along with their own SSI. Loss of SSI would otherwise result in loss of Medicaid and loss of eligibility for DDD services.

Turned down for SSI or Social Security Disability? Call us to discuss an appeal …