If given a choice, how many people would choose to live in a nursing home over their own home in their later lives? Not many. But for decades, New Jersey and other states’ Medicaid programs had close to three-quarters of individuals — seniors and people with disabilities — living in nursing homes rather than supporting them in their homes and communities. This is no longer the case in New Jersey.
New Jersey enacted a law in 2006, the Independence, Dignity and Choice in Long Term Care Act, which charged the state with expanding public expenditures for long-term services and supports by offering a larger array of home and community-based services (HCBS). The Act fostered greater consumer choice to facilitate maximum flexibility between HCBS and nursing-facility care. But over the following six years, the percentage of individuals receiving HCBS increased by only a percent or two a year.
The question continued to be how to “rebalance” or shift the balance from institutional care to HCBS, improve health outcomes for seniors and people with disabilities, increase access to services and provide the state with budget predictability for its Long Term Services and Supports (LTSS). New Jersey decided to move to Managed Long Term Services and Supports (MLTSS) through a waiver program approved by the federal government. According to research performed by the Center for Health Care Strategies (CHCS) and the National Association of States United for Aging and Disabilities (NASUAD), New Jersey is one of 19 states in 2017 which were operating MLTSS. There are also a number of states which are planning or just beginning to implement MLTSS, including Pennsylvania and Ohio.
Due to the unique nature of states’ Medicaid programs, each state has developed its own way of supporting seniors and people with disabilities. In New Jersey it was decided to fully integrate MLTSS with its long standing managed-care physical health program. Since the early 1990s New Jersey had a managed-care program for most NJFamilyCare beneficiaries and by the late 1990s to early 2000s, seniors and people with disabilities also received their physical health through Medicaid managed care. In 2012, an intensive planning process began for MLTSS with significant input from the people served, caregivers, providers and advocates. In July 2014, New Jersey integrated long-term services and supports and behavioral and physical healthcare for seniors and people with disabilities.
Because of MLTSS, New Jersey has significantly shifted the balance of the population receiving long-term supports and services (LTSS) from nursing homes to home and community-based services (HCBS). According to the most recent data presented to the Medical Assistance Advisory Committee, as of April 2018, 49.4 percent of individuals receiving LTSS received HCBS. In July 2014, when MLTSS first was first implemented only 29.4 percent of individuals received HCBS. The number of individuals residing in nursing homes has decreased since July 2014 by over 1,300. Based upon the trends (about a 0.5 percent increase in the month prior to April), at least 50 percent of individuals receiving LTSS were receiving services in the home and community by July 2018, the fourth year of the program. In addition, the number of MLTSS recipients using behavioral health increased from 55 when the program began in July 2014 to 1,089 recipients in April 2018.
New Jersey included multiple ways to evaluate the program, including creating process and outcome measurements reported by the Managed Care Organizations (MCOs). The Rutgers Center for State Health Policy (CSHP) was engaged by the state to evaluate the Medicaid Comprehensive Waiver, which included MLTSS. The initial CHSP evaluation was published in July 2016, two years after the implementation of MLTSS. Quality metrics for MLTSS included the first six months of MLTSS implementation and the MCO performance and process measurements cover more of the post-MLTSS implementation up through March 2016.
In addition to the CHSP evaluation, New Jersey chose to participate in the National Core Indicators-Aging and Disability (NCI-AD™) initiative, a joint project between NASUAD and the Human Services Research Institute (HSRI). NCI-AD’s primary aim is to collect and maintain valid and reliable data that give states a broad view of how publicly-funded services impact the quality of life and outcomes of service recipients. The measures include consumer outcomes such as community participation, choice and decision-making, safety and wellness, rights and respect, and service and care coordination. New Jersey first partnered with NCI-AD in 2015-2016 and then again in 2016-2017. In 2016-2017, over 900 residents were surveyed who had received services for a minimum of six months from MLTSS, Programs for All inclusive Care for the Elderly and Older Americans Act programs. The sample size allows individuals to review and measure results between each of the five Managed Care Organizations in MLTSS. The initial CSHP report as well as the two NCI-AD reports show that MLTSS has been beneficial for individuals and that there are areas in need of improvement.
As with any major systems reform, there have been issues needing to be resolved due to the reform. Claims payments for providers have not always been as timely as either the state or providers would want. Through partnership between providers, the MCOs and state these claims reimbursement issues continue to be resolved.
Ensuring that providers serving people who are dually eligible for both Medicare and Medicaid receive the necessary benefits from Medicare was and still may be a significant problem. The integration between Medicare and Medicaid is a national issue which many in New Jersey and other states are working to resolve with the federal government. Programs for Inclusive Care for the Elderly (PACE), which were initially planned to be eliminated when the state moved to MLTSS, are growing from four PACE programs to six, with 1,025 individuals being served by these programs, a 20 percent increase from when MLTSS was implemented. PACE provides comprehensive medical and social services to frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid. MLTSS was not intended to fix some decades-old issues such as delays in Medicaid eligibility for Aged, Blind and Disabled due to the federally mandated five year look back. In order to resolve that issue, NJ Medicaid, in July 2016, contracted with an electronic Asset Verification System to detect and verify bank accounts based on identifiers. This new system will hopefully resolve a longstanding issue which has been a concern of nursing homes.
After years of serving a large proportion of individuals needing Long Term Services in nursing homes, New Jersey now has a balance in where and how individuals are receiving these services. This type of systems reform needs the partnership of consumers, caregivers, providers, advocates and MCOs. New Jersey should be proud of this change and should continue to evaluate and improve upon this new system.