1. WELLCARE HEALTH PLANS OF NEW JERSEY, INC.
Managed Long Term Services and Supports(MLTSS)
June 8, 2015
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2. WELLCARE HEALTH PLANS OF NEW JERSEY, INC. COMPANY OVERVIEW
WellCare Health Plans of NJ, Inc. is a State of New Jersey domiciled health maintenance organization (“HMO”) and is a wholly-owned, indirect subsidiary of WellCare Health Plans, Inc. (“WellCare”) WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind, and disabled, as well as prescription drug plans. The company serves approximately 4 million members nationwide as of Sept. 30, 2014

3. New Jersey Medicaid Presence
New Jersey Presence: June2015
1140 MLTSS Program Recipients
Effective July 1, 2014, we completed the acquisition of Medicaid assets from HealthFirst Health Plan of New Jersey, Inc. ("HealthFirst NJ").
The acquired assets primarily include approximately 42,000 Healthfirst Medicaid members, who were transferred to our Medicaid plan, as well as certain provider agreements.

4. WellCare’s Network Management
New Jersey Provider Network: April 2015
1,971 Adult PCPs
1,368 Pediatric Primary Care Providers
22 Hospitals (Medicaid- Medicare)
12,751 Specialist
511 MLTSS Specialty Providers * across all specialties

5. WellCare of New Jersey – Expansion
WellCare current service area
WellCare phase 3 expansion
Go live date: 7/15
WellCare phase 4 expansion
Go live date: 9/15
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6. The MLTSS Program
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7. WellCare Care Management Program Model
Managed Long Term Services and Supports (MLTSS)- A program within the MCO providing services to Medicaid eligible individuals with substantial functional limitations due to chronic physical or cognitive limitations. MLTSS services are generally provided in lieu of nursing facility care allowing individuals to be served in the least restrictive and generally preferred community setting.
The Care Management Team uses tools including the New Jersey Choice assessment tool and the PCA assessment tool to identify members at risk for inappropriate or unnecessary nursing facility admission. Potential members may also be identified through referral sources such as State agencies, self-referrals, and through network providers.
Once enrolled, Care Managers work with MLTSS members to provide an integrated program emphasizing physical and behavioral health and long-term supports to maximize services and optimize outcomes.
Staffing for care management follows ratios as outlined below:
Nursing facility and non-pediatric special care nursing facility – 1:240
HCBS members residing in an alternative community setting – 1:120
Members receiving Home and Community Based Services – 1:60
Members receiving services in Special Care Nursing Facility – 1:48

8. WellCare’s Integrated Care Model
Members
&
Caregivers
Primary Care
Specialists
Case Management
Mental Health
Pharmacy Management
Disease Management
Home and Community-based Care
Therapy
Transportation
Optical
Community-Based Social Services
Integrated Care Management and Coordination of Care can:
• Enhance quality of life for members and family caregivers • Provide value to state customers and members
• Significantly decrease inpatient readmissions • Reduce over-utilization across multiple segments
• Reduce non-emergency ground transportation costs • Reduce inpatient bed days

9. Services Unique to MLTSS
Managed Long Term Services and Supports (MLTSS) includes:
Personal Care;
Respite;
Care Management;
Home and Vehicle Modifications;
Home Delivered Meals;
Personal Emergency Response Systems;
Mental Health and Addiction Services;
Assisted Living;
Community Residential Services;
Nursing Home Care.

10. MLTSS Care Management Program
Staffing- 28 Fulltime Care Managers serving 1143 members
RNs, LCSWs, Behavioral Health staff
7 care coordinators
Breakdown of membership
954 reside in home or community based settings
189 reside in nursing facilities
Initial census on transition was 635
2 residing in nursing facilities

11. How is Nursing Home covered under MLTSS ?
Any individuals with NJ FamilyCare entering a nursing home for the first time will have their acute and primary health care managed by the NJ FamilyCare MCOs with MLTSS
Individuals on MLTSS also will have his/her acute and primary health care services and nursing home care managed by a NJ FamilyCare MCO.
Any individual who is newly eligible for NJ FamilyCare and living in a nursing home after July 1, 2014 will have his/her care managed by a NJ FamilyCare MCO through the MLTSS program.
Nursing home residents who were considered in custodial care on Medicaid as of July 1, 2014 will remain in a fee-for-service environment. Medicaid beneficiaries living in Special Care Nursing Facilities (SCNFs) as of July 1, 2014 will remain in the fee-for-service environment for two years. 

12. Custodial Authorization Process
Effective June 2, 2014 the “30 day rule” for conversion to FFS Medicaid no longer applies and all members enrolled in WellCare Health Plans, Inc. for NJ Family care entering a nursing facility after the above date will remain as Wellcare enrollees.
Members entering nursing facility for rehabilitation services, will become eligible for a custodial authorization through WellCare if:
Member has exhausted their skilled nursing benefit through their primary coverage.
Is unable to be discharged to their former residence and/or the member expresses a desire for transition into the community
Custodial authorization will trigger need for a NJ Choice assessment in order to determine MLTSS eligibility .
WellCare NJ Health Services will conduct NJ Choice Assessment and submit to the Office of Community Choice Options for authorization for MLTSS

13. Custodial Authorization Process
Clinical Information Needed: (Please include with authorization request form.) 1. Copy and date of most recent PASSR I, if positive, include copy of PASSR II 2. Last date of covered skilled services, primary/other payer and/or copy of Medicare NOMNC 3. Last four weeks of clinical documentation (Nursing/rehab notes, medication list, history and physical exam, and discharge summary showing proof that member has reached rehab/skilled nursing potential) Please note custodial authorization will NOT be issued until documentation has been received. Authorization will be granted for 60 days upon review of documentation submitted, until NJ Choice Assessment has been completed and reviewed by the Office of Community Choice Options (OCCO). A maintenance authorization will be granted for six months upon approval and as member meets medical and eligibility criteria.

14. Nursing Facility Placement Transitions and Diversion
Short term nursing facility stays are available for MLTSS Members receiving HCBS who require temporary placement in a nursing facility due to temporary illness, serious injury, wound care, or the absence of the primary caregiver and there is a reasonable expectation that the member will be discharged back to the community within 100 days.
Prior to a NF admission, the Contractor shall confirm that a PASRR Level I, and if indicated, a PASRR Level II has been completed.
The Care Manager shall review the plan of care developed by the facility, and supplement the facility plan of care as necessary with the development and implementation of targeted strategies to improve health, functional, or quality of life outcomes or to increase and/or maintain functional abilities.
A copy of the facility plan of care and any supplements shall be maintained by the Contractor in the Member’s electronic Care Management record.

15. MLTSS Care Management and the Nursing Facility
Plan of Care for Institutional and Community Alternative Residential Settings (CARS) (9.6.4 R NJ Medicaid HMO Contract)
The Care Manager shall review the plan of care developed by the facility; and supplement the facility plan of care as necessary with the development and implementation of targeted strategies to improve health, functional, or quality of life outcomes or to increase and/or maintain functional abilities. A copy of the facility plan of care and any supplements shall be maintained by the Contractor in the Member’s electronic Care Management record.
The Care Manager shall participate in a minimum of two (2) IDT meetings per year in the nursing facility’s care planning process and advocate for the Member.
The Care Manager shall be responsible for coordination of the Member’s physical health, behavioral health, and long term care needs. This shall include coordination with the nursing facility as necessary to facilitate access to physical health and/or behavioral health services needed by the Member and to help ensure the proper management of the Member’s acute and/or chronic physical health or behavioral health conditions, including services covered by the Contractor that are beyond the scope of the nursing facility services benefit.

16. Community Transition/Money Follows the person
Money Follows the Person (MFP) - Community Transition Services
 Community Transition Services are provided to identified members to assist in transitioning from an institutional setting to a home setting in the community through coverage of non-recurring, one-time expenses.
This service is provided to support the health, safety and welfare of the member in the least restrictive environment and to meet both their physical and psychosocial needs. Allowable expenses are those necessary to enable a person to establish a basic household but do not constitute room and board.
A program supervisor within the care management department will serve as the MFP Liaison to act as the primary point of contact between the Health Plan, OCCO and the nursing facility.
Responsibilities in the liaison role include ongoing identification of members who may be eligible for community transition through participation in case conferencing with care managers and facility interdisciplinary team meetings.
The MFP liaison will ensure a smooth transition from facility based care to home and community based care through coordination of both needed services to establish the new residence and the ongoing supports to meet ADL/IADL and quality of life needs. Once the member has transitioned home the MFP liaison will compile the necessary statistical data to meet the requirements for ongoing tracking and reporting of member outcomes.
WellCare’s MFP Liaison is Lissette Verde
22 members successfully transitioned to date
5 additional members in progress

19. Patient Payment Liability (PPL)
For individuals who are placed in a nursing facility, the Care Manager shall discuss any potential Patient Pay responsibility the Member may incur. The Patient Payment Liability for Cost of Care is that portion of the cost of care that NF residents must pay based on their Available Income as determined and communicated by the CWA.
The State shall notify the Contractor of any applicable patient payment liability amounts via the 834 eligibility/enrollment file.
The Contractor shall delegate collection of the patient payment liability for the cost of care to the NF/SCNF provider.
The Contractor shall pay the NF/SCNF net of the applicable patient payment liability amount.

20. WellCare QI Department
Critical Incidents
Critical Incident--an occurrence involving the care, supervision, or actions involving a Member that is adverse in nature or has the potential to have an adverse impact on the health, safety, and welfare of the Member or others.
Critical incidents also include situations occurring with staff or individuals or affecting the operations of a facility/institution/school.
WellCare QI Department
1/13/2015

21. Critical Incident List These Must Be Reported Immediately
Suspected or evidenced physical or mental Abuse, (including seclusion and restraints, both physical and chemical);
Sexual abuse and/or suspected sexual abuse;
Neglect/Mistreatment, including self-neglect, caregiver overwhelmed, environmental;
Theft with law enforcement involvement;
Exploitation, including financial, theft, destruction of property;
WellCare QI Department
1/13/2015

22. Critical Incident List These Must Be Reported Within 24 Hours
Unexpected death of a member;
Severe injury or fall resulting in the need for medical treatment;
Medication error resulting in serious consequences;
Medical or psychiatric emergency, including suicide attempt;
Inappropriate or unprofessional conduct by a provider/agency involving the member;
WellCare QI Department
1/13/2015

23. Critical Incident List These Must Be Reported Within 24 Hours
Elopement/wandering from home or facility;
Missing person or Unable to Contact;
Facility closure, with direct impact to member’s health and welfare;
Natural disaster, with direct impact to member’s health and welfare;
The potential for media involvement;
WellCare QI Department
1/13/2015

24. Critical Incidents WellCare Policy
NJ23 QI-066 – Critical Incident Reporting
Critical Incidents include but are not be limited to the following incidents when they occur in:
Hospital/Nursing Facility/Skilled Care Nursing Facilities or
Home and Community-based long-term care service delivery settings and provider offices
Community Alternative residential settings
Adult Day Care Centers
Member’s Home
WellCare QI Department
1/13/2015

25. WellCare Responsibilities
WellCare staff that become aware of a Critical Incident (CI) will immediately ensure the safety of the member and notify appropriate agencies:
Police/911
Adult Protective Services (APS)
Dept. of Children and Families (DCF)
Office of the Ombudsman Institutionalized Elderly (OOIE)
Department of Health (DOH)
Division of Disability Services (DDS)
Division of Aging Services (DoAS)
WellCare QI Department
1/13/2015

26. Associate Responsibilities
The WellCare staff person will also notify:
Agency/Service Provider (if appropriate)
MLTSS management: Marion Smayda or Marjorie Forgang
QI Department: Rosemarie Stern and Mary Dunn via
Document the CI in EMMA using the Case Note type RQU
Care Managers will document the CI in Acute Net
Important: If the event involves a health and safety issue, arrangements must be made for alternate services/placement and must be documented in EMMA
WellCare QI Department
1/13/2015

27. Member Medicaid ID Number Date of Occurrence
Critical Incident
Information Needed for Reporting
Member Medicaid ID Number
Date of Occurrence
Date WellCare became aware of the incident
Type of Incident
Setting
Provider
Short description of the incident
Short description of the immediate actions taken to protect/halt or ameliorate the harm to the member
Short description of any underlying circumstances
Date incident investigation was completed
WellCare QI Department
1/13/2015

28. 855-642-6185 RN available 24 hours/day 7 days/week 365days/year
Program Contact
RN available 24 hours/day 7 days/week 365days/year

29. RESOURCES
Forms and Documents: newjersey.wellcare.com/provider/forms Quick Reference Quick Reference Guides: newjersey.wellcare.com/provider/resources Clinical Practice Guidelines: Clinical Coverage Guidelines: WellCare Companion Guide: newjersey.wellcare.com/provider/claimsupdates Provider Training : newjersey.wellcare.com/Provider/ProviderTraining MLTSS Provider Communications: MLTSS Provider Frequently Asked Questions (FAQs): The Comprehensive Medicaid Waiver:
The MFFS approach would begin in January 2013 and would provide integrated care coordination through Health Homes to dual eligibles that have two or more chronic conditions, HIV/AIDS and/or one mental health illness and do not require 120 or more days of long-term supports and services (LTSS). The MFFS dual program will facilitate access to and transition their members in need of long term care services greater than 120 days to MLTC (where available) or fee-for-service long term care providers.
The Capitated approach would begin in January 2014, would be called FIDA, the Fully-Integrated Duals Advantage program, and would provide a comprehensive package of services to dual eligibles in the eight NY counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester that require more than 120 days of long-term supports and services (LTSS). The primary FIDA approach would exclude individuals who receive services from OPWDD. An additional, small-scale “FIDA OPWDD” capitated approach will provide managed care to a portion of the dual population that has intellectual and developmental disabilities.