New Jersey Takes Action to Modify Medicaid Program for COVID-19


New Jersey’s Medicaid program normally has a lot of rules and red tape.  Some of the rules relate to who meets the level of care for Long Term Services and Supports (LTSS) and some relate to financial eligibility.  All of these rules require travel and manpower to implement that may not be available during this pandemic emergency.
Federal Medicaid law has a type of waiver of Medicaid rules for emergencies, like COVID-19, or before that, Superstorm Sandy.  These are called 1135 waivers, and they can be obtained much more quickly than other types of Medicaid waivers.Waivers were just granted making it easier for certain individuals to get the care they need through the Medicaid program. Two provisions particularly stand out.  First, if a person is approved for the MLTSS Home and Community-Based Services Program (formerly known as Global Options) and wants to hire her own privately-selected employee as her “Care Provider,” “Provisional provider enrollment” can be granted  if certain information for the employee is given, assuming there will be regular enrollment after the emergency is over.  This may be useful for family member providers or volunteers helping families ride out quarantine.Second, the necessity to have a PAS completed before a Medicaid-eligible person is admitted to a nursing home. Pre-Admission Screenings are now waived for 30 days for new admits, and are not required for facility to facility transfers.

Our state Medicaid director, in a letter dated March 19th, asked for such waiver authority to modify or suspend certain normal Medicaid rules retroactive to March 1st, such as:

  • Suspending Prior Authorization requirements
  • Waiving Pre-Admission Screenings as a requirement for nursing home placement (these are done by state nurses physically visiting applicants at their facilities)
  • Letting a nursing home get Medicaid payment even if they are providing services in an alternate facility due to an evacuation.
  • Making it easier for family members to serve as Medicaid-paid personal care assistants
  • Relaxing rules for filing deadlines for fair hearings
  • Allowing more Telehealth and telephonic reimbursement by Medicaid

Monday, CMS replied to Director Jacobs, clarifying that the nationwide 1135 will allow for most of these requests but that some require state plan amendments:

  • Prior authorization is a function of the state plan and will require an amendment but previous prior authorizations can be extended due to the emergency
  • Pre-Admission Screenings are waived for 30 days for new admits, and are not required for facility to facility transfers
  • MCO decision fair hearing appeals will get 120 days to be filed if it happens within the emergency period
  • Expanding eligible providers to include Medicare providers who may not have been Medicaid enrolled for the duration of the emergency
  • Provisional provider enrollment if certain information for an employee (like a family member) is given, assuming there will be regular enrollment after the emergency is over
  • Medicaid will be able to pay facilities even if they have to move residents to alternative settings during the emergency.

We strive to stay as informed as possible on Medicaid Eligibility and Medicaid benefits so that we can best guide our clients who need senior care urgently.  We will continue to ask questions and monitor the day-by-day and hour-by-hour developments during this health care crisis.

Call us for advice about Medicaid eligibility, spend-down plans, applications and appeals ……………………732-382-6070

Applying for Medicaid? Order the PAS early

“You have to get a PAS.” This is a cryptic statement frequently made to the families of patients who will be discharged from hospitals to sub-acute facilities for skilled nursing or rehabilitation care.  If someone is entering a sub-acute facility and may become financially eligible for Medicaid within 180 days, the receiving facility is obligated by state regulations to order a PAS for their patient. If a person is entering a nursing home directly from home, and may become Medicaid-eligible or is already financially eligible, the facility will typically require them to “get a PAS” before agreeing to provide a bed for them.

What is this mysterious thing? It refers to the clinical assessment called the Pre-Admission Screening that must be performed by a nurse from the Office of Community Choice Options (OCCO) to confirm that a potential Medicaid applicant meets the medical/clinical criteria to receive Medicaid services. Once the request is filed with OCCO, a “PAS-nurse” is assigned to go see the patient and perform the assessment to see if s/he is dependent in three or more Activities of Daily Living (ADL’s) and thus “meets nursing home level of care.” Once the PAS is issued, it is good for 6 months so that it will be applicable when the person becomes financially eligible for Medicaid. You can read the regulations at N.J.A.C.10:54-7.7 and N.J.A.C. 8:85-1.8: 105477 PASRR and PAS Screens – Necessity for nursing facility services 885-18 Pre-Admission Screening (PAS) admission and authorization

The law requires this assessment to be done within 30 days of receipt of the request. However, I was just informed by the business administrator of an Essex County nursing home that — at least in Essex — it is taking 3 to 4 months for the assessment to be done because there is an abundance of requests and perhaps a shortage of personnel. I have seen this problem in other counties as well.

The trap is that until a PAS is issued, a person cannot receive Medicaid benefits even if they are financially eligible.

So the legal news you can use is that you need to make sure that the PAS is ordered as early as possible if you anticipate Medicaid eligibility or nursing home placement within 6 months. Then stay on top of the process and do your best to advocate for the applicant’s medical & nursing needs so that the PAS is issued.

For legal advice on all aspects of clinical and financial Medicaid eligibility, preparation of applications and representation on appeals, call us at 732-382-6070.

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