LONG TERM CARE POLICY
Managed Long Term Services and Supports (MLTSS) Residential Modification Services
EFFECTIVE DATE
July 11, 2014
LAST REVIEWED DATE
April 5, 2024
PURPOSE
Through the Horizon NJ Health (HNJH) Managed Long Term Services and Supports (MLTSS) program, Members will receive their primary, acute, behavioral, and long-term care needs, through a person-centered delivery system, which promotes personal choice, autonomy, and self-direction. HNJH MLTSS Care Managers coordinate the integration of these services while supporting Member's individually assessed needs. MLTSS Care Managers authorize services needed for each of their assigned Members and provide oversight of those services to ensure those services occur and continue to be effective.
Through the Horizon NJ Health (HNJH) Managed Long Term Services and Supports (MLTSS) program, Residential Modification is a non-traditional service available to Members assessed to need its provision.
In accordance with requirements put forth in Article 4.9.2.E and the MLTSS Service Dictionary (Appendix B.9.0) of the State Medicaid Contract which stipulates that this service is the responsibility of the Managed Care Organization contractors, HNJH has developed this policy and procedure to outline the standards by which Residential Modifications services are provided.
SCOPE AND APPLICABILITY
This policy was developed in accordance with applicable Centers for Medicare and Medicaid Services (CMS) guidelines, the NJ Medicaid Managed Care Contract, applicable NJ State and Federal Guidelines, and national accreditation standards. This policy will be reviewed annually, revising procedures as necessary to reflect changes to specific guidelines.
This policy applies to the Medicaid/NJ FamilyCare plans issued and/or administered by Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey and/or its affiliates, including Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health (collectively “Horizon”). This policy only applies to Managed Long Term Services and Supports (MLTSS) services and/or MLTSS members, including members dually enrolled in both the MLTSS and the Fully Integrated Dual Eligible Special Needs (“FIDE-SNP”) plans.
The Department Head of Medicaid Care Management Programs or his/her designee will conduct an annual review of this policy and procedure to ensure that it is still relevant and compliant with appropriate New Jersey State and Federal Medicaid, Medicare Advantage and FIDE-SNP regulatory and accrediting requirements, and accurately reflects current operations.
The purpose of this policy is to discuss the requirements and elements that are required for Residential Modifications.
HNJH Health and Network Solutions (HNS) will periodically monitor and review the provider records of the Residential Modification Providers to ensure appropriate provider standards are maintained.
This policy applies to the MLTSS Department and Health and Network Solutions (HNS) staff.
POLICY
Residential Modifications are a non-traditional MLTSS service.
Residential Modifications are provided to a MLTSS Member based on benefit coverage and medical necessity.
HNJH is contracted with Residential Modifications providers, who must abide by all governmental, and HNJH requirements and standards.
Residential Modification services are considered to be one-time costs and are not included in the cost effectiveness analysis.
HNJH is responsible for payment to the Residential Modifications provider per occurrence.
Residential Modifications are limited to $5,000 per calendar year, $10,000 lifetime.
In general, all of the following requirements must be met to qualify for Residential Modifications:
Residential Modifications must be necessary to ensure the health, welfare and safety of the individual, or which enable him/her to function with greater independence in the home or community and without which the individual would require institutionalization.
Residential Modifications are NOT available for those MLTSS Members who have chosen to reside in a Community Alternative Residential Setting (CARS).
Adaptations to rented housing units must have the prior written approval of the landlord.
Continued tenancy of at least one (1) year is to be assured prior to approval of the request.
Modifications to public areas of apartment buildings, communities governed by a homeowner association or community trust and/or rental properties are the responsibility of the owner/landlord, association or trust and EXCLUDED from this benefit.
Residential Modifications may NOT be furnished to adapt living arrangements that are owned or leased by service providers.
All Residential Modifications are limited based on the participant’s assessed need.
The adaptation will represent the most cost effective means to meet the needs of the participant.
Modifications to the home that are of general utility and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, central air conditioning, etc. are EXCLUDED from this benefit.
Adaptations that add to the total square footage of the home are EXCLUDED from this benefit, a) EXCEPT when necessary to complete an adaptation (e.g., in order to improve entrance/egress to a residence or to configure a bathroom to accommodate a wheelchair).
All services shall be provided in accordance with applicable State/local building codes, Americans with Disabilities Act (ADA), and/or ADA Accessibility Guidelines (ADAAG) and specifications.
If it is determined that one of the above limitations would prevent HNJH from implementing a more appropriate or cost effective method of support or ensuring the health, safety and welfare of an individual, HNJH may exceed these limitations in those specific circ*mstances. Only the MLTSS Department Head or designee can approve modifications that exceed the benefit limits
A letter from the owner of the property approving the modification to the property and acknowledging that the State/HNJH is NOT responsible for the removal of the modification from the property is required.
DEFINITIONS
Caregiver (paid or unpaid): A person who assists with care for a Member who is ill, has a disability and/or has functional limitations and requires assistance with activities of daily living or instrumental activities of daily living. Unpaid caregivers or informal family caregivers include but are not limited to relatives, friends, and others who volunteer to provide assistance. Paid or formal caregivers are those who provide services in exchange for payment for services rendered.
Community Alternative Residential Setting (CARS): These types of living arrangements refer to – NJ State licensed Assisted Living settings (including Assisted Living Residences, Assisted Living Programs in Subsidized Housing, Comprehensive Personal Care Homes), Community Residential Services homes for those who have a traumatic brain injury, and Adult Mental Health Rehabilitation.
Home and Community-Based Services (HCBS): Services that are provided as an alternative to long-term institutional services in a nursing facility or Intermediate Care Facility for the Intellectually Disabled (ICF/ID). HCBS are provided to individuals who reside in the community or in certain community alternative residential settings.
Residential Modifications: Those physical modifications/adaptations to a participant's private primary residence required by his/her Plan of Care which are necessary to ensure the health, welfare and safety of the individual, or which enable him/her to function with greater independence in the home or community and without which the individual would require institutionalization. Such adaptations may include the installation of ramps and grab bars, widening of doorways, modifications of bathrooms, or installation of specialized electrical or plumbing systems that are necessary to accommodate the medical equipment and supplies which are needed for the health, safety and welfare of the individual.
POLICY PROCEDURAL WORKFLOW
Determination of need for Residential Modifications (also referred to as Home Modifications) may be made during the Member's NJ Choice Assessment, Risk Assessment, Options Counseling, and Plan of Care development process or at any time a Member request the need for a home modification.
MLTSS Care Managers review the home modification benefit with Members at least annually during Options Counseling.
Requests for Home Modifications are submitted to the Home Modification department through the Home Modification Operational Workflow process. Any dispute resolutions, initially or ongoing, for this service follows the Member Utilization Management and Appeals procedures.
If a Member qualifies for a Residential Modification, the Member or Personal Representative must sign off on agreement of the modification being completed or provided.
The MLTSS Department is responsible for ensuring that all Members are evaluated for and authorized for (if indicated) Residential Modification Services. HNJH Health and Network Solutions (HNS) complies with MLTSS provider network standards, ensuring that an adequate number and type of participating non-traditional Residential Modification providers are available. HNS also ensures that Residential Modification providers meet and maintain all governmental and HNJH credentialing/re-credentialing requirements.
REFERENCES
Regulatory References:
NJ Medicaid Managed Care Contract Article 4.9.2.E; Appendix B.4.1 Benefit Packages
New Jersey QAPI Standards (Appendix B.4.14 - Standard IX: Credentialing and Re-credentialing)
MLTSS Service Dictionary (Appendix B.9.0)
Policy References:
MLTSS Benefit Definitions and Limitations of Covered Services
MLTSS Care Management Service Authorizations & Provider Communications
REVISION HISTORY
3/28/24 Updated definition of CARS to remove inclusion of AFC and removed reference to AFC homes as approved settings for modifications.
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