Lagana, Mazzeo & Eustace Propose Fixes to Improve Delivery of Long-Term & Community-Based Services for the Elderly

Three-Bill Package Based on State Audit is also Designed to Maximize Federal Funding to Save New Jersey Taxpayers Money

Assemblymen Joseph Lagana, Vince Mazzeo and Tim Eustace have introduced a three-bill package to improve the delivery of existing state programs and services in order to help the elderly maximize their independence while also protecting taxpayer dollars.

The bills were based on recommendations from a recent State Auditor report on selected community-based senior programs within the state Department of Human Services’ Division of Aging Services. The programs, which are funded by the state and federal government and the Casino Revenue Fund, are designed to provide services to elderly residents to avoid unnecessary institutional placement.

“Essentially these bills provide a number of fixes that will increase the efficiency of existing programs designed to aid some of our most frail and vulnerable residents,” said Lagana (D-Bergen/Passaic). “At the same time, these bills also call for better notification procedures in order to make sure seniors are aware that they may be eligible for certain critical safety net programs.”

“Anyone with an aging parent or loved one knows how important it is to them to maximize their independence,” said Mazzeo (D-Atlantic). “We have a number of existing state programs designed to do just that but they’re not necessarily being utilized by everyone who is eligible. These bills will help correct that and ensure that the state is taking advantage of every federal dollar available in order to save our taxpayers money.”

“This audit was helpful in exposing several shortcomings that have either prevented seniors from accessing crucial programs or left important federal funding on the table,” said Eustace. “These changes are designed to ensure a more efficient delivery of home and community-based long-term care services while also ensuring that elderly residents and their families do not have to deal with the aggravation of trying to get authorized claims processed.”

The first bill (A-4167) is geared towards enrollees in PACE (Program of All-Inclusive Care for the Elderly) or a pre-PACE program. PACE is a comprehensive health and social services delivery system that integrates acute and long-term care services to disabled and frail, elderly persons over the age of 55, who are certified by the state as nursing home-eligible, in order to maximize their autonomy and continued independence. A pre-PACE program is a program in its initial start-up phase and includes the same comprehensive scope of services as a PACE program.

The bill would require the Department of Human Services (DHS) to contact each person enrolled in a PACE or pre-PACE program, prior to their 65th birthday, to notify them of their eligibility for the Medicare program.

The Department of Human Services is billed monthly by the facilities for each of the enrollees. The amount billed is a set amount and differs for those individuals who are dually eligible for Medicare and Medicaid and those who are solely eligible for Medicaid.

According to the state audit, the monthly rates for fiscal years 2012 and 2013 were $4,809.95 for Medicare and Medicaid recipients and $6,097.57 for Medicaid only recipients. The state pays for these charges and is reimbursed for 50 percent of the cost by the federal government.

The State Auditor identified 336 claims in which the recipient was over the age of 65 and therefore eligible for Medicare as well as Medicaid, but the recipient was not enrolled in Medicare. In these cases, the state was billed the higher Medicaid only rate and the State Auditor estimated that costs savings of over $432,000 could have been achieved if these individuals had been dual enrolled in Medicaid and Medicare.

This bill is intended to increase the number of enrollees billed at the lower rate for dual eligible participants in order to reduce costs to the state.

The second bill (A-4168) would amend the law governing PACE and Pre-PACE programs to specify that providers who contract to provide these programs on or after the bill’s effective date must submit to DHS, on a monthly basis, expenditure details of the encounters which an enrollee has had with the program.

The bill further requires that DHS utilize these expenditure details to analyze capitated rates and help ensure the efficient utilization of services from the programs.

The third bill (A-4169) pertains to services provided under the Medicaid Managed Long-Term Services and Supports section 1115 demonstration waiver program or any other Medicaid home and community-based services long-term care program.

In the case of an individual who receives services under one of these programs through a managed care organization, DHS would be required to perform a monthly review of the number of encounters the individual has had with the managed care organization, as compared with the services authorized for the individual by the program, to help ensure efficient utilization of services from the managed care organization.

If services are received through a provider whose claims are processed by a third-party billing agent, DHS is to require the third party-billing agent to perform a monthly review of the provider’s billing limits and of the services provided to the individual, to help ensure that services are provided and claims are processed if those services and claims are authorized for the individual.

All three bills have been referred to the Assembly Human Services Committee.