NJ Personal Preference Program (PPP) for NJ FamilyCare: Self-Directed Care Services, Lecture notes of Nursing

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NEW JERSEY DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

PERSONAL PREFERENCE PROGRAM

FACT SHEET

The New Jersey Personal Preference Program (PPP) offers an alternative way for NJ FamilyCare Plan A members who qualify for the Personal Care Assistant (PCA) services benefit to remain in their home and active in their community, and does not require the use of a home health care agency.

NJ FamilyCare Plan A eligibility is defined as:

 Children 18 and under are eligible with higher incomes up to 355% FPL ($7,278/month for a family of four). Parents still need to renew the coverage each year. Children age 18 and under who are lawfully admitted can be eligible even if they have lived in this country fewer than five years;  Parents/Caretaker Relatives with income up to 138% FPL ($2,829/month for a family of four) must have tax dependent children in their household in order to be eligible under this category. The dependent children in the household must be insured also. Immigrant adults must have Legal Permanent Resident status in the US for at least five years in order to be eligible for NJ FamilyCare;  Adults without dependent children with ages 19-64 and income up to 138% FPL ($1,387/month for a single person and $1,868/month for a couple). Immigrant adults must have Legal Permanent Resident status in the US for at least five years in order to be eligible for NJ FamilyCare;  Pregnant Women up to 205% FPL ($4,203/month for a family of four). Pregnant women who are lawfully admitted can be eligible even if they have lived in this country fewer than five years;  Aged, Blind, Disabled programs including Long Term Care.

The PPP’s goal is to offer you a State Plan Medicaid PCA service option that you direct and in which you manage a monthly budget and receive counseling services, in lieu of traditional agency-delivered services.

The PPP allows you to direct and manage your activities such as bathing, feeding, dressing, transferring, grooming, meal preparation, laundry and light housekeeping. The PPP provides an alternative to traditional agency services and allows you greater control of the services you receive. Please note that your budget may not pay for or provide skilled professional medical services, such as private duty nursing.

Through a monthly budget, you work with a financial consultant to develop a monthly budget, through which you will decide the services you need and the individuals and/or agencies you wish to hire to provide the identified services. If you are cognitively impaired or unable to make decisions on your own, you can choose an authorized representative to assist you.

The PPP also provides fiscal management services to assist you with the financial aspects of the program. PCG Public Partnerships, LLC (PPL) is the fiscal intermediary (FI) for the PPP, and is responsible for handling payroll responsibilities, acting as a bookkeeping service, processing time sheets and issuing paychecks to your workers.

The PPP requires greater individual responsibility, but in return, offers you greater control, flexibility and choice over the services you receive.

The Personal Preference Program Allows You to:

 Choose the home care services you want;  Hire workers, including people you know/trust such as friends, relatives and neighbors;  Schedule services to meet your individual needs;  Exercise greater independence and control over your life.

Eligibility for Self-Directed Services:

 Based on eligibility requirements for Medicaid PCA services determined by the participant’s Managed Care Organization;

 For NJ FamilyCare beneficiaries that require assistance with activities of daily living;  For individuals currently receiving (or who are eligible to receive) Medicaid PCA services from a home health agency;  Requires that participants have the ability to direct and manage services, or elect a representative that can assist them with the program.

In Order to Qualify for PCA Services, Recipients Must:

 Have NJ FamilyCare Plan A;  Obtain a doctor’s order to receive the service (do not have to be permanently disabled);  Live in a community-based residence, such as a private home, apartment, rooming house, boarding home or group home, skill development home, supervised apartment or other congregate living program where personal care is not provided as part of the service package included in the living arrangement;  Have a documented need for hands-on personal care; and  Require PCA services for at least six months.

FINANCIAL COUNSELING SERVICES

You will have an assigned financial consultant, employed by PPL, who will help you with navigating the program. Consultants serve as trainers, resource-locators and advisors. Consultants regularly check-in and answer any questions you may have for as long as you remain enrolled in the PPP.

PPL will assign a consultant that lives in your community and is familiar with the program. Where possible, PPL will provide a consultant that is bilingual. However, consultants may at times be reassigned as new consultants are hired, consultants may move to new locations, or consultants change positions. If your consultant is reassigned, you will be notified ahead of time, when possible. Your new consultant will reach out to introduce themselves.

Role of the Financial Consultant:

Provide orientation, training and consultation services to you regarding the program and with the development of the cash management plan or monthly budget.

 Respond to all critical incidents reported by you, the state program office or PPL, and assist in the resolution of any problems in securing necessary care.  Provide training and support services to you in the areas of recruitment, assistance with identifying equipment needs such as assistive technology, and other purchases not otherwise covered by NJ FamilyCare, which would reduce your need and increase your independence.  Interact with PPL as necessary to resolve issues with you and/or your authorized representative.  Complete quarterly face-to-face visits with you to monitor your progress, determine satisfaction and offer assistance.

MONTHLY BUDGET DETERMINATION

Your MCO (Aetna, Amerigroup, Horizon NJ Health, UnitedHealthcare Community Plan or WellCare) is responsible for authorizing the number of Medicaid PCA hours you are eligible to receive, to provide you with options counseling and to enroll you into the PPP.

The MCO uses the hours of service authorized from your initial PCA clinical assessment (or most recent reassessment) as the basis for determining your monthly budget. Your number of authorized hours is converted into a dollar amount using the current reimbursement rate. A standard administrative deduction is then calculated to cover the costs of counseling and bookkeeping services. The remaining amount is available to you for purchasing services.

The financial consultant will assist you in developing a cash management plan to help determine how best to spend your monthly budget to purchase services that you need.

Purchases May Include but Are Not Limited to:

 Employment of individuals, including family members, to provide personal assistance;  Cleaning services from private companies to clean your home’s personal areas including bedroom, bathroom, kitchen, etc.;  Errand service to assist with banking, shopping, post office and other types of routine tasks; and,  Laundry service from a laundromat or other provider.

Possible Additional Uses of the Monthly Allowance:

 Services from a home health agency;  Equipment, small appliance, technology or other items that increase independence (e.g., microwave oven or washing machine); and,  Supplies and equipment that promote or enhance independence that are not covered by Medicaid.

NEED FOR AUTHORIZED REPRESENTATIVE

If you are unable to manage the responsibilities of directing and supervising your own personal care needs, you will be required to have an authorized representative to act on your behalf.

An authorized representative may be your legal guardian, a family member, or any other individual identified who willingly accepts responsibility for decision- making on your behalf. They must reside in New Jersey. An authorized representative must demonstrate a personal commitment to you and be willing to follow your wishes and respect your preferences, while using sound judgment. The authorized representative receives no monetary compensation for this service and may not serve as your worker. If you desire to have an authorized representative but cannot identify a person to serve in that capacity, the financial consultant will assist you in identifying an appropriate individual to serve as an authorized representative.

BACK-UP PLAN FOR SERVICES

To best protect and serve individuals in the PPP, all participants are required to complete a Risk Assessment Profile during their initial home visit with their financial consultant. The profile determines your level of risk in case of an emergency, such as a worker calling out or a natural disaster situation. The Risk Assessment Profile will include three possible levels of risk, “High,” “Moderate,” or “Minimal.” This profile is required to be completed before you can create your cash management plan.

The Risk Assessment Profile will determine what type of back-up system, if any, will be required to participate in the PPP. If the profile indicates that you have “Minimal” or “Moderate” level of risk, a back-up plan is optional. In these cases, the financial consultant will discuss possible risks with the participant and suggest a viable back-up plan to be included in the cash management plan. The decision to include a back-up plan is entirely up to you. However, if the profile indicates you have a “High” level of risk, you are required to include a back-up plan. The financial consultant will work with you, and/or your authorized representative, to help identify an appropriate back-up plan.

A Back-Up Plan Can Include:

 A back-up worker, someone who is able to work when a regular worker calls out or is unable to work; or,  An accredited home care agency that you contract with privately to fill-in when your worker is unable to work.

Your financial consultant will continue to monitor for potential risk throughout your participation in the PPP and you are required to complete a new Risk Assessment Profile each year. If the potential for risk changes to “High,” you will be required to revise your cash management plan to include a back-up plan.

FISCAL MANAGEMENT

PPL serves as the fiscal intermediary (FI) for the Personal Preference Program and issues your budget on a monthly basis. Your budget is deposited into an account established by PPL. You then direct the PPL to make payments through your cash

management plan, as you see fit. PPL serves as your agent and handles all payroll responsibilities, tax deductions, workers’ compensation and withholding obligations. PPL provides you with a detailed financial statement, showing all payments and charges issued.

OPTIONS TO CONSIDER

NJ FamilyCare members who qualify can choose to receive Personal Care Assistant services from an individual employed by an agency in their MCO’s network of providers OR to self-direct these services through the PPP, by selecting and employing their own direct care workers. While PPP may not be the choice for all participants, it is an available option to consider.

Under the PPP, you will have new responsibilities and more choice and freedom in the services you receive. You will be the employer of record – making decisions, managing and supervising workers just as a small business.

DIFFERENCES BETWEEN PCA AND PPP

Agency Provided Personal Care Assistant (PCA) Services

Self-Directed Personal Care Assistant Services Through PPP

The participant’s MCO uses an agency from their network of providers.

Good for NJ FamilyCare members who want to choose how to direct and manage their personal care services and exercise greater control over their lives. The agency hires, trains, supervises, schedules and dismisses their workers, if needed.

The participant can hire people they know and trust (i.e. spouse, friends, relatives and neighbors). The agency is responsible for workers timesheets and payment. A participant’s NJ FamilyCare MCO is responsible for payment to the agency.

The participant (or authorized representative) is responsible for approving timesheets and payment for services authorized in the participant’s cash management plan.

The agency conducts supervisory visits to ensure program compliance.

The participant has supervisory control over their worker and how to handle tasks.

The agency is responsible for providing a backup plan.

The financial consultant will work with the participant to help identify a backup worker. The agency is responsible for how the services are provided.

The participant decides how their worker(s) will provide the services. The service is available only where the agencies are located in the participant’s MCO.

Available statewide.

The Financial Consultant will conduct an initial enrollment visit and schedule quarterly visits as well as visits at the participant’s or authorized representative’s request.

BENEFITS OF PARTICIPATING

 Decision making power is increased. Participation through the traditional agency delivered service model limits your control; however, self-directing provides more independence in directing your own care needs. Professional advice from your financial consultant is available to aide you in making your own informed decisions about the type of services necessary to meet your needs.  Support of informal caregivers is increased. You may prefer to choose a family member or friend to assist you. The PPP allows these chosen individuals to be paid for this service. This could enable a relative to stay at home and care for a spouse, parent or child, and receive payment for their services.  Appropriate and selective services. The PPP allows you and your family to decide what services are most appropriate.

HOW TO APPLY FOR THE PPP

Interested NJ FamilyCare members may contact their MCO and request options counseling or tell them they are interested in applying for the PPP to begin the enrollment process. The MCO’s Care Managers help provide options counseling, and can complete the initial enrollment packet to be forwarded to PPL.

Contact Information for NJ FamilyCare Managed Care Organizations (MCOs)

 Aetna 1-855-232-  Amerigroup 1-855-661-  Horizon NJ Health 1-855-465-  United Health Care 1-800-645-  Well Care 1-855-642-

For More Information:

Please call the PPP State Program Office Helpline Number: (609) 631-

NJ Department of Human Services

Personal Preference State Program Office

Division of Medical Assistance and Health Services (DMAHS)

P.O. Box 712

Trenton, New Jersey 08625-