Section 2 - Eligibility

Individuals Eligible to Enroll

To be eligible to enroll in the Horizon NJ Health MLTSS program, a person must:

  • Be a resident of New Jersey.
  • Be 65 years of age or older, or between the ages of 21 and 64 and determined physically disabled by the Social Security Administration or by the Disability Review Section of the Division of Medical Assistance and Health Services.
  • Qualify for Medicaid financial eligibility by:
    • Qualifying for SSI in the community, or
    • Qualifying for Medicaid only - Institutional Level, or
    • Qualifying for NJ FamilyCare (with income at or below 100 percent of the Federal Poverty Level and resources at or below $4,000).
  • Meet clinical eligibility, which is determined by a state or county professional as needing nursing facility level of care.
  • Reside in an approved community living arrangement.
  • Want to enroll and receive services in a nursing home or in a community setting instead of living in a nursing home.
  • MLTSS members may also be eligible for Horizon NJ TotalCare (HMO D-SNP) if they qualify for both Medicare and Medicaid.

If a provider wishes to refer a current or potential member for consideration for MLTSS services, he or she can call Horizon NJ Health MLTSS Member Services at 1-844-444-4410.

Horizon NJ Health MLTSS Member Identification Cards

Each Horizon NJ Health MLTSS member is mailed an ID card that has “MLTSS” printed on the front of the card. Members are required to show their card every time they visit their Horizon NJ Health doctor or dentist, when they are referred to a specialist, when they fill a prescription or have lab work done, and if they go to a hospital Emergency Room (ER). Members must keep their Horizon NJ Health MLTSS member ID card safe and never let anyone else use or borrow it. It is illegal to lend a member ID card or number to anyone. Anyone who does so could lose his or her NJ FamilyCare benefits and face prosecution.

Assessment for Risk of Nursing Home Level of Care

Only individuals who are determined to require Nursing Facility Level of Care (NFLoC) may be enrolled in MLTSS. The process and standardized tool that is used in New Jersey to make this determination is the NJ Choice Assessment System as approved and codified by the State of New Jersey. Upon enrollment, the Care Manager will request an initial assessment of each patient. This initial assessment is conducted by communicating with the member and primary caregiver/family member (if available), observing the member in his or her home environment, and reviewing any secondary documents when available. The member is considered to be the primary source of information; the Care Manager is encouraged to talk with the member in private if at all possible.

The purpose of the NJ Choice Assessment System is to complete a comprehensive assessment of the member with the goal of:

  • Maximizing the individual’s functional capacity and quality of life
  • Addressing health problems through integrated care
  • Ensuring that the individual remains in his or her home as long as possible

The Office of Community Choice Options (OCCO) of the New Jersey Department of Human Services’ Division of Aging Services makes the final eligibility determination and is responsible for issuing the final approval or denial letter to the member with a copy to Horizon NJ Health.

When an individual is determined not to require NFLoC, the person is informed by OCCO by letter of his or her right to request a Fair Hearing to appeal the determination.