WELLCARE HEALTH PLANS OF NEW JERSEY INC Managed

WELLCARE HEALTH PLANS OF NEW JERSEY, INC. Managed Long Term Services and Supports(MLTSS) June 8, 2015 © 2014 Well. Care Health Plans Inc. All rights reserved.

WELLCARE HEALTH PLANS OF NEW JERSEY, INC. COMPANY OVERVIEW Well. Care Health Plans of NJ, Inc. is a State of New Jersey domiciled health maintenance organization (“HMO”) and is a wholly-owned, indirect subsidiary of Well. Care Health Plans, Inc. (“Well. Care”) Well. Care Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla. , Well. Care offers a variety of health plans for families, children, and the aged, blind, and disabled, as well as prescription drug plans. The company serves approximately 4 million members nationwide as of Sept. 30, 2014 5/20/2021 1: 40 PM p 1

New Jersey Medicaid Presence New Jersey Presence: June 2015 1140 MLTSS Program Recipients §Effective July 1, 2014, we completed the acquisition of Medicaid assets from Health. First Health Plan of New Jersey, Inc. ("Health. First NJ"). o. The acquired assets primarily include approximately 42, 000 Healthfirst Medicaid members, who were transferred to our Medicaid plan, as well as certain provider agreements. 5/20/2021 1: 40 PM 2 p 2

Well. Care’s Network Management New Jersey Provider Network: April 2015 1, 971 Adult PCPs 1, 368 Pediatric Primary Care Providers 22 Hospitals (Medicaid- Medicare) 12, 751 Specialist 511 MLTSS Specialty Providers * across all specialties 5/20/2021 1: 40 PM 3 p 3

Well. Care of New Jersey – Expansion Well. Care current service area Well. Care phase 3 expansion Go live date: 7/15 Well. Care phase 4 expansion Go live date: 9/15 © 2014 Well. Care Health Plans Inc. All rights reserved.

The MLTSS Program 5/20/2021 1: 40 PM p 5

Well. Care Management Program Model • Managed Long Term Services and Supports (MLTSS)- A program within the MCO providing services to Medicaid eligible individuals with substantial functional limitations due to chronic physical or cognitive limitations. MLTSS services are generally provided in lieu of nursing facility care allowing individuals to be served in the least restrictive and generally preferred community setting. • The Care Management Team uses tools including the New Jersey Choice assessment tool and the PCA assessment tool to identify members at risk for inappropriate or unnecessary nursing facility admission. Potential members may also be identified through referral sources such as State agencies, self-referrals, and through network providers. • Once enrolled, Care Managers work with MLTSS members to provide an integrated program emphasizing physical and behavioral health and long-term supports to maximize services and optimize outcomes. • Staffing for care management follows ratios as outlined below: • Nursing facility and non-pediatric special care nursing facility – 1: 240 • HCBS members residing in an alternative community setting – 1: 120 • Members receiving Home and Community Based Services – 1: 60 • Members receiving services in Special Care Nursing Facility – 1: 48 5/20/2021 1: 40 PM 6 p 6

Well. Care’s Integrated Care Model Pharmacy Management Disease Management Home and Communitybased Care Mental Health Case Management Therapy Specialists Primary Care Transportation Members & Caregivers Optical Community-Based Social Services Integrated Care Management and Coordination of Care can: • Enhance quality of life for members and family caregivers • Provide value to state customers and members • Significantly decrease inpatient readmissions • Reduce over-utilization across multiple segments • Reduce non-emergency ground transportation costs • Reduce inpatient bed days As of March 31, 2014 5/20/2021 1: 40 PM 7 p 7

Services Unique to MLTSS Managed Long Term Services and Supports (MLTSS) includes: Personal Care; Respite; Care Management; Home and Vehicle Modifications; Home Delivered Meals; Personal Emergency Response Systems; Mental Health and Addiction Services; Assisted Living; Community Residential Services; Nursing Home Care. As of March 31, 2014 5/20/2021 1: 40 PM 8 p 8

MLTSS Care Management Program • Staffing- 28 Fulltime Care Managers serving 1143 members • RNs, LCSWs, Behavioral Health staff • 7 care coordinators • Breakdown of membership • 954 reside in home or community based settings • 189 reside in nursing facilities • Initial census on transition was 635 • 2 residing in nursing facilities 5/20/2021 1: 40 PM p 9

How is Nursing Home covered under MLTSS ? • • Any individuals with NJ Family. Care entering a nursing home for the first time will have their acute and primary health care managed by the NJ Family. Care MCOs with MLTSS Individuals on MLTSS also will have his/her acute and primary health care services and nursing home care managed by a NJ Family. Care MCO. Any individual who is newly eligible for NJ Family. Care and living in a nursing home after July 1, 2014 will have his/her care managed by a NJ Family. Care MCO through the MLTSS program. Nursing home residents who were considered in custodial care on Medicaid as of July 1, 2014 will remain in a fee-for-service environment. Medicaid beneficiaries living in Special Care Nursing Facilities (SCNFs) as of July 1, 2014 will remain in the fee-for-service environment for two years. As of March 31, 2014 5/20/2021 1: 40 PM 10 p 10

Custodial Authorization Process • • • Effective June 2, 2014 the “ 30 day rule” for conversion to FFS Medicaid no longer applies and all members enrolled in Well. Care Health Plans, Inc. for NJ Family care entering a nursing facility after the above date will remain as Wellcare enrollees. Members entering nursing facility for rehabilitation services, will become eligible for a custodial authorization through Well. Care if: Member has exhausted their skilled nursing benefit through their primary coverage. Is unable to be discharged to their former residence and/or the member expresses a desire for transition into the community Custodial authorization will trigger need for a NJ Choice assessment in order to determine MLTSS eligibility. Well. Care NJ Health Services will conduct NJ Choice Assessment and submit to the Office of Community Choice Options for authorization for MLTSS As of March 31, 2014 5/20/2021 1: 40 PM 11 p 11

Custodial Authorization Process Clinical Information Needed: (Please include with authorization request form. ) 1. Copy and date of most recent PASSR I, if positive, include copy of PASSR II 2. Last date of covered skilled services, primary/other payer and/or copy of Medicare NOMNC 3. Last four weeks of clinical documentation (Nursing/rehab notes, medication list, history and physical exam, and discharge summary showing proof that member has reached rehab/skilled nursing potential) Please note custodial authorization will NOT be issued until documentation has been received. Authorization will be granted for 60 days upon review of documentation submitted, until NJ Choice Assessment has been completed and reviewed by the Office of Community Choice Options (OCCO). A maintenance authorization will be granted for six months upon approval and as member meets medical and eligibility criteria. 5/20/2021 1: 40 PM p 12

Nursing Facility Placement Transitions and Diversion • Short term nursing facility stays are available for MLTSS Members receiving HCBS who require temporary placement in a nursing facility due to temporary illness, serious injury, wound care, or the absence of the primary caregiver and there is a reasonable expectation that the member will be discharged back to the community within 100 days. • Prior to a NF admission, the Contractor shall confirm that a PASRR Level I, and if indicated, a PASRR Level II has been completed. • The Care Manager shall review the plan of care developed by the facility, and supplement the facility plan of care as necessary with the development and implementation of targeted strategies to improve health, functional, or quality of life outcomes or to increase and/or maintain functional abilities. • A copy of the facility plan of care and any supplements shall be maintained by the Contractor in the Member’s electronic Care Management record. 5/20/2021 1: 40 PM 13 p 13

MLTSS Care Management and the Nursing Facility • Plan of Care for Institutional and Community Alternative Residential Settings (CARS) (9. 6. 4 R NJ Medicaid HMO Contract) • The Care Manager shall review the plan of care developed by the facility; and supplement the facility plan of care as necessary with the development and implementation of targeted strategies to improve health, functional, or quality of life outcomes or to increase and/or maintain functional abilities. A copy of the facility plan of care and any supplements shall be maintained by the Contractor in the Member’s electronic Care Management record. • The Care Manager shall participate in a minimum of two (2) IDT meetings per year in the nursing facility’s care planning process and advocate for the Member. • The Care Manager shall be responsible for coordination of the Member’s physical health, behavioral health, and long term care needs. This shall include coordination with the nursing facility as necessary to facilitate access to physical health and/or behavioral health services needed by the Member and to help ensure the proper management of the Member’s acute and/or chronic physical health or behavioral health conditions, including services covered by the Contractor that are beyond the scope of the nursing facility services benefit. 5/20/2021 1: 40 PM p 14

Community Transition/Money Follows the person Money Follows the Person (MFP) - Community Transition Services • Community Transition Services are provided to identified members to assist in transitioning from an institutional setting to a home setting in the community through coverage of non-recurring, one-time expenses. • This service is provided to support the health, safety and welfare of the member in the least restrictive environment and to meet both their physical and psychosocial needs. Allowable expenses are those necessary to enable a person to establish a basic household but do not constitute room and board. • A program supervisor within the care management department will serve as the MFP Liaison to act as the primary point of contact between the Health Plan, OCCO and the nursing facility. • Responsibilities in the liaison role include ongoing identification of members who may be eligible for community transition through participation in case conferencing with care managers and facility interdisciplinary team meetings. • The MFP liaison will ensure a smooth transition from facility based care to home and community based care through coordination of both needed services to establish the new residence and the ongoing supports to meet ADL/IADL and quality of life needs. Once the member has transitioned home the MFP liaison will compile the necessary statistical data to meet the requirements for ongoing tracking and reporting of member outcomes. • Well. Care’s MFP Liaison is Lissette Verde • 22 members successfully transitioned to date • 5 additional members in progress 5/20/2021 1: 40 PM p 15

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Patient Payment Liability (PPL) • For individuals who are placed in a nursing facility, the Care Manager shall discuss any potential Patient Pay responsibility the Member may incur. The Patient Payment Liability for Cost of Care is that portion of the cost of care that NF residents must pay based on their Available Income as determined and communicated by the CWA. • The State shall notify the Contractor of any applicable patient payment liability amounts via the 834 eligibility/enrollment file. • The Contractor shall delegate collection of the patient payment liability for the cost of care to the NF/SCNF provider. • The Contractor shall pay the NF/SCNF net of the applicable patient payment liability amount. 5/20/2021 1: 40 PM 18 p 18

Critical Incidents • Critical Incident--an occurrence involving the care, supervision, or actions involving a Member that is adverse in nature or has the potential to have an adverse impact on the health, safety, and welfare of the Member or others. • Critical incidents also include situations occurring with staff or individuals or affecting the operations of a facility/institution/school. Well. Care QI Department 19 1/13/2015 5/20/2021 1: 40 PM p 19

Critical Incident List These Must Be Reported Immediately • Suspected or evidenced physical or mental Abuse, (including seclusion and restraints, both physical and chemical); • Sexual abuse and/or suspected sexual abuse; • Neglect/Mistreatment, including self-neglect, caregiver overwhelmed, environmental; • Theft with law enforcement involvement; • Exploitation, including financial, theft, destruction of property; Well. Care QI Department 20 1/13/2015 5/20/2021 1: 40 PM p 20

Critical Incident List These Must Be Reported Within 24 Hours • Unexpected death of a member; • Severe injury or fall resulting in the need for medical treatment; • Medication error resulting in serious consequences; • Medical or psychiatric emergency, including suicide attempt; • Inappropriate or unprofessional conduct by a provider/agency involving the member; Well. Care QI Department 21 1/13/2015 5/20/2021 1: 40 PM p 21

These Must Be Reported Within 24 Hours • Elopement/wandering from home or facility; • Missing person or Unable to Contact; • Facility closure, with direct impact to member’s health and welfare; • Natural disaster, with direct impact to member’s health and welfare; • The potential for media involvement; Well. Care QI Department 22 1/13/2015 5/20/2021 1: 40 PM p 22

Critical Incidents Well. Care Policy NJ 23 QI-066 – Critical Incident Reporting • Critical Incidents include but are not be limited to the following incidents when they occur in: Ø Hospital/Nursing Facility/Skilled Care Nursing Facilities or Ø Home and Community-based long-term care service delivery settings and provider offices Ø Community Alternative residential settings Ø Adult Day Care Centers Ø Member’s Home Well. Care QI Department 23 1/13/2015 5/20/2021 1: 40 PM p 23

Well. Care Responsibilities Well. Care staff that become aware of a Critical Incident (CI) will immediately ensure the safety of the member and notify appropriate agencies: • Police/911 • Adult Protective Services (APS) • Dept. of Children and Families (DCF) • Office of the Ombudsman Institutionalized Elderly (OOIE) • Department of Health (DOH) • Division of Disability Services (DDS) • Division of Aging Services (Do. AS) Well. Care QI Department 24 1/13/2015 5/20/2021 1: 40 PM p 24

Associate Responsibilities The Well. Care staff person will also notify: Agency/Service Provider (if appropriate) MLTSS management: Marion Smayda or Marjorie Forgang QI Department: Rosemarie Stern and Mary Dunn via e-mail Document the CI in EMMA using the Case Note type RQU Care Managers will document the CI in Acute Net Important: If the event involves a health and safety issue, arrangements must be made for alternate services/placement and must be documented in EMMA Well. Care QI Department 25 1/13/2015 5/20/2021 1: 40 PM p 25

Critical Incident Information Needed for Reporting • • • Member Medicaid ID Number Date of Occurrence Date Well. Care became aware of the incident Type of Incident Setting Provider Short description of the incident Short description of the immediate actions taken to protect/halt or ameliorate the harm to the member Short description of any underlying circumstances Date incident investigation was completed Well. Care QI Department 26 1/13/2015 5/20/2021 1: 40 PM p 26

Program Contact 855 -642 -6185 • RN available 24 hours/day 7 days/week 365 days/year 5/20/2021 1: 40 PM p 27

RESOURCES https: //newjersey. wellcare. com/provider/resources/mltss Forms and Documents: newjersey. wellcare. com/provider/forms Quick Reference Guides: newjersey. wellcare. com/provider/resources Clinical Practice Guidelines: www. wellcare. com/provider/CPGs Clinical Coverage Guidelines: www. wellcare. com/provider/CCGs Well. Care Companion Guide: newjersey. wellcare. com/provider/claimsupdates Provider Training : newjersey. wellcare. com/Provider. Training MLTSS Provider Communications: http: //www. state. nj. us/humanservices/dmahs/home/AL_CRS_Administrators_Letter. pdf MLTSS Provider Frequently Asked Questions (FAQs): http: //www. state. nj. us/humanservices/dmahs/home/MLTSS_Provider_FAQs. pdf The Comprehensive Medicaid Waiver: http: //www. state. nj. us/humanservices/dmahs/home/waiver. html 5/20/2021 1: 40 PM p 28