Overview of the TennCare CHOICES Program
The TennCare CHOICES in Long-Term Services and Supports Program, or simply CHOICES, is a Medicaid Program through which long-term care is provided for elderly and physically disabled adults who are at risk of nursing home admission. In addition to nursing home care, a variety of home and community based services (HCBS) are available to prevent and / or delay nursing home admissions. These supports may include adult day care, home delivered meals, attendant care, homemaker services, home modifications, and respite care.
There are 3 beneficiary groups within CHOICES. The groups are based on care needs and the setting in which a program participant resides and receives assistance.
– Group 1 – persons who require a nursing home level of care and live in a nursing home
– Group 2 – persons who require a nursing home level of care, but choose to live at home (or in the community) and receive home and community based services
– Group 3 – persons who receive SSI payments and do NOT require a nursing home level of care, but are “at risk” of nursing home care without home and community based services
In addition to long-term care, CHOICES program participants receive medical and behavioral health benefits via a single Medicaid health plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. CHOICES program participants have several managed care health plans from which to choose.
There is an option for consumer direction of in-home care for program participants. This option allows persons flexibility with regards to who provides them with personal care assistance and homemaker services. This means that rather than be assigned one of the MCO’s network of licensed care providers, a program participant can hire, train, and even fire, their own caregiver. Select relatives, such as an adult child, can be hired. Spouses, legal guardians, and power of attorneys cannot be hired. A financial management services agency handles the financial aspects of employment responsibilities, such as tax withholding and caregiver payments.
Program participants can reside in a variety of settings. This includes private homes (the beneficiary’s home or the home of a loved one), community living support homes, community living support family model homes (adult foster care), assisted living facilities, critical adult care homes, and nursing homes.
TennCare CHOICES is an entitlement program for persons who require nursing home care and wish to reside in a nursing home (Group 1). This means applicants who meet the eligibility criteria can immediately receive program benefits.
This program is not an entitlement for persons who require nursing home care, but wish to receive home and community based services instead of being admitted to a nursing home (Group 2), or are “at risk” of nursing home placement without home and community based services (Group 3). The number of participant enrollment slots are limited and there may be a waitlist for program participation. Some slots are reserved for persons being discharged from a nursing home, as well as for persons being discharged from an acute care setting who will very likely be placed in a nursing home without home and community based services.
Tennessee’s Medicaid Program is a managed care program called TennCare that operates under a 1115 Demonstration Waiver. The TennCare CHOICES in Long-Term Services and Supports Program, which may also go by the name of TennCare CHOICES in Long-Term Care, is part of the demonstration waiver.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of the TennCare CHOICES Program
In addition to case management, a variety of home and community based services are available via TennCare CHOICES. Available benefits vary based on the group in which a program participant is enrolled. Furthermore, an individual care plan will determine the exact services and supports a program participant will receive. Potential benefits are as follows. The ones that are available for consumer direction are marked with an asterisk.
– Adult Day Care
– Attendant Care* – assistance with daily living activities (i.e., bathing, dressing, meal preparation, eating, and toiletry). Differs from personal care visits in that attendant care is not limited to a 4 hour “visit”.
– Assisted Living Services – personal care assistance, medication management, and homemaker services
– Assistive Technology – i.e., grabbers
– Benefit Counseling
– Community Living Supports / Community Living Supports Family Model – a shared home with up to 3 other persons where supervision, physical assistance, and transportation services can be received. With the family model, the beneficiaries live with a host family and is similar to adult foster care.
– Companion Care* – a live-in caregiver who provides personal care assistance and homemaker services. Limited to persons who require daytime and nighttime care and do not have an unpaid caregiver to provide such care.
– Critical Adult Care Home – a shared home with up to 4 other persons in which a healthcare professional lives and provides medical and long-term care assistance. Limited to persons who are dependent on a ventilator or have a traumatic brain injury.
– Home Delivered Meals
– Home Modifications – for safety and accessibility (i.e., grab bars, wheelchair ramps, and widening of doorways)
– In-Home Respite Care* – short-term care to alleviate a primary caregiver
– In-Patient Respite Care – short-term care in an assisted living residence or nursing home to give a primary caregiver a break
– Nursing Facility Care
– Personal Care Visits* – “visits” of 4 hours maximum to provide assistance with daily living activities (i.e., bathing, dressing, meal preparation, eating, and toiletry)
– Personal Emergency Response Systems (PERS)
– Pest Control
– Transportation* – to medical appointments and for essential shopping
While program participants can reside in community living support homes, community living support family model homes, assisted living residences, and critical adult care homes, TennCare CHOICES does not cover the cost of room and board.
Persons in Group 3 are limited to $15,000 per year in services and supports. This limit excludes minor home modifications.
Eligibility Requirements for TennCare CHOICES
The CHOICES Program is for Tennessee residents who are elderly (65+ years old) or physically disabled (21+ years old). Additional eligibility criteria is below.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. There is a minimum income allowance, set at $2,177.50 / month (effective July 2021 – June 2022), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $4,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Tennessee Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, TN Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– The applicant has a spouse living in the home.
– The applicant has a minor child (under 21 years old) living in the home.
– The applicant has a blind or disabled adult child living in the home.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC) or be “at risk” of needing this level of care. For the CHOICES Program, a Pre-Admission Evaluation (PAE) is completed to make this determination. A need for assistance with the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, and toileting) is one area of consideration. Other areas in which deficits are considered are orientation (an awareness of person, place, and event), communication, the ability to take prescribed medications, and behavior (i.e., physical aggression, wandering, and resistance to care). Persons with Alzheimer’s disease or a related dementia might exhibit such deficits due to a decline in cognitive functioning as the disease progresses. A diagnosis of dementia, does not mean one will automatically meet a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over the TN Medicaid limit(s) does not mean an applicant cannot still qualify for Medicaid / TennCare. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limits, Miller Trusts, also called qualified income trusts, can help. Specific to Tennessee, they are also called qualifying income trusts. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on medical bills, household furnishings and appliances, or even a vacation. Another option, but for married couples with a substantial amount of “excess” assets and only one spouse applying for benefits, is a Medicaid Divorce. Although not nearly as common as it was once, this planning technique allows non-applicant spouses to retain a greater amount of the couple’s assets. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Tennessee to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be executed years prior to the need for long-term care. However, there are some workarounds, such as the Modern Half a Loaf Strategy, and TN Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for the TennCare CHOICES Program
Before You Apply
Prior to applying for the CHOICES Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Applicants must be eligible for TennCare in order to enroll in TennCare CHOICES. Persons already on TennCare should contact their managed care health plan to apply for CHOICES.
Applicants not already enrolled in TennCare should contact their local Area Agency on Aging and Disability (AAAD) office to begin the application process. Alternatively, persons can call 1-866-836-6678 to be connected to their local office. As part of the application process, a level of care (functional) assessment will be completed by the AAAD office.
Additional information about the CHOICES Program can be found here. Persons can also contact TennCare’s Long-Term Services and Supports (LTSS) Help Desk at 1-877-224-0219. TennCare’s Long-Term Care Division, also called the Long-Term Services & Supports (LTSS) Division, administers the CHOICES Program.
Approval Process & Timing
The Medicaid / TennCare application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.