Navigating the landscape of long-term care can be overwhelming, especially when it comes to financial assistance. In Tennessee, Tenncare Choices In Long Term Care Program offers a crucial lifeline for seniors and adults with disabilities needing long-term services and supports. This program, often simply referred to as CHOICES, is a Tennessee Medicaid initiative designed to provide comprehensive long-term care through a managed care system. While nursing home care is a part of the program, TennCare CHOICES strongly emphasizes home and community-based services (HCBS) to help individuals remain in their homes and communities, delaying or preventing the need for institutional care. These vital supports can include adult day care, home-delivered meals, personal care, homemaker services, home modifications, and respite care, tailored to meet individual needs.
Overview of the TennCare CHOICES Program
The TennCare CHOICES in Long Term Care Program operates under Medicaid managed care, focusing on delivering long-term services and supports to Tennessee residents who are elderly or have physical disabilities. The program is structured into three distinct groups, each catering to different living situations and levels of care requirements:
- Group 1: This group is for individuals who require a Nursing Facility Level of Care (NFLOC) and are currently living in a nursing home. For those who meet the eligibility criteria, program benefits are guaranteed as an entitlement, ensuring immediate access to necessary care.
- Group 2: Designed for individuals who also necessitate a NFLOC but prefer to receive care at home or within their community through home and community-based services. It’s important to note that unlike Group 1, benefits for Group 2 are not an entitlement. Enrollment is limited, and a waitlist may exist for program participation due to the capped number of participant slots.
- Group 3: This category is for individuals who do not require a NFLOC but are considered “at risk” of needing nursing home care without the support of home and community-based services. Similar to Group 2, program benefits are not an entitlement, and participation may be subject to waitlists due to limited slots.
Participants in the TennCare CHOICES program benefit from a comprehensive healthcare approach. Beyond long-term care services, the program provides medical, dental, and behavioral health benefits through a single Medicaid health plan managed by a Managed Care Organization (MCO). These MCOs, essentially private healthcare companies, contract with networks of care providers. Program participants can select from a range of managed care health plans, currently including BlueCare, United Healthcare Community Plan, and Wellpoint (formerly Amerigroup), ensuring they have choices in their healthcare coverage.
A notable feature of TennCare CHOICES is the option for consumer direction, offering greater control over in-home care services. This option allows participants receiving in-home care to hire, train, and manage their own caregivers for personal care assistance and homemaker services, rather than being assigned a caregiver from the MCO’s network. While certain relatives, such as adult children, can be hired, spouses, legal guardians, and those with power of attorney are not eligible to be hired as paid caregivers under this program. A financial management services agency is responsible for handling the employment’s financial aspects, including tax withholdings and caregiver payments, simplifying the process for participants.
TennCare CHOICES participants have flexibility in their living arrangements. They can reside in various settings, including their own homes or the homes of loved ones, community living support homes, community living support family model homes (similar to adult foster care), assisted living facilities, critical adult care homes, and nursing homes, ensuring the program can accommodate diverse living preferences and needs.
Benefits of the TennCare CHOICES Program
TennCare CHOICES offers a wide array of benefits beyond just case management and nursing facility care. The specific benefits available are determined by the participant’s enrolled group and are further tailored by an individualized care plan. While the services can vary, potential benefits include a comprehensive suite of supports, with certain services marked with an asterisk (*) indicating they are available for consumer direction:
- Adult Day Care
- Assisted Living Services: Encompassing personal care assistance, medication management, and homemaker services.
- Assistive Technology: Including devices like grabbers to aid independence.
- Benefits Counseling: Employment support providing guidance on how earnings may affect TennCare benefits.
- Community Living Supports / Community Living Supports Family Model: Shared living environments for up to 3 individuals, offering supervision, physical assistance, and transportation. The family model provides a home-like setting with a host family, akin to adult foster care.
- Companion Care*: Live-in caregivers offering personal care and homemaker services, specifically for those needing both daytime and nighttime care and lacking an unpaid primary caregiver.
- Critical Adult Care Home: Shared residences for up to 4 individuals, staffed by a healthcare professional providing both medical and long-term care, intended for those with conditions like ventilator dependency or traumatic brain injuries.
- Employment Services and Supports
- Enabling Technology: Including sensors, remote support systems, and mobile applications to enhance care and safety.
- Home Delivered Meals
- Home Modifications: For safety and accessibility enhancements such as grab bars, wheelchair ramps, and widened doorways.
- In-Home Respite Care*: Short-term care provided at home to offer relief for primary caregivers.
- In-Patient Respite Care: Short-term care in facilities like assisted living residences or nursing homes to give primary caregivers a break.
- Personal Care Visits*: Scheduled visits to assist with Activities of Daily Living (ADLs) like bathing, dressing, meal preparation, eating, and toileting, limited to 2,580 hours annually.
- Personal Emergency Response Systems (PERS)
- Pest Control
- Transportation*: Non-medical transportation services.
It’s important to note that while TennCare CHOICES supports participants in various community living settings, including assisted living and critical adult care homes, the program does not cover the costs of room and board in these facilities. Furthermore, individuals in Group 3 have an annual limit of $18,000 for services and supports, excluding minor home modifications, emphasizing the need to carefully consider service utilization within this group.
Eligibility Requirements for TennCare CHOICES
To be eligible for the TennCare CHOICES Program, applicants must be Tennessee residents who are either elderly (aged 65+) or adults with physical disabilities (aged 21+). Beyond these basic criteria, there are specific financial and medical requirements that must be met.
Financial Criteria: Income, Assets & Home Ownership
Income: The income limit for TennCare CHOICES is set at 300% of the Federal Benefit Rate (FBR), which is adjusted annually each January. In 2024, this translates to a monthly income cap of $2,829 for a single applicant, regardless of marital status. For married couples where both spouses are applying, each spouse is assessed individually and can have income up to this limit. When only one spouse is applying, the income of the non-applicant spouse is not considered for the applicant’s eligibility. Moreover, to prevent spousal impoverishment, a portion of the applicant spouse’s income can be transferred to the non-applicant spouse as a Spousal Income Allowance, also known as a Monthly Maintenance Needs Allowance (MMMNA).
There’s a minimum MMMNA set at $2,555 per month (effective July 2024 – June 2025), ensuring the non-applicant spouse has a basic level of financial support. The maximum MMMNA in 2024 is $3,853.50 per month, potentially allowing for a higher allowance based on shelter and utility costs, but the total monthly income for the non-applicant spouse cannot exceed this maximum.
Assets: In 2024, the asset limit for a single TennCare CHOICES applicant is $2,000. For married couples with both spouses applying, the combined asset limit is $4,000. Even when only one spouse is applying, the assets of both are considered due to Medicaid’s view of marital assets as jointly owned. In such cases, the applicant spouse is limited to $2,000 in assets, while the non-applicant spouse is protected by the Community Spouse Resource Allowance (CSRA).
The 2024 CSRA allows the non-applicant spouse to retain 50% of the couple’s countable assets, up to a maximum of $154,140. If 50% of the assets is less than $30,828, the non-applicant spouse can keep the entire amount, up to $30,828.
Certain assets are exempt from Medicaid’s countable asset limit. These typically include the applicant’s primary home, household furnishings, personal effects, and a vehicle, providing some financial relief and security. It is crucial to be aware of Medicaid’s Look-Back Rule, which scrutinizes asset transfers within 60 months of application. Gifting assets or selling them below fair market value during this period can lead to a Penalty Period of Medicaid ineligibility.
Home Ownership: For many Tennessee Medicaid applicants, their home is their most valuable asset, raising concerns about potential loss. However, TN Medicaid exempts the home under specific conditions:
- If the applicant lives in the home or intends to return, and their home equity interest is $713,000 or less in 2024. Home equity is the home’s current value minus any mortgage, and equity interest is the applicant’s ownership portion.
- If the applicant’s spouse resides in the home.
- If the applicant has a child under 21 living in the home.
- If the applicant has a blind or disabled child of any age living at home.
While the home is generally protected during Medicaid benefits receipt, it may be subject to Medicaid Estate Recovery Program after the beneficiary’s death.
Medical Criteria: Functional Need
To qualify medically for TennCare CHOICES, an applicant must require a Nursing Facility Level of Care (NFLOC) or be at risk of needing this level of care. This is determined through a Pre-Admission Evaluation (PAE). The assessment considers the need for assistance with Activities of Daily Living (ADLs) such as transferring, mobility, eating, and toileting. Other factors evaluated include orientation, communication abilities, medication management, and behavioral issues like aggression or wandering. Individuals with Alzheimer’s disease or related dementias may exhibit deficits in these areas due to cognitive decline, but a dementia diagnosis alone does not automatically qualify one for NFLOC.
Qualifying When Over the Limits
Exceeding the income and/or asset limits for TennCare Medicaid does not automatically disqualify an applicant. Various Medicaid planning strategies exist to help individuals who would otherwise be ineligible to qualify for TennCare CHOICES. Some strategies are straightforward, while others are more complex and require expert guidance.
For those with income above the limit, Miller Trusts, specifically known as Qualifying Income Trusts in Tennessee, can be utilized. Excess income is deposited into these trusts, effectively removing it from countable income for Medicaid eligibility purposes.
For applicants with excess assets, Irrevocable Funeral Trusts (IFTs) are a common option. These pre-paid funeral and burial expense trusts are not counted as assets by Medicaid. Another approach is to “spend down” excess assets on allowable expenses such as medical bills, home furnishings, or even one-time expenditures like a vacation. For married couples with significant assets and only one spouse needing Medicaid, Medicaid Divorce is a less common but potentially effective strategy to protect a larger portion of the couple’s assets for the non-applicant spouse. Numerous other Medicaid planning techniques are available to address asset overages.
Improper or inadequate Medicaid planning can lead to application denial or delays in receiving benefits. Consulting with professional Medicaid Planners is highly recommended. These experts are well-versed in Tennessee’s Medicaid planning strategies and can help navigate the complex financial eligibility criteria without jeopardizing Medicaid eligibility. Many effective strategies must be implemented well in advance of needing long-term care due to Medicaid’s 60-month Look-Back Rule. However, strategies like the Modern Half a Loaf Strategy offer workarounds, and TN Medicaid Planners are knowledgeable about these options. Therefore, seeking professional advice is crucial when needing to qualify for TennCare CHOICES while exceeding income or asset limits.
How to Apply for the TennCare CHOICES Program
Before You Apply
Prior to starting the TennCare CHOICES application, it’s essential to confirm that you meet the basic eligibility requirements. Applying while exceeding income or asset limits without proper planning will likely result in denial. Utilizing a Medicaid Eligibility Test can be a helpful preliminary step to assess potential eligibility.
Gathering necessary documentation is a critical step in the application process. This includes copies of Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, bank statements for the 60 months preceding the application, and proof of income. Incomplete documentation or delays in submission are common causes for application processing delays.
Application Process
To enroll in TennCare CHOICES, applicants must first be eligible for TennCare. Current TennCare enrollees should contact their managed care health plan to initiate the CHOICES application process.
Individuals not yet enrolled in TennCare should contact their local Area Agency on Aging and Disability (AAAD) office to begin the application process. Alternatively, you can call 1-866-836-6678 to be connected to your local AAAD office. As part of the application, the AAAD office will conduct a functional (level of care) assessment.
You can also reach out to TennCare’s Long-Term Services and Supports (LTSS) Help Desk at 1-877-224-0219 for assistance. The TennCare Long-Term Care Division, also known as the Long-Term Services & Supports (LTSS) Division, is responsible for administering the CHOICES Program.
Approval Process & Timing
The TennCare/Medicaid application process can be lengthy, potentially taking up to 3 months or longer from initial application to receiving an approval or denial letter. Completing the application and gathering all required documentation can take several weeks. Applications that are incomplete or lack necessary documentation will face further delays. While federal law mandates Medicaid offices to review applications within 45 days (up to 90 days for disability applications), delays beyond these timeframes can occur. Furthermore, even after approval, waitlists may mean a waiting period of several months before receiving benefits, particularly for Groups 2 and 3 of the TennCare CHOICES program.
