The TennCare CHOICES in Long-Term Services and Supports Program, often referred to as TennCare CHOICES in Long Term Care, is Tennessee’s Medicaid program designed to provide long-term care for seniors and adults living with physical disabilities. This program operates under an 1115 Demonstration Waiver and is committed to offering a range of services, from nursing home care to home and community-based services (HCBS). The primary goal of CHOICES is to support individuals in maintaining their independence and well-being, ideally within their own homes and communities, for as long as possible.
Understanding the TennCare CHOICES Program
TennCare CHOICES is structured around three distinct groups, each catering to different needs and living situations. These groups are differentiated by the level of care required and the setting in which care is received:
- Group 1: This group is for individuals who necessitate a Nursing Facility Level of Care (NFLOC) and currently reside in a nursing home. For those who meet the eligibility requirements, program benefits are guaranteed as an entitlement.
- Group 2: This is designed for individuals who also require a NFLOC but prefer to live at home or in a community setting and receive HCBS. Participation in Group 2 is not an entitlement, and the number of available slots is limited, potentially leading to waitlists.
- Group 3: This group supports individuals who do not require a NFLOC but are considered “at risk” of needing nursing home care without HCBS. Similar to Group 2, benefits are not an entitlement, and enrollment may be subject to waitlists due to limited slots.
Participants in the TennCare CHOICES program not only receive long-term care services but also access comprehensive medical, dental, and behavioral health benefits. These healthcare services are managed through a single Medicaid health plan provided by a Managed Care Organization (MCO). MCOs are essentially private healthcare companies that manage networks of care providers. Participants can choose from available MCO health plans, which currently include BlueCare, United Healthcare Community Plan, and Wellpoint (formerly Amerigroup).
A unique feature of the CHOICES program is the option for consumer direction, particularly for those receiving in-home care. This allows participants greater control over who provides their personal care assistance and homemaker services. Instead of being assigned a caregiver from the MCO network, participants can hire, train, and manage their own caregivers. While certain relatives, such as adult children, can be hired, spouses, legal guardians, and power of attorneys are not eligible for hire. A financial management services agency is responsible for handling employment-related financial tasks, such as tax withholding and caregiver payments.
The program is flexible in terms of living arrangements, accommodating participants in private homes (either their own or a loved one’s), 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.
Benefits Offered Through TennCare CHOICES
TennCare CHOICES offers a comprehensive suite of benefits beyond just case management and nursing facility care, with a focus on HCBS. The specific benefits available can vary depending on the group a participant is enrolled in and are further tailored to individual needs through a personalized care plan. Services available under TennCare CHOICES may include:
- Adult Day Care
- Assisted Living Services: Including personal care assistance, medication management, and homemaker services.
- Assistive Technology: Such as grabbers to aid mobility and daily tasks.
- Benefits Counseling: Employment support focused on advising how earning income may affect TennCare benefits.
- Community Living Supports / Community Living Supports Family Model: Shared living arrangements for up to 4 individuals providing supervision, personal assistance, and transportation. The family model is akin to adult foster care, where beneficiaries live with a host family.
- Companion Care*: Live-in caregivers offering personal care and homemaker services. Typically for those needing both daytime and nighttime care and lacking an unpaid primary caregiver.
- Critical Adult Care Home: Shared residence for up to 5 adults with a live-in healthcare professional providing both medical and long-term care, designed for individuals dependent on ventilators or with traumatic brain injuries.
- Employment Services and Supports
- Enabling Technology: Including sensors, remote support systems, and mobile applications to enhance independence and safety.
- Home Delivered Meals
- Home Modifications: For safety and accessibility enhancements like grab bars, wheelchair ramps, and widened doorways.
- In-Home Respite Care*: Temporary care to give relief to primary caregivers.
- In-Patient Respite Care: Short-term care in facilities like assisted living residences or nursing homes, also for caregiver respite.
- Personal Care Visits*: Assistance with activities of daily living (ADLs) such as bathing, dressing, meal preparation, and toileting. Limited to 2,580 hours annually.
- Personal Emergency Response Systems (PERS)
- Pest Control
- Transportation*: Non-medical transportation services.
* Benefits marked with an asterisk are available for consumer direction, offering more control over who provides these services.
It is important to note that while TennCare CHOICES supports residency in various community settings, it does not cover the costs of room and board in settings like community living support homes, assisted living residences, or critical adult care homes.
For individuals in Group 3, there is an annual cap of $18,000 on the value of services and supports they can receive, excluding minor home modifications.
TennCare CHOICES Eligibility Criteria
To be eligible for TennCare CHOICES, applicants must be Tennessee residents who are either elderly (aged 65+) or adults with physical disabilities (aged 21+). Further eligibility hinges on financial and medical criteria:
Financial Eligibility
Income Limits: The income limit for applicants is set at 300% of the Federal Benefit Rate (FBR), adjusted annually in January. For 2024, this translates to a monthly income limit of $2,829 for both single and married applicants (each spouse is considered individually if both are applying). Importantly, when only one spouse applies, the income of the non-applicant spouse is not considered for the applicant’s eligibility.
To protect against spousal impoverishment, TennCare allows for a Spousal Income Allowance, also known as the Monthly Maintenance Needs Allowance (MMMNA). This mechanism permits the applicant spouse to transfer a portion of their income to the non-applicant spouse. The minimum monthly maintenance needs allowance is set at $2,555 (effective July 2024 – June 2025), and the maximum in 2024 is $3,853.50. The exact amount above the minimum depends on the non-applicant spouse’s shelter and utility costs, but the allowance cannot raise the non-applicant’s total monthly income above the maximum limit.
Asset Limits: In 2024, the asset limit is $2,000 for a single applicant. For married couples where both are applicants, the limit is $4,000. When only one spouse is applying, the assets of both are considered jointly owned by Medicaid. In such cases, the applicant spouse can have up to $2,000 in assets, while the non-applicant spouse is protected by the Community Spouse Resource Allowance (CSRA).
In 2024, the CSRA allows the non-applicant spouse to retain 50% of the couple’s countable assets, up to $154,140. If 50% of the assets is less than $30,828, the non-applicant spouse can keep assets up to this lower threshold.
Certain assets are exempt from Medicaid’s asset calculations, including the applicant’s primary home, household furnishings, personal effects, and a vehicle.
It’s crucial to be aware of Medicaid’s Look-Back Rule. Giving away assets or selling them below fair market value within 60 months of applying for long-term care Medicaid can lead to a Penalty Period of Medicaid ineligibility.
Home Ownership: The primary home is often a significant asset. In Tennessee, Medicaid typically exempts the home under these conditions:
- The applicant lives in the home or intends to return to it, and the home equity interest is $713,000 or less in 2024.
- A spouse of the applicant resides in the home.
- A child under 21 or a blind or disabled child of any age resides in the home.
While the home may be exempt during Medicaid benefit receipt, it might still be subject to Medicaid’s Estate Recovery Program after the beneficiary’s death.
Medical Eligibility
Medically, applicants must require a Nursing Facility Level of Care (NFLOC) or be at risk of needing this level of care. This is assessed through a Pre-Admission Evaluation (PAE). The evaluation considers the need for assistance with Activities of Daily Living (ADLs) such as transferring, mobility, eating, and toileting. Other factors include orientation, communication abilities, medication management, and behavioral issues. Conditions like Alzheimer’s disease or related dementias, which can cause cognitive decline, are also considered, though a dementia diagnosis alone does not automatically qualify an individual for NFLOC.
Qualifying for TennCare CHOICES When Over Income or Asset Limits
Exceeding the income or asset limits for TennCare / Medicaid does not automatically disqualify an applicant. Several Medicaid planning strategies can help otherwise ineligible individuals qualify.
For those with income above the limit, Miller Trusts (or Qualified Income Trusts, known in Tennessee as Qualifying Income Trusts) can be utilized. Excess income is deposited into these trusts, effectively excluding it from countable income for Medicaid eligibility purposes.
For applicants with excess assets, options like Irrevocable Funeral Trusts (IFTs) are available. These trusts for pre-paid funeral and burial expenses are not counted as assets by Medicaid. Another common approach is “spending down” excess assets on allowable expenses such as medical bills, household items, or even one-time expenses like a vacation. For married couples with significant assets and only one spouse applying, Medicaid Divorce is a less common but potentially effective strategy to protect assets for the non-applicant spouse. Numerous other Medicaid planning techniques exist to address asset limits.
It is crucial to implement Medicaid planning strategies correctly and well in advance of needing long-term care, as improper planning or last-minute actions can lead to denial or delay of benefits due to Medicaid’s 60-month Look-Back Rule. Consulting with a professional Medicaid Planner is highly recommended. These experts are knowledgeable about Tennessee-specific strategies and can help navigate the complexities of Medicaid eligibility and planning.
Applying for TennCare CHOICES
Before You Begin Your Application
Before applying, it’s essential to ensure you meet the basic eligibility requirements for TennCare CHOICES, particularly regarding income and assets. Applying without meeting these criteria can result in denial.
Gathering necessary documentation is a critical step. This typically includes Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, bank statements (for up to 60 months prior to application), and proof of income. Incomplete documentation is a common cause of application delays.
The Application Process
To apply for TennCare CHOICES, you must first be eligible for TennCare. If you are already enrolled in TennCare, contact your managed care health plan to begin the CHOICES application process.
If you are not currently a TennCare member, the first step is to contact your local Area Agency on Aging and Disability (AAAD). You can find your local office or get connected by calling 1-866-836-6678. As part of the application, the AAAD office will conduct a functional assessment to determine your level of care needs.
Additionally, you can 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 (LTSS Division) is responsible for administering the CHOICES Program.
Approval Process and Timeline
The Medicaid / TennCare application process can take up to three months or longer from initial application to receiving an approval or denial letter. Completing the application and gathering all required documentation usually takes several weeks. Applications that are incomplete or missing documentation will face delays. While federal law mandates Medicaid offices to review applications within 45 days (up to 90 days for disability cases), delays can still occur. Furthermore, due to potential waitlists, approved applicants might wait several months before actually receiving benefits.
In Summary
TennCare CHOICES is a vital program for Tennessee’s seniors and adults with disabilities, offering crucial long-term care services and supports. Understanding the program’s benefits, eligibility criteria, and application process is the first step towards accessing the care needed to enhance quality of life and maintain independence. For those navigating the complexities of long-term care and Medicaid eligibility, seeking professional guidance can be invaluable in ensuring a smooth and successful application process.
