choicesWe’ve known for some time that TennCare would be implementing some major changes in the eligibility criteria for nursing home (NH) and home and community based services (HCBS). These are services offered under the CHOICES program. The newly released Nursing Facility Level of Care (LOC) Guide tells us that to date, Tennessee has been far more generous with its long-term care benefits than most other states, a practice the legislature believes the state cannot sustain. It will be a new game beginning July 1, 2012.

To quote from the Guide:

“TennCare does not plan to simply raise the number of deficiencies required (to qualify for benefits). Rather, we are using an approach that will use the same ADLs and ADL-related and clinical criteria that we use today, and will weight each of those components on a scale of 0 to a maximum or up to 5, depending on the amount of assistance that would be required for a person with that type and level of deficiency.”

To say that the change on July 1 will be smooth is probably far too optimistic. After sitting through a presentation and reading the guide, the emergency rules, and the Q & A responses on TennCare’s website myself, I think it is safe to say that the learning curve will be steep and fraught with variations in interpretation. To share everything in the guide would be confusing and tedious, so here are the highpoints as I understand them:

  1. The Preadmission Evaluation (PAE) form is still the document everyone must complete to be considered for nursing home or community based care services. With a very few exceptions, the health and functional assessment questions on the PAE have stayed the same.
  2. Those seeking admission to a nursing home fall into CHOICES Group 1. Care in a nursing home must be expected to improve or ameliorate the individual’s physical or mental condition, to prevent deterioration in health status, or to delay progression of a disease or disability.
  3. Those who meet the same acuity level as Group 1 but who are seeking to receive a comprehensive package of home or community based services instead of care in a nursing home fall into CHOICES Group 2. Covered services include care in the home, adult day care, or assisted living. Group 2 folks must meet the same physical/functional deficit criteria as those seeking care in a nursing home.
  4. CHOICES Group 3 is new. These recipients are considered “at risk” of needing care in a nursing home but do not meet the acuity level for Group 1 or 2 and can be cared for safely in their own home for up to $15,000 per year excluding the cost of minor home modifications. Care in assisted living is not covered for Group 3.

As all these changes are taking effect, the value of an elder care advocate who knows what the guide says and who can effectively make the case for clients’ needs will exponentially increase. You can wade through the documents yourself here, but don’t feel disheartened if you find the information difficult to absorb and understand. You are not alone. Just get in touch with us at Elder Law of East Tennessee, and we will be happy to help you figure out the best ways to gain access to TennCare benefits and to guide you through the application process.