Medical Criteria for TennCare Medicaid Eligibility to Change in July

This notice has been posted on the Web site of the Bureau of TennCare (http://www.tn.gov/tenncare/pol-notice.shtml):

TennCare to Hold Public Hearing on Nursing Facility Level of Care Changes
TennCare will host a public hearing to accept comments regarding upcoming changes to the Nursing Facility Level of Care requirements for entry into CHOICES, TennCare's program of long-term services and supports for individuals who are elderly or physically disabled. These changes, which will be applied only to new applicants for CHOICES, are designed to target Nursing Facility services to persons with higher acuity of need, while simultaneously making Home and Community Based Services more broadly available.
The public hearing will be held from 1:30 to 3:30 p.m. on May 7, 2012, at the Bordeaux Branch of the Nashville Public Library, which is located at 4000 Clarksville Pike.
You can find more information about the Level of Care changes in the Nursing Facility Level of Care Guide.

What do these changes foretell for the people of Tennessee who need financial help from the State to meet their needs for long-term care?

First, however, a bit of background. In 2008, the Tennessee General Assembly enacted the Long-Term Care Community Choices Act.

The CHOICES law significantly changed the way that TennCare Medicaid benefits would be provided in the state. Structurally, the State turned over to private managed care organizations administration of the State’s Medicaid program, both the acute care portion (that pays medical expenses) and the long-term care portion (that pays for nursing home care and the like).

Beginning in 2010, the long-term care portion was implemented statewide, towards the goal of helping more people who might be able to stay in the community receiving home-and community-based services (HCBS) rather than be in a nursing home.

Thus, with some help from Tennessee’s Medicaid program, the frail elder who needs help with getting out of bed and using the toilet (“Activities of Daily Living” or ADLs) might be able to stay at home rather than move to a nursing home, which likewise would be paid for by the same Medicaid program – but at a much higher cost.

That’s why the State calls the program “CHOICES”: for people who meet the criteria for eligibility (financial and medical), they would have the choice under the Medicaid program where they would want to live.

That’s the choice, and most would likely to choose to get CHOICES services at home, paid for by Tennessee’s Medicaid program.

That’s the good part. Who wouldn’t want to stay at home if the other choice is to go to the nursing home? The issue is more complicated than that, however.

Tennessee’s “level of care” (LOC) criteria – the individual’s capacity for self-care in such basic tasks as eating, toileting, mobility, and transferring – is set to change, on July 1.

An individual who has a deficit in only one of these areas will satisfy the State’s current level of care criteria to receive nursing home services. Starting in July, however, says the Bureau of TennCare in its Nursing Facility Level of Care Guide,

Eligibility for NF [Nursing Facility] services will be based on each applicant’s cumulative score, which reflects the acuity of that person’s needs. In some instances, 3 ADL deficiencies will qualify a person for NF care (or comprehensive HCBS). In some instances only 2 ADL deficiencies and the need for a skilled service will qualify a person for NF care. And in some instances, it may require deficiencies in 4 (or more) ADLs, ADL-related or skilled or rehabilitative needs to qualify for NF LOC.

People who have one ADL deficit won’t meet this criteria for needing nursing home care anymore, but they will not automatically be denied CHOICES benefits. Instead, they would be assessed as needing a lower level of care, receiving fewer services, at home, and subject to a cap on enrollment.

The determination of a CHOICES applicant’s level of care needs -- the kind and degree of services to be provided to meet the applicant's needs -- is not made by a government agency. It is made by a private managed care organization.
 

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