How Many Choices Are There
What are the standards for qualification? To qualify for any of the three groups of Choices, an applicant must qualify medically and financially. Prior to July 1, 2012, medical qualification could be achieved by having a significant deficiency in one activity of daily living (ADL). To qualify for Choices Group 1 or 2 after July 1, 2012, the new pre-admission evaluation (PAE) standards require an applicant to score a 9 out of a possible 26 on a new weighted scale that’s made up of ADL’s. Choices Group 3, or the “at risk for nursing home care” group, uses the same ADL weighted scale, but an applicant must score between 1 and 3 in certain areas. While the PAE score ranges differ for the three groups, the financial standards are the same across the board. An applicant for benefits under any group must have less than $2,000.00 in their name to qualify for the program.
Where can an applicant qualify for Choices Group 1? When an applicant is approved for Choices Group 1, they are approved in the nursing home setting. An application for Group 1 can not be approved until the applicant has been institutionalized for at least thirty days. The thirty day clock of institutionalization starts when an applicant enters the hospital or nursing home facility and stays there consistently for the thirty days without returning home. Once the criteria of institutionalization, medical qualification, and financial qualification are met, an applicants benefits can be approved, and they will be assigned a managed care organization (MCO). Qualification under Group 1 means that the Medicaid program will assist the applicant in covering their room and board charge at the nursing home facility, charges related to many prescription drug costs, and various other needs. Because the Choices program is a cost-sharing program, the state only covers up to the point that the applicants monthly income is insufficient, as determined by the Choices worker.
How does Group 2 differ from Group 1? While Group 2 has the same PAE and financial qualification standards, the location in which an application can receive benefits is different. Group 2 participants can receive their benefits in the home or in an assisted living facility that has chosen to participate in the Choices program. However, the services for Group 2 must be cost neutral when compared to what the Choices program would pay for the same applicant that’s approved for Group 1. In the home setting, an applicant can received up to 27 hours per week in services. Very often, applicants approved in the nursing home are re-assessed to see if they would like to receive their care in one of the alternative settings that Group 2 allows. Group 2 is the reason that the program is called Choices. That is the central idea of the Choices program that an applicant for benefits can choose where they want to receive their care. Like Group 1, Choices Group 2 has some cost-sharing associated with approval. In 2014 for Group 2, all income for a single applicant above 300% of the poverty level ($2,163.00) would be owed to the Choices program for services rendered. Specifically, the (MCO) that the application is assigned to is responsible for the collection of liability owed. This is another way in which Group 2 differs from Group 1. In Group 2, the applicant is allowed to keep a substantial part of their income to pay for normal monthly household bills.
Why is Group 3 called the “at risk” group? When the medical qualification for Choices changed in July 2012, the state understood that many people would no longer qualify for the program under the new standards. Because of this, they had to develop a qualification group that encompassed those on the edge of qualification for Group 1 or 2. That group became known as Group 3 or the “at risk” group. Those approved under this category, can receive up to $15,000.00 per year in services. The $15,000.00 per year must be spread out equally over 12 months. The amount of services this provides is at the discretion of the MCO based on the cost of services. The Group 3 program was scheduled to end as of December 31, 2013, but legislators recently made the decision to extend the program through June 30, 2015.
As of January 1, 2014, the application process for Choices benefits will change. The applications for Choices will no longer be handled through the Department of Human Services (DHS). Applications filed January 1, 2014 forward will be handled through the Bureau of TennCare. The State of Tennessee is opening a new service center to help with TennCare called the Tennessee Health Connection. Many facts about the new process are unknown at this time.