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How to qualify for TennCare’s CHOICES program

Posted on Saturday, May 18, 2019 at 11:01 am

In Tennessee, around 20 percent of people receive their health insurance through TennCare, the state Medicaid plan — about 1.3 million people in all.

There are several aspects to TennCare, but one part is the CHOICES program (short for CHOICES in Long-Term Services and Supports), designed both for people in need of nursing home care and people who can’t afford the cost of an assisted living facility or nursing home, but need help remaining in their own homes. Given its purpose, most of the people served by CHOICES are seniors.

Few people know how to navigate TennCare procedures well enough to pursue these options independently. Many seniors who apply have experiential knowledge of CHOICES, but they haven’t read the numerous pages of rules and regulations surrounding each minute detail, nor should they have to.

Enter the Tennessee Senior Law Alliance (TSLA), a program launched in 2018 by Legal Aid Society of Middle Tennessee and the Cumberlands and four partner legal services organizations across the state in an effort to help low-income senior citizens. As representatives of TSLA, we want potential CHOICES recipients to understand the basics of how the program works — and how we can help.

The basics

First, a few basics: The CHOICES program offers three levels of care – from basic nursing home care to in-home care costing no more than $15,000 per year – and eligibility is determined by strict financial and medical criteria.

For example, if an individual’s monthly income is more than $2,313 and their resources are more than $2,000 (excluding a home and one car), they do not qualify for any CHOICES services, despite his or her medical condition. With nursing home costs reaching upwards of $6,000 per month, many people are left ineligible for CHOICES and incapable of paying for needed care.

In addition to these financial requirements, CHOICES also has very strict medical criteria. For certain groups, an applicant must score a nine on TennCare’s “acuity scale,” which quantifies difficulties of daily living, such as transferring from a bed to a wheelchair or being able to eat or take medications without more than limited assistance.

While these qualifications are strict, there are some options if at first you don’t qualify for CHOICES. For example, if your monthly income is too high to qualify, you could set up a Qualified Income Trust (QIT) and deposit excess money so you don’t exceed the CHOICES income cap.

An example

To understand how Legal Aid Society’s TSLA program can help, let’s imagine a hypothetical CHOICES enrollee, Ms. Smith. She has resided for a number of years in a nursing home, receiving CHOICES assistance to pay for her nursing home services. Ms. Smith receives a notice from TennCare that she is no longer eligible for CHOICES. She’s 80 years old, she is incontinent and cannot clean up after herself without assistance, she cannot move without a walker, and she cannot prepare her own meals or medication. If Ms. Smith loses her CHOICES care, she cannot afford to stay in the nursing home and she will be involuntarily discharged.

Let’s figure out why TennCare would find Ms. Smith ineligible for CHOICES. Because she always needs assistance due to her incontinence, she will be given three points on the acuity scale. But because she can get around using a walker, she will receive no points in the mobility category.

What about medication? Even if Ms. Smith can’t physically open pill bottles, she will receive no points as long as she can swallow or otherwise take medication that is placed in her hand or in a pill cup at the appropriate time.

The same strict standard applies to the eating category – despite the fact that Ms. Smith cannot prepare meals, if she can lift food to her mouth and remember to eat without verbal assistance, she will receive zero points on the scale. Despite her many limitations, she receives only three points – well short of the nine required by TennCare’s rules.

Ms. Smith may, justifiably, be very frightened to see a notice from TennCare that she will no longer be eligible for assistance paying for nursing home services that she cannot afford alone. However, she has help. Through the TSLA program, Legal Aid Society is helping seniors navigate the CHOICES application and appeals process, and thereby proving to TennCare who is truly in need of their services.

When working with a client like Ms. Smith, TSLA staff might request that TennCare perform a safety determination to see if she should continue to be eligible for CHOICES, even without scoring a nine on the scale. TSLA staff might discover that Ms. Smith experienced a number of recent falls, some of which resulted in injuries and even short-term hospitalizations. On appeal, a TSLA attorney could argue that Ms. Smith needs incontinence assistance and hands-on assistance with mobility and transfer to prevent her from falling again, thus she needs more than seven hours per day of caregiver assistance for her to be safely served. Under TennCare’s strict rules – which deny medical approval for those who cannot prove they require more than seven hours per day of care – this could preserve Ms. Smith’s CHOICES nursing home services.

Let’s figure out why TennCare would find Ms. Smith ineligible for CHOICES. Because she always needs assistance due to her incontinence, she will be given three points on the acuity scale. But because she can get around using a walker, she will receive no points in the mobility category.

What about medication? Even if Ms. Smith can’t physically open pill bottles, she will receive no points as long as she can swallow or otherwise take medication that is placed in her hand or in a pill cup at the appropriate time.

The same strict standard applies to the eating category – despite the fact that Ms. Smith cannot prepare meals, if she can lift food to her mouth and remember to eat without verbal assistance, she will receive zero points on the scale. Despite her many limitations, she receives only three points – well short of the nine required by TennCare’s rules.

Ms. Smith may, justifiably, be very frightened to see a notice from TennCare that she will no longer be eligible for assistance paying for nursing home services that she cannot afford alone. However, she has help. Through the TSLA program, Legal Aid Society is helping seniors navigate the CHOICES application and appeals process, and thereby proving to TennCare who is truly in need of their services.

When working with a client like Ms. Smith, TSLA staff might request that TennCare perform a safety determination to see if she should continue to be eligible for CHOICES, even without scoring a nine on the scale. TSLA staff might discover that Ms. Smith experienced a number of recent falls, some of which resulted in injuries and even short-term hospitalizations. On appeal, a TSLA attorney could argue that Ms. Smith needs incontinence assistance and hands-on assistance with mobility and transfer to prevent her from falling again, thus she needs more than seven hours per day of caregiver assistance for her to be safely served. Under TennCare’s strict rules – which deny medical approval for those who cannot prove they require more than seven hours per day of care – this could preserve Ms. Smith’s CHOICES nursing home services.

TSLA helps

TSLA helps seniors not only with CHOICES but also other core legal issues like housing, abuse and exploitation, consumer finance and more. We help bridge the gap between the needs of seniors and the state agencies responsible for meeting those needs.

The importance of programs like TSLA should be self-evident. It is our goal to simplify complex legal matters and help seniors get the care they deserve. If you feel you have unfairly lost your TennCare or CHOICES coverage, or if you are a senior struggling with another legal issue, please contact us. We’re also happy to work with other organizations that serve low-income and senior Tennesseans to provide attorney-lead training sessions and accept referrals.

Legal Aid Society of Middle Tennessee and the Cumberlands provides assistance on civil legal matters to eligible residents across 48 counties in Middle Tennessee and the Cumberland Plateau. Call 800-238-1443 to learn more.