CurrentTennessee Department of Finance and Administration — Division of TennCarePolicy N/A

2022 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

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Establishes maximum room-and-board charges for CHOICES members receiving covered Assisted Care Living Facility services, distinguishes covered services from non-covered costs, and sets provider payment and patient-liability requirements.

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

Policy2022 Maximum Room and Board Charges for Persons Receiving ACLF Services in the CHOICES Program

Policy CodePolicy N/A

Change TypeNew maximum allowable room-and-board charges

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionLimit CHOICES member room-and-board charges to the lesser of $2,018.50 per month or the lower amount charged to a non-CHOICES resident.

SourceLink

POLICY UPDATE CHANGES

The policy establishes new maximum allowable room-and-board charges for CHOICES members receiving ACLF services.

$2,523Monthly Personal Needs Allowance

$2,018.50Maximum monthly room and board

$1,305Maximum covered ACLF service reimbursement

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CurrentTennessee Department of Finance and Administration — Division of TennCarePolicy N/A

2022 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

Customize your policy alerts

Sign up for all Tennessee Department of Finance and Administration — Division of TennCare policy alerts

Know when Tennessee Department of Finance and Administration — Division of TennCare releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

Policy2022 Maximum Room and Board Charges for Persons Receiving ACLF Services in the CHOICES Program

Policy CodePolicy N/A

Change TypeNew maximum allowable room-and-board charges

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionLimit CHOICES member room-and-board charges to the lesser of $2,018.50 per month or the lower amount charged to a non-CHOICES resident.

SourceLink

POLICY UPDATE CHANGES

The policy establishes new maximum allowable room-and-board charges for CHOICES members receiving ACLF services.

$2,523Monthly Personal Needs Allowance

$2,018.50Maximum monthly room and board

$1,305Maximum covered ACLF service reimbursement

Maximum combined monthly payment

30 daysAdvance discharge notice

ACLF Coverage and Cost Allocation

CHOICES ACLF Service and Room-and-Board Payment Rules

CHOICES members may receive covered ACLF services only when they qualify for the benefit and the services are identified in an approved Person Centered Support Plan. Room and board is not included in the defined ACLF Services benefit and is not covered as HCBS.

ALL of the following

The individual is a CHOICES member who qualifies to receive ACLF services.
ACLF services are identified in an approved Person Centered Support Plan.
The ACLF is a CHOICES provider and accepts TennCare's reimbursement for covered ACLF Services as payment in full.

Room-and-board payment rules

The member must use personal resources to pay room and board, or room-and-board costs may be supplemented by family or other outside resources.
For 2022, the maximum monthly room-and-board charge is the lesser of $2,018.50 (80% of the $2,523 monthly Personal Needs Allowance) or the lesser amount charged to a resident who is not enrolled in CHOICES.
The room-and-board limit is 80% of the maximum Personal Needs Allowance—not 80% of the facility's room-and-board costs. If actual room-and-board costs are $2,018.50 or less per month, the full actual costs may be billed to the CHOICES member.
The room-and-board maximum is adjusted annually in accordance with the federal SSI benefit rate and applies only to CHOICES members, not other ACLF residents.
A resident or family may voluntarily elect to pay the additional difference between the ACLF's private-room and semi-private-room charges. The private-room election must not be a condition of admission and must be solely the resident's or family's decision; the additional amount may not otherwise offset room-and-board limits.

Payment and collection requirements

TennCare's covered ACLF-services reimbursement may not exceed $1,305 per month and excludes all room-and-board costs.
When covered ACLF services are combined with the maximum room-and-board charge, the maximum total facility payment is $3,323.50 for 2022, unless the individual or family voluntarily elects to pay for a private room; that election must not be a condition of admission.
Income exceeding the member's Personal Needs Allowance must be collected by the ACLF provider as patient liability and deducted from the amount billed to the MCO for covered ACLF services—not room and board. Patient-liability payments are in addition to room-and-board charges.
If the member becomes delinquent in paying room and board, the ACLF may, with proper notice, take appropriate steps to discharge the individual; at least 30 days' advance notice of discharge is required.

Covered Versus Non-Covered ACLF Costs

CHOICES covers the actual care provided to the enrollee in the ACLF—personal care, homemaker services, and medication oversight—but does not cover room and board. Providers may not bill the member or family for covered-service costs or shift those costs into non-covered room-and-board charges.

Examples of non-covered room-and-board costs

Rent, mortgage payments, title insurance, and mortgage insurance.
Property and casualty insurance and property taxes.
Utilities, resident telephone service, and cable television.
Building and grounds maintenance.
Residents' raw food costs, including individual special dietary needs; the cost of preparing, serving, and cleaning up after meals may be a covered ACLF-service component under the applicable program.

Payment Limits and Allowable Charges

Maximum Monthly Covered ACLF Service Reimbursement

Maximum reimbursement$1,305 per month for covered ACLF services

Included costsThe reimbursement applies to actual care, including personal care, homemaker services, and medication oversight provided in the ACLF

Excluded costsRoom-and-board costs are excluded from the covered ACLF service reimbursement

Maximum Monthly Room-and-Board Charge

Monthly maximumRoom-and-board charges cannot exceed $2,018.50 per month

Lesser-of ruleThe applicable charge is the lesser of $2,018.50 or any lower amount charged to a resident not enrolled in the CHOICES program

Provider Billing and Discharge Requirements

Billing Rule

Apply the room-and-board maximum

Limit room-and-board charges for CHOICES members receiving TennCare-paid ACLF services to the lesser of $2,018.50 per month or the lower amount charged to a non-CHOICES resident. A resident or family may voluntarily elect an additional private-room differential, subject to the policy limits.

Denial Risk

Do not condition admission on private-room payment

Do not require payment of the higher private-room amount as a condition of admission. The private-room election must be solely the decision of the resident and/or family.

Key Payment Terms

Personal Needs Allowance (PNA)

PurposeThe Personal Needs Allowance is the amount a CHOICES member may retain to meet community living expenses

2022 amountThe CHOICES PNA is $2,523 per month, set at 300% of the SSI federal benefit rate as of January 1, 2022

Room-and-board calculationThe maximum room-and-board charge is calculated as 80% of the maximum PNA, or $2,018.50 for 2022

Room and Board

Housing costsRoom and board includes rent or mortgage payments, title or mortgage insurance, property and casualty insurance, and property taxes

Household costsIt includes utilities, resident telephone and cable television, building or grounds maintenance, household supplies and equipment, and individual furnishings

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

Policy2022 Maximum Room and Board Charges for Persons Receiving ACLF Services in the CHOICES Program

Policy CodePolicy N/A

Change TypeNew maximum allowable room-and-board charges

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionLimit CHOICES member room-and-board charges to the lesser of $2,018.50 per month or the lower amount charged to a non-CHOICES resident.

SourceLink

On This Page

Household supplies and equipment necessary for the individual's room and board.

Furnishings used by the individual, excluding office furnishings.

Examples of covered ACLF-service costs

Salaries of personal-care support employees, homemaker employees, other support staff, and supervisors who provide oversight.
Preparing, serving, and cleaning up after meals; raw food costs are excluded.
FICA, staff health insurance, other staff benefits, workers' compensation, and unemployment compensation, apportioned to support and supervision.
Staff travel and resident travel, including vehicle depreciation.
Administrative overhead for doing business, including office supplies and furnishings; the applicable percentage of administrative staff salaries and office telephone costs; recruitment; audit fees; operating fees, permits, and licenses; the applicable percentage of office-space costs; data processing; and legal fees.
Staff liability insurance and agency liability insurance.
Staff training, development, and education.

Allocation and billing restrictions

Federal financial participation under CHOICES is limited to actual care provided to the enrollee, including personal care services, homemaker services, and medication oversight; room and board is excluded under 42 CFR § 441.310(a)(2) and the State's approved 1115 Waiver.
A CHOICES ACLF provider must accept the CHOICES reimbursement for covered ACLF Services as payment in full.
The ACLF may not bill the CHOICES member or family for any portion of covered ACLF-service costs.
The ACLF may not shift any portion of covered ACLF-service costs to non-covered room-and-board charges.

This limit applies to CHOICES members when TennCare is paying for ACLF services

Private-Room Differential

Permitted differentialThe additional amount is limited to the difference between the ACLF's private-room and semi-private-room charges for a non-Medicaid resident

Voluntary electionA resident or family may voluntarily elect to pay the higher monthly charge for a private room

Admission protectionPayment of the higher private-room amount cannot be a condition of admission

Maximum Combined Monthly Payment

Combined monthly maximumThe maximum total payment to the facility is $3,323.50 when covered ACLF services paid by TennCare are combined with room and board

Private-room exceptionThe maximum does not apply in the same manner if the individual or family elects to pay for a private room

Election requirementThe private-room option must be the choice of the resident or family and cannot be a condition of admission

Billing Rule

Accept covered-service reimbursement as payment in full

Accept the amount of reimbursement provided under CHOICES for covered ACLF services as payment in full. Do not bill the member or family for any portion of covered ACLF service costs or shift those costs to non-covered room-and-board charges.

Documentation Required

Follow notice requirements for delinquent room-and-board payments

If room-and-board payments become delinquent, take discharge steps only with proper notice. Provide at least 30 days’ advance notice of the discharge.

Food costsIt includes the resident's raw food costs, including individual special dietary needs; meal preparation, serving, and cleanup may be covered ACLF services

Covered ACLF Services

Personal-care and support staffCovered services include salaries for personal-care, homemaker, and other support employees, supervisors, and oversight staff

Meals and apportioned costsMeal preparation, serving, and cleanup are covered, along with apportioned staff benefits, worker's compensation, unemployment compensation, and related support costs; raw food costs are excluded

Other allowable costsCovered costs include staff and resident travel, administrative overhead, liability insurance, and staff training, development, and education

Patient Liability

Source of liabilityIncome exceeding the member's Personal Needs Allowance must be collected by the ACLF provider as patient liability

Billing treatmentPatient liability is deducted from the amount billed to the MCO for covered ACLF services

Not room and boardPatient liability is deducted from covered ACLF service billing, not from room-and-board charges