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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyTennCare ACLF Payment Policy Update | OpenPayer
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    CurrentTennessee Department of Finance and Administration — Division of TennCarePolicy N/A

    2023 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

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    This policy establishes maximum room-and-board charges and payment rules for CHOICES members receiving Assisted Care Living Facility services. It applies to ACLF providers and TennCare Managed Care Organizations and distinguishes non-covered room-and-board costs from covered ACLF services.

    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    Policy2023 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program
    Policy CodePolicy N/A
    Change TypeAnnual rate update
    Effective DateJanuary 1, 2023
    Next Review DateN/A
    Key ActionACLF providers must limit room-and-board charges for CHOICES members to the lesser of $2,193.60 per month or the lower amount charged to a non-CHOICES resident.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    $2,193.60/moMaximum room-and-board charge
    $1,426.84/moMaximum covered ACLF-service reimbursement
    $3,620.44/moMaximum combined facility payment

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    300% SSI FBR
    Personal Needs Allowance basis
    30 daysMinimum discharge notice

    CHOICES ACLF Payment and Room-and-Board Requirements

    CHOICES ACLF Payment and Room-and-Board Requirements

    Covered and billed according to ALL of the following payment and charge requirements:

    ALL of the following

    • ALL of the following

      • The individual is a CHOICES member receiving ACLF services in an Assisted Care Living Facility.
      • Covered ACLF-service reimbursement does not exceed $1,426.84 per month.
      • Room and board is paid by the member or supplemented by family or other outside resources and is not billed as a covered HCBS service.
      • Monthly room-and-board charges do not exceed the lesser of $2,193.60 or the lower amount charged to a resident not enrolled in the CHOICES program.

    • Private-room exception

      • 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 is not a condition of admission and must be solely the decision of the resident or family.

    • Billing prohibition

      • The provider must accept the CHOICES reimbursement for covered ACLF services as payment in full.
      • The provider may not bill the member or family for any portion of covered ACLF-service costs or shift those costs to room-and-board charges.

    Covered Services, Excluded Costs, and Payment Limits

    Covered ACLF service componentsmixedCovered
    Salaries of personal care support employees, homemaker employees, other support staff and supervisors who provide oversightSalaries of personal care support employees, homemaker employees, other support staff and supervisors who provide oversight
    The cost of preparing, serving, and cleaning up after mealsThe cost of preparing, serving, and cleaning up after meals ('raw' food costs are excluded)
    FICA, staff health insurance costs or other benefits, worker's compensation, unemployment compensationFICA, staff health insurance costs or other benefits, worker's compensation, unemployment compensation (as apportioned to support and supervision)
    Staff travelStaff travel
    Resident travelResident travel (including vehicle depreciation)
    Administrative overhead costs of doing businessAdministrative overhead costs of doing business, including office supplies and furnishings, percentage of administrative staff salaries, office telephone, recruitment, audit fees, operating fees/permits/licenses, percentage of office space costs, data processing costs, legal fees
    Staff liability insurance/agency liability insuranceStaff liability insurance/agency liability insurance
    Staff training/development/educationStaff training/development/education
    Room-and-board costs excluded from CHOICES coveragemixedNot Covered
    Rent, mortgage payments, title insurance, mortgage insuranceRent, mortgage payments, title insurance, mortgage insurance
    Property and casualty insuranceProperty and casualty insurance
    Property taxesProperty taxes
    Utilities, resident phone, cable TV, etc.Utilities, resident phone, cable TV, etc.
    Building and/or grounds maintenanceBuilding and/or grounds maintenance
    Residents' 'raw' food costs including individual special dietary needsResidents' 'raw' food costs including individual special dietary needs; the cost of preparing, serving, and cleaning up after meals may be covered under the SWW
    Household supplies and equipment necessary for the room and board of the individualHousehold supplies and equipment necessary for the room and board of the individual
    Furnishings used by the individualFurnishings used by the individual; does not include office furnishings
    Covered ACLF Services Reimbursement
    Maximum monthly reimbursement$1,426.84 per month for covered ACLF services
    Included servicesThe reimbursement applies to personal care services, homemaker services, and medication oversight provided to the enrollee in the ACLF
    Excluded costsThe reimbursement excludes all room-and-board costs
    Personal Needs Allowance
    Monthly allowance$2,742 per month as of January 1, 2023
    SSI basisThe PNA is set at 300% of the federal SSI benefit rate

    Required Provider Billing and Discharge Actions

    Billing Rule

    Apply the maximum room-and-board charge

    Limit monthly room-and-board charges for CHOICES members to the lesser of $2,193.60 or any lesser amount charged to a resident not enrolled in CHOICES.

    Billing Rule

    Handle private-room elections

    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 decision of the resident or family.

    Billing Rule

    Accept covered-service reimbursement as payment in full

    Key Policy Terms

    Assisted Care Living Facility Services
    DefinitionCovered CHOICES care services provided to an enrollee in an Assisted Care Living Facility
    Service examplesServices include personal care, homemaker services, and medication oversight
    Room and boardRoom and board is not included in the defined ACLF Services benefit
    Personal Needs Allowance
    DefinitionThe amount of money a CHOICES member is allowed to keep for community living expenses
    SSI relationshipThe PNA is based on a percentage of the federal SSI benefit rate
    2023 amount
    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    Policy2023 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program
    Policy CodePolicy N/A
    Change TypeAnnual rate update
    Effective DateJanuary 1, 2023
    Next Review DateN/A
    Key ActionACLF providers must limit room-and-board charges for CHOICES members to the lesser of $2,193.60 per month or the lower amount charged to a non-CHOICES resident.
    SourceLink
    On This Page
    CHOICES ACLF Payment and Room-and-Board RequirementsCovered Services, Excluded Costs, and Payment LimitsRequired Provider Billing and Discharge ActionsKey Policy Terms
    PurposeThe allowance is the amount a CHOICES member may keep to meet community living expenses
    Maximum Room-and-Board Charge
    Maximum monthly charge$2,193.60 per month
    Lesser-charge ruleThe charge cannot exceed the lesser of $2,193.60 or the amount charged to a resident not enrolled in CHOICES
    Private-room exceptionA resident or family may voluntarily elect to pay a higher charge for a private room; the election cannot be a condition of admission
    Maximum Combined Facility Payment
    Maximum combined payment$3,620.44 per month for covered ACLF services and room and board
    Private-room exceptionThe maximum does not apply in the same manner when the individual or family voluntarily elects to pay for a private room
    Admission requirementA private-room payment election must be solely the choice of the resident or family and cannot be required for admission
    Discharge Notice for Room-and-Board Delinquency
    Minimum noticeAt least 30 days advance notice of discharge must be provided
    TriggerThe requirement applies when a participant becomes delinquent in paying room-and-board charges
    Provider actionWith proper notice, the ACLF provider may take appropriate steps to discharge the individual

    Accept the CHOICES reimbursement 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.

    Billing Rule

    Collect patient liability separately

    Collect income exceeding the member’s Personal Needs Allowance as patient liability and deduct it from the amount billed to the MCO for covered ACLF services. Patient liability is separate from room-and-board charges.

    Denial Risk

    Follow discharge notice requirements

    If a member becomes delinquent on room-and-board charges, the provider may take appropriate steps to discharge the individual only with proper notice. At least 30 days’ advance notice of discharge must be provided.

    For 2023, the PNA is 300% of the SSI federal benefit rate, or $2,742 per month
    Maximum Room-and-Board Charge
    CalculationThe maximum room-and-board charge is 80% of the maximum PNA, or $2,193.60 per month for 2023
    What it is notThe limit is not 80% of the facility's room-and-board costs
    Lesser amountThe charge is limited to the lesser of $2,193.60 or the amount charged to a resident not enrolled in CHOICES
    Patient Liability
    DefinitionPatient liability is income that exceeds the member's Personal Needs Allowance
    Collection and deductionThe ACLF provider must collect the excess income and deduct it from the amount billed to the MCO for covered ACLF services
    Separate obligationPatient liability is separate from room-and-board costs, which must also be paid to the ACLF provider by the member