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

Revised Cost Neutrality Caps

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Revises Medicaid nursing facility reimbursement amounts used to calculate Individual Cost Neutrality Caps for CHOICES Group 2 members who qualify for nursing facility care but elect home- and community-based services, including enhanced respiratory care caps and program exclusions.

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

PolicyRevised Cost Neutrality Caps

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 1, 2022

Next Review DateN/A

Key ActionCare Coordinators should identify CHOICES Group 2 members who may need benefits previously unavailable under the former cap and assess whether their Person-Centered Support Plans should be changed.

SourceLink

POLICY UPDATE CHANGES

The standard CHOICES Individual Cost Neutrality Cap was increased to $82,250 per year based on the revised average Medicaid nursing facility reimbursement.

$82,250/yearStandard CHOICES cap

$228.41/dayAverage nursing facility reimbursement

$144,000/yearTracheal suctioning cap

$216,000/year

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

Revised Cost Neutrality Caps

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

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Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

PolicyRevised Cost Neutrality Caps

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 1, 2022

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

The standard CHOICES Individual Cost Neutrality Cap was increased to $82,250 per year based on the revised average Medicaid nursing facility reimbursement.

$82,250/yearStandard CHOICES cap

$228.41/dayAverage nursing facility reimbursement

$144,000/yearTracheal suctioning cap

$216,000/year

CHOICES Cost Neutrality Cap Applicability

CHOICES cost neutrality cap applicability

Apply the applicable cost neutrality cap only when the individual meets the CHOICES Group 2 and service-setting requirements below.

ALL of the following

ALL of the following
- The individual is enrolled in the CHOICES Program, Group 2.
- The individual would qualify to receive Nursing Facility Care.
- The individual has elected to receive home- and community-based services (HCBS).
- Apply the standard Individual Cost Neutrality Cap of $82,250 per year.

Use the applicable enhanced respiratory care cap when the individual would qualify for the corresponding nursing facility rate

ALL of the following
- The individual would qualify for the Tracheal Suctioning enhanced respiratory care Nursing Facility rate.
- Apply a cap of $144,000 per year ($12,000 per month).
ALL of the following
- The individual would qualify for the Chronic Ventilator enhanced respiratory care Nursing Facility rate.
- Apply a cap of $216,000 per year ($18,000 per month).

Exclusions

Short-term Ventilator Weaning services: no Cost Neutrality Cap amount or 5th prong comparison applies because these services are provided only in an institutional hospital or nursing facility setting.
Employment and Community First CHOICES: the stated amounts do not apply to Expenditure Caps.

Applicable Reimbursement Caps

Standard CHOICES Individual Cost Neutrality Cap

Daily amount$228.41 per day

Monthly amount$6,852.30 per month

Annual amount before rounding$82,227.60 per year

Rounded annual cap$82,250 per year

Tracheal Suctioning Enhanced Respiratory Care Cap

Monthly cap$12,000 per month

Annual cap$144,000 per year

Implementation and Care Coordination Actions

Documentation Required

Assess support plan changes after cap increase

Care Coordinators should identify CHOICES Group 2 members who may need covered benefits that were unavailable under the previous cost cap, prioritize contact with those individuals, and assess whether changes to the Person-Centered Support Plan are needed.

Note

Member notification is not required

Managed care organizations are not required to notify members about the higher cost neutrality cap.

Reimbursement and Participant Terms

Average Cost of Medicaid Nursing Facility Reimbursement

PurposeUsed to determine the Individual Cost Neutrality Cap

ProgramApplies in the CHOICES Program

Eligible populationPersons enrolled in CHOICES Group 2 who would qualify to receive Nursing Facility Care but have elected HCBS

CHOICES Group 2 HCBS Participant

Program groupCHOICES Group 2 individual

Nursing facility eligibilityWould qualify to receive Nursing Facility Care

Selected service setting

Billing Rule

Apply the appropriate individual cost neutrality cap

Apply the applicable Individual Cost Neutrality Cap for CHOICES Group 2 individuals who would qualify for Nursing Facility Care but elect HCBS. Use the enhanced cap when the individual would qualify for the corresponding Tracheal Suctioning or Chronic Ventilator rate; the cap does not apply to short-term Ventilator Weaning services or Employment and Community First CHOICES Expenditure Caps.

Standard cap: $82,250 per year.
Tracheal Suctioning rate: $144,000 per year ($12,000 per month).
Chronic Ventilator rate: $216,000 per year ($18,000 per month).
Short-term Ventilator Weaning has no Cost Neutrality Cap amount or 5th prong comparison because services are provided only in an institutional hospital or nursing facility setting.
The stated amounts apply only to CHOICES, not to Expenditure Caps in the Employment and Community First CHOICES program.