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

    Revised Expenditure Caps and Institutional Cost Limit

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    Establishes expenditure caps for specified members enrolled in Employment and Community First CHOICES Groups 6, 7, and 8, and the individually applied institutional cost limit for Section 1915(c) Statewide HCBS Waiver participants who elect home- and community-based services.

    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyRevised Expenditure Caps and Institutional Cost Limit
    Policy CodePolicy N/A
    Change TypeRevised
    Effective DateJanuary 1, 2022
    Next Review DateN/A
    Key ActionAssess whether person-centered support plan changes are needed for members who may qualify for benefits newly available under the higher cost-neutrality caps.
    SourceLink
    POLICY UPDATE CHANGES

    Calendar Year 2022 expenditure caps and the Statewide HCBS Waiver institutional cost limit were revised using updated average institutional service costs.

    The Group 6 exceptional-needs developmental-disability cap was set at $120,050 per year when basic nursing facility reimbursement is supplemented for specialized services.

    $189,375/yearPrivate ICF/IID-based annual cap
    $513,625/year

    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.

    First-year Group 8 cap
    $82,250/yearNursing facility annual benchmark
    $120,050/yearGroup 6 DD exceptional-needs cap
    $181,850/yearTracheal suctioning cap
    $253,850/yearChronic ventilator care cap

    HCBS Expenditure Caps and Institutional Cost Limits

    Group 6 Exceptional-Needs Expenditure Caps

    For Calendar Year 2022, apply the cap corresponding to the member's Group 6 eligibility category and exceptional medical or behavioral needs.

    ONE of the following Group 6 categories applies

    • ALL of the following

      • The member has an intellectual disability and is enrolled in Employment and Community First CHOICES Group 6 with exceptional medical or behavioral needs determined by TennCare.
      • The member would qualify for services in a private ICF/IID but has elected to receive HCBS.
      • Apply the private ICF/IID-based expenditure cap.$189,375 per year

    • ALL of the following

      • The member has a developmental disability but not an intellectual disability and is enrolled in Employment and Community First CHOICES Group 6 with exceptional medical or behavioral needs determined by TennCare.
      • The member would qualify for Nursing Facility services, subject to specialized services addressing needs related to the developmental disability, but has elected to receive HCBS.
      • Apply the basic Nursing Facility reimbursement amount plus the individualized specialized-services supplement.$120,050 per year

        The Calendar Year 2022 specialized-services amount is $37,813.73, combined with the average annual Nursing Facility reimbursement.

      • If applicable, apply the higher specialized-care cap for the member's qualifying need.Tracheal suctioning: $181,850 per year; chronic ventilator care: $253,850 per year

    Group 7 Expenditure Cap

    For Calendar Year 2022, apply the private ICF/IID-based expenditure cap to eligible children enrolled in Employment and Community First CHOICES Group 7.

    ALL of the following

    • The member is a child enrolled in Employment and Community First CHOICES Group 7.
    • The member would qualify to receive services in a private ICF/IID but has elected to receive HCBS.
    • Apply the expenditure cap based on the average annual cost of services in a private ICF/IID.$189,375 per year

    Group 8 Year-Specific Expenditure Caps

    For Calendar Year 2022, the Group 8 cap depends on whether the adult is in the first year or a later year of Employment and Community First CHOICES enrollment.

    Apply the cap for the applicable enrollment year

    • ALL of the following

      • The member is an adult enrolled in Employment and Community First CHOICES Group 8 and is in the first year of enrollment.
      • The member has co-occurring behavioral challenges that would qualify the member for short-term, treatment-focused services in the Harold Jordan Center, but has elected to transition from an institutional or highly structured setting into HCBS.
      • Apply the Harold Jordan Center-based expenditure cap.$513,625 per year

    • ALL of the following

    Statewide HCBS Waiver Institutional Cost Limit

    Apply the individually determined institutional cost limit to participants in the Section 1915(c) Statewide HCBS Waiver based on the applicable institutional service benchmark.

    ALL of the following

    • The individual is enrolled in the Section 1915(c) Statewide HCBS Waiver and is determined to qualify for institutional-level services while receiving HCBS.
    • Use the average annual cost of services in the applicable private ICF/IID as the individually applied Institutional Cost Limit.$189,375 per year

      The Calendar Year 2022 private ICF/IID average is $526.02 per day, rounded from $189,367.20 annually.

    Reimbursement Benchmarks and Annual Caps

    Private ICF/IID average daily cost
    Daily benchmark$526.02 per day
    Annualized amount$189,367.20 per year before rounding
    Annual cap$189,375 per year
    Private ICF/IID annual expenditure cap
    Rounded annual cap$189,375 per year
    Source calculation$526.02 per day, annualized to $189,367.20
    Applicable populationsGroup 6 members with intellectual disability and exceptional needs, Group 7 children, and Group 8 adults beginning in the second enrollment year

    Operational Actions for Support Coordinators and Plans

    Documentation Required

    Assess support-plan changes when higher caps may enable additional benefits

    MCO Support Coordinators should be mindful of ECF CHOICES Group 6, 7, and 8 members, and Independent Support Coordinators should be mindful of Statewide Waiver participants who may need covered benefits that would not have been available under the previous cost cap. Prioritize contacts with those individuals to assess whether changes to the person-centered support plan are needed.

    • Prioritize contacts with potentially affected members.
    • Assess whether changes to the person-centered support plan are needed.
    Note

    Member notification is not required for higher cap

    MCOs and the Department of Intellectual and Developmental Disabilities (DIDD) are not required to notify members of the higher cost-neutrality cap.

    Benchmark and Supplement Definitions

    Private ICF/IID average cost
    DefinitionA weighted average of the per diem rates for each private Intermediate Care Facility for Individuals with Intellectual Disabilities
    Weighting methodBased on the distribution of bed days
    Rate sourceRates are determined by the Office of the Comptroller
    Harold Jordan Center benchmark
    DefinitionThe average cost of services in the Harold Jordan Center, a short-term, treatment-focused public ICF/IID
    Enrollment periodUsed only for the first year of enrollment in Employment and Community First CHOICES Group 8
    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyRevised Expenditure Caps and Institutional Cost Limit
    Policy CodePolicy N/A
    Change TypeRevised
    Effective DateJanuary 1, 2022
    Next Review DateN/A
    Key ActionAssess whether person-centered support plan changes are needed for members who may qualify for benefits newly available under the higher cost-neutrality caps.
    SourceLink
    On This Page
    HCBS Expenditure Caps and Institutional Cost LimitsReimbursement Benchmarks and Annual CapsOperational Actions for Support Coordinators and PlansBenchmark and Supplement Definitions
    The member is an adult enrolled in Employment and Community First CHOICES Group 8 and is beginning the second year or a later year of enrollment.
  1. Apply the average annual cost of services in a private ICF/IID as the expenditure cap.$189,375 per year
    2. Harold Jordan Center average daily Medicaid reimbursement
    Daily benchmark$1,426.73 per day
    Annualized amount$513,622.80 per year before rounding
    Benchmark basisHarold Jordan Center average Medicaid reimbursement for first-year Group 8 enrollment
    Harold Jordan Center annual first-year Group 8 cap
    Rounded annual cap$513,625 per year
    Source calculation$1,426.73 per day, annualized to $513,622.80
    ApplicationAdults in Employment and Community First CHOICES Group 8 during the first year of enrollment
    Nursing facility average reimbursement
    Daily benchmark$228.41 per day
    Monthly benchmark$6,852.30 per month
    Annualized amount$82,227.60 per year before rounding
    Nursing facility monthly reimbursement benchmark
    Monthly benchmark$6,852.30 per month
    Daily basis$228.41 per day
    Annual basis$82,227.60 per year before rounding
    Nursing facility annual expenditure cap
    Rounded annual cap$82,250 per year
    Source calculation$228.41 per day or $6,852.30 per month, annualized to $82,227.60
    Rate basisWeighted average of blended nursing facility per diem rates; amounts are not discounted for patient liability
    Specialized-services supplement
    Annual supplement$37,813.73 per year
    PurposeAccounts for the average annualized cost of specialized services
    BasisDetermined by TennCare through individualized review of the person's specialized-services needs
    Group 6 DD exceptional-needs cost-neutrality cap
    Annual cap$120,050 per year
    Base amountAverage annual nursing facility reimbursement of $82,250
    Supplement included$37,813.73 per year for specialized services
    Tracheal suctioning reimbursement including specialized services
    Annual cap$181,850 per year
    Included componentSpecialized-services supplement
    Applicable needTracheal suctioning
    Chronic ventilator care reimbursement including specialized services
    Annual cap$253,850 per year
    Included componentSpecialized-services supplement
    Applicable needChronic ventilator care
    Annual cap adjustment cadence
    Adjustment timingAdjusted annually after the nursing facility rate-setting process is completed
    Effective dateAmounts apply beginning January 1 of the following calendar year
    Rate-setting basisThe average annual Medicaid nursing facility reimbursement from each July 1 rate-setting period sets the following calendar year's expenditure cap
    Population basis
    Adults whose co-occurring behavioral challenges would qualify them for short-term, treatment-focused Harold Jordan Center services
    Nursing facility average reimbursement
    DefinitionA weighted average of blended per diem nursing facility care rates
    Weighting methodBased on the distribution of bed days
    Rate conditionsRates are determined by the Division of TennCare and are not discounted for patient liability
    Specialized-services supplement
    DefinitionAn amount determined by TennCare to account for the average annualized cost of specialized services needed by a person with developmental disability receiving nursing facility services
    Determination methodBased on individualized review of the person's specialized-services needs
    Annual amount$37,813.73 per year