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

ACLF Rate Change and 2024 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

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Governs reimbursement for covered Assisted Care Living Facility services and maximum room-and-board charges for CHOICES members; applies to CHOICES ACLF providers and TennCare Managed Care Organizations.

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

PolicyACLF Rate Change and 2024 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

Policy CodePolicy N/A

Change TypeRevised

Effective DateJanuary 1, 2024

Next Review DateNot specified

Key ActionBill TennCare only for actual covered ACLF care and exclude room and board from covered-service claims.

SourceLink

POLICY UPDATE CHANGES

The maximum monthly room-and-board charge for a CHOICES member is set at the lesser of $2,263.20 or the lesser amount charged to a comparable non-CHOICES resident.

A resident or family may voluntarily pay the additional difference for a private room.

ACLF providers must accept the CHOICES covered-service reimbursement as payment in full and may not shift covered-service costs to room-and-board charges.

$1,439.61/moMaximum reimbursement for covered ACLF services

$2,829/mo

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

ACLF Rate Change and 2024 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.

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

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

PolicyACLF Rate Change and 2024 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

Policy CodePolicy N/A

Change TypeRevised

Effective DateJanuary 1, 2024

Next Review DateNot specified

Key ActionBill TennCare only for actual covered ACLF care and exclude room and board from covered-service claims.

SourceLink

POLICY UPDATE CHANGES

The maximum monthly room-and-board charge for a CHOICES member is set at the lesser of $2,263.20 or the lesser amount charged to a comparable non-CHOICES resident.

A resident or family may voluntarily pay the additional difference for a private room.

ACLF providers must accept the CHOICES covered-service reimbursement as payment in full and may not shift covered-service costs to room-and-board charges.

$1,439.61/moMaximum reimbursement for covered ACLF services

$2,829/mo

CHOICES Personal Needs Allowance

$2,263.20/moMaximum room-and-board charge

$3,702.81Maximum combined facility payment

30 daysAdvance notice for room-and-board delinquency

CHOICES ACLF Coverage and Billing Requirements

ACLF Service Eligibility and Covered Scope

CHOICES ACLF services are covered only when the member qualifies for the benefit and the services are identified in an approved Person-Centered Support Plan. Room and board is not a covered component of the ACLF Services benefit.

ALL of the following

The individual is a CHOICES member who qualifies to receive ACLF services.
The ACLF services are identified in the member's approved Person-Centered Support Plan.
The covered services consist of actual care provided to the enrollee in the ACLF, including personal care services, homemaker services, and medication oversight.
Room and board is excluded from the covered ACLF Services benefit; federal regulations and the State's approved 1115 Waiver application prohibit Medicaid coverage of room and board as HCBS.
The member must use personal resources to pay room and board, although family or other outside resources may supplement those costs up to the applicable maximum allowable charge.

ACLF Reimbursement, Patient Liability, and Billing Compliance

ACLF providers must separate covered ACLF Services from room and board, apply the applicable reimbursement and patient-liability rules, and comply with payment-in-full and billing restrictions.

ALL of the following reimbursement and billing rules apply

Reimbursement for covered ACLF Services under CHOICES must not exceed $1,439.61 per month, the rate effective July 1, 2023; this rate excludes all room-and-board costs.
For 2024, the maximum monthly room-and-board charge for a CHOICES member is the lesser of $2,263.20, representing 80% of the $2,829 monthly Personal Needs Allowance, or any lesser amount charged to a resident who is not enrolled in CHOICES.<= $2,263.20 per month
The room-and-board limit is 80% of the maximum Personal Needs Allowance, not 80% of the facility's room-and-board costs. If room-and-board costs are $2,263.20 or less per month, the full 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 to other ACLF residents.

Payment Limits and Notice Requirements

Covered ACLF Service Reimbursement

Monthly maximum$1,439.61 per month

Applies toCovered ACLF services provided under the CHOICES program

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

CHOICES Personal Needs Allowance

Monthly PNA$2,829 per month as of January 1, 2024

Calculation basis300% of the SSI federal benefit rate

Annual adjustmentAdjusted each year in accordance with the federal SSI benefit rate

Provider Billing and Resident-Account Actions

Billing Rule

Separate Covered Care From Room and Board

Bill TennCare only for the covered ACLF care provided to the CHOICES member—not for room and board. Covered ACLF services include personal care, homemaker services, and medication oversight identified in the approved Person-Centered Support Plan; room and board must remain separately payable by the member or outside resources.

The covered ACLF-services reimbursement rate may not exceed $1,439.61 per month, excluding all room-and-board costs.
Do not include room and board as a component of the HCBS benefit or in the amount billed to TennCare.

Billing Rule

Apply the 2024 Room-and-Board Maximum

For 2024, charge a CHOICES member no more than the lesser of $2,263.20 per month or the lower amount charged to a non-CHOICES resident for room and board.

The $2,263.20 limit equals 80% of the 2024 maximum Personal Needs Allowance of $2,829 per month.

Key Policy Terms

Personal Needs Allowance (PNA)

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

Policy amountUnder this policy, the PNA is set at 300% of the SSI federal benefit rate

Covered ACLF Services

DefinitionCare-related services provided to a CHOICES enrollee in an Assisted Care Living Facility

Included servicesPersonal care, homemaker services, and medication oversight

Exclusion

Policy Summary

PayerTennessee Department of Finance and Administration — Division of TennCare

PolicyACLF Rate Change and 2024 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

Policy CodePolicy N/A

Change TypeRevised

Effective DateJanuary 1, 2024

Next Review DateNot specified

Key ActionBill TennCare only for actual covered ACLF care and exclude room and board from covered-service claims.

SourceLink

On This Page

A resident or family may voluntarily elect to pay an additional charge for a private room. The additional amount is limited to the difference between the ACLF's charge to a non-Medicaid resident for a private room and a semi-private room, and may not otherwise offset the maximum allowable room-and-board charge.

Choosing or paying the higher private-room amount must be solely the decision of the resident or family and must not be a condition of admission.

For 2024, the maximum total payment to the facility, combining covered ACLF Services reimbursement and the maximum room-and-board charge, is $3,702.81, unless the individual or family elects to pay for a private room. For July 1, 2023 through December 31, 2023, the corresponding maximum total payment was $3,633.21, subject to the same private-room election rule.

Any 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 from room-and-board charges. Patient-liability payments are in addition to the member's room-and-board costs.

If the member becomes delinquent in paying room and board, the ACLF provider may, after proper notice, take appropriate steps to discharge the individual; at least 30 days' advance notice of discharge is required.

An ACLF contracting with one or more MCOs as a CHOICES provider must accept the CHOICES reimbursement for covered ACLF Services as payment in full.

The ACLF may not bill the CHOICES member or the member's family for any portion of covered ACLF Services and may not shift covered-service costs to non-covered room-and-board charges.

Room-and-board costs are not covered, including any of the following

Rent, mortgage payments, title insurance, or mortgage insurance.
Property and casualty insurance or property taxes.
Utilities, resident telephone service, cable television, or similar services.
Building or grounds maintenance.
Residents' raw food costs, including individual special dietary needs; preparation, serving, and cleanup of meals may be covered under the SWW.
Household supplies and equipment necessary for the individual's room and board.
Furnishings used by the individual, excluding office furnishings.

Room-and-Board Maximum

Calculation80% of the maximum Personal Needs Allowance

2024 monthly maximum$2,263.20 per month

Lesser-charge limitationThe charge cannot exceed any lower amount charged to a comparable resident who is not enrolled in CHOICES

Maximum Combined Facility Payment

Combined payment limit$3,702.81 for covered ACLF services and room and board

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

Admission conditionA private-room payment may not be required as a condition of admission

Room-and-Board Delinquency Discharge Notice

Minimum noticeAt least 30 days advance notice

TriggerDelinquency in paying room-and-board charges

Provider actionThe provider may take appropriate steps to discharge the individual after providing proper notice

This is a maximum room-and-board charge—not 80% of the facility's room-and-board costs.

If actual room and board is $2,263.20 or less, the full actual cost may be billed to the member.

The limit applies to CHOICES members receiving ACLF services, not other ACLF residents.

The maximum total facility payment, including covered ACLF services, is $3,702.81 per month unless a private-room election applies.

Billing Rule

Do Not Require Private-Room Payment

A resident or family may voluntarily elect to pay more for a private room, but the election must be voluntary and cannot be required for admission. The additional payment may cover only the difference between the ACLF's private-room and semi-private-room charges for a non-Medicaid resident.

The resident and/or family—not the facility—must make the decision to elect the private room.
Do not use the private-room amount to offset or increase the maximum allowable room-and-board charge for any other purpose.
Document that private-room payment was not a condition of admission.

Billing Rule

Process Patient Liability

Collect as patient liability any member income above the Personal Needs Allowance and deduct that amount from what is billed to the MCO for covered ACLF services. Patient-liability payments are separate from the room-and-board charges the member must also pay to the facility.

For 2024, the CHOICES PNA is $2,829 per month.
Apply the deduction to the amount billed for covered ACLF services—not to room and board.

Denial Risk

Prohibit Balance Billing and Cost Shifting

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

Member and family payments may be collected for room and board as permitted by the policy, but not for covered ACLF services.
Do not use room-and-board charges to recover, supplement, or otherwise offset unpaid covered-service costs.

Billing Rule

Give 30 Days' Notice for Room-and-Board Delinquency

If a CHOICES member becomes delinquent in paying room and board, the ACLF may take appropriate steps to discharge the individual only after providing proper notice. Provide at least 30 days' advance notice of the discharge.

The notice requirement applies to discharge action based on room-and-board delinquency.
Do not discharge the member without the required advance notice.

Room and board is not included in covered ACLF services

Room and Board

DefinitionNon-covered living and facility costs charged separately from covered ACLF services

ExamplesRent or mortgage payments, property and casualty insurance, property taxes, utilities, resident phone and cable, and building or grounds maintenance

Additional examplesRaw food costs, household supplies and equipment, and resident furnishings

Covered ACLF Service Cost Components

Staff costsSalaries and related benefits for personal-care support employees, homemaker employees, other support staff, and supervisors providing oversight

Meal servicesPreparing, serving, and cleaning up after meals; raw food costs are excluded

Other covered categoriesStaff and resident travel, administrative overhead, liability insurance, and staff training, development, and education