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

    ACLF Rate Change and 2025 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program

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    This policy governs reimbursement for covered Assisted Care Living Facility services and maximum room-and-board charges for CHOICES members receiving ACLF services. It applies to ACLF providers, CHOICES members, and TennCare Managed Care Organizations.

    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyACLF Rate Change and 2025 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program
    Policy CodePolicy N/A
    Change Type2025 rate and room-and-board charge update
    Effective DateJanuary 1, 2025
    Next Review DateN/A
    Key ActionCharge CHOICES members no more than the lesser of $2,320.80 per month or the lower amount charged to a non-CHOICES resident for room and board.
    SourceLink
    POLICY UPDATE CHANGES

    The maximum monthly room-and-board charge for a CHOICES member is $2,320.80 for calendar year 2025.

    The maximum total monthly payment to an ACLF for covered services and room and board is $3,789.20 for 2025.

    $2,320.80/moMaximum room and board
    $2,901/moPersonal Needs Allowance
    $1,468.40/mo

    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.

    Covered ACLF reimbursement
    $3,789.20/moCombined facility payment
    30 daysAdvance discharge notice

    CHOICES ACLF Coverage and Cost Categories

    CHOICES ACLF Coverage and Billing Criteria

    CHOICES ACLF services are covered and payable only under the following criteria and billing rules:

    ALL of the following

    • The member qualifies to receive ACLF services, and the services are identified in an approved Person-Centered Support Plan.
    • Covered ACLF services consist of actual care provided to the enrollee in the ACLF, including personal care services, homemaker services, and medication oversight.
    • The reimbursement rate for covered ACLF services under CHOICES must not exceed $1,468.40 per month, effective July 1, 2024; this rate excludes all room-and-board costs.≤ $1,468.40 per month
    • Room and board is not included in the defined ACLF Services benefit and is not payable by TennCare as a component of HCBS under 42 CFR § 441.310(a)(2) and the approved 1115 Waiver.
    • The member must use personal resources to pay room and board, although family or other outside resources may supplement the payment up to the applicable maximum allowable charge.
    • For 2025, the maximum monthly room-and-board charge is the lesser of $2,320.80 (80% of the $2,901 monthly Personal Needs Allowance) or the lesser amount charged to a resident who is not enrolled in CHOICES.≤ $2,320.80 per month
    • The $2,320.80 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 $2,320.80 or less, the full costs may be billed to the CHOICES member.

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

    • A resident or family may voluntarily elect to pay the additional difference between the ACLF's non-Medicaid private-room and semi-private-room charges. The private-room payment must not be a condition of admission, must be solely the resident's or family's decision, and must not otherwise offset the maximum allowable room-and-board charge.
    • When combined with TennCare's payment for covered ACLF services, the maximum total facility payment for 2025 is $3,789.20 per month, unless the resident or family elects to pay for a private room.≤ $3,789.20 per month
    • The maximum room-and-board charge is adjusted annually in accordance with the federal SSI benefit rate. For July 1, 2024 through December 31, 2024, the maximum total facility payment was $3,731.60, unless a private room was voluntarily elected.
    • 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; it must not be deducted from room-and-board charges.

      Patient-liability payments are in addition to the member's room-and-board obligation.

    • An ACLF that contracts with an MCO 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.
    • If the member becomes delinquent in paying room and board, the ACLF may, with proper notice, take appropriate steps to discharge the member; at least 30 days' advance notice of discharge is required.

    Covered and Non-Covered Cost Categories

    The following cost categories distinguish covered ACLF care and operating costs from room-and-board costs excluded from the CHOICES benefit:

    Covered ACLF service components include

    • Salaries of personal-care support employees, homemaker employees, other support staff, and supervisors who provide oversight.
    • The cost of preparing, serving, and cleaning up after meals; raw food costs, including individual special dietary needs, are excluded.
    • FICA, staff health insurance and other staff benefits, workers' compensation, and unemployment compensation, as apportioned to support and supervision.
    • Staff travel.
    • Resident travel, including vehicle depreciation.

    Reimbursement and Payment Limits

    Maximum covered ACLF service reimbursement
    Maximum monthly reimbursement$1,468.40 per month
    Applies toCovered ACLF services under the CHOICES program
    ExcludesAll costs pertaining to room and board
    2025 Personal Needs Allowance
    2025 monthly amount$2,901 per month
    Calculation basis300% of the federal SSI benefit rate
    Effective dateJanuary 1, 2025

    Provider Billing and Payment Responsibilities

    Billing Rule

    Apply the 2025 room-and-board cap

    For 2025, charge a CHOICES member no more than the lesser of $2,320.80 per month or any lesser amount charged to a resident who is not enrolled in CHOICES. The limit is 80% of the $2,901 monthly Personal Needs Allowance.

    Billing Rule

    Handle private-room elections

    A higher room-and-board charge may be collected only when the resident or family voluntarily elects a private room. The election must not be a condition of admission, and the additional amount is limited to the difference between the facility’s private-room and semi-private-room charges for a non-Medicaid resident.

    Key Payment and Service Terms

    Personal Needs Allowance (PNA)
    DefinitionThe amount of money a CHOICES member may retain to meet community living expenses
    2025 amount$2,901 per month as of January 1, 2025
    Calculation basis300% of the federal SSI benefit rate
    Covered ACLF services
    DefinitionActual care provided to an enrollee in an Assisted Care Living Facility for which CHOICES reimbursement may be provided
    Included carePersonal care services, homemaker services, and medication oversight
    Payment limit
    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyACLF Rate Change and 2025 Maximum Room and Board Charges for Persons Receiving Assisted Care Living Facility Services in the CHOICES Program
    Policy CodePolicy N/A
    Change Type2025 rate and room-and-board charge update
    Effective DateJanuary 1, 2025
    Next Review DateN/A
    Key ActionCharge CHOICES members no more than the lesser of $2,320.80 per month or the lower amount charged to a non-CHOICES resident for room and board.
    SourceLink
    On This Page
    CHOICES ACLF Coverage and Cost CategoriesReimbursement and Payment LimitsProvider Billing and Payment ResponsibilitiesKey Payment and Service Terms
    Administrative overhead costs of doing business, including office supplies and furnishings; the applicable percentage of administrative staff salaries; office telephone; recruitment; audit fees; operating fees, permits, and licenses; the applicable percentage of office-space costs; data-processing costs; and legal fees.
  1. Staff liability insurance and agency liability insurance.
  2. Staff training, development, and education.

    3. Room-and-board costs not covered under CHOICES include

    • Rent, mortgage payments, title insurance, and mortgage insurance.
    • Property and casualty insurance.
    • Property taxes.
    • Utilities, resident telephone service, cable television, and similar services.
    • Building and grounds maintenance.
    • Residents' raw food costs, including individual special dietary needs; preparation, serving, and cleanup associated with meals may be covered under the 1115 Waiver.
    • Household supplies and equipment necessary for the individual's room and board.
    • Furnishings used by the individual; office furnishings are not included in this exclusion.
    Room-and-board cap percentage
    Room-and-board cap80% of the maximum Personal Needs Allowance
    2025 PNA basis$2,901 per month
    PurposeLimits the maximum room-and-board charge for CHOICES members when TennCare pays for ACLF services
    2025 maximum room-and-board charge
    2025 monthly maximum$2,320.80 per month
    Lesser-charge limitationThe charge cannot exceed any lesser amount charged to a resident not enrolled in CHOICES
    Private-room exceptionA higher charge may be voluntarily elected for a private room and cannot be a condition of admission
    2025 maximum combined facility payment
    2025 combined monthly limit$3,789.20 per month for covered ACLF services and maximum room and board
    Private-room exceptionThe limit 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
    Denial Risk

    Do not balance bill covered ACLF services

    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

    Apply patient liability

    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. Collect room and board separately from patient liability.

    Documentation Required

    Manage room-and-board delinquency

    If a member becomes delinquent on room-and-board payments, provide at least 30 days’ advance notice before taking appropriate steps to discharge the individual from the facility.

    Billing Rule

    Separate covered care from room and board

    Bill only actual covered care costs provided to the enrollee in the ACLF, including personal care services, homemaker services, and medication oversight. Room and board is not reimbursable as an HCBS component.

    Covered service reimbursement may not exceed $1,468.40 per month
    Room and board
    DefinitionHousing and living expenses that are not included in the ACLF Services benefit and are not payable as HCBS
    ExamplesRent, mortgage payments, property taxes, insurance, utilities, resident phone or cable, and building or grounds maintenance
    Food and household costsRaw food, household supplies or equipment, and individual furnishings are excluded; meal preparation, serving, and cleanup may be covered
    Patient liability
    DefinitionIncome above the member's Personal Needs Allowance
    Provider responsibilityThe ACLF provider must collect the excess income as patient liability
    Billing treatmentDeduct patient liability from the amount billed to the MCO for covered ACLF services; room and board is paid separately
    Payment in full
    DefinitionThe full CHOICES reimbursement amount for covered ACLF services
    Provider obligationA CHOICES-participating ACLF must accept the reimbursement as payment in full
    Additional billing prohibitedThe provider may not bill the member or family for covered-service costs or shift those costs to room-and-board charges