A New Player in TennCare
Home and CommunityBased Services
Megan Metcalf, Staff Attorney
[email protected]
6/7/2016
Tennessee Justice Center
301 Charlotte Ave | Nashville, TN, 37201
615-255-0331
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Alphabet Soup
• HCBS: Home and CommunityBased Services
• ID: Intellectual Disability
• DD: Developmental Disability
• ICF: Intermediate Care Facility
• PAE: Pre Admission Evaluation
• LTSS: Long Term Services and
Supports
• NF LOC: Nursing Facility Level
of Care
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TennCare’s Current HCBS Programs
• Statewide Waiver: Individuals with ID needing care in
an Intermediate Care Facility. Individual cost neutrality
cap.
• Arlington Comprehensive Aggregate Cap Waiver:
Individuals with ID and members of the Arlington or
Clover Bottom classes or have transitioned from the
Statewide waiver for hitting the individual cost
neutrality cap.
• Self-Determination Waiver: Individuals with ID who do
not require residential waiver services and have an
established home with family, other caregivers, or on
their own.
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Employment and Community First (ECF)
CHOICES
• Managed LTSS model: Care
Coordination through TennCare’s
contracted Managed Care
Organizations.
• Major focus will be employment
and/or employment training of
enrollees.
• Current TennCare enrollees
should go through their MCO.
• DIDD will serve as the point of
entry for those not currently
enrolled in TennCare and will
provide program oversight and
implementation.
• Person-centered Planning and
Participant Direction.
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Target Populations
• Children under age 21 with ID/DD
living at home and who meet the
Nursing Facility Level of Care
criteria.
• Children under age 21 with ID/DD
living at home with family and
who, in absence of these
supports, are at risk of Nursing
Facility placement.
• Adults 21 and over with ID/DD
who meet the NF LOC and need
specialized ID/DD services.
• Adults 21 and over with ID/DD
who would be at risk of NF
placement, absent these
supports.
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Level of Care Criteria
• Assessed using an acuity scale that measures
how well an individual can complete certain
activities of daily living.
• PLUS: an adaptive behavior assessment
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Financial Eligibility
• Four income groups:
– SSI recipients
– Those requiring NF level services: below 300% of
the Federal Benefit Rate.
– “At risk” Demonstration Group: must have
incomes at or below 150% of the Federal Poverty
Level.
– Working Disabled Demonstration Group: at or
below 250% of the Federal Poverty Level.
• Subject to SSI-like Resource limits: $2000
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ECF CHOICES “At Risk” Demonstration
Group
• Not otherwise eligible for Medicaid in another
category,
• Meets the NF LOC criteria in place as of June
30, 2012 but not the presently used acuity
scale,
• Would be at risk of institutionalization without
ECF CHOICES services, and
• Income must be at or below 150% of the
Federal Poverty Level.
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ECF CHOICES Working Disabled
Demonstration Group
• Income criteria the same as the the Work
Incentives Eligibility Group of Medicaid from SSA
§ 19029a)(10)(A)(ii)(XIII).
– Not otherwise eligible for TennCare,
– Family income is below 250% of the FPL, and
– But for the individual’s earned income, they would be
eligible for SSI.
• Limited to individuals with intellectual and
developmental disabilities who are receiving
HCBS through the program.
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Interim ECF CHOICES At-Risk
Demonstration Group
• Ineligible for TennCare in any other category.
• Meets the NF LOC criteria in place on June 30,
2012, but not the current acuity scale.
• At risk of institutionalization without ECF
services.
• Income must be below $2199/mo.
• This category will close when the ECF “At Risk”
Demonstration Group and the Working Disabled
Demonstrations Group is established.
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Service Tiers
• Essential Family Supports
(Group 4)
• Essential Supports for
Employment and Independent
Living (Group 5)
• Comprehensive Supports for
Employment and Community
Living (Group 6)
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Essential Family Supports
• Target populations: Families with children under
21; Adults living with family that meet the “at
risk” criteria may opt in as well.
• Benefits include:
– Respite, Family Caregiver Stipend or Supportive Home
Care, Community Transportation, Assistive
Technology/Equipment/Supplies, Independent Living
Skills Training, Minor Home Modifications
• Expenditure Cap of $15,000 per year (excluding
minor home modifications)
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Essential Supports for Employment and
Independent Living
• Target population: Adults age 21 and older in the
“at risk” category
• Benefits include: Employment Services and
Supports, Personal Assistance, Community
Transportation, Assistive Technology, Minor
Home Modifications.
• Expenditure Cap:$30,000 plus a $6,000
emergency needs exception (consistent with the
exception in the Self-Determination Waiver).
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Comprehensive Supports for Employment
and Community Living
• Target Population: Adults over 21 meeting the
NF LOC criteria
• Benefits similar to ESEIL including
Employment Services and Supports
• Expenditure Cap: $45,000 for low to moderate
needs, $60,000 for high need individuals
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Employment Services and Supports
• Supported Employment
– Individual Employment Support
• Exploration, Discovery, Situational
Observation and Assessment, Job
Development Plan or SelfEmployment Plan, Job Development
or Self-Employment Start-Up, CoWorker Supports
– Supported Employment-Small
Group
– Integrated Employment Path
Services (Prevocational Training)
– Employment Discovery and
Customization
– Career Advancement
– Community Integration Support
Services
– Benefits Counseling
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Program Rollout
• 1,700 enrollees are expected to be served in the
first year
– 500 in the Essential Family Supports group
– 1,000 in the Essential Supports for Employment and
Independent Living group
– 200 in the Comprehensive Supports group
• The waiting list for all other waivers will be closed
to new additions.
• Current waiver enrollees may also elect to enroll
in the program if they wish.
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The Role for Advocates
• Familiarize yourself with
the Eligibility Categories
• Assess if ECF CHOICES is a
good fit for the client and
the family.
• Maximize Benefits on the
Program!
• Get your clients added to
the existing waiver
waiting lists by June 30,
2016.
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Questions?
Let ‘em loose!
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Thank you for being here today!
“Of all the forms of inequality, injustice in
health care is the most shocking & inhumane.”
-Martin Luther King, Jr.
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[email protected]
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