FAQs about the Long Term Care Community Choices Act of 2008
Including information about the Home and
Community Based Services (HCBS) Waiver Program

What is the Long Term Care Community Choices Act of 2008?

It is an Act which fundamentally restructures the Medicaid Long-Term Care (LTC) service delivery system for persons in Tennessee who are elderly or who have physical disabilities. It was crafted under the leadership of Governor Phil Bredesen to honor his commitment to expand home and community based services in Tennessee, working closely with key members of the General Assembly and numerous stakeholder groups.

What are some of the problems and challenges with the current long-term care system in Tennessee?

1. LTC services are fragmented.

• Access to the various types of LTC services is scattered across multiple points of entry with little or no coordination. The vast majority of Tennesseans who receive Medicaid LTC services are in nursing homes, unaware of at-home or community-based alternatives. A relatively small number find Home and Community Based Services (HCBS) through local agencies. Others receive medical home care services, such as home health and private duty nursing from the Managed Care Organizations (MCOs), often at costs much higher than nursing home care.
• Individuals who need long term care and their families have a difficult time navigating the current system. People struggle to understand their options, make informed decisions and access services in a timely manner.

2. Access and options are limited.

• The current system relies heavily on nursing facilities and the most costly services, while home and community options are extremely limited. The only community-based residential alternative to nursing home care is Assisted Care Living.
• People have little choice or opportunity to make their own decisions about the types of LTC services they need and who will provide them.

3. Limited available resources are inefficiently used.

• Today’s system is heavily dependent on the most costly services even though lower-cost alternatives may better meet the needs and desires of individuals and their families.
• The reimbursement structure does not encourage efficiency, and incentives are misaligned to push people toward the most expensive LTC option.
• Few services are aimed at preventing or delaying the need for more costly care later on.
• The system supplants rather than sustains family and other caregiving networks.

What are some of the key components of the Act?

• It provides for the expansion of home and community based services—the ability to offer more kinds of home care options and to serve more people using existing LTC funds.
• A single entity will help TennCare members access all of the different kinds of Medicaid benefits they need, including medical, behavioral, nursing facility, and home care services.
• This will be accomplished by integrating LTC within the existing managed care system, building in strong consumer protections and aligning financial incentives in order to help ensure that the right care is provided in the right place at the right time.
• Over time, these changes will help to rebalance LTC spending between institutional and home and community based care.
• The bill includes certain cost controls to help ensure that the State doesn’t make obligations or promises beyond our ability to pay for them.
• It provides for a “Single Point of Entry” to help people who need LTC and their families find out about the options that are available and how to access them.
• It includes requirements to streamline eligibility—to make changes in the system to help make it easier and faster to access LTC services.
• It provides for the expansion of more kinds of cost-effective community-based residential alternatives to nursing home care, including models like Adult Care Homes in Oregon which serve people in small, family-type settings.
• It provides for the development and implementation of an acuity-based reimbursement methodology for nursing facility services—we will pay nursing homes based on the level of need of the persons they serve.
• It also provides assistance to nursing homes (which are a critical part of the LTC continuum) in diversifying their businesses—so they can begin to offer the same kinds of services they offer in their facilities today in people’s homes as well.
• It provides for more options and choices for persons receiving HCBS, which may include the ability to select, direct, and even employ, staff who will deliver care, with careful controls in place to ensure accountability for taxpayer funds.
• It provides for some additional funding for things like meals on wheels, homemaker services, and personal care to be provided through the State-funded Options program for people who are not eligible for Medicaid and are currently on a waiting list for those services.
• It changes the licensure requirements for Assisted-Care Living Facility Services to allow the benefit to be more flexible so that people will not be forced to leave their “home” in an Assisted Living Facility in order to receive certain kinds of medical services that could safely be provided there, just as they could be in the person’s private residence.
• It establishes a LTC Oversight Committee to continue to oversee the development and implementation of the managed LTC system created by this Act to ensure that the new system needs the needs of Tennesseans who need long term care services.

How will the Act change the Long Term Care System in Tennessee?

The Long Term Care Community Choices Act of 2008 will accomplish the following goals:

• It will reorganize the LTC system. Getting into the Medicaid Long-Term Care system will be simplified and getting services in place will be faster. A one-stop shop will help people enter the LTC system if they are not on TennCare. A single entity will help TennCare members access all of the different kinds of Medicaid benefits they need, including medical, behavioral, nursing facility, and home care services. In Tennessee, this can only be accomplished by integrating long-term care within the existing TennCare managed care delivery system, building in strong consumer protections and aligning incentives to help ensure that the right care is provided in the right place at the right time, improving the quality of services received.
• It will refocus LTC services, with more attention to the wishes and needs of the person and their family.
• It will rebalance the LTC system, expanding access to cost-effective home and community-based care, and targeting Nursing Facility care to those with higher levels of need. This will allow the State to serve more people within the existing LTC budget, while also planning to meet increased future demand.

How will the Act impact Tennesseans and their families?

• One place to go for information about long-term care options
• Simple and fast process to apply for services
• A single entity to coordinate all of the kinds of medical and non-medical care needed
• More choices about the kinds of care needed, where it will be provided, and by whom
• More service options in home and community based settings that do not exist today
• More opportunity to stay in their own home and receive needed service
• Support for family caregivers who are helping meet the needs of loved ones at home.

How will consumers, family members, and advocates be involved in the implementation of these changes?

From the beginning, this has been a collaborative process. The Administration worked closely with the Special Joint Legislative Committee to Study the Development and Implementation of a LTC Plan and aging and disability consumer groups including AARP, nursing facility industry representatives and other long term care providers to develop a solution to these problems that will meet future demand of the growing aging population, add choices and options, and ensure cost effectiveness. Continued input from the people who will use this system, their family members, advocates, providers, and other stakeholders is critical to the success of the Long Term Care Community Choices Act.

What is the timeline for implementation of these changes?

There are some changes we can begin making immediately--without approval from the federal government. We are working on many of those already, including:

• Streamlining eligibility processes for persons who need long term care
• Streamlining HCBS provider enrollment and payment processes
• Developing the Single Point of Entry in order to help facilitate timely access to LTC services

Other changes will require more time and a waiver from the federal government. We anticipate spending the next year securing the needed approval, and developing the rules, contracts, policies, etc. that will be needed to begin implementation of the broader changes. This includes integration of long term care into the managed care delivery system. We hope to begin implementation starting in Middle Tennessee in July 2009, likely moving to East Tennessee about six months later--around January 2010, and then to West Tennessee around April 2010.

Are long term care home and community-based services available today?

Yes! Over the next year, we will continue to expand enrollment in our existing Home and Community-Based Services or HCBS Waiver program for persons who are elderly and/or adults with physical disabilities. We have received funding (recommended by the Governor and approved by the General Assembly) to provide services for another 2,300 people. This brings us to a total of 6,000 people statewide.

The HCBS Waiver is for people who qualify for Medicaid and who would qualify for nursing home care but want to receive more cost-effective care at home instead. It offers 13 different kinds of home care services based on the needs of each person.

What services are available through the HCBS Waiver?

The kinds of Home and Community-Based Services or HCBS provided are based on the needs of each person. These are the kinds of care a person may receive if their doctor orders them in their care plan:

• Personal Care Services - Someone to help with activities of daily living such as bathing, dressing, preparing and eating meals, toileting or transfers.
• Personal Care Attendant - Someone to help with activities of daily living for longer periods of time or to go with you to doctor’s visits or other appointments.
• Homemaker - Someone to help with household chores or errands like laundry, sweeping or grocery shopping.
• Home Delivered Meals - One healthy meal per day delivered to your home.
• Adult Day Care - A place where you can go during the day to spend time with others.
• In-Home Respite - Someone to come and stay with you in your home for a short time so your caregiver can get some rest.
• Inpatient Respite - Short stay in a nursing home or assisted care living facility so your caregiver can get some rest.
• Assistive Technology - Certain devices that help you with activities of daily living, such as grabbers or big handled eating utensils.
• Minor Home Modifications - Certain devices or changes to your home to make it easier and safer for you to be in your home, such as ramps or grab-bars.
• Personal Emergency Response System (PERS) - A call button you wear that works through your telephone so you can call for help in an emergency.
• Pest Control - Someone to come to your home a few times a year to spray for bugs or get rid of mice and rats.
• Assisted Living* - A place where you can go live that will help you with personal care needs, homemaker services, and taking your medicines correctly. *Medicaid cannot pay for your room and board.
• Case Management - A case manager to visit you at least once a month to be sure you get the care you need.

How does someone qualify for the HCBS Waiver?

To qualify for the HCBS Waiver, an individual must:

• Live in Tennessee.
• Be 65 years of age and older OR be an adult 21 years of age and older with a physical disability.
• Receive SSI payments or qualify for Medicaid through your local Department of Human Services (DHS) office. To qualify, an individual’s monthly income can’t be more than $1,911 (unless you set up an income trust) and the individual’s resources (the things you own not counting the house you live in) can’t be more than $2,000.
• Need the level of care that one would get in a nursing home, but want to get care at home instead.
• Have a safe home where waiver services can be provided.
• Have someone that will agree to check on them, or care for them, when they are not receiving waiver services. *Note: People who receive home care must be independent for most of the day, or have family and other caregivers that help meet their needs. None of these programs offer around-the-clock care.

And, to qualify for the HCBS Waiver:

• We must be able to safely and effectively meet the individual’s needs at home.
• The total cost of each individual’s care at home can’t be more than nursing home care. That includes the cost of any nursing or home health care, as well as HCBS Waiver services.

Will people get paid to take care of their family members at home?

It is important to note that, while this waiver will allow for compensation of family members, the State will carefully assess each person’s needs to help ensure that we do not begin paying for care that would have otherwise been provided without pay. Our goal is to “wrap around” the natural support networks and help sustain them, thus delaying the need for more expensive institutional care.

Needs assessments will identify “gaps” in care—where family and other uncompensated caregivers are not able to meet the person’s needs. Services will then be provided to fill those gaps and to help support unpaid family and other caregivers. Elderly and disabled participants will have the choice of deciding whether they wish such services to be provided by an agency or by other non-traditional caregivers which may include family members, friends, and neighbors.

Will non-traditional caregivers need to be licensed and employed by a health care agency?

The qualifications for persons providing care have not been finalized. However, we do not anticipate requiring licensure of family or other non-traditional caregivers. The State will define training and other requirements to help ensure the quality of care provided. Rather than requiring that family members be employed by a health care agency, the State will likely use a fiscal intermediary to manage payment and payroll taxes.

What is available for those people who don’t qualify for Medicaid?

There are also programs that offer home-delivered meals, personal care, and homemaker services for people who don’t qualify for Medicaid. These programs include Options and the National Family Caregiver program. Recently, nearly $4 million was added to the State-funded Options program. It offers similar services for people who do not qualify for Medicaid.

How does someone apply for the HCBS Waiver, Options or National Family Caregiver Programs?

Access to these services is through the local Area Agency on Aging and Disability that can be reached through a statewide toll-free number: 1-866-836-6678.

Who can someone get in touch with if they have additional questions?

For further information about the Long Term Care Community Choices Act of 2008 or the HCBS Waiver, please contact Brooke Boswell at Brooke.L.Boswell@state.tn.us or 1-877-224-0219.