CHOICES

CHOICES is Tennessee’s long-term care program for people over 65 and people with disabilities. CHOICES might help you or your loved one get long-term care. CHOICES can help you get home care you need to stay in the community. It might also pay for care in a nursing home. There are three different levels of CHOICES.

  • CHOICES 1: Nursing home care. You can be any age.
  • CHOICES 2: Home services that don’t cost more than a nursing home. You must be older than 65 years OR older than 21 with a physical disability.
  • CHOICES 3: Home services that cost up to $15,000 per year. You must be older than 65 years OR older than 21 with a physical disability. As of July 1, 2015, you must be getting Supplemental Security Income (SSI) to get CHOICES 3.

Find answers to your questions about CHOICES below.

Read about how TJC helped one family with their CHOICES application:

What do the recent changes to CHOICES 3 mean?

CHOICES 3 closed for most people on June 30, 2015! CHOICES 3 is an important way to get help at home. CHOICES 3 helps people who cannot meet the strict medical rules for CHOICES 1 or 2.

Now, only people who get Supplemental Security Income (SSI) can get CHOICES 3. SSI is a benefit for people with disabilities who have very low incomes (below $753 in 2015). SSI is not the same as Social Security.

People who were on CHOICES 3 already before June 30, 2015 can stay on CHOICES 3.

If you or a loved one may need CHOICES, you can still apply. Call the Area Agency on Aging and Disability. Their statewide number is 866-836-6678.

If your income is too high for SSI but you cannot meet the medical rules for CHOICES 2, you might still be able to get CHOICES. You might be able to get help from CHOICES if you are not safe in the community. Read more below.

You may also want to read this fact sheet about why closing CHOICES 3 is putting people at risk.

I’m already on CHOICES 3. Can I keep my CHOICES after June 30, 2015?

If you’re already on CHOICES 3 on June 30, 2015, you will get to stay on CHOICES 3. You can stay on CHOICES 3 as long as you still meet the medical and financial rules.

How do I apply for CHOICES?

There are three ways to apply:

  • Are you on TennCare now?  Call your TennCare plan. You can find their phone number on your TennCare card.
  • Are you not on TennCare now? Call the Area Agency on Aging and Disability. Ask them about CHOICES. Their phone number is 866-836-6678.
  • Are you in a nursing home? The nursing home staff should help you apply.

When you apply, someone will do an in-person test with you. They will look at your medical needs. They will see how much help you need with daily tasks. This is called a pre-admission evaluation (PAE).

You will also fill out a form about your money and assets if you’re not on TennCare yet. The person doing your PAE should help you with this form.

Who can get CHOICES?

There are two parts to getting CHOICES.

  1. Medical Need for CHOICES

To get CHOICES, your medical needs must be so serious that you need help with your daily tasks. These are called “activities of daily living.”

If you need help with any of these, you might be able to get CHOICES.

  • Transfer – You need help moving from your bed to your chair, wheelchair, tub, or toilet.
  • Mobility – You need help with walking.
  • Eating – You need help putting food in your mouth.
  • Toileting – You need help using the toilet, changing your own diaper, or cleaning up toileting accidents.
  • Expressive / Receptive Communication – You need help telling others about your needs and wants (like you’re hungry or are in pain).
  • Orientation – You need help knowing and remembering people (like your family members) and where you are.
  • Medication Administration – You need help taking your medicine.
  • Behavior –  You have behavior problems like taking off your clothes or trying to run away.
  • Need for Skilled Nursing or Rehabilitative Services – You need some types of health care from a nurse.

You might be able to get CHOICES if you need help with daily tasks. TennCare will give you a score on their “acuity scale.” Acuity means how bad your health problems are. You can get more information about the medical rules for CHOICES from this flier from Legal Aid Society of Middle Tennessee and the Cumberlands.

Here is a short flier that tells you exactly how the State defines these problems. You might want to show this paper to your doctor.

You have the right to appeal if TennCare says you can’t get CHOICES. You also have the right to appeal if TennCare says you can only get CHOICES 3, but you need more care than what CHOICES 3 will pay for.

  1. Financial (Money) Need for CHOICES

To get CHOICES, you also need to show that you have income and resources that are low enough. You will fill out a paper that asks you about what money you get each month. The paper also asks about money that you have in the bank. It also asks about other things you own that are worth money, like your house or car.

The rules for financial need for CHOICES are confusing. If you are told you can’t get CHOICES because you make too much money, you may still be able to get CHOICES. You may be able to set up a Qualified Income Trust (QIT). To get help doing this, you can call an elder lawyer. For help finding an elder lawyer, you can call the Tennessee Justice Center or your local Legal Aid office.

If you are told you cannot get CHOICES for financial reasons, but you think that TennCare has made a mistake, you can appeal.

You can get more information about the financial rules for CHOICES from this flier from Legal Aid.

What if the State says I can’t get CHOICES?

TennCare should send a letter that says you can’t get CHOICES. The letter should tell you how to appeal. An appeal tells the State that you think they made a mistake. The State will look at your case again when you appeal.

Sometimes, this fixes your problem. If not, you may get a hearing. At the hearing, you will get to tell a judge why you think TennCare made a mistake.

There are two types of appeals:

  1. Medical or PAE appeal

What if the State says you cannot get CHOICES because you don’t meet the medical rules?

You can use this appeal form. You can also write a letter about your problem. If possible, you should use a fax machine to send your appeal. Save the page showing when you faxed it. If you can’t send a fax, you can send it by mail.

You can also file an appeal by phone. Call TennCare Division of Long Term Services and Supports. Their phone number is 877-224-0219. Write down the time and date you called and the name of the person you talked to.

  1. Financial appeal

What if the State says you cannot get CHOICES because your income or assets are too high?

You can use this appeal form. (This is a different appeal form than what you use for a PAE appeal!) If possible, you should fax the appeal form. Save the page showing when you faxed it. If you can’t send a fax, you can send it by mail.

You can also file a financial appeal by phone. Call Tennessee Health Connection. Their phone number is 855-259-0701. Write down the time and date you called and the name of the person you talked to.

What if I need help in a nursing home but TennCare says I can only get care at home?

You can appeal. You are allowed to stay in the nursing home during your appeal if you are already in a nursing home. The legal case that lets you stay in the nursing home is called Doe v. Word. You can read the Doe order here. Please call the Tennessee Justice Center if your nursing home says you have to leave. Our phone number is 877-608-1009. We may be able to help you.

CHOICES 3 pays for up to 20 hours per week of help at home. You can ask for a “safety determination” if you need more than that to stay safe.

I applied for CHOICES 3 before June 30, 2015. I haven’t gotten a decision yet. Can I get CHOICES 3?

If you started your application for CHOICES 3 before June 30, 2015, you should be looked at under the old rules. That means you would not have to be getting SSI to get CHOICES 3. If you started your application before June 30 but you are turned down for this reason, you have the right to file an appeal. You may want to call TJC for help. Our toll free number is 877-608-1009.

What is a safety determination?

A safety determination is a test to see if you will be safe at home with CHOICES 3. CHOICES 3 pays for 20 hours of in-home care per week. Some people need more than that to stay safe.

If the safety determination says you cannot be safe in your home, you may be able to get nursing home care you need.

You can ask for a safety determination if the State says you can only get CHOICES 3 but you need more help.

The State has new rules about this safety test. You can read their rules here.

How do I get a safety determination?

You, your representative (friend or family member), the Area Agency on Aging and Disability, your TennCare plan, or your nursing home can ask for a safety determination.

You can call the TennCare Division of Long Term Supports and Services and ask for a safety determination. Their phone number is 877-224-0219.

You can also tell the State why you don’t think you will be safe at home. You can have your doctors, relatives, or others write about why you need help in a nursing home. They can say why 20 hours per week of care at home will not be enough for you.

Fax any documents about your case to the TennCare Division of Long Term Services and Supports. Their fax number is 615-734-5411. Write your name, Social Security Number, and date of birth on your fax cover page. If you have it, also write your PAE control number.

Remember: If you are not safe at home with CHOICES 3, you may be able to get help in a nursing home.

Can you give me an example of how a safety determination and appeal might work?

Nursing-home-photo

Laura is 70 years old. She lives at home alone. She is able to get around with a wheelchair, but she can never transfer without assistance. She needs help with toileting. She can recognize people and places. She can tell her family and friends what she needs and feels.

Laura enters a nursing home after falling and breaking her ankle. The nursing home applies for CHOICES for her. She only gets an acuity score of 6 on her PAE. She needs a 9 to get CHOICES 1 to stay in the nursing home.

Laura and her doctors feel that she is unsafe to go home. Even with some help at home from CHOICES 3, she could fall and hurt herself again. Laura files an appeal. She can stay in the nursing home during her appeal. The nursing home fills out a safety determination. Laura also sends documents to TennCare that say why she will not be safe at home. The State agrees that she won’t be safe at home. Laura gets to stay in the nursing home.

I applied for CHOICES. But I’m still waiting to hear back from CHOICES. What can I do?

The State has 90 days after you apply to let you know whether you can get CHOICES. You should not have to wait more than 90 days.

You can appeal if you applied more than 90 days ago. A court case called Wilson v. Gordon says that you can get a hearing. There is more information here.The-First-90-Days-A-Checklist-For-A-New-Admissions-Director-300x300

I’ve appealed, and now I have a hearing. What should I do?

You may be able to get a free lawyer to help at your hearing. Call your local legal aid office. You can find the phone number for your local legal aid office here.

Tennessee Justice Center also helps some people with CHOICES issues. Call us at 877-608-1009.

You can go to your hearing yourself if you can’t get a lawyer. You can win your hearing even without a lawyer. You can take a friend or advocate with you. Tell the judge about why you need CHOICES and what mistake you think the State made.

Where can I find out more about CHOICES?

  • CHOICES 3 closed for most people on July 1, 2015! Find out more about CHOICES 3 and why its closing puts Tennesseans at risk. Look at this fact sheet.
  • This great booklet from Legal Aid Society of Middle Tennessee and the Cumberlands has more information about CHOICES.
  • Most Legal Aid / Legal Services offices help some people with CHOICES problems. You can find the phone number for your local legal aid office here.
  • The Tennessee Long-Term Care Ombudsman program helps some people who have problems in a nursing home.
  • The Area Agency on Aging and Disability helps people in the community who are applying for CHOICES. Their phone number is 866-836-6678.
  • The TennCare Division of Long-Term Supports and Services is the State office that helps run the CHOICES program. Their website has some information about CHOICES.
  • The State has online trainings and papersthat help providers understand the CHOICES program.
  • A lawsuit called Doe v. Word gives people appeal rights in CHOICES. Doe says you can stay in the nursing home during your appeal if the State says you don’t meet medical rules for CHOICES. Here is a letter from the State telling nursing homes that they have to let you stay in the nursing home during your appeal. You can read the whole Doe order here.