What is the Employment and Community First CHOICES Waiver (Part 1)?

/ March 15, 2021

By Janet Shouse First of all, what is a Medicaid Waiver? And why is it important to people with disabilities? Many people with disabilities receive their health care through TennCare, our state’s Medicaid agency, but being on TennCare and being on a Medicaid Waiver are two very different things. Medicaid provides both medical and non-medical services. The non-medical services are known as “long term services and supports” or (LTSS). Many individuals with developmental disabilities and/or intellectual disabilities need long term services and supports. Long term services and supports programs are also known as waiver programs:

Prior to “waivers”, Medicaid services were only available if a person lived in an institution. That’s because the Social Security Act, which established the Medicaid program, was originally designed to provide services in institutions, such as developmental centers.
Waivers allow states to apply to ‘waive’ certain requirements, including the requirement to provide services in institutions.
Waiver types are titled with numbers that correspond with sections of the Social Security Act. (In technical terms, Tennessee operates an “1115 demonstration waiver” to operate all of TennCare as a managed care model. The CHOICES Program, which is a long term services and supports program is also operated by the managed care organizations under the 1115 waiver, and currently serves elderly people and adults over the age of 21 with physical disabilities. The state also currently operates three smaller “1915c waivers” just for LTSS for people with intellectual disabilities, operated by the Department of Intellectual and Developmental Disabilities. These three waivers are expected close to new enrollees in July 2016, pending the implementation of a new LTSS program for people with intellectual and developmental disabilities called Employment and Community First CHOICES. People currently in one of these waivers will continue to receive those waiver services.)
Waivers created opportunities for people to receive Home- and Community-Based Services. This allows individuals to get long term services and supports in their home rather than having to move into a nursing home or other institutional setting.

Tennessee received approval in February 2016 to provide a new program under the existing 1115 demonstration waiver called Employment and Community First CHOICES. The state amended its existing 1115 waiver to add a home- and community-based services program that is geared toward promoting integrated, competitive employment and independent living as the preferred option for all individuals with intellectual and developmental disabilities. This will be the first time many people with developmental disabilities who do not have an intellectual disability will have an opportunity to receive waiver services in Tennessee. The new waiver is scheduled to begin on July 1, 2016, and the current plan is to enroll 1,700 people in year 1. Who is eligible? Children and adults with intellectual and developmental disabilities who meet certain medical and financial criteria. If the individual needs help with any of these activities below, he or she may be able to enroll in the ECF CHOICES program. (This is the criteria for nursing facility level of care, and typically considered the type of care provided in a nursing home.)

Transfer – The person needs help moving from the bed to the chair, wheelchair, tub, or toilet.
Mobility – The person needs help with walking.
Eating – The person needs help putting food in his or her mouth.
Toileting – The person needs help using the toilet, changing his or her own diaper, or cleaning up toileting accidents.
Expressive / Receptive Communication – The person needs help telling others about his or her needs and wants (such as he’s hungry or she’s in pain).
Orientation – The person needs help knowing and remembering people (such as family members) and where the person is at the moment.
Medication Administration – The person needs help taking medicine.
Behavior – The person has behavior problems like taking off his or her clothes or trying to run away.
Need for Skilled Nursing or Rehabilitative Services – The person needs some types of health care from a nurse.

I say “may be able to enroll in” the program because eligibility depends on a functional assessment and meeting other TennCare criteria. For the new program, TennCare is adding a supplemental assessment that will apply adaptive and maladaptive behavioral criteria to ensure that people who do not have physical limitations but who have other deficits may qualify. The individual or family also must meet financial eligibility and asset limits. For those who meet the nursing facility level of care criteria, income can’t be more than $2,199 per month (300% of the maximum Social Security Income payment) and asset limits are $2,000, excluding the home and car. For those who are “at risk of nursing facility placement,” family income must be at or below 150% of the Federal Poverty Level, and whose resources do not exceed $2,000, excluding home and car. “At-risk” level of care means a person does not meet the nursing facility level of care, but without long term services and supports in their home would be at risk of needing nursing facility care. There will be three benefit groups in the Employment and Community First CHOICES program:

Essential Family Supports is for individuals who meet the nursing facility level of care or are “at risk” for this level of care. (This will primarily be for children under 21, but can include adults who are still living with family.) TennCare hopes to serve about 500 in the first year.
Essential Supports for Employment and Independent Living is for individuals who are “at risk” for nursing facility level of care. (This is targeted to adults over age 21, including young adults aging out of school to support transition into employment and independent community living.) TennCare hopes to enroll about 1,000 in the first year.
Comprehensive Supports for Employment and Community Living is for people who meet nursing facility level of care. (This is targeted to those over age 21 who have more intense needs and need more support to help them achieve employment and community living goals.) TennCare plans to serve about 200 in the first year.

For additional information, check out Amendment 27 , which explains in much greater detail the new Employment and Community First CHOICES program. Many thanks to Carrie Guiden, executive director of the Arc Tennessee, and Lauren Pearcy, MLTSS director, Long Term Services and Supports Division, Bureau of TennCare, for their assistance. (Next week’s blog topic: why the state is moving to the Employment and Community First CHOICES, what services will be offered, and what it means for people on the current waiver waiting list.)

Janet Shouse is a parent of a young adult with autism and she is passionate about inclusion, employment of people with disabilities, medical issues related to developmental disabilities, supports and services, public policy, legislative initiatives, advocacy, and the intersection of faith and disability. She wears many hats at the Vanderbilt Kennedy Center, including one as a disability employment specialist for TennesseeWorks.

March 2, 2021