ECF CHOICES Tennessee 2026: Groups, Services, How to Apply

Employment and Community First (ECF) CHOICES is Tennessee's primary Medicaid program for people with intellectual or developmental disabilities (I/DD). It pays for job coaching, personal assistance, respite, community living supports, assistive technology, behavioral supports, and the Family Caregiver Stipend that compensates a parent or other family caregiver caring for a Group 4 member at home.

ECF CHOICES is not the same program as TennCare CHOICES. They share the "CHOICES" name and live inside the same TennCare §1115 demonstration, but they serve different populations: CHOICES is for adults 65+ and adults 21+ with physical disabilities; ECF CHOICES is for people of any age with I/DD. ECF's group numbers, 4 through 8, pick up where CHOICES Groups 1–3 leave off precisely because the two programs share the demonstration framework.

This guide walks through who qualifies, the five-group structure, the service catalog, the Family Caregiver Stipend, the DDA application process, and how the waitlist works in 2026.

By Brevy Care Team · Last verified May 2, 2026

What ECF CHOICES Is, and Isn't

ECF CHOICES is the Tennessee Medicaid program that delivers home- and community-based services to people with I/DD. It launched July 1, 2016 under TennCare's §1115(a) demonstration, first as part of TennCare II, now rolled into the TennCare III demonstration that CMS approved on January 8, 2021 with a 10-year period extending through December 31, 2030.

The program was created to fix three real problems in Tennessee's old I/DD system:

• A multi-thousand-person waitlist had built up on the legacy §1915(c) DD waivers (Self-Determination, Comprehensive Aggregate Cap, and Statewide).
• People with developmental disabilities other than intellectual disability (autism, cerebral palsy, traumatic brain injury without ID, and others) had no HCBS pathway at all in Tennessee.
• Per-person legacy DD waiver spending was very high relative to outcomes, especially for people who could work and live more independently than the older waiver structure assumed.

The results show in TennCare's own reporting. Per the TennCare III Q1 2025 quarterly report, the number of Tennesseans with developmental disabilities other than intellectual disability who receive HCBS grew from 0 to 3,200 since ECF launched, while average per-person LTSS spend for I/DD members dropped 4.1% from $94,327 to $90,425.

The three §1915(c) DD waivers are still legally active, but they have been closed to new general enrollment since July 1, 2016. Limited exceptions exist: the Statewide waiver remains open for adults with intellectual disabilities and for Money Follows the Person institutional transitions; the CAC waiver remains open for Arlington/Clover Bottom class members and Harold Jordan Center 90-day-plus discharges; the Self-Determination waiver is fully closed.

TennCare submitted Amendment 1 to TennCare III to integrate the §1915(c) DD waivers and ICF/IID services into the §1115 managed care framework. As of the Q1 2025 quarterly report, that amendment was still pending CMS approval and remains pending as of early 2026. Verify status with TennCare before relying on integration in any planning conversation.

The Five Groups (4–8)

The ECF CHOICES group structure is the single most important thing to understand. Each group serves a different population, applies a different Level of Care standard, and has a different annual expenditure cap on services.

A few important callouts:

• Total Q1 2025 enrollment was 5,995 members against an enrollment target of 6,301, plus 3,706 of 3,951 reserve capacity slots filled.
• Group 6's exceptional-needs ceilings rise sharply for members with the most complex care needs: $158,989/year for developmental disability without intellectual disability, $208,264.10/year for DD with tracheal suctioning, and $301,339.10/year for DD with chronic ventilator care (reflecting the July 1, 2025 Enhanced Respiratory Care rate increases).
• Group 7 gained Supportive Home Care effective January 1, 2026, a recent expansion worth noting. Respite remains available in Groups 4, 5, 6, and 7 (not Group 8); Supportive Home Care remains Group 4 and Group 7 only.
• The state rule (Tenn. Comp. R. & Regs. 1200-13-01-.31) only codifies Groups 4–6. Groups 7 and 8 operate under §1115 Special Terms and Conditions and the TennCare ECF CHOICES Member Benefit Table. They are real, fully operational benefit groups, just not codified in state rule yet.

Eligibility: Three Tests

To enroll in any ECF CHOICES group, an applicant must meet a disability test, an age and Level-of-Care test, and a financial test.

Disability

ECF CHOICES requires an intellectual or developmental disability diagnosis as defined by Tenn. Comp. R. & Regs. 1200-13-01-.02:

• Intellectual disability beginning before age 18, or
• Developmental disability beginning before age 22

That second category, developmental disability without intellectual disability, is what made ECF transformative in 2016. Before ECF, an adult with autism, cerebral palsy, traumatic brain injury, or another DD without an intellectual disability had no Tennessee Medicaid HCBS pathway at all.

Age and Level of Care

These vary by group:

• Group 4, any age; meets NF LOC or At Risk for Institutionalization
• Group 5, adults 21+; At Risk for Institutionalization (or NF LOC adults choosing Group 5 if Group 6 is full)
• Group 6, adults 21+; meets NF LOC
• Group 7, children under 21; institutional-equivalent LOC plus severe behavioral support needs
• Group 8, typically adults 21+; institutional-equivalent LOC plus severe behavioral support needs (often transitioning out of institutions, hospitals, or jails)

Financial

ECF CHOICES uses the same TennCare LTSS framework as CHOICES, with four eligibility categories:

1. SSI-eligible (TennCare Medicaid at the SSI standard)
2. ECF CHOICES 217-Like Group (TennCare Standard, institutional-LOC equivalent), $2,982/month income, $2,000 in countable resources for 2026
3. Interim ECF CHOICES At-Risk Group (TennCare Standard, at-risk LOC), lower income standard around $1,995/month
4. ECF CHOICES Working Disabled Group, income up to 250% of the Federal Poverty Level, $2,000 resources

Tennessee's 60-month look-back applies for asset transfers below fair market value. For child applicants under 18 in Group 4 who do not have their own qualifying disability income, parental income generally counts under TennCare deeming rules, with limited exceptions.

If your income exceeds the relevant cap, Tennessee is an income-cap state, not medically-needy, you'll need to establish a Qualified Income Trust (QIT, also called a Miller Trust), authorized federally by 42 USC § 1396p(d)(4)(B) and implemented in Tennessee through Tenn. Comp. R. & Regs. 1240-03-03-.03(8). The seven-tier distribution waterfall, banks that accept QITs in Tennessee, attorney costs, and three worked examples are detailed in our deep guide.

Covered Services

ECF CHOICES is built on an employment-first philosophy: paid work is the central organizing goal of the program for working-age members. The service array reflects that, with deep employment supports alongside personal care, respite, family supports, behavioral supports, and assistive technology. The caps below are 2026 figures from the March 2026 ECF CHOICES Member Benefit Table.

Employment Services

Available in Groups 4–8:

• Discovery, Exploration, Job Development, Career Advancement, typically once every 1–3 years
• Job Coaching, up to 40 hours/week, or 50 hours/week if the member is employed at least 30 hours in individual integrated employment
• Co-Worker Supports, same limits, but the funding pays a co-worker instead of a job coach
• Benefits Counseling, initial 20 hours every 2 years, plus additional hours for new jobs and to maintain employment
• Supported Employment, Small Group, up to 30 hours/week (combined with related community living services)

Pre-Vocational

• Integrated Employment Path Services, up to 12 months, extendable 12 more if actively job-seeking; up to 30 hours/week combined with related services

Independent Community Living (Groups 4, 5, 6, 7, not Group 8)

• Community Integration Support Services and Independent Living Skills Training, tiered hour limits 20–50 hours/week depending on employment status
• Community Transportation, up to $225/month if Consumer Direction; otherwise capped at 12 one-way trips/week (max 2/day)

Personal Care (Groups 5 and 6 only)

• Personal Assistance, up to 215 hours/month

Family Caregiving Supports

• Respite, up to 30 days OR 216 hours/calendar year (member picks one). Available in Groups 4, 5, 6, 7. Consumer Direction allows hourly only.
• Supportive Home Care, Group 4 and Group 7 only. Group 7 access added January 1, 2026.
• Family Caregiver Stipend, Group 4 only, paid instead of Supportive Home Care. See the dedicated section below.

Family Empowerment (Groups 4 and 7)

• Community Support Development, Organization and Navigation
• Family Caregiver Education and Training, up to $500/calendar year
• Family-to-Family Support
• Health Insurance Counseling/Forms Assistance, up to 15 hours/year

Self-Advocacy (Groups 5, 6, 8)

• Individual Education and Training, up to $500/year
• Peer-to-Peer Support and Navigation, up to $1,500/lifetime
• Decision Making Supports, up to $500/lifetime, with counseling required first (available across all five groups). This is the modern replacement for the older "Conservatorship Counseling and Assistance" service line.

Assistive Technology and Modifications (all groups)

• Assistive Technology / Adaptive Equipment / Enabling Technology, combined cap $5,000/calendar year
• Minor Home Modifications, $6,000/project, $10,000/year, $20,000/lifetime

Specialized Therapy and Behavioral Supports

• Specialized Consultation and Training (Groups 5, 6, 8), up to $5,000/year ($10,000 if exceptional medical/behavioral needs); covers behavior, speech, OT, PT, nutrition, orientation/mobility, and nursing consultation
• Intensive Behavioral Family-Centered Treatment, Stabilization and Supports, Group 7 only
• Intensive Behavioral Community Transition and Stabilization Services, Group 8 only

Adult Dental (Groups 4, 5, 6, 8, not Group 7)

• Up to $5,000/calendar year, max $7,500 over three consecutive years for adults 21+

The Family Caregiver Stipend (Group 4 Only)

This is the line item that brings most families to ECF CHOICES.

The Family Caregiver Stipend (FCS) is a flat monthly cash benefit paid by the MCO directly to a family caregiver of a Group 4 member living at home. As of 2026:

• Up to $500 per month when the Group 4 member is a child under age 18
• Up to $1,000 per month when the Group 4 member is an adult age 18 or older

A few rules that trip families up:

• It is Group 4 only. Groups 5, 6, 7, and 8 do not include FCS.
• It is paid instead of Supportive Home Care. A Group 4 member receiving Supportive Home Care cannot also receive FCS for the same period.
• The caregiver is not enrolled as a Consumer-Directed Worker. FCS is a flat monthly stipend, not an hourly wage; the caregiver does not need to register with CDTN (Consumer Direct Care Network Tennessee), the program's Fiscal Employer Agent.
• Other ECF services must be in place first. FCS is not a standalone benefit, it sits on top of the member's other ECF supports.
• The exact monthly amount within the cap is need-based. The MCO Support Coordinator determines the actual stipend amount based on multiple variables.
• Tax treatment is unclear. TennCare materials don't address whether FCS qualifies for the IRS Notice 2014-7 difficulty-of-care exclusion (which generally applies to §1915(c) waiver payments to caregivers who share a home with the recipient). Because ECF CHOICES is authorized under §1115 rather than §1915(c), a tax professional should confirm treatment before assuming exclusion.

For families who are already providing extensive unpaid care for a loved one with I/DD, FCS is the most straightforward way to convert some of that care into household income, without taking on the timesheet, EVV, and payroll mechanics of Consumer Direction.

Consumer Direction in ECF CHOICES

ECF CHOICES allows Consumer Direction (the self-direction option) for four services: Personal Assistance, Supportive Home Care, Hourly Respite, and Community Transportation. Consumer Direct Care Network Tennessee (CDTN) is the contracted Fiscal Employer Agent. CDTN handles W-2 payroll, tax withholding, Electronic Visit Verification, background checks, and biweekly direct deposit.

The same spousal exclusion that applies in CHOICES applies in ECF CHOICES: a member cannot hire a spouse, conservator, legal guardian, power of attorney, or anyone serving as the member's CD Representative as their paid Consumer-Directed Worker.

The Freedom for Family Caregiving Act (Public Chapter 182 of 2025), signed by Governor Lee on April 30, 2025 and effective July 1, 2025, explicitly applies to ECF CHOICES, the same as it applies to CHOICES. PC 182 did not change Consumer Direction. What it changed is the agency-employed pathway: a TennCare-contracted home care agency can now hire a spouse, parent of an adult son or daughter, or other previously-excluded relative as a W-2 Direct Support Worker. Families who want to bring a spouse onto the payroll for an ECF CHOICES member should walk through the agency-employed pathway in our TN how to get paid as a family caregiver guide.

How to Apply

ECF CHOICES applications run through the Department of Disability and Aging (DDA), the new cabinet-level agency formed by the merger of the Department of Intellectual and Developmental Disabilities (DIDD) and the Tennessee Commission on Aging and Disability (TCAD), authorized by the Tennessee Disability and Aging Act signed April 11, 2024 and effective July 1, 2024. Commissioner Brad Turner runs the merged agency. If you see older sources referring to "DIDD" or "TCAD," they're talking about what is now DDA.

There are three on-ramps:

1. Online self-referral. Anyone can submit an ECF CHOICES referral at perlss.tenncare.tn.gov/externalreferral. This is the simplest path for families who are comfortable filling out the form.
2. If the applicant already has TennCare, call your assigned MCO and ask for an ECF CHOICES referral. The MCO Care Coordinator handles intake.
3. If the applicant does not have TennCare, call the DDA regional office for help with both the ECF application and Medicaid enrollment:
   • West Tennessee: 1-866-372-5709
   • Middle Tennessee: 1-800-654-4839
   • East Tennessee: 1-888-531-9876

Other useful contacts:

• TennCare Long-Term Services & Supports Help Desk: 1-877-224-0219
• BlueCare Tennessee: 1-888-747-8955
• UnitedHealthcare Community Plan: 1-800-690-1606
• Wellpoint Tennessee: 1-833-731-2153

Once enrolled, the assigned MCO Support Coordinator (typically a registered nurse or social worker) builds the person-centered support plan (PCSP), authorizes service hours within the Group's expenditure cap, and approves provider agencies.

The Waitlist (Referral List) and Reserve Capacity

ECF CHOICES has effectively a waitlist, TennCare calls it a Referral List. Once an enrollment target is reached, qualified applicants stay on the Referral List. Two ways to enroll above the target:

• Reservation Priority, Green Page categories enroll immediately if the applicant qualifies.
• Reservation Priority, Pink Page categories enroll only when slots become available, and TennCare describes Pink Page enrollment as "VERY limited."

Reserve Capacity slots cover the highest-need transitions and crisis situations:

1. Applicants discharged from a nursing facility or ICF/IID
2. Applicants discharged from acute care at imminent risk of NF placement
3. Applicants with intellectual disability who have an Aging Caregiver (a parent or other primary caregiver who is themselves aging into a need for care)
4. Applicants meeting Emergent Circumstances criteria (Interagency Review Committee determination)
5. Applicants meeting Multiple Complex Health Conditions criteria (Interagency Review Committee determination)

The state rule cap on reserve capacity is 250 slots, but operational reserve capacity per the Q1 2025 quarterly report is 3,951 slots, the rule has not been updated to reflect the funded operational expansion.

If the applicant has an Aging Caregiver in the home, that's worth flagging on the application, it is one of the express Reservation Priority categories.

Appeals and Rights

A denial, reduction, or termination of ECF CHOICES eligibility or services is appealable. Tennessee runs the same two appeal tracks for ECF as for CHOICES:

Eligibility appeals, for denials, terminations, or LTSS application delays exceeding 90 days, go to TennCare Connect at 1-855-259-0701 or tenncareconnect.tn.gov. The hearing must be held within 90 days for LTSS applications.

Medical/service appeals, for any Adverse Benefit Determination on an ECF CHOICES service, go to TennCare Member Medical Appeals at 1-800-878-3192. The filing deadline is 60 days from the date you find out about the problem; the standard decision is 90 days; expedited decisions (about a week) are available if waiting could endanger life or health.

Aid Pending Appeal is available for ongoing services being reduced or terminated, but only with both a timely appeal and a timely COB (Continuation of Benefits) request. The Grier Consent Decree provides additional procedural protections beyond the federal floor.

Free legal help is available through the Tennessee Justice Center, Disability Rights Tennessee, the TennCare Advocacy Program at 1-800-758-1638, regional legal aid offices, TN Free Legal Answers, and Help4TN at 2-1-1.

Common Misconceptions

"ECF CHOICES is the same as CHOICES." No. CHOICES has Groups 1–3 and serves seniors 65+ and adults 21+ with physical disabilities, applied through TennCare Connect or your AAAD. ECF CHOICES has Groups 4–8 and serves people of any age with I/DD, applied through DDA. The two programs share the §1115 demonstration and the same three MCOs, but they are otherwise distinct.

"ECF CHOICES replaced the §1915(c) DD waivers." Mostly, but not entirely. The Self-Determination, CAC, and Statewide §1915(c) waivers are still legally active and continue to serve existing participants. They closed to most new general enrollment on July 1, 2016. Limited exceptions remain, see the TennCare DD waivers page.

"Group 4 always gets the Family Caregiver Stipend." Not automatically. FCS is available to Group 4 members, but the actual amount and approval are determined by the MCO based on need; FCS sits on top of other ECF services and cannot be combined with Supportive Home Care for the same period.

"Family Caregiver Stipend is the same as Consumer Direction." No. FCS is a flat monthly stipend paid to a family caregiver, with no timesheets and no CDTN enrollment. Consumer Direction is hourly W-2 employment through CDTN with EVV and biweekly payroll. They serve different family situations.

"ECF CHOICES Group 4 is the same as Katie Beckett." No. Katie Beckett covers severely disabled minors who would qualify for institutional level of care but whose family income otherwise disqualifies them from regular Medicaid. ECF CHOICES Group 4 covers children OR adults with I/DD living at home with family who meet ECF's I/DD diagnostic and LOC criteria. The two programs sometimes serve the same families, but the eligibility and benefits are different.

"There is no waitlist for ECF CHOICES." There is, TennCare calls it a Referral List. Q1 2025 enrollment was 5,995 against a target of 6,301 plus reserve capacity. Reservation Priority and Reserve Capacity categories enroll above the target, but most applicants outside those categories will wait.

Related Terms

• HCBS waiver: The federal authority used by most states for HCBS. Tennessee uses §1115 instead.
• Consumer Directed Services (CDS): The national term for Consumer Direction.
• Managed Care Organization (MCO): BlueCare, UHC Community Plan, or Wellpoint, the plans that deliver ECF CHOICES.
• Electronic Visit Verification (EVV): The federally required time-and-location verification used by Consumer Direction caregivers.
• Money Follows the Person: The federal demonstration that helps people transition out of institutions to HCBS.
• Activities of Daily Living (ADLs): The functional measures used in Level-of-Care assessments.

Learn More

• Tennessee Medicaid Programs for Seniors (Hub)
• What You Need to Know About TennCare CHOICES
• Tennessee Katie Beckett Program
• How to Get Paid as a Family Caregiver in Tennessee
• How to Apply for Tennessee Medicaid
• Tennessee Medicaid Nursing Home Coverage

Find personalized help navigating ECF CHOICES at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. ECF CHOICES eligibility, services, expenditure caps, and waitlist dynamics change. Always verify with TennCare, the Department of Disability and Aging, your assigned MCO, or an elder-law or disability-rights attorney. Brevy is not a law firm, financial advisor, or healthcare provider.