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

Employment and Community First (ECF) CHOICES is Tennessee's Medicaid home- and community-based services program for people of any age who have an intellectual or developmental disability (I/DD). Run inside TennCare, it pays for job coaching, personal assistance, respite, community living supports, assistive technology, behavioral supports, and the Family Caregiver Stipend for a Group 4 member cared for at home.

ECF CHOICES is not the same program as TennCare CHOICES. The two share the "CHOICES" name and live inside the same TennCare Section 1115 demonstration, but they serve different populations: CHOICES is for adults 65 and older and adults 21 and older with physical disabilities; ECF CHOICES is for people of any age with I/DD. ECF's group numbers, 4 through 8, run on from CHOICES's own lower-numbered benefit groups.

Below: who qualifies, the five groups, the service catalog, the Family Caregiver Stipend, the Department of Disability and Aging (DDA) application process, and the referral list in 2026.

What ECF CHOICES Is, and Isn't

ECF CHOICES launched July 1, 2016 under TennCare's Section 1115(a) demonstration, now rolled into the TennCare III demonstration that the Centers for Medicare & Medicaid Services (CMS) approved effective January 8, 2021 for a 10-year period running through December 31, 2030.4

The program was built on a different premise than the waivers that came before it. TennCare describes ECF CHOICES as the first managed long-term services and supports program in the nation focused on integrated, competitive employment and independent community living as the first and preferred option for people with I/DD. It serves people with a developmental disability other than intellectual disability (autism, cerebral palsy, traumatic brain injury, and others) alongside people with an intellectual disability.4

The three Section 1915(c) DD waivers (Self-Determination, Comprehensive Aggregate Cap, and Statewide) are still legally active, but they have been closed to new enrollment since July 1, 2016, with limited exceptions: the Statewide and CAC waivers remain open under specific criteria (for example, Money Follows the Person institutional transitions and former Arlington, Clover Bottom, or Harold Jordan Center class members), while the Self-Determination waiver is closed.4

The Five Groups (4 through 8)

The group structure is the single most important thing to understand.1

A few important callouts:

• Group 6's exceptional-needs ceilings rise sharply for members with the most complex care needs, set at the average annualized cost of comparable institutional care: $236,450/year at the ICF/IID-equivalent level, $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.1
• Group 4 is not children-only. TennCare's plain-language brochure describes Group 4 as being for "families caring for a child under the age of 21," but the state rule itself (Tenn. Comp. R. & Regs. 1200-13-01-.02(62)) covers both children under 21 and adults age 21 or older with I/DD who live at home with family and elect to be in this group. If you are an adult with I/DD living with family, do not let the brochure's wording talk you out of asking about Group 4.1
• Which services your benefit group covers is set by that group's benefit package, so ask your MCO Support Coordinator to confirm what is in yours.1
• The state rule (Tenn. Comp. R. & Regs. 1200-13-01-.31) codifies eligibility and the Expenditure Caps for Groups 4, 5, and 6. In its own words: "There are three (3) groups in ECF CHOICES." Groups 7 and 8 are real benefit groups (TennCare's member brochure states there are five), but their caps, and Group 6's exceptional-needs caps, are set annually by TennCare memo rather than by the rule.1

Eligibility: Three Tests

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

Onset age is only half of each definition; the rule also requires substantial limitations in functioning. For intellectual disability, that means significantly sub-average intellectual functioning with related limitations in two or more adaptive skill areas; for developmental disability, substantial functional limitations in three or more major life activities (self-care, language, learning, mobility, self-direction, capacity for independent living, economic self-sufficiency) that are likely to continue indefinitely. A diagnosis on its own is not the test.

That second category, developmental disability without intellectual disability, is what made ECF transformative in 2016. Before ECF, an adult with a DD but no intellectual disability had no Tennessee Medicaid HCBS pathway at all.1

Age and Level of Care

These vary by group:1

• Group 4, children under 21, and adults 21+ who elect it, living at home with family; NF LOC or At Risk for Institutionalization1
• Group 5, adults 21+; At Risk for Institutionalization (or NF LOC adults choosing Group 5 if Group 6 is full)
• Group 6, adults 21+; NF LOC
• Group 7, children under 21; severe behavior-support needs plus the relevant level of care
• Group 8, adults with I/DD; severe behavior-support needs, moving into the community from a highly structured or supervised setting1

Financial

ECF CHOICES uses the TennCare long-term-care financial framework. An applicant must be SSI-eligible or qualify in one of the demonstration eligibility groups:1

1. SSI-eligible (TennCare Medicaid at the SSI standard)
2. ECF CHOICES 217-Like Group (institutional-level-of-care equivalent), with a maximum income standard of $2,982/month (300% of the SSI Federal Benefit Rate) and $2,000 in countable resources for 20261
3. Interim ECF CHOICES At-Risk Group (at-risk level of care)
4. ECF CHOICES Working Disabled Group, for members with earned income

Enrollment in the 217-Like Group is available only when there is an open slot in an ECF CHOICES benefit group for which the applicant meets all eligibility and prioritization criteria.1 Tennessee's 60-month look-back applies for asset transfers below fair market value.6

If your income exceeds the relevant cap, Tennessee is an income-cap state, not medically needy, so you will need to establish a Qualified Income Trust (QIT, also called a Miller Trust), authorized federally under the safe harbor at 42 U.S.C. § 1396p(d)(4)(B) and governed in Tennessee by Tenn. Comp. R. & Regs. 1200-13-20-.06.7

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 per-service limits below are the 2026 caps set in the TennCare state rule (Tenn. Comp. R. & Regs. 1200-13-01).1

Employment Services

The employment-first core of the program includes Exploration, Discovery, Situational Observation and Assessment, Job Development, Job Coaching (available to members age 16 or older), Co-Worker Supports, Career Advancement, Benefits Counseling, and Supported Employment, Small Group.1

Pre-Vocational

• Integrated Employment Path Services, which support a member working toward competitive integrated employment.

Independent Community Living

• Community Integration Support Services and Independent Living Skills Training.
• Community Transportation, limited to no more than $225/month for members using Consumer Direction.1

Personal Care (Groups 5 and 6 only)

• Personal Assistance, limited to 215 hours/month.1

Family Caregiving Supports

• Respite, limited to a maximum of 216 hours or 30 days per enrollee per year (the member chooses one).1
• Supportive Home Care.
• Family Caregiver Stipend, Group 4 only, paid in lieu of Supportive Home Care. See the dedicated section below.

Family Empowerment

• Community Support Development, Organization and Navigation.
• Family Caregiver Education and Training, up to $500/year.1
• Family-to-Family Support.

Self-Advocacy and Decision-Making

• Peer-to-Peer Support and Navigation.
• Decision Making Supports, limited to $500/lifetime.1

Assistive Technology and Modifications

• Assistive Technology and Enabling Technology, combined cap $5,000/calendar year.1
• Minor Home Modifications, $6,000/project, $10,000/calendar year, with a $20,000/lifetime maximum.1

Specialized Therapy and Behavioral Supports

• Specialized Consultation and Training, covering behavior, speech, occupational, physical, nutrition, and nursing consultation.
• Intensive behavior supports for Groups 7 and 8: treatment and stabilization for a child living with their family (Group 7), and community-transition supports for an adult (Group 8).1

Adult Dental (members age 21 and older)

• Up to $5,000/calendar year, and a maximum of $7,500 across three consecutive calendar years.1

The Family Caregiver Stipend (Group 4 Only)

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 2026:2

• Up to $500 per month when the Group 4 member is a child under age 182
• Up to $1,000 per month when the Group 4 member is age 18 or older2

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 do not address whether FCS qualifies for the federal IRS difficulty-of-care exclusion that can apply to certain Medicaid waiver payments to caregivers who share a home with the recipient. A tax professional should confirm treatment before assuming the exclusion applies.

For families already providing extensive unpaid care, FCS is the most straightforward way to convert some of it into household income without the timesheet, EVV, and payroll mechanics of Consumer Direction.

Consumer Direction in ECF CHOICES

ECF CHOICES allows Consumer Direction (the self-direction option) for designated services, including Personal Assistance, Supportive Home Care, hourly Respite, and Community Transportation. Consumer Direct Care Network Tennessee (CDTN) is the contracted Fiscal Employer Agent (FEA). CDTN handles payroll, tax withholding, Electronic Visit Verification (EVV) through the CareAttend mobile app, worker enrollment, and direct deposit; the member is the legal employer of record.1,8

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.8

The Freedom for Family Caregiving Act (Public Chapter 182 of 2025), signed by Governor Bill Lee on April 30, 2025 and effective July 1, 2025, explicitly applies to ECF CHOICES, the same as it applies to CHOICES.5 Public Chapter 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, a parent of an adult son or daughter, or another previously-excluded relative as a paid W-2 Direct Support Worker.5 To bring a spouse onto the payroll, walk through that 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 cabinet-level state agency that launched July 1, 2024 by combining the Department of Intellectual and Developmental Disabilities (DIDD) with the Tennessee Commission on Aging and Disability. DDA, led by Commissioner Brad Turner, oversees services for more than 1.5 million older adults and Tennesseans with disabilities. If you see older sources referring to DIDD or TCAD, they are describing what is now DDA.3,9

There are three on-ramps.

Other useful contacts:

Once enrolled, the assigned Support Coordinator develops the person-centered support plan (PCSP), covering services up to the member's group expenditure cap.3

The Referral List and Reserve Capacity

ECF CHOICES is not a pure first-come, first-served program. Because annual funding is limited, qualified applicants who cannot be enrolled immediately are placed on a referral list.3

Alongside that list, TennCare holds reserve-capacity slots for the applicants with the most urgent needs. Its published Reserve Capacity Groups include, among others:3

1. Aging Caregiver. This one carries hard age thresholds, and they are not the same for every applicant: the custodial parent or custodial caregiver must be at least 75 where the person served has an intellectual disability, or at least 80 where the person served has a developmental disability. A caregiver who is simply getting older does not meet the definition.3
2. Emergent circumstances, such as a primary caregiver who is recently deceased with no other caregiver available to provide needed long-term supports.
3. Institutional transition. Enrollment in ECF CHOICES is needed to move the person out of a long-term care institution (a nursing facility, or a private or public ICF/IID) into a more integrated community setting.3

If the applicant is transitioning out of an institution, or the custodial caregiver has reached the 75 or 80 threshold, flag it on the application.

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:10

Eligibility appeals, for a denial, a coverage ending, or an incorrect income or family-size determination, go through TennCare Connect at 1-855-259-0701 or tenncareconnect.tn.gov. You can also appeal when a decision has taken too long: more than 45 days for a standard application, or more than 90 days for a long-term-care application.10

Medical/service appeals, for a denial, reduction, or termination of 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; a standard appeal is usually decided within 90 days, and an expedited appeal (decided in about a week) is available when an emergency exists and the health plan agrees.10

Continuation of benefits (often called aid paid pending) is available while an appeal of a termination or denial is decided, and it runs on a tighter clock than the appeal itself: an appeal filed within 40 days of the termination or denial notice is timely, but benefits are only continued if the request is filed within 20 days of the notice, or before the coverage end date if that is later. If TennCare's action is upheld, the member may have to repay the benefits that were continued.11

Free legal help is available through the Tennessee Justice Center, Disability Rights Tennessee, regional legal aid offices, TN Free Legal Answers, and the statewide 2-1-1 help line.

Common Misconceptions

ECF CHOICES is the same as CHOICES. It is not. CHOICES (Groups 1–3) serves seniors 65 and older and adults 21 and older with physical disabilities, through TennCare Connect or an Area Agency on Aging and Disability (AAAD); ECF CHOICES (Groups 4–8) serves people of any age with I/DD, through DDA.

ECF CHOICES replaced the Section 1915(c) DD waivers. Mostly, but not entirely. The three Section 1915(c) waivers are still legally active and continue to serve existing participants; they closed to most new enrollment on July 1, 2016, with limited exceptions (TennCare DD waivers page).4

Group 4 always gets the Family Caregiver Stipend. Not automatically. The amount and approval are set by the MCO based on need, it sits on top of other ECF services, and it cannot be combined with Supportive Home Care for the same period.2

The Family Caregiver Stipend is the same as Consumer Direction. It is not. The stipend is a flat monthly payment with no timesheets and no CDTN enrollment; Consumer Direction is hourly W-2 employment through CDTN with EVV and payroll.

ECF CHOICES Group 4 is the same as Katie Beckett. It is not. Katie Beckett covers children under 18 with disabilities or complex medical needs who are not Medicaid-eligible because of their parents' income or assets. ECF CHOICES Group 4 (Essential Family Supports) covers people with I/DD living at home with family who meet ECF's diagnostic and level-of-care criteria.1 The two sometimes serve the same families, but the eligibility and benefits are different.4

There is no waitlist for ECF CHOICES. There is; TennCare calls it a referral list. Most applicants outside the reserve-capacity priority situations will wait.3

Related Terms

• HCBS waiver
• Consumer Directed Services (CDS)
• Managed Care Organization (MCO)
• Activities of Daily Living (ADLs)

Learn More

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. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.