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 TennCare CHOICES. They share a name and a Section 1115 demonstration, but CHOICES serves adults 65 and older and adults 21 and older with physical disabilities. ECF's group numbers, 4 through 8, run on from CHOICES's own lower-numbered groups.

Below: who qualifies, the five groups, the services, the 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, 2030.5

TennCare calls it the first managed long-term services and supports program in the nation to make integrated, competitive employment and independent community living 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) alongside people with an intellectual disability.5

The three Section 1915(c) DD waivers (Self-Determination, Comprehensive Aggregate Cap, and Statewide) are still legally active and still serve existing participants, but they have been closed to new enrollment since July 1, 2016, with limited exceptions: Statewide and CAC remain open under specific criteria (Money Follows the Person transitions, former Arlington, Clover Bottom, or Harold Jordan Center class members); Self-Determination is closed.5

The Five Groups (4 through 8)

Your group sets both your services and your annual cap.1

• Group 6's exceptional-needs ceilings are the average annualized cost of comparable institutional care: $236,450 at the ICF/IID-equivalent level, $158,989 for a developmental disability without intellectual disability, $208,264.10 with tracheal suctioning, and $301,339.10 with chronic ventilator care.1
• Group 4 is not children-only. TennCare's brochure describes it as being for "families caring for a child under the age of 21," but CMS's approved TennCare III terms cover both children under 21 and adults 21 or older with I/DD who live at home with family and elect this group. If you are an adult with I/DD living with family, do not let the brochure talk you out of asking.1
• Confirm your own cap with your Support Coordinator. The base caps for Groups 4, 5 and 6 come from CMS's approved TennCare III terms (Amendment 7, June 30, 2025), and Tennessee may adjust them over the life of the demonstration to reflect provider rate increases, publishing any change on TennCare's website. Groups 7 and 8, and Group 6's exceptional-needs ceilings, are institutional-cost-based and reset each year by TennCare memo. A member in Group 4, 5 or 6 cannot be disenrolled, and authorized services cannot be cut, where the only reason the cap would be exceeded is a state-directed rate increase.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 plus limitations in two or more adaptive skill areas; for developmental disability, substantial limitations in three or more major life activities (self-care, language, learning, mobility, self-direction, independent living, economic self-sufficiency) 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

An applicant must be SSI-eligible or meet the criteria for the ECF CHOICES 217-Like Group, meaning people of all ages with I/DD who would be Medicaid-eligible if their ECF services came through a Section 1915(c) waiver.1

The income limit is not one number. TennCare publishes three, as of January 2026:1

1. $2,982/month for a person approved at nursing-facility level of care, which is 300% of the $994 SSI federal benefit rate1
2. $1,995/month for a person approved at at-risk level of care rather than NF LOC1
3. $3,325/month for a person who is working and has under $994 in unearned income1

Countable resources must not be over $2,000 for a household of one; the home you live in does not count. Tennessee's 60-month look-back applies to anything given away or sold for less than its worth.6 Enrollment in the 217-Like Group is available only when there is an open slot in a benefit group for which the applicant meets all eligibility and prioritization criteria.1

Being over the limit is not the end of the road. Tennessee is an income-cap state, not medically needy, so you would establish a Qualified Income Trust (QIT, or Miller Trust) under the federal safe harbor at 42 U.S.C. § 1396p(d)(4)(B) and 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 come from CMS's approved Special Terms and Conditions and TennCare's ECF CHOICES benefit table. An MCO may authorize services above any of them as a cost-effective alternative to institutional placement.3

Employment Services

The employment-first core of the program includes Exploration, Discovery, Situational Observation and Assessment, Job Development, Job Coaching (age 16 or older), Co-Worker Supports, Career Advancement, Benefits Counseling, Supported Employment Small Group, and Integrated Employment Path Services.3

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.3

Personal Care (Groups 5 and 6)

• Personal Assistance. The 215 hours/month limit is a Group 6 cap. CMS's Special Terms and Conditions state it for the Comprehensive Supports group, not for Group 5.3

Family Caregiving Supports

• Respite, limited to a maximum of 216 hours or 30 days per enrollee per year (the member chooses one).3
• 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.3
• Family-to-Family Support.

Self-Advocacy and Decision-Making

• Peer-to-Peer Support and Navigation.
• Decision Making Supports, limited to $500/lifetime.3

Assistive Technology and Modifications

• Assistive Technology and Enabling Technology, combined cap $5,000/calendar year.3
• Minor Home Modifications, $6,000/project, $10,000/calendar year, with a $20,000/lifetime maximum.3

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.3

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

• $100 to $500 per month when the Group 4 member is a child under age 183

• $100 to $1,000 per month when the Group 4 member is age 18 or older3

• It is Group 4 only. Groups 5, 6, 7, and 8 do not include FCS.

• It is paid instead of Supportive Home Care (including Personal Assistance), never alongside it.3

• 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 say whether FCS qualifies for the IRS difficulty-of-care exclusion that can apply to Medicaid waiver payments to a caregiver sharing the recipient's home. Ask a tax professional before assuming it does.

Set your expectations here: the stipend is not meant to pay for care a family was already giving before the member enrolled, because ECF CHOICES is built to sustain and enhance natural supports rather than replace them with paid ones. Where it is authorized, it brings household income without the timesheet, EVV, and payroll mechanics of Consumer Direction.2

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) via the CareAttend app, worker enrollment, and direct deposit; the member is the legal employer of record.3,8

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), effective July 1, 2025, applies to ECF CHOICES as it does to CHOICES, but it did not change Consumer Direction. It changed the agency-employed pathway: a TennCare-contracted 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.4 To bring a spouse onto the payroll, walk 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. 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, and are taken off it based on priority groups and the availability of slot openings.5,3

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

1. Aging Caregiver. Hard age thresholds, and not the same for every applicant: the custodial parent or caregiver must be at least 75 where the person served has an intellectual disability, or at least 80 for a developmental disability. A caregiver who is simply getting older does not meet the definition.3
2. Institutional transition, where enrollment is needed to move the person out of a nursing facility or a private or public ICF/IID into a more integrated community setting.3
3. Multiple Complex Health Conditions, for a working-age person whose chronic or acquired conditions prevent them from working and who urgently needs supports to hold on to their current living arrangement.3
4. Emergent Circumstances, which is far wider than a caregiver's death and is where most waiting families' openings actually sit. It also covers a primary caregiver who is "permanently incapacitated and there is no other caregiver available"; recent loss of the person's living arrangement; "clear evidence of serious abuse, neglect, or exploitation in the current living arrangement" with no alternative available; discharge from an acute care setting at imminent risk of nursing-facility placement, or a PASRR finding that a nursing facility is inappropriate; an adult aging out of state custody, leaving an inpatient psychiatric hospital, or released from incarceration; and immediate, ongoing risk of serious harm to the person or others after other interventions have failed.3

Flag any of these on the application. Fitting a description is not by itself an enrollment. TennCare adds that "other eligibility rules also apply."3

Appeals and Rights

Tennessee runs two appeal tracks for ECF, the same as for CHOICES, and they do not share deadlines.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 go to TennCare Member Medical Appeals at 1-800-878-3192, and they cover more than an outright no. TennCare says you can appeal when it says no to a healthcare request, stops or changes your healthcare, makes you wait too long for care, leaves you with bills you think it should have paid, or when there is some other reason you cannot get care when you need it.10

Count the 60 days from the notice, not from the day you opened it. TennCare states the medical deadline as 60 days after you find out there is a problem. But ECF CHOICES runs through managed care, and 42 CFR 438.402(c)(2)(ii) gives an enrollee "60 calendar days from the date on the adverse benefit determination notice," so file from the date printed on the letter. A standard appeal is usually decided within 90 days, an expedited one in about a week when an emergency exists and the plan agrees, longer if it needs time to gather medical records.10

Keeping services running during a medical appeal is not automatic. Under 42 CFR 438.420(b) the plan continues them only if your appeal is timely, it concerns services already authorized and ordered by an authorized provider, the authorization has not expired, and you separately ask for continuation. After the plan's adverse resolution you have 10 calendar days to request a state fair hearing and continued benefits, or services stop. If you lose, the plan may recover what it paid meanwhile.10

On the eligibility track only, continuation runs on a tighter clock than the appeal: an appeal filed within 40 days of the notice is timely, but benefits continue only if you ask within 20 days of the notice, or before the coverage end date if that is later. Filing on day 35 is a timely appeal that does not keep coverage running. Both windows have a good-cause exception, and both come from a TennCare manual last revised in 2015, so confirm them with TennCare Connect. Do not apply either figure to a medical appeal.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

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

ECF CHOICES Group 4 is the same as Katie Beckett. It is not. Katie Beckett covers children under 18 whose disabilities or complex medical needs would qualify them, but whose parents' income or assets do not.1 Group 4 covers people with I/DD living at home with family who meet ECF's diagnostic and level-of-care criteria.1 The two overlap, but eligibility and benefits differ.

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.