Tennessee Medicaid HCBS Waivers (2026)

If you've searched "Tennessee Medicaid waivers" and gotten a list that includes things like "Aged & Disabled Waiver" or "Elderly & Disabled Waiver," that list is wrong for Tennessee.

Tennessee doesn't operate Medicaid HCBS programs the way most states do. Most states run a portfolio of separately authorized §1915(c) waivers, one for the elderly, one for adults with intellectual disabilities, one for children with medical complexity, and so on. Tennessee took a different path. It consolidated almost all of its long-term-care HCBS programs under a single Section 1115(a) demonstration run by TennCare (Tennessee Medicaid) and called TennCare III.

That distinction sounds technical, but it has real consequences for families. There is no "Tennessee Aged & Disabled Waiver" to apply to. The pathway for an aging parent is CHOICES. The pathway for a child or adult with intellectual or developmental disability is ECF CHOICES. The pathway for a child under 18 with a significant medical or behavioral disability is Katie Beckett. Each one has its own eligibility test, its own services, its own application door, and its own waitlist (or lack thereof).

This guide covers every HCBS pathway a Tennessee senior or family caregiver is likely to meet in 2026: the §1115 framework, the four pathways, the legacy I/DD waivers still serving grandfathered members, and Money Follows the Person.

Why Tennessee Medicaid HCBS Waivers Work Differently: §1115 vs §1915(c)

Most states operate Medicaid HCBS through individual §1915(c) Home and Community-Based Services waivers, each approved by CMS for a specific target population, running five years, and renewed.

Tennessee took a different route. Under the federal Medicaid statute's Section 1115(a) authority, states can ask CMS to approve broader "demonstration projects" that bend or replace standard Medicaid rules in exchange for budget accountability.1

On January 8, 2021, CMS approved TennCare III, a Section 1115 demonstration that:1

• Authorizes Tennessee's entire Medicaid program (acute care AND long-term services and supports) under one umbrella
• Runs through December 31, 2030, an unusually long ten-year approval period
• Uses an "aggregate cap" budget model under which Tennessee agrees to a fixed budget target in exchange for added flexibility and the chance to earn reinvestable federal savings
• Folds CHOICES, ECF CHOICES, and Katie Beckett into the demonstration as components

The practical difference for families: the analogous program for an aging parent or adult with a physical disability is CHOICES, and CHOICES is a piece of TennCare III.

Tennessee does still have three legacy §1915(c) DD waivers (more on those below), closed to general new enrollment since July 1, 2016 though two of them still admit under narrow criteria, but the broad LTSS architecture is §1115.1

The Four Tennessee Medicaid HCBS Pathways at a Glance

Almost everyone looking for Tennessee HCBS fits one of these pathways.

Pathway 1: CHOICES (the Pathway for Seniors and Adults with Physical Disabilities)

CHOICES is the program for Tennessee seniors age 65 and older and adults age 21 and older with a physical disability who need long-term services and supports. It is delivered through TennCare managed care organizations under the TennCare III §1115 demonstration, not a §1915(c) waiver.3

CHOICES is divided into three Groups:

CHOICES Group 1, Nursing Facility Care

• Who: TennCare members of all ages who qualify for and are receiving TennCare-reimbursed nursing facility care.
• Setting: Long-term residence in a Medicaid-certified nursing facility.
• Functional test: Nursing facility level of care, scored via the TennCare Pre-Admission Evaluation (PAE) on the 0-26 NF Level of Care Acuity Scale; 9 or more meets it on score alone, and there is a second route below 9 (see the PAE section below).
• Financial test: $2,982/month gross income (the Medicaid Income Cap, 300% of the 2026 Supplemental Security Income (SSI) Federal Benefit Rate of $994/month); $2,000 in countable resources. For a married applicant with a community spouse, TennCare sets the Community Spouse Resource Maintenance Allowance at one-half of the couple's total countable resources, but not less than $32,532 and not more than $162,660 as of January 2026, so a couple with modest savings is protected by the floor rather than cut to half. The maximum Minimum Monthly Maintenance Needs Allowance is $4,066.50/month. The home is excluded as a resource when it is the principal residence of the applicant, spouse, or a dependent relative, or where intent to return is established, but an institutional individual is ineligible for LTSS payments when home equity exceeds $752,000. Two things soften that equity bar, and both are easy to miss: it does not disqualify you while your spouse, your child under 21, or your blind or disabled child lawfully resides in the home, and even where it does apply TennCare provides that it can be waived if undue hardship is requested and found. Note also what "countable" is doing in the $2,000 figure. TennCare's Aged, Blind and Disabled manual excludes one vehicle of any value if it is used to transport the applicant or a household member, and staff are told to assume a vehicle is used for transportation absent evidence otherwise. The exclusion list is longer than the home and the car, so do not read $2,000 as a limit on everything you own.4
• Waitlist: None. Group 1 is a Medicaid entitlement, so anyone clinically and financially eligible is enrolled.
• Cost-neutrality cap: Not applicable to Group 1 (reimbursed on a daily nursing-facility basis).

CHOICES Group 2, HCBS in Lieu of Nursing Facility

• Who: Seniors age 65 and older and adults age 21 and older with a physical disability who meet nursing facility level of care but choose home and community-based services instead.
• Setting: Member's home, family member's home, or qualifying community-based residence.
• Functional test: Nursing facility level of care (the same PAE, 9 or more on score alone).
• Financial test: The same $2,982/month income and $2,000 asset standards as Group 1.
• Waitlist: Yes, and the target is discretionary rather than fixed in statute: the demonstration's terms say the state may establish enrollment targets for Groups 2 and 3. In its quarterly report to CMS for January through March 2025, TennCare reported a statewide Group 2 target of 11,000 against 8,759 members enrolled, plus 300 statewide reserve-capacity slots. Group 2 is not an entitlement, and at target the state may establish a waiting list, which must be managed statewide using a standardized assessment tool.3 The target is not a closed door. CMS approved it as a waiver of Medicaid's reasonable-promptness requirement, and the same paragraph gives three routes past it. (1) Reserve capacity: the state may hold slots for people leaving a nursing facility, and for people leaving an acute-care setting at imminent risk of nursing facility placement without HCBS. (2) Cost-effective alternative: an MCO whose enrollee meets the Group 2 criteria but cannot be enrolled at target may, at its sole discretion, offer HCBS as a cost-effective alternative under a plan of care, serving the person outside the target until a slot opens. (3) Transition from Group 1: a member already in Group 1 who meets the Group 2 requirements can move at any time the transition can be accomplished, even at target. Ask about all three rather than accepting the waiting list as the only path.1
• Cost-neutrality cap: $107,627.55/year in 2026, from an average nursing facility reimbursement of $294.87/day. That headline figure is not everyone's cap. It tracks the level of nursing facility reimbursement the person would actually qualify for, so a member who would qualify for Enhanced Respiratory Care is priced against a much higher ceiling: $173,010/year at the tracheal-suctioning rate, $249,977.55/year at the chronic-ventilator rate, with supporting documentation filed alongside the PAE. A ventilator-dependent applicant measured against $107,627.55 is measured against the wrong number. The cap also counts home health and private duty nursing, not just CHOICES services. A member whose care is expected to exceed their cap does not qualify to enroll or stay in Group 2, though a decision to move them to nursing facility care is appealable. The figures re-set each January.3

CHOICES Group 3, At Risk of Institutionalization

• Who: Seniors 65 and older and adults 21 and older with a disability who don't yet meet nursing facility level of care but are at risk of it without services.
• Setting: Member's home or community-based residence.
• Functional test: "At Risk" of institutionalization, below NF level of care.
• Financial test: Group 3 enrolls both SSI recipients and non-SSI recipients. TennCare's published institutional financial standards ($2,982/month Medicaid Income Cap, $2,000 in countable resources) are the Group 1 and Group 2 test; if you are pursuing Group 3, confirm the category you'd qualify under with the TennCare eligibility guide rather than assuming the institutional numbers apply.3
• Waitlist: Yes, but the target is discretionary rather than mandatory: the rule says the state may establish an Enrollment Target for Group 3, which must be at least ten percent of the Group 2 target. As of October 1, 2022, based on current appropriations, TennCare states there is an enrollment target of 1,750 for non-SSI recipients.3
• Cost-neutrality cap: $18,000/year of HCBS, excluding minor home modifications, in TennCare's own cost-effective-alternatives policy. CMS's approved terms set the figure higher, at $19,764 per calendar year on the same exclusion, so ask your care coordinator which number is being applied to your plan of care. Two published exceptions sit on top: the cap may be exceeded by an individually determined amount where that is necessary to give you access to Supported Employment or Individual Employment Support, and a Group 3 member may not be disenrolled or have authorized services reduced if the only reason the cap would be exceeded is a state-directed rate increase.3

The CHOICES HCBS array and its per-service limits are published in TennCare's Appendix A: CHOICES Benefit Table (last updated March 2026) and Table 2b of the approved demonstration terms: personal care (2,580 hours a year), adult day care (2,080 hours), in-home respite (216 hours), in-patient respite (9 days), home-delivered meals (one a day), assistive technology ($900), enabling technology ($5,000), pest control (9 units), community transportation ($225 a month under consumer direction), personal emergency response systems, employment services and supports, minor home modifications ($6,000 per project, $10,000 a year, $20,000 per lifetime, not counted against the Group 3 service limit), short-term nursing home care (90 days maximum, only for someone already getting home care who expects a short stay), and community-based residential alternatives. Note that last one: CBRA covers a community residential setting, so CHOICES is not strictly an in-your-own-home program.3

Application path: TennCare Connect at tenncareconnect.tn.gov or 855-259-0701 (Tennessee Relay Service 800-848-0298), or a paper application mailed to TennCare Connect, P.O. Box 305240, Nashville, TN 37230-5240, or faxed to 1-855-315-0669. For long-term-care help specifically, the local Area Agency on Aging and Disability (AAAD) provides in-person assistance at 1-866-836-6678, and an AAAD representative will come to the home of an applicant with a disability. Which door depends on whether you already have TennCare: the AAAD line is for someone who does not yet have it, while a current member is told to call their own health plan instead. Federal rules also put a clock on the answer: under 42 CFR 435.912(c)(3) a determination may not exceed 90 days for someone applying on the basis of disability and 45 days for everyone else, subject to documented unusual circumstances. TennCare may not use that standard as a waiting period, or deny you because it missed it.5

For full detail on CHOICES eligibility, services, and the waitlist, see our TennCare CHOICES guide.

Pathway 2: ECF CHOICES (the Pathway for People with Intellectual/Developmental Disabilities)

Employment and Community First (ECF) CHOICES is the §1115 demonstration component for Tennesseans of all ages who have an intellectual or developmental disability (I/DD). It launched July 1, 2016. Unlike CHOICES (which is age- and physical-disability-based), ECF CHOICES is diagnosis-based: eligibility depends on having an I/DD diagnosis plus meeting the level-of-care criteria for the relevant group, and it serves people with I/DD regardless of age. Financially, an applicant must either be SSI-eligible (TennCare at the SSI standard) or qualify in the ECF CHOICES 217-Like Group (people with I/DD of any age who meet NF LOC and would be eligible in the same manner as under 42 C.F.R. 435.217 if the services came through a §1915(c) waiver). There is no single ECF income number. TennCare publishes three, effective January 2026: $2,982/month at nursing facility level of care (300% of the $994 SSI Federal Benefit Rate), $1,995/month at at-risk level of care instead, and $3,325/month (250% of the federal poverty level) for someone who is working and has under $994 in unearned income. Anyone over their limit may be able to set up a Qualifying Income Trust. Countable resources must not exceed $2,000 for a household of one, the home the person lives in does not count, and nothing may have been given away or sold below value in the last five years. For an applicant under 18, parent-to-child deeming applies unless the child is 17 or older and qualifies for nursing-home level of care, or is enrolling in or transitioning from Group 7. One catch worth knowing before you apply: enrollment in the 217-Like Group is available only when there is an open slot in a benefit group for which you meet every eligibility, enrollment, and prioritization criterion.1,6

ECF CHOICES has five benefit groups, numbered Group 4 through Group 8, running on from the lower-numbered CHOICES benefit groups that sit in the same demonstration.1 Each Group has its own annual per-member expenditure cap. The base caps for Groups 4, 5 and 6 come from CMS's approved demonstration terms and the state may adjust them for provider rate increases; the Group 7, Group 8 and Group 6 exceptional-needs caps are institutional-cost-based and re-set each year by TennCare memo. Confirm the figure applied to your own plan of care with your support coordinator.

ECF Group 4, Essential Family Supports

• Who: People with I/DD living at home with family who meet NF LOC or, absent HCBS, are At Risk for Institutionalization. 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 is broader: it covers both children under 21 and adults age 21 or older who elect to be in this group. An adult with I/DD living with family should not rule Group 4 out on the brochure's wording.6
• 2026 expenditure cap: $18,420/year per person, not counting the cost of minor home modifications, with an exception available where it is necessary to give the member access to Supported Employment or Individual Employment Support benefits.6

ECF Group 5, Essential Supports for Employment & Independent Living

• Who: Adults age 21+ with I/DD who are At Risk for Institutionalization (or NF LOC adults choosing Group 5 if Group 6 is full).
• 2026 expenditure cap: $38,820/year, which TennCare may exceed by up to $6,000 per member per year for emergency needs, and may exceed again by an individually determined amount where necessary to give the member access to Supported Employment or Individual Employment Support benefits.6

ECF Group 6, Comprehensive Supports for Employment & Community Living

• Who: Adults 21+ with I/DD meeting NF LOC.
• 2026 expenditure caps (tiered by Level of Need): Low $62,268/year, Moderate $95,620/year, High $129,048/year. The state may exceed each of these case by case for a member without exceptional needs: for emergency or one-time needs (including a transitional assessment) up to $7,500 per calendar year, and separately where necessary to give the member access to Supported Employment or Individual Employment Support benefits. For members assessed with exceptional medical or behavioral needs, the cap instead tracks the average annualized cost of the comparable level of institutional care: $236,450/year (intellectual disability, the average ICF/IID cost at $647.81/day), $158,989/year (developmental disability but not ID, the average nursing facility reimbursement plus $51,361.55 for specialized services), $208,264.10/year (tracheal suctioning plus specialized services), and $301,339.10/year (chronic ventilator care plus specialized services).6

ECF Group 7, Intensive Behavioral Family-Centered Treatment, Stabilization and Supports

• Who: Children under 21 with I/DD plus severe behavioral support needs.
• 2026 expenditure cap: $236,450/year (the ICF/IID average). Behavioral health services other than Intensive Behavioral Family-Centered Treatment, Stabilization and Supports are not counted against it.6

ECF Group 8, Comprehensive Behavioral Supports for Employment and Community Living

• Who: Adults with I/DD plus severe behavioral support needs transitioning out of highly structured settings.
• 2026 expenditure caps: $513,625/year for the first year of enrollment (the average cost of a short-term, treatment-focused public ICF/IID), then $236,450/year beginning with the second year. Behavioral health services other than Intensive Behavioral Community Transition and Stabilization Services are not counted against it. A member in Group 4, 5 or 6 also has a protection worth naming: they may not be disenrolled, and authorized services may not be reduced, if the sole reason their cap would be exceeded is a state-directed rate increase.6

Because annual funding is limited, qualified applicants who cannot be enrolled immediately are placed on a referral list and enrolled based on priority groups and slot availability. An applicant may also enroll against an available reserve capacity slot. TennCare's published Reserve Capacity Groups, the ones that may enroll now because their needs are most urgent, are wider than families usually realize, and the less-quoted entries are the ones a family stuck on the referral list is most likely to qualify under:

• Aging Caregiver: a custodial parent or custodial caregiver at least 75 for a person with an intellectual disability, or at least 80 for a person with a developmental disability.
• Emergent circumstances: a primary caregiver recently deceased or permanently incapacitated with no other caregiver available; recent loss of the person's living arrangement; clear evidence of serious abuse, neglect, or exploitation with no alternative living arrangement; discharge from an acute care setting at imminent risk of nursing facility placement absent HCBS, or a PASRR finding that nursing facility placement is inappropriate; an adult aging out of state custody, discharged from 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.
• Transition out of a long-term care institution: a nursing facility or a private or public ICF/IID.
• Multiple Complex Health Conditions: a working-age person with multiple complex chronic or acquired health conditions that prevent them from working, in urgent need of supports to hold their current living arrangement and delay or prevent more expensive services.

TennCare adds that other eligibility rules also apply, so matching one of these descriptions is not by itself an enrollment.3

ECF services are employment-first, built around competitive integrated employment (Exploration, Discovery, Job Development, Job Coaching for members 16 and older, Co-Worker Supports, Career Advancement, Benefits Counseling, Supported Employment), alongside community-living and family supports. Several carry published limits: Personal Assistance up to 215 hours/month (the limit CMS states for Group 6); Respite up to 216 hours or 30 days a year, the member's choice, not combinable in the same year, and offered only where the person lives with unpaid family caregivers; Assistive and Enabling Technology $5,000 combined per year; Minor Home Modifications $6,000 per project, $10,000 per year, $20,000 lifetime; Community Transportation $225/month under Consumer Direction; Adult Dental for members 21+ at $5,000/year and $7,500 across three consecutive years; Peer-to-Peer supports $1,500 per lifetime; Decision Making Supports $500 per lifetime and only after the counseling service; Individual and Family Caregiver Education and Training $500/year each. A Family Caregiver Stipend runs $100 to $500 a month for a child under 18 and $100 to $1,000 for an adult, and may be authorized only in lieu of Supportive Home Care (including Personal Assistance), never alongside it. One limit on the limits: an MCO may authorize services above a benefit limit as a cost-effective alternative to institutional placement or other medically necessary covered benefits, so ask rather than treating a published cap as final.6

Application path: Through the Department of Disability and Aging (DDA), the cabinet-level agency formed July 1, 2024 by merging the Department of Intellectual and Developmental Disabilities (DIDD) with the Tennessee Commission on Aging and Disability. Anyone can complete the online self-referral form at perlss.tenncare.tn.gov/externalreferral; if you already have TennCare, call your managed care health plan and ask for help with a self-referral; if you do not have TennCare, call your DDA regional office.3

For full detail, see our ECF CHOICES guide.

Pathway 3: Katie Beckett (the Pathway for Children with Significant Disabilities)

Katie Beckett is Tennessee's pathway to TennCare for children under 18 with disabilities or complex medical needs who are not otherwise Medicaid-eligible because of their parents' income or assets. It rests on the "deeming exception": TennCare looks only at the child's own income and resources, not the parents'. The Department of Disability and Aging (DDA) handles medical eligibility and TennCare handles financial eligibility.6

Katie Beckett has three Parts:

Katie Beckett Part A

• Age: Under 18.
• Functional: Institutional level of care (qualifies for a hospital, nursing facility, or ICF/IID, but the family cares for the child at home).
• Benefit: Full TennCare Medicaid coverage plus up to $15,000 per child per calendar year in HCBS wraparound services (respite, supportive home care, home and vehicle modifications), with sub-limits of $5,000/year for equipment and $500/year for caregiver education.
• Premium: A premium is owed if family income exceeds 150% of the Federal Poverty Level (FPL), at the rates set in TennCare Rule Chapter 1200-13-20. Pay it within 60 days or you lose the slot: TennCare states that if the premium is not paid within 60 days, Part A enrollment is denied and the child is enrolled in Part B if a slot was available at referral.6
• Cap: Capped at 300 enrolled children statewide, funded at roughly $45 million for those 300 slots (a projected average of $150,000 per child). Children are enrolled into an open Part A slot in order of their level-of-care prioritization score, so a medically eligible child with no slot available stays on the Part A waiting list, which must be managed statewide using a standardized assessment tool and objective criteria applied consistently across the state.6

Katie Beckett Part B

• Age: Under 18.
• Functional: "At risk" of institutional care but not meeting full institutional level of care.
• Benefit: Up to $10,000 per child per year in flexible services (premium assistance, a health-care savings-type account, consumer-directed respite, supportive home care, or community-based provider services). Part B children are not enrolled in Medicaid, so families pair Part B with another health-insurance source (employer, Marketplace, CoverKids).
• Cap: Expanded to 4,700 slots (via budget transfers in August 2023 and October 2024); 4,188 children were enrolled as of December 30, 2024. A Part B slot is not guaranteed either: if none is available, the child goes on the Part B waiting list.
• The money does not roll over. TennCare's DDA states that the $10,000 budget cap may not be exceeded across the calendar year and that unspent funds cannot be carried into the next plan year, so plan the spend inside the year.6

Katie Beckett Part C

• Purpose: For a child who already has Medicaid but whose Medicaid is ending because the parents' income or resources increased.
• Benefit: Lets the child keep Medicaid if they would qualify for Part A but no Part A slot is open. Part C slots are used only when no openings remain in Part A, and a child who later gets a Part A slot must move to Part A.6

Important sequencing rule: Applicants must apply for and be determined eligible for Part B before being considered for Part A. This trips up families who assume Part A is the "first-line" option. The medical and financial halves of the application start at the same time, with DDA determining medical eligibility and TennCare determining financial eligibility.6

If you are denied, you have 30 days. TennCare gives 30 days from the date of the notice to appeal a denied application, and 30 days from the date of notice to appeal a denied Part A level-of-care determination.6

Age-out: Eligibility ends at the 18th birthday. Transition planning for ECF CHOICES (or another adult LTSS pathway) should begin well before age 18.

For full detail, see our Katie Beckett guide.

The Legacy §1915(c) DD Waivers

Before ECF CHOICES launched on July 1, 2016, Tennessee operated three §1915(c) HCBS waivers for adults with intellectual disabilities:1

• Statewide HCBS Waiver for Persons with Intellectual Disabilities (the "Statewide" waiver)
• Comprehensive Aggregate Cap Waiver (the "CAC" waiver)
• Self-Determination Waiver

These three waivers have been closed to new enrollment since July 1, 2016, with limited exceptions: the Statewide and CAC waivers remain open to certain applicants (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. New I/DD applicants generally go to ECF CHOICES instead. Members enrolled in the legacy waivers before closure remain enrolled and continue to receive services under those waivers' rules.

If your family member was already enrolled and is still receiving services, you do not need to do anything.

Money Follows the Person: The Bridge from Institution to Community

Tennessee participates in the federal Money Follows the Person (MFP) demonstration, which the Consolidated Appropriations Act, 2023 (P.L. 117-328) extended through September 30, 2027.2

MFP isn't a separate waiver. In Tennessee it is integrated directly into CHOICES: a person who transitions under MFP moves into CHOICES (or ECF CHOICES, or other waiver HCBS) for ongoing home and community-based services, so MFP supports the move while CHOICES provides the long-term care.

To be eligible for an MFP transition, TennCare lists five things a person must do: be enrolled in Medicaid; be 18 years of age or older; reside in a qualified institution (an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), a Regional Mental Health Institute, or a nursing home) for sixty (60) days; have care needs that can be adequately met in a community setting; and transition into CHOICES, ECF CHOICES, or other waiver home and community based services. Note the age bar: MFP is not a route out of an institution for a minor. And note that the five are not the whole test. TennCare's own MFP FAQ warns that the additional eligibility criteria for the waiver program a person transitions into still apply, so meeting all five does not by itself secure a place in it.2

In July 2025, TennCare Long-Term Services & Supports launched an initiative to invest $50 million in its HCBS provider network over five years, at up to $10 million a year, to help providers build capacity, serve people with higher support needs, and improve service quality.2

Cost-Neutrality and Expenditure Caps

Every Tennessee HCBS pathway operates under a cost-neutrality framework: the per-person plan of care cannot exceed what the equivalent institutional placement would cost. That federal §1115 requirement is a main reason enrollment is capped.

The 2026 expenditure caps below all trace to the current state rule (Tenn. Comp. R. & Regs. 1200-13-01) and the December 18, 2025 TennCare expenditure-cap memo.3,6

If a member's needs exceed the cap, options include: requesting an exceptional-need determination (where applicable, e.g., ECF Group 6); asking about the published exceptions, which include emergency or one-time needs and access to Supported Employment or Individual Employment Support benefits; transitioning to a higher-cap Group; or, in some cases, accepting institutional placement (CHOICES Group 1 or an ICF/IID). A cap is a ceiling on authorization, not an allowance you are entitled to spend.

How to Apply for Tennessee Medicaid HCBS Waivers: Three Doors

Each pathway has its own application door, and picking the right one first saves weeks. If you're unsure which fits, start with TennCare Connect.

For the full procedural walkthrough, see our how-to-apply guide.

The PAE: How TennCare Decides Level of Care

Most HCBS pathways require a Pre-Admission Evaluation (PAE), TennCare's level-of-care assessment that determines whether an applicant qualifies for nursing-facility-equivalent or institutional-equivalent services.6

The PAE applies the TennCare Nursing Facility Level of Care (NF LOC) Acuity Scale, which has a maximum possible total score of 26 points: up to 21 for ADL and ADL-related deficiencies and up to 5 for skilled or rehabilitative services. The score is built from the applicant's functional needs (help with Activities of Daily Living, specifically transfer, mobility, eating, and toileting, plus level of independence in communication, orientation, dementia-related behaviors, and self-administration of medications) and clinical needs (skilled or rehabilitative services such as tube feeding, wound care, ventilator care, enhanced respiratory care, and occupational and physical therapy), each weighted by how much assistance the applicant requires.6

A score of 9 is the threshold on score alone, not the only route. To meet nursing facility level of care on the score by itself, an applicant needs a total of at least 9. But an applicant who does not reach nine points is not automatically shut out: they may still qualify by meeting the at-risk level-of-care criteria on an ongoing basis and being determined by TennCare, through a Safety Determination, not to qualify for enrollment in CHOICES Group 3. If your parent scores an 8, ask specifically about a Safety Determination before accepting the result.6

The Acuity Scale is a functional and clinical measure, not a diagnosis-based one. A dementia diagnosis alone does not establish eligibility; dementia is captured behaviorally, by how often the applicant requires intervention for behaviors. An AAAD or a managed care organization Care Coordinator can help submit the PAE on the applicant's behalf, and a TennCare PAE nurse may approve a modified score for an item based on the medical documentation rather than simply approving or denying the score the submitter entered.

A denied PAE is appealable, and the clock is 30 days plus mailing time. Appeal rights attach whenever a PAE is denied or approved with an end date, and the denial letter carries the reason, those rights, and a statewide list of legal aid offices. Only a technical denial, meaning a submission error, cannot be appealed; the submitter corrects and resubmits it. Two protections run alongside an appeal. Under the Doe v. Word consent decree a nursing home may not discharge a current resident because TennCare initially denied the PAE, until the appeal is resolved or the time to file one has passed, and that expressly covers someone denied nursing facility level of care but approved for At Risk. And on a denial, the nursing facility gets 10 calendar days to file more documentation, which if it establishes nursing facility level of care preserves the original PAE effective date.6

Bottom Line

Tennessee's HCBS architecture is unusual but not complicated:1

1. One overarching demonstration (TennCare III, §1115, approved through 2030)
2. Three demonstration components for the three target populations: CHOICES (seniors and physical disabilities), ECF CHOICES (I/DD), Katie Beckett (children under 18 with significant disability)
3. Three legacy §1915(c) DD waivers still serving grandfathered members, closed to general new enrollment (Statewide and CAC still admit under narrow criteria)
4. Money Follows the Person integrated into CHOICES for transitions from institutions

The right pathway depends on the diagnosis and the age of the person who needs help. If you're not sure where to start, the AAAD network (for adults) or DDA regional intake (for I/DD) can route your inquiry. TennCare Connect is the universal door if you'd rather start online.

Learn More

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.