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 $752,000.4
• 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. Group 2 operates under a mandatory statewide Enrollment Target of 12,500 (set effective July 1, 2012 in Tenn. Comp. R. & Regs. 1200-13-01-.05), which is the maximum number enrollable at any given time, and it is not an entitlement. Once the target is reached, qualified applicants are placed on a Waiting List for CHOICES Group 2 until capacity opens. The cap is not absolute, though: the rule lets an applicant enroll even at target if they satisfy the criteria for Reserve Capacity or meet one of the rule's specified exceptions, so ask about those rather than assuming the list is the only path. Vacated slots may also be refilled immediately rather than held to the next program year, as HCBS waiver programs must do.3
• Cost-neutrality cap: $107,627.55/year in 2026 (the average daily nursing facility reimbursement of $294.87). If it can reasonably be anticipated that a member's care will exceed that cap, the member does not qualify to enroll in Group 2, or to remain enrolled in it.5

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.5

The CHOICES HCBS array is fourteen services, enumerated with their per-service benefit limits in Tenn. Comp. R. & Regs. 1200-13-01-.05(8)(l): Adult Day Care, Assistive Technology, Attendant Care, Community-Based Residential Alternatives (CBRA), Enabling Technology, Home-Delivered Meals, Homemaker Services, In-Home Respite Care, Inpatient Respite Care, Minor Home Modifications, Personal Care Visits, Personal Emergency Response System (PERS), Pest Control, and Short-Term Nursing Facility Care. Groups 2 and 3 draw on these within their caps. Note CBRA: it covers a community residential setting, so CHOICES is not strictly an in-your-own-home program.5

Application path: TennCare Connect at tenncareconnect.tn.gov or 855-259-0701 (Tennessee Relay Service 800-848-0298). 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.6

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). The maximum income standard for participants is 300% of the SSI Federal Benefit Rate, or $2,982/month in 2026. 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.1,7

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 expenditure cap, set in Tenn. Comp. R. & Regs. 1200-13-01-.31 and the annual TennCare expenditure-cap memo.

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.7
• 2026 expenditure cap: $18,000/calendar year per person (minor home modifications not counted against the cap; no other exceptions).7

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: $36,000/year, with up to a $6,000 emergency-needs exception (a $42,000/year ceiling).7

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 $54,000/year, Moderate $82,000/year, High $108,000/year. 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).7

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 (ICF/IID equivalent).7

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 (short-term treatment-focused public ICF/IID equivalent), then $236,450/year beginning with the second year.7

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: an 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, such as a primary caregiver who is recently deceased with no other caregiver available; and enrollment needed to facilitate transition out of a long-term care institution (a nursing facility or a private or public ICF/IID).8

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 worth knowing before you plan: Personal Assistance up to 215 hours/month (Groups 5 and 6); Respite up to 216 hours or 30 days a year (member's choice); Assistive and Enabling Technology $5,000 combined per calendar year; Minor Home Modifications $6,000 per project, $10,000 per year, $20,000 lifetime; Community Transportation capped at $225/month for members using Consumer Direction; Adult Dental for members 21+ at $5,000/year and $7,500 across three consecutive years; Decision Making Supports $500 per lifetime; Family Caregiver Education and Training up to $500/year. Group 4 members may take a Family Caregiver Stipend in lieu of Supportive Home Care.7

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.8

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.1

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 1200-13-20.7
• 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.7

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, 2024.9

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.1

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.9

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, a person must meet all four of these: 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; and have care needs that can be adequately met in a community setting. Note the age bar: MFP is not a route out of an institution for a minor.2

In July 2025, TennCare Long-Term Services & Supports launched an initiative to invest $50 million in its HCBS provider network over five years, expanding community-based capacity statewide.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.5,7,9

If a member's needs exceed the cap, options include: requesting an exceptional-need determination (where applicable, e.g., ECF Group 6); transitioning to a higher-cap Group; or, in some cases, accepting institutional placement (CHOICES Group 1 or an ICF/IID).

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.7

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.7

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.7

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 dementia-related behaviors. An AAAD or a managed care organization Care Coordinator can help submit the PAE on the applicant's behalf.

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.