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 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 walks through every HCBS pathway a Tennessee senior or family caregiver is likely to encounter in 2026: the §1115 framework that ties them together, the four major pathways themselves, the legacy I/DD waivers that still serve grandfathered members, and the Money Follows the Person program that helps people transition out of institutions.

Why Tennessee Is Different: The §1115 vs §1915(c) Distinction

Most states operate Medicaid HCBS through individual §1915(c) Home and Community-Based Services waivers. Each waiver is approved by CMS for a specific target population (elderly, individuals with I/DD, children with medical complexity, etc.), runs for five years, and has to be 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.

In 2021, CMS approved TennCare III, a Section 1115 demonstration that:

• Authorizes Tennessee's entire Medicaid program (acute care AND long-term services and supports) under one umbrella
• Runs for 10 years (through December 31, 2030), the longest §1115 term CMS has ever approved
• Uses an "aggregate cap" budget model where Tennessee shares federal savings with CMS if it spends below a benchmark
• Folds CHOICES, ECF CHOICES, and Katie Beckett into the demonstration as components

The practical difference for families: there is no separately-named "Tennessee Aged & Disabled Waiver" or "Tennessee Elderly & Disabled Waiver." Those are §1915(c) constructs other states use. In Tennessee, 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), but the broad LTSS architecture is §1115. As of early 2026, a §1915(c) Integration amendment that would fold the three legacy DD waivers into TennCare III was pending CMS review, meaning the consolidation may eventually be total.

The Four HCBS Pathways at a Glance

Almost every Tennessee senior or family caregiver looking for HCBS will fit one of four pathways. Here they are side by side.

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

CHOICES is the program for Tennessee adults 65+ or adults 21+ with a physical disability who need long-term services and supports. It launched in Middle Tennessee on March 1, 2010 under Governor Phil Bredesen and went statewide on August 1, 2010. Group 3 (At Risk) was added in 2012.

CHOICES is divided into three Groups:

CHOICES Group 1, Nursing Facility Care

• Who: Adults 65+ or adults 21+ with a physical disability who need nursing facility level of 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 a 0-26 acuity scale; threshold is 9 or more points.
• Financial test: $2,982/month income (300% of SSI Federal Benefit Rate); $2,000 in assets; spousal protections (CSRA up to $162,660, MMNA up to $4,066.50/month) for married couples.
• Waitlist: None, Group 1 is a Medicaid entitlement. Anyone clinically and financially eligible is enrolled.
• Cost-neutrality cap: Not applicable to Group 1 (institutional care).

CHOICES Group 2, HCBS in Lieu of Nursing Facility

• Who: Same population as Group 1, but receiving services in their own home or in an assisted-living or community-based residential setting in lieu of nursing facility placement.
• Setting: Member's home, family member's home, or qualifying community-based residence.
• Functional test: Nursing facility level of care (same PAE 9+ score).
• Financial test: Same $2,982/$2,000 standards as Group 1.
• Waitlist: Yes. Group 2 operates under a statewide enrollment cap (historically ~12,500 slots). When full, applicants are added to a waitlist and prioritized by acuity.
• Cost-neutrality cap: $107,627.55/year (2026), the per-person plan of care cannot exceed 100% of the average institutional cost.

CHOICES Group 3, At Risk of Institutionalization

• Who: Adults who don't yet meet nursing facility level of care but who would absent intervention.
• Setting: Member's home or community-based residence.
• Functional test: "At Risk", PAE score below 9 with safety determination, or score 5-8 with imminent risk.
• Financial test: Same $2,982/$2,000 standards.
• Waitlist: Yes. Group 3 has a smaller enrollment target than Group 2.
• Cost-neutrality cap: Lower than Group 2, typically capped around $18,000/year of HCBS services.

CHOICES services include personal care attendant services, homemaker services, home-delivered meals, adult day care, in-home respite, inpatient respite, assistive technology, environmental accessibility modifications, personal emergency response systems, transportation, community living supports, Employment Services & Supports (made permanent 7/1/2025), and Enabling Technology (also made permanent 7/1/2025). Personal care attendant hours are capped at 1,080/year, or 1,400/year if the member also needs household-chore or errand assistance.

Application path: TennCare Connect at tenncareconnect.tn.gov or 1-855-259-0701, or through one of Tennessee's nine Area Agencies on Aging and Disability (AAADs), the AAADs are the state's primary Single Point of Entry for CHOICES intake.

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 with intellectual or developmental disabilities. Unlike CHOICES (which is age- and physical-disability-based), ECF CHOICES is diagnosis-based, eligibility depends on having an I/DD 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).

The Group numbering picks up where CHOICES leaves off (Groups 4-8) because the two programs share the §1115 demonstration architecture.

ECF Group 4, Essential Family Supports

• Who: Children and adults with I/DD living at home with family who meet NF LOC or are At Risk.
• 2026 expenditure cap: $18,000/calendar year per person (Minor Home Modifications excluded from the cap).
• Q1 2025 enrollment: target 1,705 / actual 1,643.

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 $6,000 emergency exception (effective ceiling $42,000).
• Q1 2025 enrollment: target 2,239 / actual 2,109.

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. Exceptional medical/behavioral needs with intellectual disability up to $236,450/year (CY2026 average ICF/IID cost). Exceptional needs with developmental disability $158,989/year. DD with tracheal suctioning $208,264.10/year. DD with chronic ventilator care $301,339.10/year (reflects 7/1/2025 Enhanced Respiratory Care rate increases).
• Q1 2025 enrollment: target 2,281 / actual 2,198.

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 (private ICF/IID equivalent).
• Q1 2025 enrollment: target 26 / actual 17.
• Note: Added July 2019. Supportive Home Care and Respite added effective January 1, 2026.

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

• Who: Adults typically 21+ with I/DD plus severe behavioral support needs transitioning out of highly structured environments (institutions, jail, hospital).
• 2026 expenditure caps: $513,625/year first year of enrollment (short-term treatment-focused public ICF/IID equivalent), $236,450/year thereafter.
• Q1 2025 enrollment: target 50 / actual 28.
• Note: Added July 2019.

Total ECF CHOICES enrollment in Q1 2025 was 5,995 against a statewide enrollment target of 6,301, plus 3,706 of 3,951 reserve capacity slots filled. State rule Tenn. Comp. R. & Regs. 1200-13-01-.31 codifies only Groups 4–6; Groups 7 and 8 operate under §1115 Special Terms and Conditions and the TennCare ECF CHOICES Member Benefit Table.

ECF services include Supportive Home Care, Personal Assistance, Respite, Community Integration Support Services, Independent Living Skills Training, Supported Employment, Day Services, Behavior Services, Family Caregiver Stipend (for Group 4), Conservatorship Counsel and Assistance, Specialized Consultation, Assistive Technology, Adaptive Equipment, Specialized Medical Equipment & Supplies, Vehicle Modifications, Minor Home Modifications, Nutrition Services, Transportation, Family-to-Family Support, and Health and Safety services.

Application path: Through the Department of Disability and Aging (DDA), formed July 1, 2024 by merger of DIDD and TCAD under the Tennessee Disability and Aging Act. Regional intake numbers: West TN (866) 372-5709; Middle TN (800) 654-4839; East TN (888) 531-9876.

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 for children under 18 who have significant medical or behavioral disabilities and who would qualify for SSI except that their parents' income/resources push the family over the limit. The whole point of the program is the federal "deeming exception", when a child has a severe enough disability and is being cared for at home, federal law allows TennCare to look only at the child's own income/resources, not the parents'.

Katie Beckett has three Parts:

Katie Beckett Part A

• Age: Under 18.
• Functional: Institutional level of care (ICF/IID-equivalent).
• Benefit: Full TennCare medical coverage plus up to $15,000/year of supplemental HCBS for Tier 1; richer benefits for Tier 2.
• Premium: Sliding-scale Part A premium owed if family income exceeds 150% FPL.
• Cost test: Estimated home/community cost cannot exceed the institutional benchmark.
• Cap: 300-child program cap; acuity-prioritized waitlist when capacity is reached.

Katie Beckett Part B

• Age: Under 18.
• Functional: Significant disability not meeting full institutional LOC.
• Benefit: $10,000/year of flexible HCBS, but no full TennCare medical coverage. Families need to pair Part B with another health-insurance source (employer, Marketplace, CoverKids).
• Waitlist: First-come, first-served; not acuity-prioritized.

Katie Beckett Part C

• Purpose: A bridge category, typically used when a child is in transition between coverage states.
• Benefit: Bridge TennCare coverage during the gap.

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.

Stacking restriction: A child cannot simultaneously receive Family Support Program services and Katie Beckett (or ECF CHOICES Group 4). Choose one.

Age-out: Eligibility ends at the 18th birthday. Transition planning for ECF CHOICES (or another adult LTSS pathway) should begin well before age 18, ideally at age 16.

For full detail, see our Katie Beckett guide.

The Legacy §1915(c) DD Waivers

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

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

These waivers were closed to new enrollment when ECF CHOICES went live, and new I/DD applicants now go to ECF CHOICES instead. However, members enrolled in the legacy waivers before closure remain enrolled and continue to receive services under those waivers' rules.

As of late 2025 / early 2026, a §1915(c) Integration amendment was pending CMS review that would fold the three legacy DD waivers into the §1115 TennCare III demonstration. If approved, this would consolidate Tennessee's I/DD HCBS services under a single demonstration architecture. Until that approval, the legacy waivers continue to operate as standalone §1915(c) authority.

If your family member was enrolled in one of these legacy waivers before ECF CHOICES launched and is still receiving services, you do not need to do anything, services continue as before. Care coordinators through DDA will notify families if any program-level changes happen.

Money Follows the Person: The Bridge from Institution to Community

Tennessee participates in the federal Money Follows the Person (MFP) demonstration, which is currently funded through September 30, 2027 at $450 million per year nationally under the Consolidated Appropriations Act 2023 (P.L. 117-328).

MFP isn't a separate waiver, in Tennessee it's integrated directly into CHOICES. A nursing-facility resident who has been institutionalized at least 60 days, who can safely return home, and who is otherwise CHOICES Group 2-eligible can transition out of the facility under MFP and into community-based HCBS without any coverage gap.

How the integration works:

• The MCO Care Coordinator (an RN or social worker) acts as Transition Coordinator.
• The Coordinator develops a transition plan, conducts an in-home safety evaluation, and arranges initial services (DME, environmental modifications, personal care attendant scheduling).
• The member enrolls in CHOICES Group 2 and MFP simultaneously.
• During the 365-day federal MFP participation period, services are reimbursed at the enhanced FMAP rate (federal cost share is higher).
• After the 365-day MFP period ends, the member continues under CHOICES Group 2 with no service interruption.
• The Coordinator conducts quarterly face-to-face visits post-transition.

Historical KFF data (October 2011 – June 2013) showed 628 Tennessee transitions averaging 31 days from initiation to relocation, significantly faster than the 3.5-month national average, with a reinstitutionalization rate of approximately 10%.

Why MFP matters: Tennessee's HCBS rebalancing trajectory has moved from approximately 3% HCBS / 97% institutional spending a decade ago to approximately 40% HCBS / 60% institutional today. TennCare spending averages roughly $60,000/year per LTSS member in nursing facility care vs approximately $17,000/year in HCBS settings, a 3.5x cost differential that drives the rebalancing strategy.

In 2025, TennCare launched a $50 million HCBS provider capacity investment over 5 years (up to $10 million/year) supporting CHOICES, ECF CHOICES, the §1915(c) DD waivers, Katie Beckett, and the OPTIONS for Community Living program. This is the state's largest single HCBS capacity-building investment in years.

Cost-Neutrality and Expenditure Caps

Every HCBS pathway in Tennessee operates under a cost-neutrality framework, the per-person plan of care cannot exceed what the equivalent institutional placement would cost. This is a federal §1115 requirement and is one of the main reasons enrollment is capped (the state has to keep aggregate per-capita costs below institutional benchmarks).

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: Three Different Doors

Each HCBS pathway has its own application door. Picking the right door first saves weeks.

• CHOICES (Groups 1, 2, 3): TennCare Connect at tenncareconnect.tn.gov or 1-855-259-0701, or through one of Tennessee's nine Area Agencies on Aging and Disability (AAADs). The AAAD route is often faster for nursing-facility-bound or community-based applicants because the AAAD coordinates the PAE and the financial application in parallel.
• ECF CHOICES (Groups 4-8): Through the Department of Disability and Aging (DDA). Regional intake numbers: West TN (866) 372-5709; Middle TN (800) 654-4839; East TN (888) 531-9876.
• Katie Beckett (Parts A, B, C): Self-referral through TennCare Connect at tenncareconnect.tn.gov. Financial eligibility (TennCare) and medical eligibility (DDA LOC assessment) run in parallel.

If you're not sure which pathway fits, start with TennCare Connect, they can route a general LTSS inquiry to the correct intake agency.

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.

The PAE applies the TennCare Nursing Facility Level of Care Acuity Scale, scored 0-26 points (21 ADL points + 5 skilled-services points). The qualifying threshold is 9 or more points. Applicants scoring 5-8 may request a Safety Determination for Group 2 enrollment if they are at imminent risk of nursing facility placement.

Score components include:

• Transfer/mobility (up to 4 points)
• Eating (4 points)
• Toileting (3 points)
• Orientation (4 points)
• Communication (1 point)
• Medication self-administration (2 points)
• Dementia behaviors (3 points)
• Skilled services such as ventilator dependence (5), tracheal suctioning (4), TPN (3), wound care, tube feeding, and therapies

The PAE must be submitted by a physician, nurse practitioner, clinical nurse specialist, or physician assistant; an AAAD or MCO Care Coordinator can submit on the applicant's behalf. The Bureau of TennCare LTSS must receive an approvable PAE within 10 calendar days of either the PAE Request Date or the physician certification date, whichever is earlier.

Tennessee does not use a "CARES" assessment, that's the Florida tool. The PAE plus Acuity Scale is the Tennessee equivalent.

Bottom Line

Tennessee's HCBS architecture is unusual but not complicated once you know the basic shape:

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 but closed to new enrollment
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

• Tennessee Medicaid Programs Overview
• ECF CHOICES
• Katie Beckett Program
• TennCare CHOICES
• TennCare Eligibility & Income Limits
• Tennessee Long-Term Care & Nursing Homes

Find personalized help navigating Tennessee HCBS waivers 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.