Tennessee Medicaid Nursing Home: TennCare CHOICES Group 1

When a parent's hospitalization ends in a nursing home admission, the question that lands within forty-eight hours is the same in every Tennessee family: who is going to pay for this? A private-pay room in a Tennessee nursing facility runs roughly $9,429 a month for a semi-private room and about $10,038 a month for a private room, per the most recent CareScout Cost of Care Survey state figures.1 Long-term care insurance is rare. Medicare covers up to one hundred days of post-hospital skilled care under specific conditions and then it stops. What's left is Tennessee Medicaid nursing home coverage, paid through TennCare CHOICES Group 1.

This guide is for the family in that moment: who qualifies clinically and financially, how Tennessee's income-cap-plus-Qualified-Income-Trust framework works, what happens to the family home during life and at death, how patient liability is calculated, and how to get a parent enrolled. Tennessee's rules differ in important ways from the spend-down framework most online guides describe, and this calls those differences out where they matter.

Why Group 1 Is the Right Door

CHOICES is TennCare's umbrella for long-term services and supports for adults age 65+ and adults 21+ with physical disabilities. It has three groups, each pointing to a different setting:

• Group 1, nursing facility care. Entitled. No waitlist.
• Group 2, home and community-based services as an alternative to a nursing facility. Capped, with periodic waitlists, but a member already in Group 1 who meets the Group 2 requirements can move to Group 2 at any time the transition can be accomplished, even if the enrollment target has been reached. A parent coming home from the facility is not stuck behind that cap.2
• Group 3, a smaller HCBS package for people at risk of nursing facility placement. Capped.

If your parent has been admitted to a nursing facility, or a hospital discharge planner has told you a nursing facility admission is the only safe destination, Group 1 is the door. CHOICES integrates all nursing facility care and HCBS into TennCare's existing managed care system, and TennCare's Managed Care Contractors page says medical, behavioral, and long-term care services are covered by at-risk managed care organizations in each region of the state. The plans TennCare names on its CHOICES page as the ones a member contacts about CHOICES are BlueCare (888-747-8955), UnitedHealthcare Community Plan (800-690-1606), and Wellpoint (833-731-2153), formerly Amerigroup. Your parent's health plan assigns a Care Coordinator, and TennCare names that coordinator as one of the routes for a CHOICES member's complaint. If the problem is with the plan itself, there are routes that do not run back through it: the plan's CHOICES Consumer Advocate, TennCare's Beneficiary Support System at Disability Rights Tennessee (888-723-8193), and the Long-Term Care Ombudsman. One line matters more than any of them: a denial, reduction, or termination of services is an appeal, not a complaint, and filing it as a complaint costs you the appeal.3

A few points to clarify up front:

• Nursing facility care is full-benefit Medicaid. In Group 1 your parent keeps every TennCare benefit anyone else gets, primary care, prescriptions, hospital coverage, plus the room, board, nursing, and rehabilitation bundled into the facility's daily rate.
• TennCare is a §1115 demonstration, authorized under TennCare III and approved by CMS through December 31, 2030. Tennessee materials say "waiver" colloquially, but the authority is §1115, not §1915(c).8
• Group 1 is not a waitlist program. The most common misconception. If your parent meets the clinical and financial criteria, the only delay is paperwork.

Clinical Eligibility: The PAE Acuity Scale

Tennessee uses a single instrument to determine whether someone medically qualifies for nursing facility care: the Pre-Admission Evaluation (PAE), which applies the TennCare Nursing Facility Level-of-Care Acuity Scale. The scale runs from 0 to 26 points, a maximum of 21 from activities of daily living and the ADL-related functions, and a maximum of 5 from skilled and rehabilitative services. Nine points is the qualifying threshold on score alone.3

Here is what the scale measures:

Responses are weighted by how much assistance your parent needs, from always independent with that activity to never independent. Dementia is scored behaviorally, by how often intervention is required, not by the diagnosis itself. Most older adults entering a nursing facility from a hospital score well above 9. The PAE must be submitted by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, almost always the hospitalist or the facility medical director.3

A score below 9 is not automatically the end of the road. Level of care has two components, medical necessity of care and need for inpatient care, and the acuity score goes to the second. To satisfy it, the applicant must have a condition that as a practical matter requires daily inpatient nursing care, must be unable to self-perform that care, and must either score at least 9 or meet at-risk level of care on an ongoing basis and be determined by TennCare, through a Safety Determination, not to qualify for CHOICES Group 3. If your parent's score comes back under 9 and the clinical team believes a facility is the only safe destination, ask about that second pathway rather than assuming the score settles it.3

And a denial is appealable, on a short clock. TennCare affords PAE appeal rights whenever a PAE is denied or approved with an end date. The denial letter carries the reason, the appeal rights, and a statewide list of legal aid offices, and the deadline to file is 30 days plus mailing time. One thing cannot be appealed: a technical denial, meaning a submission error, which the submitter simply corrects and resubmits. When a PAE is denied, TennCare gives the nursing facility 10 calendar days to submit more documentation, and if that is enough to approve nursing facility level of care, the original PAE effective date is preserved, so push the facility to use those ten days. Meanwhile your parent should not be put out: 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 appeal has passed without action, and that protection expressly covers an applicant denied for nursing facility level of care but approved for at-risk level of care.3

A note on terminology: TennCare does not use a "CARES" assessment, that's Florida's tool. Tennessee's instrument is the PAE plus the Acuity Scale.

Financial Eligibility: 2026 Dollar Figures

TennCare CHOICES financial eligibility uses these thresholds. Two different clocks apply: the SSI-indexed and spousal resource limits run on the calendar year, while the community spouse's minimum income floor runs July 1, 2026 through June 30, 2027.

These figures come directly from TennCare's CHOICES guidance and the January 1, 2026 cost-neutrality memo.4

The Income Cap and the Qualified Income Trust

This is where Tennessee diverges sharply from states like Michigan or Pennsylvania. TennCare compares your parent's gross monthly income to the $2,982 Medicaid Income Cap, and an applicant above it is not income-eligible on that income alone. What TennCare offers instead is the opportunity to establish a Qualified Income Trust (QIT), which the applicant must do to become income-eligible; income eligibility is then tested again once the trust exists. That is a different mechanism from the medically needy "spend-down" a Michigan applicant uses, where excess income is spent on medical bills each month and no trust is involved. If you are comparing Tennessee against another state's rules, confirm which of the two that state runs on before you plan around it.4,6

A QIT, called a Miller Trust in other states, is an irrevocable trust into which the applicant deposits all of their income each month; income flowing through it does not count against the $2,982 cap. TennCare's manual sets a closed list of what the trust may pay: the Personal Needs Allowance, up to $20 (or another verified amount) for the trust's own expenses, the community spouse and dependent income maintenance allowances, health insurance premiums where your parent has non-TennCare coverage, and non-covered medical care recognized under state law. Nothing else. It specifically excludes trustee fees, the attorney fees of setting the trust up, court costs, funeral expenses, and past-due medical bills. On death, Tennessee receives what remains, up to the total medical assistance it paid.6

A QIT is not a do-it-yourself instrument: it must be irrevocable, name only the individual and the State of Tennessee as beneficiaries, be funded properly each month, and be reported at renewal. Ask two or three elder-law firms what they charge before you commit, and budget the fee as a real cost the trust cannot reimburse. A QIT done wrong delays eligibility for months at private-pay rates.6

Asset Spend-Down (the Real Kind)

If your parent's countable assets exceed $2,000 (or $3,000 for a couple both applying), the family will need to reduce them before approval.4 Permissible spend-down uses include:

• Paying off the resident's or community spouse's debts (mortgage, credit cards, medical bills).
• Pre-paying funeral and burial expenses through an irrevocable funeral trust.
• Home repairs and modifications.
• Replacing a worn-out vehicle (one car is exempt regardless of value).
• Paying for medical care or services Medicaid will not cover.

Impermissible spend-down is anything the look-back rule would treat as an uncompensated transfer: gifts to family members, below-market sales, and undocumented loans without a written promissory note at fair-market interest. And note this is not a medically needy spend-down. It converts countable assets into exempt ones or pays legitimate expenses; it does not let an over-income applicant qualify by spending the excess on medical bills.

The Look-Back, the Penalty Divisor, and Personal Services Contracts

Tennessee enforces the federal 60-month look-back on asset transfers preceding any TennCare CHOICES, ECF CHOICES, or institutional Medicaid application (42 USC § 1396p(c) as amended by DRA-2005; Tenn. Comp. R. & Regs. 1240-03-03-.03; TennCare ABD Manual § 125.010). Any uncompensated transfer made within those 60 months, gifts, below-market sales, payments to family members without a written caregiver agreement, is presumed to disqualify the applicant for a penalty period. Critical post-DRA-2005 rule: the penalty does NOT begin on the transfer date, it begins on the LATER of the transfer date or the date the applicant is otherwise eligible AND in a nursing facility AND would be receiving Medicaid but for the penalty.9

The penalty period is calculated by dividing the total uncompensated transfer amount by Tennessee's transfer-penalty divisor, set by the TennCare ABD Eligibility Policy Manual based on the average daily private-pay nursing facility cost in Tennessee. For 2026, per Policy 125.010 (effective January 5, 2026), the divisor is $295.87 per day ($8,846.10 per month). Each $295.87 of unprotected transfer creates roughly one day of Medicaid ineligibility, and the penalty period runs from the date the applicant would otherwise have been eligible. (Note: this is a different number from the $294.87/day CHOICES cost-neutrality cap, which gates HCBS spending, not transfers.)9

To make the math concrete: a $30,000 birthday gift from your mother to a grandchild three years before her admission triggers a penalty of roughly 102 days ($30,000 ÷ $295.87 = 101.4 days), during which your family owes the private-pay bill, roughly $31,600 at Tennessee's $310/day semi-private median.9,1

Personal Services Contracts are the legitimate workaround. A written caregiver agreement with a non-spouse family caregiver, executed before services begin, with a documented fair-market hourly rate, hours, and duties, converts what would look like a disqualifying gift into an exchange of value. The rate must match what a commercial agency would charge locally. Spouses are not paid this way; transfers between spouses are separately excepted at 42 USC § 1396p(c)(2).

Two things the TennCare manual says outright are worth knowing before you assume a penalty is survivable. There is no limit on the maximum months of ineligibility, and once a penalty period begins it runs uninterrupted even if your parent stops receiving institutional-level care. The divisor itself is taken at the time of the TennCare application or the date of the transfer, whichever is later.

But six categories of transfer are not treated as a transfer for less than fair market value at all, and a family that already made one of them is not penalized: (1) a transfer to the spouse, or to someone else for the spouse's sole benefit, before institutional Medicaid eligibility is established; (2) a transfer from the institutionalized or HCBS spouse to the community spouse during the 12-month transfer period after approval, as part of the CSRMA; (3) a transfer to, or to a trust for the sole benefit of, a minor or adult child who is blind or disabled; (4) a transfer to a trust for the sole benefit of a disabled person under 65; (5) a transfer of the home whose title went to the owner's spouse, a child under 21, a blind or disabled adult child, a sibling with an equity interest who lived there for the year before institutionalization, or a child of any age who lived there for the two years immediately before the nursing home admission and provided care that permitted the owner to stay home; and (6) a transfer made exclusively for a purpose other than qualifying for TennCare, such as satisfying a legally enforceable debt.9

There is also a hardship route past a penalty already imposed, and it has hard deadlines. Hardship exists where the institutionalized person has no available resources above the resource limit other than the uncompensated value, and applying the penalty would deprive them of medical care such that their health or life would be endangered, or of food, clothing, shelter, or other necessities. It is not available where a community spouse has available assets. A hardship request must be filed within 90 days of the application date, or if later, no more than 40 days after the date of the denial or termination notice. A request can also be filed on a change in circumstances during a penalty period; TennCare answers within 30 days; and a hardship denial may be appealed within 40 days. Diary those dates the day a penalty letter arrives.9 For the complete framework, promissory notes, life estates, Lady Bird and TOD deeds, worked examples, and common mistakes, see Tennessee's 5-Year Lookback and Penalty Divisor complete guide.

The Home: During Life and at Death

The home is usually a family's largest asset and the question every adult child asks first. Tennessee's rules during life and at death are different, and both matter.

During the resident's lifetime, the home is excluded from the resource test when it is the principal place of residence of the resident, their spouse, or dependent relatives and, if the resident is already living in a long-term care facility, intent to return home is established. Both halves, not either one. A signed statement of intent to return does real work here, and the intent is what matters legally rather than the prognosis, but on its own it is not the whole test.4

Two other relationships protect the home by taking a transfer of it outside the look-back rule: a sibling of the owner who has an equity interest in the home and lived there for at least one year before institutionalization, and a child of the owner, any age, who lived there for the two years immediately before the nursing home admission and provided care that permitted the owner to stay home.9

Separately, an institutional applicant is ineligible for LTSS payments when home equity exceeds $752,000, unless the applicant's spouse, child under 21, or blind or disabled child lawfully lives in the home. And even where the limit does apply it is not settled: TennCare can waive it where undue hardship is requested and found.4

Tennessee does NOT use TEFRA liens. This is significant. Some states place a lien on the home when the recipient enters a nursing facility, securing the state's eventual recovery interest. Tennessee's State Plan Attachment 4.17-A is explicit: "Not applicable. Tennessee does not apply TEFRA liens." So the home stays in the family's name during the resident's life, and a community spouse or qualifying relative can continue to live there. Read that answer for what it says: it disclaims the TEFRA lien species, not every lien. Federal law still permits a pre-death lien "pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual" (42 U.S.C. § 1396p(a)(1)(A)), which is a different situation from the routine TEFRA lien families are usually worried about.6

What happens at death is a different question, addressed in the Estate Recovery section below. For families weighing what proactive home-protection planning is and isn't possible in Tennessee, Medicaid Asset Protection Trusts, tenancy by the entirety, the caretaker-child and sibling-with-equity transfer exceptions, and why Lady Bird and TOD deeds don't apply in Tennessee, see the How to Protect Your Home from Medicaid in Tennessee deep guide.

Patient Liability: the Math, Walked Through

Once your parent is enrolled, the question becomes: of the income coming in each month, how much do they keep, how much goes to the facility, and how much to a community spouse?

Start with gross monthly income and subtract the deductions TennCare allows. Its Aged, Blind and Disabled Manual presents these as a list, not an order of application, and there are seven:

1. Personal Needs Allowance, $70/month, kept by the resident (see deep guide for Resident Trust Fund mechanics, sheltered workshop disregard, veterans' pension stacking, and state veterans' home override).7
2. Mandatory expenses, meaning expenses your parent is legally obligated to pay. TennCare's list includes garnishments and other withholdings, conservatorship or guardianship fees, court-ordered bankruptcy payments, court-ordered child support, court-ordered alimony, and Qualified Income Trust fees. If your parent has a QIT, do not forget that last one.7
3. Community Spouse Income Maintenance Allowance (CSIMA) for a spouse living in the community. This is the Minimum Monthly Maintenance Needs Allowance mechanic: it shifts income from the institutionalized spouse to the community spouse to bring the community spouse's total income up to a floor between $2,705.00 and $4,066.50 per month (depending on documented shelter costs).5
4. Dependent Income Maintenance Allowance (DIMA) for a dependent living in the community.
5. Health insurance premiums, coinsurance and deductibles. For most residents this is the Medicare Part B premium plus any supplemental policy.
6. Incurred medical expenses not covered by TennCare Medicaid and allowed under the State Plan.
7. An incurred medical expenses carry-forward for allowable medical expenses not previously deducted.5

Do not skip items 6 and 7 when you run the numbers at home. A resident with real uncovered medical costs has a lower patient liability than a four-line calculation suggests, and leaving those deductions out overstates what the family owes the facility.7

Order matters only when income runs out before the deductions do, and TennCare's manual does not state one. The order federal rule prescribes, at 42 CFR 435.725(c), puts the personal needs allowance first, then the maintenance needs of a spouse, then the maintenance needs of a family, then expenses not subject to third-party payment (including Medicare and other health insurance premiums, deductibles and coinsurance), then continued SSI and SSP benefits. Note that the federal order puts the spouse and family allowances ahead of health insurance premiums, not behind them.7

What's left after the allowable deductions is the patient liability, the amount paid to the facility each month as the resident's contribution to their care. The facility is obligated to collect it, and the MCO's monthly payment to the facility is reduced by the entire amount of patient liability due for that month.5

A quick worked example. A widow on Medicaid CHOICES Group 1 receives $1,950/month in Social Security and $850/month from a small pension, total gross income $2,800/month. She has no community spouse. Her Medicare Part B premium is $202.90/month (2026 standard). Her patient liability is:5,10

• $2,800 gross income
• minus $70 PNA
• minus $202.90 Medicare Part B premium
• = $2,527.10 patient liability, paid to the facility each month.5

She keeps $70 for personal needs, her health coverage continues through TennCare and Medicare, and the MCO covers the gap between her patient liability and the daily room-and-board rate.7

Add a community spouse and the number moves a long way. A husband entering the facility with $3,400/month, whose wife at home receives $1,100/month against an MMNA of $3,200, deducts the $2,100 shortfall on top of the $70 PNA and the $202.90 Part B premium, leaving $1,027.10 in patient liability instead of $3,127.10.5

That mechanic is what protects community spouses from impoverishment, and it is why the spousal income calculation is often the single highest-dollar decision in a CHOICES application. Tennessee follows the federal Income-First rule (42 USC § 1396r-5(d)(6)): a community spouse cannot increase the CSRA to generate more income unless an income shift cannot reach the MMMNA floor first. For the full spousal-protection playbook, read Tennessee Spousal Impoverishment Rules.

Tennessee follows the name-on-the-check rule: community spouse income is not counted toward the applicant's $2,982 income cap, though community spouse income may affect the MMNA calculation if it falls below the floor.5

Tennessee Medicaid Nursing Home Costs in 2026

Cost matters even when Medicaid is the destination: the family usually pays privately during the processing window, facilities ration Medicaid beds, and patient liability only makes sense against the total.

The most recent state-level figures come from the CareScout Cost of Care Survey 2025 state data tables, released in March 2026. Tennessee ranks 32nd among states for semi-private cost and 35th for private, running modestly below the national median on both.1

Read those as medians, not as a price. CareScout collected the rates from providers between July and November 2025 and reports them at the metropolitan-statistical-area level, and says outright that actual costs vary with individual care needs, provider availability, and local market conditions. The monthly and daily columns are not separately surveyed either: CareScout derives them by dividing the annual figure by 12 and by 365, which is why they are approximations. Price the specific facility you are considering rather than budgeting the statewide number.1

TennCare's average nursing-facility reimbursement, effective January 1, 2026, is $294.87 per day, below both private-pay medians.1 That gap is part of why some facilities cap Medicaid admissions.

A few practical points families should know:

• A decision can take up to 45 days, or up to 90 days when the application is filed on the basis of disability, under 42 CFR 435.912(c)(3). Those are not absolute: paragraph (e) lets the agency exceed them "in unusual circumstances," and the regulation gives examples, including when the applicant or an examining physician delays or fails to take a required action. During that window, the family is responsible for the private-pay rate. Many facilities will accept "Medicaid pending" status and not bill at the private-pay rate, but this varies by facility and is something to negotiate up front.11
• Retroactive coverage is not available to a Tennessee nursing home resident. Federal law (42 CFR 435.915) would cover services furnished in or after the third month before the application month, but CMS waived that for TennCare under the TennCare III demonstration. Tennessee's authority is "not to extend eligibility prior to the date that an application for assistance is made," and the waiver spares only pregnant women (plus 60 days postpartum), infants under one, and people under 21. A nursing facility resident is inside the waiver, so there is nothing for TennCare to backdate: it will not pay for care received before the application date. That is a statement about TennCare, not about every payer. Whether Medicare's skilled nursing benefit or another policy covers those earlier days is a separate question, and for a resident admitted straight from a qualifying hospital stay it often does, so ask the facility to bill Medicare for the days it can. File the application on the day of admission, before the financial documents are assembled, and send the rest afterward.8
• A "Medicaid bed" is a misnomer. Almost all TN facilities accept TennCare; what varies is how many Medicaid beds each holds open. Ask how many are open now and what the wait is.

Estate Recovery: What TennCare Can and Cannot Take

Estate recovery is the question every family asks about, and Tennessee's rules are narrower than families fear.

Federal law (42 USC §1396p(b)) requires every state to recover the cost of long-term services and supports from the estates of Medicaid recipients who received LTSS at age 55 or older. Tennessee implements this requirement through Tenn. Code Ann. §71-5-116, administered by TennCare's Estate Recovery Unit under TennCare State Plan Attachment 4.17-A.6

The scope:

• Who's subject: TennCare seeks recovery when all of these are met: the member received CHOICES Group 1, 2, or 3 LTSS, received it at age 55 or older, is deceased, and no waiver or hardship applies. Standard adult Medicaid with no LTSS does not drive a claim. Those are the conditions TennCare publishes, not a guarantee no other LTSS at 55 or older could be reached, so ask the Estate Recovery Unit about long-term care received outside CHOICES.
• What's reachable: the State Plan defines "estate" as all property owned immediately preceding death, as limited or expanded by T.C.A. Titles 30, 31, and 32 and by Tennessee courts. Families are often told Tennessee is "probate-only," so payable-on-death accounts, survivorship property, and life estates are untouchable. That is the common practice reading, not something 4.17-A spells out. Treat any specific asset as a question for an elder-law attorney.
• No TEFRA liens, so nothing attaches to the home while the recipient is alive. Recovery comes, if at all, after death.
• Probate priority: Per T.C.A. §30-2-317, the TennCare claim has third priority, behind only administrative costs and funeral expenses, ahead of all general creditor claims.

Survivor protections. TennCare cannot recover, and must "waive" recovery, when the member is survived by a spouse, a child under 21, or a child who is blind or disabled. The federal statute frames that as a timing bar, not permanent forgiveness: recovery "may be made only after the death of the individual's surviving spouse, if any, and only at a time when he has no surviving child who is under age 21, or is blind or permanently and totally disabled." So the protection can lapse when the surviving spouse dies or a child turns 21, and the claim can come back. Plan for that rather than treating the claim as extinguished.

Undue hardship waivers. Attachment 4.17-A defines undue hardship as any of three circumstances, and TennCare states all three to families as situations that will waive or delay recovery.

1. Sole income-producing asset. The estate property subject to recovery is the sole income-producing asset of survivors, such as a family farm or other family business, with no value limitation on that asset. TennCare says this one acts as a waiver.
2. Sibling caretaker, one year. A sibling of the member who lawfully lived in the home for the year immediately before the member's admission, provided care during that year that permitted the member to live at home rather than in an institution, and has lawfully lived in the home continuously since the date of admission.
3. Child caretaker, two years. A son or daughter who meets those same three criteria over the two years immediately before admission.

The two caregiver grounds are a deferral while the caregiver stays, not a release. The State Plan says the hardship no longer exists when that person stops residing in the home, and TennCare spells out that it no longer applies when the caretaker moves out, sells the property, or dies. If you are the child or sibling who kept your parent out of a nursing home and you still live in that house, claim the ground while you are living there, and understand that selling or moving revives the claim.6

Cost-effectiveness threshold: all claims of $10,000 and below are treated as not cost effective, and where the claim is below $10,000 the state provides a release of the claim. Recovery is also not cost effective when the estimated costs of recovery plus higher-priority claims (administrative, funeral) exceed or nearly exceed the assets in the decedent's estate.6

The process at death: A Request for Release (RFR) form goes to the member's last known address, and is also at every county probate court clerk and on the TennCare website. The family or executor returns it; TennCare responds with a release or an itemized claim. Hardship waivers are requested on the same form. If denied, the family may petition Probate Court under T.C.A. §71-5-116 to waive or defer recovery.

A note on planning: certain instruments (irrevocable life-estate deeds, properly drafted trusts) can move assets out of the probate estate before death, but none of it is a guarantee, and aggressive planning that fails costs more than it saves, a denial, a penalty period, and an unbudgeted private-pay bill. The honest version is that estate recovery is real, that the survivor protections hold for as long as those survivors qualify, that the $10,000 release means many modest estates draw no claim at all, and that nobody can tell you from a guide which of your parent's specific assets Tennessee probate law will put inside the recoverable estate.6

Choosing a Tennessee Nursing Facility

If your parent's clinical and financial picture is settled, the next decision is which facility. Three free public tools should drive that choice.

1. CMS Care Compare Five-Star Rating. Every Medicare- or Medicaid-certified facility is rated on a five-star scale, with separate stars for health inspections, staffing, and quality measures. The health-inspection star is curved against other facilities in the same state, so a Tennessee five-star home is ranked against Tennessee peers, not a national bar. Search by ZIP at medicare.gov/care-compare. The same site lists CMS's Special Focus Facilities, the poorest performers in each state, inspected about twice as often and facing termination from Medicare and Medicaid if they do not improve. Check the current Tennessee list before you tour anywhere.

2. Tennessee Health Facilities Commission inspection reports. The state licensing agency posts annual survey results and complaint investigations. Look for substantiated complaints, deficiency citations, and responses to corrective-action plans.

3. The Long-Term Care Ombudsman for the region. Call before admission and ask whether they have current concerns about a specific facility; they often have ground truth that survey results don't capture.

A few practical questions to ask any facility you're considering:

• How many Medicaid beds do you currently have open?
• What is your CMS Five-Star rating today, and have you had any deficiencies in the past 12 months?
• What is your nurse-to-resident ratio on day, evening, and overnight shifts? (No federal minimum staffing-hours rule is in force to hold them to, so their answer and the Care Compare staffing star are what you have.)
• Do you have a memory care unit, and what dementia-care training do you require of staff?
• What is your policy on "Medicaid pending" admissions, and will you bill the family at the private-pay rate meanwhile?

The Long-Term Care Ombudsman Program

Once your parent is admitted, the Long-Term Care Ombudsman is the family's free advocate inside the facility, authorized under the federal Older Americans Act §711–712 and Tenn. Code Ann. §71-2-109 and administered through the Tennessee Department of Disability and Aging. It investigates and resolves complaints made by or on behalf of residents, explains residents' rights, advocates before government agencies, and supports resident and family councils, all free and confidential. It is an advocacy program, not a regulator: it cannot order a facility to act, which is the Tennessee Health Facilities Commission's job, and it cannot serve as legal counsel.6

It covers nursing homes, assisted-care living facilities, residential homes for the aged, and other licensed long-term care settings, through nine District Ombudsman offices housed at the Area Agencies on Aging and Disability. Caseloads are heavy, so call at admission rather than after a problem develops.

How to Apply for Tennessee Medicaid Nursing Home Coverage

Tennessee CHOICES Group 1 admissions almost always run through one of two paths:

Path 1: Hospital discharge. When a parent is being discharged from a hospital to a nursing facility, the hospital's discharge planner and the receiving facility's admissions coordinator handle the bulk of the paperwork. The hospitalist or facility medical director submits the PAE. The family submits the financial application through one of TennCare's three channels: online at tenncareconnect.tn.gov, by phone to TennCare Connect at 1-855-259-0701, or on a paper application mailed to TennCare Connect, P.O. Box 305240, Nashville, TN 37230-5240 (fax 1-855-315-0669). Free in-person help is available from the local Tennessee Department of Health office or, for long-term care specifically, from the Area Agency on Aging and Disability at 1-866-836-6678, which will send a representative to the home of an applicant with a disability. That AAAD number is the route for someone who does not yet have TennCare; a current TennCare member is told to call their own health plan instead.11

Path 2: Direct admission from home. Less common. The family contacts the facility, whose admissions team requests the PAE from the resident's primary care physician, and files the financial application through TennCare Connect.

Either way, the practical sequence is:

Which decision clock a CHOICES application runs on, the 90 days for a disability-basis application or the 45 for everyone else, depends on how it was filed, and either can be exceeded in the unusual circumstances 42 CFR 435.912(e) allows.11 Whichever clock applies, TennCare will not extend eligibility to any date before the application is filed.8

Worked Example: A Tennessee Widow with Income, Assets, and a Home

A 78-year-old widow in Knoxville has $3,200/month in Social Security and a small pension, $45,000 in savings, no debt, and a paid-off house worth $220,000. Her daughter lives nearby but not with her. After a stroke, she is being discharged to a Knoxville nursing facility on a CHOICES Group 1 application.4

Clinical eligibility: Her PAE Acuity score after the stroke is 14 (help needed with eating, transfers, toileting, plus skilled wound care). Well above 9. Cleared.

Income: $3,200/month is above the $2,982 cap, so she needs a QIT, drafted by a Knoxville elder-law attorney, funded with her full monthly income, and reported on her TennCare Connect application.13,6

Assets: $45,000 exceeds the $2,000 cap by $43,000. Permissible spend-down clears it: $12,500 to an irrevocable pre-paid funeral contract, $16,000 to home repairs and accessibility work, $5,500 to a credit card and an unpaid medical bill, $9,000 to dental, vision, and hearing work TennCare does not cover. Cleared.4

Home: It is her principal residence, equity well below $752,000, and because she now lives in a facility she signs a statement of intent to return, the second half the exclusion requires. Exempt during her lifetime. Cleared.4

Patient liability calculation:

• $3,200 gross income (now flowing through QIT)
• minus $70 PNA
• minus $202.90 Medicare Part B premium
• = $2,927.10 patient liability to the facility each month.5,10

Her MCO's monthly payment to the facility is reduced by that full $2,927.10, and the MCO covers the balance of the facility's negotiated Medicaid rate. TennCare's average nursing-facility reimbursement is $294.87 per day, below the $310/day median a private-pay resident would face for the same semi-private room.1,5

Estate recovery exposure: She received CHOICES Group 1 LTSS at 78, so after her death TennCare can pursue her estate, and the home is the asset at issue. Whether an instrument such as a life-estate deed would move it outside the recoverable estate is a question for an elder-law attorney before she enters the facility, not after her death, and it cuts both ways: transferring the home now is itself an uncompensated transfer inside the 60-month look-back unless it fits an exemption.

Common Misconceptions

• "My parent will be on a waitlist for nursing home Medicaid in Tennessee." Group 1 is entitled. Group 2 (HCBS at home) is the program with periodic waitlists.
• "Tennessee requires a spend-down on monthly income." No. The route for an over-income LTSS applicant is a Qualified Income Trust. Spend-down in Tennessee LTC materials means reducing countable assets, a different thing.
• "If we transfer the house to me now, we can avoid Medicaid recovery." Maybe, but the transfer is inside the 60-month look-back. A $220,000 transfer creates roughly 744 days of ineligibility at the $295.87/day divisor, unless it fits one of the six exempt categories above.9
• "TennCare estate recovery applies to all Medicaid recipients." No. Recovery turns on a deceased member who received CHOICES LTSS at 55 or older with no waiver or hardship applying.

What to Read Next

• Tennessee Medicaid Programs Overview, how CHOICES, ECF CHOICES, Katie Beckett, standard ABD, and MSPs fit together.
• Tennessee Medicare Savings Programs (QMB / SLMB / QI), for a dual-eligible resident who needs both the Group 1 LTSS benefit and MSP premium and cost-sharing help.
• How to Apply for TennCare, application channels, document checklist, and renewal mechanics.
• How to Get Paid as a Family Caregiver in Tennessee and Respite Care in Tennessee, for families weighing the home-care path under Group 2.
• Qualified Income Trust (Miller Trust) and Nursing Facility Level of Care, the technical primers.
• Tennessee PACE Program, a structured alternative to nursing facility placement. PACE delivers integrated Medicare and Medicaid care through one interdisciplinary team; enrollment requires being 55 or older, meeting the same nursing facility level of care CHOICES applies, living in the organization's service area, and being able to live safely in the community at enrollment. Tennessee's only site is Ascension Living Alexian PACE in Chattanooga.16

Learn More

Find personalized help mapping a Tennessee Medicaid nursing home application 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.