Medicare vs Medicaid in Tennessee: TennCare Difference Explained

These two programs sound almost the same. They are not.

Medicare is federal health insurance based on age (65+) or qualifying disability. It is not income-based, anyone who paid into Social Security long enough qualifies, regardless of how much they make.

TennCare is Tennessee's name for Medicaid, a joint federal-state program that's run by the state for people with limited income and assets. The income test is real and strict, but TennCare covers things Medicare doesn't, especially long-term care.

You can have both. About 250,000 Tennesseans are "dual eligible", qualifying for Medicare AND TennCare at the same time, which is one of the best positions to be in for someone managing a chronic condition or aging parent's care. Even if you don't qualify for full TennCare, Tennessee runs three Medicare Savings Programs that can pay your Medicare premiums and copays.

This guide walks through exactly how Medicare and TennCare differ, what each one pays for in 2026, who qualifies for both, and how the two programs coordinate when you have both.

In This Guide

• Key Takeaways
• The 30-Second Answer
• What Medicare Is and What It Covers
• What TennCare Is and What It Covers
• Side-by-Side Comparison
• Can You Have Both?
• Tennessee Medicare Savings Programs
• How Medicare and TennCare Coordinate
• Dual-Eligible Special Needs Plans (D-SNPs)
• Who Pays for Long-Term Care
• How to Apply for Each
• Frequently Asked Questions

The 30-Second Answer

If a senior has worked enough quarters under Social Security and is 65 or older, they get Medicare. Period. Income doesn't matter.

If a senior also has limited income and assets, they may additionally qualify for TennCare (Tennessee Medicaid). The income tests are strict; the asset tests are real but have meaningful exemptions (a primary home and one car are typically not counted).

Many seniors are confused by Tennessee's branding. TennCare and Medicaid are the same thing. Tennessee just gave its program a different name in 1994 when it launched the §1115 demonstration. When this guide says "TennCare," that's Tennessee's Medicaid program.

The reason this distinction matters: Medicare alone has gaps, it doesn't cover long-term custodial care, has limited dental and vision benefits, and leaves seniors with copays and deductibles that can be meaningful. TennCare fills those gaps. The trick is knowing whether you qualify, and most families never find out because they assume "I'm on Medicare, so Medicaid doesn't apply to me." Wrong assumption.

What Medicare Is and What It Covers

Medicare is a federal health insurance program enacted in 1965 and administered by the Centers for Medicare and Medicaid Services (CMS). Eligibility is based on age or disability, not income.

Who qualifies:

• People age 65 or older who are U.S. citizens or have been lawful permanent residents for at least five years
• People under 65 with certain disabilities (after 24 months of receiving Social Security Disability Insurance)
• People of any age with End-Stage Renal Disease (ESRD)
• People of any age with Amyotrophic Lateral Sclerosis (ALS), coverage starts the first month of SSDI

Medicare has four parts:

The big gaps in Medicare that families need to know about:

1. No long-term custodial care. Medicare covers up to 100 days of skilled nursing facility care after a qualifying inpatient hospital stay, that's rehab, not long-term residency. Once a patient transitions from skilled to custodial care (help with bathing, dressing, eating without ongoing skilled need), Medicare stops paying. This is the single biggest financial cliff in eldercare.
2. No routine dental, hearing, or vision. Original Medicare covers only narrow medical-necessity exceptions. Most MA plans add some dental and vision benefits, but the scope varies significantly by plan.
3. 20% Part B coinsurance with no out-of-pocket cap under Original Medicare. A senior with cancer or kidney disease can rack up tens of thousands in coinsurance with no ceiling. (MA plans cap OOP; Medigap policies fill the coinsurance gap.)
4. No transportation, no homemaker services, no personal care attendants. Medicare doesn't pay for someone to come help with daily living tasks at home.

These gaps are exactly what TennCare fills for those who qualify.

What TennCare Is and What It Covers

TennCare is Tennessee's Medicaid program, operating under a federal §1115 demonstration waiver (TennCare III, approved 1/8/2021, term through 12/31/2030). Roughly 1.7 million Tennesseans are enrolled. Most members are covered through one of three Managed Care Organizations: BlueCare Tennessee, UnitedHealthcare Community Plan TN, or Wellpoint Tennessee (formerly Amerigroup).

Who qualifies (for ABD adults age 65+ in 2026):

• Income: generally at or below 100% of the SSI federal benefit rate ($994/month single, $1,491/month couple in 2026 per SSA October 24, 2025 COLA) for the standard ABD pathway, with higher limits for CHOICES institutional and HCBS (300% SSI = $2,982/month for 2026)
• Assets: $2,000 single / $3,000 couple (federal default), with the home, one car, household goods, and burial trust exempt
• Medicare beneficiaries can qualify for full TennCare on top of Medicare if they meet the income and asset tests; this is the "full-benefit dual" pathway

What TennCare covers (high level, see TennCare Covered Services for the comprehensive catalog):

• All federally-mandatory Medicaid services, inpatient hospital, outpatient, physician, lab/X-ray, family planning, nursing facility, home health, transportation
• Comprehensive prescription drug coverage through OptumRx, $1.50 generic / $3.00 brand-name copays for most adults; LTSS members exempt; the 5-prescription-per-month adult cap was eliminated effective 7/1/2025
• Comprehensive adult dental added 1/1/2023 (cleanings, fillings, crowns, dentures, root canals, extractions; Renaissance Dental administers since 11/1/2025)
• Behavioral health and substance use disorder services, fully integrated with the medical benefit; no separate carve-out
• Vision and hearing, limited adult coverage; pediatric EPSDT comprehensive
• Long-term services and supports through CHOICES, nursing facility (Group 1), HCBS in-home or assisted living (Group 2), at-risk supports (Group 3)
• Non-emergency medical transportation (NEMT), broker-arranged through Verida or Tennessee Carriers depending on MCO
• Hospice, durable medical equipment, physical/occupational/speech therapy, podiatry, chiropractic as medically necessary

Importantly for dual-eligibles: TennCare also pays the cost-sharing for Medicare services (Part A and Part B deductibles and coinsurance) for full-benefit duals and QMBs. That's how the two programs coordinate.

Side-by-Side Comparison

Can You Have Both?

Yes. About 250,000 Tennesseans qualify for both Medicare and TennCare simultaneously. That status is called "dual eligible," and it has tiers:

Full-benefit duals (Medicare + full TennCare). These members get all Medicare benefits as their primary insurance, with TennCare adding (a) cost-sharing protection on Medicare services, (b) prescription drug coverage with $1.50/$3 copays as opposed to Part D out-of-pocket, (c) all the TennCare-only benefits (dental, NEMT, LTSS, behavioral health, vision/hearing as available). This is the strongest dual-eligible status financially.

QMB Plus / SLMB Plus duals. Members who qualify for both an MSP (paying Medicare premiums and possibly cost-sharing) AND full TennCare. Functionally identical to full-benefit duals.

Partial duals (MSP only). Members whose income is too high for full TennCare but low enough to qualify for one of the three MSPs (QMB, SLMB, QI). They get Medicare cost-sharing or premium help only, no TennCare benefits beyond the MSP. Still meaningful: a QMB enrollee saves the $202.90 Part B premium plus all coinsurance and deductibles.

The single biggest reason families miss dual eligibility: they assume that since one parent gets Medicare and is over 65, Medicaid doesn't apply. That's wrong. The two programs use different eligibility tests, and being on Medicare doesn't disqualify someone from TennCare or an MSP. If household income is below ~$1,800/month single or ~$2,455/month couple, which describes a meaningful share of Tennessee seniors on Social Security alone, there's likely an MSP or full-TennCare pathway worth exploring.

Tennessee Medicare Savings Programs

If a Medicare beneficiary is too high-income for full TennCare but still has limited income, Tennessee runs three Medicare Savings Programs that can dramatically reduce Medicare costs. All three use the federally-aligned income standard (FPL plus a $20 unearned-income disregard) and the federally-aligned resource standard. The full deep guide, federal authority at 42 USC §§ 1396a(a)(10)(E), 1396u-3, 1395w-114; TN implementation under Tenn. Comp. R. & Regs. Chapter 1200-13-20 + ABD Manual § 120.015; QMB billing prohibition; Part D LIS auto-deeming; three worked examples, is at Tennessee Medicare Savings Programs: Complete 2026 Guide.

2026 resource limit for all three MSPs: $9,950 individual / $14,910 couple. These match the federally-aligned Part D Low-Income Subsidy resource limits.

Important practical points:

• MSP enrollees don't get TennCare medical benefits unless they also qualify for full TennCare separately (e.g., based on age 65+ ABD eligibility plus the income/asset tests).
• QMB has cost-sharing protection, once enrolled, providers cannot bill the QMB enrollee for Medicare deductibles or coinsurance. Federal "QMB billing protection" rules at 42 CFR §447.20 prohibit it. If a QMB enrollee gets a coinsurance bill from a Medicare provider, the bill is improper.
• Part D Extra Help is automatic for QMB, SLMB, and QI enrollees. Enrollees pay $0 Part D premium (for benchmark plans), $0 deductible, and copays of $5.10 generic / $12.65 brand-name in 2026 (per CMS CY 2026 Part D Redesign Program Instructions). For the full LIS interplay, the $20 + $65 + ½ disregards, the QMB billing prohibition under 42 USC § 1396a(n)(3)(B), the QMB-Plus / SLMB-Plus dual-eligible categories, the Part B Special Enrollment Period for newly determined MSP enrollees, and three worked examples, see Tennessee Medicare Savings Programs: Complete 2026 Guide.

How to apply. Tennessee MSP applications run through TennCare Connect at tenncareconnect.tn.gov or 1-855-259-0701. The Social Security Administration also accepts MSP applications (Form SSA-1020) and forwards them to TennCare for determination under 42 USC § 1320b-14. There is no separate paper MSP form, the standard TennCare application captures MSP eligibility automatically. The full intake walkthrough, including the paper application address P.O. Box 305240 Nashville, the AVS resource verification process under the 2024 CMS streamlining final rule, and the 45-day determination clock, is in the Tennessee Medicare Savings Programs deep guide.

How Medicare and TennCare Coordinate When You Have Both

For a full-benefit dual, the two programs work together, but in a specific order:

1. Medicare pays first for any Medicare-covered service (inpatient hospital, physician visit, durable medical equipment, etc.). Medicare's reimbursement to the provider is the primary payment.
2. TennCare pays second to cover the Part A deductible ($1,736/benefit period in 2026) and Part B coinsurance (20% on most services). For QMB-eligible duals, this protection is comprehensive.
3. TennCare-only benefits (long-term care, NEMT, dental, etc.) are paid entirely by TennCare with no Medicare involvement.
4. Prescription drugs. Dual eligibles automatically get Part D Low-Income Subsidy (Extra Help). The Part D plan pays for medications first; the LIS reduces the dual's out-of-pocket exposure to near-zero. TennCare does NOT cover most outpatient prescriptions for full-benefit duals, Part D is the primary drug payer.

Practical tip: Dual eligibles should make sure their providers know they have both programs. Hospital and physician billing systems sometimes try to bill the patient for Medicare cost-sharing without checking for QMB or full-Medicaid status. If a dual gets a bill they shouldn't, the answer is to contact the provider with proof of QMB or TennCare enrollment and request a re-bill to TennCare.

Dual-Eligible Special Needs Plans (D-SNPs)

A D-SNP is a specialized Medicare Advantage plan designed for dual-eligible members. The plan integrates Medicare and Medicaid benefits into one product with one card, one provider directory, and one care coordinator. In Tennessee, D-SNPs are available from each of the three TennCare MCOs through their Medicare Advantage subsidiaries:

• BlueCare Tennessee, D-SNP available through BlueCross BlueShield Medicare Advantage
• UnitedHealthcare, Dual Complete D-SNP for TennCare members enrolled with UHC Community Plan
• Wellpoint Tennessee, D-SNP option for Wellpoint TN dual-eligible members

D-SNPs are not mandatory for dual-eligibles, members can stay on Original Medicare plus their TennCare MCO if they prefer. The advantage of a D-SNP is integrated care management; the disadvantage is the narrower provider network compared to Original Medicare. Open enrollment for D-SNPs runs October 15 - December 7 each year, with plan-year changes effective January 1.

Who Pays for Long-Term Care in Tennessee

This is the question that drives most dual-eligibility research. The short answer:

Medicare: pays for up to 100 days of skilled nursing facility care after a qualifying 3-day inpatient hospital stay. Days 1-20 fully covered; days 21-100 the patient pays $217/day coinsurance in 2026. Medicare does NOT pay for long-term custodial nursing-facility care or assisted living.

TennCare CHOICES: pays for long-term care in three setting types:

• CHOICES Group 1, nursing facility (full coverage; member pays a calculated patient-liability amount based on income above the personal needs allowance)
• CHOICES Group 2, HCBS in the community or in an assisted living facility ($107,627.55/year cost-neutrality cap; AL R&B not covered)
• CHOICES Group 3, at-risk in-home supports (~$18,000/year cap)

For full-benefit duals receiving long-term care, Medicare and TennCare CHOICES coordinate this way: Medicare pays for skilled medical services (physician visits, hospitalizations, prescriptions, the first 100 days of skilled rehab in a nursing facility); CHOICES pays for the long-term custodial care after Medicare's coverage ends, plus all the medical cost-sharing along the way.

Long-Term Care insurance is the third payer in this picture: a private LTCI policy can cover long-term care costs that Medicare won't, and Tennessee's Long-Term Care Partnership program lets policyholders shelter assets equal to LTCI benefits paid before applying for TennCare. For families with assets above the TennCare threshold, LTCI is one of the few non-trust strategies for protecting wealth from a long nursing-facility stay.

For the deeper detail on CHOICES eligibility, patient liability, and qualified income trusts, see Long-Term Care and Nursing Home Coverage in Tennessee.

How to Apply for Each

Medicare:

• Initial Enrollment Period: the seven-month window around your 65th birthday (3 months before, the birth month, and 3 months after). Most people are auto-enrolled in Parts A and B if they're already drawing Social Security at 65; otherwise sign up via ssa.gov/medicare or visit a local Social Security office.
• Part D drug plan or MA plan: select during the Annual Election Period (October 15 - December 7) for January 1 effective date. Compare plans at medicare.gov/plan-compare.
• General Enrollment Period: January 1 - March 31 each year for those who missed initial enrollment. Late-enrollment penalties may apply.

TennCare:

• Online: tenncareconnect.tn.gov, the primary application channel
• Phone: 1-855-259-0701 (TennCare Connect)
• In person: Department of Human Services (DHS) offices accept TennCare applications and provide application assistance
• By mail: request an application by phone; submit completed forms to the address listed
• For LTSS / CHOICES applications: TennCare initiates a separate financial review plus an Acuity Care Plan / level of care assessment. The PAE (Pre-Admission Evaluation) form is used to document level of care.

For comprehensive walk-through of the TennCare application, see How to Apply for TennCare in Tennessee.

Frequently Asked Questions

Can I have both Medicare and TennCare in Tennessee?

Yes. Roughly 250,000 Tennesseans have both. If you qualify for both, you're called "dual eligible", Medicare pays first for medical services, TennCare picks up the cost-sharing and adds benefits Medicare doesn't cover (long-term care, dental, transportation, behavioral health). Even if you don't qualify for full TennCare, Tennessee's three Medicare Savings Programs can pay your Medicare premiums and copays.

Will Medicare pay for nursing home care in Tennessee?

Only short-term skilled nursing care, not long-term custodial care. Medicare covers up to 100 days of skilled nursing facility care after a qualifying 3-day inpatient hospital stay, days 1-20 fully covered, days 21-100 with a patient coinsurance of $217/day in 2026. Once skilled needs end and the stay becomes custodial, Medicare stops paying. Long-term custodial nursing care in Tennessee is paid for by TennCare CHOICES Group 1, by private long-term care insurance, or by private pay.

Will TennCare pay for my prescriptions if I'm on Medicare?

If you're a full-benefit dual eligible, TennCare doesn't pay for outpatient prescriptions directly, Medicare Part D does, with the Part D Low-Income Subsidy (Extra Help) reducing your out-of-pocket to near-zero ($0 premium for benchmark plans, $0 deductible, $5.10 generic / $12.65 brand-name copays in 2026). TennCare may cover some drugs Part D doesn't (specific over-the-counter and barbiturate categories). For QMB-only or SLMB-only enrollees not on full TennCare, Part D plus Extra Help applies the same way.

What's the income limit for TennCare in Tennessee for a senior?

For standard ABD (Aged, Blind, Disabled) eligibility, income must be at or below 100% of the SSI federal benefit rate, $994/month single, $1,491/month couple in 2026 per the SSA October 24, 2025 COLA announcement. For CHOICES institutional or HCBS eligibility, the limit goes up to 300% of SSI ($2,982/month) but a Qualified Income Trust may be required to capture income above that. The Medicare Savings Programs use higher income limits, QI goes up to ~$1,816/month single, ~$2,455/month couple.

What's the difference between QMB, SLMB, and QI?

All three are Medicare Savings Programs, with different income limits and different scopes. QMB (lowest income, ≤100% FPL + $20 disregard) covers Medicare premiums AND all cost-sharing, the most comprehensive. SLMB (100-120% FPL) covers the Part B premium only. QI (120-135% FPL) covers the Part B premium only and operates on a first-come, first-served basis each year. All three trigger automatic Part D Extra Help.

How much is Medicare Part B in 2026?

The 2026 standard Part B premium is $202.90/month, up $17.90 from $185 in 2025. The annual Part B deductible is $283. High-income beneficiaries (above $109,000 single / $218,000 joint) pay an IRMAA surcharge on top, reaching $689.90/month at the highest tier.

Does Tennessee have Medicaid expansion?

No. Tennessee is one of the states that has not expanded Medicaid under the Affordable Care Act. This means working-age adults without dependent children generally cannot qualify for TennCare unless they meet a specific category (pregnant, parent of a minor, blind, disabled, etc.). For seniors 65+, the ABD eligibility pathway operates regardless of expansion status, that's federally mandatory.

What's a D-SNP and should I enroll?

A Dual-Eligible Special Needs Plan (D-SNP) is a Medicare Advantage plan designed specifically for people with both Medicare and Medicaid. The plan integrates Medicare and TennCare benefits into one product with one card, one network, and one care coordinator. Tennessee's three TennCare MCOs (BlueCare, UHC, Wellpoint) each offer a D-SNP option through their Medicare Advantage subsidiaries. D-SNPs are optional, duals can stay on Original Medicare plus their TennCare MCO. The trade-off: D-SNPs offer integrated care management but typically have a narrower provider network than Original Medicare.

How do I apply for the Medicare Savings Programs in Tennessee?

Apply through TennCare Connect at tenncareconnect.tn.gov or 1-855-259-0701. The Social Security Administration also accepts MSP applications and forwards them to TennCare. There's no separate MSP form, the standard TennCare application captures MSP eligibility. Documentation needed: proof of identity, Social Security number, citizenship/immigration status, income (Social Security benefit letter, pension statements), and assets (bank statements, vehicle titles). Decision typically within 30-45 days.

If I'm on Medicare, do I still need to enroll in a TennCare MCO?

If you're a full-benefit dual eligible, yes, TennCare assigns you to one of the three MCOs (BlueCare, UHC Community Plan, or Wellpoint) for your Medicaid benefits even though Medicare is your primary insurance. You can request a specific MCO during enrollment; otherwise TennCare assigns one. The MCO handles your TennCare-only services (long-term care, NEMT, dental, behavioral health). You can switch MCOs annually during your enrollment anniversary or for cause.

What does Medicare cover that TennCare doesn't?

Almost nothing, TennCare for full-benefit duals is broader than Medicare alone. The narrow exceptions: (1) Medicare Part D drugs that TennCare formulary excludes for non-dual members are still covered through Part D for duals; (2) Medicare's national provider network may include providers who don't accept TennCare. In practice, full-benefit duals get the union of both benefits.

What does TennCare cover that Medicare doesn't?

Long-term custodial care (CHOICES); comprehensive adult dental; non-emergency medical transportation; integrated behavioral health; personal care services through HCBS; some hearing/vision benefits via MCO cost-effective alternatives; lower out-of-pocket on most cost-sharing. The single biggest gap TennCare fills is long-term care, which is also the most expensive category of eldercare.

What's IRMAA and does it apply to me?

IRMAA (Income-Related Monthly Adjustment Amount) is a high-income surcharge added to your Medicare Part B and Part D premiums. It applies if your modified adjusted gross income two years ago was above $109,000 single / $218,000 joint. The surcharge is on a sliding scale, with the highest tier (≥$500K single / ≥$750K joint) paying $689.90/month for Part B. If you're below those income thresholds, IRMAA doesn't apply. The IRMAA surcharge income brackets are inflation-adjusted each year and can be appealed if you've had a life-changing event (retirement, marriage, divorce, death of spouse, etc.).

Learn More

• Tennessee Medicaid Programs Overview
• Tennessee Medicare Savings Programs
• TennCare Eligibility & Income Limits
• TennCare Covered Services
• How to Apply for TennCare
• BlueCare Plus FIDE D-SNP

Find personalized help understanding Medicare and TennCare in Tennessee 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.