Tennessee PACE Program (2026)

If an aging parent needs nursing-facility-level care but wants to keep living at home, the Program of All-Inclusive Care for the Elderly (PACE) can make that possible. It is a fully integrated Medicare and Medicaid managed-care program for adults age 55 and older who meet a state's nursing-facility level of care but can live safely in the community at enrollment. In Tennessee, there is exactly one PACE program: Ascension Living Alexian PACE in Chattanooga (Hamilton County). This guide walks through every federal regulation that controls PACE under 42 CFR Part 460, every TennCare-specific rule, the financial mechanics for each enrollment path, the Interdisciplinary Team's required disciplines, and the elder-law planning issues every Tennessee family should understand before enrolling.

The short version

The Program of All-Inclusive Care for the Elderly (PACE) is a fully integrated Medicare and Medicaid managed-care program for adults age 55 and older who meet a state's nursing-facility (NF) level of care but can live safely in the community at enrollment. PACE takes on total financial risk for every service a participant needs (primary and specialty care, hospital, nursing facility, drugs, transportation, day-center attendance, in-home aides, dental, vision, hearing, behavioral health, and end-of-life care) in exchange for one monthly capitated payment from Medicare, Medicaid, or both. The key-fact box above captures who runs it in Tennessee, who pays, and how the lock-in works.

Two points matter most for a Tennessee family weighing PACE:

1. Location decides eligibility. PACE in Tennessee currently operates only in Hamilton County, so families outside that footprint should pursue TennCare CHOICES, not PACE. Eligibility otherwise follows the federal floor (age 55+; TN NF level of care under Tenn. Comp. R. & Regs. 1200-13-01-.10; residence in the service area) and TennCare CHOICES Group 1 institutional-Medicaid finances, a 2026 income cap of $2,982/month with a $2,000 individual / $3,000 couple asset limit, 60-month look-back, and full spousal impoverishment protections.2
2. PACE is a contract, not an add-on benefit. Joining PACE means transferring medical decision-making to the Interdisciplinary Team (IDT) and giving up an existing primary care doctor unless that doctor is in the PACE network. In exchange, PACE assumes responsibility for every aspect of the participant's care. Families who understand this trade-off before enrolling tend to stay; families who do not often disenroll within the first year.

Statewide expansion was proposed in 2024 (SB 459 / HB 416) but did not become a standalone public chapter; industry analysts report a 2025 TennCare PACE RFP for one new market, and as of May 2026 no second TN PACE site is operational.

What the Tennessee PACE Program Is: Federal Foundation

The statutory architecture

PACE is built on two parallel federal authorities, one Medicare, one Medicaid, that converge in a single capitated managed-care program:

• 42 USC § 1395eee (Social Security Act § 1894) authorizes Medicare to pay PACE organizations a Medicare capitation rate.
• 42 USC § 1396u-4 (Social Security Act § 1934) authorizes states to elect PACE as a Medicaid State Plan benefit.
• The Balanced Budget Act of 1997, P.L. 105-33, §§ 4801–4804, made PACE a permanent provider type in both programs after a decade as a demonstration project (Medicare PACE demonstrations began in 1986 with the On Lok Senior Health Services program in San Francisco).

The operating regulations live at 42 CFR Part 460 (Subparts A–K), with key provisions including:

• § 460.30–460.34, Program agreement and contracting with CMS and the state.
• § 460.92, 460.94, 460.96, Required services.
• § 460.102, Interdisciplinary team requirements (the eleven disciplines below).
• § 460.120, 460.122, 460.124, Grievances, internal appeals, and external appeal rights.
• § 460.150, Eligibility to enroll in a PACE program.
• § 460.158, Effective date of enrollment (first day of the month following the signed enrollment agreement).
• § 460.162, Voluntary disenrollment; § 460.164, Involuntary disenrollment.
• § 460.182, Medicaid payment, and § 460.186, PACE premiums.
• § 460.184, Post-eligibility treatment of income.1

CMS guidance is in the CMS PACE Manual (Pub. 100-11), Chapters 1–17. Chapter 4 covers enrollment and disenrollment; Chapter 8 covers IDT and care planning; Chapter 11 covers participant rights; Chapter 17 covers complaints.

The most recent significant federal change is the PACE final rule published April 23, 2024 at 89 Fed. Reg. 30448, with major provisions effective January 1, 2025. The 2024 rule:

• Imposed a Past Performance review on PACE applicants (new §§ 460.18–460.19).
• Required each PACE organization to contract with at least 26 medical specialties (cardiology, oncology, neurology, psychiatry, ophthalmology, podiatry, nephrology, pulmonology, etc.).
• Allowed electronic delivery of certain participant communications (amended § 460.200).
• Expanded CMS and state sanction authority under §§ 460.42 and 460.46, civil money penalties and enrollment/payment suspensions can now be imposed without first establishing predicate circumstances when the underlying compliance issue could lead to PACE program agreement termination.

Tennessee's PACE authorizing structure

Tennessee operates PACE under its Medicaid State Plan, Attachment 3.1-A, item #26 (per the Center for Health Care Strategies' analysis of TN's contract documents) and NOT as a service under the TennCare III §1115 demonstration. This is an important architectural distinction: most of TennCare's managed-care system runs under §1115 demonstration authority (currently TennCare III, January 8, 2021 – December 31, 2030, with an aggregate payment cap), but PACE is a separately-authorized State Plan benefit under SSA § 1934.

TennCare contracts directly with the PACE organization (currently only Alexian PACE) under a tri-party PACE Program Agreement among CMS, the State of Tennessee, and the PACE organization, as required by 42 CFR §§ 460.30–460.34.

There is no standalone Tennessee Code Annotated chapter on PACE. The state's authority comes from TennCare's general LTSS authorities at TCA Title 71, Chapter 5, plus TennCare regulations.

The principal Tennessee regulation is Tenn. Comp. R. & Regs. 1200-13-01-.10, titled "Medical (Level of Care) Eligibility Criteria for TennCare Reimbursement of Care in Nursing Facilities, CHOICES HCBS and PACE." This rule applies the same NF level-of-care test to PACE that it applies to nursing-home and CHOICES Group 1 admissions. Tenn. Comp. R. & Regs. 1200-13-01-.05 governs the TennCare CHOICES program more broadly. Together these two rules describe Tennessee's institutional-LTSS-and-PACE system.

Tennessee PACE Program Eligibility: The Four Federal Requirements Plus Tennessee's Tests

To enroll in PACE in Tennessee, an applicant must satisfy four federal eligibility requirements (42 CFR § 460.150) and Tennessee's level-of-care and financial tests.

Requirement 1: Age 55 or older

PACE is a senior program. Disability status alone is not enough, even an adult under 55 with significant LTSS needs cannot enroll in PACE. (Younger adults with disabilities should consider ECF CHOICES for I/DD or Katie Beckett if applicable.)

Requirement 2: Tennessee NF level of care

This is the clinical gatekeeper. Tennessee uses an Acuity Scale scored on the TennCare Pre-Admission Evaluation (PAE) form. To meet NF level of care for PACE (and for nursing facility / CHOICES Group 1):

• The applicant must require daily inpatient nursing care, AND
• The applicant must score 9 or more points on the TennCare NF Level-of-Care Acuity Scale.

The Acuity Scale measures:

• ADL dependence, bathing, dressing, transferring, toileting, continence, eating. Each ADL deficit is worth points based on severity.
• Skilled or rehabilitative service need, tube feeding, wound care, IV therapy, ventilator dependence, daily skilled rehab from licensed therapists.
• Behavioral and cognitive need, dementia severity, behavioral symptoms, supervision needs.
• Medical complexity, multiple chronic conditions requiring active management, recent hospitalization, instability.

A physician or qualified advanced practitioner certifies the PAE. PAE approval is valid for 90 days, if enrollment is not complete within that window, the PAE must be re-certified. PASRR (Preadmission Screening and Resident Review) is also required for any applicant transitioning from a hospital stay or with a major mental illness or intellectual disability diagnosis.

CHOICES Group 2 (HCBS) uses an alternative pathway with lower acuity (the "at-risk" determination), but PACE follows the same higher 9-point standard as nursing facility and CHOICES Group 1. This means some seniors who qualify for CHOICES Group 2 HCBS will not qualify for PACE.

Requirement 3: Reside in the PACE service area

The PACE organization's service area is defined in its CMS-state-PACE program agreement and is geographic, typically defined by ZIP codes within counties. Alexian PACE serves Hamilton County, Tennessee, only. A senior who lives in Bradley County, Marion County, Rhea County, or Hamilton County's surrounding areas outside the approved service-area ZIP codes is not eligible for Alexian PACE.

This is the single biggest constraint on PACE enrollment in Tennessee: the vast majority of TN's senior population lives outside Alexian PACE's service area and therefore has no PACE option whatsoever. Statewide expansion has been politically active (see 2024 SB 459 below) but no second site is operational as of May 2026.

Requirement 4: Able to live safely in the community at enrollment

PACE is a community-based program. The participant must be able to live safely in the community with PACE services at the time of enrollment. A participant currently residing in a nursing facility can transition to PACE if PACE assesses that, with PACE supports (day center, in-home aide, transportation, primary care), the participant could move to a community setting safely. PACE then becomes the participant's medical and LTSS coverage going forward, including coverage if the participant later needs nursing facility placement.

Tennessee financial eligibility

Because PACE participants are receiving Medicaid LTSS, the financial test is the TennCare CHOICES Group 1 / institutional Medicaid test. For 2026:2,3,4

Source for the 2026 income cap: The 2026 SSI Federal Benefit Rate is $994/month for an individual ($1,491 for a couple), reflecting the 2.8% Social Security COLA effective for January 2026 (increased SSI payments began December 31, 2025). 300% × $994 = $2,982/month, Tennessee's institutional Medicaid / PACE income cap for calendar year 2026.5,2

If income exceeds the cap, the applicant must establish a Qualified Income Trust (QIT, also called a Miller Trust) under 42 USC § 1396p(d)(4)(B). PACE financial eligibility uses QITs the same way CHOICES Group 1 does.6

The three enrollment paths

What "no cost-sharing" does and does not mean. For a participant eligible for Medicaid, a PACE organization may not charge a premium (42 CFR § 460.186(d)) and must accept the capitation payment as payment in full, with two carve-outs written into the rule itself: any applicable Medicaid spend-down liability, and any amount due under the post-eligibility treatment of income process at 42 CFR § 460.184.1 Tennessee is an income-cap state that runs exactly that post-eligibility calculation: TennCare counts the participant's income, deducts the personal needs allowance, any trust-expense allowance, spousal allocation, health-insurance premiums and Item D amounts, and the remainder is the participant's monthly financial liability.6 So a TennCare PACE participant with meaningful monthly income should expect a patient-liability figure, not a flat $0. Ask Alexian PACE and your TennCare eligibility counselor for your specific number in writing before you enroll.

Cross-payer mechanics for dual-eligibles (the typical TN PACE participant): CMS pays the PACE organization the Medicare Advantage-equivalent rate adjusted by the PACE frailty adjuster (which boosts the rate to reflect that PACE participants are sicker than the average MA member). TennCare pays the PACE Medicaid capitation rate under the CMS PACE Medicaid Capitation Rate Setting Guide effective 1/1/2025. Together these two payments fund the participant's care; the participant pays nothing.

Why Medicare-only PACE is uncommon in Tennessee: The Medicaid-equivalent capitation portion runs to several thousand dollars per month at national averages, which makes PACE prohibitively expensive for a Medicare-only senior. On top of that capitation, a Medicare-only participant pays the PACE organization's Part D premium. The national benchmark that premium is set against is the 2026 Medicare Part D national base beneficiary premium of $38.99/month; the amount Alexian PACE actually charges is set by its own Part D bid, so ask the program for its current figure rather than assuming the national number.7 The Federal PACE for Veterans pilot (run by the VA in partnership with CMS and NPA) offers a workaround for Medicare-only veterans by having the VA pay the Medicaid-equivalent share, but as of May 2026 it is not publicly confirmed whether Alexian PACE participates in this pilot. Veterans considering PACE should ask Alexian PACE directly and consult a TN VA-accredited claims agent.

The Only PACE Site in Tennessee: Ascension Living Alexian PACE

Site profile

Alexian PACE was founded as Alexian Brothers PACE by the Alexian Brothers Health System (a Catholic religious health-care order). The Alexian Brothers Health System merged into Ascension in 2012, and the program was rebranded as Ascension Living Alexian PACE. It remains the only PACE site that has ever operated in Tennessee.8

Sites that DO NOT exist (debunking common misinformation)

It is common for online directories, generative-AI assistants, and stale state agency webpages to list PACE sites in Tennessee that are not real. As of May 2026:

• No PACE in Knoxville / Knox County. Past internet references to "PACE of Tennessee" or "Adult Care Services PACE" in Knoxville do not correspond to an operational PACE site; CMS does not list one.
• No PACE in Nashville / Davidson County. Despite Nashville being TN's largest senior population center, no PACE site operates there.
• No PACE in Memphis / Shelby County. "Memphis PACE" does not exist.
• No PACE in Tri-Cities (Kingsport / Johnson City / Bristol).
• No PACE in Jackson / West TN.
• "Tennessee Volunteer PACE" does not appear in any CMS or NPA program directory.

The National PACE Association (NPA) maintains an authoritative directory at npaonline.org. As of 2026 there are 202 PACE programs operating in 33 states and the District of Columbia, and 17 states have no PACE program at all.9 None of the recent openings has been in Tennessee, which still has its single Chattanooga site.

2024 statewide expansion: SB 459 / HB 416

The 2024 push for TN PACE expansion was real and well-supported but did not result in a standalone public chapter:

• SB 459 / HB 416 (113th General Assembly, 2023–24): Sponsors Sen. Bo Watson (R-Hixson) and Rep. Hemmer with co-sponsors Clemmons, Vital, Hakeem, Martin, Helton-Haynes.
• Purpose: Direct TennCare to establish a statewide PACE program, beginning with expansion into Meigs, Rhea, and Bradley counties (adjoining Hamilton).
• Bill enrollment ramp targets: 2,000 by 1/1/2024; 3,000 by 1/1/2025; 5,000 by 1/1/2026, aspirational and not met.
• Disposition: SB 459 received a 9–0 favorable vote from Senate Health & Welfare on 4/3/2024 and was placed on Senate Finance, Ways and Means Committee calendar for 4/23/2024. The House version (HB 416) was taken off notice in the House Finance, Ways and Means Subcommittee on 4/17/2024. The substantive expansion language did not become a standalone public chapter in the 113th General Assembly.
• However, State of Reform reporting and industry analyst tracking (Health Dimensions Group's "PACE Growth 2025 Year in Review") indicate Tennessee issued a 2025 PACE RFP for one new market with a modest annual state-share appropriation plus federal match. The award status as of May 2026 is not publicly confirmed by TennCare.
• No second TN PACE site is operational as of May 2026.

Families considering relocation to access PACE should call TennCare LTSS Help Desk at 1-877-224-0219 to confirm current site status before making any geographic decision.

What does PACE cover?

The PACE benefit is unusually broad. Under 42 CFR §§ 460.92, 460.94, and 460.96, PACE must cover all Medicare- and Medicaid-covered services PLUS any additional services the IDT determines the participant needs.

Medical and clinical services

• Primary care by the PACE clinic's internal team
• Specialty care, at minimum 26 contracted medical specialties as of the April 2024 final rule (cardiology, oncology, neurology, psychiatry, ophthalmology, podiatry, nephrology, pulmonology, gastroenterology, endocrinology, urology, dermatology, orthopedics, ENT, etc.)
• Hospital inpatient and outpatient, full Medicare Part A coverage
• Skilled nursing facility care if needed (PACE pays the nursing home directly)
• Emergency and urgent care 24/7
• Prescription drugs, Medicare Part D fully embedded; the PACE organization is itself the participant's Part D plan
• Laboratory, radiology, diagnostic imaging
• Behavioral health and mental health services, outpatient counseling, psychiatric medication management, substance use disorder treatment
• Dental, vision, audiology, podiatry, more comprehensive than standard Medicare/Medicaid (Medicare has very limited dental/vision coverage; PACE typically covers cleanings, dentures, glasses, and hearing aids)
• Durable medical equipment, prosthetics, orthotics

Long-term services and supports

• Adult day health center attendance at the PACE day center, frequency determined by the IDT, anywhere from once a week to five days a week
• Personal care / home health aide services in the home
• Skilled nursing in the home (visiting RN or LPN)
• Therapies, physical, occupational, speech, recreational
• Meals at the day center; sometimes home-delivered
• Nutritional counseling with a registered dietitian

Wraparound and social services

• Transportation to and from the PACE day center, all PACE-authorized appointments, the participant's home, and family events as appropriate
• Caregiver respite, built into the day-center model (caregiver gets respite while participant is at the center)
• Social work and care coordination, assigned PACE social worker
• Spiritual care, chaplaincy services
• End-of-life and palliative care, PACE provides comprehensive palliative care without requiring transition to Medicare hospice

The PACE Interdisciplinary Team, Eleven Required Disciplines

Under 42 CFR § 460.102(b), every PACE organization must maintain an Interdisciplinary Team (IDT) for every participant. The IDT is the heart of the PACE model, it is the body that assesses the participant, develops and updates the care plan, authorizes services, and serves as the single decision-making forum for the participant's medical and LTSS care.

The IDT must include the following eleven disciplines:

1. Primary care provider, physician, nurse practitioner, or physician assistant
2. Registered nurse
3. Master's-level social worker (MSW)
4. Physical therapist
5. Occupational therapist
6. Recreational therapist or activity coordinator
7. Dietitian (registered)
8. PACE center manager
9. Home care coordinator
10. Personal care attendant or his/her representative
11. Driver or his/her representative

A single individual may fill two roles if appropriately licensed and qualified for both.

The IDT meets to develop and revise each participant's care plan. Comprehensive assessments are required at: (a) enrollment, (b) at least every 6 months thereafter, and (c) on any significant change in the participant's condition. The April 2024 final rule reaffirmed the IDT structure and added requirements around competence, training, and documentation of IDT participation.

Family members and authorized representatives have the right to participate in IDT meetings under 42 CFR § 460.106(a)(2). Brevy strongly recommends that the family caregiver or an authorized representative attend every IDT meeting, these meetings are where care decisions actually get made.

What does PACE cost, and who pays for it?

PACE is paid on a per-member-per-month (PMPM) capitation from up to four payers stacked together for a single participant:

1. Medicare Parts A & B capitation, CMS pays the PACE organization the Medicare Advantage-equivalent rate adjusted by the PACE frailty adjuster. The frailty adjuster boosts the rate to reflect that PACE enrollees are sicker than the average MA member. The 2026 frailty-adjusted rate varies by PACE organization based on its participant population's risk profile.
2. Medicare Part D capitation, the PACE organization operates an enrollment-restricted Part D plan. The CY 2026 Part D redesign applies, and the 2026 Medicare Part D national base beneficiary premium is $38.99/month, the benchmark plan premiums are measured against. A Medicare-only PACE participant pays the PACE organization's own Part D premium; dual-eligibles pay no Part D premium or cost-sharing, because full Extra Help / LIS covers it.7
3. Medicaid (TennCare) LTSS capitation, TennCare pays the PACE Medicaid PMPM under the CMS PACE Medicaid Capitation Rate Setting Guide effective 1/1/2025. The TN-specific 2026 PMPM is set in the TennCare-Alexian PACE Program Agreement and is not routinely public.
4. Other payers as applicable, private pay, VA (under the Federal PACE for Veterans pilot in participating sites), and any third-party coverage.

The capitated model is the PACE program's central policy bet: by giving PACE organizations a fixed monthly payment for total responsibility for a participant's care, PACE creates a strong incentive to prevent costly admissions (ER visits, hospital stays, NF placement) through proactive primary care, day-center attendance, and comprehensive home support. National PACE outcomes data show that PACE participants have lower rates of preventable hospitalization, lower rates of NF placement, and longer life expectancy than comparable seniors in fee-for-service Medicare/Medicaid.

The trade-off is lock-in, see next section.

Lock-In: The Most-Misunderstood Feature of PACE

A PACE participant may receive only those services authorized by the PACE Interdisciplinary Team. Use of any non-PACE provider, even one's prior primary care doctor, without IDT pre-authorization is at the participant's expense and is NOT covered by Medicare or Medicaid. Confirm the exact terms in your signed PACE enrollment agreement, which is where the organization spells out its own authorization rules.

This is because Medicare and Medicaid have already paid the PACE organization the full capitation; they will not pay again for services rendered by a non-PACE provider to a PACE participant.

What this means in practice

• Your primary care doctor changes. Joining PACE means transferring primary care to the PACE clinic's internal medical team. If your existing PCP is not in the PACE network (and Alexian PACE generally uses internal PACE clinic providers), you cannot continue with that PCP.
• Specialist visits require IDT authorization. Non-emergency specialty care must be pre-authorized by the IDT and provided by a PACE-contracted specialist. The April 2024 final rule requires PACE orgs to contract with at least 26 specialties, but the participant's choice within those specialties is the PACE organization's network.
• Hospital admissions: PACE pays for hospital stays. PACE participants are not restricted to specific hospitals for emergencies, but routine elective hospital procedures must be authorized by the IDT.
• No use of non-PACE-contracted providers. A participant who insists on continuing to see a non-PACE specialist either pays out-of-pocket or disenrolls from PACE.
• Emergencies are covered out-of-network without prior IDT authorization. The participant or family must notify the PACE organization as soon as possible after an emergency.

Why lock-in is the #1 reason for disenrollment

Family members frequently want to retain longstanding doctor relationships ("Mom has been seeing Dr. Smith for 20 years; we're not going to change"). Families that join PACE without understanding lock-in often discover the constraint within 1–3 months and disenroll. Families that understand it going in, and explicitly choose comprehensive coordinated care over continuity with a specific PCP, typically remain enrolled and have favorable outcomes.

The PACE enrollment counselor will discuss lock-in during the intake process, but Brevy strongly recommends asking explicit questions:

1. "Will my current primary care doctor continue to see me, or do I have to switch to the PACE clinic?"
2. "If I want to see [specific specialist], is that doctor in the PACE network?"
3. "What happens if I want a second opinion?"
4. "What if I want to use a non-PACE pharmacy?"

How do you enroll, disenroll, or switch?

Enrollment process

The full process typically takes 4 to 8 weeks. Families can reduce processing time by gathering financial documentation (Social Security and pension award letters, bank statements going back 5 years for the look-back review, deeds, vehicle titles, life insurance policies, and burial trust documents) before contacting Alexian PACE.

Voluntary disenrollment (42 CFR § 460.162)

A PACE participant may voluntarily disenroll from the program without cause at any time, under 42 CFR § 460.162(b).1 Disenrollment is effective the first day of the next calendar month. The participant must complete a written disenrollment form provided by Alexian PACE.

The participant retains all Medicare and Medicaid eligibility upon disenrollment, they simply transition back to fee-for-service Medicare (or to a Medicare Advantage plan of their choosing) and to TennCare's standard managed care for their Medicaid services. If the participant wants to enroll in CHOICES after disenrolling from PACE, they must contact the TennCare LTSS Help Desk (1-877-224-0219) to request CHOICES enrollment; the PAE typically remains valid if within 90 days.

Involuntary disenrollment (42 CFR § 460.164)

Involuntary disenrollment is permitted only for the reasons listed at 42 CFR § 460.164(b), and the State administering agency must review it and find that the PACE organization has adequately documented acceptable grounds before it takes effect (§ 460.164(f)).1 Those narrow reasons include:

• Failure to pay required premiums (relevant to Medicare-only and private-pay participants)
• Engaging in disruptive or threatening behavior such that the participant's continued enrollment seriously impairs the PACE org's ability to furnish services to that participant or others
• Moving out of the service area (out of Hamilton County for Alexian PACE)
• No longer meeting NF level of care AND state determination that participant is not eligible for "deeming continued LOC" protection (which allows PACE to retain participants whose acuity has improved due to PACE care)

Involuntary disenrollment requires state review and a documented appeal process. Retroactive disenrollment is generally not permitted; PACE organizations may not retroactively disenroll except in rare administrative-error cases approved by CMS.

Switching between CHOICES and PACE

A TennCare member cannot be enrolled in CHOICES and PACE simultaneously. Joining one effectively disenrolls the other.

• CHOICES → PACE: Member contacts Alexian PACE, undergoes IDT assessment and PAE recertification (current PAE typically transferable if within validity period), signs PACE enrollment agreement; effective 1st of next month; CHOICES MCO is automatically notified and disenrolls the member from CHOICES. There should be no coverage gap.
• PACE → CHOICES: Participant submits voluntary disenrollment to PACE; effective 1st of next month; participant must re-enroll in TennCare standard managed care and request CHOICES enrollment through the LTSS Help Desk (1-877-224-0219); PAE remains valid if within 90 days.

PACE vs. CHOICES, The Decision Tree

For a Tennessee senior who meets NF level of care, the practical question is: PACE or CHOICES? Geography forces the answer for the vast majority of TN seniors (because Alexian PACE covers only Hamilton County), but for Hamilton County families the choice is real and consequential.

When PACE wins

• Multiple chronic conditions requiring frequent medical management (diabetes + CHF + COPD with multiple comorbidities). PACE's IDT-coordinated primary care reduces the participant's burden of managing many specialists.
• Early-to-moderate dementia with caregiver burden. PACE day center attendance gives the family caregiver 8+ hours/day of supervised care and respite, and the day-center setting is built for cognitive and behavioral support.
• Frequent ER use or hospital readmissions. PACE's 24/7 IDT access and proactive primary care reduce preventable admissions.
• Highly coordinated care across many specialties. PACE provides a single point of accountability; CHOICES fragments care across the participant's PCP, the MCO's care coordinator, and various specialists.
• Hamilton County resident.
• Dual-eligible. No premium and no PACE cost-sharing across all PACE-authorized services is decisive for a dual-eligible (a TennCare post-eligibility share of cost can still apply, as it would under CHOICES).

When CHOICES wins

• Geographic. Outside Hamilton County, CHOICES is the only option.
• Strong preference for existing PCP. PACE's lock-in means transferring to the PACE clinic. Families that value continuity with a specific doctor should choose CHOICES.
• Family caregiver wants Consumer Direction. TennCare CHOICES allows family caregivers to be paid through Consumer-Directed Services or through the Public Authority model. PACE does not allow family-caregiver paid roles (PACE delivers all personal care through PACE-employed or PACE-contracted aides). Tennessee's 2025 paid-family-caregiver expansion under the Freedom for Family Caregiving Act (Public Chapter 182, 2025) runs through CHOICES, not PACE, see TN family caregiver guide.
• Specific specialist or facility outside the PACE network. A participant who needs a specific specialist not in Alexian PACE's network and is unwilling to accept the IDT process should choose CHOICES.
• Preference for assisted living over day-center model. CHOICES Group 1 will pay for nursing-facility placement; PACE keeps the participant in the community by design (though it pays for NF placement when needed).
• Existing Medicare Advantage plan the participant values. Joining PACE disenrolls the participant from any other MA plan.

A common mistake: joining PACE for the day center alone

Some families enroll in PACE primarily because of the adult day center (which provides social engagement, meals, and supervision). PACE day centers are excellent, but the trade-off is total medical lock-in. If a family wants only adult day care, TennCare CHOICES Group 2 may cover Adult Day Health Center as an HCBS service (within the annual cap) without requiring lock-in to a single medical provider. Discuss this with a CHOICES MCO Care Coordinator before enrolling in PACE for day-center reasons alone.

Three Worked Examples

Example 1: Mr. and Mrs. Brown, Chattanooga (Hamilton County), Where PACE shines

Mr. Brown is 76. He has Type 2 diabetes (insulin-dependent), congestive heart failure (NYHA Class II), early Alzheimer's (MoCA 18/30), and ADL dependence in bathing, dressing, and toileting. Mrs. Brown is 74 and his primary caregiver, but she has osteoarthritis and chronic back pain. They live in their Chattanooga home of 35 years. The figures in this example apply Tennessee's 2026 institutional-Medicaid income and asset limits.2,3

Income: Mr. Brown $2,200/month Social Security + $400 pension = $2,600/month. Mrs. Brown $1,800/month Social Security. Combined $4,400/month. Assets: Combined countable $80,000 (savings and a CD). Home (exempt). One car (exempt). Recent ER visits: three in the past six months.2

Eligibility analysis: (figures below apply Tennessee's 2026 institutional-Medicaid limits)2,3

• NF LOC: Mr. Brown has insulin-dependent diabetes + CHF + Alzheimer's + ADL dependence in 3 domains, likely scores 11–13 on the Acuity Scale. Meets NF LOC.
• Service area: Hamilton County resident. Eligible for Alexian PACE.
• Income: $2,600/month is below the $2,982 cap. No QIT needed.
• Assets: $80,000 combined exceeds the $2,000 individual cap. Spousal impoverishment analysis: Mrs. Brown as community spouse keeps half ($40,000) up to the maximum $162,660, so she keeps the full $40,000. Mr. Brown's own $40,000 share exceeds his $2,000 cap, so he must spend down or restructure the excess before eligibility.
• MMMNA: Mrs. Brown's $1,800 income is $905.00/month below the $2,705.00 floor, so Mr. Brown's PACE post-eligibility income treatment allows a spousal diversion of at least that shortfall before any patient-liability amount is set. (Her allowance can be higher if her housing and utility costs support an excess shelter allowance; TennCare computes the exact figure.)3

Recommended path: Spend down Mr. Brown's excess countable assets (pay off any debts, prepay funeral, home repairs, replace worn car if applicable). Apply for PACE through Alexian. Mr. Brown enrolls; Mrs. Brown remains in the community as community spouse. PACE covers Mr. Brown's primary care, specialty care (cardiology, neurology), Alzheimer's care, day center attendance four days a week, in-home aide assistance with bathing on non-day-center days, all medications, transportation, and emergency hospital coverage. Mrs. Brown gets respite while Mr. Brown is at the day center; her own income is protected under MMMNA.

Why PACE over CHOICES here: Mr. Brown's medical complexity + recent ER visits + Mrs. Brown's caregiver burden are exactly what PACE is designed for. The IDT coordinates his diabetes, CHF, and Alzheimer's care; the day center provides Mrs. Brown 4 days/week respite; preventable ER visits drop because PACE primary care is proactive.

Example 2: Mrs. Garcia, Memphis (Shelby County), Where geography forces the answer

Mrs. Garcia is 72. She has the same medical profile as Mr. Brown, Type 2 diabetes, CHF, early Alzheimer's, ADL dependence. She lives alone in Memphis.

PACE eligible? Mrs. Garcia meets NF LOC and the financial test, BUT she lives in Shelby County, not Hamilton County, so she is geographically ineligible for Alexian PACE, the only PACE site in Tennessee.

Recommended path: TennCare CHOICES, likely Group 2 (HCBS at-risk demonstration) or Group 1 (NF-level entitlement) depending on safety and slot availability. Memphis is served by Amerigroup Tennessee, BlueCare Tennessee, and UnitedHealthcare Community Plan as TennCare CHOICES MCOs. The CHOICES Adult Day Health Center benefit can provide some of what PACE day centers do (within the annual cap of 216 hours/year for in-home respite or higher for ADHC services). Family members can be paid through Consumer Direction for some personal care.

Example 3: Mr. Holt, Cleveland TN (Bradley County), On the edge of expansion

Mr. Holt is 68. He has end-stage COPD on home oxygen, Type 2 diabetes, and recent stroke with left-side weakness. He lives in Cleveland (Bradley County), 30 miles from Chattanooga.

PACE eligible? No, Bradley County is not in Alexian PACE's approved service area. It is one of the counties named in the 2024 SB 459 expansion bill (along with Meigs and Rhea), but the bill did not pass as a standalone public chapter and no second TN PACE site is operational as of May 2026.

Recommended path: TennCare CHOICES (likely Group 1 NF or Group 2 HCBS at-risk). Mr. Holt could relocate to Hamilton County to access PACE, but that requires uprooting his life and family and is rarely worth it. If TennCare's 2025 PACE RFP results in a Bradley County site coming online in 2026 or 2027, Mr. Holt would become eligible at that point. Brevy will update this guide when any second TN PACE site is confirmed.

How do you appeal a denial or file a grievance?

Internal PACE appeals (42 CFR § 460.122)

A PACE appeal is a participant's challenge to a service-coverage or service-payment denial, reduction, or termination. The PACE organization must:

• Have written procedures for accepting both oral and written appeals
• Have the appeal reviewed by an impartial third party appropriately credentialed in the relevant discipline
• Resolve the appeal no later than 30 calendar days after receipt (standard timeline)
• Use an expedited timeline, as expeditiously as the participant's health condition requires (typically 72 hours), when delay would seriously jeopardize life or health
• Provide written notice of any adverse decision describing external appeal rights under § 460.124

The participant has the right to receive disputed services pending the appeal if requested timely.

Grievances (42 CFR § 460.120)

A grievance is a complaint about service quality or delivery, it is NOT a coverage denial. Examples: rude staff, dirty day center, late transportation, lost prescription. PACE organizations must have a grievance process and respond timely.

External appeal rights (42 CFR § 460.124)

After an adverse PACE-internal appeal decision, the participant may pursue:

• Medicare Independent Review Entity (IRE), for Medicare-covered services. Request must be filed in writing within 60 days of the PACE third-party reviewer's decision. The IRE is an independent CMS contractor that reviews Medicare PACE appeals.
• Medicaid State Fair Hearing (TennCare), for Medicaid-covered services. TennCare State Fair Hearings are governed by Tenn. Comp. R. & Regs. Chapter 1200-13-19. The participant has the right to receive disputed services pending resolution if requested timely.

The PACE organization must assist the participant in choosing the right forum and forward the appeal as appropriate. For mixed Medicare/Medicaid services, the participant may pursue both forums.

TN-specific complaint pathways

• TennCare Solutions: 1-800-878-3192 (TTY 1-800-772-7647), TennCare's member advocacy and complaint line
• TennCare LTSS Help Desk: 1-877-224-0219, specific to long-term services and PACE
• Tennessee Long-Term Care Ombudsman (Tennessee Commission on Aging and Disability): assists participants in residential and HCBS settings, including PACE day-center concerns
• CMS PACE Manual Chapter 17, federal complaint guidance

Elder-Law Planning Considerations

PACE participants are receiving Medicaid LTSS, which means three federal Medicaid planning rules apply with full force:

1. The 60-month look-back

The look-back under 42 USC § 1396p(c) applies to TN PACE financial-eligibility determinations because PACE is Medicaid LTSS. Uncompensated transfers within 60 months trigger a penalty period using TN's 2026 penalty divisor of $295.87/day.4

Practical takeaway: Do NOT advise yourself or your family that "PACE doesn't have a look-back." It does. Treat PACE eligibility planning identically to nursing facility Medicaid planning for transfer-rule purposes. See Tennessee 5-Year Lookback and Penalty Divisor: Complete 2026 Guide for the full mechanics including DRA-2005 penalty start-date rule, exempt transfers (caregiver child, sibling exception, spousal, blind/disabled child, sole-benefit trust), DRA-2005 SPIA requirements, promissory note three-prong test, life estate one-year residency rule, Modified Half-a-Loaf, personal services contracts, and undue hardship waivers.4

2. Estate recovery

Estate recovery under 42 USC § 1396p(b) and Tenn. Code Ann. § 71-5-116 reaches long-term services and supports received at age 55 or older, and PACE is Medicaid LTSS. TennCare's own published recovery conditions name the member's receipt of CHOICES Group 1, 2, or 3 services; it does not publish a separate PACE roster, so if you are planning around a PACE enrollment, ask TennCare directly how it will compute the claim against the estate. Do not assume PACE is outside estate recovery.6

Three limits apply whatever the program. TennCare does not seek recovery while the member is living. Federal law bars recovery while the member is survived by a spouse, or by a child under 21 or a child who is blind or disabled, though that is a timing bar rather than permanent forgiveness: the protection can lapse when the surviving spouse dies or the child turns 21. And recovery is treated as not cost effective for claims of $10,000 and below, where the State releases the claim; the State Plan also waives recovery for undue hardship, including where the estate property is the sole income-producing asset of survivors, such as a family farm.6 See Tennessee Medicaid Estate Recovery: Complete Guide for the full analysis.

3. Spousal impoverishment

42 USC § 1396r-5(h)(1)(A) explicitly defines an "institutionalized spouse" to include an individual receiving services under a PACE program. Therefore the Community Spouse Resource Allowance (CSRA), Minimum Monthly Maintenance Needs Allowance (MMMNA), and resource assessment protections do apply to married couples where one spouse is in PACE.

For 2026: CSRA is $32,532 minimum / $162,660 maximum; MMMNA is $2,705.00 floor / $4,066.50 ceiling; the resource assessment is conducted at the time of PACE enrollment with assets snapshotted on the first day of the first continuous period of institutionalization or PACE enrollment.3

The Income-First rule under DRA-2005 (42 USC § 1396r-5(d)(6)) applies to PACE participants the same way it applies to NF Medicaid applicants. TennCare's Single Fixed Annuity model under ABD Manual § 125.015 § 7(c)(ii) is available for fair-hearing CSRMA expansion. Hughes v. McCarthy, 734 F.3d 473 (6th Cir. 2013), is controlling 6th Circuit precedent on community-spouse SPIAs and applies equally to PACE applications.3

4. Qualified Income Trust

Tennessee is an income-cap state. If gross monthly income exceeds the 2026 cap of $2,982/month, the applicant must establish a Qualified Income Trust under 42 USC § 1396p(d)(4)(B) to qualify financially for PACE, same as for nursing-facility Medicaid or CHOICES Group 1.2,6

5. Hospice election

PACE organizations generally treat election of the Medicare hospice benefit as incompatible with continued PACE enrollment, so a participant who elects hospice is normally disenrolled. Get that confirmed by Alexian PACE in writing before electing hospice, because the consequence is losing the PACE benefit. PACE itself provides comprehensive palliative and end-of-life care without requiring disenrollment. Many PACE participants choose to remain in PACE rather than transition to Medicare hospice, they receive the same comprehensive end-of-life support from a familiar IDT.

Families with a PACE participant approaching end of life should weigh:

• Medicare hospice: Free, fully covered, but requires disenrollment from PACE and transitioning the care team to a hospice agency.
• Continuing in PACE: Continuity with the existing IDT, comprehensive end-of-life support including in-home care and pain management, but the participant's care needs must continue to fit within PACE's scope.

6. Advance care planning

Joining PACE means the IDT becomes the medical decision-making body. A durable power of attorney for healthcare designating a family agent remains valid, but the agent's ability to direct care to non-PACE providers without IDT authorization is limited because non-PACE care is uncovered.

For families considering PACE, the elder-law attorney should review:

• Existing specialist relationships and feasibility of continuity
• Family caregivers' role (PACE does not allow family-paid Consumer Direction)
• Clarity that PACE is the IDT's program, not a participant's-choice program

What do families most often get wrong about PACE?

A handful of misconceptions cause the most trouble, each one distinct from the points covered in the sections above:

1. "PACE is just adult day care." False. PACE is fully integrated comprehensive medical and LTSS coverage; the day center is one component of a much broader program.

2. "Once you join PACE you can't leave." False. A participant may voluntarily disenroll without cause at any time under 42 CFR § 460.162(b), effective the first of the next month.1

3. "PACE is a nursing home." False. PACE is a community-based program; participants must live in the community at enrollment. PACE pays for nursing-facility care if and when needed, but the program's purpose is to keep participants out of NF placement.

4. "PACE participants can't use Medicare hospice." Technically true but misleading. Electing Medicare hospice normally means leaving PACE. However, PACE itself provides comprehensive end-of-life and palliative care without requiring disenrollment, and most PACE participants who reach end of life choose to remain in PACE.

5. "Joining PACE triggers a transfer-of-asset penalty independently." False with nuance. PACE itself is not a "long-term care institution" that triggers 42 USC § 1396p(c) transfer penalties the way nursing-facility admission does. But the underlying TennCare LTSS financial-eligibility determination does include the 60-month look-back and does impose transfer penalties for uncompensated transfers, because PACE participants are receiving Medicaid LTSS. Treat PACE financial eligibility the same as nursing-facility Medicaid eligibility for look-back purposes.

6. "PACE protects assets from estate recovery." False. Estate recovery under 42 USC § 1396p(b) and Tenn. Code Ann. § 71-5-116 reaches Medicaid long-term services and supports received at age 55 or older, and PACE is Medicaid LTSS. The survivor protections (surviving spouse, child under 21, blind or disabled child) are a timing bar that can lapse, not a permanent exemption.6

Pending Policy Watch

April 2024 PACE final rule, fully effective 1/1/2025

89 Fed. Reg. 30448 (April 23, 2024). Most provisions became effective June 3, 2024; the contract-year 2025 changes (Past Performance review, 26-specialty contracting requirement, expanded sanction authority) are in effect for 2026. No major changes to PACE rules are pending at the federal level for 2027 as of May 2026.

2026 Medicare Part D changes

The Inflation Reduction Act's Part D redesign continues to apply to PACE Part D plans. The 2026 Part D out-of-pocket cap is $2,100 (national); the 2026 national base Part D premium is $38.99/month. Dual-eligibles in PACE pay nothing in Part D cost-sharing because they have full Extra Help / Low-Income Subsidy.10,7

Tennessee 2025 PACE RFP

Industry trackers (Health Dimensions Group's "PACE Growth 2025 Year in Review") report Tennessee issued a PACE RFP for one new market in 2025, funded by a modest annual state-share appropriation plus federal match. Award status as of May 2026 is not publicly confirmed by TennCare. Brevy is monitoring and will update this guide if any second TN PACE site is confirmed.

Federal PACE for Veterans pilot

The VA, in partnership with CMS and NPA, is expanding access to PACE for Medicare-only veterans without Medicaid by having the VA pay the Medicaid-equivalent share. Pilot is expanding to multiple states; whether Alexian PACE participates is not publicly confirmed. Veterans considering PACE should ask Alexian PACE directly.

National PACE growth

As of 2026, 202 PACE programs operate in 33 states and the District of Columbia. Nearly 78,000 dually eligible individuals were enrolled as of May 2026; because the monthly CMS enrollment counts exclude Medicaid-only participants, total PACE enrollment is closer to 92,000.9 PACE's growth is fastest in states with explicit expansion policies (CA, MA, PA, NY); Tennessee's growth has lagged due to the absence of a second site.

Where to Get Help in Tennessee

Legal aid:

• Tennessee Justice Center, TennCare advocacy; tncenter.org
• Legal Aid Society of Middle Tennessee and the Cumberlands, Nashville; covers 48 counties
• Legal Aid of East Tennessee, Knoxville; covers 26 counties
• West Tennessee Legal Services, Jackson; covers 17 counties
• Memphis Area Legal Services, Memphis; covers Shelby and surrounding counties

Elder-law attorneys:

• National Academy of Elder Law Attorneys (NAELA), naela.org/findlawyer; filter by Tennessee
• Tennessee Bar Association Elder Law Section, tba.org

Family caregiver resources:

• Tennessee Caregiver Resource Hub
• How to Get Paid as a Family Caregiver in Tennessee, Freedom for Family Caregiving Act (Public Chapter 182, 2025) expansion of paid family caregiving (note: paid family caregiving in TN runs through CHOICES Consumer Direction, not PACE)

When to Hire an Elder-Law Attorney

Hire an elder-law attorney for PACE planning if:

• The applicant has a community spouse and meaningful combined countable assets (spousal impoverishment planning is non-trivial; a wrong CSRA election or annuity strategy can cost the family tens of thousands of dollars)
• The applicant has made any uncompensated transfers (gifts, transfers to children, retitling) in the past 60 months, an attorney can help structure exempt transfers (caregiver child, sibling exception, sole-benefit trust) and rebut intent presumptions
• The applicant has income above the cap (QIT drafting and TennCare prior approval)
• The applicant owns real property other than the primary residence (vacation home, investment property, family farm)
• The applicant has had a recent significant medical event and is considering PACE vs. CHOICES vs. NF placement
• The family is considering PACE for a Medicare-only senior (Federal PACE for Veterans pilot eligibility analysis)

Tennessee elder-law attorney fees for PACE planning vary widely with the complexity of the case. Many attorneys offer flat-fee Medicaid planning packages that include QIT drafting, asset restructuring, spousal impoverishment analysis, and PAE submission assistance; ask for a written fee quote up front.

You probably don't need an attorney if:

• The applicant is a single person with income under the cap and countable assets already under the individual asset limit
• No transfers in the past 60 months
• Hamilton County resident
• All family members agree on the plan

Related Reading

• Tennessee Medicaid (TennCare), Complete 2026 Pillar Guide, the umbrella TennCare overview
• Tennessee Medicaid Eligibility and Income Limits, the 2026 income cap, asset rules, look-back, CSRA
• Tennessee Spousal Impoverishment Rules, full mechanics behind the CSRA + MMMNA protections that apply to PACE under 42 USC § 1396r-5(h)(1)(A)
• Tennessee 5-Year Lookback and Penalty Divisor, 60-month look-back rules; DRA-2005 penalty start-date rule; exempt transfers; Hughes v. McCarthy SPIA precedent
• Tennessee Qualified Income Trust (Miller Trust), required for PACE applicants with income above the cap
• Tennessee Medicaid Estate Recovery, who is subject, the survivor timing bar, the cost-effectiveness threshold, and hardship waivers
• Tennessee Personal Needs Allowance, the NF Personal Needs Allowance, Community PNA, and Resident Trust Fund
• Tennessee Long-Term Care Nursing Home Guide, comparison framework for NF vs. PACE vs. CHOICES Group 1
• Tennessee CHOICES Program, the alternative to PACE; Groups 1, 2, and 3
• Tennessee ECF CHOICES (I/DD), for adults with intellectual/developmental disabilities (alternative track to PACE)
• Tennessee Katie Beckett, for children with significant disabilities
• Tennessee BlueCare Plus FIDE-SNP, managed-care alternative for dual eligibles
• Tennessee How to Apply for Medicaid, application process, document checklist
• How to Get Paid as a Family Caregiver in Tennessee, paid family caregiving in TN runs through CHOICES Consumer Direction, not PACE

Learn More

Find personalized help comparing Tennessee PACE and CHOICES 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.