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).

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.1 The PACE benefit must include all Medicare-covered services, all Medicaid-covered services in the state plan, and anything else the PACE interdisciplinary team decides a participant needs to improve and maintain their health.5 The PACE organization is paid a monthly capitation amount rather than per service.2 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 TennCare Rule 1200-13-01; 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.6,7
2. PACE is a contract, not an add-on benefit. The PACE organization becomes the participant's sole service provider: outside emergencies, all care, including primary care and specialist visits, comes from the PACE organization or a provider it authorizes, so an existing doctor stays only if PACE authorizes them.3 In exchange, the Interdisciplinary Team (IDT) decides and arranges the participant's care.

TennCare's PACE page lists living in Hamilton County as an eligibility requirement and points applicants to a single program, Alexian PACE, so check that page before assuming PACE has reached another part of the state.1

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) is the Medicare authority.
• 42 USC § 1396u-4 (Social Security Act § 1934) is the Medicaid authority; Tennessee offers PACE as a Medicaid State Plan benefit.
• The Balanced Budget Act of 1997 (P.L. 105-33) added both sections to the Social Security Act.1

The operating regulations live at 42 CFR Part 460, with key provisions including:

• § 460.92, the required benefit package.5
• § 460.121 and § 460.122, service determination requests and appeals.5
• § 460.150, Eligibility to enroll in a PACE program.
• § 460.160, annual level-of-care recertification and deemed continued eligibility.8
• § 460.162, Voluntary disenrollment; § 460.164, Involuntary disenrollment.
• § 460.182, Medicaid payment, and § 460.186, PACE premiums.
• § 460.184, Post-eligibility treatment of income.2

CMS adds program guidance in its PACE Manual.3

Tennessee's PACE authorizing structure

Tennessee runs PACE as a Medicaid State Plan eligibility group. The state plan's "PACE Participants" page (SPA TN-21-0010, effective October 1, 2021) covers people who would be eligible for Medicaid under institutional rules and who take part in PACE, and requires that they be enrolled in a PACE program under a PACE program agreement and need, or would need without continued PACE services, nursing-facility level of care.1 That sets PACE apart from CHOICES, which TennCare runs under its TennCare III Section 1115 demonstration.9

TennCare's Division of Long Term Services and Supports oversees PACE together with the sponsoring PACE organization, currently Alexian PACE.10

The level-of-care rule comes from TennCare Rule 1200-13-01, which TennCare's Pre-Admission Evaluation manual names as its primary authority. That manual applies one nursing-facility level-of-care test to PACE and to CHOICES Groups 1 and 2 ("for an applicant to qualify for CHOICES Group 1, 2 or PACE, NF LOC must be approved"), while CHOICES Group 3 uses a separate "At Risk" level of care.1

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

To enroll in PACE in Tennessee, an applicant must meet the federal requirements in 42 CFR § 460.150 (age, level of care, service area, any program-specific conditions in the PACE program agreement, and the ability to live safely in the community at enrollment) plus Tennessee's financial test.2

Requirement 1: Age 55 or older

PACE starts at age 55.2 Disability status alone is not enough: 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. TennCare decides level of care through the Pre-Admission Evaluation (PAE), which registered nurses in TennCare's Division of Long Term Services and Supports review. To meet nursing-facility level of care, 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 score at least 9 on the TennCare NF Level-of-Care Acuity Scale (or meet a narrow at-risk alternative tied to a TennCare Safety Determination).10

The Acuity Scale scores two kinds of need:10

• Functional needs: help with transfer, mobility, eating and toileting, plus communication, orientation, behaviors, and taking medications. These can add up to 21 points.
• Skilled or rehabilitative needs: tube feeding, wound care, occupational or physical therapy, ventilator care, and enhanced respiratory care. These can add up to 5 points.

Every answer has to be backed by the medical evidence sent with the PAE, and a TennCare PAE nurse can approve a lower score than the one submitted. If the PAE is denied, the denial letter explains why and how to appeal, and the deadline is 30 days plus mailing time.10

PACE uses the same nursing-facility level of care as CHOICES Groups 1 and 2. CHOICES Group 3 uses a separate "At Risk" level of care, so someone approved only for At Risk care can qualify for Group 3 but not for PACE.1

Requirement 3: Reside in the PACE service area

Federal rules require the applicant to live in the PACE organization's service area, and TennCare's PACE page lists "You must live in Hamilton County" among its eligibility criteria.1 Alexian PACE serves Hamilton County, Tennessee, only. A senior in a neighboring county such as Bradley, Marion or Rhea is outside it.

This is the biggest limit on PACE in Tennessee: most of the state lies outside Hamilton County, so most Tennessee families have no PACE option and should look at TennCare CHOICES instead.

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

PACE is a community-based program. At the time of enrollment, the applicant must be able to live in a community setting without jeopardizing their health or safety.2 After that, enrollment continues regardless of later changes in health status unless the participant leaves voluntarily or is involuntarily disenrolled, and the benefit covers all Medicaid-covered services in the state plan, so PACE stays the participant's coverage even if nursing-facility care is later needed.8,5

Tennessee financial eligibility

Because PACE participants are receiving Medicaid LTSS, the financial test is the TennCare CHOICES Group 1 / institutional Medicaid test. For 2026:6,7

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 2026.11,6

Because Tennessee's PACE eligibility group covers people who would qualify under institutional rules, the same income cap applies.1 An applicant over the cap is given the chance to set up a Qualified Income Trust (QIT, also called a Miller Trust) under 42 USC § 1396p(d)(4)(B) and must do so to become income-eligible; income placed in a valid QIT is treated as unavailable.12

The three enrollment paths

What "no cost-sharing" does and does not mean. Medicare and Medicaid deductibles, copayments and coinsurance don't apply to care the PACE team approves, and a participant with Medicare but not Medicaid pays a premium for the long-term care part of PACE plus a Part D premium.13 For a participant eligible for Medicaid, a PACE organization may not charge a monthly premium (42 CFR § 460.186(d)) and must accept the Medicaid capitation amount 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 § 460.184.2 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.12 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.

Who pays PACE for a dual-eligible participant (most TN PACE participants, per TennCare): Medicare and TennCare each pay the PACE organization, and the organization must accept the Medicaid capitation amount as payment in full. The participant pays no premium, though a TennCare share of cost can still apply, as above.2,1

Why Medicare-only PACE is uncommon: A participant with Medicare but not Medicaid pays a monthly premium equal to the Medicaid capitation amount (plus a Medicare capitation amount if they have only Part A or only Part B), which is the full Medicaid share of the cost.2 Nationally, Medicare-only enrollees are under 1 percent of PACE enrollment.14 That participant also pays a premium for Medicare Part D drugs.13 For reference, the 2026 Medicare Part D national base beneficiary premium is $38.99/month; the amount Alexian PACE charges for its drug coverage is its own figure, so ask the program for it rather than assuming the national number.15

The Only PACE Site in Tennessee: Ascension Living Alexian PACE

Site profile

TennCare's PACE page directs applicants to Alexian PACE (Ascension Living Alexian PACE) at 425 Cumberland Street, Chattanooga, TN 37404, or 423-698-0802, and lists living in Hamilton County as a requirement.1

If you've seen a PACE site listed somewhere else in Tennessee

If a directory or search result shows a PACE program in Knoxville, Nashville, Memphis, the Tri-Cities or anywhere outside Chattanooga, check it against TennCare's own PACE page before you rely on it. That page names only Alexian PACE and requires Hamilton County residence, and CMS's September 2026 list of PACE state websites sends Tennessee readers to the same page.1

Nationally, the National PACE Association's September 2026 roster counts 205 PACE programs operating in 33 states and the District of Columbia, which leaves 17 states with none.14 Living in a PACE state isn't enough on its own: eligibility runs through a program's service area, which is why Tennessee, a PACE state, offers it only in Hamilton County.14

Before you move for PACE

Families thinking about relocating to Hamilton County for PACE should first confirm the current service area with Alexian PACE at 423-698-0802, the contact TennCare's PACE page lists.1 For other long-term-services questions, TennCare's LTSS Help Desk is 1-877-224-0219.16

What does PACE cover?

The PACE benefit is unusually broad. Under 42 CFR § 460.92, PACE must cover all Medicare-covered services, all Medicaid-covered services in the state plan, and any other services the IDT decides are necessary to improve and maintain the participant's overall health.5 Deductibles, copayments and coinsurance don't apply to care the team approves.13

Medical and clinical services

• Primary care by the PACE clinic's internal team
• Specialty care from specialists the PACE organization authorizes
• 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
• 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 when the IDT decides they're needed
• Durable medical equipment, prosthetics, orthotics

Long-term services and supports

• Adult day health center attendance at the PACE day center, as often as the IDT decides
• 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, and the participant's home
• 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

How the PACE Interdisciplinary Team Decides Your Care

The Interdisciplinary Team (IDT) is the heart of the PACE model. It decides which services a participant gets, and those decisions must rest on an evaluation of the participant's current medical, physical, emotional and social needs and on current clinical standards.5

Families have a direct way in. A participant, a designated representative, or a family caregiver can ask for a service, orally or in writing, to any PACE employee or contractor who gives the participant direct care. The full team must decide as fast as the participant's condition requires and no later than 3 calendar days after it receives the request, with an extension of up to 5 days allowed in some cases. Before denying a request, team members must reassess the participant in person, and a denial must come both orally and in writing, with the specific reasons and the right to appeal.5

That makes it worth having the family caregiver or a designated representative stay close to the team: a request a caregiver makes starts the same clock as one the participant makes.

What does PACE cost, and who pays for it?

PACE is paid a fixed monthly capitation per participant rather than a fee per service, and who pays depends on the participant's coverage:2

1. TennCare pays the Medicaid capitation amount for a participant with Medicaid, and the PACE organization must accept it as payment in full. That participant pays no monthly premium, though a TennCare post-eligibility share of cost can still apply.
2. Medicare pays for a participant with Medicare.
3. The participant pays a monthly premium only if they don't have Medicaid: an amount equal to the Medicaid capitation amount (plus a Medicare capitation amount if they have only Part A or only Part B), and a premium for Medicare Part D drugs if they have Medicare.13

For reference, the 2026 Medicare Part D national base beneficiary premium is $38.99/month.15 A participant pays no deductible, copayment or coinsurance for drugs the PACE team approves.13

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

Lock-In: The Most-Misunderstood Feature of PACE

A PACE participant must get all needed care, including primary care and specialist visits (other than emergency services), from the PACE organization or a provider it authorizes, and while enrolled receives Medicare and Medicaid benefits solely through the PACE organization. Seeing a provider PACE hasn't authorized, even a longtime primary care doctor, can leave the participant fully and personally liable for the bill. When enrolling, the applicant signs an enrollment agreement acknowledging that the PACE organization must be their sole service provider, so read that agreement before signing.3

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 PACE doesn't authorize your existing doctor, you can't keep using that doctor at PACE's expense.3
• Specialist visits require IDT authorization. Non-emergency specialty care must come from a specialist the PACE organization authorizes, so the participant's choice of specialist is limited to 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 the exception to the sole-provider rule.3 Tell the PACE organization about an emergency as soon as you can so it can take over follow-up care.

Settle the doctor question before you enroll

Many families want to keep a longtime doctor. If that doctor isn't one the PACE organization authorizes, joining PACE means changing doctors, so it is far better to find that out during intake than after enrollment.

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

Families can speed things up by gathering financial documents before contacting Alexian PACE: Social Security and pension award letters, bank statements covering the 60-month look-back, deeds, vehicle titles, life insurance policies, and burial trust documents.7

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), but it isn't immediate: disenrollment takes effect on the first day of the month after Alexian PACE receives the participant's notice, and PACE stays all-inclusive until then.2 Electing the Medicare hospice benefit or joining another Medicare or Medicaid plan, including a separate Medicare drug plan, also counts as leaving PACE.4

Nearly everyone in TennCare, including people who also have Medicare, gets TennCare services through one of its managed care organizations.10 A participant who leaves PACE and wants CHOICES can ask TennCare's LTSS Help Desk (1-877-224-0219) how to apply.16

Involuntary disenrollment (42 CFR § 460.164)

Involuntary disenrollment is permitted on the grounds set out at 42 CFR § 460.164(b), and the conditions attached to them matter:2

• Nonpayment of a premium, a Medicaid spend-down liability, or a post-eligibility share of cost counts only if the participant fails to pay after a 30-day grace period and doesn't make satisfactory arrangements to pay.
• Disruptive or threatening behavior requires the PACE organization to document in the medical record its reasons for proposing disenrollment and all its efforts to fix the situation.
• Noncompliant behavior tied to a condition is protected. PACE may not disenroll someone for noncompliant behavior, which includes repeatedly ignoring medical advice or missing appointments, if the behavior is related to a mental or physical condition, unless it puts the participant's or others' safety at risk. For a family member with dementia, this protection matters.

An involuntary disenrollment isn't immediate either. It takes effect on the first day of the next month that begins 30 days after PACE sends notice, and before it takes effect the State administering agency must review it and determine that the PACE organization has adequately documented acceptable grounds. The federal sections behind these rules don't themselves give the participant a personal appeal or fair-hearing right against an involuntary disenrollment, so if a notice arrives, ask Alexian PACE and TennCare in writing what review is available.2

Losing nursing-facility level of care on paper doesn't automatically end PACE. The State must recheck level of care at least once a year (it can waive the recheck permanently when no improvement is expected), and a participant who no longer meets it can be deemed still eligible until the next annual review if, without PACE, they would reasonably be expected to meet it again within 6 months.8

Switching between CHOICES and PACE

A participant can't be in PACE and another Medicare or Medicaid prepayment plan or optional benefit at the same time: joining PACE ends the other enrollment, and joining another plan after enrolling in PACE counts as leaving PACE.4

• CHOICES → PACE: Contact Alexian PACE (423-698-0802).1 PACE uses the same nursing-facility level of care as CHOICES Groups 1 and 2, so ask whether your current PAE can be used. Ask Alexian PACE and your CHOICES care coordinator to confirm the switch date in writing so there's no gap in coverage.
• PACE → CHOICES: Give Alexian PACE notice; disenrollment takes effect the first day of the month after PACE receives it.2 Then ask TennCare's LTSS Help Desk (1-877-224-0219) about CHOICES enrollment.16 CHOICES Group 1 (nursing-home care) has no enrollment target, but Group 2 home care does, so a Group 2 slot isn't guaranteed.9

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 most TN seniors (because Alexian PACE covers only Hamilton County), but for Hamilton County families the choice is real and consequential.1

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. Time at the PACE day center gives the family caregiver regular stretches of respite, and the day-center setting is built for cognitive and behavioral support.
• Frequent ER use or hospital readmissions. PACE's coordinated primary care is built to catch problems before they turn into another admission.
• 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 deductibles or copayments for team-approved care is a strong draw for a dual-eligible (a TennCare post-eligibility share of cost can still apply).13

When CHOICES wins

• Geographic. Outside Hamilton County, CHOICES is the only option.1
• 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.
• A family member wants to be the paid caregiver. In TennCare CHOICES, Consumer Direction lets the member hire family members, though not a spouse, as paid workers.10 Public Chapter 182 of 2025 also bars TennCare and its contracted provider agencies from refusing to employ a qualified family caregiver because of the family relationship, and the programs it names include CHOICES but not PACE.17 If paying a family caregiver matters, ask Alexian PACE directly before enrolling, and see the 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.
• Nursing-home care is already the plan. CHOICES Group 1 covers people receiving Medicaid-reimbursed nursing-facility care and has no enrollment target, while PACE requires that the person be able to live safely in the community at enrollment.9,2
• Existing Medicare Advantage plan the participant values. Joining PACE ends enrollment in any other Medicare Advantage plan.4

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 Groups 2 and 3 list adult day care among their home- and community-based services, up to 2,080 hours per calendar year, without moving all medical care to one provider.18 Discuss this with a CHOICES MCO Care Coordinator before enrolling in PACE for day-center reasons alone.

Three Worked Examples

These are illustrative composites, not real families. The dollar figures are hypothetical, chosen to show how the 2026 rules work.

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.6

Income: Mr. Brown $2,200/month Social Security + $400 pension = $2,600/month, which counts against Tennessee's $2,982 income cap on its own. Mrs. Brown $1,800/month Social Security. Combined $4,400/month.6 Assets: Combined countable $80,000 (savings and a CD). Home (exempt). One car (exempt). Recent ER visits: three in the past six months.

Eligibility analysis: (figures below apply Tennessee's 2026 institutional-Medicaid limits)6

• NF LOC: Mr. Brown has insulin-dependent diabetes + CHF + Alzheimer's + ADL dependence in 3 domains, so he may well reach the 9-point Acuity Scale threshold, but only TennCare's PAE review decides.10
• 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.
• Spousal income allowance: Mrs. Brown's $1,800 income is $905.00/month below the $2,705.00 standard maintenance amount, so part of Mr. Brown's income can go to her to close that gap before his share of cost is set, but only if the money is actually transferred to her. Her allowance can be higher if her housing and utility costs support an excess shelter allowance, up to the $4,066.50 federal maximum; TennCare computes the exact figure.6

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 income is protected by the spousal income allowance.

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; and PACE's primary care aims to head off avoidable ER visits.

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: Group 2 home care if a slot is open under its enrollment target, or Group 1 nursing-home care, which has no enrollment target.9 TennCare's three health plans, Wellpoint (formerly Amerigroup), BlueCare and UnitedHealthcare Community Plan, are listed for West Tennessee as for every region.10 CHOICES home care can cover some of what a PACE day center does: adult day care up to 2,080 hours a year and in-home respite up to 216 hours a year.18 Family members, though not a spouse, can be hired as paid workers through Consumer Direction.10

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. TennCare's PACE page lists Hamilton County residence as a requirement, and Bradley County is outside it.1

Recommended path: TennCare CHOICES (Group 1 nursing-home care or Group 2 home care).9 Mr. Holt could relocate to Hamilton County to access PACE, but that means uprooting his life and family and is rarely worth it. Brevy will update this guide if TennCare's PACE page adds a second program.

How do you appeal a denial or file a grievance?

Start with a service request (42 CFR § 460.121)

Most disputes begin as a request. A participant, a designated representative, or a family caregiver can ask for a service orally or in writing, and the full IDT must decide within 3 calendar days (up to 5 more in some cases). Before denying, team members must reassess the participant in person, and a denial must be given orally and in writing with the specific reasons and notice of the right to appeal under 42 CFR § 460.122.5 Keep that written denial: it is your roadmap for the appeal.

Appeals inside PACE (42 CFR § 460.122)

Follow the appeal steps in the denial notice, and ask Alexian PACE for its appeal procedure, deadlines and any outside review in writing at the same time, so a deadline doesn't pass while you wait for an answer.

Level-of-care and enrollment denials

If TennCare denies the PAE, the denial letter gives the reason, the appeal rights and a statewide list of legal aid offices, and the deadline is 30 days plus mailing time. TennCare's Division of LTSS handles PACE enrollment appeals. A technical denial, which is a submission error, can't be appealed; it is corrected and resubmitted.10

Grievances

A grievance is a complaint about service quality or delivery, not a coverage denial: late transportation, staff conduct, conditions at the day center. Raise it with Alexian PACE in writing and keep a copy.

Other Tennessee contacts

• TennCare LTSS Help Desk: 1-877-224-0219, TennCare's line for long-term services and supports questions16
• Tennessee Long-Term Care Ombudsman: 1-877-236-00137, an advocacy program (not a regulator) for residents of nursing homes, assisted-care living facilities and other long-term care facilities, run through the Tennessee Department of Disability and Aging12

Elder-Law Planning Considerations

PACE participants are receiving Medicaid LTSS, which means these 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.7

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 when a penalty starts, the exempt transfers (to a spouse, to a blind or disabled child, of the home to a caregiving child or sibling, and to certain trusts), and hardship requests.7

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.12

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.12

The State Plan also recognizes three kinds of undue hardship. The first is where the estate property is the sole income-producing asset of survivors, such as a family farm or other family business. The other two protect caregivers: a sibling who lived in the member's home for one year immediately before the member's admission, gave care that let the member stay home, and has lived there continuously since; or a son or daughter who meets the same tests over two years. The two caregiver grounds delay recovery only while that sibling or child keeps living in the home, so moving out or selling ends the protection.12 See Tennessee Medicaid Estate Recovery: Complete Guide for the full analysis.

3. Spousal impoverishment

TennCare applies the federal spousal-impoverishment rules when one spouse needs long-term services and supports, whether institutional Medicaid or home- and community-based care.6 Ask TennCare to confirm how the community-spouse protections will be applied before a married parent enrolls in PACE.

For a 2026 snapshot, the community spouse keeps one-half of the couple's combined countable resources, bounded at $32,532 minimum and $162,660 maximum. That maximum caps the one-half computation, not what a court order or a hardship ruling can protect. TennCare takes the snapshot at the first period of continuous confinement and uses the bounds for the snapshot's year, not the application year. On income, the community spouse's maintenance needs standard is $2,705.00 a month (effective July 1, 2026) plus any excess shelter allowance, up to the $4,066.50 federal maximum.6

An administrative judge can raise the protected amount when more is needed to bring the community spouse's income up to the maintenance needs standard. A community spouse who gets SSI, SNAP, QMB or similar needs-based help may decline some of the allowance if accepting it would cut those benefits, but whatever is declined counts as the other spouse's resources and must be spent down.6

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 1.6,12

5. Hospice election

Electing the Medicare hospice benefit after enrolling counts as voluntarily disenrolling from PACE, so a participant who elects hospice leaves the program.4 Talk it through with the IDT first, because the consequence is losing the PACE benefit. PACE's own benefit covers the end-of-life care the IDT decides is needed, so staying in PACE is a real option.5

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

• Medicare hospice: Means leaving PACE and moving care to a hospice agency's team.
• 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 (Consumer Direction is a CHOICES option, not a PACE one)10
• 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 day of the month after PACE receives the notice.2

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 counts as leaving PACE.4 But PACE's own benefit covers the end-of-life care the IDT decides is needed, so a participant doesn't have to leave to get it.5

5. "PACE has no look-back." False. TennCare's 60-month look-back applies to transfers before any institutional or HCBS long-term-care application, and PACE eligibility in Tennessee rests on institutional rules, so treat a PACE application like a nursing-home application for transfer purposes.7,1

6. "PACE protects assets from estate recovery." Don't assume it does. 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.12

What's Current for 2026

2026 Medicare Part D figures

Under the Inflation Reduction Act's Part D redesign, the 2026 out-of-pocket threshold on covered Part D drugs is $2,100, and spending counted toward it includes certain payments made on the enrollee's behalf, such as Extra Help.19 The 2026 national base Part D premium is $38.99/month.15 Inside PACE, a participant pays no deductible, copayment or coinsurance for drugs the PACE team approves.13

National PACE numbers

The National PACE Association's September 2026 roster counts 205 PACE programs operating in 33 states and the District of Columbia. As of May 2026, nearly 78,000 dually eligible individuals were enrolled in PACE; because CMS's monthly enrollment data exclude Medicaid-only enrollees, total PACE enrollment is closer to 92,000.14

Watching for a second Tennessee site

Brevy will update this guide if TennCare's PACE page adds a program beyond Alexian PACE.1

Where to Get Help in Tennessee

Legal aid: If TennCare denies a PAE, the denial letter includes a statewide list of legal aid offices, so keep it with your appeal papers.10

Family caregiver resources:

• Tennessee Caregiver Resource Hub
• How to Get Paid as a Family Caregiver in Tennessee, covering CHOICES Consumer Direction and the agency-employed route under Public Chapter 182 of 202510,17

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 (the protected share depends on the snapshot year, and a court order or hardship ruling can raise it)6
• The applicant has made any uncompensated transfers (gifts, transfers to children, retitling) in the past 60 months; an attorney can check whether a transfer fits one of TennCare's exempt categories, such as a home transferred to a caregiving child or to a sibling with an equity interest, or a transfer made exclusively for another purpose, and can help with a hardship request7
• The applicant has income above the cap (a Qualified Income Trust must meet TennCare's requirements, including being irrevocable)12
• 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, who would pay a monthly premium equal to the Medicaid capitation amount2

Tennessee elder-law attorney fees for PACE planning vary with the complexity of the case. Ask whether the attorney offers a flat fee covering QIT drafting, asset restructuring, spousal-impoverishment analysis and PAE help, and get a written 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 months7
• 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 community-spouse resource and income protections
• Tennessee 5-Year Lookback and Penalty Divisor, 60-month look-back rules; penalty start-date rule; exempt transfers
• 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 through CHOICES Consumer Direction and agency-employed family caregivers

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.