TennCare CHOICES 2026: Eligibility, Groups, Services Guide

TennCare CHOICES is Tennessee's Medicaid program for adults who need nursing-home-level care. It pays for care in a nursing facility, or, much more often, for the personal care, attendant care, respite, adult day, home modifications, and other services that let someone stay in their own home or an assisted living community instead.

CHOICES is the most important long-term care program in Tennessee. It's also one of the most misunderstood. It is not a §1915(c) HCBS waiver like most other states use; it lives inside TennCare's §1115 demonstration. It has three different groups with very different rules. And the home-and-community side of the program (Group 2) has a real waitlist that you should understand before you apply.

This guide walks through who qualifies, what's covered, how Consumer Direction works, and what the application actually looks like in 2026.

What TennCare CHOICES Is, and Isn't

CHOICES (Choices in Long-Term Care) is the long-term services and supports (LTSS) part of TennCare. Most state Medicaid programs use a §1915(c) HCBS waiver to deliver home- and community-based long-term care. Tennessee does it differently: CHOICES sits inside the TennCare III §1115(a) demonstration, which CMS approved on January 8, 2021 with an unprecedented 10-year approval period through December 31, 2030.

Why the §1115 structure matters in practice:

• Managed care delivery. Every CHOICES member is enrolled in a TennCare MCO, which handles the care coordination and pays the providers. There is no fee-for-service CHOICES.
• Aggregate cap, not per-person federal entitlement on the HCBS side. Group 2 (HCBS) is structurally capped, which is why a waitlist exists in 2026.
• Continuity through demonstration renewals. Because the §1115 was approved through 2030, CHOICES has roughly five years of authorized runway from 2026.

CHOICES launched in Middle Tennessee on March 1, 2010 and went statewide on August 1, 2010. The "At Risk" Group 3 was added in 2012 and reopened to new enrollment on October 1, 2022 with a 1,750-slot non-SSI target. Employment Services & Supports and Enabling Technology became permanent CHOICES benefits effective July 1, 2025.

The PACE alternative, Hamilton County only. Tennessee operates exactly one Program of All-Inclusive Care for the Elderly (PACE) site: Ascension Living Alexian PACE in Chattanooga, serving Hamilton County. For adults 55+ who meet nursing facility level of care and live in the service area, PACE is a structurally different alternative to CHOICES Group 2, fully integrated Medicare + Medicaid through one capitated provider, no waitlist, but lock-in to PACE-authorized providers under 42 CFR § 460.164. The 2024 SB 459 / HB 416 statewide expansion bill did not pass as a standalone public chapter, so PACE is not currently available outside Hamilton County. Outside the Alexian service area, CHOICES is Tennessee's primary HCBS pathway.

The Three Groups

CHOICES has three groups, and the differences matter, they determine where you can receive care, whether there's a waitlist, and how much the program will spend on your services.

Group 1: Nursing Facility Care

Group 1 is for adults age 65+ or adults 21+ with a physical disability who meet Nursing Facility Level of Care and live in a Medicaid-certified nursing facility.

Group 1 is a Medicaid entitlement. There is no cap and no waitlist. Anyone clinically and financially eligible is enrolled. The MCO pays the facility a daily rate, and the resident contributes their patient liability (everything above the $70/month Personal Needs Allowance, raised from $50 effective 1/1/2025 under Public Chapter 986 of 2024) toward the cost.

Group 2: HCBS In Lieu of a Nursing Facility

Group 2 covers the same population, adults 65+ or adults 21+ with a physical disability who meet NF Level of Care, but delivers services in the community: at home, in an assisted living facility, or in a small group residential setting.

Group 2 is not an entitlement. It operates under a statewide enrollment cap (historically about 12,500 slots; verify the current cap on TennCare's CHOICES page). When the cap is full, applicants go on a waitlist prioritized by acuity and risk of institutional placement.

Group 2 services are subject to a per-person cost-neutrality cap equal to TennCare's average daily nursing facility reimbursement. Per the January 1, 2026 cost-neutrality memo, that cap is $294.87/day, or $107,627.55/year. If a member's care plan needs more than the cap, they generally have to move to Group 1 (nursing facility) instead.

Group 3: At Risk of Nursing Facility Placement

Group 3 covers adults who don't yet meet the full NF Level of Care standard but are at imminent risk of needing it. Group 3 was added in 2012 as a demonstration population, with about 1,750 non-SSI slots reopened to new enrollment in October 2022.

The Group 3 cost ceiling is much lower: roughly $18,000/year in HCBS, excluding minor home modifications. Group 3 is a smaller, more targeted program, it's designed to keep someone with a 5–8 point Acuity Score from declining into a nursing-facility-level need.

Eligibility: Three Tests, All Required

To qualify for CHOICES Group 1 or Group 2, you have to clear three gates. Group 3 follows the same financial and age tests but uses a lower clinical standard plus a Safety Determination.

Age and Disability

CHOICES serves:

• Adults age 65 and older, or
• Adults age 21 to 64 with a physical disability that meets Social Security's disability standard

Younger Tennesseans with intellectual or developmental disabilities are served by ECF CHOICES and the §1915(c) DD waivers, not CHOICES.

Clinical: The PAE and the Acuity Scale

Tennessee uses the Pre-Admission Evaluation (PAE) as its level-of-care test. The PAE applies the TennCare Nursing Facility Level of Care Acuity Scale, scored from 0 to 26 points (21 ADL points plus 5 skilled-services points).

The qualifying threshold is 9 or more points for Group 1 and Group 2. Applicants who score 5–8 may request a Safety Determination for Group 2 if they are at imminent risk of nursing facility placement, or apply for Group 3.

The Acuity Scale weighs:

• Activities of Daily Living: transfers/mobility (up to 4 points), eating (4), toileting (3), bathing/dressing, plus orientation (4), communication (1), medication self-administration (2), and dementia behaviors (3).
• Skilled services: ventilator dependence (5), tracheal suctioning (4), TPN (3), wound care, tube feeding, and various therapies.

The PAE is submitted by a physician, nurse practitioner, clinical nurse specialist, or physician assistant. An Area Agency on Aging and Disability (AAAD) or your assigned MCO Care Coordinator can submit it on the applicant's behalf. The Bureau of TennCare Long Term Services & Supports must receive an approvable PAE within 10 calendar days of either the PAE Request Date or the physician certification date, whichever is earlier.

One common confusion to clear up: Tennessee does not use a "CARES" assessment. CARES is the Florida tool. Tennessee's tool is the PAE plus the Acuity Scale.

Financial: Income and Asset Tests

For 2026:

• Single applicant income limit: $2,982/month (300% of the SSI Federal Benefit Rate of $994/month).
• Single applicant countable asset limit: $2,000.
• Couples, both applying: $3,000 in combined countable assets.
• Community Spouse Resource Allowance (CSRA): the at-home spouse may keep one-half of countable assets up to a maximum of $162,660, with a minimum protected resource standard of $32,532. (Snapshot mechanics, fair-hearing increases, SFA model, Hughes v. McCarthy: see the TN spousal impoverishment guide.)
• Minimum Monthly Maintenance Needs Allowance (MMNA / MMMNA), effective 7/1/2025–6/30/2026: minimum $2,643.75/month, maximum $4,066.50/month, depending on shelter costs. (Excess Shelter Allowance formula, Income-First rule, court-ordered support: see the TN spousal impoverishment guide.)
• Home equity cap: $752,000. The primary residence is exempt if the applicant (or spouse, or a disabled or minor child) lives there or documents intent to return. (For the full rulebook on what the home equity cap means, the intent-to-return mechanic, and which planning tools work in Tennessee, see How to Protect Your Home from Medicaid in Tennessee.)

Tennessee is an income-cap state, not a medically-needy state. If your income exceeds $2,982/month, you cannot use spend-down, you must establish a Qualified Income Trust (QIT), which is Tennessee's name for what other states call a Miller Trust. The QIT redirects excess income each month so the applicant's countable income falls under the cap. Setting up a QIT is straightforward but should usually be done with help from an elder-law attorney to avoid mistakes that cost months of eligibility.

The look-back is 60 months (5 years) for asset transfers under 42 USC § 1396p(c) as amended by DRA-2005. The 2026 transfer-penalty divisor is $295.87/day ($8,846.10/month) per the TennCare ABD Eligibility Policy Manual, Policy 125.010 (dated January 5, 2026). (Note: this is a different metric from the $294.87/day CHOICES Cost Neutrality Cap, which gates HCBS expenditures vs. nursing-facility cost, not transfer penalties.) Critically, the penalty period does not start on the transfer date, under DRA-2005 it starts on the LATER of the transfer date or the date you would otherwise qualify for CHOICES. See the TN 5-Year Lookback and Penalty Divisor complete guide for exempt transfers, DRA-2005 SPIA requirements, promissory note rules, Modified Half-a-Loaf strategy, undue hardship waivers, and worked examples.

Covered Services

CHOICES covers a broad HCBS service array for Group 2 and Group 3, plus full nursing facility care for Group 1. The care plan is built around what each member needs, not everyone gets every service. The annual caps below are 2026 figures from the TennCare CHOICES Member Benefit Table.

A few important callouts:

• The Group 2 cost-neutrality cap is $107,627.55/year ($294.87/day). The sum of the services above can't exceed that ceiling. Group 3's service ceiling is much lower at roughly $18,000/year.
• Skilled Nursing and Private Duty Nursing are delivered through TennCare's standard Medicaid benefit, not the CHOICES service array. PDN requires at least 8 hours of continuous skilled nursing need in a 24-hour period and is capped at 16 hours/day after age 21.
• CHOICES never pays room and board. If a member lives in an assisted living facility under Group 2's Assisted Living Services, the member pays room and board from their income; CHOICES pays only the care services.
• Group 1 short-term NF stays of 90 days or less preserve the higher Community PNA ($2,982/month) so the member can return home without losing their housing.

Patient Liability: What the Member Pays

This is one of the most confused topics in TennCare planning, because the rules are radically different between Group 1 and Group 2/3.

Group 1 (nursing facility): The member keeps a $70/month Personal Needs Allowance and turns over the rest of their income to the facility as patient liability, after these statutory deductions:

1. Medicare Part B and supplemental insurance premiums
2. The community spouse's MMNA ($2,643.75–$4,066.50/month for 2025–2026)
3. Family allowance for dependent children or parents
4. Court-ordered support obligations

Group 2 / Group 3 (HCBS at home): The member receives a much higher Community Personal Needs Allowance equal to the full Special Income Standard ($2,982/month, 300% of SSI FBR in 2026). That means most HCBS members owe little or no patient liability while living at home. Patient liability for Group 2/3 is paid directly to the assigned MCO, not to a facility. (Group 2 short-term NF stays of 90 days or less preserve this Community PNA, see the deep guide for mechanics, ECF CHOICES Groups 4-8 parity, and the legacy 1915(c) ID waiver 200%/300% disparity.)

Tennessee follows the name-on-the-check rule for spousal income. Income paid in the community spouse's name is not counted toward the applicant's $2,982/month cap. Community spouse income may still affect the MMNA calculation if it falls below the floor.

Consumer Direction: Hiring Family as Caregivers

CHOICES Consumer Direction (CD) is Tennessee's self-direction option. Under CD, the member becomes the legal employer of their own caregivers, with Consumer Direct Care Network Tennessee (CDTN) acting as the contracted Fiscal Employer Agent. CDTN handles payroll, tax withholding, Electronic Visit Verification (EVV), background checks, and biweekly direct deposit.

CD is available for Attendant Care, Companion Care, In-Home Respite, Personal Care Visits, and Non-Medical Transportation.

The critical question for most families is who can be hired. Under Consumer Direction, the member can hire:

• Adult children
• Siblings
• Parents (of an adult son or daughter who is the member)
• Friends and other relatives

The member cannot hire under Consumer Direction:

• A spouse
• A court-appointed conservator
• A legal guardian
• A power of attorney
• Anyone serving as the member's CD Representative

That spousal exclusion is the single most-asked-about rule, and it survived the Freedom for Family Caregiving Act (Public Chapter 182 of 2025). PC 182 changed the agency-employed pathway so that spouses can be hired by a TennCare-contracted home care agency as W-2 employees, but it did not change Consumer Direction. Spouses who want to be paid as caregivers in Tennessee should review our companion guide on how to get paid as a family caregiver in Tennessee, which walks through the agency-employed pathway in detail.

CDTN's CHOICES contact line is 1-888-444-3109. Hourly rates are set by the member within the budget authorized by the MCO Care Coordinator and within CDTN's published wage memo. In 2026 typical CHOICES CD personal care attendant rates fall in roughly the $11–$15/hour range; verify the current ceiling with CDTN at the time of hire.

The MCO You Pick Matters

All CHOICES members are mandatorily enrolled in one of three TennCare MCOs as of 2026:

• BlueCare Tennessee, operated by BlueCross BlueShield of Tennessee. Member services: 1-888-747-8955.
• UnitedHealthcare Community Plan of Tennessee. Member services: 1-800-690-1606.
• Wellpoint Tennessee (rebranded from Amerigroup in 2024). Member services: 1-833-731-2153.

All three operate statewide. Network providers, prior authorization rules, and ancillary benefits (transportation, OTC, value-added services) vary modestly between them. Your MCO's Care Coordinator, typically a registered nurse or social worker, develops your person-centered support plan, authorizes service hours, approves provider agencies, and makes the quarterly home visits required for Group 2 and Group 3 members.

CHOICES members may change MCOs during open enrollment (typically annually) or for cause at any time. If you see an older source referring to "Amerigroup Tennessee," it's the same organization that's now Wellpoint Tennessee.

The Group 2 Waitlist

Because Group 2 is capped, most regions of the state maintain a waitlist when the cap is full. Wait times vary significantly by AAAD region and by priority category:

• High-priority applicants (nursing-home residents who want to transition home, or community applicants at imminent risk of institutionalization) often move quickly, sometimes within weeks.
• Standard-priority applicants may wait months. In high-demand regions, waits have historically stretched longer.

While waiting for Group 2, families have a few options:

• Apply for Group 1 if a nursing facility is the right setting now. Group 1 has no waitlist; it's an entitlement.
• Apply for the Money Follows the Person (MFP) demonstration if the applicant is currently in a qualified institution (nursing facility, ICF/IID, or regional mental health institute) for at least 60 days. MFP is integrated directly into CHOICES, qualifying members enroll in both simultaneously, ensuring continuous HCBS coverage after the federal MFP participation period ends. MFP is federally funded through September 30, 2027 under the Consolidated Appropriations Act 2023.
• Look at OPTIONS for Community Living, the parallel state-funded program run by the AAADs that does not require Medicaid eligibility but offers a smaller service package.

Tennessee has been quietly rebalancing its long-term care spending for more than a decade. A decade ago roughly 3% of TennCare LTSS spending went to HCBS and 97% to institutional care. Today the split is closer to 40% HCBS / 60% institutional. TennCare spending averages roughly $60,000/year per LTSS member in a nursing facility versus approximately $17,000/year in HCBS, a 3.5x cost differential that drives the rebalancing strategy and makes Group 2 a state priority even with the cap.

In 2025 TennCare launched a $50 million HCBS provider capacity investment over five years (up to $10 million/year) supporting CHOICES, ECF CHOICES, the §1915(c) DD waivers, Katie Beckett, and OPTIONS for Community Living, aimed squarely at the workforce and provider gaps that have constrained Group 2 enrollment.

How to Apply for TennCare CHOICES

The CHOICES application has six stages. Expect the full process to take 3 to 6 months from initial intake to services starting, longer if you're waiting for a Group 2 slot.

1. Start the application. Three on-ramps work equally well: (a) call TennCare Connect at 1-855-259-0701 or apply online at tenncareconnect.tn.gov; (b) call your local Area Agency on Aging and Disability at 1-866-836-6678 (the AAAD will help you complete the application and the PAE); or (c) ask the hospital discharge planner to start the application if your loved one is in the hospital.
2. Phone screening. TennCare or the AAAD asks basic questions about age, disability, functional need, and household income to confirm you're in the right program.
3. PAE assessment. A physician, nurse practitioner, clinical nurse specialist, or physician assistant completes the Pre-Admission Evaluation, including the Acuity Scale. The Bureau of TennCare LTSS must receive an approvable PAE within 10 days.
4. Financial eligibility review through TennCare. Eligibility staff review income, assets, the 60-month look-back, and (if needed) help establish the QIT.
5. MCO assignment and Person-Centered Support Plan. Once clinical and financial eligibility are confirmed and a slot is available, the MCO Care Coordinator builds the individualized support plan with the member and family.
6. Service start. The Care Coordinator arranges providers, and services begin, typically within two to four weeks of plan approval.

If your CHOICES application has been pending for more than 90 days, the delay itself is appealable as a denial.

Appeals and Rights

A denial, reduction, or termination of CHOICES eligibility or services is appealable. Tennessee runs two distinct appeal tracks, governed by Tenn. Comp. R. & Regs. 1200-13-14-.11 and the Grier Consent Decree.

Eligibility appeals, for denials, terminations, or LTSS application delays exceeding 90 days, go to TennCare Connect:

• Phone: 1-855-259-0701
• Online: tenncareconnect.tn.gov
• Mail: Eligibility Appeals, P.O. Box 23650, Nashville TN 37202-3650
• Fax: 1-844-563-1728

The hearing must be held within 90 days for CHOICES (LTSS) applications, versus 45 days for non-LTSS.

Medical/service appeals, for any Adverse Benefit Determination on a CHOICES service (denial, reduction, or termination of hours), go to TennCare Member Medical Appeals:

• Phone: 1-800-878-3192
• Mail: P.O. Box 593, Nashville TN 37202-0593
• Email: TMMA.Contact.Center@tn.gov
• Fax: 1-888-345-5575

The filing deadline for medical appeals is 60 days from the date you find out about the problem. The standard decision timeline is 90 days; expedited decisions (about a week) are available if waiting could endanger life or health.

Aid Pending Appeal (also called Continuation of Benefits, or COB) is available for ongoing services being reduced or terminated, but only if you file both a timely appeal and a timely COB request. The Grier Consent Decree provides additional procedural protections beyond the federal floor, including allowing CHOICES members to proceed directly to a State Fair Hearing concurrent with the MCO appeal level.

Free legal help is available through the Tennessee Justice Center, the TennCare Advocacy Program at 1-800-758-1638, regional legal aid offices (West TN Legal Services, Legal Aid Society of Middle TN, Legal Aid of East TN, Memphis Area Legal Services), TN Free Legal Answers, and Help4TN at 2-1-1 or help4tn.org.

Common Misconceptions

"CHOICES is a §1915(c) waiver." It isn't. CHOICES sits inside TennCare's §1115(a) demonstration. That structural choice is why Tennessee delivers CHOICES through MCOs, why the Group 2 enrollment cap exists, and why the program's authority is renewed in 10-year increments rather than 5-year waiver cycles.

"My income is over $2,982 so my parent can't qualify." Tennessee is income-cap, not medically-needy. A Qualified Income Trust (Miller Trust) solves the problem in most cases. An elder-law attorney can set one up correctly; a botched QIT can cost months of eligibility.

"My spouse can be my paid caregiver under Consumer Direction." No. Consumer Direction excludes spouses, conservators, guardians, and powers of attorney. PC 182 of 2025 opened the agency-employed pathway for spouses, but Consumer Direction still excludes them.

"A dementia diagnosis qualifies for Group 2 automatically." No. The PAE Acuity Scale is functional, not diagnostic. Early-stage dementia with intact ADLs often does not score 9. Moderate or late-stage dementia with safety concerns, wandering, and inability to manage medications usually does.

"CHOICES will pay my parent's assisted living rent." No. CHOICES Group 2 Assisted Living Services pays for the care delivered in an assisted living facility, never the room and board. The resident pays room and board from their own income.

"There's no waitlist for CHOICES." There is no waitlist for Group 1 (nursing facility). Group 2 (HCBS) is capped and most regions maintain a waitlist when the cap is full. Group 3 has its own slot target.

Related Terms

• HCBS waiver: The federal authority most states use for HCBS. Tennessee uses §1115 instead.
• Nursing Facility Level of Care (NFLOC): The clinical eligibility test that the PAE administers.
• Consumer Directed Services (CDS): The national term for what Tennessee calls Consumer Direction.
• Activities of Daily Living (ADLs): The functional measures the PAE Acuity Scale scores.
• Personal Needs Allowance (PNA): The amount a Group 1 resident keeps each month from their income.
• Managed Care Organization (MCO): The plans (BlueCare, UHC Community Plan, Wellpoint) that deliver CHOICES.
• Electronic Visit Verification (EVV): The federally required time-and-location verification system used by Consumer Direction caregivers.

Learn More

• Tennessee Medicaid Programs for Seniors (Hub)
• How to Apply for Tennessee Medicaid
• How to Get Paid as a Family Caregiver in Tennessee
• Tennessee ECF CHOICES
• Tennessee Katie Beckett Program
• Tennessee Medicaid Nursing Home Coverage
• Tennessee PACE Program (Hamilton County only), the integrated Medicare + Medicaid alternative for adults 55+ in Chattanooga; structurally different from CHOICES (capitated, lock-in, no waitlist)

Find personalized help navigating TennCare 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.