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 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. Nursing facility enrollment still runs ahead of the home and community side: 13,797 against 11,886 as of June 30, 2024.1

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 effective January 8, 2021 through December 31, 2030, stating it "is approving this demonstration for a period of 10 years" so the state would face less administrative burden from frequent renewals.8

Why the §1115 structure matters in practice:

• Managed care delivery. CMS's approval records that "TennCare III operates totally in a managed care environment," and TennCare's own manual describes CHOICES as the vehicle that integrates all nursing facility care and HCBS into that existing managed care system. The Bureau's Division of Long Term Services and Supports administers and oversees CHOICES in partnership with the contracted MCOs.4
• An explicit waiver of reasonable promptness. CMS waived Social Security Act §1902(a)(8) "[t]o the extent necessary to enable the state to limit enrollment in CHOICES 2 and 3 to the enrollment target(s) established by the state, as authorized under STC 33.d." That named waiver, not the §1115 structure by itself, is what lets Tennessee cap Group 2 and Group 3.8
• Continuity through 2030. Because the §1115 was approved through December 31, 2030, CHOICES has roughly five years of authorized runway from 2026.8

The CHOICES At Risk Demonstration Group, which receives Group 3 services, "will be opened to new enrollment effective October 1, 2022, up to an enrollment target of 1,750 new individuals enrolled in the group."8

The PACE alternative, Hamilton County only. TennCare's PACE page lists "You must live in Hamilton County" among its four published PACE eligibility criteria and directs applicants to Ascension Living Alexian PACE in Chattanooga. PACE is a structurally different alternative to CHOICES Group 2, integrating Medicare and Medicaid through one provider. Federal rules add conditions beyond age and geography: under 42 CFR 460.150(b) an enrollee must be 55 or older, need nursing facility level of care as the state determines it, live in the PACE service area, and meet any additional conditions in the PACE program agreement; 460.150(c)(1) also requires that they be able to live in a community setting at enrollment without jeopardizing their health or safety. One thing PACE does not require: 460.150(d) provides that eligibility to enroll is not restricted to Medicare or Medicaid beneficiaries, so a potential enrollee may be, but need not be, entitled to Part A, enrolled in Part B, or eligible for Medicaid. Outside the Alexian service area, CHOICES is Tennessee's primary HCBS pathway.9

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 TennCare members of all ages who qualify for and are receiving TennCare-reimbursed nursing facility services; the age and physical-disability limits below apply to Groups 2 and 3, not to Group 1. The rule ties Group 1 to a Bureau determination that the member meets Nursing Facility Level of Care.2,3

Group 1 has no cap and no waitlist. The rule's Enrollment Target, "the maximum number of individuals who can be enrolled in CHOICES Group 2 or Group 3," does not reach Group 1, and Group 1's enrollment criteria impose no capacity requirement.2 The MCO pays the facility a daily rate, and the resident contributes their patient liability (everything above the $70/month Personal Needs Allowance, set by Tenn. Code Ann. § 71-5-147 for income available on or after 1/1/2025) toward the cost.10,11

Group 2: HCBS In Lieu of a Nursing Facility

Group 2 covers people age 65 and older, and people 21 and older who have one or more physical disabilities as defined in the TennCare rule, who meet NF Level of Care but receive services in the community instead: at home, in an assisted living facility, or in a small group residential setting.

Group 2 operates under a statewide Enrollment Target, a cap on how many people can be enrolled at any given time. TennCare reports the target to CMS each quarter; in its Quarterly Monitoring Report for January through March 2025, the most recent one published on medicaid.gov, it reported a statewide Group 2 target of 11,000 against 8,759 members enrolled, plus 300 statewide reserve-capacity slots. An applicant who cannot be enrolled "shall be placed on a Waiting List for CHOICES Group 2."2

But the target is not a closed door, and the STCs say so in the same paragraph. CMS's approved special terms and conditions name three routes past a full target, and the first two are the ones families most often need:

• Reserve capacity. The state "may reserve slots in CHOICES 2 for individuals being discharged from a NF and for individuals being discharged from an acute care setting who are in imminent risk of being placed in a nursing facility setting absent the provision of home and community-based services." If you are leaving a nursing home, or leaving a hospital and headed for one without help at home, ask about a reserve slot rather than accepting a place on the list.
• Transition from Group 1. An enrollee "being served in CHOICES 1 who meets the requirements to enroll in CHOICES 2 can enroll in CHOICES 2 at any time such a transition can be accomplished, even if an enrollment target for CHOICES 2 has been reached," and is served outside the target until a slot opens.
• HCBS as a cost-effective alternative. An MCO whose enrollee meets the Group 2 criteria but cannot be enrolled because the target is met "has the option, at its sole discretion, of offering HCBS as a cost-effective alternative to the individual under a plan of care." This one is the plan's call, not yours.8,2

Group 2 services are subject to a per-person Individual Cost Neutrality Cap equal to the average cost of the level of nursing facility reimbursement the member would otherwise draw. Effective January 1, 2026, per TennCare's December 18, 2025 memo, that figure is $294.87/day, or $107,627.55/year.2

That is the Level 1 default, not the only cap. The ceiling tracks the level of nursing facility reimbursement the person would actually qualify for: a member who would qualify for Level 2 or skilled NF reimbursement gets a cap set at the average cost of that care, and a member who would qualify for Enhanced Respiratory Care gets a higher one still, set by the same memo at $173,010/year for someone who would draw the tracheal-suctioning rate and $249,977.55/year for someone who would draw the chronic-ventilator rate. A ventilator-dependent applicant priced against $107,627.55 is being priced against the wrong ceiling; the supporting documentation goes in with the PAE or the Cost Neutrality Determination. The cap can also be exceeded, by an amount set per individual, where that is necessary to give the member access to Supported Employment or Individual Employment Support.2

If the MCO determines a member's needs can no longer be met safely in the community within their cap, the member can be transitioned to nursing facility care instead. That determination is appealable through TennCare's Division of LTSS, which handles CHOICES enrollment appeals including denial and termination of enrollment.2

Group 3: At Risk of Nursing Facility Placement

Group 3 has the same target population as Group 2 but covers people who do not meet NF Level of Care and who, without CHOICES HCBS, are "At Risk for Institutionalization." It adds a limit Group 2 doesn't have: a Group 3 member must qualify for TennCare either as an SSI recipient or through the CHOICES At-Risk Demonstration Group. TennCare states that as of October 1, 2022, based on current appropriations, there is an enrollment target of 1,750 for non-SSI recipients (a target for new At-Risk enrollment, not a total Group 3 cap).2,8

The Group 3 cost ceiling is much lower, and the two governments publish different numbers for it: TennCare's own cost-effective-alternatives policy refers to an $18,000 expenditure cap, while CMS's approved special terms and conditions set the limit at $19,764 per calendar year, excluding the cost of minor home modifications, and let the state adjust it for provider rate increases. Ask your Care Coordinator which figure your plan is being measured against. The same employment-services exception applies here, and nobody is disenrolled or reduced if the only reason their cap would be exceeded is a state-directed rate increase.2 Group 3 is a smaller, more targeted program, designed to keep someone who scores under 9 on the Acuity Scale from declining into a nursing-facility-level need.

Eligibility: Three Tests, All Required

To qualify for CHOICES Group 2, you have to clear three gates. Group 1 uses the same clinical and financial tests but is open to TennCare members of any age who are receiving TennCare-reimbursed nursing facility care. Group 3 uses the same target population and financial tests but a different clinical standard.

Age and Disability

The Group 2 and Group 3 target populations are:

• People age 65 and older, or
• People age 21 and older who have one or more physical disabilities as defined in Tenn. Comp. R. & Regs. 1200-13-01-.022

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).4

The qualifying threshold is a total score of at least 9 for Group 1 and Group 2.4

There is a second route for someone who scores under 9, and its condition runs opposite to what most families expect: you meet NF LOC by meeting the at-risk LOC criteria on an ongoing basis and being determined by TennCare, through a Safety Determination, not to qualify for Group 3. Group 3 isn't a fallback you pick alongside this route; being screened out of Group 3 is what opens it.4

The Acuity Scale weighs two sets of measures, and the rule caps them separately:

• Activities of Daily Living and ADL-related functions: transfer, mobility, eating, and toileting, plus communication (expressive and receptive), orientation (to person and place), dementia-related behaviors, and self-administration of medications. Each answer carries a weighted value set by how much help you need, on a scale running from "Always" independent with that activity to "Never" independent. This whole set carries a maximum of 21 points.4
• Skilled and/or rehabilitative services: tube feeding, wound care, occupational therapy, physical therapy, ventilator care, and enhanced respiratory care. This whole set carries a maximum of 5 points, so a skilled need adds to an ADL score rather than carrying one on its own.4

The per-answer weighted values live in the rule's own scoring tables, not in any published summary. The PAE itself is reviewed and adjudicated by registered nurses in TennCare's Division of Long Term Services and Supports, who set the appropriate score from the supporting medical documentation rather than simply approving or denying the score the submitter entered. So ask your AAAD or MCO Care Coordinator to walk you through the completed PAE, and through who files it and by when, in writing rather than from a secondhand summary: the filing timeframe is the part families most often get wrong. A denied PAE carries appeal rights, and the denial letter says so.4

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.4

Financial: Income and Asset Tests

For 2026:3

• Single applicant income limit: $2,982/month (300% of the Supplemental Security Income (SSI) Federal Benefit Rate of $994/month).
• Countable resource limit: $2,000. TennCare's Institutional Medicaid policy states the standard flatly as $2,000 and publishes no separate both-spouses-applying figure, so don't assume a higher combined limit if both spouses apply. "Countable" is doing real work in that sentence: one vehicle is excluded regardless of value if it is used to transport the applicant or a household member (staff are told to assume it is, absent evidence otherwise), the home is excluded on the terms below, and the manual's exclusion list runs longer than both. Do not read $2,000 as a limit on everything you own.
• Community Spouse Resource Maintenance Allowance (CSRMA): the at-home spouse's protected share is the greater of one-half of the couple's combined countable resources (bounded below by $32,532 and above by $162,660 as of January 2026), a court-ordered amount, or an amount an appeals officer sets for hardship. Read $162,660 for what it is: a cap on the one-half computation, not an absolute ceiling on what the community spouse may keep. (Snapshot mechanics, fair-hearing increases, Hughes v. McCarthy: see the TN spousal impoverishment guide.)10
• Maintenance Needs Standard: the community spouse's income floor is the Standard Maintenance Amount of $2,705.00/month (effective 7/1/2026) plus any Excess Shelter Allowance, not the $2,705.00 alone; the federal maximum Monthly Maintenance Needs Allowance is $4,066.50/month (effective 1/1/2026). (Excess Shelter Allowance formula, Income-First rule, court-ordered support: see the TN spousal impoverishment guide.)10
• Home equity cap: $752,000. Read the homestead exclusion as the manual writes it, because it is an "and," not an "or": the home is excluded while it is the principal place of residence of the applicant, spouse, or dependent relatives and, if the applicant lives in a long-term care facility, intent to return home is established. The equity cap has its own escape hatches. TennCare's manual applies it "unless one of the following lawfully resides in the individual's home": the spouse, a child under 21, or a blind or disabled child under 42 U.S.C. 1382c. And even where the cap does bite, it is rebuttable rather than settled: "The home equity limit can be waived if an undue hardship is requested, and a determination is made that undue hardship exists." (For the full rulebook, see How to Protect Your Home from Medicaid in Tennessee.)

Tennessee is an income-cap state. If your gross income exceeds the $2,982/month Medicaid Income Cap, TennCare's Institutional Medicaid policy says you "will be provided with the opportunity to establish a Qualified Income Trust (QIT)", Tennessee's name for what other states call a Miller Trust, after which your income eligibility is tested again.3 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 when you make the transfer. Under the TennCare manual's rule (which mirrors 42 USC § 1396p(c)(1)(D)(ii)) it starts on the LATER of two dates: (a) the date you are eligible for Institutional Medicaid and would have been eligible for CHOICES but for the improper transfer, or (b) the first day of the month in which the assets were transferred, not the transfer date itself. 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.12

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 limits below are the per-service benefit limits TennCare publishes in the CHOICES rule itself, at Tenn. Comp. R. & Regs. 1200-13-01-.05(8)(l), which enumerates fourteen CHOICES HCBS and the limit that applies to each.2

Two of the rule's fourteen services are not broken out above: Homemaker Services and CBRA (Community-Based Residential Alternatives). Ask your Care Coordinator for their published limits if either is in your plan. And note what is not on the rule's list of fourteen: care coordination. A Care Coordinator is an MCO staff role, not a CHOICES service you are separately authorized for.2

A few important callouts:

• The Group 2 cost-neutrality cap is $107,627.55/year ($294.87/day) at Level 1, higher for members who would qualify for a higher nursing facility reimbursement level. The sum of the services above, plus home health and private duty nursing, can't exceed that ceiling. Group 3's service ceiling is much lower.
• Home health and Private Duty Nursing sit outside the CHOICES service array. Neither appears among the fourteen CHOICES HCBS the rule enumerates, and the cost-neutrality rule names "CHOICES HCBS, HH and PDN services" as separate categories that all count toward the cap. Their coverage rules and hour limits belong to the standard TennCare benefit, so get the current PDN authorization criteria from your Care Coordinator in writing rather than assuming a CHOICES limit applies.2
• CHOICES never pays room and board. On the CHOICES Member Benefit Table the benefit is called Assisted Care Living Facility, it is covered for Group 2 and Group 3 (not Group 1), and it is limited to 1 unit per day, 12 months per year. The table states it plainly: you must pay for your room and board. CHOICES pays only the care services.13
• Short-Term NF Care is a Group 2/3 benefit, not a move to Group 1. It is one of the fourteen CHOICES HCBS the rule enumerates, so an HCBS member can use a short nursing facility stay without leaving the community program.2

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:10

1. Medicare Part B and supplemental insurance premiums
2. The community spouse's income maintenance allowance (the $2,705.00/month Standard Maintenance Amount effective 7/1/2026 plus any Excess Shelter Allowance, capped at $4,066.50/month effective 1/1/2026), deducted only to the extent the income is actually made available to the community spouse10
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.)10,11

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.3 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.5

CDTN's TennCare-approved rate schedule prices Personal Care Visits, Attendant Care, In-Home Respite, and Companion Care, the services members most often self-direct.5

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 their spouse under Consumer Direction. Tennessee CHOICES also generally bars these people from being the paid CD worker:

• 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.6 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 contact line is plan-specific, so call the one that matches your MCO: UnitedHealthcare 1-888-444-3109, Wellpoint 1-888-398-0664, BlueCare Tennessee 1-888-450-3240.5

The member sets each worker's wage, within the budget the Care Coordinator authorizes and up to a TennCare-approved maximum that varies by service. On the CDTN CHOICES rate schedule (Rev. 07/30/2025): Personal Care Visit (T1019 UC) averages $18.31/hour, maximum $19.16; Respite (S5150 UC) averages $16.36, maximum $18.93; Companion Care is a daily rate, $158.97 average and $163.33 maximum per 24/7 day. What is charged against the member's budget is higher than the wage because it includes employer taxes ($20.17 average against an $18.31 Personal Care wage). Verify the current schedule with CDTN at the time of hire. One tax note for your preparer: the IRS FICA/FUTA difficulty-of-care exemption applies when the worker is the member's child, parent, or spouse.5

The MCO You Pick Matters

CHOICES runs entirely through managed care. CMS's approval records that "TennCare III operates totally in a managed care environment," and TennCare's Managed Care Contractors page states that medical, behavioral and long-term care services are covered by at-risk Managed Care Organizations in each region of the state. TennCare's CHOICES page lists these plans as the ones a member contacts about CHOICES:4

All three appear in TennCare's West, Middle, and East Tennessee health-plan tables alongside a fourth entry, TennCare Select. TennCare says all three of its Managed Care Organizations passed NCQA accreditation but doesn't say which plans that count means, so don't read the CHOICES list as ruling TennCare Select out; ask TennCare Connect what you can choose between.

Your plan's Care Coordinator builds your person-centered support plan and authorizes services. If you switch plans, TennCare Policy Manual CON 19-001 requires the receiving MCO to continue your CHOICES HCBS for a minimum of 30 days, and after that it may not reduce them until it has done a comprehensive needs assessment, developed a plan of care or person-centered support plan, and authorized and started services under that new plan. Read the bound the policy actually carries: it is written for members in CHOICES Group 2 or 3 or ECF CHOICES, the groups that receive HCBS, and it is a floor on the receiving plan, not a ceiling on how long your services last. (An older source saying "Amerigroup Tennessee" means Wellpoint.)4

The Group 2 Waitlist

Because Group 2 has an Enrollment Target, an applicant who cannot be enrolled when the target is full "shall be placed on a Waiting List for CHOICES Group 2."2

Nobody can honestly quote you a typical wait. TennCare publishes no remaining-slot count, and enrollment at a full target turns on whether Reserve Capacity is available or you meet one of the rule's exceptions, so the wait is condition-dependent rather than a fixed queue. Ask your AAAD or MCO where your own application stands.2

Before you settle into the wait, check whether you belong in one of the reserve-capacity categories: leaving a nursing facility, or leaving an acute care setting at imminent risk of nursing facility placement. Those are the situations the reserve slots exist for. And if you are already in Group 1, the STCs let you move to Group 2 at any time the transition can be accomplished, target or no target.8

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, and it is also the doorway back out through the Group 1 to Group 2 transition above.
• Apply for the Money Follows the Person (MFP) demonstration. TennCare lists five things you must do: be enrolled in Medicaid; be 18 or older; have resided in a qualified institution (an ICF/IID, a Regional Mental Health Institute, or a nursing home) for 60 days; have care needs that can be adequately met in a community setting; and transition into CHOICES, ECF CHOICES, or other waiver HCBS. MFP supports the move while CHOICES provides the ongoing services. Clearing all five is still not the whole test: TennCare's own MFP FAQ warns that the additional eligibility criteria for the waiver you transition into apply on top, so meeting the five does not by itself secure a place. Federal MFP funding runs through September 30, 2027 under the Consolidated Appropriations Act, 2023.14 Know the scale before you count on it: TennCare's CY2024 MFP grant award of $17,001,725.03, approved December 5, 2024, targets transitioning 65 individuals per year into community settings, and since 2023, 63 members have transitioned from qualified institutions to HCBS (28 actively enrolled, 28 having completed 365 days in the community, 7 disenrolled).1
• 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 is actively investing in community capacity. In July 2025 TennCare Long-Term Services & Supports launched an initiative to invest $50 million in its HCBS provider network over five years to expand community-based capacity.14

Set that against where Tennessee actually stands, because the shift toward home care here is neither finished nor steady. In the 2023 LTSS rebalancing brief published on medicaid.gov, HCBS accounted for 52.1% of Tennessee's total Medicaid LTSS expenditures, placing the state in the bottom quartile on the expenditure rebalancing ratio, against 63.8% of Medicaid LTSS expenditures nationally; and 72.0% of Tennessee's Medicaid LTSS users received HCBS in 2023, down from 79.9% in 2022, which also puts it in the bottom quartile on the user ratio. The brief names Tennessee and Pennsylvania as the states with the largest decreases in that user ratio over the two years, but does not rank them. Inside CHOICES the two sides are close: as of June 30, 2024, TennCare reported 13,797 people in CHOICES Nursing Facility Services (down from 14,811 a year earlier) and 11,886 in CHOICES Home and Community Based Services (up from 11,656), plus 5,889 in Employment and Community First CHOICES. Read that as: the community side is growing, but slowly, and a Group 2 slot is still genuinely scarce.1

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.

If you have waited more than 90 days for a decision on a long-term-care application, you can ask TennCare for a delayed hearing. That request carries a short clock of its own: if TennCare asks you for the facts needed to finish the application, or for proof that you applied at all, you have 10 days to send it, and TennCare denies the application, or the delayed-hearing request, if it does not arrive in time.15

Appeals and Rights

A denial, reduction, or termination of CHOICES eligibility or services is appealable. TennCare adjudicates its own fair hearings internally, and an Administrative Judge renders the final decision. There are two distinct tracks.16

Eligibility appeals, for a denial, a coverage ending, an income or family-size error, or a delayed decision, go to TennCare Connect:

• Phone: 1-855-259-070116
• Online: tenncareconnect.tn.gov
• Mail: the Eligibility Appeal form to Eligibility Appeals Unit, P.O. Box 23650, Nashville, TN 37202-365016

Read the 90 days the right way. It is not a promise your hearing happens within 90 days. It is the wait that entitles you to ask for one: more than 45 days without a decision on a standard application, or more than 90 days on a long-term-care application like CHOICES, lets you request a delayed hearing. And the federal rule at 42 CFR 431.221(d) is a ceiling, not a guarantee: 90 days from the mailing of the notice is the most a state may allow, and Tennessee allows less. Your operative deadlines are the 60 days on the medical track and the 40 days on the eligibility track; an appellant who waits on the federal 90 days loses the appeal.15,16

Medical/service appeals are filed directly with TennCare Member Medical Appeals, free at 1-800-878-3192, or by mail, by fax, or online through your TennCare Connect account.16 This track is not limited to an outright denial. TennCare says you can appeal when it says no to a healthcare request, when it stops or changes your healthcare, when you have to wait too long to get healthcare, when you have bills or have paid out of pocket for care you think TennCare should have covered, and when there is some other reason you cannot get healthcare when you need it.15

You have 60 days to file. TennCare words that as 60 days after you find out there is a problem, but because CHOICES is delivered through managed care, 42 CFR 438.402(c)(2)(ii) gives an enrollee "60 calendar days from the date on the adverse benefit determination notice" to appeal to the plan. Count from the date printed on the notice, not from the day you opened it, or you can be out of time. The appeal is usually decided within 90 days, though a plan-level standard appeal must be resolved no later than 30 calendar days after the plan receives it. An expedited appeal is available when there is an emergency and the health plan agrees, so it is not something you can invoke on your own say-so; it is decided in about a week, but can take longer if the plan needs more time to get your medical records.15

Keeping services running during a medical appeal is a separate request, and it is not automatic. Under 42 CFR 438.420(b) the plan continues benefits only if all five conditions hold: you filed the appeal on time, the appeal is about the termination, suspension or reduction of previously authorized services, an authorized provider ordered them, the original authorization period has not expired, and you timely filed for continuation of benefits as a request of its own, on top of the appeal. After the plan's adverse decision you have 10 calendar days to request a state fair hearing and continued benefits, even though you get 90 to 120 days to request the hearing itself. If the final decision goes against you, the plan may recover the cost of services furnished while the appeal was pending.15

On the eligibility track, continuation runs on two clocks, and the shorter one keeps your coverage on. These windows come from TennCare's Administrative Manual policy 200.055, which governs eligibility appeals only, so do not apply them to a medical appeal. An appeal filed within 40 days of the termination or denial notice is timely, and benefits are continued if the request is filed within 20 days of the notice (or before your coverage end date, if later), pending the Administrative Judge's final decision. Filing on day 35 is a timely appeal that does not continue benefits. Missing either date does not close the door by itself: TennCare can accept a late appeal, and can still continue benefits, on a showing of good cause, which designated attorneys in the Eligibility Appeals Unit decide. Even continued benefits can be stopped before a decision, but only if the hearing determines the sole issue is one of federal or state law or policy and TennCare tells you so in writing. If TennCare's action is upheld you may have to repay what was continued, so this is a real decision, not a free option.16

Do not file a complaint when you meant to file an appeal. TennCare draws the line itself: "Complaints or grievances should not be filed in the event of a denial, reduction, or termination of a member's services (also known as an Adverse Benefit Determination)." A member told of a reduction or termination is entitled to information about how to appeal it and about the state fair hearing process. If the problem is with the plan rather than a service decision, TennCare's LTSS Member Resources page gives routes that do not run back through the plan: the CHOICES Consumer Advocate at your health plan, TennCare's Beneficiary Support System (Disability Rights Tennessee) at (888) 723-8193, and the Long-Term Care or Community Living Supports Ombudsman at (866) 836-6678.4

Free legal help with a TennCare appeal: the Tennessee Justice Center, your regional legal aid office, and TN Free Legal Answers.

Common Misconceptions

"CHOICES is a §1915(c) waiver." It isn't; it sits inside TennCare's §1115(a) demonstration, and its HCBS are paid as demonstration expenditures for "home and community-based waiver-like services ... furnished to TennCare CHOICES enrollees." Don't over-read that: the Group 2 and 3 caps rest on a specific CMS waiver of reasonable promptness under §1902(a)(8), not on the §1115 structure itself, and §1915(c) waivers routinely carry capped slots too.8

"My income is over $2,982 so my parent can't qualify." An applicant over the cap is given the opportunity to set up a Qualified Income Trust (Miller Trust), after which income eligibility is re-tested.3

"My spouse can be my paid caregiver under Consumer Direction." No. PC 182 of 2025 opened the agency-employed pathway for spouses, but Consumer Direction still excludes them, along with conservators, guardians, and powers of attorney.5

"A dementia diagnosis qualifies for Group 2 automatically." No. The PAE Acuity Scale is functional, not diagnostic: the rule captures dementia as an ADL-related function, scored by how often the applicant requires intervention for dementia-related behaviors rather than by the diagnosis itself. What moves the total score is documented need for help with transfers, mobility, eating, toileting, communication, orientation, and self-administration of medications, so it is the functional record in the PAE that decides it.4

"CHOICES will pay my parent's assisted living rent." No. The Assisted Care Living Facility benefit pays for the care delivered in an assisted living facility, never the room and board, which the resident pays from their own income.13

"There's no waitlist for CHOICES." There is no waitlist for Group 1 (nursing facility). Group 2 has an Enrollment Target, reported at 11,000 against 8,759 enrolled in TennCare's January to March 2025 quarterly report, and an applicant who cannot be enrolled goes on a Waiting List, though the 300 reserve-capacity slots and the STCs' three named exceptions can still permit enrollment at a full target. For Group 3 the rule only says the state may establish a target, which must be at least 10% of the Group 2 target.2

Related Terms

• HCBS waiver: The federal authority most states use for HCBS. Tennessee uses the §1115 demonstration instead.8
• 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 $70/month a Group 1 resident keeps from their income.11
• 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

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.