Understanding TennCare and the CHOICES Program
TennCare is the name for Tennessee's Medicaid program, which is a joint federal and state program providing health coverage to low-income individuals. For long-term care needs, including assisted living, the relevant program is known as TennCare CHOICES in Long-Term Services and Supports. This program is designed to help older adults and people with physical disabilities access the services they need, either in their own home, in a nursing facility, or in an assisted living facility.
The CHOICES program operates through Home and Community Based Services (HCBS) waivers. A waiver is an alternative to institutional care, allowing states to use Medicaid funds to cover services provided in community settings, like assisted living. The program is vital for many seniors who prefer to live in a community setting rather than a nursing home but require a significant level of support to do so safely.
How TennCare CHOICES Covers Assisted Living
When it comes to assisted living, it is crucial to understand that the CHOICES program provides financial assistance for services, not the cost of housing. This means TennCare will cover a portion of the care services received by an eligible resident, such as help with activities of daily living (ADLs) or medication management. The individual or their family remains responsible for the "room and board" portion of the bill, which includes rent, meals, and utilities.
Within the CHOICES program, eligible individuals are sorted into groups based on their needs. Group 2 is for seniors (age 65+) and adults with physical disabilities (age 21+) who require a nursing home level of care but choose to receive care in an assisted living facility or at home instead. Group 3 is for those who do not yet need a nursing home level of care but require home or community-based services to prevent them from needing that higher level of care in the future. The level and amount of service coverage vary by group.
What Services Does CHOICES Cover?
For assisted living residents in the CHOICES program, covered services can include:
- Personal Care: Assistance with daily tasks like bathing, dressing, and mobility.
- Medication Management: Help ensuring medications are taken correctly and on schedule.
- Homemaker Services: Assistance with light housekeeping, laundry, and meal preparation.
- Adult Day Care: Services provided in a group setting during the day.
- Transportation: Non-emergency medical transportation to appointments.
Eligibility Requirements for TennCare CHOICES
To qualify for TennCare CHOICES, applicants must meet both financial and medical eligibility criteria. These criteria are subject to change annually and can be complex, so it is often wise to consult with an elder law attorney or local Area Agency on Aging and Disability (AAAD) for the most current information.
Financial Eligibility (as of 2025)
- Income Limit: For an individual applicant, the monthly income limit is set at 300% of the Federal Benefit Rate. As of 2025, this amount is $2,901 per month. For married applicants, the rules are more complex and provide protections for the non-applicant spouse.
- Asset Limit: An individual applicant's countable assets are generally limited to $2,000. Certain assets are considered exempt, such as the primary home (if the applicant intends to return or a spouse resides there) and one vehicle.
- Look-Back Period: Tennessee, like other states, has a five-year look-back period. This means that any assets gifted or sold for less than fair market value in the 60 months prior to applying for TennCare can result in a period of ineligibility.
Medical Eligibility
Applicants must demonstrate a medical need for long-term services. This requires a formal assessment to determine if the individual needs a "nursing home level of care". This involves showing a need for assistance with ADLs. An assessor reviews the applicant's health history, functional limitations, and support systems to determine eligibility.
The Application Process: Navigating the System
Applying for the CHOICES program can be a multi-step process. The first step for those not currently enrolled in TennCare is to contact their local AAAD. A representative from the AAAD can help with the application and provide guidance on the necessary paperwork. Current TennCare members should contact their Managed Care Organization (MCO) to begin the process.
- Initial Contact: Call the statewide number at 1-866-836-6678 to be connected with your local AAAD.
- Information Gathering: Be prepared to provide detailed information about the applicant's financial situation (income, assets) and health status.
- Assessment: A medical assessment will be scheduled to determine the level of care needed.
- Enrollment: If deemed eligible, enrollment in the CHOICES program follows. Placement on a waiting list is possible, as the program is not an entitlement.
Important Considerations for Families
Facility Participation
It is vital to confirm that a specific assisted living facility accepts TennCare CHOICES payments before moving forward. Not all facilities in the state participate in the program.
Room and Board Exclusion
Remember, the program only covers care services, not the rent or food. While CHOICES recipients can keep a small portion of their income as a personal needs allowance, the majority of the monthly income often goes toward covering room and board expenses.
Qualified Income Trusts
For applicants with income slightly over the eligibility limit, a Qualified Income Trust (QIT), also known as a "Miller Trust," can be a viable option to help meet the income requirements.
How CHOICES Compares to Other Payment Options
| Feature | TennCare CHOICES | Private Pay | Long-Term Care (LTC) Insurance |
|---|---|---|---|
| Covers Services | Yes (for eligible services) | Yes | Yes (depending on policy) |
| Covers Room & Board | No | Yes | Sometimes (depending on policy) |
| Financial Eligibility | Strict income and asset limits | No limits | No limits |
| Medical Eligibility | Requires nursing home level of care or at-risk status | No medical qualification required | May require medical underwriting upon application |
| Potential Waiting List | Yes, as it is a waiver program | No | No |
| Who Pays | Government (state and federal) | Individual/Family | Insurance Provider |
For more detailed information on eligibility and the application process, please consult the official TennCare CHOICES program website.
Conclusion: Making an Informed Decision
Tennessee's Medicaid program, TennCare, does pay for assisted living services, but it's not a straightforward process. The CHOICES program is a vital resource for covering the costs of care, provided the applicant meets stringent financial and medical criteria. Families must be aware of the program's limitations, particularly the exclusion of room and board costs, and must verify that their chosen facility accepts TennCare payments. By understanding the eligibility requirements and navigating the application process with care, eligible seniors can access the financial support they need to secure quality care in an assisted living community. Advance planning and seeking professional guidance are often the best strategies to ensure a smooth and successful transition.
