A Tennessee social worker once described TennCare CHOICES this way: imagine that for every Medicaid LTC enrollee in the state, the answer to “who decides what care your parent gets” is the same person — and it’s not the state, and it’s not the nursing home, and it’s not the doctor. It’s a case manager at the Managed Care Organization that holds the contract. If you don’t know which MCO that is and which case manager carries your parent’s file, you are flying blind through the most consequential decisions of their care.
Tennessee was an early adopter of managed long-term services and supports — MLTSS — under the umbrella of its 1115 demonstration waiver.1 Where most states still run pieces of their Medicaid LTC system fee-for-service, TN consolidates the entire benefit (nursing-facility, in-home services, assisted-living options) into a managed product administered by three private MCOs. The CHOICES program has been operating in this form since 2010, with periodic CMS renewal. For adult children helping a Tennessee parent navigate Medicaid LTC, the MCO is the system. This piece walks through how CHOICES is organized, what the three enrollment groups mean, and the four navigation moves that change outcomes.
How CHOICES is structured
Three groups, three MCOs, one bureau. The Bureau of TennCare contracts with each MCO to deliver the full CHOICES benefit statewide; the MCOs build provider networks (nursing facilities, in-home aide agencies, assisted-living facilities under the limited TN waivers), authorize services within the rules, and assign case managers to individual enrollees.
The three CHOICES groups
Group membership determines what kind of care CHOICES will pay for and where it can be delivered. The groups are defined in TennCare rules and the CHOICES Provider Operations Manual:2
- Group 1 — Nursing-Facility Care. For enrollees who meet the medical-eligibility standard for nursing-facility (NF) level of care and are receiving care in an NF. Open enrollment; no cap.
- Group 2 — HCBS at NF Level of Care. For enrollees who meet the same NF medical-eligibility standard but receive services at home or in another community setting. The choice between Group 1 and Group 2 is, in principle, the enrollee’s; in practice, geography and provider availability shape it. Group 2 has an enrollment cap statewide.
- Group 3 — HCBS at At-Risk Level (Interim Eligibility).For enrollees who don’t yet meet the NF level-of-care standard but are at imminent risk of needing it. Service package is more limited; enrollment is capped and often has a waiting list.
The three MCOs and why they aren’t interchangeable
As of 2026, three MCOs administer CHOICES statewide: Wellpoint (the entity that absorbed Amerigroup), BlueCare Tennessee (a BlueCross BlueShield of TN subsidiary), and UnitedHealthcare Community Plan.3 Each operates under the same state contract, with the same benefit menu and the same statutory floor for services. The differences are operational and material:
- Provider networks.Each MCO contracts with a subset of Tennessee nursing facilities, home- health agencies, and assisted-living waiver providers. A facility that’s in-network for BlueCare may not be in-network for United, and switching MCOs is the path to placement — not a request to the facility.
- Case management cadence. Each MCO assigns a case manager to every enrollee. Caseload sizes, communication norms, and authorization turnarounds vary. Families with persistent service delays often discover the underlying issue is the case manager, not the MCO at the institutional level.
- Plan-specific value-adds.Each MCO offers limited extra services beyond the CHOICES floor — care-coordination apps, caregiver-support resources, occasional benefit enhancements. None of these change the substance of CHOICES but they shape the experience.
The Pre-Admission Evaluation (PAE) is the gate
Before Medicaid can pay for any CHOICES service, the enrollee must clear the Pre-Admission Evaluation — the medical-eligibility screen for nursing-facility level of care.5 The PAE uses a points-based assessment of activities of daily living (bathing, dressing, transferring, toileting, eating) and medical complexity (cognitive status, medications, skin integrity, mobility). The score determines whether the applicant meets the NF threshold (Group 1 or 2), the at-risk threshold (Group 3), or neither.
PAE denials happen. They are most common when:
- The assessment is conducted in a hospital setting where the patient appears more capable than at baseline (recent acute illness, sundowning not visible during the screen).
- The supporting documentation is incomplete — no primary-care physician notes, no current medication list, no statement from the family caregiver about home function.
- The applicant is “between groups” on the points scale and the assessor errs lower.
A denial is appealable under Tenn. Code Ann. § 71-5-110, and reversal rates are non-trivial when the family submits additional supporting documentation. Don’t treat a first PAE denial as a final answer.
The financial eligibility piece
Beyond the medical screen, CHOICES applicants must meet financial eligibility:4
- Income at or below 300% of SSI ($2,901/month in 2026). Tennessee is an income-cap state. Above the cap, the applicant must establish a Qualified Income Trust (Miller trust) to divert excess income; without one, the application is denied. See our companion guide on the Texas Miller trust mechanics — TN’s rules are substantially similar.
- Countable resources at or below $2,000 for a single applicant. The principal residence is exempt if the applicant intends to return; one vehicle is exempt; household goods are exempt; a modest burial fund is exempt. The CSRA for a community spouse is the federal maximum ($157,920 in 2026).
- 60-month transfer review. Tennessee applies the standard federal look-back. Uncompensated transfers in the 60 months before application generate a penalty period.
The four moves that change outcomes
For families approaching or already inside CHOICES, the four conversations worth having early:
- Identify the MCO and the case manager by name.If your parent is already enrolled in TennCare, call 1-800-878-3192 (the general enrollee line) and ask which CHOICES MCO they’re assigned to and the case manager contact. This single piece of information unlocks most of the rest. If you don’t know the MCO, you can’t engage the MCO; if you don’t know the case manager, you’re calling the wrong people.
- Tour facilities by MCO network, not just by reputation.The best nursing facility in your county may not be in your parent’s MCO’s network. Before placement, ask each tour candidate which CHOICES MCOs they accept. Reconcile that against your parent’s assignment; if there’s a mismatch, change the MCO before placement, not after.
- Get the POA? and healthcare POA? squared away.Tennessee uses the Uniform Power of Attorney Act (Tenn. Code Ann. § 34-6-101 et seq.) for financial agency, and a separate Advance Directive for health care under Tenn. Code Ann. § 68-11-1801 et seq. Without these, an adult child cannot communicate effectively with the MCO, the case manager, or the facility on substantive decisions.
- Apply for Group 3 early if early signs warrant it.If a parent is showing mild-to-moderate decline but doesn’t yet need nursing-level care, the Group 3 interim enrollment can layer in HCBS support that delays or avoids the harder transition. The catch is enrollment caps and waiting lists; an application today is not a service tomorrow. Filing early is how a spot becomes available when need crosses the threshold.
The PACE alternative
A handful of PACE? (Program of All-Inclusive Care for the Elderly) sites operate in Tennessee in select counties. PACE is a separate Medicare-plus-Medicaid program for nursing-home-eligible seniors who can still live in the community, with comprehensive medical and social care at PACE centers. For families in a PACE service area, the PACE option is worth comparing against CHOICES — the care coordination is more intensive but the geographic constraint is tighter.
The estate-recovery piece
Tennessee conducts Medicaid estate recovery under Tenn. Code Ann. § 71-5-116. Recovery is limited to probate assets, consistent with CMS minimum standards. Property held in a revocable living trust, property with a named beneficiary (TOD deed, beneficiary designation), and property held in joint tenancy generally escapes recovery. Tennessee’s hardship-waiver application is narrower than some neighboring states; survivors should consult elder-law counsel about positioning before a recovery claim attaches.6
The bottom line
Tennessee’s CHOICES program is a comparatively mature MLTSS system, with most of the administrative edges smoothed over fifteen-plus years of operation. The benefit substance is what statute requires; variation comes from MCO performance, case-manager responsiveness, and provider-network composition. Families that identify the MCO, build a relationship with the case manager, and align facility tours with network composition spend less of the discharge week on phone calls and more on actual decisions. Families that show up to the discharge meeting not knowing the MCO’s name end up with whichever facility had a bed open.