CMS approves TennCare 1115 waiver expanding benefits for families and Tennesseans with disabilities


Maddie McCarthy


The Division of TennCare announced in May that the Centers for Medicare and Medicaid Services (CMS) approved the division’s Medicaid 1115 Demonstration waiver’s TennCare III amendment. 

The division’s statement noted that the general assembly approved the amendment as part of Gov. Bill Lee’s Strong Families Initiative in 2023.

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The amendment has three major provisions: eligibility expansion for parents and caretaker relatives of dependent children, coverage of diapers for children under two, and enhancement of home and community-based services (HCBSs) for people with disabilities.

The eligibility expansion for parents and caretaker relatives increases the income threshold to 100 percent of the federal poverty level (FPL). Clare Sullivan, co-chair of the Tennessee Health Care Campaign (THCC) Advocacy Committee, said policy advocates were pleased to see CMS’ approval of the eligibility expansion.

“That 100 percent benchmark had been the goal of TennCare previously, but over the past few years the state’s criteria did not keep up with the changes in the FPL, and families fell increasingly into that gap,” Sullivan said. “We expect that many families have suffered through an unnecessary loss of coverage during this past year’s redetermination process because that gap existed.”

The second provision of the amendment adds a diaper benefit for children covered by TennCare and the Children’s Health Insurance Program (CHIP).

Under the amendment, TennCare will cover up to 100 diapers per month per child under two years of age. The National Diaper Bank Network says diapers can cost up to $100 per month per child. Tennessee and Delaware will be the first states to offer this benefit.

“The decision to use ‘shared savings’ from TennCare III to provide diapers was also welcome, and a good example of how Medicaid funds might be used to address many of the other social and economic needs of low-income families our state is not fully addressing,” Sullivan said. “We understood it as a creative way to utilize shared savings that our TennCare agency splits with CMS under the terms of the TennCare III waiver.”

Sullivan said THCC learned of the diaper benefit during the same budget presentation where it was revealed that Tenncare reverted around $700 million in federal public health emergency funds to the state’s general fund to balance unanticipated gaps.

“That, plus the state’s continued resistance to closing the coverage gap for the hundreds of thousands of other Tennesseans who would be in the Medicaid expansion population (like caregivers earning between 100 to 138 percent of the FPL), dampened the response for us a bit,” Sullivan said.

TennCare is working to launch the diaper benefit soon.

The HCBS enhancements included in the waiver will add employment services and support as a benefit for individuals covered under CHOICES, one of TennCare’s managed long-term support services programs. Members of the CHOICES groups that cover adults 21 and older with a disability or adults over 65 who use HCBSs will be able to access the benefit.

Jeff Strand, public policy director at the Tennessee Disability Coalition, said the benefit is similar to benefits provided by the Employment and Community First (ECF) CHOICES program. He said the supports, while useful for some CHOICES members, are time-limited. 

The benefit “fades out” over time, regardless of a person’s ability to work completely independently, Strand said, leading to people losing their employment.

“The option to work for people with disabilities, including those in the CHOICES working-age population, is an important one for the community,” Strand said. “For those that want access to the workplace under these circumstances, this is great. We hope that those that are not interested in this service are very free to decline without jeopardizing their eligibility status otherwise, and without undue pressure to participate.”

Strand said the coalition hopes the new CHOICES employment services, alongside a new Medicaid buy-in law the coalition helped pass during the 2024 legislative session—which intends to reduce employment barriers for Tenneseans with disabilities by removing the risk of losing Medicaid services—and the Vocational Rehabilitation program, will all be viable options for the Tennessee disability community to choose from to gain employment.

An additional provision of the waiver includes community transportation as a HCBS benefit for members of all CHOICES groups. 

Strand said making transportation a CHOICES benefit is good, but making the benefit easy to use would make it great. In the past, transportation benefits have been notoriously difficult to access. 

For example, Strand said a family caregiver of a CHOICES member would be unable to reimburse themselves for transporting the member to places like work. However, a neighbor could be reimbursed for driving the caregiver and the member to the workplace.

“Greater access to the community, to which a transportation benefit begets, is unassailably a good thing, so we applaud TennCare’s inclusion in this amendment. We likewise hope that TennCare recognizes the importance of the benefit and moves to make it as easy and simple to use as possible.”

— Strand

The HCBS section of the amendment also revises some service definitions, including which professionals are able to provide benefits counseling. Strand expressed concern over adding the Work Incentive Practitioner (WIP-C) certification as an eligible benefits counselor. 

Community Work Incentive Coordinators (CWICs) were originally the only professionals able to provide official benefits counseling. Strand said some CWICs have spent time trying to rectify mistakes made due to inaccurate information provided by non-credentialed benefits counselors like WIP-Cs. He added that navigating benefits can be extremely complicated, and requires the knowledge of CWICs, who are trained by the Social Security Administration.

“We believe this type of benefits counseling and advice is too important to lower the standard for those providing the service,” Strand said. “CWICs are experts in their field and are best suited for this vital role.”

Stand said the coalition would like to see larger changes in the TennCare amendment, but they appreciate the additional benefits. He added that he hopes any changes, such as the benefits counseling definition, do not harm the Tennessee disability community.

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