TennCare, Tennessee’s Medicaid program, covers a broad set of medically necessary services for enrolled adults: inpatient and outpatient hospital care, physician visits, prescription drugs, dental, behavioral health, home health, hospice, long-term services and supports, and non-emergency medical transportation. Several categories familiar from private insurance are excluded for adults 21 and older, most notably routine vision, hearing aids, cosmetic procedures, and fertility treatment. What follows walks through each benefit area, the limits that apply, and where coverage stops.
Hospital, Physician, and Emergency Care
For adults in the standard benefit packages (B, D, and E), TennCare pays for inpatient and outpatient hospital care, physician services, laboratory and X-ray work, and emergency ambulance transport when medically necessary.1TennCare. TennCare Benefit Packages Physical, occupational, and speech therapy are covered to restore, improve, or stabilize impaired function, with speech therapy requiring evidence of continued medical progress.2Cornell Law Institute. TennCare Medicaid Rules, Section .04 The rules do not set hard visit caps for these therapies, but your managed care plan may require prior authorization.
Chiropractic care for adults 21 and older is covered only when the managed care plan determines it to be cost-effective, is limited to spinal manipulation to correct a subluxation, and has required prior authorization since January 2022.3Wellpoint. Adult Chiropractic Clinical Guideline Tennessee Community health clinic visits, organ transplants, reconstructive breast surgery, and hospice are also on the covered list.
Emergency services cannot be subjected to prior authorization, and plans cannot deny payment solely because a provider did not get preapproval. Emergency care must be available 24 hours a day.2Cornell Law Institute. TennCare Medicaid Rules, Section .04 TennCare Medicaid adults pay no copay for emergency room visits. TennCare Standard adults between 134 and 199 percent of the federal poverty level owe an $8.20 copay for non-emergency ER use, and those at 200 percent or above owe $50; both are waived if the visit leads to a hospital admission.4TennCare. Co-Pays Other Than Pharmacy Co-Pays
Prescription Drugs
The pharmacy benefit is run by OptumRx as a mandatory generic program. When a generic equivalent exists, you must use it unless your doctor documents a serious adverse reaction or a contraindication to an inactive ingredient.5OptumRx. TennCare Preferred Drug List A short list of high-risk classes, including anticonvulsants, atypical antipsychotics, HIV antivirals, immunosuppressants, and oncology agents, allows brand-name approval when the generic has failed therapeutically.
As of July 2025, the former five-prescription monthly cap is gone. A two-brand-name limit per month still applies, but drugs on the automatic exemption list do not count toward it.6TennCare. Pharmacy Benefits Drugs that are not on the preferred drug list are non-preferred and need prior authorization, which usually means trying and failing two preferred alternatives first.
A separate over-the-counter formulary covers common pain relievers (acetaminophen, aspirin, ibuprofen, naproxen), naloxone nasal spray, several contraceptive options including Opill, omeprazole, insulin (ReliOn Novolin), nasal steroid sprays, nicotine replacement products, and topical treatments such as hydrocortisone and antifungal creams.7OptumRx. TennCare OTC Drug Formulary Cough and cold medications are generally not covered for adults 21 and older.
Dental
Adult dental is broader than many enrollees expect, managed by Renaissance and provided at no cost to the member. Covered services include oral health screenings, examinations, X-rays and other diagnostics, cleanings, topical fluoride, fillings, crowns, root canals, extractions, gum health treatment, and oral cancer screenings.8TennCare. Dental Services You are entitled to two preventive cleanings per year.9TennCare. TennCare Announces Change in Dental Plan Management Renaissance assigns each member a dentist, and you can change that assignment at any time through the Renaissance member portal.
Members in Employment and Community First CHOICES or 1915(c) waivers may qualify for additional dental services such as sedation and behavior management, though those services count toward the member’s home and community-based services expenditure cap.8TennCare. Dental Services
Behavioral Health
Mental health and substance use disorder treatment is covered based on medical necessity across the full continuum of care.10TennCare. Behavioral Health Services That includes psychiatric inpatient treatment, crisis stabilization, and residential treatment facilities; partial hospitalization, intensive outpatient programs, and intensive community-based treatment; individual and family psychotherapy, substance use disorder counseling for adults, and medication management; and support services such as peer support, psychosocial rehabilitation, applied behavior analysis, and supported housing.
Psychiatric residential treatment is reimbursed in facilities not classified as Institutions for Mental Disease, with initial authorization for up to 90 days.11ASPE. State Behavioral Health Conditions, Tennessee Adult residential substance use disorder treatment does not appear to be covered through the standard Medicaid benefit. Members in crisis can call or text 988 to reach the Suicide and Crisis Lifeline.
Vision and Hearing
Adult vision coverage is narrow. It is limited to the medical evaluation and management of abnormal eye conditions such as glaucoma, diabetic retinopathy, cataracts, and macular degeneration.1TennCare. TennCare Benefit Packages Routine eye exams, refractions, and eyeglasses are not covered. The one carve-out for corrective eyewear is the first pair of cataract glasses or contact lenses after cataract surgery.12Healthcare Value Hub. Tennessee Medicaid Services and Immigrant Coverage A managed care plan may choose to offer routine vision exams or eyeglasses as a cost-effective alternative, but that is at the plan’s discretion and not a guaranteed benefit.
Hearing coverage is tighter still. Hearing aids, cochlear implants, and audiological therapy are specifically excluded for adults 21 and older.13Cornell Law Institute. TennCare Standard Rules, Section .10 Exclusions Speech pathology and audiology may be covered as part of a home health visit, but standalone hearing devices and therapy are not available to adults.
Home Health, Medical Equipment, and Hospice
Home health is covered when medically necessary. Nursing is limited to eight hours per day and 27 hours per week, or 30 hours per week for members who qualify for a higher level of nursing facility care. When nursing and home health aide services are combined, the cap is eight hours per day and 35 hours per week, rising to 40 hours per week at the higher care level.1TennCare. TennCare Benefit Packages
Durable medical equipment is covered across adult benefit packages when it withstands repeated use, serves a medical purpose, and is appropriate for home use. Prosthetic and orthotic devices require a written physician request documenting medical necessity, and prior approval is needed when the billed amount reaches $150 or more.14TennCare. TennCare Rules, Chapter 1200-13-01
Hospice is covered for adults certified by a physician as having a terminal illness with a life expectancy of six months or less. The benefit periods track Medicare: an initial 90 days, a second 90 days, and unlimited subsequent 60-day periods.15TennCare. TennCare Policy Manual, BEN 07-001 Covered hospice services include nursing, physician care, medical social work, counseling, physical, occupational, and speech therapy, home health aide and homemaker services, medical supplies, pain and symptom-management drugs, and short-term inpatient and respite care. Electing hospice generally means waiving curative treatment for the terminal illness, though TennCare continues to cover care for unrelated conditions. Hospice patients owe no copays.
Long-Term Services and Supports
Adults who need or are at risk of needing nursing home care may qualify for the CHOICES program, which covers both nursing facility care and home and community-based alternatives. Groups 1 and 2 are for adults who require a nursing home level of care and can choose a facility or home-based services instead. Group 3 is for adults at risk of needing nursing home care who receive SSI, with services capped at $18,000 per year.16Medicaid Planning Assistance. TennCare CHOICES Program
Home and community-based services available through CHOICES include personal care visits (up to 2,580 hours per year), adult day care (up to 2,080 hours per year), one home-delivered meal per day, personal emergency response systems, in-home respite care (up to 216 hours per year), assistive technology (up to $900 per year), enabling technology (up to $5,000 per year), home modifications (up to $6,000 per project, $10,000 per year, and $20,000 lifetime), companion care, assisted living, community living supports, and pest control.16Medicaid Planning Assistance. TennCare CHOICES Program Several of these, including personal care, companion care, and respite, can be consumer-directed, meaning the member hires their own caregiver.
Adults with intellectual or developmental disabilities may qualify for Employment and Community First CHOICES, which adds services such as specialized medical equipment, adaptive technology, and supported employment.1TennCare. TennCare Benefit Packages
Rides to Medical Appointments
Non-emergency medical transportation is available to any member who lacks a way to get to a covered appointment. Rides must be scheduled at least two business days in advance, either online or by phone through your managed care plan.17TennCare. Non-Emergency Medical Transportation Benefit Each plan has its own transportation line: BlueCare at 1-855-735-4660, TennCare Select at 1-866-473-7565, UnitedHealthcare at 1-866-405-0238, and Wellpoint at 1-866-680-0633. Members with their own vehicle may qualify for mileage reimbursement at the federal rate, and those near a bus route can receive round-trip bus passes.18Wellpoint. Transportation Benefits
What Isn’t Covered for Adults
The exclusion list for adults 21 and older is long, and some entries catch new enrollees off guard.13Cornell Law Institute. TennCare Standard Rules, Section .10 Exclusions Notable items TennCare will not pay for include:
- Hearing aids, cochlear implants, and audiological therapy.
- Routine eye exams, refractions, eyeglasses, contact lenses, and LASIK, apart from the post-cataract exception and medically necessary eye care.
- Cosmetic surgery, breast augmentation, hair transplants, tattoos, and body piercing.
- Artificial insemination, fertility drugs, and treatments for impotence or sexual dysfunction.
- Prescription weight-loss and hair-growth drugs, though OTC Alli capsules are covered under the OTC formulary.
- Cough and cold medications.
- Waterbeds, heating pads, grab bars, ramps, and home modifications outside the CHOICES waiver.
- Biofeedback, animal therapy, art therapy, music therapy, dance therapy, and hypnosis.
- Experimental treatments lacking FDA or Institutional Review Board approval, or still in early-phase clinical trials.
- Out-of-state and out-of-country care, except in emergencies or with prior authorization for urgent or network care.
Nutritional supplements and food formulas are generally excluded for adults, with exceptions for medically necessary enteral and parenteral nutrition and PKU treatment.
What You Pay
Most TennCare Medicaid adults pay little or nothing out of pocket. TennCare Medicaid enrollees have pharmacy copays but are not charged copays for other medical services, including ER visits.4TennCare. Co-Pays Other Than Pharmacy Co-Pays TennCare Standard enrollees with income at or above 100 percent of the federal poverty level pay copays for most services, on a tiered schedule that rises with income.19TennCare. Eligibility Categories Hospice care is exempt from copays entirely.
If your plan denies a service, cuts back on care, or causes excessive wait times, you have appeal rights. A standard medical appeal must be filed within 60 days and is usually decided within 90 days; an expedited appeal, available when waiting could endanger your health, is decided in about a week.20TennCare. How to File a Medical Appeal You can file by phone at 1-800-878-3192, or by email, fax, or mail, and you have the right to keep an existing service in place while the appeal is pending.