Medicaid Waiver Programs: HCBS & Home-Based Care Coverage Explained

Medicaid waiver programs, also known as Home and Community Based Services (HCBS), are waivers that enable states to provide long-term care services for people who can live in their home and community instead of in a nursing facility or institution. One of the most important advantages of Medicaid is these waivers—the services received for an individual can cost anywhere between $30,000 to $100,000+ per year depending on the state and the level of need. Waivers are authorized by the federal government in various sections of the Social Security Act, most notably section 1115 of the Act (for other research and demonstration waivers) and section 1915(c) of the Act (for HCBS-specific waivers). There are currently about 267 Section 1915(c) waiver programs in operation in 47 states plus the District of Columbia. As part of a national rebalancing that shifted away from institutional care, today HCBS represents 64.6% of all Medicaid long-term services and supports (LTSS) expenditures, up sharply from 1.1% in 1981. But enrollment caps on HCBS waivers and budget limitations leave some 710,000 people around the country waiting for HCBS waiver services. Arizona, Rhode Island and Vermont have HCBS that is provided only through Section 1115 demonstration waivers, not 1915(c) waivers.

This guide is designed to provide information about Medicaid waiver programs, distinction between waiver types (1915(c) vs. 1115 waivers), eligibility, services, and waitlists for 2026. Information is from Medicaid.gov and the CMS, KFF and Congressional Research Service reports. 

What are Medicaid waiver programs?

Medicaid waiver programs are tools that states use to "waive" certain federal Medicaid regulations, and offer services that require waiving of traditional Medicaid services. Under federal law, normally states provide Medicaid services equally to all those who qualify and provide defined services in any setting. There are waivers for states to disregard these rules.

The most common type, Section 1915(c) waivers, provide HCBS to people who would otherwise need institutional care (typically nursing facility level of care). States prove to CMS that the cost of HCBS is not higher than the cost of institutional care (also known as "budget neutrality" or "cost neutrality"). Upon approval, a state will provide certain services that are not covered by regular Medicaid, such as personal care attendant, adult day care, home modifications, respite services, and others.

Section 1115 demonstration waivers (also called research and demonstration waivers) provide states greater flexibility to use new strategies to deliver, enroll, and fund Medicaid services and to expand the scope of Medicaid coverage. Waivers should "work towards program goals" and in most cases will need to be budget neutral.

Section 1915(b) waivers give states the option of limiting provider choice or implementing managed care delivery systems. They don't approve HCBS, but can be used in conjunction with 1915(c) waivers ("Combination Waivers") to allow HCBS to be delivered via managed care networks.

Other authorities are 1915(i) State Plan HCBS (which allows HCBS without the institutional level of care requirement), 1915(j) SDoPAS, and 1915(k) Community First Choice (CFC).

See our Medicaid guide for details on Medicaid coverage. 

Eligibility for HCBS waivers

Generally, the requirements for access to 1915(c) HCBS are that the individual is Medicaid eligible and the individual is required to be at the institutional level of care.

You must meet your state's income and asset limits (which are usually the same as for nursing home Medicaid) to be eligible for Medicaid. In most states, the income limit for long-term care Medicaid is $2,982/month. The asset limits differ from state to state, but are generally $2,000 for an individual.

Institutional level of care requires that you need the level of care commonly given in an institution, such as a nursing home. This is assessed by the state and includes evaluating your need for assistance with activities of daily living (ADLs) (bathing, dressing, eating, toileting, mobility), managing medications and many other care needs.

Distinct groups of waivers are for distinct groups of people—such as aging seniors, adults with intellectual and developmental disabilities, adults with physical disabilities, children with autism, people with traumatic brain injury, people with HIV/AIDS, people with mental health conditions, and others.

There are eligibility requirements for each state-specific waiver. For instance, the state of California has six 1915(c) HCBS waivers, such as those for people with HIV, and for seniors with disabilities. Hawaii only has one waiver which is for intellectual and developmental disabilities. There are four waiver programs in Florida, one of which is for people with rare genetic disorder, Familial Dysautonomia.

If you are a Medicaid planning attorney, find more information here.

What HCBS waivers cover

There are a variety of HCBS waiver services available in each state and program, with federal regulations allowing states to provide a wide range of services. Common services include:

Personal care services: Bathing, dressing, grooming, toileting, eating, mobility and other activities of daily living.

Cleaning, laundry, meal preparation, shopping and other home duties.

Adult day care: Care and activity for adults during the day in facilities other than their home.

Respite care: Temporary care to provide the family caregiver with a rest.

Home Modifications: Wheelchair Ramp, Grab Bars, Accessible Bathrooms, Widening doorways, etc.

Specialized medical equipment and supplies: In addition to the durable medical equipment, specialized communication equipment, and other adaptive equipment.

Transportation: Non-emergency medical transportation service and social activity transportation service and other transportation services.

Companion services: Assistance and company to the person who cannot be left unattended.

Behavioral health services: Mental health and behavioral services that are more comprehensive and specialized.

Skilled nursing: Part time skilled nursing at home. Physical, occupational, speech and other therapy services.

Case management: Service and care coordination. The ability to hire, train, manage, and dismiss caregivers is a feature of many 1915(c) waivers, and is often referred to as "consumer direction" or "self-direction. In self-directed care, family members (in some states, spouses) may be able to be paid as caregivers. Among the most sought-after waiver features is this one.

If your Medicare plan provides home health benefits, check out our home health guide.

State-by-state waiver variations

State variations in waiver programs are dramatic. Some examples:

California: Six 1915(c) waivers (HCBS, IHO, Self-Determination, In-Home Operations, HIV/AIDS, NF/AH) serving different populations.

Florida: Four waivers (iBudget for developmental disabilities, LTSS, Familial Dysautonomia, Adult Day Health).

Texas: Multiple waivers including HCS (Home and Community-Based Services for IDD), TxHmL (Texas Home Living), CLASS (Community Living Assistance and Support Services), and others.

New York: Multiple waivers serving different populations including OPWDD (Office for People with Developmental Disabilities) waivers and others.

Mississippi: Several waivers including TBI/SCI (Traumatic Brain Injury/Spinal Cord Injury), Assisted Living, and others.

Arizona, Rhode Island, and Vermont: Operate HCBS exclusively through Section 1115 demonstration waivers rather than 1915(c) waivers.

State variations make navigation challenging. Always check your state's specific waivers, eligibility criteria, available services, and waitlist status. Contact your state Medicaid office or your local Area Agency on Aging for information.

Waiver waitlists

Wait lists are one of the most challenging aspects of HCBS waiver programs. Approximately 710,000 individuals were on waiting lists for Section 1915(c) and Section 1115 HCBS waiver programs nationwide as of 2024.

Waitlists exist because states cap waiver enrollment. The federal government requires states to demonstrate budget neutrality, and states typically cap enrollment to control costs. When demand exceeds capacity, waitlists form.

Wait times vary dramatically: some waivers have no waitlists, others have lists of 5-10+ years. Texas's HCS waiver, California's various waivers, and many state IDD waivers have notably long waitlists.

Priority placement is available in many states for certain situations: people transitioning from institutions to the community, people in crisis (homelessness, caregiver hospitalization, abuse situations), individuals aging out of foster care, or other specified priority groups.

While waiting for a 1915(c) waiver, you may receive limited services through other Medicaid programs. Community First Choice (CFC) services, if your state has implemented 1915(k), are typically available without a waitlist and provide a "floor" of services. Personal Care Services through Medicaid State Plan, available in over half of states, also typically don't have waitlists.

How to apply for HCBS waivers

Applications typically go through your state Medicaid agency or designated Area Agency on Aging.

The process typically involves: Apply for Medicaid (if you don't already have it). Request HCBS waiver evaluation. Undergo functional assessment to determine institutional level of care need. Choose a participating provider or self-direct your services. Develop a person-centered care plan. Begin services after approval.

Most states allow application by phone, online, or in person. The application process can be complex; many families work with a Medicaid planning attorney for assistance, particularly when asset planning is needed to qualify for Medicaid first.

If denied, you have the right to appeal. Look carefully at the denial notice for your appeal deadline (typically 30-60 days). Review the notice to understand why you were denied and prepare your arguments. You may need additional medical evidence or witness statements.

Free assistance is available through your state's State Health Insurance Assistance Program (SHIP), your local Area Agency on Aging, your state's Aging and Disability Resource Center, or nonprofits like ARC chapters for individuals with intellectual or developmental disabilities.