What Is an HCBS Waiver? Medicaid Home & Community Services

What Is an HCBS Waiver?

Why It Matters

Every state's Medicaid plan must include nursing facility services for adults 21 and over, but home and community-based services are an optional benefit.3 An HCBS waiver is one way a state can pay for the attendant care, home modifications, and respite that would let someone stay at home, and it lets the state offer that help to specific groups and cap how many people get it.3,4

For a family that wants a parent, spouse, or child to stay at home, that matters. For an older adult who would otherwise need nursing facility care, the right waiver can be the difference between entering a facility and aging in place with personal assistance, home-delivered meals, and an emergency-response system. For the family, it can mean not having to leave a job to provide unpaid care.1,4

What the "Waiver" Actually Waives

Regular Medicaid is built in two ways that favor institutional care:

1. Nursing facility care is mandatory; home care is optional. Nursing facility services are a required benefit in every state's plan, while home and community-based benefits exist only where a state has elected them.3
2. Comparability and statewideness. Medicaid benefits are generally subject to comparability and statewideness rules. Once a state adds an optional service to its state plan, it must provide that service to everyone eligible through the pathways that grant the standard benefit package, so it cannot offer extensive home care to one group and not another.3

A 1915(c) waiver lets the federal government waive certain of these Medicaid requirements for a defined population (for example, older adults, adults with intellectual or developmental disabilities, or children who are medically fragile). A waiver lets a state offer optional benefits only to specific groups and cap enrollment.1,3 In exchange, the state commits to cost neutrality: average per-person spending under the waiver may not exceed what institutional care would have cost.1

How Waiver Services Differ from Regular Medicaid

HCBS waiver services are added on top of base Medicaid. They are an array of home and community-based services, medical or non-medical, that let someone get long-term care at home or in the community as an alternative to an institution.4

What a waiver covers depends on the waiver. Services found in state waiver arrays include:4,5

• Personal attendant care. Help with bathing, dressing, meal prep, and mobility.
• Nursing. Care from a nurse delivered at home.
• Respite care. Short-term paid care so family caregivers can rest.
• Adult day care. Supervised daytime care outside the home.
• Minor home modifications. Changes such as ramps and grab bars.
• Emergency response services. A pendant or similar system that calls for help.
• Home-delivered meals. Meals brought to the person's home.
• Dental services. Offered in some waiver arrays.
• Case management. A coordinator who helps arrange and monitor services.
• Assisted living services. Some waivers pay for the care services delivered in an assisted living setting, but federal rules bar a waiver from paying for room and board there, so the resident pays rent and meals from their own income.5

The Waitlist Problem

Because a state may cap waiver enrollment, many states keep a waiting list for their waivers (Texas calls it an "interest list").2,4 For families, the wait is often the hardest part of the system.

According to KFF's 23rd survey of state officials who administer Medicaid home care, 41 states maintained HCBS waiver waiting or interest lists in 2025, with more than 600,000 people on them nationally; every state except Florida answered. Among the 33 of those states that reported a wait time, people on the lists got services after an average of 32 months in 2025, down from 40 months in 2024. KFF cautions that waiting lists are an incomplete measure of unmet need and are not necessarily comparable across states or over time.2

The wait is not evenly distributed. KFF reports that:2

• People with intellectual or developmental disabilities (I/DD) make up almost three-quarters (74%) of the waiting-list population.2
• Older adults and adults with physical disabilities account for nearly one-quarter (23%).2
• The remaining 4% includes medically fragile or technology-dependent children, people with traumatic brain or spinal cord injuries, people with mental illness, and people with HIV/AIDS.2

Under the 2024 Ensuring Access to Medicaid Services final rule (CMS-2442-F), a state that caps a waiver and keeps a waiting list will have to report each year on how it maintains that list, including whether it screens and periodically re-screens people for eligibility, how many people are on it, and the average time people newly enrolled in the past 12 months spent waiting. That requirement is not in force yet: states must comply beginning July 9, 2027, and a state that delivers HCBS through a managed care contract has until its first rating period beginning on or after that date.2

How to Get on a Waiver

The exact process varies by state. Texas's rules show how the sequence works.

Get on the list even if you are not sure you will use it. In Texas, signing up does not require proving eligibility, and a place in a first-come, first-served line cannot be made up later.4

Waivers vs. State Plan HCBS

Not all Medicaid home and community services require a waiver. A state can also offer optional home and community-based services through its regular state plan.3 The enrollment caps and interest lists that make waiver access so hard are a waiver feature: it is under a waiver, unlike regular Medicaid, that a state may limit how many people it serves and open an interest list when demand exceeds the waiver's approved capacity.4

Community First Choice (Section 1915(k)), added by the Affordable Care Act, is an optional Medicaid State Plan benefit, not a waiver, through which a state may furnish home and community-based attendant services and supports. To qualify, a person must be eligible for Medicaid, be in an eligibility group that includes nursing facility services or have income at or below 150% of the federal poverty level, and be determined at least once a year to otherwise need an institutional level of care, such as that of a hospital or nursing facility.1 People already on a 1915(c) waiver interest list may be able to receive CFC services while they wait, if they meet the CFC eligibility and coverage rules.4 The Section 1915(i) HCBS State Plan Option lets a state cover home and community-based services through a state plan amendment, without seeking a federal waiver; the state establishes the benefit by submitting that amendment to CMS for review and approval. Only a minority of states operate an approved 1915(i) benefit, and the roster shifts from year to year as states add or end benefits.6

CFC covers more than attendant care alone: personal assistance services, habilitation services, emergency response services, and support management. A waiver array can add more. Texas STAR+PLUS HCBS adds nursing, respite care, assisted living, dental services, home-delivered meals, and minor home modifications; the state's Health and Human Services Commission notes that STAR+PLUS HCBS operates like a 1915(c) waiver but is actually provided through Texas's 1115 Healthcare Transformation Waiver.4

Common Misconceptions

"An HCBS waiver is the same as home health." It is not. Medicaid home health is a regular state plan benefit, ordered by a physician or other qualified practitioner as part of a written plan of care, that covers part-time or intermittent nursing, home health aide services, and medical supplies and equipment.7 HCBS waiver services are a separate array of long-term supports, medical or non-medical, that let someone live at home instead of in an institution: help with daily tasks, respite, home modifications, and meals.4

"If I'm on Medicaid, I'm automatically on the waiver." You are not. Base Medicaid and waiver enrollment are separate: you have to meet an institutional level of care and get a waiver slot, which may mean waiting on an interest list.1,4 There can be other doors. In Texas, someone already on Medicaid and enrolled with an MCO may be able to bypass the STAR+PLUS HCBS interest list through the upgrade process, and a nursing facility resident may become eligible through Money Follows the Person.4

"A waiver replaces regular Medicaid." It does not. Waiver services are added on top of base Medicaid, not swapped in for it.4

"I earn too much to qualify." Maybe not. Check the income rule for long-term-care Medicaid in your state, not the one for regular Medicaid. In Tennessee, for example, someone seeking TennCare long-term services and supports, including CHOICES home and community-based services, is income-eligible at or below the 2026 Medicaid Income Cap of $2,982 a month (300% of the $994 SSI federal benefit rate). Someone over the cap can set up a Qualified Income Trust (Miller Trust) to become income-eligible, though income placed in the trust still counts toward what they pay for care each month.8

Related Terms

• 1915(c): The section of the Social Security Act that authorizes HCBS waivers.1
• Individual Service Plan (ISP): The written plan of a waiver member's services. In Texas STAR+PLUS, the managed care plan's service coordinator develops the ISP with the member, family members, and the provider, and the plan is reviewed at least every 12 months, when the member's needs change significantly, or when the member asks.9
• Level of care (LOC): The determination that someone would otherwise need institutional care. To be eligible for a 1915(c) waiver, a person must be evaluated as needing the level of care provided in a hospital, a nursing facility, or an intermediate care facility for individuals with intellectual disabilities (ICF/IID), and reevaluated at least once a year.1
• Service coordinator: The case manager who arranges waiver services and the service plan. In Texas STAR+PLUS, service coordination is the managed care plan's duty, and a STAR+PLUS HCBS member must get a face-to-face visit at least twice a year.9
• Interest list: Another name for the HCBS waiver waiting list.
• Managed Care Organization (MCO): A health plan that contracts with a state Medicaid program. In Texas, for example, a Medicaid member already enrolled with an MCO may be able to reach STAR+PLUS HCBS through the upgrade process instead of the interest list.4
• Medicaid spend-down: The medically needy pathway that lets someone whose countable income exceeds the Medicaid income standard become eligible by incurring medical expenses equal to the excess.10

Learn More

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The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.