What Is an HCBS Waiver?

Why It Matters

Regular Medicaid will pay for a nursing home, but it usually will not pay for the attendant care, home modifications, or respite days that would let someone stay in their own home. An HCBS waiver is the Medicaid program that closes that gap.

Most families want a parent, spouse, or child to stay at home. For an older adult, the right waiver can be the difference between entering a nursing facility and aging in place with attendant care, home-delivered meals, an emergency-response system, and a dedicated service coordinator. For the family, it can mean not having to leave a job to provide unpaid care.

What the "Waiver" Actually Waives

Under regular Medicaid, three federal rules create a bias toward institutional care:

  1. Comparability. Every Medicaid enrollee must get the same benefits, so a state cannot offer extensive home care to one group and not another.
  2. Statewideness. Benefits must be available statewide, not only in select counties.
  3. Institutional entitlement. Nursing-facility care is a guaranteed Medicaid entitlement; the equivalent services delivered at home are not.

A 1915(c) waiver asks the federal Medicaid program to set aside these rules for a defined population (for example, adults age 65 and older, adults with intellectual or developmental disabilities, or children who are medically fragile). In exchange, the state commits to cost neutrality: it will spend no more per person on waiver services than it would have spent on institutional care.

How Waiver Services Differ from Regular Medicaid

Regular Medicaid covers medical care: doctor visits, hospital stays, prescriptions, and limited home health. HCBS waiver services are different. They are the supports that let someone live independently, added on top of base Medicaid.

Common waiver services include:

  • Personal attendant care. Help with bathing, dressing, meal prep, medication reminders, and mobility.
  • Respite care. Short-term paid care so family caregivers can rest.
  • Adult day health. Supervised daytime care at a community center, including meals, activities, and health monitoring.
  • Home modifications. Ramps, grab bars, widened doorways, and roll-in showers.
  • Assistive technology. Emergency-response pendants, GPS trackers for people with dementia, and communication devices.
  • Home-delivered meals. Usually one hot meal per day.
  • Habilitation. Training in daily-living skills, especially for adults with intellectual or developmental disabilities.
  • Case management. A service coordinator who builds the care plan and arranges providers.
  • Assisted living services. In some waivers, Medicaid pays for the services portion (not the room and board) of an assisted living facility.

One practical difference from base Medicaid: waiver services usually do not require prior authorization for each visit. The service coordinator builds an individual service plan (ISP) that authorizes a block of hours up front, and the provider delivers against it.

The Waitlist Problem

Because states may cap waiver enrollment, most HCBS waivers keep a waiting list (some states call it an "interest list"). For families, the wait is the single hardest part of the system.

According to KFF's national survey of state HCBS programs, 41 states maintained HCBS waiver waiting or interest lists in 2025, with more than 600,000 people on them nationally. The average wait before services began was 32 months, down from 40 months in 2024.

The wait is not evenly distributed. KFF reports that:

Waiting lists for I/DD waivers can stretch a decade or more, while lists for older-adult waivers are usually shorter. Under the 2024 Ensuring Access to Medicaid Services final rule (CMS-2442-F), the Centers for Medicare & Medicaid Services (CMS) will require every state with a capped waiver to report each year on how it maintains its list, including how many people are waiting and how long they wait. That reporting requirement phases in beginning July 2027.

How to Get on a Waiver

The exact process varies by state, but the sequence is consistent.

1
Step 1

Identify the right waiver

Each waiver serves a specific population: older adults, children with medical needs, or adults with intellectual or developmental disabilities. Your state Medicaid agency's website lists the waivers it operates.

2
Step 2

Get on the interest list

This is usually a single phone call to the state agency. Sign up as early as possible, even if the person does not need services yet, because most lists are first-come, first-served.

3
Step 3

Wait for your name to come up

When you near the top of the list, the state reaches out to begin a formal application.

4
Step 4

Complete the financial and functional screens

Financial eligibility follows institutional Medicaid rules (more generous income limits than regular Medicaid, plus an asset test), and functional eligibility requires a level-of-care determination.

5
Step 5

Build the service plan

Once enrolled, a service coordinator assesses your needs in person and writes the individual service plan (ISP) that authorizes your services.

Get on the list even if you are not sure you will use it. Declining services later is easy; moving up the line once you have fallen behind is not.

Waivers vs. State Plan HCBS

Not all Medicaid home and community services require a waiver. Federal law also lets a state offer HCBS as a regular state plan benefit, which is an entitlement with no enrollment cap and no waiting list.

Community First Choice (Section 1915(k)) provides attendant and habilitation services to Medicaid members who meet a nursing-facility level of care, regardless of waiver enrollment. The Section 1915(i) HCBS State Plan Option lets a state cover home and community-based services through a state plan amendment without a waiver, and therefore without a waiting list or an institutional level-of-care test. Only a minority of states operate an approved 1915(i) benefit.

State plan services typically cover less than a full waiver (for example, fewer attendant-care hours and no home modifications), but there is no cap. In Texas, Community First Choice provides baseline attendant and habilitation services to Medicaid members with a nursing-facility level of care.

Common Misconceptions

"An HCBS waiver is the same as home health." It is not. Home health is short-term, skilled medical care ordered by a doctor (nursing visits, physical therapy) and covered by regular Medicaid or Medicare. HCBS waiver services are long-term, non-medical supports: help with daily tasks, respite, home modifications, and meals.

"If I'm on Medicaid, I'm automatically on the waiver." You are not. Base Medicaid and waiver enrollment are separate. You have to apply, qualify at the higher functional level of care, and have an open slot (or come off the waitlist).

"A waiver replaces regular Medicaid." It does not. Waiver members keep all their regular Medicaid benefits (doctor visits, hospital, prescriptions) and get the waiver services on top. The waiver is additive.

"I earn too much to qualify." HCBS waivers use institutional Medicaid income and asset rules, which are more generous than regular Medicaid. In income-cap states, an individual whose monthly income is at or below the special income limit (300% of the 2026 SSI federal benefit rate of $994, which works out to $2,982 per month) can qualify. A person over that limit can use a Qualified Income Trust (Miller Trust) to become eligible.

  • 1915(c): The section of the Social Security Act that authorizes HCBS waivers.
  • Individual Service Plan (ISP): The written care plan a service coordinator builds for each waiver member, listing approved services and provider assignments.
  • Level of care (LOC): The clinical determination that someone would otherwise require institutional care. Usually nursing-facility LOC for older-adult waivers, and ICF/IID LOC for I/DD waivers.
  • Service coordinator: The case manager who arranges waiver services, monitors the care plan, and is the member's main point of contact with the managed care plan or state agency.
  • Interest list: Another name for the HCBS waiver waiting list.
  • Managed Care Organization (MCO): In many states, HCBS waiver services are delivered through MCOs under managed long-term services and supports programs.
  • Medicaid spend-down: The income-reduction pathway some people in medically needy states use to meet Medicaid eligibility before joining a waiver.

Learn More

MedicaidTexas Medicaid HCBS WaiversTexas HCBS waiver programs help seniors stay home instead of a nursing facility. Learn how STAR+PLUS HCBS, CLASS, HCS, interest lists, and applying work. MedicaidSTAR+PLUS Waiver ProgramTexas STAR+PLUS covers Medicaid managed care for seniors 65+. The HCBS waiver income limit is $2,982/month, and Community First Choice has no waitlist. MedicaidTexas Medicaid Programs for SeniorsTexas Medicaid programs for seniors 65+ include STAR+PLUS, CAS, HCBS waivers, and PACE. Find out what each one covers, who qualifies, and how to enroll. MedicaidTexas Medicaid Nursing Home CoverageTexas Medicaid pays for nursing home care with no waitlist. See the 2026 income ($2,982) and asset ($2,000) limits and what the at-home spouse gets to keep.

Find personalized help understanding senior care benefits at brevy.com.

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.

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