::hero{eyebrow="Georgia Medicaid" headline="Georgia Medicaid Section 1915(c) HCBS Waivers Framework" subhead="How Section 1915(c) of the Social Security Act at 42 USC 1396n(c) authorizes states to waive statewideness comparability and other state plan requirements to deliver long-term services and supports in homes and communities, how 42 CFR 441.300 through 441.310 implements the statute through person-centered planning conflict-free case management cost neutrality state assurances and quality improvement strategy, how the HCBS Final Rule reshaped settings requirements, how the HCBS Access Rule phases in eighty percent direct care worker pass-through and wait list transparency, how electronic visit verification captures service delivery, how Olmstead integration mandates drive 1915(c) use, and how Georgia's seven HCBS waivers including CCSP SOURCE ICWP NOW COMP Katie Beckett TEFRA and Money Follows the Person map to the federal framework."} ::

Section 1915(c) of the Social Security Act is the statutory spine of Georgia's home and community-based services system. Every Georgia Medicaid waiver that lets a person live at home with services instead of a nursing facility or an Intermediate Care Facility for Individuals with Intellectual Disabilities derives its authority from this single section of federal law. The Community Care Services Program (CCSP), Service Options Using Resources in a Community Environment (SOURCE), the Independent Care Waiver Program (ICWP), the New Options Waiver (NOW), the Comprehensive Supports Waiver Program (COMP), Katie Beckett TEFRA, and Money Follows the Person all sit on top of the Section 1915(c) framework. Each waiver has its own population, services, slot count, and administering agency, but the rules that constrain and shape them flow from Section 1915(c) and the implementing regulations at 42 CFR Part 441 Subpart G.

For Georgia families navigating long-term care, the framework matters because it explains why waivers exist, why they have waiting lists, why they require evaluations of need for institutional level of care, why person-centered plans must be reviewed every year, and why the case manager developing the plan generally cannot work for the agency providing the services. The framework also explains why Georgia chose to operate seven different waivers rather than one combined program: each waiver targets a specific population and demonstrates cost neutrality on its own terms. Understanding the framework helps families know what to expect during the application, what their rights are during service planning, how to advocate when needs change, and where to appeal when a denial or reduction feels wrong.

For policymakers, advocates, providers, and researchers, the framework matters because every reform conversation in the Georgia long-term services and supports system runs into it. Expanding slot counts requires cost neutrality justification. Adding new services requires Appendix amendments and CMS approval. Modifying provider rates affects compensation pass-through requirements under the new HCBS Access Rule. Closing or shifting waivers affects waiting list dynamics across the system. The framework is not background context. It is the operating system.

This guide translates Section 1915(c) for Georgia families and stakeholders. It walks through the federal statutory authority and what it allows and prohibits, the regulatory implementation at 42 CFR 441.300 through 441.310, the HCBS Final Rule and what it changed about settings and conflict-free case management, the cost neutrality calculation and why it drives slot caps and waiting lists, the five-year renewal cycle and mid-cycle amendment process, the new HCBS Access Rule and its eighty percent direct care worker pass-through requirement, electronic visit verification under Section 12006 of the 21st Century Cures Act, the Olmstead v. L.C. integration mandate and how 1915(c) operationalizes it, the differences between 1915(c) and other HCBS authorities (Section 1115 demonstrations, 1915(i), 1915(j), 1915(k)), and how Georgia's seven HCBS waivers map to the framework. Worked examples illustrate how the framework plays out for real participants. A frequently asked questions section addresses common questions. A contact directory provides the phone numbers families and stakeholders need.

::callout{title="Key takeaways"}

  • Section 1915(c) of the Social Security Act at 42 USC 1396n(c) authorizes the Secretary of HHS to waive four specific state plan requirements so states can deliver long-term services and supports in homes and communities instead of nursing facilities or ICF/IIDs.
  • The four waivable provisions are statewideness (1902(a)(1)), comparability of benefits (1902(a)(10)(B)), eligibility comparability (1902(a)(10)(C)(i)(III)), and reasonable standards for income and resources (1902(a)(17)). Section 1915(c) does not waive fair hearings, EPSDT for children, mandatory benefits for state plan eligibles, or other core federal requirements.
  • States must demonstrate cost neutrality: aggregate per-participant cost cannot exceed the cost of institutional care. This is the legal basis for slot caps and waiting lists.
  • Section 1915(c) waivers can use the institutional special income rule, allowing eligibility at incomes up to 300 percent of the SSI federal benefit rate ($2,982 monthly in 2026).
  • 42 CFR 441.301(c) requires person-centered service plans, reviewed at least annually, developed through a process directed by the participant.
  • 42 CFR 441.301(c)(1) requires conflict-free case management: the case manager generally cannot be employed by or financially connected to the provider delivering services. Rural single-provider exceptions require firewall protections.
  • The HCBS Final Rule at CMS-2249-F (effective March 17, 2014, transition through March 17, 2023) reshaped settings requirements: integration in greater community, choice in services and providers, privacy and lockable doors in provider-owned residential settings, and a heightened scrutiny presumption for settings with institutional characteristics.
  • The HCBS Access Rule at CMS-2442-F (May 2024, phased through July 2028 and July 2030) requires at least 80 percent of payment for personal care, homemaker, and home health aide services to go to direct care worker compensation, plus compensation and wait list reporting.
  • Electronic Visit Verification under Section 12006 of the 21st Century Cures Act and 42 CFR 441.570 requires electronic capture of six data elements for personal care visits (effective 2021) and home health visits (effective 2023). Georgia uses Tellus/Sandata as the state EVV aggregator.
  • Section 1915(c) waivers are initially approved for three-year terms with subsequent five-year renewals. Mid-cycle Appendix amendments allow service additions, slot increases, rate changes, and other operational updates without a full renewal.
  • Olmstead v. L.C., 527 U.S. 581 (1999), and Title II of the ADA at 42 USC 12132 establish that unjustified institutionalization is discrimination. Section 1915(c) is the primary federal Medicaid tool for Olmstead compliance.
  • Georgia operates seven HCBS pathways: CCSP and SOURCE (administered by DHS Division of Aging Services through 12 Area Agencies on Aging), ICWP (administered directly by DCH), NOW and COMP (administered by DBHDD), Katie Beckett TEFRA (technically a state plan eligibility category under Section 1902(e)(3)), and Money Follows the Person (transition demonstration).
  • Spousal impoverishment protections under Section 1924 apply to all 1915(c) waivers, allowing the community spouse to retain income and assets up to federal limits (2026: CSRA $32,532 to $162,660; MMMNA $2,643.75 to $4,066.50). ::

What Section 1915(c) is and why it exists

By Brevy Care Team · Last verified May 12, 2026

Before 1981, Medicaid had a strong institutional bias. The federal mandatory benefit included nursing facility care, but home and community alternatives were largely unavailable through Medicaid. States that wanted to serve people at home had to pay for those services out of state-only funds. The result was a system that paid generously for nursing facility placement but would not pay to keep someone at home with personal care, day services, or environmental modifications even when home-based care would cost less and the person clearly preferred it.

The Omnibus Budget Reconciliation Act of 1981 added Section 1915(c) to the Social Security Act to address this institutional bias. Section 1915(c) lets the Secretary of HHS waive specific Medicaid state plan requirements so a state can use Medicaid funds for home and community-based services for people who would otherwise need institutional care. The statutory text is at 42 USC 1396n(c).

The animating logic of 1915(c) is twofold. First, many people would prefer to live in their own homes or in community settings rather than in institutions. Second, in many cases home and community-based services cost less than institutional care, particularly when family caregivers contribute substantial unpaid care. By letting states use Medicaid funds for HCBS targeted at people who would otherwise need nursing facility or ICF/IID care, Section 1915(c) creates a more humane and often less expensive alternative.

Section 1915(c) waivers grew rapidly through the 1980s and 1990s as states recognized both the cost savings and the preference of participants for community living. By the early 2000s, Section 1915(c) waivers covered millions of Medicaid participants nationwide. The Olmstead v. L.C. decision in 1999, which held that unjustified institutionalization is discrimination under the Americans with Disabilities Act, accelerated state expansion of HCBS waivers as a tool for Olmstead compliance.

Today Section 1915(c) is the largest single source of federal Medicaid funding for HCBS, though Section 1915(i) state plan HCBS, Section 1915(k) Community First Choice, and Section 1115 demonstrations also fund HCBS through different mechanisms. Georgia uses Section 1915(c) for the bulk of its HCBS spending, with Section 1115 (Pathways and P4HB) and Section 1902(e)(3) (Katie Beckett) playing supplementary roles.

What Section 1915(c) actually waives

This is the most common point of confusion. Section 1915(c) does not waive all of Medicaid. It waives four specific provisions of Section 1902, the section of the Social Security Act that establishes state plan requirements:

Section 1902(a)(1) statewideness. The state plan must operate uniformly throughout the state. A 1915(c) waiver does not have to operate statewide. Georgia's ICWP, for example, has operational variations by region. Slot allocation by region is permitted under 1915(c) but would violate state plan rules.

Section 1902(a)(10)(B) comparability of services. The state plan must provide comparable benefits to all eligible individuals in similar circumstances. A 1915(c) waiver lets participants receive HCBS services not available to the broader Medicaid population. Without this waiver, the state would have to offer personal support services and adult day health to every eligible Medicaid recipient, not just waiver participants.

Section 1902(a)(10)(C)(i)(III) eligibility comparability. The state plan must provide comparable benefits within each eligibility group. A 1915(c) waiver lets states target specific populations such as adults aged 65 and older (CCSP), people with developmental disabilities (NOW and COMP), or children with significant medical needs (Katie Beckett TEFRA pathway, though Katie Beckett technically uses a different authority).

Section 1902(a)(17) reasonable standards for determining income and resources. The state plan must use reasonable standards. A 1915(c) waiver lets the state use the institutional special income rule, which permits eligibility at incomes up to 300 percent of the SSI federal benefit rate (currently $2,982 monthly in 2026). This is critical: without the waiver, the income limit for HCBS would be the regular Medicaid limit, which for many groups in Georgia is substantially lower.

What 1915(c) does not waive matters just as much:

  • Fair hearing rights under Section 1902(a)(3) remain
  • EPSDT (Early Periodic Screening Diagnostic and Treatment) for children under 21 under Section 1905(a)(4)(B) remains
  • Mandatory benefits for state plan eligibles remain (1915(c) participants get the full Medicaid card plus waiver services)
  • Section 1916 cost sharing limits remain
  • Quality and access protections under Section 1902(a)(30)(A) remain
  • Federal nondiscrimination requirements remain
  • Provider qualifications and certification requirements remain

The narrow scope of what Section 1915(c) waives is the source of much of its operational rigor. Because so much of Medicaid law continues to apply to waiver participants, waivers must operate within a complex framework of state plan requirements layered with waiver-specific terms.

The regulatory framework: 42 CFR Part 441 Subpart G

The implementing regulations for Section 1915(c) are at 42 CFR 441.300 through 441.310. They were substantially revised in 2014 by the HCBS Final Rule and again in significant ways by the 2024 HCBS Access Rule.

42 CFR 441.300 scope

Section 441.300 establishes the scope of HCBS waivers and confirms that the Secretary may approve waivers consistent with the statutory authority at Section 1915(c).

42 CFR 441.301 application contents

Section 441.301 is the most operationally important regulation. It specifies what must be in a waiver application and what assurances and operational requirements the state must meet. The key subsections:

441.301(c) Person-centered service plan requirements. Every waiver participant must have a person-centered service plan developed through a process directed by the individual. The plan must reflect what is important to the individual and what is important for the individual, use plain language, include strategies for resolving conflict or disagreement, provide informed choice regarding services and providers, identify risk factors and mitigation, be agreed to in writing, be reviewed and revised at least every 12 months and when needs change, and document who provides services and where.

441.301(c)(1) Conflict-free case management. The case manager developing the person-centered plan generally cannot be employed by or have a financial interest in the provider delivering services. Rural single-provider exceptions are allowed with firewall protections.

441.301(c)(4) HCBS settings characteristics. Settings must be integrated in the greater community, support full access to community life, optimize individual initiative autonomy and independence, facilitate choice of services and providers, and (for provider-owned residential settings) ensure privacy, choice of roommate, visitor access, daily schedule choice, freedom to furnish and decorate, and ability to control finances.

441.301(c)(5) Heightened scrutiny. Settings located on the grounds of public institutions, in buildings that also provide inpatient institutional treatment, or that have the effect of isolating individuals are presumed not to be HCBS settings. States can rebut this presumption through heightened scrutiny review and CMS approval on a site-by-site basis.

42 CFR 441.302 state assurances

Section 441.302 requires states to give CMS specific assurances:

  • Health and welfare of waiver participants is safeguarded
  • Financial accountability mechanisms are in place
  • Level of care evaluations are conducted by qualified evaluators using a documented process
  • Plans of care are developed and implemented
  • Participants are informed of and offered choice between waiver services and institutional care
  • Participants are offered choice of qualified providers
  • Fair hearing rights are protected

42 CFR 441.303 supporting documentation

Section 441.303 specifies the supporting documentation states must provide for waiver applications including:

  • Description of the waiver including services and provider qualifications
  • Cost neutrality calculations
  • Quality improvement strategy
  • Targeting and eligibility criteria
  • Service plan development and monitoring process

42 CFR 441.304 duration of waivers

Initial 1915(c) waivers are approved for three years. Subsequent renewals run for five years. CMS can approve waiver amendments mid-cycle for service additions, slot changes, rate modifications, and other operational updates.

42 CFR 441.305 and 441.306 quality

These sections require states to operate a quality improvement strategy with measures across six domains: administrative authority, level of care, service plan, qualified providers, health and welfare, and financial accountability. States must submit quality strategy updates with each waiver renewal and annual reports through the CMS 372 process.

42 CFR 441.310 limits

Section 441.310 imposes specific limits on what 1915(c) waivers can do. For example, waivers cannot provide room and board (except in adult foster care or similar settings under specific conditions), and waivers cannot duplicate services available through the state plan.

The HCBS Final Rule and what it changed

The HCBS Final Rule, published as CMS-2249-F (settings) and CMS-2296-F (1915(c) and 1915(i)) on January 16, 2014, with an effective date of March 17, 2014, was the most significant change to HCBS policy in a generation. The rule addressed long-standing concerns that some "HCBS" settings were institutional in character despite the home-and-community-based label.

Why the rule was needed

In the years leading up to the rule, advocates had documented HCBS settings that operated more like institutions: large group homes with restricted access to the community, day programs that did not facilitate community integration, employment settings that segregated workers with disabilities from the broader workforce, and provider-owned residences where participants had little choice in roommates, daily schedule, or community access. The HCBS label was being applied to settings that did not actually provide home-and-community-based experiences in any meaningful sense.

What the rule requires

The rule established characteristics that every HCBS setting must have:

Integration in greater community. Participants must have access to community resources, employment in competitive integrated settings, and engagement in community life.

Support for autonomy and independence. Settings must optimize individual initiative.

Choice. Participants must have choice in services, providers, and settings, including non-disability-specific settings.

Privacy and dignity in residential settings. For provider-owned or controlled residential settings:

  • Lockable doors with the participant having keys
  • Choice of roommate (if shared)
  • Freedom to furnish and decorate
  • Daily schedule choice
  • Visitor access at any time
  • Privacy in interaction with visitors
  • Ability to control personal finances

Heightened scrutiny

The rule established a presumption that certain settings are not HCBS:

  • Settings located in publicly or privately operated institutional facilities
  • Settings located on grounds of or immediately adjacent to public institutions
  • Settings that have the effect of isolating participants from the broader community

States can rebut the presumption through heightened scrutiny review. The state must document why the setting is community-based despite its location or characteristics, conduct on-site verification, gather participant input, and submit the analysis to CMS. CMS makes a setting-by-setting determination.

Transition period

The original implementation deadline was March 17, 2019, then extended to March 17, 2023, then extended further with corrective action plans for settings still in transition. States submitted statewide transition plans with site assessments, validation activities, and remediation strategies. The Georgia statewide transition plan is publicly available through DCH and underwent multiple revisions over the transition period.

Cost neutrality: the constraint that drives everything

Section 1915(c)(2)(A) requires that the average per capita cost of services to waiver participants not exceed the average per capita cost that would have been incurred for institutional care for those participants. This is cost neutrality.

The math

CMS calculates cost neutrality using four factors:

Factor D: average annual cost of waiver services per participant Factor D-prime: average annual cost of state plan (acute) Medicaid services for waiver participants Factor G: average annual cost of institutional services per recipient (nursing facility or ICF/IID) Factor G-prime: average annual cost of state plan (acute) Medicaid services for institutional recipients

The cost neutrality formula requires Factor D plus Factor D-prime to be less than or equal to Factor G plus Factor G-prime. In plain language: the total cost of caring for a waiver participant must not exceed the total cost of caring for that person in an institution.

Per-waiver, not state-wide

Cost neutrality is calculated per waiver, not across the state's HCBS portfolio. Georgia must demonstrate cost neutrality for CCSP independently from SOURCE, ICWP, NOW, and COMP. This is why states often operate multiple targeted waivers rather than a single combined HCBS waiver: each waiver demonstrates cost neutrality against its specific comparator institutional setting (nursing facility for CCSP, ICF/IID for NOW and COMP).

The five-year demonstration

States project cost neutrality for the entire waiver period (initial three years, subsequent five years) at application. The state must submit:

  • Projected average annual cost of waiver services for each year
  • Projected average annual cost of institutional services
  • Slot counts and assumptions about participant utilization
  • Service utilization assumptions
  • Rate assumptions

CMS reviews projections and may require adjustments before approval.

Annual reporting via CMS 372

Each year states submit a CMS 372 report documenting actual expenditures and demonstrating ongoing compliance with cost neutrality. If actual costs deviate from projections in ways that threaten cost neutrality, states must take corrective action.

Why this drives waiting lists

Cost neutrality is the legal basis for slot caps and waiting lists. States cannot serve unlimited numbers of participants if doing so would exceed cost neutrality. Slot counts in each waiver are set to maintain projected cost neutrality. When a state wants to expand a waiver, it must propose expansion through an Appendix amendment or renewal that demonstrates ongoing cost neutrality at the higher slot count.

In contrast, Section 1915(i) state plan HCBS has no cost neutrality cap and therefore cannot legally maintain waiting lists. The legal architecture is fundamentally different. This is why states that adopt 1915(i) usually do so for narrowly defined populations where they can predict and budget for the entitlement caseload.

Slot allocation and waiting list dynamics

Each waiver has a federally approved slot count specified in Appendix B of the waiver application. Slots become available through:

  • Participant mortality
  • Aging out (for waivers targeting children)
  • Transition to institutional care
  • Voluntary disenrollment
  • Loss of eligibility (income, residency, level of care)

When slots become available, the state allocates them according to the waiver's targeting and prioritization rules. Different waivers in Georgia use different allocation approaches:

CCSP and SOURCE

DAS allocates CCSP and SOURCE slots through the 12 Area Agencies on Aging covering all 159 Georgia counties. Allocation is generally first-come-first-served subject to functional eligibility, with priority for individuals at imminent risk of nursing facility placement. CCSP and SOURCE typically operate with manageable wait times rather than long static waiting lists.

ICWP

ICWP operates with a substantial waiting list. DCH allocates slots when they become available, with priority for individuals at risk of institutional placement.

NOW and COMP

DBHDD operates NOW and COMP with priority categories:

  • Emergency: imminent risk of institutionalization, family crisis, abuse or neglect, no caregiver
  • Urgent: caregiver aging or has health issues, lack of services creates risk within 12 months
  • Planning: lower urgency, transition planning needed within 12 to 24 months

Wait times for NOW and COMP can be substantial, particularly for individuals in the planning category. Georgia operates a Short Term Assistance Resource (STAR) program that provides emergency support pending permanent slot allocation.

Reserved capacity for Money Follows the Person

A portion of each waiver's slots is reserved for Money Follows the Person transitions. This ensures that institutional residents who want to transition to the community have guaranteed access to a waiver slot. Reserved capacity is documented in each waiver's Appendix B.

Person-centered planning

42 CFR 441.301(c) sets specific requirements for the person-centered service plan that every waiver participant must have.

Process

The plan must be developed through a process directed by the individual. The participant decides who attends planning meetings, what is discussed, and what services are chosen. The case manager facilitates but does not dictate. Family members, friends, and other supporters can attend at the participant's invitation.

Content

The plan must reflect what is important to the individual (preferences, goals, lifestyle choices) and what is important for the individual (health and safety needs). It must include:

  • Description of strengths, needs, and preferences
  • Goals and outcomes the participant wants to achieve
  • Services and supports needed including provider, frequency, and duration
  • Risk factors and mitigation strategies
  • Backup plans for service interruption
  • Cultural considerations
  • Use of plain language
  • Strategies for resolving conflict or disagreement
  • Informed choice regarding services and providers
  • Signatures of the participant and other key parties

Review

Plans must be reviewed and revised at least every 12 months and when the participant's needs change. The annual review is not a paperwork formality. It is the opportunity for the participant to assess what is working, what is not, and what changes are needed.

Conflict-free development

42 CFR 441.301(c)(1)(vi) requires that the case manager developing the plan generally cannot be employed by or have a financial interest in the provider delivering services. The rule recognizes that case managers who work for service providers face structural incentives to recommend services from their employer. Conflict-free case management ensures that the participant's needs and preferences drive the plan, not the provider's revenue.

Rural single-provider exceptions

Rural areas with a single qualified provider can request exception from the strict conflict-free requirement. The state must:

  • Document the lack of alternative providers
  • Implement firewall protections: separate staff for case management vs service delivery
  • Operate internal grievance processes for participants
  • Conduct independent review of plans
  • Submit ongoing CMS monitoring data

Most of Georgia operates conflict-free case management without exception.

Health and welfare assurances

42 CFR 441.302(a) requires states to safeguard the health and welfare of waiver participants. This generates several operational requirements:

Critical incident reporting

States must maintain a system for reporting and tracking critical incidents including abuse, neglect, exploitation, falls with injury, medication errors, missing persons, unexplained injuries, and deaths.

Mortality review

For certain populations (particularly individuals with intellectual and developmental disabilities), the state conducts mortality reviews to identify patterns and improve services.

Backup plans

Person-centered plans must include backup plans for situations where the primary provider cannot deliver services (worker illness, weather emergencies, provider closure). The backup plan identifies alternative providers, informal supports, or contingency arrangements.

Provider qualifications and monitoring

States set qualifications for each service provider category (training, certification, background checks, ongoing competency demonstration). Provider monitoring includes initial and ongoing review.

Service plan implementation

States must verify that services in the person-centered plan are actually being delivered. This is one purpose of EVV (see below).

Electronic Visit Verification (EVV)

Section 12006 of the 21st Century Cures Act of 2016 mandates Electronic Visit Verification for Medicaid Personal Care Services and Home Health Care Services. The regulatory implementation is at 42 CFR 441.570.

What EVV captures

For every visit, the EVV system must electronically capture six data elements:

  1. Type of service performed
  2. Individual receiving the service
  3. Date of the service
  4. Location of service delivery
  5. Individual providing the service
  6. Time the service begins and ends

Effective dates

Personal care services: January 1, 2021 (with one-year good faith effort extension for some states) Home health services: January 1, 2023

Penalties for non-compliance

States that fail to implement EVV face Federal Medical Assistance Percentage (FMAP) reductions: 0.25 percentage point in year one of non-compliance, escalating to 1.0 percentage point by year four. The financial consequence is substantial for states with large HCBS programs.

Georgia implementation

Georgia uses a state-aggregator EVV model with the vendor Tellus (now part of Sandata) approved for personal care and home health services. Providers can use the state vendor or an approved alternative vendor that submits compliant data to the state aggregator.

Operational implications

EVV affects how personal care workers clock in and out (typically through a smartphone app, telephony, or in-home device), how providers bill for services, and how the state verifies service delivery. EVV data also supports critical incident analysis and quality improvement.

The HCBS Access Rule

The Ensuring Access to Medicaid Services rule (CMS-2442-F), published May 2024 with phased effective dates, is the most significant federal HCBS policy change since the 2014 HCBS Final Rule. The Access Rule imposes new transparency, access, and compensation requirements across HCBS programs.

80 percent compensation pass-through

The most consequential provision requires at least 80 percent of payments for personal care, homemaker, and home health aide services to go to direct care worker compensation (wages plus benefits). Provider administrative costs, training, supervision, and profit must come from the remaining 20 percent.

Phase-in:

  • Most states: July 9, 2028
  • Small states with hardship exception: July 9, 2030

Compensation reporting

States must report direct care worker compensation annually, broken down by service category, provider type, and geographic region.

Wait list transparency

States must publicly report wait list data including the size of the wait list, characteristics of individuals on the list (with privacy protections), average wait times, and movement off the list.

Person-centered service plan reassessment

Plans must be reassessed at least annually and when needs change. The state must monitor reassessment timeliness as a quality measure.

Critical incident reporting

States must operate a critical incident system with specific reporting categories and timeliness requirements.

HCBS grievance system

States must operate a grievance system for HCBS participants. Grievances are distinct from appeals of adverse benefit determinations: grievances cover service quality, provider conduct, and other complaints that do not fit the appeals framework.

Phase-in dates

Most provisions begin July 9, 2025, with full implementation including the 80 percent pass-through by July 9, 2028 (most states) or July 9, 2030 (small states with hardship exception).

Operational implications for Georgia

The 80 percent pass-through will require significant operational changes for HCBS providers. Many providers historically allocate more than 20 percent of revenue to administration, supervision, training, and overhead. Compliance will require either rate increases (to maintain the same overhead share at a higher revenue base) or operational restructuring (to reduce overhead and increase direct worker compensation). DCH is engaged in stakeholder consultation about Georgia's implementation approach.

Renewal cycle and amendments

Initial three-year term

A new 1915(c) waiver is approved for an initial three-year term per 42 CFR 441.304(a). The shorter initial term gives CMS and the state time to evaluate operations before committing to a longer cycle.

Five-year renewal

After the initial term, waivers are renewed for five-year terms per 42 CFR 441.304(b). Renewal applications must include updated cost neutrality projections, quality improvement strategy update, settings compliance status, slot count adjustments, and service additions or modifications.

Public notice and tribal consultation

42 CFR 441.304(f) requires public notice for new waivers and renewals with a minimum 30-day comment period. Tribal consultation is required for states with federally-recognized tribes. Georgia conducts public notice through the DCH website and stakeholder meetings.

Mid-cycle amendments

Between renewals, states can amend approved waivers through Appendix amendments. Common amendments:

  • Add or modify services
  • Increase slot count
  • Adjust rates
  • Update quality strategy
  • Modify provider qualifications

CMS review for amendments is generally faster than for new applications or renewals. Public notice is required for substantive amendments.

Appendix K emergency amendments

During the COVID-19 public health emergency, CMS authorized Appendix K emergency amendments that allowed states to make rapid changes to waiver operations: telehealth substitution, suspended in-person requirements, temporary service expansions, modified provider qualifications, and family caregiver payment expansion in some states. Many flexibilities have been extended or made permanent through subsequent amendments or the Consolidated Appropriations Act 2023.

How Section 1915(c) compares to other HCBS authorities

Section 1915(c) is the largest HCBS authority but not the only one. Understanding the alternatives helps explain why states choose Section 1915(c) for some populations and other authorities for others.

Section 1115 demonstrations

Section 1115 of the Social Security Act at 42 USC 1315 gives the Secretary much broader authority to waive Section 1902 provisions and authorize expenditures for demonstration projects. Where 1915(c) waives four specific 1902 provisions, 1115 can waive almost any 1902 provision.

Key differences:

  • 1115 has broader waiver authority
  • 1115 has budget neutrality at the state-wide level (calculated across all Medicaid expenditures); 1915(c) has cost neutrality per-waiver
  • 1115 has Special Terms and Conditions as the operating contract; 1915(c) has Appendices A through K
  • 1115 is generally approved for five-year terms; 1915(c) is three-year initial then five-year
  • 1115 supports broader populations (uninsured adults, alternative benefit plans, etc.); 1915(c) is HCBS-specific

Georgia uses Section 1115 for Pathways to Coverage and Planning for Healthy Babies but not for any HCBS waiver. States like Tennessee (TennCare III) use Section 1115 for their entire Medicaid program including HCBS.

Section 1915(i) State Plan HCBS

Section 1915(i) at 42 USC 1396n(i) lets states cover HCBS as a state plan benefit rather than as a waiver. The Deficit Reduction Act of 2005 added Section 1915(i); the Affordable Care Act of 2010 substantially expanded the option through Section 2402.

Key differences from 1915(c):

  • 1915(i) is an entitlement (no legal wait lists)
  • 1915(i) does not require institutional level of care (uses needs-based criteria)
  • 1915(i) cannot use the institutional special income rule (uses state plan income standards)
  • 1915(i) cannot target as narrowly as 1915(c) but allows several target populations

Because 1915(i) is an entitlement, states have generally been cautious about adopting it. The financial exposure of an open-ended entitlement is significant. Georgia does not currently operate a 1915(i) program.

Section 1915(j) Self-Direction

Section 1915(j) at 42 USC 1396n(j) authorizes self-directed services (sometimes called "cash and counseling"). Under 1915(j), participants direct their own services: hiring and firing workers, setting rates within budget limits, and choosing services. The authority can be combined with 1915(c). Some of Georgia's waivers include self-direction elements.

Section 1915(k) Community First Choice (CFC)

Section 1915(k) at 42 USC 1396n(k), added by ACA 2010 Section 2401, authorizes Community First Choice as a state plan benefit (not a waiver). CFC provides personal care assistance, backup systems, and skills training to support community living.

Key differences from 1915(c):

  • CFC is a state plan service (entitlement)
  • CFC provides 6 percent enhanced FMAP for CFC services (versus regular FMAP for 1915(c))
  • States must offer CFC statewide if they adopt it
  • CFC requires institutional level of care eligibility

Georgia does not currently operate CFC.

PACE (Program of All-Inclusive Care for the Elderly)

PACE operates under separate Section 1894 authority and is a capitated payment model that combines Medicare and Medicaid for dual-eligibles age 55 and older who meet nursing-facility level of care. PACE participants receive comprehensive care through a PACE organization that takes full financial responsibility for all care.

Key differences from 1915(c):

  • PACE is capitated; 1915(c) is fee-for-service
  • PACE requires 55+ age and nursing-facility level of care; 1915(c) varies by waiver
  • PACE cannot be combined with 1915(c) for the same individual at the same time
  • PACE is voluntary enrollment

Georgia operates PACE in Atlanta-metro and is expanding to additional regions.

Olmstead, the ADA, and the integration mandate

The Supreme Court's decision in Olmstead v. L.C., 527 U.S. 581 (1999), held that the unjustified institutionalization of people with disabilities is discrimination under Title II of the Americans with Disabilities Act (42 USC 12132). The Court established that states must provide community-based services when:

  1. Treatment professionals determine community placement is appropriate
  2. The individual does not oppose such placement
  3. Placement can be reasonably accommodated taking into account the state's resources and the needs of others with disabilities

Section 1915(c) is the primary federal Medicaid tool for Olmstead compliance. By using 1915(c) waivers, states create the funding pathway for community-based services that the Olmstead integration mandate requires.

DOJ enforcement and state settlements

The Department of Justice has used Olmstead enforcement to drive state HCBS expansion through settlement agreements. Multiple states have entered comprehensive Olmstead settlements requiring expanded HCBS capacity, supported housing, and crisis services.

Georgia's 2010 DOJ Olmstead settlement

Georgia entered a DOJ Olmstead settlement in 2010 focused on people with developmental disabilities and serious and persistent mental illness. The settlement required:

  • Expanded HCBS waiver capacity for people with DD
  • Supported housing for people with serious mental illness
  • Crisis intervention services
  • Assertive Community Treatment (ACT) teams
  • Independent monitor oversight

The settlement has shaped Georgia's HCBS expansion for over a decade. Many of the NOW and COMP slot additions, supported housing development, and crisis service expansions trace to the settlement requirements.

Spousal impoverishment

Section 1924 of the Social Security Act (originally enacted in the Medicare Catastrophic Coverage Act of 1988) protects a community spouse's income and resources when the other spouse needs long-term care.

Pre-ACA: institutional spousal impoverishment

Spousal impoverishment historically applied only to institutional care. A spouse in a nursing facility was eligible for spousal impoverishment protections, but a spouse on a 1915(c) HCBS waiver was not.

ACA Section 2404 and subsequent extensions

The Affordable Care Act of 2010 Section 2404 extended spousal impoverishment to all 1915(c) HCBS waiver participants for a five-year period. Subsequent legislation extended the protection multiple times. The Bipartisan Budget Act 2018 extended through 2018, the Consolidated Appropriations Act 2023 §5121 extended through September 30, 2027.

2026 figures

  • Community Spouse Resource Allowance (CSRA) minimum: $32,532
  • CSRA maximum: $162,660
  • Minimum Monthly Maintenance Needs Allowance (MMMNA): $2,643.75
  • Maximum MMMNA: $4,066.50

These figures are adjusted annually for inflation and apply equally to 1915(c) waiver participants in Georgia and to institutional participants.

Georgia's seven HCBS pathways mapped to the framework

Each Georgia HCBS pathway maps to specific elements of the federal framework. The administrative responsibility varies by pathway.

CCSP (Community Care Services Program)

  • Authority: Section 1915(c)
  • Population: aged (65+) or adults with disabilities at nursing facility level of care
  • Administrator: DHS Division of Aging Services through 12 Area Agencies on Aging
  • Services: personal support, adult day health, alternative living services, emergency response, home-delivered meals, personal emergency response, respite, skilled nursing, environmental modifications
  • Slots: approximately 11,000 to 13,000 active
  • Eligibility: institutional special income rule (300% SSI, $2,982 monthly in 2026)
  • Cost neutrality comparator: nursing facility

SOURCE (Service Options Using Resources in a Community Environment)

  • Authority: Section 1915(c) and 1915(b)(4) (selective contracting) combined
  • Population: aged or disabled with primary care home model
  • Administrator: DHS Division of Aging Services through enhanced PCMH providers
  • Services: same as CCSP plus enhanced care coordination through a primary care physician
  • Slots: integrated with CCSP enrollment counts
  • Key differentiator: primary care physician coordinates all services

ICWP (Independent Care Waiver Program)

  • Authority: Section 1915(c)
  • Population: physical disability ages 21 to 64 at hospital or nursing-facility level of care
  • Administrator: DCH directly
  • Services: personal support, case management, respite, environmental modifications, specialized medical equipment, alternative living services
  • Slots: approximately 1,600
  • Waiting list: typically substantial

NOW (New Options Waiver)

  • Authority: Section 1915(c)
  • Population: adults with developmental disabilities with moderate support needs
  • Administrator: DBHDD through regional offices
  • Services: community living support, community access, respite, supported employment, behavioral support, environmental adaptations
  • Slots: approximately 5,000 to 6,000
  • Waiting list: significant (often multi-year for non-emergency)

COMP (Comprehensive Supports Waiver Program)

  • Authority: Section 1915(c)
  • Population: adults with developmental disabilities with extensive support needs
  • Administrator: DBHDD through regional offices
  • Services: more intensive than NOW including residential supports
  • Slots: approximately 5,000 to 7,000
  • Waiting list: significant

Katie Beckett TEFRA

  • Authority: Section 1902(e)(3) (TEFRA 1982 Section 134), not Section 1915(c), but functions as an HCBS pathway
  • Population: children with significant medical needs who would qualify for hospital or nursing-facility level of care
  • Allows parents' income to be disregarded for the child's eligibility
  • Provides full state plan Medicaid benefits (no specialized waiver services beyond standard EPSDT)
  • Administrator: DCH through contracted vendor
  • No waiting list (state plan eligibility category)

Money Follows the Person (MFP)

  • Authority: Section 1915(c) waiver participation combined with DRA 2005 demonstration enhanced FMAP
  • Population: individuals transitioning from institutions (90+ days in nursing facility or ICF/IID)
  • Services: transition coordination, enhanced FMAP for 12 months post-transition, transition coordination services
  • Administrator: DCH with DAS and DBHDD coordination
  • Status: demonstration extended through CARES Act and Consolidated Appropriations Act 2023

Worked examples

Eleanor 78 Atlanta CCSP

Eleanor lives in DeKalb County. She has moderate dementia, hypertension, and arthritis. After a fall and brief hospitalization, her geriatrician determines she needs nursing-facility level of care but can stay home with services. Her daughter Janet contacts the Atlanta Regional Commission (the Area Agency on Aging serving the metro Atlanta region).

A CCSP care manager visits Eleanor at home and conducts the Determination of Need-Revised (DON-R) assessment. The score confirms nursing-facility level of care. Eleanor's monthly Social Security income is $1,800, below the 300% SSI threshold of $2,982 monthly. She owns no countable resources above the $2,000 limit.

The care manager develops Eleanor's person-centered service plan with Eleanor and Janet. The plan includes personal support 4 hours daily, adult day health 3 days weekly, home-delivered meals, and emergency response. Eleanor expresses that her goals are to stay in her own home, see her grandchildren regularly, and continue attending her church.

Janet remains the primary caregiver evenings and weekends. The plan includes a backup plan for situations where the personal support worker is unavailable: Janet covers, and a backup worker from the agency provides relief on weekends.

Cost neutrality math: CCSP services for Eleanor cost approximately $35,000 annually. Nursing facility placement would cost approximately $90,000 annually. The waiver saves substantial federal-state dollars per participant while letting Eleanor live where she wants to live.

The care manager reviews the plan annually. After 18 months, Eleanor's dementia progresses and her personal support hours increase to 6 hours daily.

Marcus 32 Macon ICWP

Marcus sustained a spinal cord injury in a motor vehicle accident at age 30. After acute rehab at the Shepherd Center in Atlanta, he returned to his apartment in Macon. He cannot independently perform activities of daily living: he needs assistance with transfers, bathing, dressing, bowel and bladder management, and meal preparation.

ICWP eligibility requires physical disability ages 21 to 64 and hospital or nursing-facility level of care. Marcus's functional assessment confirms eligibility. He had been on the ICWP waiting list for 14 months before a slot opened.

His ICWP services include personal support 8 hours daily, case management, environmental modifications (a ramp at his apartment building entrance and an accessible bathroom retrofit), and specialized medical equipment (a manual wheelchair and pressure-relief cushion). He also receives state plan Medicaid services including durable medical equipment, prescription drugs, and outpatient rehab therapy.

His person-centered plan documents his goal of independent living and employment. After 18 months, Marcus begins part-time remote work as a customer service representative. His earned income remains below the 300% SSI threshold, so ICWP eligibility continues.

The plan includes a backup plan for personal support coverage if his primary worker is unavailable. The backup plan identifies a second worker through the agency and Marcus's mother as a contingent unpaid caregiver for short gaps.

Aisha 28 Savannah COMP

Aisha has severe intellectual disability and autism with significant behavioral needs. She graduated from school at age 21 and lived with her aging parents until age 28. Her family had been on the COMP waiting list for six years in the planning priority category.

When Aisha's father was diagnosed with cancer, her family documented urgent priority due to caregiver health issues. DBHDD escalated her status from planning to urgent. When a COMP slot became available through another participant's institutional placement (a death in a host home), Aisha was offered the slot.

Her DBHDD support coordinator developed a person-centered plan with Aisha (using augmentative communication), her family, and the host home provider. The plan placed her in a host home setting with one other resident, with community living supports, community access services, structured day programming, and behavioral support.

The host home meets HCBS settings requirements: Aisha has a lockable door, choice in roommate, can decorate her space, and has access to the community. Her plan documents her expressed preferences (including her love of music and her preferred meals) and her family's input.

The conflict-free case management standard means the support coordinator is not employed by the host home provider. The support coordinator monitors plan implementation and quality.

Annual person-centered plan reviews include Aisha's preferences and progress on her goals. After two years, her behavioral support needs decrease and her day programming expands to include a supported employment trial.

Jamil 8 Albany Katie Beckett TEFRA

Jamil has a complex congenital heart condition requiring ongoing pediatric cardiology care, durable medical equipment, and skilled nursing in the home. His parents earn $95,000 combined, which is above regular Medicaid income limits for children at his family's household size.

Without Katie Beckett TEFRA, Jamil would not qualify for Medicaid based on his parents' income. He would have to rely on his father's employer health plan, which does not cover the level of in-home skilled nursing he requires.

Under Section 1902(e)(3) (TEFRA Section 134), Georgia disregards parent income for children who meet specific medical and functional criteria. Jamil's pediatric cardiologist completes the medical review documenting that he would meet hospital or nursing-facility level of care without home-based services.

Once approved, Jamil receives the full Medicaid state plan benefit including private duty nursing 12 hours daily. These services allow him to live at home with his family rather than in a pediatric long-term care facility.

Katie Beckett TEFRA is not technically a Section 1915(c) waiver. It is a state plan eligibility category authorized by Section 1902(e)(3). But it functions as Georgia's primary HCBS pathway for medically complex children, and it is regulated through the same DCH framework that governs the 1915(c) waivers.

Diana 65 Augusta SOURCE

Diana has Type 2 diabetes, COPD, and early-stage chronic kidney disease. After hospitalization for diabetic complications and pneumonia, her medical team recommends home-based supports plus tight primary care coordination to prevent readmissions.

Diana enrolls in SOURCE. The SOURCE primary care medical home model means her SOURCE primary care provider coordinates all her care: cardiology, nephrology, endocrinology, pulmonology, and her HCBS services (personal support, adult day, home-delivered meals).

The integrated coordination reduces Diana's emergency department visits and hospital readmissions. Her A1C improves from 9.8 to 7.4 over 12 months. Her COPD exacerbations decrease in frequency and severity.

Her person-centered plan includes her goals around managing her conditions, maintaining her garden, and visiting her grandchildren in Atlanta twice yearly. The plan is reviewed at six months because of significant health improvement and then annually thereafter.

Tyrell 24 Columbus NOW

Tyrell has Down syndrome with mild-to-moderate support needs. He transitioned out of high school at age 22 through Georgia's school-to-adult-services transition planning. DBHDD placed him on the NOW waiting list at planning priority.

After 18 months on the waiting list, a slot opened. NOW services include community living supports (Tyrell lives with his parents but a support worker helps him develop independence skills), community access for recreation, supported employment (he works 25 hours weekly at a community grocery store with a job coach), and respite for his family.

Annual person-centered planning includes Tyrell's stated goals: increased independence, savings toward a future apartment, and dating. His support plan documents these goals and identifies steps to achieve them.

Conflict-free case management means his DBHDD support coordinator does not work for the community living supports provider or the supported employment provider. The support coordinator monitors quality and connects Tyrell with resources independent of any provider's revenue interest.

Practical guidance

How to apply for a Georgia HCBS waiver

Each waiver has a distinct entry point:

  • CCSP and SOURCE: contact the Georgia Aging and Disability Resource Center at 1-866-552-4464 or the Area Agency on Aging serving your county
  • ICWP: contact ICWP case management at 770-961-6880
  • NOW and COMP: contact DBHDD Intake and Evaluation at 1-800-715-4225 to be added to the planning list and complete functional assessment
  • Katie Beckett TEFRA: contact the Katie Beckett office at 770-344-0823
  • Money Follows the Person: contact ADRC at 1-866-552-4464 if you or a family member is in a nursing facility or ICF/IID for 90+ days and wants to transition

What to expect in the assessment

The assessment confirms eligibility for the waiver including:

  • Functional eligibility (does the person need institutional level of care)
  • Financial eligibility (income, resources, spousal impoverishment if married)
  • Categorical eligibility (age, disability, diagnosis)

Functional assessments use standardized tools: DON-R for CCSP and SOURCE, MAPP-IT or similar for NOW and COMP, ICWP-specific instrument for ICWP.

What rights you have during person-centered planning

Federal law (42 CFR 441.301(c)) guarantees that you direct the planning process. You decide who attends. You decide what is discussed. You decide which services and providers you want from among the qualified options. You can disagree with proposed services and request alternatives. You can request a plan review more often than annually if your needs change.

What to do if you are denied

A denial of waiver eligibility or a denial or reduction of waiver services is an adverse benefit determination. You have the right to:

  • A written notice explaining the denial
  • An appeal through the state fair hearing process
  • Aid paid pending (continued services) if you appeal within 10 days of the notice
  • Free legal assistance through Georgia Legal Services or Disability Rights Georgia

What the HCBS Access Rule will change

Beginning in 2025 and phasing in through 2028 and 2030, the HCBS Access Rule will:

  • Require at least 80% of payments for personal care, homemaker, and home health aide services to go to direct care worker compensation
  • Require state wait list and compensation reporting
  • Require annual person-centered plan reassessment
  • Require an HCBS grievance system

These changes are designed to improve direct care worker wages and benefits, increase transparency, and strengthen consumer protections.

::accordion :::accordion-item{title="What is Section 1915(c) and why does it matter for Georgia families?"} Section 1915(c) of the Social Security Act at 42 USC 1396n(c) is the federal statute that lets states use Medicaid funds for home and community-based services for people who would otherwise need nursing facility or ICF/IID care. Every Georgia Medicaid HCBS waiver (CCSP, SOURCE, ICWP, NOW, COMP) derives its authority from this section. Section 1915(c) is what makes it possible for an older adult to receive personal care at home with Medicaid funds, for an adult with a developmental disability to receive supported employment through Medicaid, or for a person with physical disability to receive environmental modifications through Medicaid. Without Section 1915(c), Medicaid would only pay for institutional care. :::

:::accordion-item{title="What does Section 1915(c) actually waive?"} Section 1915(c) waives four specific provisions of Section 1902 of the Social Security Act: statewideness (1902(a)(1)), comparability of benefits (1902(a)(10)(B)), eligibility comparability (1902(a)(10)(C)(i)(III)), and reasonable standards for income and resources (1902(a)(17)). It does not waive other Medicaid requirements. Waiver participants still have fair hearing rights, EPSDT rights for children under 21, mandatory state plan benefits, cost sharing protections under Section 1916, and quality and access protections. :::

:::accordion-item{title="What is cost neutrality and why are there waiting lists?"} Section 1915(c)(2)(A) requires that the average per capita cost of waiver services not exceed the cost of institutional care. This is cost neutrality. States project costs for the waiver period and must demonstrate ongoing compliance annually through the CMS 372 report. Cost neutrality is the legal basis for slot caps and waiting lists: states cannot serve unlimited participants if doing so would exceed the cost neutrality cap. In contrast, Section 1915(i) state plan HCBS has no cost neutrality cap and therefore cannot legally maintain wait lists. Georgia's wait lists for NOW and COMP can be multi-year. CCSP and SOURCE typically have shorter waits. :::

:::accordion-item{title="What is conflict-free case management?"} 42 CFR 441.301(c)(1)(vi) requires that the case manager who develops a participant's person-centered service plan generally cannot be employed by or have a financial interest in the provider delivering services. The rule recognizes that case managers who work for service providers face structural incentives to recommend services from their employer. Conflict-free case management ensures the participant's needs and preferences drive the plan. Rural areas with a single qualified provider can request an exception with firewall protections. Most of Georgia operates conflict-free case management. :::

:::accordion-item{title="What is the HCBS Final Rule and what did it change?"} The HCBS Final Rule at CMS-2249-F (effective March 17, 2014) reshaped what counts as an HCBS setting. Settings must be integrated in the greater community, support full access to community life, optimize autonomy, and facilitate choice. Provider-owned residential settings must ensure privacy (lockable doors), choice of roommate, visitor access, daily schedule choice, and ability to control finances. Settings located on grounds of institutions or that isolate participants are presumed not to be HCBS settings unless the state rebuts the presumption through heightened scrutiny review. The transition period extended through March 17, 2023, with corrective action plans for settings still in transition. :::

:::accordion-item{title="What is the HCBS Access Rule and when does it take effect?"} The HCBS Access Rule at CMS-2442-F (May 2024) imposes new transparency and access requirements: at least 80 percent of payment for personal care, homemaker, and home health aide services must go to direct care worker compensation; states must publicly report compensation, wait list data, and person-centered plan reassessment timeliness; states must operate an HCBS grievance system; and person-centered plans must be reassessed annually plus when needs change. Most provisions begin July 9, 2025. The 80 percent pass-through phases in through July 9, 2028 (most states) or July 9, 2030 (small states with hardship exception). :::

:::accordion-item{title="What is Electronic Visit Verification?"} Section 12006 of the 21st Century Cures Act and 42 CFR 441.570 require electronic capture of six data elements for personal care and home health visits: type of service, individual receiving the service, date, location, individual providing the service, and start and end times. EVV was effective January 1, 2021 for personal care and January 1, 2023 for home health. Georgia uses Tellus (now part of Sandata) as the state EVV aggregator. Providers can use the state vendor or an approved alternative vendor. :::

:::accordion-item{title="What income limit applies to 1915(c) waivers in Georgia?"} Section 1915(c) waivers can use the institutional special income rule, which permits eligibility at incomes up to 300 percent of the SSI federal benefit rate. In 2026, this is $2,982 monthly. Georgia uses this rule for CCSP, SOURCE, ICWP, NOW, COMP, and Katie Beckett TEFRA. Spousal impoverishment under Section 1924 applies if the waiver participant is married, allowing the community spouse to retain income up to the MMMNA ($2,643.75 to $4,066.50 monthly in 2026) and resources up to the CSRA ($32,532 to $162,660 in 2026). :::

:::accordion-item{title="How long does it take to get a Georgia waiver slot?"} Wait times vary substantially by waiver. CCSP and SOURCE typically have manageable wait times with priority for individuals at imminent risk of nursing facility placement. ICWP wait times are substantial. NOW and COMP wait times are significant, often multi-year for individuals in the planning priority category. Emergency priority can shorten the wait. Georgia operates a Short Term Assistance Resource (STAR) program for emergency support pending permanent NOW or COMP slot allocation. :::

:::accordion-item{title="How is Section 1915(c) different from Section 1115?"} Section 1115 demonstrations at 42 USC 1315 give the Secretary much broader authority to waive Section 1902 provisions and authorize expenditures. Section 1115 has state-wide budget neutrality (calculated across all Medicaid expenditures), Special Terms and Conditions as the operating contract, and typically five-year terms. Section 1915(c) has per-waiver cost neutrality, Appendices A through K as the operating framework, and three-year initial then five-year renewal terms. Georgia uses Section 1115 for Pathways to Coverage and P4HB but not for HCBS waivers. Some states like Tennessee operate their entire Medicaid program (including HCBS) under Section 1115 authority. :::

:::accordion-item{title="Can I direct my own services under a Georgia waiver?"} Section 1915(j) authorizes self-directed services (sometimes called "cash and counseling"). Some of Georgia's 1915(c) waivers include self-direction elements that let participants hire and fire workers, set rates within budget limits, and choose services. Self-direction is not available in every waiver or for every service. Ask the case manager or support coordinator whether self-direction is available for your waiver and what services it covers. :::

:::accordion-item{title="What is Olmstead and how does it affect HCBS in Georgia?"} Olmstead v. L.C., 527 U.S. 581 (1999), held that unjustified institutionalization of people with disabilities is discrimination under Title II of the ADA at 42 USC 12132. States must provide community-based services when treatment professionals recommend community placement, the individual does not oppose it, and placement can be reasonably accommodated. Section 1915(c) is the primary federal Medicaid tool for Olmstead compliance. Georgia entered a comprehensive DOJ Olmstead settlement in 2010 focused on people with developmental disabilities and serious mental illness, which has driven HCBS expansion for over a decade. :::

:::accordion-item{title="What happens if I am denied a waiver or my services are reduced?"} A denial of waiver eligibility or a reduction in waiver services is an adverse benefit determination. You have the right to a written notice explaining the action, the right to appeal through the state fair hearing process, and (if you appeal within 10 days of the notice) the right to aid paid pending (continuation of services during the appeal). Free legal assistance is available through Georgia Legal Services Program (1-833-457-7529) and Disability Rights Georgia (1-800-537-2329). The Georgia Long-Term Care Ombudsman (1-866-552-4464) can also assist with concerns about service quality or provider conduct. :::

:::accordion-item{title="Who do I call if I have a question about a Georgia HCBS waiver?"} For CCSP, SOURCE, or general aging and disability questions, call the Aging and Disability Resource Center at 1-866-552-4464. For NOW or COMP questions, call DBHDD Intake and Evaluation at 1-800-715-4225. For ICWP questions, call 770-961-6880. For Katie Beckett TEFRA, call 770-344-0823. For Money Follows the Person, call ADRC at 1-866-552-4464. For appeals or legal assistance, call Georgia Legal Services at 1-833-457-7529 or Disability Rights Georgia at 1-800-537-2329. ::: ::

How Brevy can help

Brevy's care navigators help Georgia families understand the HCBS waiver framework, identify which waivers may fit their family member's needs, navigate the application and assessment process, advocate during person-centered planning, and appeal denials or service reductions. Our team includes social workers, registered nurses, and benefits specialists with deep experience in Georgia Medicaid HCBS. Visit brevy.com to learn more about our services or to request a no-cost consultation.

::cta{title="Georgia Medicaid HCBS Waivers: Phone Directory" body="If you or a family member may need home and community-based services through a Georgia Medicaid waiver, these are the contacts you may need. Save them. Call them. Apply, appeal, advocate."}

  • DCH Medicaid Member Services: 1-866-211-0950
  • Georgia Aging and Disability Resource Center (ADRC): 1-866-552-4464 (CCSP, SOURCE, MFP, Long-Term Care Ombudsman)
  • DBHDD Intake and Evaluation: 1-800-715-4225 (NOW, COMP)
  • ICWP Case Management: 770-961-6880
  • NOW/COMP Waiver Services Section: 404-657-2252
  • Katie Beckett TEFRA: 770-344-0823
  • Disability Rights Georgia: 1-800-537-2329
  • Georgia Legal Services Program: 1-833-457-7529
  • Georgia Long-Term Care Ombudsman: 1-866-552-4464
  • AARP Georgia: 1-866-295-7281
  • The Arc of Georgia: 1-800-836-2724
  • CMS Region IV (Atlanta): 404-562-7150
  • Georgia Medicaid Fair Hearings: 404-651-7400
  • OSAH (Office of State Administrative Hearings): 404-651-7400
  • Brevy Care Navigation: brevy.com ::

This guide reflects federal law and Georgia Medicaid policy as of May 12, 2026. Federal regulations, state plan amendments, waiver renewals, and CMS guidance change periodically. Always verify current rules, slot availability, waiting list status, and procedures with DCH, the relevant administering agency, or your case manager or support coordinator. Brevy publishes informational guides at brevy.com to help Georgia families navigate eldercare, disability services, and Medicaid. Brevy is not a law firm and does not provide legal advice. For legal questions about waiver eligibility, denials, appeals, or rights, consult Georgia Legal Services Program (1-833-457-7529) or Disability Rights Georgia (1-800-537-2329).

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Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.