Georgia Medicaid Section 1915(i): HCBS State Plan Option Guide

Georgia delivers its Medicaid home and community-based services (HCBS) under Section 1915(c) waiver authority, not through Section 1915(i). That state plan option lets a state cover HCBS through a state plan amendment instead of a federal waiver, so it is not built on the waiver's institutional level-of-care test. For a Georgia family, that means the home care, day services, and personal support you can actually reach run through the state's four Section 1915(c) waivers, which do require an institutional level of care and can carry waiting lists. This guide explains what the Section 1915(i) HCBS state plan option is, how it differs from a waiver, why Georgia uses waivers instead, and what your family can do today.1

In This Guide

• What the Section 1915(i) HCBS state plan option is
• How 1915(i) differs from a 1915(c) waiver
• How Georgia delivers Medicaid HCBS without the 1915(i) state plan option
• What Georgia's non-adoption of the Medicaid HCBS state plan option means
• Which states have adopted Section 1915(i)
• Frequently asked questions
• Learn More

What the Section 1915(i) HCBS state plan option is

Section 1915(i) of the Social Security Act is a Medicaid state plan option. It lets a state cover home and community-based services through a state plan amendment, the same way it covers doctor visits or hospital care, rather than through a federal waiver. Congress created the option in the Deficit Reduction Act of 2005 and amended it in the Affordable Care Act. A state that wants the benefit submits a state plan amendment to CMS for review and approval.1

That structural choice, a state plan benefit rather than a waiver, is the whole point of 1915(i). A waiver is a special, time-limited grant of permission with its own rules; a state plan benefit is part of the standing Medicaid program. Self-direction, where the participant hires, supervises, and directs their own workers or controls an individualized service budget, is available under 1915(i) just as it is under 1915(c) waivers and other Medicaid authorities, but it is a state election, not an automatic feature.3

For most families, though, the limiting factor is availability. Only a minority of states operate an approved 1915(i) benefit, so for the majority, including Georgia, the option exists on paper in federal law but not in their state's Medicaid program.1

How 1915(i) differs from a 1915(c) waiver

The difference that matters to a real family is the level-of-care test. A Section 1915(c) waiver may only cover someone for whom the state has determined that, without the waiver's services, the person would need the level of care provided in a hospital, a nursing facility, or an intermediate care facility for individuals with intellectual disabilities (ICF/IID). That determination has to be repeated at least once a year.3

That institutional standard, nursing facility level of care and its analogues, is itself a clinical judgment that each state defines for itself, looking at things like help needed with activities of daily living, skilled-nursing needs, and cognitive impairment. There is no single federal threshold; the bar is set state by state.4

Section 1915(i) takes the other route. Because it adds HCBS to the Medicaid state plan instead of running through the waiver authority, it is not built on that institutional level-of-care gate. That design is what lets a 1915(i) benefit reach people whose needs are real but not yet nursing-home level, the population a waiver's level-of-care requirement turns away.1,3

A second structural contrast is capacity. A 1915(c) waiver may limit the number of people it serves: the state's waiver application specifies a maximum number of unduplicated participants for each waiver year, which is a limit on the size of the program. Federal law bars the Secretary from limiting that number to fewer than 200, but that is a constraint on what CMS may impose, not a promise that any particular waiver has 200 slots open for you. That cap is the mechanism behind the waiting lists families hit on the waiver side. A state plan benefit is not built around that kind of enrollment cap.3

How Georgia delivers Medicaid HCBS without the 1915(i) state plan option

Georgia runs its home and community-based services through four active Section 1915(c) waivers, and its waiver applications, including the one for the Elderly and Disabled Waiver, request approval under Section 1915(c) authority rather than as a state plan benefit:2,1

• Elderly and Disabled Waiver Program (EDWP), administered by the Georgia Department of Community Health (DCH), serves older adults and adults with physical disabilities who require nursing facility level of care. It is delivered through two service-delivery models, not two separate waivers: the Community Care Services Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE), which pairs the same service array with physician-led care coordination.
• Independent Care Waiver Program (ICWP), administered by DCH, serves adults who apply between the ages of 21 and 64 with severe physical disabilities or traumatic brain injury who require hospital or nursing facility level of care.
• New Options Waiver (NOW) and the Comprehensive Supports Waiver (COMP), both administered by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD), serve people with intellectual and developmental disabilities who require an ICF/IID level of care. NOW and COMP differ mainly in the intensity of support they fund.

Every one of those four is a 1915(c) waiver, so every one carries the institutional level-of-care requirement and the enrollment caps that come with the waiver authority.3 That is exactly the gap a 1915(i) benefit would fill, and Georgia has not put one in place. Georgia's paid-family-caregiver pathways run through these same waivers and related programs, not through any 1915(i) benefit; a relative who gets paid to provide care in Georgia does so as a waiver service, not under 1915(i).5

What Georgia's non-adoption of the Medicaid HCBS state plan option means

The person who loses out is the one in the middle: someone with a serious mental illness, an acquired brain injury, early-stage cognitive decline, or a developmental disability with lighter support needs, who needs real community help but does not yet meet a nursing facility or ICF/IID level of care. In a 1915(i) state, that person might qualify for HCBS through the state plan. In Georgia, the 1915(c) waivers that fund the richest HCBS are gated behind the institutional level-of-care test, so a sub-institutional applicant often does not qualify, or waits.3

That does not leave a Georgia family with nothing. The practical path is to get assessed and find the right door rather than wait for a 1915(i) benefit the state has not put in place.

Which states have adopted Section 1915(i)

Only a minority of states operate an approved 1915(i) benefit, and the exact roster changes from year to year as states add new benefits or end existing ones. The clearest federal count is a dated one: as of October 2015, 16 states and the District of Columbia had approved 1915(i) state plan amendments on file with CMS. Treat that, and any other fixed list, as a snapshot.1

Individual states are easier to pin down than the roster as a whole. CMS renewed Arkansas's 1915(i) state plan HCBS benefit effective March 1, 2024. Separately, MACPAC identified seven states (Connecticut, Indiana, Iowa, Louisiana, Montana, Texas, and Wisconsin) as offering both a 1915(c) waiver and a 1915(i) mental health state plan amendment as of September 2015, and Indiana and Iowa each still describe operating 1915(i) programs on their own agency sites.1

Because a state establishes a 1915(i) benefit by submitting a state plan amendment to CMS for review and approval, and can end one the same way, a state's status can shift between publications. The reliable check is that state's own Medicaid agency or its approved state plan amendment, not a published count. CMS's 1915(i) authority page explains how that amendment and approval process works.1

One common confusion is worth flagging: the fact that a state runs a community-based behavioral health program does not mean the program uses 1915(i) authority. Texas's Youth Empowerment Services program for youth with serious emotional and behavioral difficulties, for instance, is a 1915(c) waiver, even though Texas separately offers a 1915(i) mental health state plan amendment. Always check the specific federal authority a program runs under rather than assuming it from the population it serves.1

Learn More

Find personalized help navigating Georgia Medicaid HCBS options 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.