A Medicaid waiver is a special program that allows states to use Medicaid funding to provide services that are not typically covered under standard Medicaid rules. The most common type of Medicaid waiver — called a home and community based services waiver or HCBS waiver — allows states to pay for care provided in home and community settings rather than in a nursing home or other institutional setting.
Medicaid waivers are one of the most important and least understood benefits available to seniors and people with disabilities who need long term care services but want to remain in their homes or communities rather than move to a nursing home.
Why Medicaid waivers exist
Traditional Medicaid was originally designed primarily to pay for institutional care such as nursing home care. Over time it became clear that many people who qualified for nursing home level care would prefer to receive care at home or in community settings — and that providing care in those settings is often less expensive than nursing home care.
Medicaid waivers were created to give states the flexibility to use Medicaid funds for home and community based care. States must apply to the federal government for permission to operate waiver programs and must demonstrate that the programs will not cost more than institutional care would for the same population.
Types of Medicaid waivers
There are several types of Medicaid waivers but the most common and most relevant for seniors and people with disabilities are:
- Home and community based services — HCBS — waivers — also called 1915(c) waivers, these programs pay for a wide range of services that help people remain in their homes or communities including personal care assistance, adult day care, home health care, respite care, assistive technology, home modifications, and transportation
- 1115 research and demonstration waivers — allow states to test new approaches to delivering Medicaid services including expanding eligibility to populations not normally covered
- Managed long term services and supports — MLTSS — programs that deliver long term care services through managed care organizations rather than fee for service arrangements
What HCBS waivers cover
The specific services covered by HCBS waivers vary by state but commonly include:
- Personal care assistance — help with bathing, dressing, grooming, and other daily activities
- Home health aide services
- Adult day care
- Respite care for family caregivers
- Assisted living and residential care in some states
- Home modifications such as grab bars, ramps, and widened doorways
- Assistive technology and medical equipment
- Transportation to medical appointments
- Meal delivery programs
- Case management and care coordination
- Behavioral health services
Who is eligible for HCBS waivers
Eligibility for HCBS waivers varies by state and by the specific waiver program. Generally to qualify a person must:
- Meet the financial eligibility requirements for Medicaid in their state
- Meet a level of care requirement — typically needing nursing home level care or a comparable level of care
- Be a resident of the state offering the waiver
- Meet any additional eligibility criteria specific to the waiver program such as age or disability type
Unlike standard Medicaid which is an entitlement program — meaning everyone who qualifies must be served — HCBS waiver programs have limited slots. This means that even if you meet the eligibility requirements you may be placed on a waiting list until a slot becomes available.
Waiting lists for HCBS waivers
Waiting lists for HCBS waiver programs are a significant challenge in many states. Some states have waiting lists of thousands of people and wait times of several years. This makes it important to apply as early as possible even if you do not currently need services.
Contact your state’s Medicaid agency or local Area Agency on Aging to find out about waiver programs in your area and how to get on the waiting list.
How HCBS waivers differ from standard Medicaid
Standard Medicaid covers a defined set of mandatory and optional services that all eligible beneficiaries are entitled to receive. HCBS waivers go beyond standard Medicaid to cover additional services specifically designed to support people in home and community settings.
The key differences are:
- Entitlement vs limited slots — standard Medicaid is an entitlement. HCBS waivers have limited enrollment slots and waiting lists.
- Services covered — HCBS waivers cover services not available under standard Medicaid such as home modifications, assistive technology, and adult day care
- Setting — HCBS waivers are specifically designed to support care in home and community settings as an alternative to nursing home care
Self-directed care options
Many HCBS waiver programs offer a self-directed care option that gives participants more control over their own care. Under self-directed care participants can:
- Choose their own caregivers including in some states family members
- Manage a personal budget for care services
- Decide how and when services are provided
Self-directed care gives participants greater flexibility and autonomy compared to traditional agency-provided care. It is particularly popular among younger people with disabilities and people who prefer to have family members provide their care.
How to apply for an HCBS waiver
The application process for HCBS waivers varies by state but generally involves:
- Contacting your state’s Medicaid agency or local Area Agency on Aging to find out what waiver programs are available in your area
- Completing a Medicaid application if you are not already enrolled in Medicaid
- Undergoing a level of care assessment to determine whether you meet the care needs criteria for the waiver program
- Completing a waiver-specific application
- Being placed on a waiting list if slots are not immediately available
- Developing a person-centered care plan with a case manager once enrolled
Finding waiver programs in your state
The best resources for finding HCBS waiver programs in your state include:
- Your state’s Medicaid agency — contact information is available at medicaid.gov
- Your local Area Agency on Aging — find yours at eldercare.acl.gov or by calling the Eldercare Locator at 1-800-677-1116
- The HCBS.org website which provides information about home and community based services programs across the country
Key terms to know
- Medicaid waiver — a special program that allows states to use Medicaid funding for services not covered under standard Medicaid rules
- HCBS waiver — home and community based services waiver, a program that pays for care in home and community settings as an alternative to nursing home care
- Level of care assessment — an evaluation that determines whether a person needs nursing home level care and therefore qualifies for an HCBS waiver
- Self-directed care — a waiver option that gives participants control over their own care including the ability to hire their own caregivers
- Entitlement program — a program in which everyone who meets the eligibility criteria must be served
- Waiting list — a list of eligible people waiting for an available slot in a waiver program
- Area Agency on Aging — a local organization that helps older adults and families navigate care options and benefits
Sources
- Medicaid.gov — Home and Community Based Services
- Centers for Medicare and Medicaid Services
- Administration for Community Living — eldercare.acl.gov
- USA.gov
This article is for general informational purposes only and does not constitute legal or financial advice. Medicaid waiver programs vary significantly by state and are subject to change. Contact your state Medicaid agency or local Area Agency on Aging for the most current information specific to your situation.