Medicaid Waivers
What Are Medicaid Waivers?
Medicaid Waivers are special programs approved by the federal government that allow states to “waive” certain Medicaid rules. They give states flexibility to expand services to specific groups, target benefits to certain regions, and test new care models. Unlike standard Medicaid, which must follow uniform rules for certain groups (like pregnant women, people with disabilities, and seniors), waivers can tailor eligibility, services, and delivery methods.
One of the most common uses of waivers is to offer Home and Community-Based Services (HCBS) to seniors and people with disabilities who might otherwise need nursing home care. Services may include personal care, respite, adult day care, homemaker help, and supervision—allowing recipients to remain at home or in community settings.
Why Do People Choose Waiver Programs?
Pros: They help people age at home, reduce caregiver burnout, and are usually less expensive for states than institutional care. Many waivers allow consumer direction—recipients can choose and even pay relatives (in some states, spouses) to provide care.
Cons: Waivers are not entitlements. States limit the number of participants, which means waitlists can last months or even years.
What Benefits Can Waivers Provide?
While benefits vary, most waivers include some combination of:
- Case management
- Personal care and homemaker services
- Respite care
- Adult day health or adult day care
- Home modifications and adaptive equipment
- Meal delivery or congregate meals
- Non-emergency transportation
- Personal emergency response systems
- Transition services from an institution to the community
Care can be provided in a recipient’s home, a relative’s home, adult foster care, assisted living, or memory care—but Medicaid generally will not pay for room and board in these settings.
Who Qualifies for a Medicaid Waiver?
Financial Criteria (2025 example):
- Income up to 300% of the Federal Benefit Rate ($2,901/month)
- Asset limit: $2,000 for individuals (spouses may keep up to $157,920 in resources)
- Income of a non-applicant spouse is not counted
Functional Criteria: Most waivers require a Nursing Facility Level of Care (NFLOC)—meaning without these services, the person would likely need nursing home placement. Some states allow applicants who are “at risk” of institutionalization.
What Is the Application Process?
Applicants must contact their state Medicaid agency, verify income and assets, and provide documentation. Many states have a 60-month look-back period to ensure no assets were given away below market value. Some states, like California and New York, have exceptions or shorter look-back rules.
Because waivers have waitlists and state-specific rules, many applicants benefit from consulting a Medicaid planner before applying.
What Types of Medicaid Waivers Exist?
| Waiver Type | Also Called | Purpose | Key Features |
|---|---|---|---|
| 1915(c) HCBS Waivers | Home & Community-Based Services | Provide long-term care outside nursing homes | May allow consumer direction; services include personal care, respite, home modifications |
| 1915(b) Waivers | Freedom of Choice / Managed Care | Deliver Medicaid via managed care networks | Can be combined with 1915(c); limits provider choice to network |
| Combination Waivers | 1915(b)/(c) | Managed care delivery of HCBS | May have waitlists for long-term care; no wait for basic medical services |
| 1115 Demonstration Waivers | Research & Demonstration | Test new Medicaid delivery models | Highly flexible; can expand coverage, change benefits, or alter retroactive coverage |
How Do States Apply for Waivers?
States apply through the Centers for Medicare & Medicaid Services (CMS). Approval times vary: 1915(b) and 1915(c) waivers typically within 90 days; 1115 waivers have no time limit. Waivers must be renewed periodically, and even after approval, states are not required to implement them.
