Home and Community-Based Services (HCBS) Waivers

Home and community-based services (HCBS) waivers are the main way Medicaid pays for long-term care outside nursing homes. They let states offer services such as personal care at home, adult day care, respite, home modifications and assisted living services to people who would otherwise need a nursing home. Every state has at least one. This guide explains what a waiver is, how it works, who qualifies, and what families should know about applying.

Figures change periodically. Double-check current amounts before relying on them.

The short version

A waiver is federal permission, granted by the Centers for Medicare & Medicaid Services (CMS), for a state to “waive” certain Medicaid rules so it can offer HCBS to a target group.
The most common type is the section 1915(c) waiver, created by Congress in 1981.
Waivers can target specific groups (such as older adults, people with physical disabilities, or people with intellectual or developmental disabilities), limit enrollment, and operate in only part of a state.
Most waivers require a nursing-home level of care (or another institutional level of care) and must cost no more, on average, than institutional care.
Financial rules are usually similar to nursing home Medicaid, often using the special income limit ($2,982 a month in 2026 in many states) and spousal impoverishment protections.
Because of enrollment caps, many waivers have waiting lists.

What “waiver” means

Normal Medicaid rules require states to offer the same services to everyone who qualifies, statewide, under the same income rules. Section 1915(c) of the Social Security Act lets states waive three of those requirements:

Comparability, so services can be offered only to a target group;
Statewideness, so a waiver can operate in only certain areas;
Income and resource rules for the community, so states can use institutional rules (such as the special income limit and spousal protections) for people living at home.

In exchange, the state must show that the waiver is cost-neutral (average cost per person no more than institutional care), protects health and welfare, and offers participants choice between waiver services and institutional care.

Other federal options

Section 1915(i) state plan HCBS. Lets states offer HCBS as a state plan benefit to people with needs below the institutional level, without enrollment caps (though states can set needs-based criteria).
Section 1915(k) Community First Choice. A state plan option for attendant services with extra federal funding.
Section 1915(j) self-directed personal assistance.
Section 1115 demonstrations. Broad research and demonstration waivers that many states use to run managed long-term care programs.
Section 1915(b) waivers. Allow states to require managed care enrollment, often combined with 1915(c) (“1915(b)/(c)”).

Services commonly offered

Waivers vary, but commonly include:

case management or care coordination;
personal care or attendant care;
homemaker and chore services;
adult day care or adult day health;
respite;
home-delivered meals;
personal emergency response systems;
environmental accessibility adaptations (home modifications);
specialized medical equipment and supplies;
non-medical transportation;
assisted living services;
adult foster care or companion services;
caregiver training and support;
self-directed services, often including paid family caregivers.

Who qualifies

Target group and level of care

Each waiver serves a defined group, such as people 65 and older, adults with physical disabilities, or people with intellectual or developmental disabilities. Most require that the person meet the state’s institutional level of care, usually the nursing-home level of care for waivers serving older adults. See Nursing home level of care.

Financial eligibility

Waivers usually use financial rules similar to nursing home Medicaid:

Assets: often $2,000 for a single person (where the single limit is $2,000, a couple who both apply can usually keep $3,000; Pennsylvania’s medically needy limit is $2,400 per spouse). Some states are higher. See Asset limits by state.
Income: many states use the special income limit of 300 percent of the SSI benefit, $2,982 a month in 2026. People above it may need a Miller trust in income cap states, or may qualify through a medically needy pathway in other states.
Spousal protections: federal law (Affordable Care Act section 2404, as extended by the Consolidated Appropriations Act, 2023) requires states to apply the spousal impoverishment rules to married people eligible for HCBS through September 30, 2027, unless Congress extends it again. See Spousal impoverishment rules.
Look-back: in most states, gifts within 60 months can cause a penalty for waiver services.

Post-eligibility treatment of income

Unlike nursing home residents, waiver participants live at home and need money for rent and food. States set a maintenance needs allowance for waiver participants that lets them keep more income. Income above that allowance may go toward the cost of services.

How to apply

Contact the right agency. Waivers for older adults are often run by the state’s aging or disability agency, or through the Area Agency on Aging or an aging and disability resource center.
Request a level-of-care assessment.
Apply for Medicaid using the long-term care application, if not already enrolled.
Join the waiting list, if there is one.
When a slot opens, a case manager develops a person-centered service plan.
Services begin.

See Applying for a waiver.

The person-centered service plan

Federal rules (42 CFR 441.301) require a person-centered planning process, led by the participant to the extent possible, that reflects their preferences and goals. The plan lists services, providers, amounts and backup arrangements. Participants can ask for changes and appeal decisions they disagree with.

Settings rules

Waiver services must be delivered in settings that meet the federal HCBS settings rule, which aims to make sure participants have full access to community life, privacy, choice and control. This affects assisted living and other residential settings that serve waiver participants.

Waiting lists

Because states can cap enrollment, many waivers have waiting lists. Some states use priority categories, for example for people leaving nursing homes or at greatest risk. See Waiver waitlists by state.

A simple example

Thomas, 78, has COPD and heart failure and needs help with bathing, dressing and meals. He lives alone. His state’s aging waiver has a short waiting list. He completes the level-of-care assessment and Medicaid application. His income is $2,400 a month, under the state’s special income limit, and his savings, after buying a prepaid funeral and paying off a credit card, are under $2,000. When his slot opens, his case manager arranges 20 hours a week of personal care, home-delivered meals, a medical alert system and grab bars. He keeps enough income to pay his rent and food.

Key terms

1915(c) waiver: the federal authority most states use for HCBS.
Target group: the population a waiver serves.
Slot: a place in a waiver with capped enrollment.
Cost neutrality: the requirement that average waiver costs not exceed institutional costs.
Person-centered service plan: the participant’s written plan of services.

Waivers for younger people and other groups

Although this site focuses on older adults, states also run waivers for children with complex medical needs, adults with intellectual or developmental disabilities, people with brain injuries, and people with HIV or mental illness. Waivers for people with intellectual or developmental disabilities often have the longest waiting lists. A family caring for both an aging parent and an adult child with a disability may deal with two different waivers, run by different agencies, with different rules.

What happens if the waiver ends or changes

States must renew 1915(c) waivers periodically (an initial approval usually lasts three years and renewals five years) and can amend them. Changes may affect services, provider rates or enrollment caps. Participants must receive notice of reductions in their own services and can appeal. Keeping copies of every service plan and notice helps if a dispute arises.

Common mistakes

Waiting until a crisis to apply, when the waiting list could have started earlier.
Applying to the wrong waiver for the person’s target group.
Not mentioning a spouse, so the spousal protections are not applied.
Giving money to family before applying, which can cause a penalty for waiver services too.
Not appealing when services are denied or reduced.

Getting help

The Area Agency on Aging or aging and disability resource center can explain the state’s waivers. A Certified Medicaid Planner can help with financial eligibility and spousal protections, and can coordinate the timing of the application with the waiting list.

Frequently asked questions

Is a waiver the same as Medicaid? A waiver is a Medicaid program. A person in a waiver has Medicaid coverage plus waiver services.

Can I be in more than one waiver? Generally no, though people can switch if they qualify for another.

Does a waiver pay for room and board? Generally no, except for respite in a facility and limited live-in caregiver costs.

What if the waiver is full? Join the waiting list and ask about state plan services, PACE, or priority categories.

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.