Waivers and Managed Care: How States Deliver Long-Term Care at Home
Nursing home care is a guaranteed Medicaid benefit. Most care at home, in adult day programs and in assisted living is delivered differently: through waivers, state plan options and, in many states, managed care plans. These programs decide what services are available, who can get them, and whether there is a wait. This section explains how they work in plain language.
Figures change periodically. Double-check current amounts before relying on them.
The short version
- A waiver is federal permission for a state to offer home and community-based services (HCBS) to a target group, such as older adults or people with disabilities, outside the usual Medicaid rules.
- Waivers can cap enrollment, so many have waiting lists. State plan services generally cannot.
- Most waivers require a nursing-home level of care and use financial rules similar to nursing home Medicaid, including spousal protections and, in most states, the look-back.
- Many states deliver long-term care through managed long-term services and supports (MLTSS) plans, which coordinate and pay for care.
- “Community Medicaid” usually means regular Medicaid for people living at home, which can include some long-term care services in some states.
Guides in this section
- Home and community-based services (HCBS) waivers
- Waiver waitlists by state
- Managed long-term services and supports (MLTSS)
- Community Medicaid
Waiver, state plan or managed care: a quick comparison
| Waiver (1915(c)) | State plan service | Managed care (MLTSS) | |
|---|---|---|---|
| Who gets it | A target group the state chooses | Everyone who qualifies | Enrollees in the state’s program |
| Enrollment cap? | Allowed | No | Depends on the program |
| Typical services | Personal care, homemaker, respite, adult day, home modifications, assisted living services | Home health, personal care (in many states) | Same services, arranged by a plan |
| Who manages care | State or local case managers | State or providers | The plan’s care coordinators |
Where to go next
- To see what each kind of care covers, see Care and benefits.
- To understand who qualifies, see Eligibility overview.
- For your state’s programs and figures, see the state guides.
Because programs, names and waiting lists differ so much by state, many families find it helpful to talk with a Certified Medicaid Planner, who can match needs to programs and handle the financial side of the application.
Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.