Home and community-based services (HCBS) are Medicaid-funded supports that allow people to receive care in their own homes or communities instead of in nursing homes, hospitals, or other institutions. These programs serve older adults, people with intellectual or developmental disabilities, people with physical disabilities, and individuals with mental health or substance use disorders. In 2021, Medicaid spent approximately $82.5 billion on HCBS, making it a larger category of spending than institutional care ($66.6 billion) for the first time in the program’s history.
Who Qualifies for HCBS
To qualify, you need to meet two main criteria: financial eligibility for Medicaid and a functional need for care at an institutional level. That second part is key. States assess whether your care needs are serious enough that you would otherwise qualify for placement in a nursing home or similar facility. If so, HCBS lets you receive equivalent support while staying in your community.
States can further narrow their programs to serve specific groups. Some waivers target only people over a certain age, while others focus on particular diagnoses like autism, traumatic brain injury, cerebral palsy, epilepsy, or HIV/AIDS. This means two people in the same state with similar care needs might qualify for different waiver programs, or one might qualify while the other doesn’t, depending on how the state has structured its waivers.
Types of Services Available
HCBS programs generally fall into two broad categories: health services that address medical needs and human services that support daily living. On the health side, this includes skilled nursing care delivered at home, occupational and physical therapy, dietary management, personal care assistance, hospice care, and durable medical equipment like wheelchairs or hospital beds. Case management, which coordinates all of these services, is also a core component.
The human services side covers the practical aspects of staying in your home safely. This includes help with bathing, dressing, eating, and transferring in and out of bed. It also includes homemaker and chore services, home-delivered meals, transportation, home repairs and safety modifications (like grab bars or ramps), adult day programs, and senior centers. Some programs even cover legal services such as help preparing a will, financial management, and regular phone check-ins for people living alone.
Respite care is another important service. It provides temporary relief for family caregivers, giving them a break while ensuring the person they care for is still supported. Habilitation services help people acquire or maintain daily living skills they need to remain in the community.
How States Administer These Programs
HCBS doesn’t work like a single national program. States operate their programs through federal waivers, the most common being the Section 1915(c) waiver. This waiver lets states offer specific bundles of home and community services to defined populations as an alternative to institutional care. These waivers are typically approved for three to five years, with five-year renewal periods, and states can cap enrollment and limit per-person costs.
States can also use Section 1115 demonstration waivers, which give broader authority to redesign how Medicaid works. These are usually statewide, affect larger populations, and include a research component. Both types of waivers must meet a cost-neutrality requirement: federal spending under the waiver can’t exceed what it would have been without it.
The practical result is that HCBS looks different depending on where you live. One state might offer a robust menu of services for people with developmental disabilities but have limited options for older adults. Another might do the opposite. The specific services, eligibility rules, and funding levels vary significantly from state to state.
Self-Directed vs. Agency-Managed Care
Most HCBS is delivered through one of two models. In the traditional agency model, a home health agency or service provider assigns workers to you and manages the logistics of your care. You receive the services, but the agency handles hiring, scheduling, and supervision.
The self-directed model flips that dynamic. You (or a representative acting on your behalf) take control of your services. This means you can recruit, hire, train, and supervise the people who provide your care. In many states, self-direction also includes “budget authority,” meaning you decide how your allocated Medicaid funds are spent across different service categories. This model gives more flexibility and personal control, but it also requires more active management on your part.
The Settings Rule and Your Rights
Federal rules require that HCBS settings genuinely integrate people into their communities rather than isolating them. Under these requirements, any setting where you receive services must support your access to the broader community, provide opportunities to seek competitive employment, and ensure you have the same degree of community access as someone not receiving Medicaid services. You must be able to choose your setting from among available options, including settings that aren’t specifically designed for people with disabilities.
The rules also protect your rights to privacy, dignity, and freedom from coercion. Services must be built around a person-centered plan that reflects your own preferences and goals, not a one-size-fits-all template. You direct the planning process, and the plan documents the options available based on your individual needs and, for residential settings, your resources.
Cost Compared to Institutional Care
HCBS is significantly less expensive per person than institutional care. In 2021, total Medicaid spending on HCBS per user was about $32,000, compared to more than $45,000 per user for institutional long-term care. That gap is one of the central policy arguments for expanding these programs: people generally prefer to stay home, and it costs less to support them there.
Waiting Lists Remain a Major Barrier
Despite the cost advantages, access to HCBS is far from guaranteed. Forty-one states maintain waiting lists for their programs, and that number has barely changed since 2016. As of 2025, more than 600,000 people are on waiting or interest lists nationwide.
The average wait to access services is 32 months, though this varies dramatically by population. Waivers targeting older adults and people with physical disabilities have the shortest average waits at about 15 months. People with intellectual or developmental disabilities wait an average of 37 months. Waivers serving people with autism have the longest waits, averaging 63 months, or more than five years.
How to Apply
The application process starts with your state Medicaid agency or its local equivalent, which varies by state. Some states route applications through Area Agencies on Aging for older adults, or through developmental disability offices for people with I/DD. The general sequence involves establishing Medicaid financial eligibility, completing a functional assessment to determine whether you meet the institutional level-of-care threshold, and then, if approved, developing a person-centered service plan that outlines which services you’ll receive and how they’ll be delivered.
Because each state designs its own programs with different target populations, eligibility criteria, and available services, the most reliable starting point is contacting your state Medicaid office directly or searching for your state’s specific HCBS waiver programs. If a program has a waiting list, getting your name on it as early as possible matters, given that waits can stretch for years.