An HCBS waiver is a Medicaid program that pays for long-term care services delivered in your home or community instead of in a nursing home or other institution. HCBS stands for Home and Community-Based Services. The “waiver” part means that states get permission from the federal government to waive certain standard Medicaid rules so they can offer these services to people who would otherwise need institutional care. Over 600,000 people are currently on waiting lists for these programs nationwide, which gives you a sense of both how valuable and how limited they can be.
How the Waiver Works
Under normal Medicaid rules, states must offer the same services to everyone who qualifies, across the entire state. HCBS waivers, authorized under Section 1915(c) of the Social Security Act, let states bend three key rules. First, they can limit the program to specific areas of the state where the need is greatest or where providers are available, rather than offering it statewide. Second, they can restrict services to specific groups of people who are at risk of being placed in an institution. Third, they can adjust income and resource rules so that people who would only qualify for Medicaid inside a nursing home can instead qualify while living at home.
That last point is especially important for families. Without the waiver, a person might technically have too much income to get Medicaid at home but would automatically qualify if they entered a nursing facility. The waiver closes that gap, using the same financial framework (including spousal impoverishment protections) so that a spouse isn’t forced into poverty when their partner needs care.
Who Qualifies
To receive HCBS waiver services, you generally need to meet two sets of criteria: financial eligibility and functional eligibility.
Financial eligibility varies by state, but many states use what’s called the 300% special income standard. In Kansas, for example, that threshold is $2,163 per month for one person. Some states set their own limits that differ from this. If your income falls below the threshold, you may qualify. States can also apply spousal impoverishment rules, which protect a portion of a couple’s combined income and assets for the spouse who doesn’t need care.
Functional eligibility means you must need the same level of care you’d receive in an institution. States assess this through an in-person evaluation that looks at your ability to perform daily activities like bathing, dressing, eating, and managing medications. If the assessment determines you need nursing-home-level care, you meet the functional requirement, even though the actual services will be delivered at home. Once approved, you’re also entitled to keep a personal needs allowance (at least $30 per month, though many states set it higher) for personal expenses.
Who These Waivers Serve
States design their HCBS waivers around specific populations. The most common groups include older adults who need daily assistance, people with intellectual or developmental disabilities, people with physical disabilities, and people with traumatic brain injuries or other conditions that require ongoing support. A single state often runs several different waivers, each tailored to a different population with its own set of covered services and eligibility criteria.
Services Typically Covered
The exact list of services depends on the state and the specific waiver, but HCBS programs generally cover a broad mix of supports designed to keep you safe and independent at home. Common services include:
- Personal care assistance: help with bathing, dressing, grooming, and other daily tasks
- Respite care: temporary relief for family caregivers
- Home modifications: ramps, grab bars, widened doorways, and other changes that make your home accessible
- Adult day health services: supervised daytime programs that provide social activities, meals, and health monitoring
- Assistive technology: devices and equipment that support daily living
- Homemaker services: help with cooking, cleaning, laundry, and shopping
- Skilled nursing: medical care provided in your home by a licensed nurse
- Transportation: rides to medical appointments and community activities
Some states also cover employment support, behavioral health services, and specialized therapies. Because each state designs its own waiver, the specific services available to you depend entirely on where you live.
Self-Directed Care Options
Many HCBS waivers include a self-directed option that gives you significant control over your own care. Under this model, you (or a representative acting on your behalf) can recruit, hire, train, and supervise the people who provide your services. This is sometimes called “employer authority.”
Some programs also give you “budget authority,” meaning you have decision-making power over how your Medicaid funds are spent within your approved plan. A supports broker or counselor helps you navigate the process, acting as a liaison between you and the program. A financial management service handles the administrative side: payroll, tax withholding, workers’ compensation, timesheets, and employee benefits. Self-direction has been available in many states since the 1990s and is designed to give participants the same kind of choice and flexibility that people without disabilities take for granted.
Waitlists Are Common
One of the biggest challenges with HCBS waivers is getting in. Forty-one states maintain waiting lists or interest lists for people who want to receive home-based care, and that number has barely changed since 2016. As of 2025, more than 600,000 people are on these lists nationwide, a 14% increase from 2024 alone. Wait times vary dramatically by state and by waiver type. Some people wait months; others wait years, particularly on waivers serving people with intellectual and developmental disabilities.
Being placed on a waitlist means you’ve expressed interest or applied, but the state has reached its enrollment cap for that particular waiver. States set these caps when they submit their waiver applications to the federal government. When a slot opens, the next person on the list is typically contacted for an eligibility assessment.
How to Apply
The application process starts with your state’s Medicaid agency or the agency that manages long-term care services. In many states, this is the Department of Health and Human Services, the Department of Aging, or a similar office. You can usually begin by calling your state’s Medicaid helpline or visiting their website to find the specific HCBS waivers available in your area.
After you express interest, the state will evaluate both your financial situation and your care needs. The financial review looks at your income and assets. The functional assessment is typically conducted by a case manager or nurse who visits you at home and evaluates how much help you need with daily activities. If you meet both criteria and a slot is available, you’ll work with a case manager to develop a care plan that outlines the specific services you’ll receive, how often, and from which providers. If no slot is open, you’ll be placed on the waitlist.
Different Types of HCBS Authorities
The 1915(c) waiver is the most common type, but it’s not the only way states deliver home and community-based services. Section 1115 demonstration waivers give states broader flexibility to redesign their Medicaid programs, and some states use them to expand HCBS in ways that 1915(c) doesn’t allow. There’s also the 1915(i) state plan option, which lets states offer HCBS without a waiver at all, to people who don’t necessarily meet an institutional level of care. And the 1915(k) Community First Choice option provides personal care services as an entitlement rather than through a capped waiver.
The practical difference for you is that 1915(c) waivers can have enrollment caps and waitlists, while state plan options like 1915(i) and 1915(k) generally cannot. Which authorities your state uses shapes both the services available to you and how long you might wait to access them.