HCBS stands for Home and Community-Based Services, a category of Medicaid programs that pays for long-term care in your own home or community instead of in a nursing home or other institution. These programs cover a wide range of support, from help with bathing and dressing to home-delivered meals and home modifications, all designed to keep people out of institutional settings when that’s what they prefer. As of 2024, roughly 710,000 people are on waiting lists to access these services across 40 states.
How HCBS Programs Work
The federal government sets broad guidelines for HCBS, but states design and run their own programs. This means the specific services available, who qualifies, and how long you wait vary significantly depending on where you live. States can tailor their programs to serve specific populations, like older adults, people with intellectual or developmental disabilities, children with complex medical needs, or people with serious mental illness.
The core idea behind HCBS is cost neutrality: the cost of caring for someone at home through a waiver program cannot exceed what Medicaid would pay for that person in a nursing facility. In practice, states report no difficulty meeting this requirement because institutional care is expensive. A single person receiving personal care, meal delivery, and periodic respite care at home typically costs Medicaid far less than a nursing home bed.
Types of Services Covered
HCBS programs generally cover two broad categories: health services and human services. On the health side, this includes skilled nursing visits, physical and occupational therapy, personal care assistance, case management, medication management, and durable medical equipment. On the human services side, the options expand to things many people don’t associate with Medicaid at all.
- Personal care: Help with dressing, bathing, toileting, eating, and moving between a bed and chair
- Home modifications: Ramps, grab bars, widened doorways, and other safety changes
- Homemaker and chore services: Cleaning, laundry, and household maintenance
- Meal programs: Home-delivered meals or access to congregate meal sites
- Adult day care: Supervised daytime programs that also give family caregivers a break
- Transportation: Rides to medical appointments and community activities
- Respite care: Temporary relief for family caregivers
- Supported employment: Job coaching and workplace support for people with disabilities
Not every state offers every service. Each state selects which services to include based on the populations it targets and the funding it has available.
Who Qualifies
Eligibility for HCBS has two layers: financial and functional. You must first qualify for Medicaid based on your income and assets. The second requirement is functional, meaning you need to demonstrate that you require a certain level of care. For the most common type of HCBS program (the 1915(c) waiver), you must meet a nursing facility level of care. In plain terms, a clinical assessment has to show that without these services, you would need to be in a nursing home.
Some states also run programs under a different authority (called 1915(i)) that serve people who need less intensive support. These programs can target specific groups, like people with behavioral health conditions or technology-dependent children, without requiring that the person meets the threshold for nursing home care.
There’s also an important practical requirement: you must have an unmet need for at least one HCBS service. If your needs are already fully met by family, friends, or other programs, you won’t qualify even if you meet the financial and medical criteria. You need to actually use at least one HCBS service during your plan year to maintain eligibility.
The Different HCBS Authorities
States can offer home and community-based services through several different legal pathways, which is part of why the system can feel confusing. The three most common are:
1915(c) waivers are the oldest and most widely used. They let states “waive” certain Medicaid rules. For instance, a state can limit the program to certain regions instead of offering it statewide, or make services available only to people at risk of institutionalization. These waivers require cost neutrality and target people who need an institutional level of care.
1915(i) state plan options let states build HCBS into their standard Medicaid benefits rather than running a separate waiver program. These can serve people with lower levels of need and must be available to all eligible individuals statewide. States can target these benefits to specific populations, like elderly adults or people with particular conditions.
1915(k) Community First Choice is a state plan option focused specifically on personal attendant services. States that adopt it receive a 6 percentage point increase in their federal matching rate for those services, giving them a financial incentive to expand access to hands-on daily care.
Self-Directed Care
One of the more significant features of many HCBS programs is the option to self-direct your services. This means you (or a representative acting on your behalf) get decision-making authority over your care. You can recruit, hire, train, and supervise the people who provide your services. In many states, this includes the ability to hire family members as paid caregivers.
Self-direction can also extend to budget authority, where you control how Medicaid funds allocated to your care are spent. You receive an individualized budget based on your assessed needs, developed through a person-centered planning process. A financial management service helps handle the paperwork: payroll, tax withholding, workers’ compensation, and tracking your spending against the budget. You make the decisions about what to purchase and who to hire, while the financial management entity handles the administrative side.
Waiting Lists Are Common
The biggest practical barrier to HCBS is access. In 2024, more than 710,000 people were on waiting lists or interest lists across 40 states. The average wait to begin receiving services was 40 months, or about three and a half years.
Wait times vary dramatically depending on the population being served. People with intellectual and developmental disabilities face the longest waits, averaging 50 months. Waivers serving children average 44 months. By contrast, waivers targeting people with mental illness average just 6 months. These differences reflect both the demand for services and the capacity states have built for each population.
Some states maintain formal waiting lists where your place is held in order, while others use interest lists that function more as a registry of people who want services. The distinction matters because a waiting list implies you’ll eventually be served in order, while an interest list may not carry the same guarantee. In 2024, the split was nearly even: about 354,000 people on formal waiting lists and 356,000 on interest lists.
How to Apply
Because HCBS programs are state-run, the application process differs everywhere. In general, you start by contacting your state Medicaid office or your local Area Agency on Aging. Many states also have aging and disability resource centers that serve as a single point of entry for long-term care services.
The process typically involves a financial eligibility determination through Medicaid and a separate functional assessment to evaluate your care needs. If you qualify, a case manager or service coordinator develops a person-centered service plan that spells out which services you’ll receive, how often, and from whom. Your plan is reassessed annually, and your service package can be adjusted if your needs change. In states with waiting lists, qualifying for a program doesn’t mean services start immediately. You may be placed on a list and contacted when a slot opens.