Medicaid Home and Community-Based Waiver Services (HCBS)

Medicaid is a federally funded program that provides health care coverage to low-income individuals and families. There was a time when Medicaid only covered personal care and supportive services if they were provided in a nursing home or other long-term care setting. That included help with activities such as:

• medication reminders
• meal preparation
• bathing, and
• grocery shopping.

Now, eligible recipients can often get the extra help they need to stay in their own homes—instead of moving to an institution— through Medicaid home and community-based services (HCBS) waivers.

But not every state has an HCBS waiver program, and the programs vary from state to state. So, your eligibility for Medicaid HCBS services and the type of services available will depend on where you live.

What Are Medicaid Home and Community-Based Service Waivers?

In 1981, the Social Security Act was amended to add Section 1915(c), allowing states to use Medicaid funds to pay for home-based services for seniors or disabled individuals through HCBS waivers. (42 U.S.C § 1396n.) Under the law, each state's HCBS program must be approved by the Centers for Medicare and Medicaid Services (CMS).

HCBS programs are sometimes called "waiver" programs because states get CMS approval to waive certain Medicaid program requirements. Federal law normally requires a state to offer Medicaid services equally to everyone eligible for Medicaid regardless of their disabling condition. For example, a state can't run a Medicaid program that pays for prescriptions for physical conditions but not for mental conditions.

With a waiver, a state can create an HCBS program that benefits a targeted population. So, a state could offer HCBS benefits like in-home personal care services to Medicaid recipients with physical conditions but not those with mental conditions.

Over time, HCBS programs have become increasingly popular as public opinion has become more critical of institutionalization. In 1990, Congress enacted the Americans With Disabilities Act (ADA) to protect people with disabilities from discrimination. In 1999, the U.S. Supreme Court decided the case of Olmstead v. LC (527 U.S. 581), holding that unnecessarily segregating disabled individuals in institutions is illegal discrimination.

Medicaid HCBS programs are essential tools that states can use to comply with the ADA and the Olmstead ruling. So these programs have expanded since Olmstead, thanks partly to additional federal funding and incentives provided through the Affordable Care Act of 2010 and the American Rescue Plan Act of 2021.

Who Is Eligible for HCBS Services?

In general, states can create home and community-based services programs to benefit seniors or disabled individuals of any age—as long as the beneficiaries are eligible for Medicaid. But not everyone who is eligible for Medicaid can qualify for HCBS benefits. States generally target their HCBS programs to particular populations, so who is eligible for HCBS services varies from state to state.

Congress intended HCBS benefits to help keep people in their own homes and avoid institutional care. So, to qualify for home-based community services through a Medicaid waiver program, you must need institutional-level care, as defined by your state. To meet that criteria, you'll generally need medical evidence of a particular diagnosis or a professional assessment of your inability to do certain activities of daily living.

Most states with HCBS waiver programs have more than one HCBS program, each for different groups of people. For example, Oregon operates seven different HCBS waiver programs, offering need-based benefits to targeted groups, like children and adults with physical disabilities, those with developmental disabilities, and seniors. Other states have HCBS programs that target populations by diagnoses, such as:

• HIV/AIDS
• traumatic brain injury, or
• autism.

Hawaii's single HCBS waiver program provides benefits only to individuals with intellectual and developmental disabilities, while California has six Medicaid waivers, including programs for individuals with HIV and disabled seniors. And one of Florida's four waiver programs targets individuals with Familial Dysautonomia (FD) or Riley-Day syndrome, a rare genetic disorder. Your state's Medicaid agency can tell you what HCBS waiver programs you might qualify for.

A few states make HCBS benefits available to all Medicaid recipients who need institutional-level care through the Community First Choice (CFC) option, established by the Affordable Care Act. Learn more about Medicaid's Community First Choice program.

What Are Home and Community-Based Services?

The states have broad discretion over the eligibility and the kinds of services they offer in their HCBS programs. Common services provided by HCBS programs include:

• help with household chores and meal preparation
• funding for special diets
• modifications to homes for accessibility
• case management services
• transportation services
• adult day care
• respite care
• supported employment services, like sheltered workshops or vocational counseling, and
• particular kinds of therapy not funded in regular state Medicaid programs, like:
  • speech therapy
  • hearing or auditory-verbal therapy (AVT)
  • physical therapy, or
  • occupational therapy.

Each waiver offers services to meet the unique needs of the waiver group. And the states have broad discretion over the groups targeted and the services covered for that group. For instance, California's senior services program waiver covers all of the following:

• care management
• respite care
• homemaker services
• personal care
• adult day care
• assistive technology
• community transition services (including moving, utility set-up, and minor home repairs/maintenance)
• money management
• non-medical home equipment
• nutritional services
• social support
• supplemental protective supervision
• therapeutic counseling and services, and
• transportation services.

As another example, Florida's long-term care HCBS waiver covers all those services for seniors (except money management and community transition services). But Florida's Medicaid waiver covers additional services, such as:

• adult companions
• intermittent and skilled nursing
• assisted living
• behavior management
• home-delivered meals
• medication administration and management, and
• personal emergency response system services.

How Do You Apply for HCBS Benefits?

Every state has its own HCBS waiver programs, so start by finding out which Medicaid HCBS waiver services are available where you live. Your state Medicaid agency can tell you about the HCBS program eligibility requirements you'll need to meet. You can find your state Medicaid agency's contact information using the state search tool at Medicaid.gov.

What If You're Denied Medicaid HCBS Services?

If you're denied home and community-based services, you have the right to appeal. Look carefully at the denial notice to find your appeal deadline, and make sure you file your appeal before that date.

Also, review the notice to find out why you were denied, so you can start preparing your arguments before your hearing. You might need to gather more medical evidence or witness statements, which will take time.

If your state Medicaid agency says you don't meet the "institutional level of care" requirement, find out how your state defines the level of care needed to qualify for Medicaid coverage for nursing home care. You'll need to know what the standard is so you can show that you meet it. You should be able to find that information in the state regulation listed on your denial notice, but you might have to ask your state Medicaid agency for the information.

You may want to find an attorney to represent you in your appeal. You can contact your local legal aid office to learn whether they represent clients in Medicaid appeals or you can contact a lawyer. (You can browse the free lawyer directories on Lawyers.com or Avvo.com, two sites that are part of the Nolo family.)

Federal Medicaid rules also allow you to have a relative, friend, or any other spokesperson that you choose to help you with your appeal. You can also represent yourself. Find out more about how to appeal when Medicaid denies you a service.