For decades, nursing homes were seen as the default option for people who needed long-term care. But for many older adults and individuals with disabilities, institutional care isn’t ideal—it’s expensive, restrictive, and separates them from their communities. That’s why Medicaid created Home and Community-Based Services (HCBS), a program designed to help people receive the care they need in their homes or local communities rather than in facilities.
HCBS is now one of the fastest-growing parts of Medicaid. It supports millions of Americans who want to maintain independence, dignity, and quality of life, all while reducing the overall cost of care. Here’s what HCBS is, who qualifies, what’s covered, and how to access these benefits.
What Are Home and Community-Based Services (HCBS)?
Home and Community-Based Services are a category of Medicaid benefits that fund care and support outside of institutional settings like nursing homes or hospitals. Instead of paying for round-the-clock facility care, Medicaid can pay for personal assistance, home health services, and even modifications to make homes safer.
The goal is simple: help people live independently, stay connected to their families and communities, and delay or avoid nursing home placement.
HCBS is not one specific program—it’s a set of optional services that states can offer through special Medicaid authorities, most commonly Section 1915(c) waivers. Every state manages its own HCBS system, which means benefits and eligibility rules can vary widely.
Who Qualifies for HCBS
Eligibility for Home and Community-Based Services depends on three main factors: age or disability, functional need, and financial status.
Typically, HCBS serves:
Older adults who need help with daily living activities but don’t want to move to a nursing home.
People with physical disabilities who need long-term care supports.
Individuals with intellectual or developmental disabilities (IDD) who require ongoing assistance.
Children and adults with serious mental health conditions who need supportive community care.
To qualify, a person generally must:
Meet Medicaid’s financial eligibility rules in their state (based on income and assets).
Need a “nursing home level of care.” States assess whether you require the same level of assistance that would normally qualify you for a nursing facility.
Be able to receive care safely at home. Services are designed to meet needs while maintaining safety and health standards outside of institutions.
Some states have waiting lists for HCBS waivers, particularly for programs serving people with developmental disabilities. However, states continue to expand these programs to reduce wait times.
What Services Are Covered Under HCBS
The beauty of HCBS is its flexibility. It’s tailored to individual needs rather than a one-size-fits-all approach.
Typical covered services include:
Personal care assistance: Help with bathing, dressing, eating, or mobility.
Homemaker or chore services: Help with cooking, cleaning, or grocery shopping.
Skilled nursing and therapy: In-home nursing care, physical, occupational, or speech therapy.
Respite care: Temporary relief for family caregivers.
Home modifications: Installing ramps, grab bars, or widening doorways for accessibility.
Adult day health programs: Structured daytime services offering medical care, meals, and social interaction.
Transportation: Rides to medical appointments, adult day care, or community activities.
Case management: Coordination of services across multiple providers.
Some states even include supported employment or community integration services for people with developmental disabilities, helping them live and work independently.
Here’s a snapshot of what HCBS typically looks like:
| Category | Examples of Covered Support |
|---|---|
| Personal Assistance | Bathing, dressing, eating, mobility help |
| In-Home Support | Nursing, therapy, medical equipment |
| Family & Caregiver Support | Respite care, training, support groups |
| Environmental Modifications | Ramps, railings, safety upgrades |
| Community-Based Programs | Adult day health centers, job training |
HCBS coverage emphasizes dignity and self-determination. Enrollees often have a say in their care plan and can choose who provides their services—including family members in many states.
The Difference Between Standard Medicaid and HCBS
Standard Medicaid covers medical care—doctor visits, hospital stays, prescriptions. HCBS goes beyond traditional healthcare by funding long-term supports that keep people functional and independent.
For example:
Medicaid may pay for a hospital stay after surgery.
HCBS can then step in to cover home health visits, meal prep, and physical therapy to recover at home.
This transition from “sick care” to supportive care helps people avoid unnecessary hospital readmissions and long-term institutionalization.
How HCBS Waivers Work
Most states operate HCBS through 1915(c) waivers, which allow Medicaid to fund community-based care as an alternative to institutional care. These waivers give states flexibility to design programs for specific populations—like seniors, people with developmental disabilities, or individuals with brain injuries.
Some states have combined or modernized their waivers through 1115 demonstration waivers or Community First Choice (CFC) programs, simplifying enrollment and expanding access.
Each waiver outlines:
The target population (e.g., elderly adults, children with autism).
The services offered.
The number of participants (since waivers can cap enrollment).
Because states can tailor waivers, no two programs look exactly alike. It’s important to review your state’s Medicaid website or contact your local Medicaid office for specific details.
How to Apply for HCBS
Applying for Home and Community-Based Services follows the same general process as applying for Medicaid, with some added assessments.
Start with your state’s Medicaid office. Applications can usually be completed online, by phone, or in person.
Complete a functional needs assessment. A caseworker or nurse evaluates your ability to perform daily activities like bathing, dressing, or cooking.
Provide financial documentation. You’ll need proof of income, assets, and identity.
Select or develop a care plan. Once approved, you’ll work with a care coordinator to create a customized service plan.
Choose your providers. Depending on the state, you can pick from agency caregivers or manage your own attendants through a self-directed option.
If you already receive Medicaid but not HCBS, you can request a waiver screening through your local social services agency.
The Growth of HCBS in the U.S.
Home and community-based care has become central to how states manage long-term care costs and improve quality of life. Today, more than half of all Medicaid long-term care spending goes toward HCBS rather than institutional care—a complete reversal from 20 years ago.
Recent federal initiatives have encouraged even greater expansion. The American Rescue Plan Act (ARPA) gave states temporary funding boosts to strengthen home care systems, improve workforce pay, and reduce waiting lists. Many states are now making those improvements permanent.
Why HCBS Matters for Families
Families often carry the emotional and financial burden of caregiving. HCBS programs can ease that strain by providing resources that allow loved ones to age in place safely.
Benefits include:
More family involvement and flexibility in care decisions.
Greater independence and dignity for the person receiving care.
Cost savings compared to institutional care.
It’s also a win for states and taxpayers: home-based care generally costs 30–50% less than comparable nursing home care.
Common Challenges and Limitations
While HCBS offers enormous benefits, it’s not without obstacles. Some challenges include:
Waiting lists: High demand means long delays in some states.
Caregiver shortages: Finding reliable in-home aides can be difficult, particularly in rural areas.
Administrative complexity: Different waivers, eligibility rules, and paperwork can make navigation confusing.
Limited respite or specialized care availability: Not all states cover every service.
Advocates continue to push for broader funding and streamlined enrollment to ensure equitable access.
Tips for Maximizing HCBS Benefits
Get on waiting lists early: Even if you’re not sure you’ll need services soon, applying now can secure your spot.
Ask about self-directed options: Many states let you hire and train your own caregiver—including family members.
Reassess annually: Needs and eligibility can change; request reassessments if your condition evolves.
Stay connected to case managers: They can help coordinate services and identify new benefits as they become available.
The Bottom Line
Medicaid’s Home and Community-Based Services give people more freedom to live where and how they want while receiving the care they need. These programs not only improve quality of life but also keep long-term care costs manageable for families and the system as a whole.
If you or a loved one may qualify, contact your state Medicaid office to explore HCBS waivers and application options. The sooner you apply, the faster you can access life-changing support that helps you stay home, stay safe, and stay connected.
