What is Medicaid Home Care (HCBS)?

Many older adults and people with disabilities require assistance with self-care such as bathing, dressing, and eating. Help with such services is known as “long-term care” and may be provided in institutional settings such as nursing facilities or in people’s homes and the community, including assisted living facilities. Four in ten adults incorrectly believe that Medicare is the primary source of coverage for low-income people who need nursing or home care, but Medicaid is the primary payer—covering two-thirds of all home care spending in the United States in 2022. With House Republicans considering $2.3 trillion in Medicaid cuts over 10 years—a nearly one-third reduction in Medicaid spending—the availability of home care could be affected in future years. This issue brief provides an overview of what Medicaid home care (also known as “home- and community-based services” or HCBS) is, who is covered, and what services were available in 2024. About 4.5 million people receive Medicaid covered home care services annually.

This brief is one of several describing data from the 22^nd KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (hereafter referred to as a state), which states completed between April and October 2024. Other issue briefs from the survey describe the number of people on waiting lists for home care, how home care programs support family caregivers, payment rates for home care providers, and how Medicaid covers people in assisted living facilities. The survey was sent to each state official responsible for overseeing home care benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida, Indiana, and Utah responded to the 2024 survey, but response rates for certain questions were lower. Where possible, KFF supplemented survey data with previously reported or publicly available data to provide information for the states that did not respond. Key takeaways include:

• Nursing facility care is a required Medicaid benefit, but states can choose whether or not to provide most home care services. A key component of home care is personal care, which helps people who need assistance with self-care (such as bathing and dressing) and household activities (such as taking medications and preparing meals).
• Medicaid home care can be offered through either the Medicaid state plan or as part of a specialized waiver. All states offer Medicaid home care through either 1915(c) waivers (47 states), 1115 waivers (14 states), personal care offered as a state plan benefit (34 states), or the Community First Choice option (10 states) (Figure 1).
• Most states provide Medicaid home care through waivers that offer benefits specifically targeted to people with intellectual or developmental disabilities (48) and people ages 65 and older or who have physical disabilities (46).
• Waivers’ coverage of different home care services, such as day services, supported employment, and home-based services, vary by the target populations they serve.

Proposed cuts to Medicaid spending may have broad implications for home care, including for the workforce, support for family caregivers, and states’ ability to cover various services. House Republicans’ proposals to reduce federal Medicaid spending by $2.3 trillion over 10 years—roughly one-third of Medicaid spending—could fundamentally change how Medicaid financing works, consequently impacting enrollees’ access to care. Cuts of this magnitude would put states at financial risk, forcing them to raise new revenues or reduce Medicaid spending by eliminating coverage for some people, covering fewer services, and (or) cutting rates paid to home care workers and other providers. Such difficult choices would have implications for home care because over half of Medicaid spending finances care for people ages 65 and older and those with disabilities, the enrollees most likely to use home care and related services.

What programs do states use to provide Medicaid home care?

Unlike institutional long-term care, nearly all home care is optional for states to provide under Medicaid. States are required to cover home health—which consists of part-time nursing services; home health aide services; and medical supplies, equipment, and appliances—but all other home care services are provided at the discretion of the states. States use various federal legal “authorities,” also known as programs, to offer home care, which are generally categorized as being part of the Medicaid state plan or part of a waiver. If services are provided through a state plan, they must be offered to all eligible individuals. In contrast, services provided under waivers, such as 1115s or 1915(c)s, may be restricted to specific groups based on geographic region, income, or type of disability. Waivers may include a wider range of service types than can be provided under state plans, but states may limit the number of people receiving waiver services. When the number of people seeking services exceeds the number of waiver slots available, states may use waiting lists to manage participation in the waiver.

All states have at least one home care program and many states have multiple programs. Home care is most frequently offered through 1915(c) waivers (47 states) and the personal care state plan benefit (34 states), and less frequently offered through 1115 waivers (14 states) or the Community First Choice option (10 states) (Figure 1). KFF estimates that 4.5 million people used Medicaid home care in 2021 compared with only 1.4 million people who used institutional long-term care.

All states offer people assistance with self-care and household activities under the personal care benefit, but they use different programs to do so. The primary home care benefit is personal care, which provides people with assistance with the activities of daily living (such as eating and dressing) and the instrumental activities of daily living (such as preparing meals and managing medication). States most commonly cover personal care through waivers (45 states), followed by the state plan (34 states).

How are people eligible for Medicaid home care?

Most people who are eligible for Medicaid home care qualify on the basis of having a disability or being ages 65 and older. Medicaid eligibility pathways in which eligibility is based on old age or disability are known as “non-MAGI” pathways because they do not use the Modified Adjusted Gross Income (MAGI) financial methodology that applies to children, pregnant individuals, parents, and other non-elderly adults with low incomes. In addition to considering income and age or disability status, non-MAGI eligibility pathways usually require people to demonstrate that they have limited savings and other financial resources (e.g., assets). Because nearly all non-MAGI pathways are optional, eligibility levels vary substantially across states.

Most states allow people with somewhat higher incomes to qualify for Medicaid home care, but income is capped at 300% of the supplemental security income limit ($2,901 per month in 2025) and assets are usually limited to $2,000 per person. Medicaid enrollees who use long-term care must also meet requirements related to their functional needs which are generally measured in terms of the ability to perform activities of daily living such as eating and bathing. Over half of people who use Medicaid home care are enrolled in Medicare as well; such people are also known as dual-eligible individuals.

In 2024, states operated over 300 different programs for Medicaid home care, many of which targeted a specific population. Most programs (258) were operated through 1915(c) waivers with 14 operated through 1115 waivers. (Waivers include those from all 51 states, not only the 48 states that responded to KFF’s survey.) The most common waiver programs target people with intellectual or developmental disabilities (48 states) and people who are ages 65 and older or have physical disabilities (46 states). Each year, some states’ waiver programs change: In 2024, Indiana added a new waiver for people who are ages 65 and older or have physical disabilities and North Dakota closed one. Also in 2024, Minnesota established a new program that is funded with state-only dollars to provide home care for people ages 65 and older who live in the community but require a nursing facility level of care. Unlike most Medicaid programs, Minnesota’s state-funded program requires participants to pay for a share of the total costs.

What services does Medicaid home care cover?

Besides personal care, Medicaid home care covers an array of services to help people with the activities of daily living and the instrumental activities of daily living. KFF asked states about what services they provide through Medicaid home care programs using the Centers for Medicare and Medicaid Services’ list of services, which are categorized in a comprehensive taxonomy. The taxonomy was developed to provide common language for describing home- and community-based services across waivers and state plans. Those services vary widely, including adult day care, supported employment, round-the-clock care, services to support unpaid family or friends who are caregivers, home-delivered meals, and non-medical transportation (Table 1).

All responding states cover supported employment (48), while nearly all (47) cover equipment, technology, and modifications, nursing services, home-based services, and day services in any home care program (Appendix Table 3). States often also offer other additional services for specific populations. For example, California offers specialized childcare and nutritional counseling through its waiver serving people with HIV/AIDS, Colorado offers virtual attendant services through its waivers serving people who are ages 65 and older or have disabilities and people with mental health conditions, and Minnesota offers respite, day support, and homemaker services through its waiver for children who are medically fragile or technology dependent. Among the categories defined by the Centers for Medicare & Medicaid Services, the least-frequently covered service was rent and food expenses for a live-in caregiver.

States use waivers that target specific populations to offer tailored benefits, and covered services differ among different types of waivers (Figure 3, Appendix Table 4). Some services, such as equipment, technology and modifications, home-based services, and day services, are covered by most states and in most waiver programs. However, other services are much more targeted to specific populations. Comparing services among the most commonly-offered waivers (those serving people with intellectual and developmental disabilities and people who are ages 65 and older or have physical disabilities), shows some services are widely covered by one type of waiver but not the other. For example, 45 states cover supported employment for people with intellectual or developmental disabilities, but only 13 cover the service for people who are ages 65 and older or have physical disabilities, a population less likely to be working. Alternatively, home-delivered meals are covered by 36 states under waivers serving people who are ages 65 and older or have physical disabilities, but only under 14 states’ waivers serving people with intellectual and developmental disabilities. By enabling states to cover, at times, different services per target population, waivers allow states to customize services to the needs of the specific populations they serve.

How do states use managed care to provide home care?

All but 11 states use managed care to provide at least some home care (Figure 4). In managed care, states pay managed care plans a set fee—often called a capitation payment—for each person enrolled and the managed care plans are responsible for providing all services to enrollees. Use of managed care to provide home care has been growing over time, with states using managed care to make their Medicaid spending more predictable and to help coordinate the services enrollees use.

Managed care is more commonly used for benefits provided through the state plan or 1115 waivers than for 1915(c) waivers (Figure 5, Appendix Table 5). Among the 14 states with 1115 waivers, 10 use managed care plans to provide at least some home care, over half of states use managed care plans to provide at least some home health through the state plan, and nearly half use managed care plans to provide some personal care, also through the state plan. Managed care was much less common under the 1915(c) waivers, particularly for waivers serving people with intellectual or developmental disabilities—of the 47 states with such waivers, only 8 provided any of the benefits through managed care.