Medicaid HCBS Waivers (1915(c)): How They Work

What an HCBS waiver is

HCBS stands for Home and Community-Based Services. A 1915(c) HCBS waiver lets a state provide Medicaid-funded long-term services and supports to a person in their home or community instead of in an institution. The name "waiver" comes from the fact that the state is allowed to waive some normal Medicaid rules to make this work.

Nearly every state and Washington DC runs HCBS waivers. As of the Medicaid.gov figure, about 257 HCBS waiver programs are active nationwide. A state can run as many separate waivers as it wants, each aimed at a different group.

The rules a state waiver must follow

Every 1915(c) waiver must (source: Medicaid.gov):

• Show that serving people at home does not cost more than serving them in an institution.
• Protect the health and welfare of the people served.
• Use reasonable provider standards.
• Follow an individual, person-centered plan of care.

The three rules states are allowed to waive

This is the part that helps autistic children whose family income is too high for regular Medicaid:

1. Statewideness: the state can run the waiver in only part of the state.
2. Comparability of services: the state can offer waiver services to only certain groups at risk of institutional care, such as children with developmental disabilities.
3. Community income and resource rules: this is the big one. The state can cover people who would only qualify for Medicaid in an institution, and it can ignore the parents' income and resources when deciding if the child qualifies. This is how a middle-income or higher-income family can still get their disabled child onto Medicaid.

Who can get a waiver

The state picks a target group. It can target by age or by diagnosis, and Medicaid.gov specifically lists autism as an example of a diagnosis a state can target. To qualify, the child must need a "level of care" that would otherwise be met in an institution (such as a hospital, nursing facility, or intermediate care facility). The state sets the maximum number of people it will serve.

What waivers cover

Waivers can cover a wide mix of services beyond standard Medicaid, including:

• Case management and service coordination
• Respite care (short breaks for the family caregiver)
• Habilitation (day and residential)
• Personal care and home health aide services
• Home or vehicle modifications
• Specialized equipment and supplies

The catch: waiting lists

Because a state can cap the number of waiver slots, HCBS waivers often have waiting lists. Some lists are years long. This is the single biggest weakness of the waiver path. A child can be found eligible and still wait for an open slot.

Contrast this with the TEFRA state plan option, which by law cannot have a waiting list. See medicaid-tefra-katie-beckett.

Where this fits

• HCBS waivers and the TEFRA/Katie Beckett option are the two main ways to get Medicaid for a disabled child based on the child's own income, not the parents' income.
• Once a child has Medicaid, medicaid-epsdt-aba-coverage (EPSDT) requires the state to cover medically necessary ABA and therapies.
• Each state names and runs its own waivers differently. Look up your state's waivers at kidswaivers.org and confirm with your state Medicaid office.