Medicaid Home and Community-Based Services for Older Adults: A Primer – Justice in Aging

Introduction

When asked about where they want to live as they age, almost all older adults say they want to live in their homes and get the services they need in the community as opposed to moving into a nursing facility.^[1] Unfortunately, the reality is that many older adults cannot make the choice to live at home because they do not have the necessary financial resources or access to paid support.

While significant barriers to home and community-based services (HCBS) exist for most individuals who need them, those barriers are even greater for older adults with limited income and savings, and for people of color and other marginalized communities, due to historical and present-day discrimination.

A 2025 survey found that 44% of adults age 60 and older reported having a disability, including nearly 30% percent who reported having difficulty with daily activities such as dressing or bathing, walking or climbing stairs, preparing meals, or doing errands alone.^[2] Additionally, 8% of people age 65+ reported serious difficulty concentrating, remembering, or making decisions.^[3] These types of functional limitations increase with age: about half of individuals age 75 and older and 75% of individuals age 85 and older reported difficulties with daily activities.^[4]

In addition, racial disparities exist among older adults with disabilities.^[5] For example, Black older adults are nearly twice as likely, and Hispanic older adults are nearly 1.5 times as likely as white older adults to have Alzheimer’s and other dementias.^[6] Prevalence is also high among American Indians, with a 2024 study finding that 54% of American Indian elders have a cognitive impairment, including 10% who have dementia.^[7]

Despite the common need for HCBS, Medicare and Medicaid are not funded and structured to provide this care to the growing older adult population. Medicare, which is the primary health insurance for older adults age 65 and older, does not cover the comprehensive, daily support that many older adults with disabilities need, and the home-based care it does cover is difficult to access. Medicaid, which is only available to people with limited income and savings, is the primary payer of HCBS, but it is also difficult to access and coverage varies depending on where you live.

This primer provides an overview of Medicaid HCBS and how states are doing in terms of serving older adults with disabilities in the community. It also discusses the gaps and inequities in the HCBS system.

What is the Institutional Bias in Medicaid?

Medicaid covers long-term services and supports (LTSS)^[9] provided in two categories of settings: institutional care, such as nursing homes, and home and community-based services (HCBS). However, these two categories of settings are not equally accessible due to federal Medicaid law’s historical and continued bias towards institutional care.^[10]

At the core of the institutional bias is the fact that federal Medicaid law requires states to cover nursing facility and other institutional care but does not require states to cover HCBS.^[11] The result is a patchwork of HCBS programs within and across states that leaves people with disabilities of all ages vulnerable to losing access if they move or if their needs or income change. In addition, states often turn to reducing services or eligibility for HCBS when they face budget shortfalls since federal law permits cuts to HCBS and other a non-mandatory benefits.^[12]

Over the years, there have been many different amendments to federal law and policy to increase coverage of and access to HCBS. This effort, sometimes referred to as “rebalancing,” has resulted in a significant shift in Medicaid spending.

In 2023, over 63% of total Medicaid spending on LTSS went to HCBS, up from less than 10% in the early 1980s when HCBS were first authorized.^[16] But increased spending on HCBS alone is not sufficient to meet consumer needs.^[17] Because states are not required to cover HCBS, significant barriers and inequities in access to HCBS persist based on where a person lives, as well as their age, disability, and race, as discussed in more detail below.

What are Home and Community Based Services?

Home and community-based services (HCBS) is an umbrella term for health care and other services provided to an individual in their own home and in more integrated community-based settings, as opposed to institutional settings such as nursing homes and psychiatric hospitals. HCBS enable many people with disabilities of all ages to live independently and fully participate in their communities as they choose.

HCBS include both medical care and a broader range of non-medical services to support an individual’s daily living activities and community integration, such as:

• Home health care (such as skilled nursing care; physical, occupational, and speech therapy; and pharmacy services)
• Durable medical equipment (such as wheelchairs, oxygen, and assistive technology)
• Individual, group, or center-based day supports (such as adult day programs)
• Congregate meal sites and home-delivered meal programs
• Personal care (such as assistance with bathing, dressing, eating, transferring, and toileting)
• Transportation
• Caregiver training and respite
• Housekeeping and chore services
• Case management
• Financial and legal services
• Hospice care
• Home repairs and modifications

HCBS Settings Rule

The HCBS Settings Rule is a federal regulation that supports the right of people with disabilities of all ages to live and receive Medicaid services in integrated, community-based settings. The Settings Rule has been in effect since 2014 and applies to Medicaid HCBS provided in community settings, including congregate settings such as adult day programs, assisted living facilities, and group homes. The Settings Rule requires that all settings where Medicaid-funded HCBS (both waiver and state-plan services) are delivered:

• Be integrated in and help provide full access to the greater community;
• Improve self-determination and independence in making life choices;
• Be chosen by the individual from among residential and day options, including settings that are not only for people with disabilities (called “non-disability specific settings”);
• Ensure the right to privacy, dignity, respect, and freedom from coercion and restraint;
• Access to eviction protections for residents of provider owned or controlled settings comparable to those living in private homes;
• Provide an opportunity to work in a typical job in the community (called “competitive integrated employment”);
• Provide people with an option to choose to live in their own unit or bedroom in the place where they live (called a residential setting); and
• Ensure there is a choice of services and providers.

The Settings Rule re-enforces the federal law that institutions, including nursing facilities, are not allowed to receive funding through Medicaid HCBS programs.^[22]

The Medicaid Access Rule, which was finalized in 2024, builds on the HCBS Settings Rule to strengthen quality, oversight, and access to HCBS.^[23] Among other things, the Access Rule requires states to establish clear complaint processes for HCBS enrollees, monitor and report serious incidents of abuse or harm, and report waitlist procedures and quality measures.

How is Eligibility for HCBS Determined?

Eligibility for HCBS requires an individual to meet both financial and functional criteria. Both criteria vary from state to state and program to program.

Financial Eligibility

Financial eligibility considers both the individual’s income and assets and depends on the state and the particular HCBS program.^[24] Eligibility for state-plan HCBS programs usually follows the financial eligibility thresholds for the aged, blind, disabled Medicaid category (also known as the “poverty-related pathway”), which ranges from 74% to 138% of the federal poverty limit (FPL).^[25] For assets, states typically apply limits of $2,000/individual ($3,000/couple).^[26] Both the income and asset limits correspond to financial eligibility standards for Supplemental Security Income (SSI), a Social Security program that provides modest financial assistance to people who are unable to work enough to meet their basic needs, including older adults with low or no Social Security or pension income, and younger people with significant disabilities.^[27]

Thirty-four states also allow older adults age 65+ and people with disabilities to qualify for Medicaid through the “medically needy” pathway, which allows individuals with countable incomes above the aged, blind, disabled Medicaid limits to “spend down” their income by subtracting incurred medical-related expenses to reach the state’s medically needy income limit (between 48% and 74% of the federal poverty level depending on the state).^[28] A federal rule finalized in 2024 gives states the option to allow individuals living in the community to project their health care and HCBS costs when determining their financial eligibility for Medicaid, rather than requiring them to actually incur these expenses first.^[29]

For HCBS waiver programs discussed below, most states follow the “special income rule,” which allows individuals to qualify with income up to 300% of the SSI rate.^[30] These higher income limits for HCBS waivers is a recognition that the aged, blind, and disabled Medicaid limits are too low for many people who need HCBS to qualify for Medicaid coverage and also be able to cover the expenses of living in the community. The dollar amount of the income limit changes every year and can vary within a state from program to program.^[31] States can also expand financial eligibility limits for HCBS state-plan benefits under 1915(i) authority or for HCBS services included in an 1115 demonstration.^[32] States have varying limits on how much income an individual receiving HCBS can keep as a “maintenance needs allowance” and varying rules about home equity as an asset.^[33] States may also require HCBS enrollees to spend a percentage of their income on their care.^[34]

In addition, Medicaid’s “spousal impoverishment protections” make it possible for an individual who needs a nursing home level of care to qualify for Medicaid and receive long-term services and supports, while allowing their spouse to retain a modest amount of income and resources to pay for rent, food, and medication. Congress established these protections first for spouses of individuals entering nursing facilities and extended this protection to eligibility for HCBS in all states beginning in 2014. This expansion, which is not yet permanent, helps mitigate the institutional bias by ensuring married couples have the same financial protections whether care is provided in a facility or in the community.^[35]

Functional Eligibility

In addition to meeting financial criteria, individuals applying for HCBS must undergo a functional assessment to determine eligibility and establish a care plan. For most HCBS programs, the individual must have functional needs that require an institutional level of care.^[36] The threshold for institutional level of care, however, varies by state. For example, a state may require a person to have difficulty with three or four activities of daily living (bathing, dressing, transferring to or from bed/chair, toileting, eating) to be eligible.^[37]

States do have options for creating HCBS programs with a lower functional eligibility standard. The 1915(i) state plan option, which has been authorized since 2005, permits states to serve people who require less than institutional level of care.^[38] Some states are pursuing Section 1115 demonstration waivers that would provide HCBS to some people with a lower level of care need.^[39]

In addition, H.R. 1 added an option for states to create 1915(c) waivers, beginning in 2028, to allow people with lower than institutional level of care to access HCBS so long as the average time individuals with higher level of care spend on the state’s 1915(c) waitlists does not increase.^[40]

Service Planning

Most states first determine whether an individual’s functional capacity meets the level of care eligibility standard and then determine what HCBS services are appropriate and necessary to develop the service plan. Both the eligibility and service plan assessments are based on the individual’s need for assistance with activities of daily living (bathing, dressing, transferring to or from bed/chair, toileting, eating) and instrumental activities of daily living (e.g., housekeeping, taking medication, managing money, grocery shopping and meal preparation, communication, transportation).^[41]

For federally mandated home health services, eligibility must be based on medical necessity and must include utilization controls. There are no similar federal eligibility requirements for optional services like HCBS except that they must be equally available to all recipients who satisfy the state’s service criteria.

Medicaid HCBS can include a range of supports and services, but the actual HCBS authorized are personalized based on what the individual needs and wants. Recent federal rulemaking strengthened existing service planning requirements to prioritize the enrollee leading their person-centered planning process to help ensure the HCBS authorized support the individual’s goals.^[42]

Many people receiving Medicaid HCBS also depend on “natural supports,” that is caregiving and other support from family and friends as opposed to paid assistance. However, it is important to note that under federal Medicaid regulations, HCBS service plans cannot compel family members to provide unpaid assistance.^[43] 

What Are the Types of HCBS Programs States Offer?

States can choose to cover HCBS in one of two ways: through their state Medicaid plan or through a waiver program. Today, all 50 states and DC do provide HCBS to adults age 65 and older and certain other populations through combinations of state plans and waivers. However, what the specific services are, who is eligible, and how many people are served varies significantly from state to state.

Medicaid State Plan

Under federal Medicaid law, all states must provide a minimum set of “home health” benefits under their state plan.^[47] Home health is the only HCBS benefit that states are required to provide.^[48] These mandatory services include part-time nursing and home health aide services and durable medical equipment.[49] Fewer than 1 million individuals receive mandatory home health benefits,^[50] as these services overlap with other Medicaid HCBS programs and with Medicare home health, which is primary coverage for individuals dually eligible for Medicaid and Medicare.

States may amend their Medicaid plans to include personal care services^[51] as well as a broader scope of HCBS, through authorities in Social Security Act Sections 1915(j) (Self-Directed Personal Assistant Services),^[52] 1915(k) (Community First Choice),^[53] and 1915(i) (State Plan HCBS).^[54] Because these programs are offered through the state’s Medicaid plan, they must conform to the requirements that all state plan services are subject to. Stated simply, this means that these programs must be available to all individuals who meet the eligibility criteria in the state equally and cannot be limited to certain counties, for example.

Medicaid HCBS Waivers

The second avenue by which a state can offer HCBS is through what is known as a waiver program. Types of waivers programs include 1915(c) waivers^[55] and Section 1115 Research and Demonstration Project Waivers.^[56] These programs are aptly named because they allow states to waive certain federal requirements that are otherwise binding on Medicaid programs, including allowing states to provide long-term care in home and community-based settings instead of institutional settings.

Additional waived requirements include the comparability requirement to offer services in equal amount, duration, and scope to all eligible populations, the requirement to offer services statewide, and Medicaid’s strict income and asset limits. Because states can disregard these requirements, HCBS waiver programs may only be available in certain areas of a state and are typically targeted to specific populations, such as older adults and people with physical disabilities or people with intellectual and developmental disabilities.^[57] Many HCBS waivers include caps on the number of people eligible for services, and often have more relaxed financial eligibility requirements than state plan benefits.[58]

All but four states have at least one 1915(c) waiver, and most states have multiple waivers targeted to specific populations.^[59] All states with 1915(c) waivers serve older adults through one or more of these waivers.^[60] Section 1115 waivers are less common—only 15 states use them for HCBS, including the four states that do not have 1915(c) waivers.^[61]

Money Follows the Person Program

In addition to state plan amendments and waivers, Congress has also created other demonstration programs that aim to enhance access to HCBS.^[62] One example that is especially important to older adults is the Medicaid Money Follows the Person (MFP) program.

MFP is a demonstration program that helps adults with disabilities of all ages move out of institutions and into the community and helps states develop infrastructure to expand HCBS.^[63] MFP provides a year of HCBS for individuals who have been living in an institution for at least 60 days. In addition to supports and services authorized through the state plan or waiver, MFP also authorizes payment for enhanced services and supplemental services not typically covered by Medicaid, such as household set up costs and security deposits.^[64]

As with most HCBS programs, the availability of MFP and the services it covers vary from state to state. Since the program began in 2008, 46 states and Washington, D.C. have implemented MFP to help more than 127,000 individuals transition out of institutions.^[65] As of 2026, 38 states and DC have MFP programs, with authorization and funding set to expire at the end of September 2027.^[66]

How do States Pay for HCBS?

Due to the optional nature of these benefits and the flexibility states have in designing their HCBS programs, not everyone who needs or is eligible for Medicaid HCBS can access it.

In addition to setting the scope of services and the populations who are eligible for HCBS, states also have choices in how they pay providers: fee-for-service or capitated payments for each covered person. Under traditional “fee-for-service,” the state pays providers directly according to payment rates it sets. Under capitated programs, states pay a managed care plan an amount for each person enrolled in an HCBS program, and the managed care plan then contracts with and pays the providers. Currently, 39 states are operating managed long-term services and supports (MLTSS) programs to pay for HCBS for at least some populations.^[67]

Another capitated payment program some states have implemented is PACE—Program of All-Inclusive Care for the Elderly. PACE programs typically serve individuals who are dually eligible for Medicare and Medicaid and employ an interdisciplinary team to provide all covered services, both medical and LTSS, on-site at a day center.^[68] Participants may also receive services at home or by referral as necessary. Nationwide, over 96,000 individuals ages 55+ are enrolled in PACE programs across 33 states and Washington, DC.^[69]

How does Access to HCBS Vary across States?

Every state covers HCBS for older adults and other populations beyond the mandatory home health care benefit. However, due to the optional nature of these benefits and the flexibility states have in designing their HCBS programs, not everyone who needs or is eligible for Medicaid HCBS can access it.

One measure of access is the number of people who are waiting for an opening in their state’s HCBS waiver programs. Most states have waiting lists for some waivers because they have capped the number of “slots” available, but the size of the waiting lists ranged from 141 people in North Dakota to nearly 182,000 people in Texas in 2025.^[70] In total, over 600,000 people were on a waiting list for HCBS in 2025, including more than 182,000 seniors and people with physical disabilities.^[71] Individuals on those waiting lists wait an average of 40 months to begin receiving HCBS.^[72]

These numbers are likely only a fraction of the unmet need because there are many people who need HCBS and are in fact eligible but are not on waiting lists, particularly older adults who are less familiar with how to navigate the service system. For example, as of 2025, 31 states had no older adults on waiting lists.^[73] Yet, over two-thirds of these states were spending more on institutional care than on HCBS for this population in 2023.^[74] Moreover, the eligibility criteria for Medicaid HCBS are quite narrow, leaving many others who need this support to live independently ineligible for Medicaid coverage.

Another measure of access is the balance of enrollment and spending on LTSS between HCBS and institutional care. While we know that of all Medicaid enrollees age 65 and older, less than 10% reside in a nursing facility or other institutional setting,^[75] the balance is much different among older adults who need and are eligible for LTSS.

Across all states, less than 65% of LTSS expenditures in 2023 went towards HCBS despite people enrolled in HCBS accounting for 87% of the LTSS population. ^[76] Unmet need becomes even more apparent when analyzing enrollment and spending by population. Of Medicaid enrollees age 65 and older receiving LTSS in 2023, approximately two-thirds received HCBS, while the national average LTSS spending on HCBS for older adults was only 47%.^[77]

In other words, the majority of states are spending more on institutional care than on HCBS for older adults. These percentages vary widely across states. For example, Colorado, New York, Oregon, Washington and Wisconsin all spend over 60% of their LTSS expenditures on HCBS for older adults.^[78] This contrasts with states like Alabama, Arkansas, North Dakota, and West Virginia that spend less than 20% of their LTSS expenditures for older adults on HCBS.

What are the Gaps & Inequities?

The data demonstrates the gap in access to HCBS for older adults: nine out of 10 older adults express a desire to live at home as they age, yet only six in 10 who have Medicaid coverage for long term care are getting HCBS.

Although every state does offer HCBS, there are significant gaps in access to these programs. As demonstrated above, access to HCBS varies widely from state to state and even within states because many HCBS programs are operated through waivers of federal law. In addition, because federal Medicaid law does not require states to provide HCBS to all populations who need LTSS, significant race and population-based inequities arise and often intersect.

Unmet need for HCBS is difficult to measure. Notably, no national survey currently collects data on LTSS needs across all populations and ages. That said, estimates indicate that 17.6 million adults nationwide, including over 9 million people age 65+, likely need LTSS.^[80] However, only about 8.4 million people receive Medicaid HCBS.^[81] And a recent analysis found that one in four adults age 60+ with disabilities had unmet personal assistance needs at some point in 2025.^[82]

The data demonstrates the gap in access to HCBS for older adults: nine out of 10 older adults express a desire to live at home as they age, yet only six in 10 who have Medicaid coverage for long term care are getting HCBS.^[83] In states like Alabama, Kentucky, Louisiana, Maine, North Dakota, and Tennessee, fewer than four in 10 older adults enrolled in Medicaid LTSS receive HCBS.^[84]

Among older adults, there are also disparities in access for people of color in some states. For example, in 2018, half of Michigan’s population lived in 10 counties in the southeast part of the state. In one of those, Wayne County, 40% of older adults were non-white. However, only one-third of the state’s total HCBS waiver slots were available in those 10 counties. In other words, there was only one waiver slot for every 58 eligible individuals in those counties compared to one slot for every 20 eligible individuals in the rest of the state.^[85]

Lack of provider availability can also negatively impact access to services for particular communities. In New Jersey, the six counties with the greatest number of older residents are Bergen, Ocean, Middlesex, Essex, Monmouth, and Morris. Ocean, Monmouth, and Morris counties are less racially diverse with fewer older adults compared to Bergen, Middlesex, and Essex counties. Yet, of the 75 total facilities accepting Medicaid in these six counties, 68% (or 51 facilities) are available in Ocean, Monmouth, and Morris counties.^[86] The data is consistent with research finding that assisted living facilities are located disproportionately in higher income and less racially diverse communities.^[87]

Another example is inequitable access to HCBS for people with Alzheimer’s and other dementias. At age 80, 75% of people with dementia live in a nursing home compared to 4% of the general population.^[88] This inequity compounds other race-based inequities because rates of dementia are higher among Black, Hispanic, and American Indian older adults.

Finally, an underlying barrier in access to HCBS that exists in every state and every community is affordable and accessible housing. When a Medicaid enrollee resides in a nursing facility or other institution, Medicaid covers the costs of room and board, in addition to the health care and LTSS costs. However, aside from a few limited demonstration programs, Medicaid does not pay for housing for people who are receiving or need HCBS. Individuals who are unhoused, including a growing number of older adults, face the ultimate barrier to accessing HCBS and are more likely to be forced into an institution. Like other barriers to HCBS, the housing barrier is disproportionately among people of color with limited wealth.^[89]

Conclusion

Addressing these gaps and barriers will require fundamental systemic changes that are centered in equity, yet the financial hardships imposed on states by H.R. 1 threaten the opposite result. States must consider revenue strategies and long-term costs to avoid cutting HCBS. Modernizing eligibility rules and systems, improving data, and coordinating with housing and other agencies are also necessary steps that can and should be taken immediately.

At the federal level, undoing the harms of H.R. 1 and strengthening HCBS through both Medicaid and Medicare are key. The policies needed include making HCBS a mandatory Medicaid benefit, adding a comprehensive home care benefit to Medicare, investing in the HCBS infrastructure and direct care workforce, and expanding and streamlining eligibility.

Endnotes

1. AARP Research, “2024 Home and Community Preferences: A National Survey of Adults Ages 18-Plus,”(Dec. 2024). ↑

2. Urban Institute, “One in Four Older Adults with Disabilities Had Unmet Needs for Personal Assistance in 2025,” (July 2026). ↑

3. ACL, “2023 Profile of Older Americans,” at 18 (May 2024). ↑

4. Freedman, et. al, “Trends In Care Needs Among Older US Adults Diverged By Age, 2011–22,” Health Affairs, (July 7, 2026). ↑

5. ATI Advisory, Disparities in LTSS Needs and Supportive Resources at Age 55, and Outcome Disparities During the Next Decade (Dec. 2023). ↑

6. Alzheimer’s Ass’n, “2026 Alzheimer’s Disease Facts and Figures,” at 34 (Apr. 21, 2026). ↑

7. National Institute on Aging, “Older American Indians May Experience Higher Levels of Cognitive Impairment than Previously Thought,” (May 15, 2024). ↑

8. Schubel, Jessica et. al, Health Affairs, “History Repeats? Faced With Medicaid Cuts, States Reduced Support for Older Adults and Disabled People,” (Apr. 16, 2025). ↑

9. See 42 C.F.R. § 438.2 (“Long-term services and supports (LTSS) means services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of their choice, which may include the individual’s home, a worksite, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting.”) ↑

10. When Medicaid was enacted in 1965, funding for long-term care was limited to paying for skilled nursing facility (SNF) stays for individuals 21 or older. At the time, states were given an option to cover home health and private duty nursing services. In 1970, due to the high cost of SNFs, Congress made home health services for individuals who need a nursing facility level of care a mandatory benefit. ↑

11. 42 U.S.C. §§ 1396a(10)(A), 1396d(a)(4)(A); see also, e.g., 42 USC §§ 1396n(c), (j), (k) and (i). ↑

12. Schubel, Jessica et. al, Health Affairs, “History Repeats? Faced With Medicaid Cuts, States Reduced Support For Older Adults And Disabled People,” (Apr. 16, 2025). ↑

13. See Olmstead v. L.C., 527 U.S. 581 (1999) (holding that a state must allow a person to receive long-term care services in the community if the person does not oppose living in the community, a professional has deemed community living to be appropriate, and provision of such services can be reasonably accommodated by the state).↑

14. U.S. Dep’t of Justice, “Statement of the Department of Justice on Enforcement of the Integration Mandate of Title II of the Americans with Disabilities Act and Olmstead v. L.C.,” (2011). ↑

15. Principal Deputy Assistant Attorney General Lenora C. Pettit, U.S. Department of Justice Office of Legal Counsel, ”Application of the Rehabilitation Act and Americans with Disabilities Act to State Institutionalization of Patients with Severe Mental Illness or Disabilities“ (Jun. 18,2026). ↑

16. CMS, “Trends in Users and Expenditures for Home and Community-Based Services as a Share of Total Medicaid Long-Term Services and Supports Users and Expenditures, 2023,” (Oct. 2025). ↑

17. Parik, Romil et. al, “Examining State Policies and Administrative Factors as Determinants of Consumer-Reported Unmet Service Needs in Publicly Funded Home- and Community-Based Services in the United States,” Journal of Market Access & Health Policy, (Oct. 2, 2025),(finding that higher HCBS spending relative to institutional care is associated with greater unmet HCBS needs, and that fiscal rebalancing does not automatically translate into improved service access, and indicating that financial investments must be paired with infrastructure). ↑

18. See, e.g., Associated Press-NORC Ctr. for Public Affairs, “Research, Long Term Care: Perceptions, Experiences, and Attitudes Among Americans 40 or Older,” (2013). https://apnorc.org/projects/long-term-care-perceptions-experiences-and-attitudes-among-americans-40-or-older/ (survey shows Americans “overestimate the long-term care services that Medicare will cover”). ↑

19. 42 C.F.R. §§ 409.30(a), 409.31(b), 409.32, 409.61(b). In 2024, the average length of stay in a nursing facility under Medicare was only 30 days. Medicare Payment Advisory Commission (MedPAC), “Report to the Congress: Medicare Payment Policy: Chapter 7 Skilled Nursing Facility Services”, at 224, Table 7-3 (Mar. 2026). ↑

20. See CMS, Medicare.gov: Home Health Services; Homebound means “You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury, or leaving your home isn’t recommended because of your condition. You’re normally unable to leave your home, but if you do it requires a major effort.” CMS, “Medicare and Home Health Care”, at 5 . ↑

21. See, e.g., Integrated Care Resource Center, “Strategies to Support Dually Eligible Individuals’ Access to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies” (Jan. 2019). ↑

22. Home and Community-Based Setting Requirements for Community First Choice and Home and Community-Based Services (HCBS) Waivers, 79 Fed. Reg. 2948, 3030-31 (Jan. 16, 2014) (codified at 42 C.F.R. § 441.301(c)(4)). ↑

23. Ensuring Access to Medicaid Services (CMS-2442-F), 89 Fed. Reg. 40542 (May 10, 2024). ↑

24. KFF, “Medicaid Eligibility for Older Adults and People with Disabilities (Non-MAGI) in 2026,” (Apr. 30, 2026). ↑

25. Id. at App. Table 5. Note: States have flexibility in what income is counted towards eligibility including flexibility to disregard income in determining whether an individual’s income is at or below the income eligibility limit. Most states disregard income 5% or less above the eligibility limit, but some states disregard more. For example, in California, the state disregards any countable income above 100% FPL up to 138% FPL, in effect making the income eligibility limit 138% FPL In California. ↑

26. Id. at App. Table 5. ↑

27. Justice in Aging, “FAQ: Supplemental Security Income (SSI)” (Mar. 5, 2026). ↑

28. KFF, Non-MAGI Medicaid Eligibility in 2026, supra note 23. ↑

29. Justice in Aging,”Final Rule to Streamline Access to Medicaid (Oct. 30, 2025). ↑

30. Id. at App. Table 5. ↑

31. In 2026, 300% of the SSI benefit rate is $2,982. ↑

32. See KFF, “Medicaid Financial Eligibility in Pathways Based on Old Age or Disability in 2022: Findings from a 50-State Survey,” at App. Table 5 (Jul. 11, 2022); KFF, “Waivers with Eligibility Changes,” (last updated Jul. 4, 2026). ↑

33. 45 C.F.R. § 435.726; see also KFF, “Medicaid Eligibility Levels for Older Adults and People with Disabilities (Non-MAGI) in 2026” App. Table 7, (Apr. 7, 2025); Justice in Aging, “H.R. 1 Imposes New Limit on Home Equity for Medicaid Long-Term Services and Supports Effective 2028,” (Apr. 9, 2026) (Effective January 1, 2028, H.R. 1 restricts and freezes the maximum amount of home equity that is excluded when determining eligibility for Medicaid LTSS at $1 million.). ↑

34. 42 C.F.R. § 435.217. ↑

35. Justice in Aging, “Fact Sheet: Make the Expanded Spousal Impoverishment Protection Permanent,” (Jan. 2023). ↑

36. Centers for Medicare and Medicaid Services, ”Home & Community-Based Services 1915(c)” (last visited Jul. 29, 2026). ↑

37. KFF, “What is Medicaid Home Care (HCBS)?” (Feb. 18, 2025); Medicaid and CHIP Payment and Access Commission, ”Eligibility for Long-Term Services and Supports” (Mar. 22, 2022).↑

38. Id. ↑

39. KFF, ”Waivers with Eligibility Changes” (last updated Jul. 14, 2026). ↑

40. 42 U.S.C. § 1396(n)(c)(11). (Note that the law prohibits provider reimbursements through these new waivers from going towards benefits like health insurance and training for direct care workers.) ↑

41. Administration for Community Living, “What is Long-Term Care”. ↑

42. 42 C.F.R. § 441.301(c)(1)-(3). ↑

43. Justice in Aging, “Voluntary Means Voluntary: Coordinating Medicaid HCBS with Family Assistance” (2016). ↑

44. KFF, “Medicaid in the Territories: Program Features, Challenges, and Changes” (Jan 25, 2019); KKF, “Recent Changes in Medicaid Financing in Puerto Rico and Other U.S. Territories”(Oct. 28, 2024). ↑

45. MACPAC, MACStats: EXHIBIT 17. Total Medicaid Benefit Spending by State and Category (FY 2024), (Feb. 2026). ↑

46. See Puerto Rico Department of Health, “Money Follows the Person Long Term Services Support Assessment (LTSS) Request for Proposal (RFP),” (Jan. 18, 2024); CMS, “HHS expands home and community-based services in five new states and territories for older adults and people with disabilities,” (Aug. 22, 2022). ↑

47. 42 USC §§ 1396a(10)(D); 1396d(a)(7); see 42 C.F.R. § 440.210(a)(1). ↑

48. See 42 C.F.R. § 440.70. Note that mandatory home health services are more limited in scope compared to optional home and community-based services, and can include service caps and other utilization controls. ↑

49. KFF, “Medicaid Home Care (HCBS) in 2025,” (Jan. 2026). ↑

50. KFF, “Medicaid Enrollees Using Home Care Services (HCBS),” (2023). ↑

51. 42 C.F.R. § 440.167. ↑

52. CMS, Self-Directed Personal Assistant Services 1915 (j). ↑

53. CMS, Community First Choice (CFC) 1915 (k). ↑

54. CMS, Home & Community Based Services 1915(i). ↑

55. CMS, Home & Community-Based Services 1915(c),. ↑

56. CMS, About Section 1115 Demonstrations. ↑

57. A waiver typically targets one of several categories of people with disabilities: older adults and people with physical disabilities (often combined), people with intellectual and developmental disabilities, people who are medically Fragile/Tech Dependent Children, people with HIV/AIDS, people with mental health needs, and people with traumatic brain injuries or spinal cord injuries (TBI/SCI). ↑

58. KFF,”What is Medicaid Home Care (HCBS)?,” (2025). ↑

59. KFF, “Medicaid Home Care (HCBS) in 2025,” (Jan. 5, 2026). ↑

60. Id. ↑

61. Id. ↑

62. Another example is the Balancing Incentive Program that provided federal grants from 2011 to 2015 to 21 states that were spending less than 50% of their total Medicaid LTSS expenditures on HCBS. The grants were used to increase access to HCBS by establishing “no wrong door” systems in Medicaid, using core standardized assessment instruments, and implementing conflict-free case management systems. CMS, Balancing Incentive Program. ↑

63. CMS, Money Follows the Person Program. ↑

64. Kaiser Family Foundation, “Medicaid’s Money Follows the Person Program: State Progress and Uncertainty Pending Federal Funding Reauthorization,” (Nov. 25, 2019). ↑

65. CMS, “Money Follows the Person (MFP): Updated MFP Grant Recipient Transitions as of December 31, 2023 (Dec. 2025). ↑

66. Community Living Policy Center, Money Follows the Person: Promoting Freedom, State Innovation, & Costs Savings (2026). ↑

67. KFF, “Medicaid Home Care (HCBS) in 2025,” (Jan. 5, 2026). ↑

68. CMS, Programs of All-Inclusive Care for the Elderly Benefits. ↑

69. National PACE Association, “PACE in the States,” (July 2026). ↑

70. KFF, “Number of People Waiting for Medicaid Home Care (HCBS), by Target Population and Whether States Screen for Eligibility,” (2025). ↑

71. Id. ↑

72. KFF,” A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2024,” (Oct. 2024).↑

73. KFF, “Number of People Waiting for Medicaid Home Care (HCBS), by Target Population and Whether States Screen for Eligibility,” (2025). ↑

74. Justice in Aging’s analysis of CMS LTSS expenditure data for 2023 compared to KFF waiting list data for 2025. ↑

75. CMS, 2026 Medicaid & CHIP Beneficiaries at a Glance (Jan. 2026). ↑

76. CMS, Trends in Users and Expenditures for Home and Community-Based Services as a Share of Total Medicaid Long-Term Services and Supports Users and Expenditures, 2023, at 1 (Oct. 17, 2025). ↑

77. Id. at 11. ↑

78. Justice in Aging’s analysis of CMS LTSS expenditure data for 2023, Table B2. ↑

79. CMS, Analysis of Data Quality in the Transformed Medicaid Statistical Information System Analytic Files for Identifying Medicaid Home and Community-Based Services and Institutional Long-term Services and Supports, 2023, (Oct. 2025). ↑

80. Community Living Policy Center, “Who Needs LTSS,”(2025). ↑

81. CMS, “Medicaid Long-Term Services and Supports Users and Expenditures by Service Category, 2023. ↑

82. Urban Institute, “One in Four Older Adults with Disabilities Had Unmet Needs for Personal Assistance in 2025,” (July 2026). ↑

83. Pew Research Center, “Most older adults who live at home want to age in place, but they aren’t entirely confident they’ll get to” (Feb. 26, 2026). ↑

84. Justice in Aging’s analysis of CMS LTSS expenditure data for 2023, Table B1. ↑

85. AARP Michigan, “Disrupting Disparities: A Continuum of Care for Michiganders 50 and Older”, at 17, (Apr. 2019). ↑

86. Justice in Aging, ”An Equity Framework for Evaluating and Improving Medicaid Home and Community-Based Services,“ at 5 (Jun. 2023). ↑

87. Id. ↑

88. Alzheimer’s Ass’n, “2026 Alzheimer‘s Disease Facts and Figures,” at 45. ↑

89. Prunhuber, Patti and Kwok, Vivian, Justice in Aging, “Low-Income Older Adults Face Unaffordable Rents, Driving Housing Instability and Homelessness,” (Feb. 2021). ↑