1915(c) Waivers by State: Enrollment, Spending, and Waiting Lists

Section 1915(c) waivers by state look very different depending on where you live: 46 states and the District of Columbia run a combined 267 approved programs, while four states use no 1915(c) waivers at all. Each state chooses its own target populations, sets its own enrollment caps, and defines its own services, which is why enrollment in 2023 ranged from roughly 194,300 people in Illinois to zero in states that route home and community-based services through other Medicaid authorities.¹²

Which States Use 1915(c) Waivers

Almost every state operates at least one 1915(c) waiver. The exceptions are Arizona, New Jersey, Rhode Island, and Vermont, which deliver their home and community-based services entirely through Section 1115 demonstration waivers.¹

Those four states use 1115 authority to reach populations a standard 1915(c) waiver would not cover. Arizona’s Long-Term Care System (ALTCS) extends services to working-age adults with mental illness or intellectual and developmental disabilities who do not meet nursing facility criteria. Rhode Island’s comprehensive 1115 demonstration covers adults with Alzheimer’s disease and related dementias. Vermont’s Global Commitment to Health waiver serves people at risk of institutionalization under broader clinical criteria than 1915(c) allows.³

Fifteen additional states run 1115 waivers alongside their 1915(c) programs, so the choice is not always either-or.⁴

Enrollment by State

Enrollment differences reflect state population, how many waivers each state runs, and whether the state uses 1915(c) alongside or in place of other Medicaid authorities. According to KFF data for 2023, the largest 1915(c) enrollments were:

Illinois: approximately 194,300 enrollees
California: 184,400
New York: 145,800
Minnesota: 107,500
Ohio: 85,100
Indiana: 82,200
Virginia: 70,700
Colorado: 65,300
Georgia: 64,500

Some smaller-population states enrolled sizable numbers relative to their size, including Oregon (56,900), Iowa (29,400), and Idaho (24,200).²

Nine states recorded zero 1915(c) enrollment in the KFF figures: Arizona, Maine, Michigan, Missouri, New Jersey, North Carolina, Rhode Island, Tennessee, and Vermont. These states either rely on 1115 demonstrations for their home and community-based services or deliver them through other Medicaid authorities.²

What States Decide for Themselves

A 1915(c) waiver lets a state set aside three normal Medicaid rules: the requirement that benefits be available statewide, the requirement that they be comparable across eligible groups, and certain income and resource rules. That flexibility is the reason waivers differ so much from one state to another.⁵

Target Populations

Each waiver defines its own group by age, diagnosis, or both. Common categories across the states include elderly individuals, people with physical disabilities, people with intellectual or developmental disabilities, individuals with traumatic brain injuries, technology-dependent children, people with HIV/AIDS, and people with serious behavioral health conditions.⁵ To qualify, a person must meet the state’s criteria for institutional care, meaning they would be eligible for a nursing home or intermediate care facility but choose to receive services at home or in the community.

Financial Eligibility

Many states use what’s called the “special HCBS waiver group” (or “217 group”), which allows income up to 300 percent of the federal Supplemental Security Income benefit rate, roughly $2,901 per month for an individual as of 2025.¹

Enrollment Caps

Every state sets its own cap on how many people each waiver will serve at once. Caps are the direct reason waiting lists exist under 1915(c), and they are why demand and enrollment can look so different across state lines.

Services Covered

The statute identifies a core set of services states can offer through a 1915(c) waiver:⁶

Case management
Homemaker and home health aide services
Personal care (help with bathing, dressing, eating, and other activities of daily living)
Adult day health
Habilitation, including day and residential supports
Respite care for unpaid family caregivers

States can propose additional services that help individuals avoid or transition out of institutional settings. In practice this means supported employment, home modifications, assistive technology, and specialized therapies show up in some state waivers and not others.⁵

Spending and How States Fund Their Share

Total 1915(c) waiver spending reached $62.4 billion in calendar year 2022, nearly half of all Medicaid-covered home and community-based services spending. Community-based care has grown from 1.1 percent of Medicaid long-term services and supports expenditures in 1981 to 64.6 percent in 2022.¹

On average, waiver services cost far less than institutional care. As of May 2023, the national average per-capita waiver cost was $58,485, compared to $154,125 for institutional care, or about 62 percent less.⁷ Every waiver must meet a cost-neutrality test: the average per-capita Medicaid expenditure for people in the waiver cannot exceed what the state would have spent on institutional care for the same individuals.⁸

The federal government pays part of the cost through the Federal Medical Assistance Percentage (FMAP), which varies by state. States fund their share through a mix of sources: state-appropriated tax revenues in 94 percent of states, local government sources like county and property taxes in 34 percent of states, and healthcare-related taxes such as nursing facility franchise fees. Intergovernmental transfers and certified public expenditures are the two most common mechanisms for moving those funds.⁹

Waiting Lists by State

Because states cap enrollment, demand for waiver slots consistently exceeds supply. In 2025, more than 600,000 people were on waiting or interest lists across 41 states, a 14 percent increase from the prior year. Twenty-nine states reported growing lists, and 12 reported shrinking ones.¹⁰

The average wait for services, based on data from 33 states, was 32 months. Waits varied sharply by population:

People with intellectual or developmental disabilities: 37 months (about 74 percent of the total waiting list population)
Older adults and people with physical disabilities: 15 months
People with autism: 63 months (the longest waits of any group)

¹⁰

Comparing waiting lists across states can be misleading. Six states — Florida, Iowa, Oklahoma, Oregon, South Carolina, and Texas — do not screen for Medicaid eligibility before placing people on a waiting list, and those six alone account for more than 325,000 of the national total. States that screen up front will show smaller lists, but the difference reflects list management, not necessarily actual need.¹

A 2024 CMS final rule now requires states to report annually on how they maintain waiting lists, including whether they screen for eligibility beforehand and whether they periodically rescreen. More detailed reporting requirements take effect in 2027, which should improve state-to-state comparability going forward.¹

How States Deliver Services

States choose whether to deliver waiver services on a fee-for-service basis or through managed care organizations. Under managed care, the state pays a plan a set monthly fee (a capitation payment) for each enrollee, and the plan handles service delivery.

Managed care participation is growing. In 2025, 26 states used managed care for at least some of their 1915(c) waivers, up from 22 states in 2024.⁴

Waivers serving people with intellectual or developmental disabilities are an exception. Of 47 states surveyed by KFF, only 8 used managed care for any I/DD waiver benefits; most states continue to serve this population through fee-for-service arrangements or specialized provider networks.⁴

How 1915(c) Fits Alongside Other State Options

Most states run 1915(c) waivers alongside other Medicaid authorities, each with different rules. Knowing which authorities your state uses affects who can qualify and whether waiting lists apply.

Section 1115 Demonstrations

Broader than 1915(c) waivers, 1115 demonstrations typically operate statewide, require a research or evaluation component, and give states flexibility to use demonstration savings to fund services Medicaid would not otherwise cover. Arizona, New Jersey, Rhode Island, and Vermont use 1115 as their sole HCBS authority; 15 more states pair 1115 waivers with 1915(c) programs.⁶⁴

Section 1915(i) State Plan HCBS

The 1915(i) option lets states offer HCBS through their state plan without a waiver. It does not require an institutional level of care, has no cost-neutrality requirement, and cannot use enrollment caps or waiting lists. It must be offered statewide. Sixteen states and the District of Columbia have adopted 1915(i), including Arkansas, California, Connecticut, Delaware, Idaho, Indiana, Iowa, Maryland, Michigan, Mississippi, Nevada, New Hampshire, Ohio, Oregon, and Texas.¹¹

Section 1915(k) Community First Choice

Available since October 2011, 1915(k) allows states to provide attendant services through the state plan and comes with a 6 percentage point increase in the federal match for those services. Individuals can receive 1915(k) services and 1915(c) waiver services at the same time.¹²¹³

Recent Changes Affecting State Programs

The One Big Beautiful Bill Act, signed on July 3, 2025, is projected to reduce federal Medicaid spending by roughly $911 billion over a decade, with consequences that will play out state by state.⁴

Section 71171 of the law creates a new standalone 1915(c) waiver type, effective July 1, 2028, that would let states serve people who do not meet a nursing facility or ICF/IID level of care. To use it, a state must set needs-based criteria more stringent than its other 1915(c) waivers, demonstrate that the new waiver will not increase wait times for existing waiver services, and attest to cost neutrality relative to institutional care. States would also submit annual reports on service costs, service duration by type, and participant counts.¹⁴ Take-up is expected to be limited, in part because most states already carry substantial waiting lists that would make the “no increase in wait times” test hard to meet.⁴

At the state level, Oregon launched a new 1915(c) waiver in 2025 that pays parents of minor children with disabilities for providing attendant care, along with a new 1115 waiver for older adults and people with physical disabilities that supports in-home services and family caregivers.⁴ To find out which waivers operate in your state, what populations they serve, and whether a waiting list applies, contact your state Medicaid agency directly, since eligibility criteria, covered services, and enrollment capacity are all set at the state level.

1
Congress.gov. Medicaid Section 1915(c) Home and Community-Based Services Waivers
2
KFF. Medicaid Enrollees Using Home Care Services
3
ADvancing States. 1115 Waiver Review Full Report
4
KFF. Medicaid Home Care (HCBS) in 2025
5
Medicaid.gov. Home and Community-Based Services 1915(c)
6
MACPAC. Waivers
7
Medicaid.gov. Estimating Factor D Considerations for 1915(c) Waiver Program Costs
8
Medicaid.gov. HCBS 1915(c) Cost Neutrality
9
Medicaid.gov. HCBS Waiver Payments and Financing Trends
10
KFF. A Look at Waiting Lists for Medicaid Home and Community-Based Services From 2016 to 2025
11
CMS. HCBS 101 Presentation
12
Medicaid.gov. Community First Choice (CFC) 1915(k)
13
eCFR. Community First Choice, 42 CFR Part 441 Subpart K
14
ADvancing States. Summary of OBBBA