When people search for a “Medicare waiver,” they are almost always looking for a Medicaid waiver — a program that lets a state pay for care in your home or community instead of sending you to a nursing home. Medicare itself does not cover ongoing personal care, so the waiver that keeps people out of institutions comes from Medicaid. More than 250 active waiver programs run across nearly every state, serving roughly 1.7 million people through home and community-based services.1Medicaid.gov. Section 1915(c) Waiver Program Participants in 2020
Why the Name Is Misleading
Medicare pays for doctors, hospitals, prescriptions, and short-term skilled nursing or home health after a hospital stay. It does not pay for the ongoing care most people need to remain at home: help with bathing, meals, housekeeping, or supervision. Medicaid does. When a state gets federal permission to deliver that Medicaid-funded care in someone’s home rather than in a facility, the authorization is called a waiver.
Many people carrying Medicare also qualify for Medicaid. These “dual eligibles” use Medicare for medical care while a Medicaid waiver picks up home-based services Medicare will not cover.2Centers for Medicare & Medicaid Services. Beneficiaries Dually Eligible for Medicare and Medicaid Because the waiver often comes up in the same enrollment conversation as Medicare, the label stuck even though the legal authority sits entirely on the Medicaid side.
One waiver really does belong to Medicare, and it has nothing to do with long-term care. Section 1135 of the Social Security Act lets the HHS Secretary temporarily waive certain Medicare rules during a declared emergency — for example, letting out-of-state doctors treat patients or suspending prior-authorization requirements. These waivers expire when the emergency ends or after 60 days, whichever comes first.3Centers for Medicare & Medicaid Services. 1135 Waivers If you are planning for a parent’s care at home, this is not the tool you need.
The Waivers That Actually Pay for Home Care
Medicaid waivers are named for the section of the Social Security Act that authorizes them. Three types cover most of what people are looking for.4MACPAC. Waivers
Section 1915(c) Home and Community-Based Services Waivers
This is the waiver most families end up on. A 1915(c) waiver lets a state provide long-term services at home or in the community instead of in an institution.5Medicaid.gov. Home and Community-Based Services 1915(c) States design each waiver for a specific group — older adults, people with intellectual or developmental disabilities, individuals with traumatic brain injuries, medically complex children — and set their own enrollment limits, service menus, and geographic scope.6Centers for Medicare & Medicaid Services. National Overview of 1915(c) HCBS Waivers Average per-person spending under the waiver cannot exceed what the state would have spent on institutional care for the same population.4MACPAC. Waivers
Section 1915(b) Managed Care Waivers
A 1915(b) waiver lets a state require Medicaid beneficiaries to enroll in a managed care plan, limit a program to certain parts of the state, or offer enhanced benefits to managed care enrollees.4MACPAC. Waivers States often pair a 1915(b) with a 1915(c) so that home and community-based services flow through a managed care organization coordinating all of a person’s care.
Section 1115 Demonstration Waivers
Section 1115 gives the HHS Secretary the broadest authority: permission to approve experimental projects that further Medicaid’s goals, even when they depart from normal rules.7Medicaid.gov. About Section 1115 Demonstrations States have used 1115 waivers to expand Medicaid to new populations, overhaul payment systems, fund substance-use treatment, and cover non-medical needs like housing assistance and home-delivered meals. These demonstrations must be budget-neutral to the federal government.8MACPAC. Section 1115 Research and Demonstration Waivers
What Services You Can Get
The point of an HCBS waiver is to provide the support that keeps you out of a facility. Standard services under 1915(c) waivers include personal care (help with bathing, dressing, and meals), case management, home health aide visits, adult day health programs, habilitation, and respite care that gives family caregivers a break.9Medicaid.gov. Home and Community-Based Services 1915(c) – Section: What’s Covered? States can add more with CMS approval: home modifications like wheelchair ramps, transportation to medical appointments, specialized medical equipment, and accessibility adaptations.
Many states offer a self-directed option, where you receive a budget and hire your own caregivers rather than accepting whoever an agency assigns. Under 1915(c) waivers, states can allow you to pay certain family members. A spouse or the parent of a minor child can be paid only for care that goes beyond what’s normally expected in that family role, and states set their own rules about which relatives qualify. Some states exclude spouses entirely; others permit it with extra documentation. Ask your case manager whether participant-directed services are available in your program.
Who Qualifies
An HCBS waiver has two separate gates. You must meet the financial rules, and you must show that you need the level of care a nursing home provides.
Income and Assets
Because these are Medicaid programs, the limits are low. In most states, a single applicant 65 or older must have income below roughly $2,982 per month and countable assets of no more than $2,000 to qualify for a nursing-home-level waiver in 2026. A handful of states use significantly higher asset limits, some above $100,000, so the threshold depends on where you live. Countable assets generally exclude your primary home up to a certain equity value, one vehicle, personal belongings, and prepaid burial arrangements.
If you’re married and only one spouse is applying, the non-applicant spouse has protections against impoverishment. Federal rules let the community spouse keep a resource allowance of up to $162,660 in 2026 and receive a monthly income allowance drawn from the applicant spouse’s income.10Medicaid.gov. Spousal Impoverishment These protections exist so that married couples are not penalized for choosing home care over a nursing home.
Level of Care
Meeting the financial rules is not enough. You must also show that you need the level of care a nursing home provides. States determine this through a functional assessment, usually a face-to-face evaluation in your home conducted by a nurse or social worker. The assessor reviews your ability to perform daily activities, your medical diagnoses, medications, cognitive status, and behavioral health needs. Each state uses its own assessment tool, and there is no single federal standard for what counts as nursing-home level of care.11MACPAC. Functional Assessments for Long-Term Services and Supports You must also be able to live safely in the community with the waiver services available.
How to Apply
Start by contacting your state Medicaid office, your local Area Agency on Aging, or a designated intake agency (sometimes called a Single Entry Point). These offices can tell you which waiver programs run in your area and which ones you might qualify for. Most states operate a toll-free helpline or online portal for initial inquiries.
From there, two tracks run in parallel. Your county human services office or state Medicaid agency handles the financial determination, reviewing income, assets, and household composition. A case management agency or state assessor handles the clinical side, conducting the functional assessment. Both determinations must be complete before you can enroll.
Once you’re approved, a case manager builds your service plan: which waiver services you need, how many hours of care per week, and which providers will deliver them. The case manager coordinates annual reassessments to confirm you still meet the eligibility criteria and that the plan reflects your current needs.
Waiting Lists
Unlike regular Medicaid, HCBS waivers are not an entitlement. States choose the maximum number of people each waiver will serve, and when the slots fill, everyone else goes on a waiting list.5Medicaid.gov. Home and Community-Based Services 1915(c) As of 2024, more than 710,000 people were waiting for HCBS waiver services nationally. Some states clear their lists in months. Others have backlogs of several years, especially for waivers serving people with intellectual or developmental disabilities.
You do not receive waiver services while you wait. You may still qualify for standard Medicaid benefits like doctor visits, hospital care, and prescriptions, but the home-based supports that keep people out of institutions are not available until a slot opens. This is why applying early matters. If you or a family member might need long-term care in the next few years, getting on a waiting list now preserves your place in line.
PACE: The Closest Thing to a Real Medicare Waiver
The Program of All-Inclusive Care for the Elderly is the closest a beneficiary comes to a combined Medicare and Medicaid arrangement for long-term care. PACE organizations receive a fixed monthly payment from both programs to cover all of a participant’s medical and long-term care needs, from primary care and prescriptions to personal care, adult day services, transportation, and nursing home stays if needed.12Medicare.gov. PACE
To join, you must be at least 55, live in the service area of a PACE organization, need a nursing-home level of care as certified by your state, and be able to live safely in the community with PACE support.12Medicare.gov. PACE The trade-off is that PACE becomes your sole source of care: PACE doctors, PACE pharmacies, PACE-contracted specialists. If you enroll in a separate Medicare drug plan while in PACE, you’ll be disenrolled. Not every area has a PACE organization, but where they exist, they offer a comprehensive alternative to running a waiver alongside regular Medicare.
If Your Waiver Is Denied or Reduced
If your application is denied, or if the state reduces or terminates services you already receive, federal law guarantees a fair hearing. The state must send written notice explaining the action, the reasons, and how to request a hearing. For terminations or reductions, that notice must arrive at least 10 days before the action takes effect.13Medicaid.gov. Notice Considerations for Conducting Renewals at the Individual Level
You have up to 90 days from the date the notice is mailed to request a fair hearing.14eCFR. 42 CFR 431.221 – Request for Hearing Timing matters for another reason: if you file your request before the effective date of the state’s action, the state must keep your existing benefits in place until a final decision is issued.15Medicaid.gov. Understanding Medicaid Fair Hearings Miss that deadline by even a day and you can lose services during the months an appeal takes. If the hearing upholds the state’s decision, some states may require you to repay the cost of services received while the appeal was pending.
At the hearing, you can present evidence, bring witnesses, and have someone represent you. Many legal aid organizations provide free representation in Medicaid fair hearings, and you don’t need a lawyer to request one. The written notice from the state should include specific instructions on how and where to file.