Medicaid waiver programs may allow you to get long-term medical care at home or in a community facility. Medicare usually limits the amount of these services you can receive.

If you or a loved one has a complex health condition that requires a high level of care, you may be concerned about insurance coverage. Medicare has strict limits on the long-term benefits you can receive at home or at a long-term care facility.

However, a Medicaid waiver program may help you get the high-level care and services you need, either at home or in a community-based facility near you.

In the United States, each state has different requirements and conditions for their waiver programs for home and community-based services (HCBS). You’ll need to check your state’s Medicaid guidelines to see whether you’re eligible.

Keep reading to learn more about Medicare and the Medicaid waiver program.

Section 1915(c) of the Social Security Act describes a waiver program that authorizes home and community-based services (HCBS) to provide health care and other basic necessities to people who would otherwise receive care in a long-term care facility.

A community-based program, in this case, isn’t a nursing home. It refers to the care you might receive in the following places:

With this program, you may be eligible for the following:

  • assistance with the activities of daily living from a home health aide, personal care aide, or homemaker
  • services like rehabilitation with a physical therapist or speech and language pathologist
  • transportation, meal delivery, and adult day care services

Because Medicaid is run by state governments, each state’s waiver program operates differently. States can’t target specific populations to receive these benefits, but they can target different health conditions in the waiver program.

Some of the conditions HCBS programs commonly cover include:

The Medicaid waiver program is one of many ways that Medicare and Medicaid work together to meet beneficiaries’ healthcare needs.

It’s possible to enroll in both Medicare and Medicaid since their eligibility requirements are different.

If you qualify for both programs, you are “dual-eligible.” Most of your healthcare needs are likely to be covered by one program or the other.

What’s the difference between Medicare and Medicaid?

Medicare is a federal program that provides healthcare coverage for people with certain disabilities and those 65 and older. You must be a U.S. citizen or permanent legal resident to qualify for Medicare.

Unlike Medicaid, Medicare doesn’t base your eligibility on your income level, and the program is primarily funded through payroll taxes.

Medicaid is a program that federal and state governments run jointly to provide healthcare coverage to people with low incomes and limited resources. People of various ages are enrolled in Medicaid.

It is possible to be enrolled in both Medicare and Medicaid at the same time.

Eligibility rules differ from state to state, but a few guidelines apply in most states. One is that you must need a level of care similar to what you’d receive in a nursing facility.

For most people, that means around-the-clock access to medical services, plus personal care services like help with dressing, bathing, and going to the bathroom.

What counts as a nursing home-level of care is different in every state. Contact your state’s Medicaid office to see if you or someone in your care is eligible.

Because HCBS waivers are not an entitlement, states are allowed to limit the number of people who can receive care through the program. That means you may be placed on a waiting list if your state has reached its maximum number of eligible participants.

To apply for services through an HCBS waiver, you’ll need to contact your state’s Medicaid office to find out about the eligibility requirements.

You can look up contact information for your state Medicaid office by using the search tool on the right side of the Medicaid website.

What is the purpose of a Medicaid waiver?

While all states must provide nursing home and home healthcare for people on Medicaid who demonstrate a functional and financial need, Medicaid waivers allow states to run their Medicaid programs with more flexibility. This may mean that instead of receiving care at a nursing home, you may be able to get similar care at home or in a community care facility.

In America, each state has different requirements and conditions for its HCBS waiver program. You’ll need to check your state’s Medicaid guidelines to see whether you’re eligible.

What states have the best Medicaid waiver programs?

The “best” state Medicaid waiver programs typically provide more funding for long-term care than others. Programs in different states may provide various types of care through the waiver program.

According to data from the Kaiser Family Foundation, the five states with the best Medicaid benefit programs are New York, New Hampshire, Wisconsin, New Jersey, and Pennsylvania. These states provide approximately 65% more funding per person to their Medicaid programs than bottom-level states.

Where can I find out what types of Medicaid waivers are available in my state?

To apply for services through an HCBS waiver, you’ll need to contact your state’s Medicaid office to find out about their eligibility requirements. You can find information about HCBS waivers for your individual state by using the search tool on the right side of this page.

What is the income limit for Medicaid waivers in my state?

You can find information about Medicaid eligibility (including income limits) for individual states on this website.

Medicare and Medicaid work together to make healthcare services available to people with complex health conditions in need of long-term care.

The Section 1915(c) HCBS waiver program allows people to receive medical and personal care services at home or in a community-based facility, such as a caregiver’s home or an assisted living facility.

Each state’s eligibility requirements for this program differ, so contact the Medicaid office in your state to find out whether you qualify and if there’s a waiting list for participants with your health condition.

If you are eligible and your state has openings in the program, you may be able to receive services like meal delivery, transportation, and assistance with daily activities in addition to medical services.