Medicaid Home Care: HCBS Waivers, Waiting Lists, and Getting Paid as a Family Caregiver

Here's the short answer. Medicaid can pay for long-term care at home through programs called Home and Community-Based Services (HCBS) waivers. Nearly every state has at least one. To qualify, a person must have low income and assets, and must need the same level of care as a nursing home. Many waivers let the person choose their own caregiver, and states may pay a relative for that work. The catch: each state caps how many people a waiver can serve, so many programs have waiting lists. Rules and program names vary by state. Your state Medicaid office is the place to apply.

What an HCBS Waiver Is

Medicaid's default long-term care benefit is nursing facility care. A waiver lets a state "waive" that rule and pay for care in a person's home or community instead. The most common type is called a 1915(c) waiver, after the section of federal law that allows it. About 257 of these waiver programs are active nationwide, and nearly all states and DC offer at least one.

Each waiver serves a specific group. A state might run one waiver for older adults, another for people with intellectual disabilities, and another for children who depend on medical technology. So the first question is always: which waiver in my state fits this person?

Waivers can cover a wide mix of medical and non-medical help. Common services include:

• Personal care: hands-on help with bathing, dressing, toileting, and eating.
• Homemaker and chore services: light housework, laundry, shopping.
• Home health aide visits.
• Adult day health programs.
• Respite care: a paid substitute so the family caregiver can take a break.
• Case management: someone who coordinates the plan of care.

Some waivers also pay for home changes like ramps and grab bars, medical equipment, home-delivered meals, and rides to appointments. What's on the list depends on the waiver.

Who Qualifies

A waiver has two gates, and you have to pass both.

1. Medical need. The person must need the level of care the state would require for a nursing home or similar facility. The state does an assessment, usually looking at how much help the person needs with daily activities. They must also fit the waiver's target group and need at least one service the waiver offers.
2. Money. The person must be financially eligible for Medicaid. For long-term care, that means limits on both income and countable assets. States review past transfers of money or property, so gifts can cause a penalty period. Our guide to Medicaid spend-down and look-back rules explains this.

Two more things matter. The person has to choose the waiver instead of a facility. And having Medicare does not disqualify anyone. Many waiver participants are dual eligible, with Medicare paying for medical care and Medicaid paying for long-term support.

Why There Are Waiting Lists

Regular Medicaid is an entitlement: if you qualify, you're covered. Waivers are different. Each state decides the maximum number of people a waiver will serve. When those slots are full, new applicants wait, sometimes for years. Federal rules don't require states to keep waiting lists, and states manage them differently. Ask how your state orders its list.

What to do while you wait:

• Get on the list now. Apply as soon as you think the person qualifies, even if they don't need much help yet. Ask how the state orders its list.
• Ask about other programs. Some states offer personal care or attendant services through their regular Medicaid plan rather than a waiver. Ask your state Medicaid office what's available without a wait.
• Use Medicare's benefits. If the person has Medicare, it covers part-time skilled home health care after an illness or injury. It won't cover long-term custodial care. See Medicare hospice and home health benefits.
• Call the Eldercare Locator at 1-800-677-1116. Your local Area Agency on Aging may have respite, meals, and caregiver support that don't depend on Medicaid.

Getting Paid as a Family Caregiver

Many waivers let the person receiving care choose who provides it. That's called self-direction or consumer direction. Under self-direction, the participant, or a representative, gets to recruit, hire, train, and supervise their own workers. In many states, that worker can be a family member.

Here is what federal Medicaid guidance says about paying relatives:

• Relatives and legal guardians (an adult child, a sibling, a grandchild) may be paid to provide waiver services, including personal care, if the state allows it and they meet the state's worker qualifications.
• Spouses and parents of minor children are treated differently. The law calls them "legally responsible individuals." A state may pay them only at its option, and only for care that goes beyond what a spouse or parent would ordinarily provide. The state must define what that "extraordinary care" means.
• States choose their own policy. On its waiver application, each state picks whether it pays relatives at all, pays them only in certain circumstances, or pays them with no special limits. Because of this, the answer to "can Medicaid pay me?" truly is different in every state, and can differ between waivers in the same state.
• Family caregivers must meet the same rules as other workers. States set qualifications such as training and often require background checks. Payment is only made for hours of service actually provided.

When self-direction is offered, the state must provide help running it. A financial management service handles payroll, tax withholding, and employer paperwork, so the family doesn't have to. A support broker or counselor helps the participant direct their services and acts as a go-between with the program. Some programs also give the participant a budget and let them decide how to spend it on approved goods and services.

How to Apply

1. Contact your state Medicaid agency or its aging and disability office. Find it in our State Medicaid Directory. Ask which HCBS waivers exist for the person's age and condition, and whether there's a waiting list.
2. Request a level-of-care assessment. The state or its contractor will evaluate how much help the person needs.
3. Apply for Medicaid if the person isn't already enrolled. Expect to document income, assets, and recent transfers. See Medicaid Eligibility, Waivers & Long-Term Care.
4. Ask about self-direction if a family member wants to be the paid caregiver. Ask which relatives the state allows and what training or checks are required.
5. Keep records. Save the assessment, your application date, and any waiting-list confirmation.

Common Questions

Related Guides

• Caregivers: Managing Medicare or Medicaid for Someone Else
• Does Medicare Cover Nursing Home or Long-Term Care?
• Medicaid Eligibility, Waivers & Long-Term Care
• Medicaid Spend-Down and Look-Back Rules
• Dual Eligible: Medicare and Medicaid Together
• Official: Medicaid.gov: Home & Community-Based Services