Adults who need daily help with bathing, dressing, or meal preparation can receive paid assistance at home through Medicaid in dozens of states, bypassing the need for a nursing home. The federal framework that makes this possible dates to 1983, when Congress created Section 1915(c) of the Social Security Act. A 2024 final rule from the Centers for Medicare and Medicaid Services now requires states to report waiting-list data and service-delivery timelines for these home and community-based services, or HCBS, setting up a new test of whether transparency drives faster access.
New CMS reporting rules raise the stakes for HCBS access
The tension behind this shift is straightforward: Medicaid has long allowed states to cover in-home care, but the speed and scope of that coverage vary sharply from state to state. Some applicants wait months or years on lists before receiving services. The 2024 final rule, designated CMS-2442-F, establishes national standards intended to make those gaps visible. States must now track and publish data on how long people sit on HCBS waiting lists and how quickly services begin once approved.
The rule is part of a broader push to strengthen access to HCBS by tightening expectations around timeliness, adequacy of provider networks, and oversight of managed care plans. For the first time, states will have to report standardized metrics on how quickly people move from application to assessment, from assessment to approval, and from approval to the start of services. CMS can then compare states on these measures, rather than relying on inconsistent self-reporting or advocacy surveys.
The practical question is whether this reporting requirement will actually accelerate enrollment. States that comply early and publish their data could face political and legal pressure to shrink their waiting lists, since the numbers will be publicly available in a uniform format. Lawmakers, auditors, and disability-rights groups will be able to point to concrete benchmarks when arguing for more funding or policy changes. States that drag their feet on reporting face less immediate public scrutiny but risk falling behind as CMS and national advocates use the new data to highlight outliers.
The hypothesis that early reporters will see faster community-based enrollment growth rests on a familiar assumption: public data creates accountability, and accountability creates urgency. Once families can see that neighbors in another state receive personal care within weeks while they wait months, it becomes harder for officials to treat delays as inevitable. Transparent metrics also give administrators a way to diagnose bottlenecks, such as slow functional assessments or insufficient provider capacity in rural areas.
The legal backdrop adds weight. The Department of Justice enforces the integration mandate of Title II of the Americans with Disabilities Act, as interpreted in the Supreme Court’s Olmstead v. L.C. decision. According to DOJ’s enforcement statement, public entities may violate the ADA by promoting or financing unnecessary segregation. That language gives states a direct incentive to expand HCBS rather than default to institutional placement, especially when data show that people who qualify for community services are left waiting while nursing home beds remain available.
What Section 1915(c) waivers actually cover at home
The legal authority for Medicaid-funded in-home care is specific. Under Section 1915(c), codified at 42 U.S.C. Section 1396n, the Secretary of Health and Human Services may waive certain Medicaid requirements so states can pay for home and community-based services for people who would otherwise need institutional-level care. The statute explicitly lists the types of services a waiver may cover: case management, homemaker and home health aide services, personal care, adult day health, and respite care. States may also include other services approved by the Secretary that help people remain in the community, but room and board costs remain excluded.
These waivers let states target particular populations, such as older adults, people with physical disabilities, or individuals with intellectual and developmental disabilities. States can cap enrollment, limit services to certain geographic areas, or set different benefit packages for different groups, as long as they demonstrate that the waiver is cost-neutral compared with institutional care. Those design choices, combined with capped slots, are a major reason waiting lists develop even when people meet the medical criteria for an institutional level of care.
Separate from waivers, Medicaid personal care services pay for assistance with activities of daily living in the home or community. This is a distinct benefit category that some states offer through their regular Medicaid state plans rather than through a waiver. The difference matters for applicants: state plan services typically do not carry the same enrollment caps or waiting lists that waiver programs do, because they function like other mandatory or optional Medicaid benefits that must be available to all eligible enrollees who meet the criteria.
States also have other HCBS authorities beyond 1915(c), including state plan options and demonstration projects that can blend medical and social supports. CMS describes these mechanisms in its overview of HCBS authorities, noting that states may combine them to build broader community-based systems. For example, a state might use a 1915(c) waiver for people with high needs while relying on a state plan option for lower-intensity personal care, reducing pressure on the waiver waiting list.
CMS maintains a searchable listing of active waivers by state, which shows the range of 1915(c) programs currently operating and the populations they serve. As the new reporting rules take hold, those program descriptions will increasingly sit alongside performance data on timeliness and access. Together, they will offer a clearer picture of whether Medicaid is meeting its promise to support people with disabilities and older adults in their homes, or whether structural limits in waiver design and funding still steer too many into institutions.
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