You asked which states have Medicaid waivers that permit them to offer home- and community-based services (HCBS), including self-directed personal care assistance (PCA) and attendant care, to adults under age 65.

SUMMARY

It appears that every state, except Nevada, and the District of Columbia offer home- and community-based care to adults under the age of 65 who have disabilities through federal HCBS waivers. Most of these states also offer PCA or attendant services, either as part of a range of home- and community-based services or as a separate HCBS waiver program.

This report includes those states that offer the range of services, including personal care assistance, to adults with disabilities (who are generally between the ages of 18 and 64) through federal HCBS waivers.

The report does not include waiver programs that target specific subgroups within the adults with disabilities population, such as adults with mental retardation, HIV/AIDS, or acquired brain injury. Many states, including Connecticut, have separate waiver programs for these populations. Let us know if you would like information on these programs.

It should also be noted that while many states have HCBS waivers, they serve a limited number of individuals. This is done in part to meet the federal government’s rule that the waivers are cost-neutral, but also to allow states to control Medicaid costs.

For purposes of this report, PCA services are those that help individuals with activities of daily living during certain times of the day, while attendant services are those that an individual receives 24 hours a day, seven days a week. These terms are often used interchangeably.

MEDICAID WAIVERS

Home and Community Based Waivers—Section 1915(c) of the Social Security Act

In 1981, President Reagan signed into law Section 1915(c) of the federal Social Security Act, the Home and Community-Based Services Waiver program. Until that time, Medicaid’s “institutional bias” meant that Medicaid would pay for long-term care only when it was provided in institutional settings. Since then, most states have used the waiver to create more appropriate, less costly alternatives for their elderly and disabled populations. For adults under 65, these programs generally combine medical and non-medical services in a community based setting. Sometimes, they include PCA or attendant care, where the individual hires someone directly to help with activities of daily living, such as bathing and dressing.

Table 1 shows the states that have HCBS waivers for these adults and which of these include PCA or attendant services, either as part of a larger service package or as a separate waiver program.

Table 1: State Medicaid HCBS Waivers for Adult

Under-65 Populations

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Source: Centers for Medicare and Medicaid Services (2003, 2004 reports)

[1] Connecticut has a “stand-alone” HCBS waiver for PCA services for people with disabilities under age 65. Other HCBS services for this population are provided under state-funded programs.

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