States vary widely in the Medicaid home and community-based services they offer, but policymakers lack a detailed, current picture of those differences.

Medicaid is the largest payer of long-term services and supports (LTSS) in the United States. While institutional care is a mandatory Medicaid benefit, coverage of home- and community-based services (HCBS) remains optional. Over the past three decades, states have made notable progress shifting LTSS away from institutional settings and toward HCBS, primarily by expanding services through Medicaid waivers. But because waivers allow states to target populations, limit enrollment, or restrict services geographically, the availability and scope of HCBS vary substantially from state to state, and individuals with similar needs may face very different access to care depending on where they live.

Although several organizations track HCBS enrollment and spending, no current, comprehensive source catalogs the full range of waiver services states offer or how those services vary by target population. This gap limits policymakers’ ability to assess unmet need, compare state strategies, and make informed decisions about program design.

NORC conducted a review of state Medicaid HCBS waivers and developed case studies reflecting promising approaches to increasing access to benefits.

NORC conducted a detailed landscape analysis of Medicaid HCBS waivers across all 50 states and the District of Columbia. The project included a manual review of all active 1915(c) waivers to document the types of services offered, the populations served, and other key program characteristics. This catalog has been developed into a public-facing resource, hosted by the Commonwealth Fund, that provides a clear, current picture of HCBS availability by state.

To complement the landscape analysis, NORC, in partnership with national HCBS leaders, identified two states—Colorado and Florida—that demonstrate promising approaches to HCBS implementation. These case studies explore how selected states have structured their programs to meet the needs of diverse populations, including older adults and individuals with disabilities. The case studies draw on an analysis of Medicaid claims data, review of various policy documents, and interviews with state stakeholders to provide a detailed look at how these programs operate in practice.