Section 1915 (c) of the federal Medicaid Act provides the basis for Home and Community-based (HCB) Waiver programs. The Medicaid HCB Waiver programs allows States to provide services, some not available through the Medicaid State Plan, to individuals who would otherwise require care in an institutional setting. Prior to the development of HCB Waivers, the only Medicaid-funded long-term care benefit was an institutional placement. The Centers for Medicare & Medicaid Services (CMS) is responsible for approving and monitoring a State’s Medicaid HCB Waiver. CMS is a division of the U. S. Department of Health and Human Services.

 When the HCB Waiver option is chosen, the state must make several assurances to CMS. The State must assure that necessary safeguards are taken to protect the health and welfare of all recipients, assure that all recipients have an individualized plan of care and a system for reviewing the plan of care, assure that services are provided by qualified providers, assure that all recipients require the level of care that would be provided in an institution, assure that the recipient’s need for the specified level of care is periodically reevaluated and assure that the administration of the Waiver services/program is consistent with the Waiver application approved by CMS. The State must assure that: 

• Individuals are given the choice of either institutional or home and community-based services
• Individuals are informed of all reasonable alternatives available under the Waiver,
• Individuals are given the choice of providers of services, and
• The expenditures under the Waiver will not exceed, in the aggregate, the amount that would have been spent if the recipient had chosen institutionalization

Medicaid Waiver participants receive services similar (but not identical) to those available in an institution, but in a home and/or community based setting. They may receive services that are an extension of the State Medicaid Plan or services that are unique to the Waiver. The average cost of providing Waiver services must be equal to or less expensive than the average cost of institutional care. In addition, any service provided through an HCB Waiver must prevent institutionalization.