How Medicaid Home and Community Based Services Waitlists Work

Waitlist Basics
Almost all of Medicaid’s Home and Community Based Services (HCBS) Waivers have a limited number of enrollment spots, which means many of them have waitlists. Once all the enrollment spots are full, additional applicants are placed on a waitlist. How these waitlists operate, like the HCBS Waiver programs themselves, can vary by state and with each program. Those details are explained in the next section.

Nursing Home Medicaid and Aged, Blind and Disabled Medicaid (also called state plan or Regular Medicaid for seniors) do not have waitlists because they are entitlement programs, which means all eligible applicants are guaranteed by law to receive benefits without wait. However, it’s important to note that sometimes nursing homes are full, or they may have private-pay beds available but not any beds for Medicaid beneficiaries. In these cases the specific nursing home may have a waitlist, but the eligible senior who applied for Nursing Home Medicaid is still guaranteed to receive care in a nursing home, they will just have to find a nursing home with open spaces.

Likewise, some Aged, Blind and Disabled (ABD) Medicaid programs that provide long term care services and supports may also have limited funds or limited spaces. So, a senior might have to wait for specific benefits within the program, but they would still be enrolled in the program and ABD Medicaid.

Waitlist Operations – Placement, Priority and Scope
How HCBS Waiver waitlists are organized and processed depends on the state and the HCBS Waiver, but not all of them have waitlists. An independent study from KFF (which uses data from 2016-21) says that 37 states have HCBS Waivers with waitlists.

In 28 of those 37 states, applicants are screened for financial and functional (medical) Medicaid eligibility before being placed on waitlists. Those states are Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, South Carolina, Tennessee, Utah, Virginia, West Virginia and Wyoming.

In the other nine states (Alaska, Iowa, New Mexico, Ohio, Oklahoma, Oregon, Pennsylvania, Texas and Wisconsin), applicants are placed on waitlists without being screened for eligibility. So, a client could be waiting for long term care services through an HCBS Waiver only to find out they are ineligible when they get to the top of the list. On the plus side, they could get on the waitlist before they are fully eligible, and then use their time on the waitlist to become eligible. And since many medical conditions, especially dementia, deteriorate over time, there could also be a strategy to coordinate waitlist time with the increasing medical need that will make clients functionally eligible.

According to the study from KFF (formerly the Kaiser Family Foundation), 28 of the 37 states that have waitlists prioritize length of time on the waitlist when it comes to taking people off the list and enrolling them in an HCBC Waiver program. However, most states have more than one priority group. In 23 states, emergency/crisis situations are used to prioritize waitlist status. Twenty-one states prioritize Medicaid beneficiaries moving from institutions and returning to the community. And 17 states prioritize based on risk of institutionalization.

Waitlists can be state-wide, and most are state-wide in states with low population. However, in bigger states they can be organized into smaller regions, like counties. In some states, like California, waitlists are broken down by the agencies that provide the long term care services.

Waitlist Waiting Times
The KFF study, which was published on Nov. 28, 2022, reported that the average waiting period for many Medicaid programs targeting seniors is two months, but it can be as long as two years.

In the end, a surprisingly few number of people actually enroll in the HCBS Waiver program for they were put on the waiting list. In a 2022 study in Texas, it was found that just under 7% of the people wait-listed ended up enrolled in the program. The study analyzed the 18,649 who came to the top of the waitlist for Texas’s STAR+PLUS Waiver, and the numbers breakdown as follows:

• 9,423 (50.5%) No response from individuals when their name came to the top of the list
• 3,283 (17.6%) Declined/Denied
• 2,187 (11.7%) Application Withdrawn
• 1,551 (8.3%) Deceased
• 1,256 (6.7%) Enrolled
• 2,500 (13.5%) Other

Given the large scale of this study, one might comfortably assume a similar situation exists in other states.

Medicaid HCBS Waiver Waitlists By State

The following are exact waitlist details for HCBS Waiver programs in specific states. If you don’t see the state you’re looking for in this version of the article, check with area Medicaid officials to find out about specific HCBS Waiver waitlist details.

California
Instead of state-wide waitlists, California has multiple waitlists that are area-specific and organized by agencies for two of its HCBS Waivers that are relevant to seniors – the Assisted Living Waiver (ALW) and the Home and Community-Based Alternative Waiver.

The Assisted Living Waiver (ALW) uses 30 Care Coordination Agencies (CCA) located across the state, and each one of them operates their own ALW waitlist. This link has a complete list of these CCAs with contact information and counties served. As of February 2023, there were 9,118 people enrolled in the ALW, and 3,316 on the waitlists. As for prioritization, “Institutional Transitions” (people on the waitlist who had been residing in an institution such as a nursing home for at least 60 days prior to application) are prioritized over “Community Enrollment” (which is anyone who does not qualify as Institutional) on the ALW waitlists. Community Enrollments are then prioritized on a simple first-come, first-served basis.

California’s Home and Community-Based Alternative Waiver has 9 agencies that each have their own waitlist. These waitlists are prioritized on a first-come, first-served basis, but “special circumstances may qualify an applicant for priority enrollment,” according to the California Department of Health Care Services. This webpage has a list of the 9 agencies, including their contact information and areas served.

Texas
Texas’s lone HCBS Waiver that provides long term care services for seniors is the STAR+PLUS Waiver. According to an August 2022 report from Texas Health and Human Services, there were 24,049 people enrolled in the STAR+PLUS program during 2022. As of April 30, 2022, there were 11,630 on the STAR+PLUS interest list (“interest lists” are what Texas Medicaid calls a waitlist). These are prioritized on a first-come, first-served basis.

Texas is one of the states that does not screen applicants before placing them on the interest list, so some of the people on the list will be denied when they get to the top of the list rather than be enrolled in the program. While others on the list will use the time to become financially, or medically, eligible, as discussed above.

Florida
Florida’s Medicaid Waiver program is called the Statewide Medicaid Managed Care (SMMC) Long-Term Care program, and its waitlist is based on need.

Florida’s Aging and Disability Centers work with the state’s Department of Elder Affairs to screen each SMMC applicant and assign them a priority score based on their medical condition. There are eight levels, or “Ranks,” of priority scores, with Rank 1 being the lowest and Rank 8 being the highest. Florida uses this method to ensure “the most fragile Floridians are offered Long-term Care Program enrollment when it becomes available,” according to the Florida Agency for Health Care Administration, which also has a webpage with SMMC waitlist details.