KFF surveyed Medicaid officials in all 50 states and D.C. between April and July 2025. Over 5 million people receive Medicaid home and community-based services annually. The 2025 reconciliation law reduces federal Medicaid spending by $911 billion (14%) over a decade. All states offer HCBS through optional waiver and state plan programs. The most common are 1915(c) waivers (47 states) and personal care state plans (33 states). Forty-six states cover services supporting self-direction, which assist people in managing participant-directed services. Nursing facility care is required, but most home care is optional for states. All but 11 states use managed care to provide at least some home care.

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