From the desk of Ellen Burton, MPH and Sari Lelchook, MPH 

The Working Families Tax Cut (WFTC) created a new 1915(c)(11) waiver option, giving states a way to bring older adults into home and community-based services (HCBS) earlier, before they reach an institutional level of care. The legislation set aside $100 million to help states plan and implement the waiver, with the Centers for Medicare and Medicaid Services (CMS) set to begin approving applications by July 2028. Full written guidance hasn’t been released yet, but enough is known now for states to start assessing readiness and shaping their waiver design.

States pursuing a 1915(c)(11) will need to:

• Set eligibility criteria below their institutional level-of-care threshold, using it as a starting point rather than a hard cutoff. States can narrow this further with age- or condition-based target groups, such as populations with dementia or other conditions common among older adults in their state.
• Meet the same requirements that apply to existing 1915(c) waivers — person-centered planning, cost neutrality, and quality reporting among them.
• Demonstrate the new waiver won’t meaningfully lengthen wait times for people already seeking institutional level of care. States that currently run a 1915(c) waitlist can still pursue this option as long as that wait doesn’t grow.
• Hold per capita spending under the cost of institutional care and report annually on spending, service duration, and enrollment.

States can also expect an award letter detailing their portion of the $100 million (fully federally funded, with no state match required), followed by a waiver application and updated Technical Guide by the end of 2027, giving states roughly three months to apply and CMS a similar window to review before approvals begin in July 2028. Once approved, waivers will draw down federal funds at the same match rate as other Medicaid waiver programs.

Why This Matters for Aging

This waiver gives states a way to connect with older adults sooner, before low-acuity needs turn into a crisis that lands someone in a nursing facility. Falls, hospitalizations, and caregiver burnout are common tipping points toward institutional placement, and earlier, lower-cost supports can help delay or avoid that outcome altogether. Because states set eligibility below their existing institutional threshold, they have room to prioritize the populations they know best — people already on waitlists, those living with dementia or other conditions prevalent in older adults in their state, or regions where community-based service options are thinnest.

For many states, this is also a chance to bring federal dollars behind work they’re already doing. A number of states currently fund pre-institutional HCBS programs entirely out of state general funds, precisely because they’ve seen how earlier, lower-acuity support delays or prevents costlier institutional care. Those states have effectively already done the legwork — building out eligibility criteria, service menus, and provider relationships — which lowers the lift of standing up a 1915(c)(11) waiver considerably. And at a moment when many of these state-funded programs are under pressure to prove they’re sustainable, this waiver offers a real path to shoring them up with federal match instead of state dollars alone.

Provider capacity deserves attention early too. Before adding a new population, states should look at whether their existing network of aging service providers has room to grow without straining service for people already enrolled.

Start Cross-Agency Exploration Now

Getting the state unit on aging, the Medicaid agency, providers, and other stakeholders to the table early gives states a clearer read on whether this waiver fits their goals and their budget. That kind of coordination up front helps avoid overlap with existing programs, protects current waiver capacity, and puts states in a stronger position when it’s time to apply.

Next Steps You Can Take Today

1. Bring together the unit on aging, Medicaid, finance, and program leadership to start planning as a group.
2. Use waitlist, claims, and assessment data to identify who this waiver could realistically reach.
3. Look at service utilization and talk to stakeholders to understand where the biggest needs are.
4. Start modeling the fiscal and operational impact so you’re ready when CMS opens applications.
5. Take stock of provider capacity to confirm your network can support new enrollees without disrupting current services.

Ready to take the next step? Contact one of our aging experts today to learn how PCG can support you.

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