For decades, states have used state dollars to support older adults and people with disabilities before their needs reach an institutional level of care. Some of these programs serve people who are financially eligible for Medicaid but don’t qualify for existing HCBS waivers. The new Section 1915(c)(11) waiver authority gives states a chance to examine whether some of these state-funded investments could become part of a federally matched Medicaid strategy. The opportunity is meaningful but not automatic. States will need to determine whether their current populations and services align with the new authority, what program changes would be required, and whether the fiscal and programmatic benefits justify the administrative effort.
Why This Matters for States
Historically, states that wanted to provide supports before institutional level of care had limited Medicaid financing options. Many that chose to invest state dollars in prevention may already have assessment tools, eligibility processes, provider networks, and service packages in place. If a state can adapt those components into a compliant 1915(c)(11) application, it may be able to draw federal matching funds for services now paid for with state dollars. That could reduce state spending or increase the program’s impact while helping bend the LTSS cost curve.
The timing is important. States face growing HCBS demand, workforce shortages, waiting list pressure, and ongoing efforts to rebalance LTSS away from institutional care. For states with existing prevention programs, 1915(c)(11) may be less a new policy direction than a way to strengthen current strategies with federal resources.
Start Cross-Agency Exploration of 1915(c)(11) Waiver Options Now
A deliberate, cross-agency planning process — spanning Medicaid, operating agencies, your state budget office, providers, advocates, and people with lived experience across aging, I/DD, physical disability, and behavioral health populations — will help states judge whether a 1915(c)(11) waiver is feasible, sustainable, and aligned with broader LTSS goals.
Without it, states risk creating eligibility criteria that overlap with existing waivers instead of clearly distinguishing pre-institutional need, causing wait times to increase for individuals with institutional level of care, and creating fiscal or reporting gaps from insufficient modeling. Early coordination protects existing waiver capacity and builds a stronger case for CMS approval.
Start With Three Questions
A strong planning process begins with a crosswalk between existing prevention programs and the core elements of a waiver design, including target population, level-of-care criteria, financial eligibility, services, provider qualifications, assessments, quality measures, and cost neutrality. States should ask:
- Are we already serving a potential 1915(c)(11) population?
- Which existing investments could qualify for federal participation?
- Would converting or redesigning a program create enough value to justify the effort?
The states best positioned to move quickly will pair a clear policy rationale with data, fiscal modeling, and an implementation plan grounded in their existing HCBS infrastructure.
Next Step You Can Take Today
- Inventory state-funded programs that serve people before institutionalization.
- Crosswalk target populations, eligibility rules, assessments, services, providers, and quality requirements against 1915(c)(11) requirements.
- Model potential federal participation, state savings or reinvestment, implementation costs, and longer-term fiscal effects.
- Decide which programs to convert or redesign, which to keep state-funded, and where a new program may be warranted.
- Engage stakeholders, including individuals and families, providers, advocates, agencies, and budget leaders, throughout the process.
Connect with us to evaluate whether your state’s existing prevention investments could support a 1915(c)(11) strategy.
(800) 210-6113 | [email protected] | 1915(c)(11) Waiver Solutions