Section 1915(c) waiver: the Medicaid home and community-based services authority, and where rides fit

Section 1915(c) of the Social Security Act is the Medicaid authority behind most home and community-based services (HCBS) programs, the benefits that help people stay at home instead of entering a nursing facility or other institution. For a transportation company it matters because many of these programs buy rides to day programs, jobs and community activities, and those rides follow different rules from NEMT. The ride service itself is covered under waiver transportation. This entry covers the program around it. The 1915(b) and 1115 authorities that states use for NEMT delivery are in section 1915(b) waivers and section 1115 waivers.

What a 1915(c) waiver lets a state do

A 1915(c) waiver lets a state cover long-term services in a person’s home or community when that person would otherwise need the level of care a hospital, nursing facility or intermediate care facility provides. To make that work, the statute lets the state set aside three ordinary Medicaid rules:

• Statewideness. The program can run in only part of the state, where the need is greatest or the providers are.
• Comparability. Services can go to a chosen group, such as adults with developmental disabilities, instead of every Medicaid member.
• Community income and resource rules. The state can cover people who would qualify for Medicaid only if they lived in an institution.

Services must follow a written plan of care, and the average cost per person cannot exceed what the state expects to spend on institutional care for the same people. According to Medicaid.gov, about 257 HCBS waiver programs are active nationwide, so a single state often runs several, each for its own group.

A 2025 law adds a second kind. From July 1, 2028, section 1915(c)(11) lets CMS approve a separate waiver for people who do not yet need institutional care, if the state sets its own needs-based criteria. That waiver follows the same three-year and five-year approval cycle.

Who runs a waiver

A state agency runs it, not the NEMT broker. CMS’s technical guide says a waiver may be operated by the Medicaid agency itself or by another state agency, called the operating agency, under a written agreement, as long as the Medicaid agency keeps ultimate authority. A state may also hand named tasks to county human services agencies or contracted entities, if the delegation is written down.

That is why a NEMT broker contract does not by itself bring waiver trips. The broker arranges the transportation the state plan requires. Waiver rides are authorized through each participant’s service plan, and a provider enrolls under that waiver’s own standards.

How many people a waiver serves

Each waiver sets its own limit, and rides cannot grow past it. Under 42 CFR 441.303(f)(6), the state must say how many unduplicated people it will serve in each year, and that figure limits the waiver unless CMS approves a larger one. The statute adds a floor: the Secretary “shall not limit to fewer than 200 the number of individuals in the State” who may receive services.

When the cap is full, a state may keep a waiting list. Starting July 9, 2027, 42 CFR 441.311(d)(1) requires states to report to CMS each year how they maintain the list, how many people are on it, and how long people enrolled in the past 12 months waited.

How long CMS approves a waiver

CMS approves a new waiver for three years and renews it in five-year periods. That comes from section 1915(c)(3) and 42 CFR 441.304(a) and (b). A waiver that includes people entitled to both Medicare and Medicaid can run five years from the start, under section 1915(h)(2).

A renewal is the moment services change. The state must run a public input process on changes to a waiver’s services or operations, finishing at least 30 days before it submits the change to CMS or puts it into effect, and must publish notice of significant changes to how it sets payment rates. If rides pay too little in a waiver, that notice is where to comment.

Where rides sit in the service list

The federal list of waiver services does not include transportation as a service of its own, so a state adds it as an “other service.” The list in 42 CFR 440.180(b) names case management, homemaker, home health aide, personal care, adult day health, habilitation and respite care. Rides are not on it. Under 42 CFR 440.180(b)(9), a state may request other services that CMS approves as cost effective and necessary to avoid institutionalization, and CMS’s technical guide places non-medical transportation there, beside home accessibility adaptations and vehicle modifications.

Three consequences follow:

• A waiver need not include rides. Each state decides whether to offer them and writes its own limits into the service definition.
• Rides can be bundled. When a day program’s rate already includes transportation, the guide says the state must prevent duplicate billing of non-medical transportation.
• Age is not a bar. Non-medical transportation may be furnished to waiver participants under age 21.

How to start a company that sells these rides is in starting a non-medical transportation business.

Federal rules that reach waiver providers

Three federal rules touch waiver providers: the settings criteria, and two parts of the May 2024 access rule (89 FR 40542).

• Settings. 42 CFR 441.301(c)(4) says the settings where waiver services are delivered must be integrated in the community and support full access to it, to the same degree as people who do not get HCBS.
• Incident reporting. Providers report critical incidents within state timeframes, with the 2024 rule applying from July 9, 2027. The critical incident entry has the list of events.
• Pay adequacy. Paragraph 441.302(k) requires providers of homemaker, home health aide and personal care to spend 80 percent of what they receive on direct care worker pay, beginning six years after July 9, 2024. It does not cover transportation, and the paragraph still appears in the eCFR text current on October 2, 2026.

Keeping a record for each waiver trip

Payment for waiver transportation is limited to rides needed to reach a service or activity in the participant’s service plan, so each trip needs its own record. Every trip in HealthRide carries its own GPS-recorded miles, timestamps and signature, and the trip log can be exported, so each ride has a record to set against the plan.