Nursing-home care is mandatory under Medicaid because Congress wrote it into the original 1965 law as a guaranteed benefit for eligible people. Broader home care is optional because federal law leaves most home and community-based services, called HCBS, to each state to decide. HCBS means help with daily life at home or in the community rather than in a facility. For families facing dementia, this split shapes what help is guaranteed, what help varies by state, and how long help may take.
Medical information disclaimer: This article is for general educational purposes only and does not provide medical advice, diagnosis, or treatment. Always consult a physician or other qualified health professional about symptoms, medications, tests, or treatment decisions.
Official resources:
- Check eligibility on Justiceinaging’s official study page — Use this page to check the study’s participation requirements.
- Register through Kff’s official page — Use this page to review requirements and register directly.
Table of Contents
- What does Medicaid have to cover?
- Why is the mandatory home benefit so narrow?
- How did broader home care become an option?
- What does this mean for dementia families?
What does Medicaid have to cover?
Medicaid must cover nursing-facility care for eligible beneficiaries. The Congressional Research Service traces this guarantee to Medicaid's original 1965 law in its September 2022 review of Medicaid long-term care rules.
Only two long-term services are mandatory: nursing-facility stays and home-health services. KFF reports in its 2025 overview of Medicaid home care that all other long-term services, including most HCBS, are optional state choices.
Why is the mandatory home benefit so narrow?
The required home-health benefit covers part-time nursing, home-health aide visits, and medical supplies, equipment, and appliances for home use. It does not pay for full daily supervision, meal preparation, or round-the-clock personal care.
That gap matters in dementia. A person may need cueing, redirection, night supervision, and help with bathing, dressing, and meals. Those supports usually fall under optional HCBS, not the narrow mandatory benefit.
How did broader home care become an option?
Congress added Section 1915(c) waiver authority in 1981. It lets states cover broader HCBS as an alternative for people who would otherwise need institutional care.
Justice in Aging calls the resulting split Medicaid's "institutional bias" in its August 2026 primer on HCBS for older adults. Federal law requires institutional coverage but does not require states to cover HCBS.
What does this mean for dementia families?
A person who meets financial and functional rules is guaranteed nursing-home coverage. The same person may face different eligibility rules, service packages, enrollment caps, or waits for home care, depending on the state.
Unlike the nursing-facility entitlement, states may cap 1915(c) waiver enrollment and keep waiting lists. KFF found in its review of waiting lists from 2016 to 2025 that 41 states had HCBS waiting lists in 2025. Ask your state Medicaid agency these practical questions:.
- Which HCBS waiver or state-plan program could cover dementia care at home?
- What functional test decides whether someone needs nursing-facility-level care?
- Is enrollment capped now, and how long is the current wait?
- What services are covered during the wait, including mandatory home health?
