Yes, home care hours could shrink for some dementia patients after 2028. The federal law does not directly order fewer dementia hours, but it cuts state Medicaid funding that pays for those hours.
Home- and community-based services, called HCBS, help people stay at home instead of moving to a nursing home. APA Services says President Trump signed the One Big Beautiful Bill Act on July 4, 2025. APA Services cites CBO estimates of about $1 trillion in cuts over 10 years and 11.8 million losing Medicaid directly.
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Table of Contents
- Why 2028 puts pressure on state budgets
- Could eligibility and costs change for families?
- Does the law add any home-care option?
- What can dementia families check now?
Why 2028 puts pressure on state budgets
Starting in fiscal 2028, the law phases the Medicaid provider-tax safe harbor down from 6% to 3.5% by 2032. The Kansas Health Institute says in its analysis of the law's Medicaid impact this shrinks federal matching funds states use for home care.
States decide optional HCBS hours, rates and caps, so smaller budgets can mean fewer approved hours. KFF found in its 2026 survey of waiting lists that nearly 650,000 people were on Medicaid HCBS lists across 40 states. They waited an average 34 months, so dementia families already face a strained system.
Could eligibility and costs change for families?
Grants for Seniors notes Section 71108 caps the home-equity exclusion for Medicaid long-term-care eligibility at $1 million starting Jan. 1, 2028, without inflation adjustment. Community Solutions reports in its tracker of the budget megabill that cost barriers rise from Oct. 1, 2028.
Expansion adults above 100% of poverty can be charged up to $35 per service, capped at 5% of household income. New York already tightened home-care eligibility on Sept. 1, 2025, according to Falcon Rappaport and Berkman. It now requires limited assistance with 3 daily activities, or supervisory cueing with 2 activities for diagnosed dementia or Alzheimer's. This shows how states can narrow hours without a federal order to cut dementia care.
Does the law add any home-care option?
KFF says Section 71121 creates a new 1915(c) waiver option effective July 1, 2028. It lets states cover home- and community-based services for people who do not meet institutional level-of-care. Institutional level-of-care means needing enough daily help to qualify for a nursing home.
For early dementia, this option could open support before nursing-home need develops. But states must choose to use it, and funding pressure may limit how many slots they offer. Families should watch whether their state files for this waiver.
What can dementia families check now?
Ask your Medicaid office for your current assessment, approved hours, and any state cap or waitlist notice. Keep paper copies of assessments, denials, and hour notices.
CMS says Medicare's GUIDE dementia program covers only about $2,625 or about 72 respite hours yearly in its GUIDE model fact sheet. Use that respite plan alongside Medicaid, not as a replacement for lost hours.
- Ask what daily activities qualify and how dementia supervision counts
- Ask if your state plans the new 2028 waiver and who qualifies
- Save for possible $35 service charges within the 5% income cap
- List home equity and check the $1 million exclusion rule
