Most people, asked where they would like to grow old or live with a disability, say the same thing: at home. Home and community-based services, or HCBS, are the part of Medicaid built to make that answer possible. They pay for the help that lets someone stay in their own home or community instead of moving into an institution.
Prasar Health exists to help people get care and keep living at home, so HCBS is the backdrop for everything we build. This piece explains what HCBS are, where the commitment to community care comes from, and why two unglamorous services, transportation and adult day programs, carry so much of the weight.
What are home and community-based services?
HCBS are long-term services and supports delivered where people live rather than in a nursing facility or other institution. Medicaid.gov describes the main vehicle, the section 1915(c) waiver, as a way for people to "get long-term care services and supports in their home or community, rather than in an institutional setting." Standard services listed there include case management, homemaker, home health aide, personal care, adult day health, habilitation, and respite care.
States also offer HCBS through other Medicaid authorities, such as state plan options and demonstrations. Each state chooses which services to cover, for whom, and in what amounts, so the HCBS landscape looks different in every state.
Where the commitment to community care comes from
Two pillars sit under modern HCBS policy.
The first is civil rights law. In Olmstead v. L.C. (1999), the U.S. Supreme Court held that unjustified segregation of people with disabilities is discrimination under Title II of the Americans with Disabilities Act. As the Department of Justice's ADA.gov explains, a person with a disability must be served in the community when community-based services are appropriate to the person's needs, the person does not oppose them, and the state or local government can reasonably modify its programs to provide them.
The second is Medicaid's own rule for what counts as "community." The HCBS settings requirements at 42 CFR 441.301(c)(4) require settings to be integrated in and support full access to the greater community, to protect privacy, dignity, and freedom from coercion, and to support autonomy and choice. CMS's guidance for non-residential settings makes clear these requirements apply to non-residential settings, such as day programs, as well as residential ones.
Why aging in place depends on the in-between services
Discussions of HCBS tend to focus on care delivered inside the home: aides, nurses, meal delivery. Those matter. But a person living at home also has to get to the dialysis center, the cardiologist, and the pharmacy, and often needs somewhere safe and engaging to spend the day while a family caregiver works. Two services fill those gaps.
Transportation
Medicaid's non-emergency medical transportation benefit exists because a covered service is worthless if the member cannot reach it. CMS's Medicaid Transportation Coverage Guide frames transportation as a critical part of access to care for beneficiaries who have no other means of getting there. For someone who no longer drives, the NEMT van is the difference between keeping regular appointments and missing care. Our explainer on what NEMT is and how Medicaid covers it goes into the details.
Adult day programs
Adult day centers offer supervision, meals, activities, and in health-model programs nursing and therapeutic services, during the day, with participants going home each evening. Adult day health is a standard 1915(c) waiver service. For a family caring for a parent with dementia, a few days a week at a center can be what keeps caregiving sustainable. Our guide to adult day services covers models, eligibility, and payment.
What makes community care work in practice
The policy framework is the easy part. Day to day, community care is delivered by small, local providers: a transportation company with a dozen vans, a day center with forty participants. They carry real responsibility with thin margins and little administrative help. In our experience, a few things decide whether those providers can keep going:
- Reliability. A ride that shows up on time and a center that knows who is in the building. Missed pickups and lost attendance records are the failures people feel.
- Documentation that holds up. Medicaid pays for services it can verify. Providers who capture records at the moment of service get paid and pass reviews. See documentation that survives a Medicaid audit.
- Less paperwork per person served. Every hour a director spends reconstructing a billing file is an hour not spent with participants.
That is the job Prasar Health's products are built for: ZeitRide for transportation providers and Adult Day Genie for adult day centers, two independent tools aimed at the same goal.
The bottom line
HCBS are how Medicaid turns "people should be able to live at home" into actual services. Their success depends less on any single program than on the ordinary infrastructure around them: getting people where they need to go, and giving them somewhere good to be during the day. Supporting the providers who do that work is how Prasar Health helps people keep living at home.
Frequently asked questions
What are home and community-based services (HCBS)?
Medicaid-funded long-term services and supports delivered in a person's home or community rather than an institution, such as personal care, homemaker services, adult day health, respite, and case management. States choose which services to offer and to whom.
What is a 1915(c) waiver?
A Medicaid authority under section 1915(c) of the Social Security Act that lets states provide home and community-based services to people who would otherwise need an institutional level of care. Nearly all states and DC operate at least one.
What did the Olmstead decision require?
In Olmstead v. L.C. (1999), the Supreme Court held that unjustified segregation of people with disabilities violates Title II of the ADA. People with disabilities must be served in the community when that is appropriate, the person does not oppose it, and the government can reasonably modify its programs to provide it.
Do the HCBS settings rules apply to adult day centers?
Yes. CMS guidance states the HCBS settings requirements apply to non-residential settings, such as day programs, as well as residential settings, for people receiving Medicaid-funded HCBS.
Why is transportation important for aging in place?
People who no longer drive still need to reach medical care. Medicaid's non-emergency medical transportation benefit ensures members without other means can get to covered services, which keeps living at home workable.
Prasar Health builds software for Medicaid-funded community care: ZeitRide for non-emergency medical transportation and Adult Day Genie for adult day centers. More insights.