Necessary Shifts for Medicaid Waivers

By Rosita Njeumi

Background

Medicaid defines assistive technology (AT) as an item, piece of equipment, service animal, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants. Assistive technology is defined in Section 1915(c). This section also outlines other specialized supplies and equipment that could be considered AT. However, Medicaid home and community-based services (HCBS) programs primarily provide Medicaid coverage of AT for adults. This coverage is for all states and the District of Columbia, though what is covered fully is varied by state and program. Some AT is covered within this law [5]. 

Assistive technology is a broad term and can include remote support services and enabling technology. Remote support services involve the use of enabling technology such as detectors, sensors, reminders, and wearable devices. This remote support requires support professionals who provide remote support from a secure location who are in charge of overseeing individuals who receive this type of service [1].  

The use of assistive technology, remote support services, and enabling technology is to support people with intellectual and developmental disabilities (IDD) to operate safely in their homes and stay in their communities rather than be transferred to an institution or have 24/7 physical care. The goal is to provide tools for independence, functionality, and safety. Section 1915(c) and HCBS cover certain assistive and enabling technologies when they are medically necessary and aligned with an individual’s service plan [1]. 

Laws for Coverage

The Centers for Medicaid and Medicare Services (CMS) is the administrative authority for the Home and Community Based Services (HCBS) waivers. Due to the need for use of broadband for connectivity, CMS has utilized the Federal Communications Commission’s (FCC) Emergency Broadband Benefit program and the Broadband Infrastructure Program. These programs are outside of CMS, so it requires states and users to navigate information, eligibility criteria, data support, and programmatic needs [6]. 

CMS requires waivers to describe multiple factors. This includes assurances and requirements, levels of care, waiver administration and operation, participant access, and eligibility. It also involves participant services, including limitations and restrictions; service planning and delivery; participant direction of services; participant rights; participant safeguards; quality improvement strategies; financial accountability; and cost-neutrality demonstrations [2]. 

Medicaid is the most dominant source of public funding of long-term services and supports. (LTSS) for the IDD community; in 2019, about 93% of state developmental disability agencies listed the HCBS waiver program as their primary means of funding. Agencies devise the rules by which individuals qualify for HCBS waivers that cover remote support services. Some states maintain separate waitlists for each waiver. Some allow people to be on multiple waitlists. Lastly, some use different methods of prioritizing people on their waitlists. This has resulted in an overcapacity of individuals requiring support [6]. 

Necessary Improvements 

Waivers differ from state to state for who is eligible for services and what level of funding will be allocated, resulting in long lists of those awaiting services. Even the processes involved in applying for support and qualifying for waivers are time-consuming. It can be confusing and difficult to apply because there is an average of twelve different funding authorities per state that can be used to purchase technology. Due to these complexities, families can feel frustrated trying to obtain remote support for those family members. This burden can be lessened if there is a more standard approach amongst federal and public agencies. This will also allow for clear benchmarks to be set for comparisons [6]. Families can be further helped if there is a nationwide implementation of navigator programs. These programs already exist, but they are not unified in approaches. This program guides caregivers through available resources that the Medicaid Waiver provides (Disability Program Navigator (DPN)). The benefit of patient navigator programs has been long established in areas of underserved populations [4]. 

There is huge state variation in these waivers, from age thresholds (some are considered adults at 18, others at 21), diagnostic criteria, cost limits, wait list size, and enrollment capacity [3]. For example, section 1915(c) waivers serving adults with an intellectual disability or developmental disability cover some AT. While some who do receive waivers are physically disabled or 65 and older, their AT is not covered [5]. These support services across varying states need to have uniform methods, rules, regulations, and requirements. In order to do this, there need to be cross-agency and department workgroups, integrated cross-waiver planning, and coordinated clinical and non-clinical use [1]. This could clear up confusion and enable more access to assistive technologies for future purposes. 

Another issue is environmental modifications; not all states cover this initiative to help improve the usage of assistive and enabling technologies. Environmental modifications require that adaptations be necessary to support independent living; however, some waivers exclude specific devices. For example, the Indiana PathWays for Aging and West Virginia Aged and Disabled Waiver will not cover home security or video monitoring systems. Whilst the Iowa HD and Minnesota Elderly Waivers offer the use of devices for environmental modifications, including monitoring or surveillance systems with cameras, GPS trackers, motion detection, and home security systems [7]. If there are clear, broad definitions of assistive technology, enabling technology, and remote support to encompass current and potential new innovations across state and federal plans and/or programs, then what can be included would not be up for debate. In many states there is no definition for enabling technology. There are instances where

individual device types are defined in great detail, and there are instances where there is no clear category for a product that uses a new technology [1].

A financial strain can still impact federal, state, caregiver, and local entities. Despite Medicaid coverage, the estimated cost of caring for an individual with autism spectrum disorder (ASD) in the United States, including healthcare and non-healthcare services, is $17,081 per year, beyond the cost of caring for a child without ASD [4]. In order to better address the technological needs, it would help to establish a budget line(s) for these technologies. These lines can better illustrate the needs of a population since they outline actions that are affordable within budget limits while still producing a positive outcome. This is a more comprehensive approach for supporting assistive technologies. States could make specific budget lines dedicated to enabling technologies. By allocating funds for these technologies, states can prioritize their implementation and ensure adequate financial resources are available [1]. 

Limitations 

The caregivers and/or family members need more mental health intervention if possible, and that is not explicitly included in what is covered. Their mental and physical health directly affects those with IDD and physical disabilities. Though more can be done, it can be a challenge for employees of any organization, agency, and program to properly manage existing and emerging technology services. This requires proper training, recruiting, and team effort to fully actualize goals, missions, or visions. These technologies may be hard to access for them as well or even harder to distribute equitably. An educated staff must be passionate and motivated to help others receive and utilize these technologies. If they do not care, then they probably will not be of much help to achieving the users' goals. 

Conclusion 

Medicaid waivers are a useful tool for those with IDD. The use of such waivers can result in more independence, learning, and overall quality of life. There need to be changes in regard to reform, policy, and guidelines at both the state and federal levels to produce greater outcomes for users. Though not perfect, it could improve to provide more coverage of assistive technologies, enabling technologies, and remote support services. 

References 

[1] Advancing States. (2024). The State of Enabling Technology in LTSS Programs in 2024.  https://www.advancingstates.org/sites/default/files/The%20State%20of%20Enabling%20Technology%20in%20LTSS%20Programs%20in%202024%208.7.pdf  

[2] Friedman, C. (2023). Assistive technology for people with intellectual and developmental disabilities in the United States in Home- and Community-Based Services. Disability and Rehabilitation: Assistive Technology, 19(6), 2213–2220. https://doi.org/10.1080/17483107.2023.2272849 

[3] Jorling, E. (2026). Medicaid HCBS Waivers: Where You Live Dictates Your Care | AcademyHealth. Academyhealth.Org. https://academyhealth.org/blog/2026-07/medicaid-hcbs-waivers-where-you-live-dictates-your-care 

[4] Mastrogiannis, A. M., Steinway, C., Santos, T. C., Chen, J., Berens, J., Davis, T., Cornacchia, M., Woodward, J., Riddle, I., Spicer, B., Wright, C., Lindquist, L. A., & Jan, S. (2024). Medicaid long‐term services and supports and caregiving needs of caregivers of individuals with intellectual and developmental disabilities. Journal of Applied Research in Intellectual Disabilities, 37(5). https://doi.org/10.1111/jar.13289 

[5] Medicaid and CHIP Payment and Access Commission (MACPAC). (2026). State Medicaid Coverage of Assistive Technology for Adults Using Home- and Community-Based Services - Policy in Brief. https://www.macpac.gov/publication/state-medicaid-coverage-of-assistive-technology-for-adults-using-home-and-community-based-services/ 

[6] Tanis, E., Wagner, J., Sedor, G., Pickard K., & Tassé M. (2023). Expanding the Use of Remote Supports for People with Intellectual and Developmental Disabilities: An Interdisciplinary Working Group Report Interdisciplinary Working Group. https://nisonger.osu.edu/wp-content/uploads/2023/03/expanding-the-use-of-remote-supports-whitepaper.pdf 

[7] Zawada, S., Fogus, M., Mills, E., Fortune, E., & Cepoi, L. (2026). State Variation in Smart Device Eligibility for Aging-in-Place Services: Recent Trends in Medicaid Section 1915(c) Waiver Coverage for Older Adults. Clinical Interventions in Aging, Volume 21, 1–9. https://doi.org/10.2147/cia.s629091