How we grade every state's HCBS system A–F. Every factor, weight and anchor below is the code that actually runs — this page is generated from the scoring engine itself, so what we publish and what we compute cannot drift apart.
We score five things about each state's home and community-based services system: how many people are stuck waiting, how much the state spends, how much control families get over their own budget, how many programs exist, and whether the money goes to community care or institutions. Each is scored 0–100 against a fixed bar — not against the other states — then weighted and added up. Every number comes from a public federal or state source, and every source is linked next to the number on each state's page. Where we couldn't source something, we say so and leave it out rather than guessing.
Medicaid long-term services and supports spending by state, split between community-based and institutional care. Covers both fee-for-service and managed care. Source for two of our five factors.
Annual 50-state survey. Source for how many people are on each state's waiver waiting lists, by target population, and whether the state screens applicants for eligibility before adding them.
The actual approved application each state files with CMS. We read the self-direction elections directly out of Appendix C, D and E of each state's primary comprehensive IDD waiver — not from a summary.
Authoritative roster of currently approved Section 1915(c) waivers. Source for how many programs each state operates.
State resident population, used as the denominator for per-capita spending and waiting-list burden.
Each state receives a composite score from 0–100 built from five weighted factors.
| Factor | Weight | What it measures |
|---|---|---|
| Waitlist Burdenpeople waiting per 100,000 residents | 30% | How many people are queued for HCBS waiver services, scaled to state population. Lower is better. Replaces v1.0's unmeasurable 'average wait in months'. |
| HCBS Spending Per CapitaUSD per resident | 25% | Total Medicaid HCBS expenditure divided by state population. Higher spending means more available services. |
| Self-Direction Indexindex 0-100 | 20% | Composite of six sub-dimensions read directly from approved CMS 1915(c) waiver applications. See §08. |
| Waiver Program Count & Breadthindex 0-100 | 15% | Number of active 1915(c) waivers, range of populations served, and whether the state offers Community First Choice or 1915(i) state plan HCBS. |
| Institutional vs. Community Balancepercent of LTSS spending on HCBS | 10% | Share of the state's Medicaid long-term services and supports spending that goes to community-based rather than institutional care. |
Each factor is scored 0–100 against a fixed bar, not against how other states happen to be doing. This matters: it means a state's grade moves when that state moves, not when the rest of the country shifts around it. It also means the whole country can be doing badly and the grades will show it, rather than always producing a comfortable spread of A's and F's.
Two of the five factors are already meaningful 0–100 indexes, so they are used directly. The other three are anchored to round numbers near the 10th and 90th percentile of observed state performance in the 2026 baseline (CMS CY2023 TAF + KFF FY2025). Those anchors are then frozen and reused at every refresh. Values past either end are clamped rather than allowed to run off the scale.
| Factor | Scores 0 | Scores 100 |
|---|---|---|
| Waitlist Burden0 people waiting per 100,000 residents scores 100. 225 per 100,000 — the 90th percentile of observed state burden in the 2026 baseline — scores 0. Eighteen jurisdictions report no waiting list at all and score 100 here. | 225 | 0 |
| HCBS Spending Per Capita$200 per resident (approximately the 10th percentile of observed state spending in the 2026 baseline) scores 0; $675 (approximately the 90th percentile) scores 100. The national average is roughly $429. | 200 | 675 |
| Self-Direction IndexAlready an absolute 0-100 index: the share of the six self-direction rights the state's primary IDD waiver actually grants. No rescaling applied. | 0 | 100 |
| Waiver Program Count & BreadthAlready an absolute 0-100 index composed from waiver count, populations served, and Community First Choice / 1915(i) availability. No rescaling applied. | 0 | 100 |
| Institutional vs. Community Balance40% of LTSS spending going to HCBS (approximately the 10th percentile) scores 0; 78% (approximately the 90th percentile) scores 100. The national average is 63.8%. | 40 | 78 |
Little or no waiting list, HCBS spending near the top of the country, most self-direction rights granted, and a broad program inventory.
Short queues and above-average performance on most factors. Usually strong on two or three factors with one clear weak spot.
Middle of the country. Typically a real waiting list, average spending, and partial self-direction — or strong access paired with thin funding.
Below average on most factors. Long queues, spending near the bottom of the country, or self-direction rights the state's waiver does not grant.
Bottom of the country on the factors that decide access. Typically a very large waiting list relative to population combined with low HCBS spending. Every F state still operates waiver programs — an F is about how hard they are to get into, not whether they exist.
Each band is divided into thirds to produce the plus and minus grades. An A+ is 95 or above; an A− starts at 85. There is no F+ or F−.
Computed.We could source at least 80% of the model's weight for this state. The grade stands on its own.
Provisional. Between 50% and 80% of the weight was sourceable. We publish the score, rescaled to what we could measure, and label it. Five jurisdictions are provisional today — four of them because they run HCBS through an 1115 demonstration instead of 1915(c) waivers, so our waiver- inventory factor genuinely does not describe them.
No grade. Below 50%, we publish no letter at all rather than a number that looks more solid than it is.
Every state page shows a confidence level alongside the grade, taken from the least reliable input that fed it, and lists every caveat that applied.
We checked every jurisdiction that reported nobody waiting against its own state agency sources. Seventeen reported a zero. Two survived. Ten were contradicted outright and five could not be corroborated either way.
The federal survey asks specifically about Section 1915(c) waiver waiting lists. A zero in that column does not mean nobody is waiting — it means no waiver waiting-list count was reported. We found queues living outside it in almost every form: devolved to county lead agencies in Minnesota, to Designated Agencies in Vermont, to Area Agencies in New Hampshire and to regional health plans in Michigan; sitting in a separate autism waiver in Connecticut and North Dakota; in a children's programme in Oregon; in a residential placement list in New York; and recorded in Washington as 22,964 people found eligible who receive no paid services. The District of Columbia opened a waiting list on 1 January 2026, after the survey was taken.
Where a state's own sources contradict the survey, or where nothing corroborates it, we now leave the waiting-list factor unscored and say so on that state's page. That moves fifteen jurisdictions to a provisional grade and means we publish no grade at all for three, which is the honest result. Only Hawaii and California survived the check.
Every grade on this site is now calculated by a scoring engine from public federal and state data, with a citation attached to each individual value. Four changes from v1.0, all of them forced by what the data would and would not support:
A six-factor model published as a specification. Its grades were assigned editorially rather than calculated, and several were materially out of date — Oklahoma was graded on a waiting list that the state had already cut from thirteen years to about one. Everything on this page replaced it in August 2026.
The Self-Direction Index is 20%of the composite and is built from six sub-dimensions, each read out of the state's approved CMS waiver application. Every answer maps to a number; the index is the average of the sub-dimensions we could source. A state needs at least four of the six to be scored at all.
| Sub-dimension | Scoring |
|---|---|
| Individual Budget Authority | yes = 100 · no = 0 |
| Employer-of-Record Model | participant w2 = 100 · both = 67 · agency = 0 |
| Family-Hiring Rights | yes = 100 · restricted = 50 · no = 0 |
| Conflict-Free Case Management | yes = 100 · partial = 50 · no = 0 |
| Spending-Plan Flexibility | high = 100 · medium = 50 · low = 0 |
| Goods & Services Authority | yes = 100 · no = 0 |
These are the elections a state made in its approved waiver application — its policy as filed with CMS. They describe what families are entitled to ask for, not how easy the state makes it in practice.
