Medicaid pays for nursing homes by right, but home care is capped

A person who qualifies for a nursing home under Medicaid gets a place by right. A person who wants to stay home often gets a waitlist. A Nonprofit Quarterly piece argues this is a choice built into Medicare and Medicaid, not an accident, and that it leaves families and local nonprofits to fill the gap.

What the rules say

Medicare mostly pays for medical treatment. It says it does not cover most long-term care, including ongoing help with everyday tasks at home or in a facility. Medicaid covers part of that gap, and it is the nation's main public payer for long-term care.

But the rules differ by setting. Nursing-facility care is mandatory for eligible people. The Centers for Medicare & Medicaid Services (CMS) confirms states may not cap it or put eligible people on waiting lists. Many home and community services are optional for states, which can cap enrollment and keep waiting lists.

The numbers

• More than 600,000 people were on Medicaid home care waiting or interest lists in 2025.
• The average reported wait was about 32 months, though lists are defined differently by state.
• Family caregivers gave an estimated 49.5 billion unpaid hours in 2024.
• AARP valued that care at about $1.01 trillion, more than combined federal, state and local Medicaid spending that year.

Who it affects

Older adults and people with disabilities feel it first. CMS reports that nearly one million US households include an adult with an intellectual or developmental disability who is supported by an aging caregiver. The article also cites parents of severely impaired children in Florida who were eligible for 80 hours of home care but received significantly less.

Community organizations step in with help finding services, meals, rides, caregiver support, social connection, prevention and advocacy. The author says that money for this work is often fragmented, not guaranteed or time-limited. The result is a safety net without steady funding.

What to do

For anyone running a home-care agency or a nonprofit, the practical point is to plan for long waitlists and uncertain funding. Track demand for your services closely, and keep a clear calendar of grant deadlines. The piece is an argument, not a new rule. It calls on philanthropy and programs such as Medicaid and Medicare to treat community living supports as a lasting public commitment.