How we grade every state's HCBS system A–F. Our data sources, composite weighting, normalization approach, and honest limitations — published so you can verify our work.
Annual HCBS waiver program report filed by every state with CMS. Primary source for waiver slots, expenditures, and unduplicated participant counts.
Transformed Medicaid Statistical Information System. State-level enrollment, service utilization, and claims data.
Waitlist survey data, per-capita HCBS spending, institutional vs. community balance ratios.
Waiver applications, renewals, and amendments filed with CMS. Source for program-specific eligibility, caps, and target populations.
National Association of State Directors of DD Services. Self-determination program status, waitlist management approaches.
Each state receives a composite score from 0–100 based on six weighted factors. Factors are normalized using min-max scaling across all 50 states plus D.C., then weighted and summed.
| Factor | Weight | Description |
|---|---|---|
| HCBS Spending Per Capita | 25% | Total HCBS expenditure divided by state population with IDD. Higher per-capita spending = more available services. |
| Waitlist Length (Months) | 25% | Average months from application to enrollment across the state's waiver programs. Shorter = better. |
| Waiver Program Count & Breadth | 15% | Number of distinct waiver programs and the range of populations served (IDD, aging, TBI, physical disability). |
| Self-Determination Availability | 15% | Whether the state offers participant-directed budgeting (full SD, partial, or none). |
| Institutional vs. Community Balance | 10% | Ratio of community-based spending to institutional spending. Higher community balance = better. |
| Application Accessibility | 10% | Online application availability, language access, intake phone responsiveness, and geographic coverage. |
Full self-determination, short waitlists (<12 mo), high per-capita HCBS spending, broad waiver inventory
Partial SD or moderate waitlists (12-24 mo), above-average spending, multiple waiver options
Limited programs, waitlists 24-48 months, average spending, narrow waiver coverage
Long waitlists (48+ mo), below-average spending, few waiver options, no SD
No DD-specific waiver or extremely limited access, institutional bias in spending
Each factor is normalized using min-max scaling: score = (value - min) / (max - min) × 100. The min and max are drawn from the full set of 50 states plus D.C. for each factor independently.
For inverse factors (waitlist length), the score is flipped: shorter waitlists produce higher scores. The final composite score is the weighted sum of all normalized factor scores, capped at 0–100.
Full refresh: Annually in Q1, when new CMS Form 372 and KFF survey data become available. All 50 states re-scored.
Interim updates: Monthly spot checks for major policy changes (new waivers, waitlist freezes, legislative action). States with material changes are re-scored mid-cycle.
Current vintage:CMS FY 2023 + KFF 2024 + state filings through April 2026. The “Live · CMS data Apr '26” badge on the homepage reflects the most recent data incorporated.
Six-factor composite model. CMS FY 2023, KFF 2024, and state filings through April 2026.
The “Self-Determination Availability” factor (15% of the composite) is itself scored from six sub-dimensions. Each state receives a sub-score for every dimension, which are averaged into the overall self-direction factor score.
Whether the participant (or their representative) serves as the employer of record for direct-support workers, or whether an agency retains that role.
Why it matters: Employer-of-record status determines who hires, fires, schedules, and supervises workers. W-2 employer authority gives the participant true hiring power.
Data source: State FMS (Financial Management Services) contracts, CMS Appendix E.
Example states: Washington (W-2 via DDA Individual Providers), Massachusetts (W-2 via PCA program), Georgia (Agency model in most COMP waivers).
Whether the participant can hire family members (parents, spouses, siblings) as paid caregivers under the waiver.
Why it matters: Many families already provide unpaid care. Allowing paid family caregivers reduces turnover, improves care consistency, and provides economic support to the family unit.
Data source: State waiver applications (Appendix C/E), Medicaid state plan amendments.
Example states: California (YES — parents can be paid IHSS providers), Pennsylvania (Restricted — spouse only in some waivers), New York (NO for legally responsible relatives in most OPWDD programs).
Whether the state has implemented CMS requirements for conflict-free case management — ensuring the entity coordinating services is independent from entities providing services.
Why it matters: When the same organization both coordinates and delivers services, there is a financial incentive to steer participants toward in-house services regardless of fit or preference.
Data source: CMS HCBS final rule compliance reports, state transition plans.
Example states: Ohio (YES — County Boards of DD separated coordination from service delivery), Illinois (Partial — transitioning), Virginia (YES — completed separation).
How much latitude the participant has to reallocate funds across budget categories without prior authorization.
Why it matters: Rigid spending plans that require amendment approval for any change undermine self-direction in practice, even when budget authority exists on paper.
Data source: State FMS policies, spending-plan amendment procedures documented in waiver applications.
Example states: Colorado (High — flexible reallocation within SLS), Ohio (Med — SELF waiver allows some reallocation with SSA approval), Florida (Low — iBudget categories are rigidly defined).
Whether the participant can purchase goods, equipment, and non-traditional services (e.g., gym memberships, technology, home modifications) from their individual budget.
Why it matters: Goods and services authority allows participants to address needs that traditional service categories miss — adaptive technology, community memberships, and environmental modifications that promote independence.
Data source: CMS waiver applications (Appendix E — goods and services category), state self-direction program manuals.
Example states: California (YES — Self-Determination Program includes goods and services), Ohio (YES — SELF waiver includes goods and services), New Jersey (NO — DDD waivers do not include a goods and services category).