What Is a 1915(c) Waiver? How Home and Community Waivers Pay for Rides

Some of your Medicaid riders are also enrolled in a home and community waiver. They can ride with you twice over: once to dialysis as a NEMT trip, and again to their job or day program as a waiver trip. The two trips come from different programs, with different rules and different billing.

What a 1915(c) waiver is

Section 1915(c) of the Social Security Act lets a state pay for home or community services, other than room and board, under a written plan of care. The people served must be ones who, without those services, would need the level of care of a hospital, a nursing facility, or an institution for people with intellectual disabilities. Each waiver serves one or more target groups, such as older adults, people with a brain injury, or people with intellectual or developmental disabilities.

As of September 2026, Medicaid.gov says nearly every state and DC offers these waivers, and about 257 are active nationwide. The federal rules that shape them:

Rule	What it means	Source
Cost neutrality	Average spending per person on the waiver may not exceed what the state would spend on institutional care	Section 1915(c)(2)(D)
Rules the state may set aside	Statewideness, comparability of services, and income and resource rules in the community	Section 1915(c)(3)
Service plan	Every service is delivered under a written plan of care	Section 1915(c)(1)
Term	3 years for a new waiver, then 5-year renewals	42 CFR 441.304
Size	The state sets a maximum number of people served each year and may keep a waiting list	42 CFR 441.303(f)(6)
Services	Listed services such as adult day health, habilitation, and respite, plus other services CMS approves	42 CFR 440.180

One change is already scheduled. Public Law 119-21, signed July 4, 2025, added section 1915(c)(11). Starting July 1, 2028, CMS may approve standalone waivers for people who do not need an institutional level of care, using needs-based criteria the state sets and CMS approves.

How waiver rides differ from NEMT

CMS’s technical guide for 1915(c) waivers (version 3.6, January 2019) defines non-medical transportation as a service that lets waiver members reach waiver services and other community services, activities, and resources in their service plan. It is offered in addition to NEMT and does not replace it. Family, neighbors, friends, or community agencies that can give the ride for free are used first.

	NEMT	1915(c) non-medical transportation
Where the rider goes	Medicaid-covered medical care	Waiver services and community places in the service plan
Federal rule	42 CFR 431.53 and 440.170	Section 1915(c), 42 CFR 440.180, and the approved waiver
Who can ride	Medicaid members who need a ride to covered care	Only people enrolled in that waiver
Who approves the trip	The state, its broker, or a health plan	The case manager, through the service plan
Who you enroll with	A broker, a health plan, or the state	The state Medicaid agency or the agency that operates the waiver

A ride shows up in a waiver in one of three ways:

1. As its own service. The waiver lists non-medical transportation, sometimes under another name, with its own code and rate. Iowa’s waivers bill it as S0215 per mile or T2003 per one-way trip, under rate limits effective July 1, 2024.
2. Inside another service’s rate. Adult day health or day habilitation may include the ride. CMS requires the state to prevent double billing, so you cannot bill a separate ride for the same trip. See adult day care transportation.
3. Not at all. A ride to a doctor, dialysis, or any other state plan medical service is billed as NEMT.

For a side-by-side of the two terms, see NEMT vs NMT.

Where to find the ride rules in a waiver

Every approved waiver is a long application with lettered appendices. Medicaid.gov’s State Waivers List links each state’s waivers, and Iowa’s pages, for example, offer the approved application as a download. These are the parts a ride company needs.

Appendix	What it tells you
B, Participant access and eligibility	Who qualifies and the cap on members each year
C, Participant services	Each service’s definition, limits, units, and provider qualifications
D, Participant-centered planning	Who writes the service plan that authorizes your trips
F, Participant rights	Fair hearings and any state complaint system
I, Financial accountability	How rates are set and how claims are paid
J, Cost neutrality demonstration	The state’s estimate of users, units, and cost per unit

A real example: Iowa’s Intellectual Disabilities waiver

Iowa’s HCBS Intellectual Disabilities waiver (IA.0242.R07.02, amendment effective January 1, 2026) shows how this reads in practice:

• Appendix C lists a service called Transportation, added as an “other service” under 42 CFR 440.180(b)(9). It covers business errands, essential shopping, travel to and from work or day programs, and trips that reduce social isolation. It excludes rides to medical services.
• Units. One unit is one mile or one one-way trip. The upper rate limit is in the Iowa Administrative Code.
• No double billing. Transportation is not paid on top of supported community living when that service’s rate already includes the ride.
• Who may provide it. Nursing facilities, area agencies on aging, regional transit authorities, community action agencies, supported community living providers, and NEMT providers. A NEMT provider qualifies by being in good standing with and taking part in Iowa Medicaid’s NEMT program, and the NEMT broker makes sure the provider is qualified. For NEMT providers, Iowa Medicaid’s Provider Services unit verifies qualifications every five years.
• Appendix B caps the waiver at 14,780 people a year.
• Appendix J estimated first-year ride costs, starting July 1, 2024, at an average of $25.96 per one-way trip and $6.49 per mile. These are the state’s estimates, not the rates a provider is paid.

Waivers change. Iowa HHS plans to move members of this waiver into its new HOME waivers in 2027 (FAQ updated July 2026), so the new waiver documents will carry the ride rules from then on. For Iowa’s rates and forms, see the Iowa state guide.

How a ride company joins a 1915(c) waiver

1. Find the waivers that pay for rides. Filter the State Waivers List by your state and 1915(c), then search each waiver’s Appendix C for transportation.
2. Check the provider qualifications. They list the licenses, insurance, and training each kind of provider needs.
3. Enroll as a waiver provider with your state Medicaid agency or the agency that operates the waiver. CMS says states must keep enrollment continuous and open to every willing and qualified provider, and may not cap providers through a bid. The exception is a waiver that runs alongside a 1915(b) waiver limiting provider choice.
4. Get each trip into the service plan. You bill only rides the case manager authorizes.
5. Keep a trip record for every ride, with the member, date, times, addresses, and driver.

State forms, driver rules, and rates are in how to become a waiver transportation provider. States can also run home and community services under a demonstration instead. Tennessee’s TennCare III added a community transportation benefit in an amendment CMS approved on May 17, 2024. See section 1115 waiver.