How Medicaid Pays for Home Care in Oregon

The K Plan: why Oregon's attendant care has no waiting list

Oregon covers attendant care through Community First Choice, a Medicaid state plan option it adopted in 2013 and calls the K Plan, after the section of federal law authorizing it — 1915(k). The defining feature is a prohibition rather than a promise: a state running Community First Choice cannot cap enrollment 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).Section 1915(k) Community First Choice provides home- and community-based attendant services covering help with daily activities, instrumental tasks, and health-related tasks as a state plan benefit; participating states receive a six-percentage-point FMAP increase, must serve people meeting an institutional level of care, and cannot cap enrollment — the authority behind Oregon's K Plan and the reason it carries no waiting list.. Not chooses not to. Cannot.

Hold that against the rest of the country. In 2025, 41 states reported HCBS waiting or interest lists, roughly 0.7 million people were on one, and the average wait for waiver services ran about 32 months 2Ref 2KFF (Kaiser Family Foundation) (2025).A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2025.41 states had HCBS waiting or interest lists in 2025, roughly 0.7 million people were on such lists, and the average wait for waiver services was about 32 months — the national baseline Oregon's uncapped authority departs from.. Those queues are not a consequence of scarcity. They are what a different legal authority permits, and Oregon took the one that forbids them.

In Oregon the question is not whether a slot exists. It is whether the person meets the level of care. Community First Choice must serve people meeting an institutional level of care, and a state taking it receives a six-percentage-point increase in its federal match as the trade 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).Section 1915(k) Community First Choice provides home- and community-based attendant services covering help with daily activities, instrumental tasks, and health-related tasks as a state plan benefit; participating states receive a six-percentage-point FMAP increase, must serve people meeting an institutional level of care, and cannot cap enrollment — the authority behind Oregon's K Plan and the reason it carries no waiting list.. Medicaid covers close to 70% of home care spending nationally, with an estimated 5.1 million enrollees using it 3Ref 3KFF (Kaiser Family Foundation) (2025).Medicaid Home Care (HCBS) in 2025.Medicaid pays for nearly 70% of U.S. home care spending and an estimated 5.1 million Medicaid enrollees use home care, establishing Medicaid as the dominant payer regardless of which authority a state chooses.. Oregon is unremarkable in relying on Medicaid, and unusual in the authority it chose.

Which makes cross-border comparison actively misleading. Medicaid home care in idaho and medicaid home care in georgia are built on capped waivers, so a family who reads those rules first will misunderstand both why waits exist there and why Oregon's do not. Ask does medicaid pay for home care without naming a state and there is no true answer available.

What Community First Choice covers in Oregon, and what it demands first

The K Plan pays for attendant services: hands-on help with activities of daily living such as bathing, dressing, toileting, transferring, and eating; help with instrumental tasks like cooking, laundry, shopping, and medication reminders; and help with health-related tasks 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).Section 1915(k) Community First Choice provides home- and community-based attendant services covering help with daily activities, instrumental tasks, and health-related tasks as a state plan benefit; participating states receive a six-percentage-point FMAP increase, must serve people meeting an institutional level of care, and cannot cap enrollment — the authority behind Oregon's K Plan and the reason it carries no waiting list.. In practice that arrives as an assessed number of hours per month, delivered by a homecare worker in the person's own home.

Medicaid offers states several legal routes to fund care at home, and the choice determines everything downstream: 1915(c) waivers, the 1915(i), (j), and (k) state plan options, and 1115 demonstrations differ in whom a state may cover and whether enrollment can be capped 4Ref 4Centers for Medicare & Medicaid Services (2025).Home & Community Based Services Authorities.Medicaid covers home and community based services through several distinct authorities — 1915(c) waivers, the 1915(i)/(j)/(k) state plan options, and 1115 demonstrations — which differ in whom a state may cover and whether enrollment can be capped.. Oregon runs 1915(k) as its backbone, keeping waivers beside it for what Community First Choice does not reach.

The requirement people underestimate is the level-of-care test. This is not a program for anyone who could use a hand; the state must serve people who meet an institutional level of care 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).Section 1915(k) Community First Choice provides home- and community-based attendant services covering help with daily activities, instrumental tasks, and health-related tasks as a state plan benefit; participating states receive a six-percentage-point FMAP increase, must serve people meeting an institutional level of care, and cannot cap enrollment — the authority behind Oregon's K Plan and the reason it carries no waiting list. — people who would otherwise qualify for a nursing facility. Oregon expresses that through a service priority level assessment scoring dependence in specific daily activities, and the hours follow the score. An Oregon application is won or lost in that assessment, which is also where an appeal will live. It is the main event, not a formality.

Oregon's Home Care Commission and the homecare worker registry

Oregon voters built the machinery for this in November 2000 and put it in the state constitution. Ballot Measure 99 created the Oregon Home Care Commission, charged with defining the qualifications and training of workers who serve people receiving Medicaid in-home services, and with maintaining a registry those people use to find one. A constitutional amendment is a strange place for a workforce program, and it tells you how contested the question was.

A homecare worker is a defined legal category in Oregon, not a loose description: a person enrolled to deliver in-home services to a Medicaid consumer, who has cleared a background check and met the commission's standards. The registry is public infrastructure — a searchable list of those workers, with the areas they travel to, the hours they want, and the tasks they will do.

Worth being clear about what a registry is. It is a search tool, not a referral, not a recommendation, and not evidence that anyone listed has room this week. Learning to read it — filtering by area and task, understanding that a listing is an advertisement rather than an assignment — is the skill Oregon's model asks of families in place of the agency other states would have handed them.

Who is the employer? In Oregon, the person receiving the care

This is the structural fact that surprises nearly everyone, and it has consequences all the way down. In Oregon's in-home Medicaid program the consumer — the person receiving services, or their representative — is the employer of record. They interview, hire, set the schedule, direct the work, and end it when it is not working. The state pays the worker; it does not supervise them.

Medicaid's self-directed model is precisely this: a beneficiary manages a budget and selects, hires, trains, and manages their own caregiver, and in some states that caregiver may be a family member 5Ref 5Centers for Medicare & Medicaid Services (2025).Self-Directed Services.Medicaid self-directed service delivery lets a beneficiary manage a budget and select, hire, train, and manage their own caregiver, including in some states paying a family member — the model Oregon uses as the default shape of its in-home program rather than as an option.. Most states offer it as a special option for the unusually capable. Oregon made it the ordinary shape of the program.

The upside is continuity and fit — one worker who knows the person, chosen by the person, instead of a rotation of whoever was available. The downside is that recruiting, scheduling, and covering a call-out at 6am are the household's problem in a way they are not elsewhere. Adult children, friends, and neighbors are commonly hired this way. A spouse is narrower: Oregon has a limited pathway with its own criteria, worth raising with a case manager rather than assuming either way.

Where an Oregon application goes: APD, Type B agencies, and not the CCO

Oregon divides its Medicaid administration in a way that routinely sends people to the wrong door for weeks. The Oregon Health Authority runs the medical side of the Oregon Health Plan. Long-term services and supports — the K Plan, the assessment, the hours, the case management — sit with the Department of Human Services, under Aging and People with Disabilities. Two agencies, one Medicaid program.

Most Oregon Health Plan members receive medical care through a Coordinated Care Organization, a regional plan holding physical, behavioral, and dental health. Long-term care is generally carved out of it. So the plan named on someone's insurance card is usually not the entity deciding their home care hours, and calling it first costs a week for nothing.

Oregon adds one more layer. In much of the state the local Area Agency on Aging is a Type B agency, meaning it performs the Medicaid work — eligibility, assessment, case management — under contract, alongside its Older Americans Act services. Elsewhere a state office does it directly. So the correct first call depends on the county, and the question that routes a family is: who performs the APD assessment here.

Oregon Project Independence: home care without Medicaid

Oregon has funded home care outside Medicaid since 1975, which is unusual enough and old enough to plan around. Oregon Project Independence pays for in-home services — personal care, housekeeping, respite, adult day — for people who need help but do not qualify for Medicaid. It runs on state dollars, so it carries no federal match and no asset test.

This addresses the situation that has no answer in most of the country. Medicare does not pay for ongoing custodial or personal care, which leaves paying out of pocket, long-term care insurance, or Medicaid 6Ref 6Administration for Community Living (2025).Costs of Care.Medicare does not pay for ongoing custodial or personal care, leaving out-of-pocket payment, long-term care insurance, or Medicaid as the realistic ways to fund help with daily living — the gap Oregon Project Independence was created to fill.. That list has a hole precisely where a great many families live: too much income or savings for Medicaid, nowhere near enough to buy care at market rates. Oregon Project Independence was built for the hole.

Its limits are real. State-funded means appropriated, which means finite — it is not an entitlement the way the K Plan is. It uses a sliding fee based on income, local agencies apply their own priority rules, and it can carry its own wait. But it has existed for half a century, and it is routinely missed by families who ask only about Medicaid, hear no, and stop.

What still involves waiting in Oregon — and it is not the benefit

Oregon took the queue out of the benefit and left it in the labor market. Community First Choice cannot cap enrollment 1Ref 1Centers for Medicare & Medicaid Services (2025).Community First Choice (CFC) 1915(k).Section 1915(k) Community First Choice provides home- and community-based attendant services covering help with daily activities, instrumental tasks, and health-related tasks as a state plan benefit; participating states receive a six-percentage-point FMAP increase, must serve people meeting an institutional level of care, and cannot cap enrollment — the authority behind Oregon's K Plan and the reason it carries no waiting list., so an eligible Oregonian does not wait for a slot. What they may wait a long time for is a person: an authorization for a set number of hours a month is not a homecare worker who has capacity, lives within a plausible drive, and wants those hours on those days.

That changes what is worth worrying about. The paperwork question — is this person eligible, how many hours — has a determinate answer and an appeal path behind it. The staffing question has neither. It is a wage question, a housing question, and in a coastal or eastern county a distance question, and it is frequently the binding constraint. The registry lists who has enrolled; it does not conjure supply.

One more honest caveat. Community First Choice covers attendant services, not every support a person might need. Pieces outside it can run through a waiver instead — a different authority, with different rules about whom it may cover and whether enrollment can be capped 4Ref 4Centers for Medicare & Medicaid Services (2025).Home & Community Based Services Authorities.Medicaid covers home and community based services through several distinct authorities — 1915(c) waivers, the 1915(i)/(j)/(k) state plan options, and 1115 demonstrations — which differ in whom a state may cover and whether enrollment can be capped.. So someone can live in a state with no waiting list for the main benefit and still meet a wait at the edges. Which authority funds which piece is worth asking a case manager.