Key Takeaways
- States participating in the Community First Choice (CFC) program treat personal care as an entitlement – meaning no waitlist, no enrollment cap, and no lottery for eligible Medicaid recipients.
- CFC states are not the only path to no-waitlist services – Minnesota, Wisconsin, California, and Oregon have eliminated certain disability service waitlists through entirely different mechanisms.
- The One Big Beautiful Bill Act (OBBBA), signed July 4, 2025, is already reshaping state rankings – at least nine states proposed reducing HCBS funding by early 2026.
- HCBS waiver services do not transfer between states – moving to a better-ranked state means restarting the eligibility process, not inheriting existing benefits.
- The complete state-by-state breakdown – including tier rankings, waitlist data, and decision frameworks by disability type – is covered in the All 50 States Ranked for Disability Support: The Complete Reference Guide.
For most Americans with disabilities, the state they live in shapes nearly every part of daily life – what services are available, how long the wait is, and whether personal care is even accessible. Most states make people wait. A specific set of states don’t.
Most States Make You Wait – These Don’t
Across the country, hundreds of thousands of people with disabilities are sitting on Medicaid Home and Community Based Services (HCBS) waiver waitlists. These are not short waits. In North Carolina, the effective wait for the Innovations Waiver can stretch up to 15 years. In Kentucky, the Michelle P. Waiver carries documented waits of approximately 7-10 years. In Texas, Medicaid waiver interest lists across HHSC programs hold more than 198,000 people waiting an average of 5-15 years.
And yet, in a handful of states, eligible Medicaid recipients can access personal care and attendant services with no waitlist at all.
Why Waitlists Exist (And Why CFC Bypasses Them)
Entitlement vs. Waiver: A Critical Distinction
Most HCBS services are delivered through Medicaid waivers. These programs have a fixed number of enrollment slots. When those slots fill up, states create waitlists.
Entitlement programs work differently. When a service is an entitlement, any eligible person has a legal right to receive it. The state cannot cap enrollment or close the door when funding gets tight. Medicaid itself – the broader health insurance program – is an entitlement. Community First Choice extends that same principle to a defined set of personal care and attendant services.
The 6% Federal Incentive Driving CFC Adoption
States don’t adopt CFC out of pure altruism. The Affordable Care Act built a financial reward into the program: states that implement CFC receive a 6 percentage point increase in their Federal Medical Assistance Percentage (FMAP) for CFC expenditures. That funding boost is the primary reason more states have moved toward adoption over the past decade.
Current CFC states include Washington, Oregon, Maryland, Texas, Colorado, Connecticut, Montana, New York, and Alaska, among others. In each of these states, eligible Medicaid recipients can access CFC personal care services without a waitlist.
Two states achieved no-waitlist status through a completely different route. Minnesota eliminated its Developmental Disabilities (DD) waiver waitlist in 2016 through sustained state funding investment and county-based service coordination. Whereas Wisconsin delivers entitlement-model HCBS through its Family Care and IRIS (Include, Respect, I Self-Direct) programs, which carry no enrollment caps.
Finally, there is the unique approach of California’s Lanterman Developmental Disabilities Services Act which creates a legal entitlement to developmental disabilities services for eligible individuals.
How All 50 States Were Ranked
Eight Categories Used in This Series’ Ranking
The full 50-state ranking published by Diamonds of Disability measures eight categories that directly affect daily disability life:
- Medicaid waiver access and HCBS waitlists
- In-home caregiver support and consumer direction
- Housing affordability
- Transportation accessibility
- Vocational rehabilitation outcomes
- State tax treatment of disability benefits
- Disability services infrastructure
- Healthcare access and insurance coverage rates
The primary data backbone is the AARP Long-Term Services and Supports (LTSS) Scorecard 2023, covering all 51 jurisdictions across 50 indicators. That’s supplemented by KFF HCBS waitlist data (2025), WorldPopulationReview’s 27-factor 2026 disability index, and the Policygenius 2024 disability livability ranking.
Tier-by-Tier State Breakdown
Tier 1: The Strongest States
Minnesota holds the #1 position – the only state that combines an eliminated DD waiver waitlist, entitlement-model HCBS, consumer-directed care with family member payment options, and a #1 AARP LTSS Scorecard ranking. Washington State ranks #2 on the AARP Scorecard and adds no state income tax on disability benefits. Massachusetts leads on healthcare access, with a 98.3% insurance rate for disabled residents – the highest nationally. Oregon (#4 in the series ranking) brings 25+ years of no-waitlist status for DD services. Wisconsin (#6 in the series ranking) delivers waitlist-free HCBS. California (#8 in the series ranking) carries the Lanterman Act entitlement for approximately 380,000 DD services recipients.
Tiers 2-3: Strong Programs With Real Tradeoffs
Tier 2 includes states like Connecticut (CFC participant, strong Medicaid), Colorado (new CFC entitlement as of July 2025, among the highest employment rates for disabled workers nationally at 54%), and Hawaii (strong disability rights, but extremely high cost of living). New York (#7 in the series ranking) participates in CFC, offers high state SSI supplements, and hosts a large disability services nonprofit ecosystem – offset by extreme NYC housing costs and rural-urban service gaps.
Tier 3 covers a wide range – from Texas (#34 in the AARP Scorecard), where CFC personal care is available without a waitlist but HHSC waiver interest lists hold more than 198,000 people with 5-15 year waits, to Nebraska and North Dakota, which rank well for employment outcomes and affordability despite limited urban transit. Idaho (#35 in the AARP Scorecard) carries a serious red flag: as of 2026, the governor had proposed eliminating Medicaid HCBS entirely in response to OBBBA – a move that would push it directly to Tier 5 if enacted.
Tiers 4-5: Significant and Severe Gaps
Tier 4 and 5 states share a common pattern: long waitlists, thin services infrastructure, limited rural access, and in many cases, documented histories of HCBS cuts during prior Medicaid funding pressure. North Carolina’s Innovations Waiver carries waits of up to 15 years for new applicants. Kentucky, Louisiana, and West Virginia score worst on the AARP LTSS Scorecard, with the highest need and the lowest capacity of any state.
Six states – Florida, Iowa, Oklahoma, Oregon, South Carolina, and Texas – do not screen applicants before placing them on HCBS waitlists, which inflates reported numbers and means some people wait years before learning they were ineligible to begin with.
The One Big Beautiful Bill Act Is Already Reshaping Rankings
The One Big Beautiful Bill Act (OBBBA), signed July 4, 2025, cuts approximately $1 trillion from federal Medicaid over the next decade. By early 2026, at least nine states had proposed eliminating or reducing HCBS funding in response. Any relocation decision made today should treat current state rankings as a starting point, not a guarantee. Monitoring state-level budget proposals through 2026 and beyond is necessary before committing to a move.
Moving for Better Care? Do This First
State Waivers and HCBS Services Don’t Transfer – You Restart
The most important practical fact about interstate moves for disability support: HCBS waiver services do not transfer between states. Moving from Minnesota to Wisconsin – even between two entitlement-model states – means a full re-application, a new eligibility determination, and potentially a new waitlist. The exception is CFC states, where the entitlement structure means eligible new residents can access personal care without a waitlist from the start of Medicaid eligibility. That’s exactly why CFC states are the strongest destination option for people who need personal care now, not in five years.
Federal Benefits Do Transfer, But SSI Amounts May Vary
Federal SSI and SSDI payments follow the recipient across state lines – the federal base amount travels with the person. But state SSI supplements vary significantly. Connecticut, Massachusetts, New York, Vermont, and California offer among the highest state supplements nationally.
Match Your Priority to the Right State
No single state is the right answer for every disability. Identify the highest-priority need first, then filter by state:
- Personal care without a waitlist: Start with CFC states or entitlement-model states like Minnesota and Wisconsin.
- Developmental disabilities (ID/DD): No-waitlist options are Minnesota, Wisconsin, Oregon, and California (Lanterman Act). Avoid Texas (5-15 year HCS wait), North Carolina (up to 15-year effective wait), Kentucky, and Louisiana.
- Maximum affordability on SSI: Mississippi, Arkansas, West Virginia, Kansas, and Nebraska have the lowest housing costs – but trade off against thinner services.
- Employment and career building: North Dakota leads on Ticket to Work participation; Colorado ranks among the highest for overall employment rate for disabled workers (54%); Wisconsin and Massachusetts round out the top tier.
- Specialized medical access: Massachusetts, New York, the Maryland/DC corridor, and Minnesota lead on provider density and healthcare access.
The right state depends entirely on the specific services needed, the diagnosis, and the local provider. Use Diamonds of Disability’s state rankings as the basis for your research and stay vigilant for news of further cuts at the state level.
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