Positive Approaches Journal, Volume 14, Issue 2

Volume 14 ► Issue 2 ► September 2025

Support Insights: How HCBS Help Create More Accessible Environments.

Molly Sadowsky and Conner Carlton

Many people with intellectual and developmental disabilities (IDD) require assistance with activities of daily living, including bathing, dressing, and eating.¹ Most states provide Home and Community Based Services (HCBS) to assist with these tasks through Medicaid Waiver programs.² Waiver programs may be designed to serve specific populations, such as older adults and people with disabilities, and often have medical and financial eligibility requirements. Each year, about 4.5 million people receive HCBS through 1915(c) or 1115 waivers, or through the Community First Choice option. Nearly all states provide HCBS waivers to people with IDD.¹

In Pennsylvania, HCBS are provided to people with IDD through 1915(c) waivers, including the Adult Autism Waiver (AAW), Community Living Waiver, Consolidated Waiver, and Person/Family Directed Support Waiver (PFDS).³ As of February 2025, there were nearly 40,000 people enrolled across all intellectual disability and autism spectrum disorder (ID/A) waivers in Pennsylvania, including nearly 20,000 people receiving services through the Consolidated Waiver, over 13,000 receiving them through the PFDS waiver, and about 7,500 receiving them through the Community Living Waiver. Demand for wavier services remains high, with recent estimates indicating at least 13,000 people on the waitlist for services.³

Home accessibility modifications are covered under most HCBS waivers and are important in supporting health, safety, and independence for people with IDD. Most of the current housing stock lacks basic accessibility features like no-step entry, wide halls and doorways, and electric controls and switches.⁴ In 2021, it was estimated that across all states, only 1.5% of people with IDD enrolled in HCBS waiver programs received environmental modifications.⁵ In 2021, 314 people with IDD received environmental modification services in Pennsylvania, accounting for less than 1% of individuals enrolled in ID/A waivers. Statewide, Pennsylvania was projected to spend about $1.7 million on environmental modification services, which amounted to only 0.05% of all HCBS spending that year and about $5,000 per participant.⁵ The most common home modifications requested included ramps and/or lifts, widening doorways and hallways, bathroom modifications, specialized electrical and/or plumbing equipment for medical use, and grab bars and/or handrails.⁵

All HCBS programs in Pennsylvania provide Home Accessibility Adaptation Services for people with disabilities to increase accessibility in their homes. Each waiver program includes two categories of these services: 1) equipment, technology, and modifications and 2) home and/or vehicle accessibility adaptations. In Pennsylvania, ID/A waivers cover physical modifications to the primary residence of the waiver participant, including homes that are owned or leased by parents or relatives. Modifications must be specified in the participant’s Individual Support Plan as necessary for the participant to live with greater independence in their home. Home modifications include the cost of installation, repair, maintenance, and extended warranties for the modifications. For AAW and PFDS waiver participants, there is a $20,000 cap per participant over a 10-year period in the same home.

Inaccessible home environments for people with IDD may increase risk for adverse outcomes like falls and injuries and introduce barriers to independent and community-based living that HCBS waivers aim to support. Across all states, there is evidence suggesting that despite a potential need, few people with IDD receive environmental modifications through the HCBS waiver programs they are enrolled in, which may decrease community participation among people with IDD.⁶ Further research is therefore needed to understand the need for and receipt of environmental modifications for people enrolled in HCBS waiver programs in Pennsylvania.