What is the difference between HCBS and an ICF/IID?

HCBS provides Medicaid services in a person's home or community, mainly through waivers that states can cap. An ICF/IID is a licensed, certified facility that provides 24-hour care and active treatment for people with intellectual disability or related conditions. ICF/IID care is an institutional benefit that states may not limit or put behind a waiting list.

Is an ICF/IID a group home?

Not necessarily. Group home describes a type of setting, while ICF/IID is a Medicaid certification. A setting is an ICF/IID only if it is state-licensed, meets the federal conditions of participation and provides active treatment (42 CFR 440.150). Medicaid's general definition of an institution covers settings serving four or more unrelated people (42 CFR 435.1010).

What is active treatment in an ICF/IID?

Active treatment is the continuous program of specialized and general training, treatment, health services and related services that each resident must receive under federal rules (42 CFR 483.440(a)). It is built on an individual program plan developed by an interdisciplinary team. Services that only maintain people who are already generally independent do not qualify.

Can someone move from an ICF/IID to HCBS?

Yes. People who need an ICF/IID level of care generally meet the institutional level-of-care requirement for I/DD waivers, which exist to help people avoid institutional care (42 CFR 441.300). Moving usually depends on an open waiver slot, because states can cap waiver enrollment and keep waiting lists.

HCBS vs. ICF/IID: Community services vs. facility care

HCBS delivers Medicaid supports at home and in the community, mostly through waivers states can cap, while an ICF/IID is a licensed facility providing 24-hour care and active treatment as an institutional benefit that states may not waitlist.

HCBS (home and community-based services) are Medicaid supports delivered in a person's own home, family home, group home or community, mostly through Medicaid waivers that states can cap. An ICF/IID (intermediate care facility for individuals with intellectual disabilities) is a licensed, federally certified facility that provides 24-hour care and "active treatment" as a Medicaid institutional benefit. Federal rules for ICFs/IID are at 42 CFR 440.150 and 42 CFR Part 483, Subpart I. The main HCBS waiver rules are at 42 CFR Part 441, Subpart G.

The two are linked. To qualify for most I/DD waivers, a person must need the level of care an ICF/IID provides, and waiver services are meant to help the person avoid living in one (42 CFR 441.300 and 441.301(b)).

HCBS vs. ICF/IID at a glance

What it is. HCBS: Services in the home and community, mainly through 1915(c) waivers. ICF/IID: A licensed facility providing 24-hour care and active treatment.
Federal rules. HCBS: 42 CFR 441, Subpart G (waivers); 42 CFR 440.180 (services). ICF/IID: 42 CFR 440.150; 42 CFR 483, Subpart I (conditions of participation).
Entitlement. HCBS: States set the number of waiver slots and may keep waiting lists. ICF/IID: Optional benefit, offered in every state. States may not limit access or use waiting lists.
Eligibility. HCBS: Institutional level of care, in a waiver's target group. ICF/IID: Needs and receives active treatment; I/DD or a related condition that began before age 22.
Planning. HCBS: Person-centered service plan, reviewed at least every 12 months. ICF/IID: Individual program plan by an interdisciplinary team, coordinated by a QIDP.
Setting standard. HCBS: HCBS settings rule: community integration, choice, privacy, autonomy. ICF/IID: Facility conditions of participation, including minimum staffing ratios.
Staff. HCBS: DSPs under state provider standards. ICF/IID: Direct care staff with required training; QIDP oversight.
Oversight. HCBS: State waiver quality systems, reviewed by CMS. ICF/IID: Survey and certification by the state survey agency.
Share of people with I/DD (KFF, 2021). HCBS: About 700,000 of 729,000 nonelderly Medicaid LTC users. ICF/IID: The rest used institutional care, mostly in ICFs.

What an ICF/IID is

Under 42 CFR 440.150, ICF/IID services are provided in a facility that:

Is licensed by the state.
Has the primary purpose of providing health or rehabilitative services to people with intellectual disability or related conditions.
Meets the federal conditions of participation in 42 CFR Part 483, Subpart I.

The person must also receive active treatment. Medicaid.gov describes the benefit as "the most comprehensive benefit in Medicaid." It is an optional state benefit, but every state offers it. States may not limit access to it or put it behind a waiting list, as they can with HCBS.

Key facility rules include:

Active treatment: Each resident must receive a continuous active treatment program aimed at gaining skills and independence. Services that only maintain people who are already generally independent don't count (42 CFR 483.440(a)).
QIDP: A qualified intellectual disability professional must integrate, coordinate and monitor each resident's program (42 CFR 483.430(a)).
Staffing: Direct care staff must be awake and on duty around the clock in certain living units. Minimum staff-to-client ratios range from 1 to 3.2 up to 1 to 6.4, depending on residents' needs (42 CFR 483.430(d)).
Training: Staff must get initial and continuing training focused on residents' needs and be able to show those skills (42 CFR 483.430(e)).

Medicaid's general definition of an institution covers a setting that serves four or more unrelated people (42 CFR 435.1010). The state survey agency licenses and certifies each ICF/IID.

What HCBS is

HCBS covers a broad menu of services, including habilitation, supported living, day habilitation, respite, personal care, case management and supported employment (42 CFR 440.180). Most HCBS for people with I/DD runs through 1915(c) waivers (see What is an HCBS waiver?). As of September 2026, Medicaid.gov counts about 257 active 1915(c) programs.

HCBS is built around two federal requirements:

A written person-centered service plan, built through person-centered planning, with a reassessment and plan review at least every 12 months (42 CFR 441.301(b) and (c)).
The HCBS settings rule (42 CFR 441.301(c)(4)). Settings must be integrated in the community, offer full access to community life, support choice, protect privacy and dignity, and support independence.

The trade-off is access. States set the maximum number of people each waiver serves. In KFF's 2025 survey, 41 states reported waiting lists, and 74% of the more than 600,000 people waiting had I/DD. The average wait for I/DD services was 37 months.

How the two compare in scale

Medicaid long-term care for people with I/DD has shifted heavily toward HCBS. KFF reports that of the 729,000 nonelderly people with I/DD who used Medicaid long-term care in 2021, about 700,000 received home and community-based care. Most of those in institutional care were in ICFs. For all populations, KFF counted 5.1 million Medicaid home care users in 2023, compared with 1.4 million in institutional long-term care.

How it varies by state

The balance between ICF/IID care and HCBS differs from state to state, as do waiver design, rates and target groups. KFF reports that Arizona, New Jersey, Rhode Island and Vermont run HCBS through section 1115 demonstrations rather than 1915(c) waivers. Your state's developmental disabilities agency and health department survey office publish the details.

Why it matters for providers and DSPs

Different rulebooks: An agency running both ICFs/IID and waiver homes answers to facility conditions of participation and survey teams in one, and to waiver provider standards and the settings rule in the other. Documentation, staffing and training requirements differ.
Staff roles: DSPs in an ICF/IID carry out active treatment programs written under a QIDP's oversight. In HCBS, DSPs work toward goals in the person-centered plan. The core skills overlap, but the paperwork and supervision don't.
Entitlement vs. slots: Because ICF/IID care can't be waitlisted and waiver slots can, state budget choices land differently on each. That affects which programs grow.
Policy direction: Federal community-integration policy, including the Olmstead debate, and state rate studies shape where people with I/DD live and where DSP jobs will be.