State Variation in Smart Device Eligibility for Aging-in-Place Services: Recent Trends in Medicaid Section 1915(c) Waiver Coverage for Older Adults

Abstract

Purpose

With caregiver workforce shortages on the rise, devices with embedded sensors (“smart devices”) hold promise for supporting older adults in community and at-home settings. The purpose of this study was to describe recent trends in coverage related to smart devices in Home and Community-Based Services (HCBS) waivers.

Patients and Methods

This analysis examined at-home services as outlined in recent Medicaid 1915(c) waivers (January 31, 2020 – May 1, 2026) offered to older adults (age 60 and older) among the 50 states and District of Columbia. Data were obtained from Medicaid waiver applications specific to older adults or including older adult populations with physical disabilities/frailty, using state and CMS repositories. Data elements extracted included waiver text and metadata, assistive technology (AT) categories, and references to smart devices. Descriptive statistics were applied.

Results

Thirty-nine states and D.C. (78.4%) implemented 66 waivers targeting older adults. Three states (MN, OK, and PA) offered the most smart device coverage across AT categories, with smart devices permitted most frequently in the Personal Emergency/Emergency System category (62.1%). While most waivers permit smart devices using broad device eligibility terminology, explicit references for smart devices were identified in 39.4% of waivers across 19 states concentrated in the US Rust Belt, New England, and Atlantic South, including but not limited to motion sensors, smart pens, and GPS trackers.

Conclusion

This study outlines emerging state-by-state variability in Medicaid coverage for smart devices under HCBS waivers. Future research should assess the relationship between state waiver terminology and smart devices that receive coverage across states.

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Introduction

In the United States, the growing aging population combined with the caregiver workforce shortage contributes to increases in institutional care utilization, from emergency department (ED) visits to nursing home admissions.^1,2 In contrast, older adults who receive resources to age-in-place, in community settings and at home, demonstrate enhanced quality-of-life (QoL) and improved health outcomes, including fewer ED visits.^3–5

One pathway by which older adults can receive support to remain at home, including long-term care, is the Medicaid Home and Community-Based Services (HCBS) waiver program, which enables States to develop services to support living at home with the goal of preventing institutionalization in certain populations, including older adults.⁶ Authorized by section 1915(c) of the Social Security Act, these 1915(c) waivers allow States to offer technology supports for independent living, including but not limited to assistive technology (AT) and emergency monitoring.^7,8 Not including medical treatments covered by insurance, services outlined in 1915(c) waivers typically encompass, but are not limited to, home modifications, assistance with activities of daily living, and other personal care services.^7,8 Under this authority, states also have the flexibility to determine specific eligibility criteria as well as the scope of services and budgetary considerations for these supports, many of which continue to be delivered virtually since the COVID-19 Public Health Emergency.^9,10

Alongside these policy changes, the use of remote monitoring devices by older adults has soared in recent years.¹¹ When combined with an internet connection, embedded sensors, and data processing capabilities, these devices, known as smart devices, can observe patients in real-world settings, capturing previously inaccessible insights about real-world effects. Simultaneously, more states than ever before have submitted 1915(c) waiver proposals to the Centers for Medicare and Medicaid Services (CMS) explicitly outlining smart devices, also known as sensor-based devices, as eligible technologies for providing specific HCBS services to older adults; however, HCBS waivers vary across states, influencing device choices and potentially introducing location-based gaps in access to smart devices.^12–14 Despite numerous analyses showing how state policies contribute to inequitable access to virtual clinical services, few have detailed specifics in 1915(c) waivers for technology supports for non-clinical, aging-in-place services.^7,15,16 To address this gap, this study aims to describe the state of smart device eligibility in 1915(c) waivers for older adults in community settings and at home.

Materials and Methods

Medicaid 1915(c) waivers from all 50 states and the District of Columbia (D.C.) were aggregated from state agency repositories and CMS databases for screening. Only recent waivers, defined as a new waiver effective or a waiver modification effective between the start of the COVID-19 Public Health Emergency (January 31, 2020) and May 1, 2026, were included.¹⁷ Terminated waivers were excluded from this analysis. As no human subjects participated in this research, ethical approval was not required for this analysis of Medicaid waivers.

Among recent Medicaid 1915(c) waiver applications, only those applying to older adults, or adult populations with physical disability/frailty that includes older adults, were included in this study. Aligned with the minimum age eligible for community supportive services under the Older Americans Act, older adults were defined as those aged 60 and older.¹⁸ Waivers focused on medically fragile, technology-dependent, neurological/intellectual/developmental disability populations were excluded as beyond the scope of this analysis. As the scope of this analysis focused on aging-in-place, transition services from institutional care to community settings were also excluded.

To examine waiver content, one author (SZ) read each waiver, extracted text explicitly referencing devices (Table 1), and assessed coverage for devices across relevant AT categories. Relevant AT categories were those consistent with current literature as well as the April 2026 Medicaid and CHIP Payment and Access Commission (MACPAC) policy brief summarizing the number of states offering AT coverage under 1915(c) waivers across older adult, disabled, medically fragile, and brain injury populations. These categories include specialized equipment (medical or non-medical), AT, personal emergency/emergency system, home or environmental modifications, other (remote support, remote monitoring, virtual monitoring), and medication reminders.⁷

Table 1.

Search Terms for Annotating Included 1915 (c) Waivers

Device Search Terms
Device	Smart device*
Sensor*	Monitor*
Sensing system*	Mechanical system

Note: * denotes a term frequently indicating a smart device.

After extracting all waiver text related to devices in AT categories, one reviewer (S.Z.) annotated specific references to smart devices. When reviewing the extracted text that referenced devices, text referring to smart devices was annotated if the following terms were used: sensor, sensing system, monitor, and smart device (Table 1). A smart device was classified as permitted under a waiver when one of these terms, or a monitoring system using a device with sensor(s), was explicitly used in a description for a service. A smart device was also classified as permitted under a waiver if the waiver did not explicitly exclude a smart device, as defined by the search terms. Environmental modifications were limited to the home and surrounding yard/property. Smart devices outlined for telehealth clinical services, rather than support for activities of daily living (ADL), were excluded as well. All authors reviewed and approved of the exploratory search methodology.

For each waiver, the following information was extracted into a database (Supplementary Table 1): waiver title, population, effective date (month and year), and waiver type. Also, a boolean response (yes or no) was recorded for each AT category that outlines a service permitting smart devices - specialized equipment (medical or non-medical), AT, personal emergency/emergency system, home or environmental modifications, other (remote support, remote monitoring, virtual monitoring), and medication reminders – and for the column “Explicit Mention of Smart Device” (Supplementary Table 1). Text referencing devices was extracted for each waiver in Supplementary Table 2. For all waivers operated by a state, results were summarized numerically across AT categories, recording each service that permitted a smart device (Table 2). Explicit mentions of smart devices were summarized qualitatively below.

Table 2.

Comparison of Services Permitting Smart Devices across Waivers Operated by a State

State Name	Specialized Equipment (Medical or Non-Medical)	Assistive Technologies	Personal Emergency/ Emergency System	Home or Environmental Modifications	Medication Reminders	Other (Remote Support, Remote Monitoring, Virtual Delivery, Virtual Monitoring, Wellness Monitoring)	Total Services That Permit Smart Devices by State (Referenced in Waivers)
Alabama		3	1				4
Alaska	1						1
Arizona	No Medicaid Waiver						0
Arkansas			1				1
California	1	1					2
Colorado	1		2		1	2	6
Connecticut		2	2				4
Delaware	No Medicaid Waiver						0
D.C.							0
Florida							0
Georgia		1		1	1		3
Hawaii	No Medicaid Waiver						0
Idaho	1		1				2
Illinois			1		1		2
Indiana	1		1				2
Iowa	1		3	3	1		8
Kansas	2		2		2	2	8
Kentucky							0
Louisiana	1	2	2			2	7
Maine		1	1			1	3
Maryland							0
Massachusetts	2	3	1			1	7
Michigan	1	2	2		1		6
Minnesota	2	1	1	2		1	7
Mississippi	1						1
Missouri	1						1
Montana	1		1				2
Nebraska		1	1				2
Nevada	1		2				3
New Hampshire	1		1				2
New Jersey	No Medicaid Waiver						0
New Mexico	No Medicaid Waiver						0
New York		1	1				2
North Carolina		1	1	1			3
North Dakota	No Medicaid Waiver						0
Ohio	2		2				4
Oklahoma	1	1	1	1		1	5
Oregon							0
Pennsylvania	1	1	1		1	1	5
Rhode Island	No Medicaid Waiver						0
South Carolina	1		1			1	3
South Dakota	2		2				4
Tennessee	No Medicaid Waiver						0
Texas	No Medicaid Waiver						0
Utah	3	2	3		3		11
Vermont	No Medicaid Waiver						0
Virginia	1	1	1				3
Washington	2					1	3
West Virginia			1				1
Wisconsin	1	1	1			1	4
Wyoming	No Medicaid Waiver						0
Total Waivers Describing Services That Permit Smart Devices by AT Category	33	25	41	8	11	14

Note: Empty box = no waiver outlining a service that permits smart devices for the AT category.

Results

From January 31, 2020 to May 1, 2026, the majority of states (46 states and D.C.; 92.2%) introduced at least one new 1915(c) waiver or waiver modification, resulting in 247 waivers identified and aggregated for screening. Of the 247 aggregated waivers, 26.7% (n = 66), from 39 states and D.C., were included, focusing on older adults or adult populations with physical disability/frailty that included older adults (Supplementary Table 1). Six states (11.8%) - Alabama, Iowa, Massachusetts, Missouri, Utah, and Washington - implemented 3 waivers for older adults. Thirteen states (25.5%), among them Arkansas, California, Colorado, Connecticut, Illinois, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Nevada, Ohio, and South Dakota, implemented 2 waivers for older adults, while the remaining 20 states and DC implemented only 1 waiver (41.2%). Of the 66 included waivers, 13 (19.7%) from 11 states did not include any provisions related to devices.

The most common AT category permitting smart devices is the Personal Emergency/Emergency System category, with 41 waivers (62.1%) outlining services that can include smart devices (Figure 1). This category is followed by Specialized Equipment (Medical or Non-Medical), which outlined services that can include smart devices in 50.0% of waivers. Next, the AT category referenced services that permit smart devices in 37.9% of waivers; the Other (remote support, remote monitoring, virtual delivery, virtual monitoring, wellness monitoring) category referenced services permitting smart devices in 21.2% of waivers; Medication Reminders referenced services permitting smart devices in 16.7% of waivers; and the Home or Environmental Modifications category referenced services permitting smart devices in 12.1% of waivers (Table 2).

Figure 1.

References in Waivers Describing Services that Permit Smart Devices by AT Category.

Among states with waivers, 3 states – Minnesota, Oklahoma, and Pennsylvania - offered the most comprehensive access to smart devices, spanning 5 out of 6 AT categories (Table 2). No state included recent waiver approvals or modifications addressing smart devices across all 6 AT categories (Table 2). Across states, Utah’s waivers outlined services (n = 11) for which smart devices might be eligible more frequently than any other state, followed by IA (n = 8) and KS (n = 8). Regarding explicit referencing to covering smart devices, less than half of recent waivers (39.4%; n = 26) across 19 states outlined specific smart device considerations. States introducing explicit references for smart devices are primarily clustered across the Rust Belt (MN, IA, WI, IL, IN, OH, PA), New England (ME, NH, MA, CT), the Atlantic South (NC, SC, GA), and where the mountainous western region meets the central prairies (UT, CO, KS, OK) (Figure 2).

Figure 2.

Map of States Explicitly Referencing Smart Devices in 1915(c) Waivers.

The Specialized Equipment AT category was primarily defined by function: covered devices enable waiver program participants to improve performance in ADLs. Notably, the South Dakota HOPE Waiver lists “sensors” as covered equipment “used to increase, maintain, or improve functional capabilities of consumers”. Though limited, some waivers list specific device types as eligible for coverage under this AT category. For instance, the Indiana PathWays for Aging Waiver listed “voice activated smart devices” as reimbursable. Also, the Utah Waiver for Individuals Age 65 or Older outlines eligible “wearable technology such as watches/bracelets or necklaces” equipped with GPS and geo-fenced monitoring to detect wandering. The New York Nursing Home Transition and Diversion Waiver established unique exclusion criteria for monitoring devices, requiring devices to have FDA approval as Class II hospital grade medical devices.

While the AT category frequently overlaps with the Specialized Equipment category, most states outline separate services for both. The Georgia Elderly and Disabled Waiver lists motion activated electronic devices, memory aids (smart pen), motion sensors, and telecare devices exclusively for medication management as eligible AT. The Louisiana CC Waiver lists electronic tablet devices as eligible AT. The Maine Elderly and Adults with Disabilities Waiver outlines remote monitoring technologies, including computers, sensors, video cameras, voice- and motion-activated devices, communication devices, and mobility devices, as eligible components of a 24/7 monitoring service. The Massachusetts Frail Elder Waiver covers “electronic comfort animals” as AT to “support waiver participants who express feelings of loneliness, anxiety, or a desire for companionship”. Through the Oklahoma Advantage Waiver, “smart phones, tablets, audiovisual/virtual assistant technology, [and] sensors” are classified as AT.

Designed to prevent hospitalization, devices covered under the Personal Emergency/ Emergency System AT category include a help button and pair one or more wearable devices with a smartphone application for high-risk patients who live primarily alone. Devices to facilitate falls detection are eligible for coverage in some waiver programs, like those in Massachusetts Frail Elder Waiver and Illinois HCBS Waiver for Persons Who are Elderly. Other programs, like those run under the Iowa HCBS HD and Pennsylvania Community HealthChoices Waivers, outline hardware specifics for a Personal Emergency Response System (PERS), including an in-home medical communications transceiver and a remote, portable activator. The Minnesota CADI Waiver’s 24/7 remote support emergency monitoring program supports live, two-way communication to offer “on-call counseling and problem solving and/or immediate response for assistance at the participant’s home due to a health or personal emergency”.

Environmental modifications, another AT category, require that adaptations be necessary to support independent living; however, some waivers exclude specific devices. For example, the Indiana PathWays for Aging and West Virginia Aged and Disabled Waiver will not cover home security or video monitoring systems. In contrast, the Iowa HD and Minnesota Elderly Waivers offer the most comprehensive set of eligible monitoring devices used as environmental modifications, including monitoring or surveillance systems with camera, GPS trackers, motion detection, and home security systems. Also, the North Carolina CAP/DA Waiver explicitly lists “smart home devices” and “specialized monitoring systems” as potentially eligible.

Some waivers outline unique remote programs that rely on devices, classified here in the AT category “Other”. The Washington COPES Waiver, for instance, offers Adult Day Care programs that deliver support with ADL via smart devices. While the Massachusetts Frail Elder and Colorado (HCBS-CIH and HCBS-EBD) Waivers outline remote monitoring services, the Oklahoma Advantage Waiver specifically permits motion sensing and GPS devices in its remote support program. The South Carolina Community Choices Waiver outlines that its telemonitoring program tracking participant physiological status must use FDA-approved Class II hospital grade medical devices. Notably, the Kansas HCBS for the Frail Elderly Waiver offers a unique remote monitoring program of vital signs using a telemonitoring mattress and real-time audio-visual wellness monitoring with daily personal hygiene and biomarker observations.

Regarding medication management programs, most waivers depict electronic medication dispensing devices with auditory, visual or voice reminders, tracking, and the capacity to provide tailored reminders; however, the Georgia Elderly and Disabled Waiver explicitly lists the broad term “telecare devices” as eligible for delivering reminders. In addition, two Utah waivers describe a “Medication Reminder System (Not Face-to-Face)” that is provided by a third-party entity and can include reminder techniques that use telecommunication devices.

Discussion

In this study, references to heterogenous device types were identified across the 66 included 1915(c) waivers. A review of each waiver found that most (60.6%; n = 40) did not explicitly reference a smart device, offering no categorical inclusion of smart devices under an AT category. Among those waivers that did explicitly mention a smart device, motion sensors, smartwatches, GPS trackers, and smart pens emerged as the referenced smart devices eligible for coverage in different AT categories. While most state waivers included PERS services that do not exclude smart device use, a growing number of states have introduced tailored remote support or monitoring programs beyond emergency response, supporting vitals monitoring, coaching, and ADLs enabled by smart devices. While few waivers referenced devices in the context of home modifications (n = 8), differences in eligible device types covered by environmental modifications might one day exacerbate health disparities in states with restrictive modification lists. This is particularly relevant as some everyday household items, like wireless routers, have emerged as potential unobtrusive smart devices, showing promise with regard to tracking mobility, wandering, and falls.¹⁹ A concrete example of differences in device eligibility introducing barriers to smart devices is the Ohio PASSPORT Waiver PERS provisions, which exclude remote video monitoring capability. As such, devices that receive approval for PERS in Ohio under this waiver may necessarily not include video sensors, while neighboring participants in Pennsylvania face no such device restrictions.

Combined, these trends suggest a gradual transition from using specialized equipment and ATs to transmitting continuous data for real-time, personalized monitoring in community and at-home settings. As the list of smart devices continues to evolve, the potential for developing augmented monitoring programs that use predictive algorithms to identify at-risk participants is high. The development of predictive monitoring tools using smart device data is critical to safely reducing institutionalization rates and making aging-in-place a reality for older adults; however, the innovation lag in policy, which renders waiver nomenclature frequently outdated, may complicate eligibility criteria for artificial intelligence algorithms applied to smart device data in 1915(c) waivers.²⁰ As more devices than ever before integrate multimodal sensors, beneficiaries in states with waivers using narrow device taxonomy may receive different devices than those in states with less prescriptive provisions.^7,21,22 In contrast to waivers that outline service function, categories, and rules, those with device-specific language may suppress the adoption of newer technologies via outdated definitions, thereby rendering safety-net beneficiaries unable to access newer technologies, impacting potential long-term health outcomes for older adults and, more broadly, Medicaid financing. Among the states for researchers to pay close attention to in the coming years are those with explicit smart device references in AT category services, some of which are home to substantive rural and geographically isolated populations: CO, CT, GA, IL, IN, IA, KS, LA, ME, MA, MN, NH, NC, OH, OK, PA, SC, UT, and WI.

Among the limitations of this analysis is the scope, which excluded budget and funding provisions outlined in waivers for devices, and the set of broad terms used for the keyword search. Furthermore, we did not include a comparative analysis of maintenance, customization, and upkeep for devices covered by 1915(c) waivers. In addition, no waivers solely targeted rural participants, limiting possible geographic analyses. Also, the majority of waivers focus on post-diagnostic phases, i.e after prescription or after frailty and reduced mobility emerges, limiting application for early intervention and preventive efforts, which are critical to developing sustainable aging-in-place models.

Conclusion

These findings support the need for deeper understanding of association between state waiver terminology and the smart devices that receive coverage to better evaluate and address state barriers to accessing high-quality, cutting-edge technologies in older adult Medicaid populations.

Funding Statement

Support for this research was provided via the Columbia University Health and Aging Policy Fellowship, awarded to Dr. Zawada, with funding from The John A. Hartford Foundation, The Atlantic Philanthropies, The Ralph C. Wilson, Jr. Foundation, and West Health.

Abbreviations

CMS, Centers for Medicare & Medicaid Services; HCBS, Home and Community-Based Services; QoL, quality-of-life; AT, assistive technology; ADL, activities of daily living; PERS, Personal Emergency Response System; MACPAC, Medicaid and CHIP Payment and Access Commission.

Disclosure

Mrs Emily Mills reports support for the manuscript from Intuition Robotics during the conduct of the study; stock or stock options from Intuition Robotics outside the submitted work. Dr Emma Fortune reports support for the manuscript from Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery during the conduct of the study; grants or contracts from Mayo Clinic, National Heart Lung and Blood Institute; Meeting/travel support from Mayo Clinic; equipment/materials/services from Apple Investigator Support Program outside the submitted work. The author(s) report no other conflicts of interest in this work.