Medicaid is the single largest payer for long-term senior care in the United States, covering nursing home costs for millions of seniors. But Medicaid coverage varies dramatically by state — from comprehensive home and community-based services (HCBS) with minimal waitlists to bare-bones nursing home coverage with restrictive eligibility.
Our Medicaid pillar evaluates four factors: income eligibility limits (30%), HCBS waiver scope (30%), assisted living coverage (25%), and Medicaid expansion status (15%). States at the top offer more pathways for seniors to receive care in their preferred setting.
Medicaid is one of five pillars in our Elder Care Index. See how states rank on affordability, quality, staffing, access, or view the overall rankings.
Eight states score 85 on Medicaid support: D.C., Minnesota, Arizona, California, New York, Maine, Vermont, and Colorado. What they share: Medicaid expansion, assisted living coverage through HCBS waivers, and comprehensive home and community-based service programs. These states offer the most pathways for seniors to receive care in their preferred setting — not just nursing homes, but home care, adult day programs, and community services.
Wyoming scores 15 — the lowest by far. It's one of only 8 states that haven't expanded Medicaid, the only state that effectively doesn't cover assisted living through Medicaid, and its HCBS waiver program is minimal. With just 36 nursing homes statewide, families who can't afford private-pay care face stark choices. The next-lowest state (Mississippi at 40) at least covers assisted living and has more HCBS options.
Seven of the bottom 10 states on Medicaid support haven't expanded Medicaid: Wyoming, Mississippi, Florida, Tennessee, South Carolina, South Dakota, and Kansas. Expansion primarily covers adults under 65, but it correlates with broader Medicaid infrastructure investment. States that haven't expanded tend to have thinner safety nets across the board, affecting seniors through provider availability and program scope even beyond direct coverage rules. See affordability rankings for how costs compare in these states.
| # | State | Grade | Score | Expanded | Covers AL | HCBS Scope |
|---|---|---|---|---|---|---|
| 1 | District of Columbia | A | 85 | Yes | Yes | Comprehensive |
| 2 | Minnesota | A | 85 | Yes | Yes | Comprehensive |
| 3 | Arizona | B | 85 | Yes | Yes | Comprehensive |
| 4 | California | B | 85 | Yes | Yes | Comprehensive |
| 5 | New York | B | 85 | Yes | Yes | Comprehensive |
| 6 | Maine | C | 85 | Yes | Yes | Comprehensive |
| 7 | Vermont | C | 85 | Yes | Yes | Comprehensive |
| 8 | Colorado | C | 85 | Yes | Yes | Comprehensive |
| 9 | New Mexico | C | 85 | Yes | Yes | Comprehensive |
| 10 | Washington | D | 85 | Yes | Yes | Comprehensive |
| 11 | Rhode Island | D | 85 | Yes | Yes | Comprehensive |
| 12 | Oregon | D | 85 | Yes | Yes | Comprehensive |
| 13 | Massachusetts | D | 85 | Yes | Yes | Comprehensive |
| 14 | Alaska | F | 85 | Yes | Yes | Comprehensive |
| 15 | Connecticut | F | 85 | Yes | Yes | Comprehensive |
| 16 | North Dakota | A | 70 | Yes | Yes | Limited |
| 17 | Kansas | A | 70 | No | Yes | Comprehensive |
| 18 | Nebraska | A | 70 | Yes | Yes | Limited |
| 19 | Missouri | A | 70 | Yes | Yes | Limited |
| 20 | Arkansas | A | 70 | Yes | Yes | Limited |
| 21 | Iowa | A | 70 | Yes | Yes | Limited |
| 22 | Kentucky | A | 70 | Yes | Yes | Limited |
| 23 | Oklahoma | B | 70 | Yes | Yes | Limited |
| 24 | Utah | B | 70 | Yes | Yes | Limited |
| 25 | Louisiana | B | 70 | Yes | Yes | Limited |
| 26 | Wisconsin | B | 70 | No | Yes | Comprehensive |
| 27 | Indiana | B | 70 | Yes | Yes | Limited |
| 28 | Alabama | B | 70 | Yes | Yes | Limited |
| 29 | Ohio | B | 70 | Yes | Yes | Limited |
| 30 | Montana | B | 70 | Yes | Yes | Limited |
| 31 | North Carolina | C | 70 | Yes | Yes | Limited |
| 32 | Illinois | C | 70 | Yes | Yes | Limited |
| 33 | Nevada | C | 70 | Yes | Yes | Limited |
| 34 | Pennsylvania | C | 70 | Yes | Yes | Limited |
| 35 | Idaho | C | 70 | Yes | Yes | Limited |
| 36 | Michigan | D | 70 | Yes | Yes | Limited |
| 37 | Georgia | D | 70 | Yes | Yes | Limited |
| 38 | Virginia | D | 70 | Yes | Yes | Limited |
| 39 | West Virginia | D | 70 | Yes | Yes | Limited |
| 40 | Hawaii | F | 70 | Yes | Yes | Limited |
| 41 | Delaware | F | 70 | Yes | Yes | Limited |
| 42 | Maryland | F | 70 | Yes | Yes | Limited |
| 43 | New Hampshire | F | 70 | Yes | Yes | Limited |
| 44 | New Jersey | F | 70 | Yes | Yes | Limited |
| 45 | South Dakota | A | 55 | No | Yes | Limited |
| 46 | Texas | C | 55 | No | Yes | Limited |
| 47 | South Carolina | D | 55 | No | Yes | Limited |
| 48 | Tennessee | F | 55 | No | Yes | Limited |
| 49 | Florida | F | 55 | No | Yes | Limited |
| 50 | Mississippi | D | 40 | No | Yes | Minimal |
| 51 | Wyoming | F | 15 | No | No | Minimal |
How we calculate these scores → Our Methodology
Most states offer some Medicaid coverage for assisted living through HCBS waivers, but it typically covers only the care services — not room and board. Coverage levels, waitlists, and eligibility rules vary dramatically by state. Wyoming is the only state with virtually no Medicaid assisted living coverage.
States with comprehensive HCBS waivers — like Oregon, Washington, Minnesota, California, and New York — offer the broadest coverage. These states provide robust alternatives to nursing home placement, including home care, adult day services, and community-based programs.
Medicaid expansion primarily covers adults under 65, but it indirectly benefits seniors by strengthening the overall Medicaid infrastructure and provider networks. States that haven't expanded (like Texas, Florida, and Mississippi) tend to have thinner safety nets overall.