The Affordable Care Act (ACA) significantly expands Home and Community-based Services (HCBS) in the Medicaid program. Four HCBS programs – two brand new – promote and fund policies that help beneficiaries access needed services in the community and facilitate appropriate transitions from nursing homes to integrated settings. (1) Two of the programs, Money Follows the Person (MFP) and the Balancing Incentive Program (BIP), specifically focus on “rebalancing” from an over-emphasis on funding institutional care to promoting coverage of HCBS. The other two, the new Community First Choice (CFC) program and the modified § 1915(i) program, allow states to administer HCBS through their Medicaid state plans instead of relying on temporary waiver programs. (2) All four HCBS programs seek to expand access to HCBS services, empower individuals to choose where and how they live, maintain beneficiary protections and shift states to a more person-centered model of care. The ACA reforms also accommodate state flexibility in program design. And since HCBS are typically cheaper than institutional care, states that successfully rebalance should save money. The four optional HCBS programs have different features that impact state participation, which has varied widely in the post-ACA landscape.