Developing home and community-based service (HCBS) alternatives to institutional care has been a priority for many state Medicaid programs over the last two decades and the focus of Medicaid policy debates recently. While the majority of Medicaid long-term care dollars go toward institutional care, the national percentage of Medicaid spending on HCBS has more than doubled from 1992 to 2003. This report presents a summary of the main trends to emerge from the data for the three Medicaid HCBS programs, and findings from the survey of policies used on 1915(c) waivers in 2005.