The Patient Protection and Affordable Care Act of 2010 (ACA) enacted the most significant opportunities for optional state expansion of Medicaid-financed home- and community-based services (HCBS) since 1981, when Congress enacted the section 1915(c) waiver program. Three of the ACA provisions, the Balancing Incentive Program (BIP), the Community First Choice (CFC) state plan option, and the health home state plan option, offer states enhanced federal Medicaid matching funds as long as they meet federal requirements. The ACA also expanded two HCBS programs established under the Deficit Reduction Act of 2005 (DRA) by extending the Money Follows the Person (MFP) Rebalancing program through 2016 and expanding the scope of services and eligibility under the section 1915(i) HCBS state plan option. Although state interest in implementing these programs has been fairly robust, some states have been concerned about their ability to contribute their share of matching funds and pressures on limited state staff to implement the programs. This background paper reviews the HCBS programs under the ACA, factors affecting state uptake, and future considerations for policymakers.