State-designed HCBS encompass case management, adult day care, home health aide assistance, personal care, assisted living services and respite care. Section 1915(c) of the Social Security Act permits the Department of Health and Human Services Secretary to approve Medicaid waivers that allow for long-term services and supports to be delivered in the community instead of institutional settings. The Deficit Reduction Act also created a capped HCBS option that allows states to offer these services without having to obtain administrative waiver approval. (See Program of All-Inclusive Care for the Elderly.) Provisions in the Affordable Care Act (ACA) give states incentives to expand their HCBS programs to balance spending between institutional care and HCBS.