The HCBS Settings Rule: Looking Back and Forging Ahead

Executive Summary

This report from the National Health Law Program and the Community Living Policy Center provides recommendations for the continued implementation of the 2014 Medicaid Home and Community-Based Services (HCBS) Settings Rule after the very lengthy transition phase to implement the new requirements formally ended in 2023. It is based on interviews with stakeholders representing state and national disability organizations and advocacy groups as well as published sources. The HCBS Settings Rule seeks to ensure that Medicaid HCBS are provided in settings that promote autonomy, community integration, and individual choice in a safe and respectful environment.

Our recommendations center on five key components to successful implementation:

  • effective person-centered planning;
  • transparent and multifaceted stakeholder engagement;
  • simplified and responsive individual complaint/grievance systems;
  • strategic site visits for ongoing monitoring; and
  • clearly defined oversight and enforcement roles for CMS and states on the HCBS settings requirements.

In January 2014, the Centers for Medicare & Medicaid Services (CMS) finalized a landmark regulation for people with disabilities, known as the Home and Community-Based Services (HCBS) Settings Rule. For the first time, the agency established standards to define the characteristics that qualify a setting as “community-based” for the purposes of Medicaid services. HCBS include a range of services, but especially center around supports for completing activities of daily living, like eating, bathing, and moving about, along with other services needed to live in the community, like help with household chores, managing money, or supported employment. The rule aimed to distinguish clearly between funding streams for HCBS and those for institutional long-term services and supports (LTSS). The publication of the final rule marked the end-product after nearly a decade of stakeholder engagement, with multiple rounds of public comment on various proposed approaches.

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