Medicaid Home and Community-Based Services Settings Rules

Medicaid’s Home and Community-Based Services (HCBS) program provides critical community services to people with disabilities and seniors.  HCBS was created as an alternative to living in an institution.  But until recently, there were no standards for community-based settings funded under HCBS programs.  As a result, many HCBS settings have characteristics of institutions, like a lack of choice, privacy, access to the broader community, and opportunities to interact with people without disabilities.

In January 2014, the Centers for Medicare & Medicaid Services (CMS) released final rules that for the first time establish standards for HCBS settings. These rules require HCBS settings to provide opportunities for participants to engage in community life, have access to the community, control their personal resources, and seek employment in competitive settings. The purpose of these rules is to ensure that individuals receiving services through HCBS programs have full access to the benefits of community living and to help states comply with their obligations under the Americans with Disabilities Act (ADA) as affirmed by the Supreme Court’s Olmstead decision.

The HCBS Settings Rules hold the potential to transform systems to support real inclusion and integration — people living in their own homes and working in community jobs with fair pay — and to move away from models that congregate people together in residential and day programs where they have little autonomy, choice, and interaction with the broader community.

Significant aspects of the rule require that all HCBS settings:

  • Provide people with disabilities access to the broader community
  • Facilitate relationships with people without disabilities (other than paid providers and staff)
  • Provide people with disabilities control over daily life decisions like what to eat, when to go to sleep, and who can visit
  • Give people with disabilities opportunities for competitive integrated employment, and
  • Ensure people with disabilities can choose what services they receive and who provides them.

The Rule gave states until March 2019 to come into compliance.  In May 2017, CMS extended the timeline for implementation by three years, to March 2022. States must develop a transition plan describing how they will come into compliance, seek public input on the plan, and submit it to CMS for approval. It is critical that stakeholders and consumers in each state become involved in their state’s transition process, particularly when states seek public input on proposed plans.  States are in the process of developing their transition plans now.

CPR is leading a coalition of national disability organizations working to ensure that implementation of the HCBS settings rules achieve systems change so that people with disabilities can live, work, receive services, and fully engage in community life.  The HCBS Advocacy Coalition educates and provides advocacy tools to disability advocates nationally, tracks states’ transition plans and implementation, and advocates for strong implementation of the rules with federal agencies.  The HCBS Advocacy Coalition’s website includes resources about the rules, as well as a map to track individual state activities.

The HCBS Advocacy Coalition has developed a three part tool-kit to educate stakeholders about the HCBS Settings Rule:

The Medicaid Home and Community-Based Services Rule:  What You Should Know!
Home and Community Based Services Rules Q&A: Settings Presumed to be Institutional & the Heightened Scrutiny Process
HCBS Setting Rules: How to Advocate for Truly Integrated Community Settings

For a recent update on implementation of the Rule, see this fact sheet that CPR created for the National Association of Councils on Developmental Disabilities.