HCBS Requirements in the CMS Access Rule: What’s Next for Implementation?

On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) released three final rules, including the Ensuring Access to Medicaid Services final rule (Access Rule). The Access Rule aims to improve health outcomes for Medicaid beneficiaries, including those who receive home and community-based services (HCBS), by setting requirements for increased transparency, data monitoring, and beneficiary engagement. CMS also posted an Access Rule fact sheet and an effective dates chart. (The two other final rules are the Managed Care Access, Finance, and Quality final rule (Managed Care Rule), and Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting final rule.)This post continues our Aurrera Health blog series on the Access and Managed Care Final Rules. It focuses on the provisions specific to HCBS to help states and partners digest the new requirements and consider their next steps.

What Are the New HCBS Access Requirements?

The Access Rule aims to comprehensively enhance access to and increase quality of HCBS. It puts forth requirements intended to address the direct care workforce, enhance oversight of beneficiary health and safety, and increase transparency of state HCBS implementation strategies. Key provisions include:

• person-centered planning, which requires states to reassess functional needs of HCBS waiver enrollees every 12 months and ensure the person-centered service plan is reviewed and revised.

• a grievance process, which requires states to establish a fee-for-service (FFS) grievance system for beneficiaries to raise concerns regarding Access Rule person-centered planning requirements and the 2014 HCBS Settings Rule. 

• an incident management system, which requires states to operate and maintain an electronic system that identifies, reports, triages, investigates, resolves, tracks, and trends critical incidents. 

• payment adequacy, which requires states to ensure at least 80% of all Medicaid payments for a subset of HCBS are spent on compensation for direct care workers. 

• payment transparency, which requires states to publish FFS payment rates and establish an interested parties advisory group that consults on direct care worker rates.

• waiting lists, which require states to report the total number of individuals on HCBS waiver waiting lists, and averages for how long individuals are wait-listed and how long it takes for individuals to begin receiving services after being removed from waiting lists.

• quality measures, which require states to meet a new set of standardized HCBS quality measures, including establishing performance targets for each measure and describing quality improvement strategies.

By strengthening data collection, the new regulations make it easier to monitor certain aspects of beneficiaries’ HCBS access. For example, waiting list requirements will provide HCBS enrollment and service usage data, and transparency requirements will provide HCBS payment rates and provider network data across all states, particularly as they pertain to direct care workers. Strengthened and ongoing data collection provides the foundation for informed decision-making, targeted interventions, and quality improvement initiatives.

What Are Implementation Considerations? 

Implementing the Access Rule will be complex. States may face numerous challenges due to overlapping implementation timelines across provisions and requisite engagement across state departments; additionally, because there aren’t federal funds to assist with implementation, capacity may be a significant constraint, as states must allocate already limited resources (e.g., personnel and funding) to effectively carry out the requirements within tight timelines. To comply with waiting list reporting requirements, states will have to track service authorization information and service start times, and this will necessitate resources to develop or modify existing documentation management systems. This system alignment will require extensive coordination and collaboration because states may house service authorization and claim information in two separate systems, and different areas of government may oversee these two systems.States must also be strategic and thoughtful when it comes to stakeholder engagement. They must ensure meaningful communication with direct service workers serving on the interested parties advisory group, as their participation is crucial to meeting the payment adequacy provisions. State Medicaid agencies will also need to invest time in cultivating partnerships to fulfill the electronic incident management system functional data sharing provision; consensus must be reached on the scope, utilization, and privacy concerns related to the data.

What are Promising Practices for Implementation?

In our first blog post, we noted that past efforts may serve as models for states that are newly approaching the issues included in the Access Rule. In particular, we highlighted state efforts to support HCBS direct care worker compensation.

• In certain states, many FFS schedules are already accessible. Washington State posts FFS fee schedules as well as billing guides for most services, including habilitative and home health services, on a public web page.

• Some states publicly share their 1915(c) HCBS waiver waiting lists:

• Iowa publishes a HCBS waiting list summary on a monthly basis.

• Minnesota publishes a dashboard that identifies the number of individuals waiting by service and age group on a quarterly basis.

• Colorado publishes an updated strategic plan each year with a variety of access indicators including the number of individuals on the waiting list that need services immediately. Colorado has a dedicated HCBS enrollment and waiting list web page that details this information, as well as policies and procedures pertinent to HCBS waiver enrollment, including a user-friendly FAQ. 

Aurrera Health Blog Series on Access and Managed Care Final Rules 

Implementing the final rules will require significant resource investment for states. Aurrera Health will continue this blog series to synthesize major provisions of the Access and Managed Care final rules, look at state experiences to identify lessons, and provide insights that can inform implementation plans. We look forward to helping states and other stakeholders understand and implement requirements to support Medicaid beneficiary access. If you would like to discuss how we can help your state, please reach out to Aurrera Health Managing Principals Megan Thomas or Kristal Vardaman.

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Author

Karina Virrueta Running [Deputy Director]