CMS Releases HCBS Transition Plan Guidance

On Friday the Centers for Medicare and Medicaid Services (CMS) released the latest iteration of the Center for Medicaid and CHIP Services (CMCS) Home and Community Based Services Toolkit, which is designed to assist states in preparing to submit their Statewide Transition Plans in conjunction with the new Medicaid regulations for residential and non-residential home and community-based settings. 

The Statewide Transition Plan is the vehicle through which states assess their current compliance with the new regulation, and describe to CMS how they will comply with the new requirements. The guidance makes explicit that the Statewide Transition Plan must include “the state’s assessment of the extent to which its regulations, standards, policies, licensing requirements, and other provider requirements ensure settings that comport with the requirements” in the recent regulation.  CMS indicates that “the state may also assess individual settings/types of settings to further document their compliance.” The guidance indicates that “in situations where the state standards do not coincide with the Federal standards, it is possible that specific settings are still in compliance with the Federal requirements.” In such a case, CMS says, “a state may choose to assess individual sites to determine which are/are not in compliance with the Federal standard,” and suggests that “such an assessment may impact the time frames proposed to bring settings into compliance.” The Plan must also include a “description of the state’s oversight process to ensure continuous compliance.”

States that conduct specific site evaluations may do so through “a variety of standard processes” including “licensing reviews, provider qualification reviews, and support coordination visit reports.” States may engage individuals receiving services and representatives of consumer advocacy entities in the assessment process. States may also administer surveys to providers to determine whether the settings in which those providers operate meet the home and community-based settings requirements. In this instance, providers could “self-assess” their compliance with the Federal requirements or provide information required by the state to make a determination of compliance. When states do not have full knowledge of the settings in their system, CMS strongly encourages, at a minimum, a sampling approach to on-site reviews. In addition, CMS says, “where the state is submitting evidence that a setting presumed not to be home and community-based is in fact home and community-based and does not have the qualities of an institution, evidence of a site visit will facilitate the heightened scrutiny process.”

The guidance provides specifics regarding what CMS expects to see in a Statewide Transition Plan, including:

Assessment: A detailed description of the state’s assessment of compliance with the home and community-based settings requirements and a statement of the outcome of that assessment. If the process of assessment is not yet complete and has required, or will require, greater than six months for review, the state must submit justification for the additional time frame. The assessment must include the state’s best estimate of the number of settings that: 1) fully align with the Federal requirements; 2) do not comply with the Federal requirements and will require modifications; 3) cannot meet the Federal requirements and require removal from the program and/or the relocation of individuals; 4) are presumptively non-home and community-based but for which the state will provide justification/evidence to show that those settings do not have the characteristics of an institution and do have the qualities of home and community-based settings;

Remediation: A detailed description of the remedial actions the state will use to assure full compliance with the home and community-based settings requirements, including timelines, milestones and monitoring process. When relocation of beneficiaries is part of the state’s remedial strategy, the Statewide Transition Plan should include:

  • An assurance that the state will provide reasonable notice to beneficiaries and due process to these individuals;
  • A description of the timeline for the relocation process;
  • The number of beneficiaries impacted; and
  • A description of the state’s process to assure that beneficiaries, through the person-centered planning process, are given the opportunity, the information, and the supports to make an informed choice of an alternate setting that aligns, or will align, with the regulation, and that critical services/supports are in place in advance of the individual’s transition.

Time frame and milestones: The time frame and milestones for state actions, including assessment and remedial actions, must be included. If the state intends to conduct an assessment after adopting new standards, the state should “provide information on how, in the interim, the state will communicate the need for change, educate providers, inform individuals and families, and establish a time frame for the activities. The state must also include a complete timetable for coming into full compliance.”

Public Input Process: A description of the public input process, with a summary of public comments, including “the full array of comments whether in agreement or not with the state’s determination of the system-wide compliance and/or compliance of specific settings/types of settings; a summary of modifications to the Statewide Transition Plan made in response to public comment; and in cases where the state’s determination differs from public comment, the additional evidence and rationale the state used to confirm the determination.” The Transition Plan must also include the URL where the Statewide Transition Plan is posted.

CMS also further delineates the requirements for public input into the Statewide Transition Plan. Prior to filing with CMS, a state must provide no less than a 30-day period for that input; CMS “encourages states to seek input from a wide range of stakeholders representing consumers, providers, advocates, families, and other related stakeholders.” The process for individuals to submit public comment should be “convenient and accessible for all stakeholders, particularly individuals receiving services.” CMS requires states to post the Statewide Transition Plans on their website in an easily accessible manner and include a website address for comments. At least one additional option for public input, such as public forums, is required. CMS reiterates that the Statewide Transition Plan requirements “set forth that states must provide evidence of two statements of public notice and requests for public input, the timeframe for public input (which verifies that a minimum of 30-days was afforded for public review and comment), and a description of the public input process.” The state must also provide an assurance that the Statewide Transition Plan, with any modifications made as a result of public input, is posted for public information no later than the date of submission to CMS, and that all public comments on the Statewide Transition Plan are retained and available for CMS review for the duration of the transition period or approved waiver. CMS emphasizes that “states can use summary documents or offer explanations of contents of the Statewide Transition Plan, in addition to the document itself,” but “must ensure the full Statewide Transition Plan is available to the public for comment.” Further, CMS underlines that substantive changes in an approved StatewideTransition Plan will require public comment.

FMI: The new toolkit is available at