State Associations Offer Recommendations to CMS on Implementation of HCBS Rule

The National Association of State Directors of Developmental Disabilities Services (NASDDDS), the National Association of Medicaid Directors (NAMD), and the National Association of States United for Aging and Disabilities (NASUAD) have joined together to send a letter to the Centers for Medicare and Medicaid Services (CMS) thanking the agency for its efforts to develop the new home and community-based services (HCBS) regulation and raising “concerns pertaining to CMS’ expectations for state implementation plans and ongoing compliance activities.” Calling the new regulation “a watershed in the 30+ years of experience with the Medicaid HCBS waiver program,” the letter recognizes “the tremendous, multi-year effort it took to advance this community-based focus.” The letter goes on to describe “critical challenges” in implementation the three organizations have identified and offers recommendations to address them.

The letter recommends “two overarching steps that” the three signatory organizations “believe would facilitate a more efficient transition process for states, and ultimately to ensure Medicaid clients can fully integrate into their communities.” These steps are:

  • consistent coordination with several entities within the Department of Health and Human Services (HHS); and
  • ongoing collaboration with state agencies responsible for overseeing and administering home and community-based systems.

The letter goes on to offer more detailed explanations and recommendations.

One recommendation emphasizes the need to “develop a systemic approach to implementation in order to assure that the rule results in the intended outcome.” To this end, the letter suggests that “as a first step, CMS should allow states to describe the changes they plan to make to the administrative components of their systems and then measure the adherence to their own settings rules,” which could be followed where necessary by an assessment of individual settings could follow. Focusing on this “step-wise approach of broader systemic assessment and change,” the letter suggests, “will allow states to set clear standards and expectations across systems, rather than engaging settings on an individual basis.”

The letter also calls on HHS to establish a workgroup consisting of “representatives of state agencies, including Medicaid and operating agencies, and HHS staff from the key agencies” that would “focus on developing guidance, ensuring coordination and strengthening the partnership across the federal agencies and with states.” The purpose of the group would be to help develop specific implementation materials and tools, such as guidance on conducting a systemic review of the state system, examples of service definitions for settings, and review criteria and performance measures to be used by CMS to determine state compliance, to help convert the expression of desired outcomes for community services found in the rule into actionable “examples of allowable activities, acceptable physical characteristics, required certifications [and] benchmark[s] for expected outcomes that are reflective of the diverse populations served through HCBS programs.”

FMI: The letter is available at