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On July 21, 2022, the Centers for Medicare & Medicaid Services (“CMS”) released its first-ever nationally standardized Home- and Community-Based Services (“HCBS”) quality measure set to encourage consistent quality measurement within state Medicaid HCBS programs.1 The HCBS quality measure set is provided in a State Medicaid Director Letter (“SMDL”) that describes the purpose of the measure set, the measure selection criteria, and considerations for implementation.2 The goal of the measure set is to provide insight into HCBS program quality and provide states with a framework to measure and improve health outcomes for people receiving long-term services and support (“LTSS”) using Medicaid.
The measure set is currently voluntary for states to use, but CMS indicates in the SMDL that it plans to incorporate use of the measure set into the reporting requirements for specific authorities and programs, such as the Money Follows the Person (“MFP”) program and future section 1115 demonstrations that include HCBS. CMS is encouraging states to use measure set corresponding information within the SMDL to assess and develop quality and outcomes in their HCBS programs. CMS has expressed an intent to update the measure set in the future by adding new measures that address potential measure gaps.
Measures Included in the HCBS Quality Measure Set
CMS has organized the measures by section 1915(c)33 waiver assurances and subassurances. The SMDL notes that section 1915(c) waivers are most commonly used by states and account for about half of HCBS spending nationally, therefore CMS focused on aligning the measure set with section 1915(c) reporting requirements. This organization method is intended to support states with using the measure set in their HCBS programs
The measure set currently includes measures that address the Service Plan section 1915(c) waiver subassurances, and some of the Health and Welfare section 1915(c) waiver subassurances. It is important to note that the measure set, by itself, cannot be used to completely meet and evaluate all section 1915(c) waiver subassurances, because all of the subassurances were not included. In addition to the 1915(c) waiver subassurances, the measure set includes measures to address HCBS quality and outcomes in regard to:
- access, which is defined for the purposes of the measure set as the level to which the beneficiary/family caregiver/natural support is aware of and able to access resources (e.g., peer support, respite, crisis support, information, and referral) that support overall well-being;
- Rebalancing, which is commonly defined as achieving a more equitable balance between the share of spending and use of services and supports delivered in home- and community-based settings relative to institutional care;
- community integration, which is focused on ensuring the self-determination, independence, empowerment, and full inclusion of children and adults with disabilities and older adults in all parts of society; and
- HCBS settings requirements, as defined in the HCBS Settings final rule, which establishes requirements for the qualities of settings in which Medicaid HCBS are provided under sections 1915I, 1915(i), and 1915(k) of the Social Security Act.
Though some of the measures included in the measure set are applicable for only certain delivery system types (e.g., managed care measures for states with only fee-for service programs), CMS advises states to use the measure set, to the extent applicable, regardless of delivery system type. If using the measure set, CMS encourages states to assess their performance at least twice a year, set performance goals, and develop a quality improvement plan to meet their goals. A second planned guidance document will be issued to describe how states can use the measure set as part of their HCBS quality measurement, reporting, and improvement activities, including to meet federal requirements for their HCBS programs (such as required reporting for section 1915(c) waiver assurances and subassurances).3
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 CMS announcement available at https://www.cms.gov/newsroom/press-releases/cms-releases-first-ever-home-and-community-based-services-quality-measure-set (last Aug. 5, 2022).
 SMD# 22-003 available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd22003.pdf (last accessed Aug. 5, 2022).
 See https://www.medicaid.gov/sites/default/files/2019-12/3-cmcs-quality-memo-narrative_0.pdf for more information on required reporting for section 1915(c) waiver assurances and subassurances.