Compliance deadlines tied to CMS’ Ensuring Access to Medicaid Services Final Rule (Access Rule) home and community-based services (HCBS) provisions will start to arrive in 2027, with additional milestones in 2028 through 2030. In a recent webinar, ATI experts Bill Hanna and Cleo Kordomenos were joined by Camille Dobson, deputy executive director at ADvancing States, to discuss next steps for impacted healthcare stakeholders. According to Dobson, “the time is past due for work to start.”
Six HCBS Provisions Anchor the Access Rule’s Compliance Timeline
The Access Rule, finalized in 2024, updates Medicaid access, accountability, and quality standards across both fee-for-service and managed care delivery systems. Six provisions focus specifically on HCBS:
- Standardized national quality measure set
- Critical incident management requirements
- Person-centered planning documentation
- Public wait list and access reporting
- A fee-for-service grievance system
- Payment transparency and adequacy reporting
Timelines and applicability vary depending on whether a state delivers HCBS via fee-for-service or managed care. CMS has already delayed enforcement of some provisions, including the fee-for-service grievance system and elements of payment transparency, to December 2027 and January 2029, respectively.
Standardizing HCBS Quality Measurement Remains a Challenge
The new quality measure set represents an attempt to bring a shared, national definition to something that has historically varied widely by state and program, but two structural challenges complicate implementation. First, HCBS programs are often organized by population, meaning Medicaid, aging, and disability agencies frequently maintain separate systems with different data definitions, even when the same individuals move across programs. Second, quality measurement in HCBS is centered on a person’s individual needs and goals rather than a fixed clinical outcome. Dobson explained that variability makes it challenging to characterize HCBS quality with consistent, comparable metrics used elsewhere in Medicaid. Producing measures that capture individual experience without sacrificing cross-program comparability remains one of the central design challenges ahead.
Plans and Providers Generate the Data Reported by States
While states carry the formal Access Rule compliance obligation, they do not generate the underlying data themselves. As Hanna explained, “the data that the state has to report comes from the care that providers provide.” Person-centered service plans, incident documentation, and payment records all originate at the point of care delivery, not within the state agency itself. This positions plans and providers as active partners for states in establishing compliance. Plans and providers that analyze their own data and bring operational experience to state conversations will be better equipped to shape how states design their reporting methodologies.
HCBS Spending Growth Could Intensify Federal and State Scrutiny
Hanna noted that states are under pressure to execute HCBS measurement well, sharing that “Medicaid has never been under such scrutiny. As HCBS spending increases, this scrutiny isn’t going to go away; in fact, it may get more attention because the costs in HCBS are significantly higher than the costs in [the] expansion population.” As HCBS serves a growing population of older adults and people with complex needs, states, plans, and providers have a growing imperative to invest early in data infrastructure, cross-agency coordination, and provider-plan collaboration.
A Narrowing Implementation Window for States, Plans, and Providers
With 2027 and 2028 deadlines approaching, states, plans, and providers have a window to shape how implementation unfolds before requirements are finalized. Plans and providers that engage states as informed partners early can help develop workable solutions rather than adapt to ones designed without their input.