Anticipating HCBS Provisions of the Medicaid Access Rule
While work requirements have captured the Medicaid policy conversation, CMS’ Ensuring Access to Medicaid Services Final Rule (CMS-2442-F) is already moving from policy into implementation, with some provisions taking effect now and others phasing in through 2028 and beyond. Even as Access Rule compliance deadlines begin to arrive, state Medicaid agencies continue to have meaningful choices to make about how requirements are built into programs and systems. Managed care plans and Home- and Community-Based Services (HCBS) providers can add value by understanding the rule and working with their state partners to shape implementation in ways that build on existing strengths and reduce the need for reactive system changes.
The HCBS Quality Measure Set (QMS) is one of the most concrete near-term opportunities within the broader Access Rule for managed care plans and providers to add their voice, with proposed measures outlined for public comment through May 28, 2026. States will ultimately decide how to incorporate the HCBS QMS into their programs, contracts, and reporting, while managed care plans and providers can inform those decisions and ready their own operations. Stakeholders that engage early will be better positioned to shape how measures are prioritized and to align implementation with existing strengths rather than absorbing requirements after they are fully set.
Why the HCBS QMS Matters Now
Until now, HCBS quality measurement has been fragmented across waivers, state plan authorities, and managed care contracts, resulting in a patchwork of measures and reporting expectations. The proposed QMS gives all parties a common language for assessing performance. In addition to prompting stakeholder feedback, the proposed measure set is a benchmark for identifying readiness gaps that will need attention regardless of how the final measure set lands.
CMS proposes up to 23 mandatory measures, with biennial state reporting starting July 9, 2028 and stratified reporting phasing in through 2032. The exact number of required measures will vary based on the HCBS populations served and the experience-of-care surveys states choose to use.
The HCBS QMS is a state reporting obligation, but the operational work requires coordination across the full HCBS ecosystem. As the implementation deadline nears, states will need to work with managed care plans, providers, and other partners to ensure reliable and scalable reporting capacity across programs, populations, and delivery systems. Needs and opportunities will vary at each level of the ecosystem.
State Medicaid Agencies
Every state’s path to HCBS QMS implementation will look different, but all stand to gain from inventorying existing data, strengthening cross-program governance, and engaging partners across programs, agencies, systems, and vendors.
Many states already field participant experience surveys, collect case management data, and work with external quality review organization (EQRO) partners on managed long-term services and supports (MLTSS) quality. The greater challenge will be producing a coherent state-level view of HCBS quality at the level expected by CMS; this effort will require governance arrangements many states do not yet have in place. Three practical questions can help steer early planning:
- What HCBS data already exist across programs and populations?
Mapping the state’s HCBS landscape – populations served, Medicaid authorities involved (1915(c) waivers, HCBS-related 1115 demonstrations, and state plan options such as 1915(i), (j), and (k)) – and the data captured for each program highlights where the state is close to QMS-ready and where it needs to augment data infrastructure. - Who needs to be at the table?
HCBS data and program responsibility are often fragmented across multiple teams, including agencies overseeing aging and disability, intellectual and developmental disabilities, and behavioral health. Bringing them together requires clear ownership, governance, and a commitment to harmonizing measures across populations and delivery systems. Doing so prospectively enables states to address conflicting metrics, duplicative reporting, and gaps in what leaders need to manage HCBS. - How can managed care plans, EQROs, analytics vendors, and survey vendors support implementation?
Clarifying contracted partner roles early helps states tap existing capacity, avoid duplicative work, and align QMS implementation with existing quality infrastructure. It also creates an opening to gauge which current contractors can meet new requirements and where states should build additional internal or external capacity.
Medicaid Managed Care Plans
For Medicaid managed care plans with LTSS and HCBS lines of business, the HCBS QMS is a strategic consideration. The measures will rely heavily on plan data, provider networks, and care management practices. State managed care quality strategies are likely to align more explicitly with HCBS QMS domains, and HCBS-related performance will feature prominently in procurements, contracts, performance guarantees, and quality withholds.
Managed care plans should consider:
- How much of the portfolio is affected by HCBS QMS-related changes?
Determine, by state, which products include HCBS, how many enrollees receive HCBS, and the main provider types involved; multi-state plans can use variation in HCBS program structures as a business advantage by acting early to understand their portfolio across states, identify state-specific priorities, and bring concrete, cross-state lessons to states as they shape HCBS QMS solutions. - Are core HCBS data assets QMS-ready?
Review whether assessment and care plan dates and key fields are consistently recorded for HCBS enrollees in centralized, queryable systems; whether encounters for core HCBS services can be reliably identified and distinguished from institutional care; and what information already exists on enrollee experience with HCBS, including participant experience surveys, complaints, and appeals. - How can managed care plans be constructive partners to states?
Plans add the most value when they help translate state policy into operationally realistic approaches, anticipating implementation challenges and proposing solutions that align with state goals. Practical contributions include participating actively in state workgroups and feedback processes; sharing concrete information on what HCBS data plans can provide today versus what would require new development; suggesting realistic implementation timelines; and updating provider contracts and incentives in dialogue with states so expectations stay consistent across the system
Providers
Provider-level effects of the HCBS QMS will vary by market. For most providers, the care model itself may not need to change, but documentation will need to better align with how states track quality. Where states pair new reporting expectations with realistic timelines, technical assistance, and supportive rate strategies, providers can use the HCBS measures to demonstrate value and improve outcomes. In states that do not, thinly capitalized HCBS providers may be asked to do more with less. In either case, providers already invested in strong assessments, person-centered planning, care transitions, and community-based service delivery are well-positioned to use the measures as a platform for demonstrating performance, strengthening relationships with states and managed care plans, and improving their standing in contracting and network decisions
Providers should consider:
- How do current practices map to the HCBS QMS?
Leadership teams can inventory how the organization documents functional assessments, reassessments, person-centered goals, service delivery, and setting type to see where current practices already align with likely QMS expectations and where documentation is inconsistent or incomplete. As suggested for states and managed care plans, this approach focuses on leveraging existing strengths while tightening gaps in how quality will be assessed. - Where can documentation of existing work be strengthened?
Focused improvements include timely entry of assessment and service plan dates; clear recording of goals and preferences; consistent coding of HCBS settings; and documentation of follow-up after hospitalizations or major status changes. Many providers already track quality indicators but may not frame them in QMS terms. Selecting a small set of HCBS-relevant metrics, reviewing them regularly in leadership forums, and reinforcing documentation through training and supervision will align existing practice with the new measures. - How can providers coordinate with managed care plans in MLTSS markets?
Plans will be expected to show HCBS quality performance to states, and providers that collaborate with plan partners on QMS preparation will be well positioned to establish efficient reporting and participate in value-based or incentive arrangements linked to HCBS outcomes. The same coordination that supports state reporting also helps providers demonstrate reliability and value to their payer partners.
What’s Next: More Insights on the Access Rule
The HCBS QMS is one provision in a larger rule with a multi-year implementation arc amid a crowded Medicaid implementation agenda. Each provision carries its own implementation calendar, data demands, and implications for how states, managed care plans, and providers will need to work together.
In the coming weeks, ATI will share additional insights on other Access Rule provisions that warrant attention, including electronic incident management requirements and HCBS rate reporting requirements.
ATI Advisory works with state Medicaid agencies, managed care plans, and HCBS providers to translate the federal regulatory slate into actionable implementation plans, assess data and operational readiness, and support the design and steering of the cross‑stakeholder coordination needed for successful implementation.
Contact us to talk through what Access Rule provisions like the HCBS QMS mean for your organization, including comment review and data support ahead of the May 28 deadline.