Home and Community-Based Settings Regulation – Heightened Scrutiny Guidance

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

On March 22, 2019, CMS issued a set of guidance responses associated with the January 2014 home and community-based settings final rule in the form of an 11-page FAQ document. The cover letter is addressed to State Medicaid Directors.  Here are 3 key points excerpted from that letter:

  • The FAQs discuss settings identified by the regulation as being presumed to have the qualities of an institution, unless CMS determines through a heightened scrutiny review that the settings do not have the qualities of an institution and that the settings do have the qualities of home and community-based settings. The FAQs focus on settings that have “the effect of isolating individuals receiving Medicaid [Home and Community-Based Services] HCBS from the broader community of individuals not receiving Medicaid HCBS.” Where noted, this guidance replaces or supplements prior guidance; content not specifically referenced in the attached as being replaced remains in effect.
  • CMS is issuing this guidance in keeping with a letter from CMS Administrator Seema Verma to the nation’s Governors on March 14, 2017, indicating the intention to provide additional flexibility to states and to streamline implementation efforts associated with the home and community-based settings regulation.
  • In addition to information clarifying the heightened scrutiny process, the FAQs also clarify two other topics that have often been raised with CMS: whether an individual’s private residence should be assessed for compliance with the settings criteria, and whether an individual should reside in a compliant setting in order to receive Medicaid reimbursement for non-residential HCBS.

All states and Washington, D.C. must have transition plans in place no later than March 17, 2022 in order to ensure settings meet federal HCBS standards and thus continue to receive Medicaid funding.

Visit the Medicaid.gov Statewide Transition Plans website to see where your state is in this process. I encourage you to also check out the Home & Community Based Services Final Regulation website as well for additional information including the final rule, press releases and fact sheets.