By Alison Barkoff, Acting Administrator and Assistant Secretary for Aging

The Centers for Medicare & Medicaid Services (CMS) published a proposed rule, Ensuring Access to Medicaid Services (Access Rule) to improve access to — and quality of — Medicaid services and promote health equity across the Medicaid program.

The proposed rule applies to all Medicaid services, including the home and community-based services (HCBS) that are vital to people with disabilities and older adults. This means that input from ACL’s network is critical. 

Comments must be received by July 3, 2023.

The proposed Access Rule is groundbreaking. It is both broad in scope and responsive to issues that are important to the aging and disability communities. The proposed rule strengthens many aspects of Medicaid HCBS, including the direct care workforce, health and safety protections, quality of services, and state accountability and transparency, by introducing new requirements in each of these areas. ACL worked closely with our CMS colleagues in developing this rule to ensure that the experiences and priorities of people receiving Medicaid HCBS and their families, along with ACL’s disability and aging networks, were considered.

In 1993, Congress added section 1915(c) to the Social Security Act, authorizing the creation of the Medicaid HCBS waiver program. Forty years later, nearly two million people are supported to live in the community by the program. The proposed Access Rule recognizes the important role Medicaid HCBS is now playing and the need to ensure that people can access these critical services.

What’s most important for people with disabilities and older adults to know?

The proposed rule is complex, and despite our best efforts to be succinct, this blog post is very long! If you don’t have time to dig in, here’s what’s most important to know right now.

Under the proposed Access Rule:

• At least 80% of all Medicaid payments for specific HCBS — homemaker services, home health aide services, and personal care services — must be spent on compensation for direct care workers to help address the direct care workforce crisis.
• States must report information on their section 1915(c) HCBS waiver waitlists, including the length of the waitlists. They also must report whether people can access services across section HCBS authorities once the services are approved. This data allows a comparison of HCBS accessibility in different states.
• States must demonstrate that as part of person-centered planning, a reassessment of need is completed at least once a year for people continuously enrolled in HCBS programs. They also must demonstrate that service plans are reviewed and revised annually based on that reassessment. 
• States must operate and maintain an electronic incident management system (using a common minimum definition for what is considered a “critical incident”) and investigate, address, and report on the outcomes of the incidents within specified timeframes.
• States must establish and manage a grievance process for people receiving HCBS in fee-for-service plans. (This already exists in Medicaid managed care.) This system will give people a way to notify their state Medicaid agency if they have a complaint about how a provider or state is complying with Medicaid requirements. 
• States must report on a set of nationally standardized quality measures specifically for HCBS established by CMS.

Community living is a civil right, but many people with disabilities and older adults need HCBS to exercise it. HCBS can make it possible for people to live where they want to live, to work in careers they choose, to stay connected to friends and family, and to participate in the community in ways that are meaningful to them.

But people must be able to access HCBS, and the services must be high quality. This proposed rule takes significant steps toward ensuring both.