The HCBS Quality Measures Set Under the CMS Access Rule: A Guide - Knowledge Services

Quality in healthcare is directly related to patient access to covered services. Recently, The Centers for Medicare & Medicaid Services (CMS) announced updates to Medicaid regulations, including CMS-2442-F “Ensuring Access to Medicaid Services Final Rule.” This rule is designed to improve access to care, quality, and health outcomes. The CMS Access Rule also aims to better address health equity issues in the Medicaid program across fee-for-service (FFS), managed care delivery systems, and in-home and community-based services (HCBS) programs. 

What Is “The Access Rule?” 

CMS created the Access Rule to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs. To improve overall access to care, the CMS Access Rule requires the following items: 

• Adopt the HCBS Quality Measure Set
• Review Person-Centered service plans annually 
• Implement an electronic incident management system 
• Develop a formalized complaint process for FFS HCBS beneficiaries 
• Establish Beneficiary Advisory Council
• Report on waiting list and service delivery timelines
• Ensure 80% of Medicaid payments to direct care workers
• Publish FFS Medicaid payment rates for public access 

HCBS Quality Measure Set 

The HCBS Quality Measure Set is a set of nationally standardized quality measures for Medicaid-funded HCBS. The intention is to promote more common and consistent use within and across states of nationally standardized quality measures in HCBS programs. It also creates opportunities for CMS and states to:

• Have comparative quality data on HCBS programs
• Drive improvement in quality of care and outcomes for people receiving HCBS
• Support states’ efforts to promote equity in their HCBS programs

CMS developed a resources manual for states containing supplemental information about the quality measures in the HCBS Quality Measure Set.  

As part of the HCBS Quality Measure Set adoption within the CMS Final Access Rule, states must collect data through an experience of care survey and report on the measures to CMS. CMS lists three survey instruments for states to use for data collection and reporting, including the National Core Indicators (NCI) surveys, the CAHPS surveys, and the POMS surveys.  

The HCBS Quality Priority  

Within the HCBS Quality Measure Set, there are three key priorities which enhance the HCBS programs. These priorities emphasize the importance of satisfaction and quality of life and highlight the need for equity in service delivery. Key priorities include: 

• Access: The level of access that the beneficiary is aware of and their ability to access resources that support overall well-being.
• Rebalancing: Striving to create a more balanced distribution of spending and utilization of services between home and community-based settings, relative to institutional care.
• Community Integration: Ensures the empowerment and full inclusion of children and adults with disabilities in all parts of society. 

These priority areas collectively aim to improve the overall effectiveness and responsiveness of HCBS programs, fostering better outcomes for individuals and their communities.

CMS Access Rule Meaningful Measures 

The Meaningful Measures Initiative is a framework designed to identify high-priority areas for quality measurement to improve health outcomes. Its purpose is to deliver value by empowering people to make informed care decisions while reducing the burden on clinicians and hospitals. These measure areas include: 

• Medication management 
• Admissions and readmissions to hospitals 
• Transfer of health information and interoperability 
• Preventive care 
• Management of chronic conditions 
• Prevention, treatment, and management of behavioral and mental health 
• Prevention and treatment of substance abuse disorders including opioid use disorders 
• Risk-adjusted mortality 
• Equity of care 
• Community engagement 
• Patient-focused episode of care 
• Risk-adjusted total cost of care 
• Appropriate use of healthcare 
• End-of-life care according to preferences 
• Personalized care aligned with the patient’s goals 
• Functional outcomes 
• Patient’s experience of care 

Aligning the HCBS Quality Measures Set with this framework supports better care coordination, enhanced patient experiences, and improved health outcomes for people who rely on these vital services. 

NQF Domains 

The National Quality Forum (NQF) Domains are to drive evidence-based research in support of quality measure development, guide quality improvement efforts, and highlight the important areas for measure development. These domains are: 

• Service Delivery & Effectiveness 
• Person-Centered Planning and Coordination 
• Choice and Control 
• Community Inclusion 
• Caregiver Support 
• Workforce 
• Human and Legal Rights 
• Equity 
• Holistic Health & Functioning 
• System Performance and Accountability 
• Consumer Leadership in System Development 

With the NQF Domains incorporated in the HCBS quality measures set, stakeholders can ensure that care is consistently person-centered, equitable, and supportive of individuals’ ability to live independently in their communities. 

Waiver Assurance/Sub-Assurances 

The HCBS 1915 © waiver assurances and sub-assurances are critical components within the HCBS Quality Measures Set. These assurances are designed to ensure that states meet specific standards when administering HCBS programs, focusing on protecting the health and welfare of individuals receiving services. The sub-assurances serve as benchmarks for evaluating and improving the quality of care, ensuring services are delivered effectively and safely to meet the needs of individuals in home and community settings. These 1915 © waiver assurances/sub-assurances contain the following: 

Service Plan Assurance: The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.  

• Sub-assurance 1: Service plans address all participants’ assessed needs and personal goals, either by the provision of waiver services or through other means. 
• Sub–assurance 2: Service plans are revised annually or when warranted by changes in the waiver participant’s needs. 
• Sub-assurance 3: Services are delivered following the service plan. This includes the type, scope, amount, duration, and frequency specified in the service plan. 
• Sub–assurance 4: Participants are given a choice between/among waiver services and providers. 

These sub-assurances help ensure the service plan is meeting and continues to meet the needs of waiver participants. 

Health and Welfare Assurance: The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare.  

• Sub-assurance 1: The state demonstrates on an ongoing basis that it identifies, addresses, and seeks to prevent instances of abuse, neglect, exploitation, and unexplained death. 
• Sub–assurance 2: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.  
• Sub-assurance 3: State policies and procedures for the use or prohibition of restrictive interventions are followed. 
• Sub–assurance 4: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.  

These sub-assurances help ensure waiver participants have and maintain health and welfare. 

Get Up to Speed with the CMS Access Rule 

As the CMS Final Access Rule comes into effect, states will evaluate their current state and implement quality improvements to meet the Final Rule requirements. With 10+ years of experience in facilitating surveys for State Government, including the NCI-AD, NCI-IDD, and CAHPS surveys, Knowledge Services is eager to assist States in adopting the HCBS Quality Measure Set as part of the CMS Final Access Rule. Contact us today to learn more about how we can assist your organization with survey management.