[Federal Register Volume 91, Number 81 (Tuesday, April 28, 2026)]
[Notices]
[Pages 22823-22841]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2026-08190]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2453-NC]
RIN 0938-ZB99


Medicaid Program; 2028 Medicaid Home and Community-Based Services 
Quality Measure Set

AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of 
Health and Human Services (HHS).

ACTION: Notice with comment period.

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SUMMARY: The Home and Community-Based Services (HCBS) Quality Measure 
Set is a set of nationally standardized quality measures for Medicaid-
funded HCBS that is intended to promote more common and consistent use 
within and across States of nationally standardized quality measures in 
HCBS programs, create opportunities for CMS and States to have 
comparative quality data on HCBS programs, and drive improvement in 
quality of care and outcomes for people receiving HCBS. The purpose of 
this notice with comment period is to solicit public comment on the 
2028 HCBS Quality Measure Set. Specifically, it is intended to solicit 
public comment on: proposed mandatory and voluntary measures for the 
2028 HCBS Quality Measure Set; how States collect, calculate, and 
report data on the measures in the proposed 2028 HCBS Quality Measure 
Set; the proposed measures in the 2028 HCBS Quality Measure Set for 
which States are required to report stratified data, including rural/
urban status; the proposed stratification factors for each of the 
measures in the 2028 HCBS Quality Measure Set for which States are 
required to report stratified data; the populations for which States 
are proposed to report the measures in the 2028 HCBS Quality Measure 
Set; and the proposed reporting schedule.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, by May 28, 2026.

ADDRESSES: In commenting, please refer to file code CMS-2453-NC.
    Comments, including mass comment submissions, must be submitted in 
one of the following three ways (please choose only one of the ways 
listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov/docket/CMS-2026-0332. Follow 
the ``Submit a comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-2453-NC, P.O. Box 8016, 
Baltimore, MD 21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-2453-NC, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Jennifer Bowdoin, (410) 786-8551.

SUPPLEMENTARY INFORMATION: 
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following 
website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to 
view public comments. We will not post on Regulations.gov public 
comments that make threats to individuals or institutions or suggest 
that the commenter will take actions to harm an individual. We continue 
to encourage individuals not to submit duplicative comments. We will 
post acceptable comments from multiple unique commenters even if the 
content is identical or nearly identical to other comments.

I. Background

A. Medicaid Home and Community-Based Services (HCBS)

    Home and community-based services (HCBS) provide opportunities for 
Medicaid beneficiaries to receive services in their own homes and 
communities rather than in institutions. Medicaid coverage of HCBS 
varies by State and can include a combination of medical and non-
medical services, such as case management, homemaker, personal care, 
adult day health, habilitation (both day and residential), and respite 
care services. HCBS programs serve a variety of targeted population 
groups, including older adults and children or adults with intellectual 
and developmental disabilities (IDD), physical disabilities, mental 
health/substance use disorders, and complex medical needs. In fiscal 
year (FY) 2023, 8.4 million Medicaid beneficiaries received HCBS, and 
HCBS accounted for $145.9 billion in Medicaid expenditures.\1\
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    \1\ Carpenter, Alexandra, Cara Stepanczuk, Caitlin Murray, and 
Andrea Wysocki. ``Trends in Users and Expenditures for Home and 
Community-Based Services as a Share of Total Medicaid Long-Term 
Services and Supports Users and Expenditures, 2023.'' Mathematica, 
October 17, 2025. Accessed at https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltss-rebalancing-brief-2023.pdf.

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[[Page 22824]]

B. HCBS Quality Measure Set

    In July 2022, we issued State Medicaid Director Letter # 22-003 \2\ 
to release the first official version of the HCBS Quality Measure Set. 
In April 2024, we issued two Center for Medicaid and CHIP Services 
(CMCS) Informational Bulletins: (1) an informational bulletin \3\ to 
update the HCBS Quality Measure Set, hereinafter referred to as the 
2024 HCBS Quality Measure Set; and (2) an informational bulletin \4\ 
that establishes and describes HCBS Quality Measure Set reporting 
requirements for the 41 States and territories participating in the 
Money Follows the Person (MFP) demonstration.\5\ Specifically, 
beginning in fall 2026 and every other year thereafter, MFP grant 
recipients are required to report on the HCBS Quality Measure Set for 
all Medicaid-funded HCBS under sections 1915(c), (i), (j), and (k) of 
the Social Security Act (the Act), as well as section 1115 
demonstrations that include HCBS. Reporting must include all eligible 
individuals (or a representative sample of eligible individuals) 
receiving HCBS under these authorities; reporting on the HCBS Quality 
Measure Set is not limited to MFP program participants receiving HCBS 
under those authorities. MFP grant recipients are expected to report in 
the aggregate across all of their HCBS programs and are not expected to 
report separately for each HCBS program. For the initial reporting 
period in 2026, MFP grant recipients are expected to report on the 
subset of measures in the 2024 HCBS Quality Measure Set identified as 
mandatory measures. These include up to 20 measures derived from four 
experience of care surveys,\6\ two assessment/case management system 
measures (Long Term Services and Supports (LTSS)-1 and LTSS-2), and 
three rebalancing measures that use administrative (that is, claims and 
encounter) data (LTSS-6, LTSS-7, and LTSS-8). Grant recipients also 
have the option for CMS to report on the administrative data measures 
(LTSS-6, LTSS-7, and LTSS-8) on their behalf using data from the 
Transformed Medicaid Statistical Information System (T-MSIS) Analytic 
Files. Additional information on each of these measures is provided in 
Table 4 in section II.A. of this notice with comment period.
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    \2\ CMS State Medicaid Director Letter. SMD# 22-003 Home and 
Community-Based Services Quality Measure Set. July 2022. Accessed at 
https://www.medicaid.gov/federal-policy-guidance/downloads/smd22003.pdf.
    \3\ CMCS Informational Bulletin, ``2024 Home and Community-Based 
Services (HCBS) Quality Measure Set (QMS).'' Published April 11, 
2024. Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/cib041124.pdf.
    \4\ CMCS Informational Bulletin, ``Home and Community-Based 
Services (HCBS) Quality Measure Set (QMS) Reporting Requirements for 
Money Follows the Person (MFP) Demonstration Grant Recipients.'' 
Published April 11, 2024. Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/cib04112024.pdf.
    \5\ MFP is a grant-funded demonstration program that was 
initially authorized by the Deficit Reduction Act of 2005 (Pub. L. 
109-171). For more information on the MFP demonstration program, see 
https://www.medicaid.gov/medicaid/long-term-services-supports/money-follows-person.
    \6\ MFP grant recipients are not necessarily expected to conduct 
all four of the experience of care surveys, but they are expected to 
survey all of the major population groups included in their State's 
HCBS programs, if a survey included in the HCBS Quality Measure Set 
is available for that population. Some experience of care surveys 
have not been tested with all populations enrolled in HCBS programs. 
Depending on the populations served by the State's HCBS programs and 
the particular survey instrument(s) that a State selects to use, MFP 
grant recipients may need to use multiple experience of care surveys 
to ensure that all major population groups are included. MFP grant 
recipients are only expected to use as many surveys as are necessary 
to assess the experience of care for the major population groups 
included in the State's HCBS programs. As a result, the number of 
experience of care surveys that a State must conduct and the number 
of corresponding measures it must report may vary. For instance, if 
a State conducts the HCBS Consumer Assessment of Healthcare 
Providers and Systems (CAHPS) survey for all of its HCBS populations 
for which a survey is available in the 2024 HCBS Quality Measure 
Set, it would need to report on five experience of care survey 
measures, in addition to the two assessment/case management system 
measures and the three administrative measures. As another example, 
if a State conducts National Core Indicators-Aging and Disabilities 
(NCI-AD) and National Core Indicators Intellectual and Development 
Disabilities (NCI-IDD), it would need to report on five measures 
from each of those surveys (10 experience of care survey measures in 
total), in addition to the two assessment/case management system 
measures and the three administrative measures.
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    In the May 10, 2024 Federal Register, we issued a final rule 
titled, ``Ensuring Access to Medicaid Services'' (89 FR 40542) 
(hereinafter referred to as the Access rule), that included reporting 
requirements for States for section 1915(c) waiver programs, codified 
at 42 CFR 441.311, and made applicable to HCBS furnished under sections 
1915(i), (j), and (k) of the Act through cross-references at 42 CFR 
441.474(c), 441.745(a)(1)(vii), and 441.580(i). Section 441.311(c) 
requires that States report every other year, beginning July 9, 2028, 
on the HCBS Quality Measure Set. Specifically, we required at Sec.  
441.311(c)(1)(i) that States report every other year, according to the 
format and schedule prescribed by the Secretary through the process for 
developing and updating the HCBS Quality Measure Set finalized at Sec.  
441.312(d), on measures identified in the HCBS Quality Measure Set as 
mandatory for States to report. At Sec.  441.311(c)(1)(ii), we 
finalized our policy that States may report on measures in the HCBS 
Quality Measure Set that are not identified as mandatory or as measures 
the Secretary will report on behalf of States. At Sec.  
441.311(c)(1)(iii), we required States to establish performance 
targets, subject to our review and approval, for each of the measures 
in the HCBS Quality Measure Set that are identified as mandatory for 
States to report or are identified as measures for which we will report 
on behalf of States, as well as to describe the quality improvement 
strategies that they will pursue to achieve the performance targets for 
those measures. At Sec.  441.311(c)(1)(iv), we finalized the policy 
that States may establish State performance targets for other measures 
in the HCBS Quality Measure Set that are not identified as mandatory 
for States to report or as measures for which the Secretary will report 
on behalf of States as well as to describe the quality improvement 
strategies that they will pursue to achieve the performance targets. At 
Sec.  441.311(c)(2), we established that we will report on behalf of 
the States, on a subset of measures in the HCBS Quality Measure Set 
identified in Sec.  441.312(d)(1)(iii). Further, at Sec.  
441.311(c)(3), we finalized the policy that States may, but are not 
required to report on measures that are not yet required but will be, 
and on populations for whom reporting is not yet required but will be 
phased in in the future. States must comply with the HCBS Quality 
Measure Set reporting requirements at Sec.  441.311(c) beginning July 
9, 2028.
    Regulations at Sec.  441.312 set requirements for developing the 
HCBS Quality Measure Set. Specifically, at Sec.  441.312(c)(1), we 
required that the Secretary identify, and update no more frequently 
than every other year, beginning no later than December 31, 2026, the 
quality measures to be included in the HCBS Quality Measure Set. At 
Sec.  441.312(c)(2), we required that the Secretary make technical 
updates and corrections to the HCBS Quality Measure Set annually as 
appropriate. At Sec.  441.312(c)(3), we required that the Secretary 
consult at least every other year with States and other interested 
parties (who are described in more detail at Sec.  441.312(g)) to:
     Establish priorities for the development and advancement 
of the HCBS Quality Measure Set;
     Identify newly developed or other measures that should be 
added to the HCBS Quality Measure Set, including to address gaps in the 
measures included in the HCBS Quality Measure Set;

[[Page 22825]]

     Identify measures that should be removed as they no longer 
strengthen the HCBS Quality Measure Set; and
     Ensure that all measures included in the HCBS Quality 
Measure Set reflect an evidenced-based process including testing, 
validation, and consensus among interested parties; are meaningful for 
States; and are feasible for State-level, program-level, or provider-
level reporting as appropriate.
    At Sec.  441.312(c)(4), we required that the Secretary develop and 
update in consultation with States, no more frequently than every other 
year, the HCBS Quality Measure Set using a process that allows for 
public input and comment. The process for allowing public input and 
comment was finalized at Sec.  441.312(d) and requires the Secretary to 
address the following:
     Identify all measures in the HCBS Quality Measure Set, 
including newly added measures, measures that have been removed, 
mandatory measures, measures that the Secretary will report on States' 
behalf, measures that States can elect to have the Secretary report on 
their behalf, and measures for which the Secretary will provide States 
with additional time to report and the amount of additional time 
provided;
     Provide technical information to States on how to collect 
and calculate data on the measures in the HCBS Quality Measure Set;
     Provide a standardized format and reporting schedule for 
reporting on the measures in the HCBS Quality Measure Set;
     Provide procedures that States must follow in reporting 
the required HCBS Quality Measure Set measure data;
     Identify specific populations for which States must report 
the measures in the HCBS Quality Measure Set, including people enrolled 
in a specific delivery system type such as a managed care plan or fee-
for-service, people who are dually eligible for Medicare and Medicaid, 
older adults, people with physical disabilities, people with IDD, 
people who have serious mental illness, and people who have other 
health conditions; and provide technical information on attribution 
rules for determining how States must report on measures for 
beneficiaries who are included in more than one population;
     Identify the measures in the HCBS Quality Measure Set that 
must be stratified by race, ethnicity, sex, age, rural/urban status, 
disability, language, or such other factors; and
     Describe how to establish State performance targets for 
each of the measures in the HCBS Quality Measure Set.
    At Sec.  441.312(e), we established that, as part of the process 
for developing and updating the HCBS Quality Measure Set, the Secretary 
may provide that mandatory State reporting for certain measures and 
reporting for certain populations will be phased in over a specified 
period of time, taking into account the level of complexity required 
for such State reporting. At Sec.  441.312(f), we established a phase-
in schedule for stratified reporting that requires States to provide 
stratified data for 25 percent of the measures in the HCBS Quality 
Measure Set by July 9, 2028, 50 percent by July 9, 2030, and 100 
percent by July 9, 2032. We also established that, in specifying the 
measures and the factors by which States must report stratified 
measures, the Secretary will consider whether such stratified sampling 
can be accomplished based on valid statistical methods, without risking 
violating beneficiary privacy, and, for measures obtained from surveys, 
whether the original survey instrument collects the variables or 
factors necessary to stratify the measures, and such other factors as 
the Secretary determines appropriate.

C. Development of the Proposed 2028 HCBS Quality Measure Set

    To develop the proposed HCBS Quality Measure Set for the first year 
of public reporting required by Sec.  441.311 in 2028 (hereinafter 
referred to as the 2028 HCBS Quality Measure Set), a public call for 
measures was released in July 2024 to solicit public input on measures 
to include in the 2028 HCBS Quality Measure Set. The public call for 
measures allowed any member of the public to suggest measures for 
addition to or removal from the HCBS Quality Measure Set, using the 
2024 HCBS Quality Measure Set \7\ as the basis for developing the 2028 
HCBS Quality Measure Set. Twenty-four measures were suggested for 
addition to the HCBS Quality Measure Set through the public call for 
measures (Table 1), while 15 measures were suggested for removal (Table 
2).\8\
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    \7\ For a full list of measures in the 2024 HCBS Quality Measure 
Set, see Appendix A of the CMCS Informational Bulletin, ``2024 Home 
and Community-Based Services (HCBS) Quality Measure Set (QMS).'' 
Published April 11, 2024. Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/cib041124.pdf.
    \8\ For more information on each measure suggested for addition 
or removal, see https://www.mathematica.org/-/media/internet/features/2025/hcbs-quality-measure-set/qmsreview-mis.pdf.

Table 1--Measures Suggested for Addition to the HCBS Quality Measure Set
                  Through the Public Call for Measures
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                     Measures suggested for addition
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Consumer Assessment of Healthcare Providers and Systems (CAHPS[supreg])
 Health Plan Survey, Adult Version, Measures:
    CAHPS Health Plan Survey, Adult Version: Enrollees' Rating of Health
     Plan.
National Core Indicators-Aging and Disabilities (NCI-ADTM) Measures:
    NCI-AD: Percentage of People Who Can Get an Appointment to See or
     Talk to Their Primary Care Doctor When They Need to.
    NCI-AD: Percentage of People in Group Settings Who Always Have
     Access to Food.
    NCI-AD: Percentage of People in Group Settings Who Are Able to
     Choose Their Roommate.
    NCI-AD: Percentage of People in Group Settings Who Are Able to
     Furnish and Decorate Their Room However They Want to.
    NCI-AD: Percentage of People in Group Settings Who Are Able to Lock
     the Door to Their Room.
    NCI-AD: Percentage of People Who Have Access to Mental Health
     Services If They Want Them.
    NCI-AD: Percentage of People Who Have Needed Assistive Equipment and
     Devices.
    NCI-AD: Percentage of People Who Know Whom to Contact If They Have a
     Complaint About Their Services.
National Core Indicators[supreg] Intellectual and Developmental
 Disabilities (NCI[supreg]-IDD) Measures:
    NCI-IDD: The Percentage of People Who Report That There Are Rules
     About Having Friends or Visitors at Home.
    NCI-IDD: The Percentage of People Reported To Be Using a Self-
     Directed Supports Option.
    NCI-IDD: The Percentage of People Who Report Staff Do Things the Way
     They Want Them Done.
    NCI-IDD: The Percentage of People Who Report That They Know Whom to
     Talk to If They Want to Change Services.
Rehabilitation Research and Training Center on HCBS Outcome Measurement
 (RTC/OM) Measures:
    RTC/OM: Experiences Seeking Employment.
    RTC/OM: Experiences Using Transportation.
    RTC/OM: Job Experiences.

[[Page 22826]]

 
    RTC/OM: Meaningful Activity.
    RTC/OM: Personal Choices and Goals--Self-Determination Index.
    RTC/OM: Services and Supports--Self-Determination Index.
    RTC/OM: Social Connectedness.
    RTC/OM: System Supports Meaningful Consumer Involvement.
    RTC/OM: Feelings of Safety Around Others.
    RTC/OM: Freedom from Experiences of Abuse and Neglect.
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  Table 2--Measures Suggested for Removal From the HCBS Quality Measure
                Set Through the Public Call for Measures
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                     Measures suggested for removal
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Home and Community-Based Services (HCBS) Consumer Assessment of
 Healthcare Providers and Systems (CAHPS[supreg]) Measures:
    HCBS CAHPS: Staff Listen and Communicate Well.
    HCBS CAHPS: Transportation to Medical Appointments Composite
     Measure.
Long-Term Services and Supports (LTSS) Measures:
    LTSS-1: Comprehensive Assessment and Update.
    LTSS-2: Comprehensive Person-Centered Plan and Update.
    LTSS-3: Shared Person-Centered Plan with Primary Care Provider.
    LTSS-7: Minimizing Facility Length of Stay.
Healthcare Effectiveness Data and Information Set (HEDIS) \9\ Measures:
    Plan All-Cause Readmission.\10\
National Core Indicators-Aging and Disabilities (NCI-ADTM) Measures:
    NCI-AD: Percentage of Non-English Speaking Participants Who Receive
     Information About Their Services in the Language They Prefer.
    NCI-AD: Percentage of People Who Are Able to See or Talk to Their
     Friends and Family When They Want To.
    NCI-AD: Percentage of People Who Had Adequate Follow-Up After Being
     Discharged from a Hospital or Rehabilitation/Nursing Facility.
    NCI-AD: Percentage of People with Concerns About Falling Who Had
     Someone Work with Them to Reduce Risk of Falls.
    NCI-AD: Percentage of People Who Know How to Manage Their Chronic
     Conditions.
    NCI-AD: Percentage of People Who Are Ever Worried for the Security
     of Their Personal Belongings.
    NCI-AD: Percentage of People Who Feel Safe Around Their Support
     Staff.
    NCI-AD: Percentage of People Whose Money Was Taken or Used Without
     Their Permission in the Last 12 Months.
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    An independent HCBS Quality Measure Set Review Workgroup \11\ 
comprising representatives from State agencies, managed care plans, 
beneficiary advocates, providers and provider associations, 
researchers, measure developers, and other subject matter experts was 
established in fall 2024. The purpose of the workgroup was to review 
and identify gap areas in the HCBS Quality Measure Set and recommend 
changes for improvement. In particular, the workgroup reviewed each of 
the measures suggested for addition or removal through the public call 
for measures and, in spring 2025, voted on the recommendations. The 
measures recommended by the workgroup for addition to or removal from 
the HCBS Quality Measure Set are provided in Table 3.\12\
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    \9\ HEDIS is a set of performance measures developed by the 
National Committee for Quality Assurance (NCQA). For more 
information on HEDIS, see https://www.ncqa.org/hedis/.
    \10\ In the summary of measures suggested for removal (available 
at https://www.mathematica.org/-/media/internet/features/2025/hcbs-quality-measure-set/qmsreview-mis.pdf.), the Plan All-Cause 
Readmission Measure is referred to as ``Managed Long-Term Services 
and Supports (MLTSS): Plan All-Cause Readmission.'' We refer to the 
measure here as a HEDIS measure to align with standard terminology 
used by States, managed care plans, and other entities involved in 
health care quality measurement and reporting.
    \11\ For more information on the HCBS Quality Measure Set Review 
Workgroup, see https://www.mathematica.org/features/hcbsqmsreview.
    \12\ For more information on the workgroup's recommendations, 
see https://www.mathematica.org/-/media/internet/features/2026/hcbs-quality-measure-set/2028hcbsqmsreview-final-report.pdf.

  Table 3--Measures Recommended by the HCBS Quality Measure Set Review
 Workgroup for Addition To or Removal From the HCBS Quality Measure Set
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                    Measures Recommended for Addition
National Core Indicators-Aging and Disabilities (NCI-ADTM) Measures:
    NCI-AD: Percentage of People Who Have Access to Mental Health
     Services If They Want Them.
    NCI-AD: Percentage of People Who Have Needed Assistive Equipment and
     Devices.
    NCI-AD: Percentage of People Who Know Whom to Contact If They Have A
     Complaint About Their Services.
National Core Indicators[supreg] Intellectual and Developmental
 Disabilities (NCI[supreg]-IDD) Measures:
    NCI-IDD: Percentage of People who Report that They Know Whom to Talk
     to If They Want to Change Services.
                    Measures Recommended for Removal
Long-Term Services and Supports (LTSS) Measures:
    LTSS-1: Comprehensive Assessment and Update.

[[Page 22827]]

 
    LTSS-2: Comprehensive Person-Centered Plan and Update.
    LTSS-3: Shared Person-Centered Plan with Primary Care Provider.
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    The proposed 2028 HCBS Quality Measure Set considers the 
recommendations of the HCBS Quality Measure Set Review Workgroup,\13\ 
existing reporting requirements for the 41 States and territories 
participating in the MFP demonstration, and our responses to comments 
in the Access rule. Our intent in issuing this notice with comment 
period is to satisfy, in part, the requirements established at Sec.  
441.312(c)(4) that the Secretary, in consultation with States, develop 
and update, no more frequently than every other year, the HCBS Quality 
Measure Set using a process that allows for public input and comment. 
Specifically, the intent of this notice with comment period is to 
solicit public comment on: proposed mandatory and voluntary measures 
for the 2028 HCBS Quality Measure Set; how States collect, calculate, 
and report data on the measures in the proposed 2028 HCBS Quality 
Measure Set; the proposed measures in the 2028 HCBS Quality Measure Set 
for which States are required to report stratified data; the proposed 
stratification factors for each of the measures in the 2028 HCBS 
Quality Measure Set for which States are required to report stratified 
data; the populations for which States are proposed to report measures 
in the 2028 HCBS Quality Measure Set and the proposed attribution rules 
for reporting on beneficiaries who meet criteria for more than one HCBS 
population; and the proposed reporting schedule. We will solicit public 
comment on the reporting format and how States establish State 
performance targets for the 2028 HCBS Quality Measure Set through the 
Paperwork Reduction Act notice and comment process (see section III. of 
this notice with comment period).
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    \13\ Although we do not generally discuss in detail the feedback 
obtained through the public call for measures in this notice with 
comment period, our consideration of the recommendations of the 
workgroup is intended to also consider the feedback obtained through 
the public call for measures.
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II. Provisions of the Notice With Comment Period

A. Proposed Mandatory Measures in the 2028 HCBS Quality Measure Set

    As discussed earlier in sections I.A. and I.C. of this notice with 
comment period, we used the 2024 HCBS Quality Measure Set as the basis 
for the 2028 HCBS Quality Measure Set. We also considered the 
recommendations of the HCBS Quality Measure Set Review Workgroup, 
existing reporting requirements for the 41 States and territories 
participating in the MFP demonstration, and our responses to comments 
in the Access rule. Based on these considerations, we are soliciting 
comment on a proposed approach for the 2028 HCBS Quality Measure Set 
that is discussed in more detail later in this section and generally 
aligns with the mandatory measures required for MFP grant recipients to 
report on in 2026, with proposed modifications to reduce the number of 
participant-reported experience of care survey measures. We are also 
soliciting comment on whether we should instead require the same set of 
mandatory measures in the 2028 HCBS Quality Measure Set as is required 
for MFP grant recipients to report on in 2026.
    In particular, we indicated in the Access rule that we intend to 
retain each of the measures in the HCBS Quality Measure Set for at 
least 5 years to ensure the availability of longitudinal data, unless 
there are serious issues associated with the measures (such as related 
to measure reliability or validity) or States' use of the measures 
(such as excessive cost of State data collection and reporting or 
insurmountable technical issues with State reporting on the measures) 
(89 FR 40665). Consistent with this intent, we generally sought to 
align the proposed mandatory measures for 2028 with those required for 
MFP grant recipients to report on in 2026, in order to promote 
alignment, parsimony, and harmonization of HCBS quality measures, and 
to be responsive to the feedback received through the Access rule 
notice and comment process and extensive engagement with States, State 
associations, and other interested parties. At the same time, we 
recognize the importance of balancing these goals with considerations 
related to reporting burden, feasibility, and the overall composition 
of the measure set. As such, we are proposing a modified set of 
mandatory measures for 2028 that generally aligns with the measures 
required for MFP reporting in 2026, while reducing the number of 
participant-reported experience of care survey measures. Specifically, 
we are proposing to require States to report in 2028 on the same set of 
mandatory measures as is required for MFP grant recipients to report on 
in 2026, with the exception of two experience of care survey measures, 
which we are not proposing as mandatory measures in 2028. The two 
measures that are mandatory for MFP grant recipients to report on in 
2026 that we are not proposing as mandatory in 2028 are: HCBS CAHPS: 
Planning Your Time and Activities composite measure (which we referred 
to in the 2024 HCBS Quality Measure Set as HCBS CAHPS: Community 
Inclusion and Empowerment composite measure but is referred to here 
using the measure name in the most recent technical specifications for 
the HCBS CAHPS measures \14\); and Personal Outcome Measures[supreg] 
(POM: People Live in Integrated Environments.
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    \14\ Available at https://www.medicaid.gov/medicaid/quality-of-care/quality-of-care-performance-measurement/cahps-home-and-community-based-services-survey.
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    The Planning Your Time and Activities composite measure is 
calculated using scores on six items in the HCBS CAHPS survey: \15\
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    \15\ For more information on calculating the results on 
composite measures for the HCBS CAHPS survey, see Appendix C at 
https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2024-hcbs-chartbook.pdf.
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     Question 75: In the last 3 months, when you wanted to, how 
often could you get together with these family members who live nearby? 
Response options: Never; Sometimes; Usually; Always.
     Question 77: In the last 3 months, when you wanted to, how 
often could you get together with these friends who live nearby? 
Response options: Never; Sometimes; Usually; Always.
     Question 78: In the last 3 months, when you wanted to, how 
often could you do things in the community that

[[Page 22828]]

you like? Response options: Never; Sometimes; Usually; Always.
     Question 79: In the last 3 months, did you need more help 
than you get from {personal assistance/behavioral health staff{time}  
to do things in your community? Response options: Yes; No.
     Question 80: In the last 3 months, did you take part in 
deciding what you do with your time each day? Response options: Yes; 
No.
     Question 81: In the last 3 months, did you take part in 
deciding when you do things each day--for example, deciding when you 
get up, eat, or go to bed? Response options: Yes; No.
    The second measure that is mandatory for MFP grant recipients to 
report on in 2026 but that we are not proposing as mandatory for 2028 
is the POM: People Live in Integrated Environments measure, which uses 
an interview protocol that assesses whether people live in environments 
where they are integrated into the community.
    We continue to believe that the measures identified for MFP 
reporting are generally feasible for States to report without undue 
burden and focus on important aspects of quality for people receiving 
HCBS and for HCBS systems, including person-centered planning and care, 
community integration, safety, transportation, and LTSS system 
rebalancing. However, we are not proposing the HCBS CAHPS: Planning 
Your Time and Activities composite measure as mandatory in 2028 because 
we have received concerns from interested parties that some of the 
items included in the composite measure may be more reflective of 
individuals' social relationships than of their experiences with their 
HCBS and are outside the control of HCBS programs. We have received 
similar concerns regarding POM: People Live in Integrated Environments, 
which may assess factors that are outside the control of HCBS programs, 
and, as a result, we are also not proposing this measure as mandatory 
in 2028. We invite comment on whether we should require States to 
report on HCBS CAHPS: Planning Your Time and Activities or POM: People 
Live in Integrated Environments in 2028. We also request comment on 
whether there are additional measures that should be mandatory and 
whether any of the proposed mandatory measures should instead be 
voluntary or removed from the 2028 HCBS Quality Measure Set.
    Table 4 provides the proposed mandatory measures in the 2028 HCBS 
Quality Measure Set. For each proposed measure, the table includes the 
CMS Measure Inventory Tool (CMIT) \16\ identification (ID) number, the 
measure steward, the measure name, the type of data source, the method 
of reporting to CMS, and brief technical specifications. Table 4 also 
identifies whether each mandatory measure is proposed for required 
stratification. Our proposed stratification requirements are discussed 
in section II.C. of this notice with comment period. The CMIT ID, 
measure steward, and measure name are provided to clearly identify each 
proposed measure. Commenters are encouraged to use the CMIT ID and/or 
the measure name as written in the table when referencing specific 
measures in comments. The type of data source provides information on 
the type of data States would need to collect and analyze to report on 
the measure, as determined by the measure steward. The technical 
specifications provide information on the numerator and denominator for 
each measure and are provided for informational purposes only. More 
detailed information on each measure is available in CMIT or from the 
measure steward for each measure. The method of reporting to CMS 
provides information on our proposed method for States to report the 
results of each proposed measure. We discuss the proposed method of 
reporting each measure later in this section.
---------------------------------------------------------------------------

    \16\ CMIT is available at https://cmit.cms.gov/cmit/#/.
---------------------------------------------------------------------------

    We are soliciting comment on whether to include a total of 23 
mandatory measures in the 2028 HCBS Quality Measure Set. The measures 
include two measures that require data from assessments or case 
management systems, three measures that require administrative data, 
and 18 participant-reported measures from experience of care surveys. 
It is important to note that we are not proposing to require that all 
States report on all 23 measures. As discussed in more detail later in 
this section, we are soliciting comments on whether States should be 
required to report participant-reported experience of care survey 
measures from one or more of the four experience of care surveys 
proposed for inclusion in the HCBS Quality Measure Set. Because States 
serve different HCBS populations and may use one or more of the four 
proposed experience of care surveys, the total number of measures a 
State would report would be expected to range from 9 to 19. The 
measures that each State would be required to report include four to 
five participant-reported measures from each applicable experience of 
care survey selected by the State, two assessment/case management 
system measures, and three administrative data measures. We are also 
proposing to provide States with the option for CMS to conduct analyses 
and report on the three administrative data measures on the State's 
behalf using data from T-MSIS Analytic Files, thereby potentially 
reducing the number of measures that the State would need to report by 
three. We discuss these proposals in more detail below in this section.
    Consistent with the 2024 HCBS Quality Measure Set, the proposed 
2028 HCBS Quality Measure Set relies heavily on measures derived from 
four surveys that assess the experience of care for one or more 
population groups included in HCBS programs. The four surveys include 
HCBS CAHPS, NCI-AD Adult Consumer Survey, NCI-IDD In-Person Survey 
(IPS), and Personal Outcome Measures[supreg] (POM). HCBS CAHPS is a 
cross-disability survey that has been tested for use with older adults 
and adults with physical disabilities, IDD, acquired brain injury, and 
mental health or substance use disorders.\17\ The NCI-AD Adult Consumer 
Survey is a survey of older adults and adults with physical 
disabilities that includes nearly 100 indicators designed to understand 
overall performance of public aging and physical disability 
systems.\18\ NCI-IDD IPS is an annual multi-State cross-sectional 
survey of adult recipients of State developmental disabilities systems' 
supports and services.\19\ POM is an interview-based tool that collects 
data on 21 indicators to better understand the desired outcomes of 
adults with IDD, adults with psychiatric disabilities, and older 
adults.\20\
---------------------------------------------------------------------------

    \17\ For more information on the HCBS CAHPS survey, see https://www.medicaid.gov/medicaid/quality-of-care/quality-of-care-performance-measurement/cahps-home-and-community-based-services-survey.
    \18\ For more information on the NCI-AD Adult Consumer Survey, 
see https://nci-ad.org/about/the-surveys/.
    \19\ For more information on NCI-IDD IPS, see https://idd.nationalcoreindicators.org/in-person-individual/.
    \20\ For more information on POM, see https://www.c-q-l.org/tools/personal-outcome-measures/.
---------------------------------------------------------------------------

    Based on the 2026 MFP reporting requirements, we are not proposing 
to require that States conduct all four experience of care surveys to 
report on the proposed mandatory measures in the 2028 HCBS Quality 
Measure Set. Rather, we are soliciting comment on whether to require 
States to conduct one or more of the four experience of care surveys 
for each of the major population groups (for example, older adults, 
adults with IDD, adults with physical disabilities, adults with serious 
mental illness, adults with acquired brain injury) receiving services 
under the

[[Page 22829]]

State's HCBS programs, if a survey is available for use with each 
relevant population.\21\ These population groups are consistent with 
those referenced in Sec.  441.312(d)(5). Under this proposal, States 
would be required to use as many surveys as are necessary to assess the 
experience of care for the major population groups included in the 
State's HCBS programs. The number of surveys that each State would need 
to conduct and, in turn, the number of experience of care survey 
measures that each State would need to report to meet the HCBS Quality 
Measure Set reporting requirements would vary depending on the 
populations served in the State's HCBS programs and the survey(s) 
selected by the State to use. States that opt to conduct the HCBS CAHPS 
survey, for instance, may be able to report on the mandatory survey 
measures solely through use of that survey. However, we anticipate, 
based on the extensive use of NCI-AD and NCI-IDD across States and our 
understanding of the surveys currently in use by States,\22\ that most 
States would likely need to conduct at least two surveys to report on 
the mandatory survey measures and that States would generally need to 
conduct a maximum of three surveys to fully meet the proposed 
requirements. As a result, we estimate that each State would report a 
total of 9 to 19 proposed mandatory measures in the 2028 HCBS Quality 
Measure Set. This includes four to five participant-reported measures 
from each applicable experience of care survey, two assessment/case 
management system measures, and three administrative data measures.
---------------------------------------------------------------------------

    \21\ We note that there is a lack of proposed measures in the 
HCBS Quality Measure Set for children and youth. We are working to 
address that gap and expect to propose the inclusion of measures 
focused on children and youth in the HCBS Quality Measure Set in the 
future.
    \22\ For more information on States' use of HCBS CAHPS, NCI-AD, 
and NCI-IDD, see https://www.medicaid.gov/state-overviews/scorecard/measure/State-Administration-of-Experience-of-Care-Surveys-for-Long-Term-Services-and-Supports?measure=HC.21&measureView=state&dataView=pointInTime&chart=map&timePeriods=%5B%222021%22%5D.
---------------------------------------------------------------------------

    We invite comment on our proposal to require that States conduct 
one or more of the four experience of care surveys for each of the 
major population groups (for example, older adults, adults with IDD, 
adults with physical disabilities, adults with serious mental illness, 
adults with acquired brain injury) receiving services under the State's 
HCBS programs, if a survey is available for use with each relevant 
population. We also solicit comment on whether we should exclude any of 
the surveys from the 2028 HCBS Quality Measure Set.
    As we also discuss in section II.D. of this notice with comment 
period, individuals receiving HCBS under more than one HCBS program or 
delivery system during the same reporting period could potentially be 
included in the survey sample for more than one experience of care 
survey. For instance, if an individual receives HCBS through both fee-
for-service and managed care delivery systems during the same reporting 
period, they may be included in the survey samples for more than one 
experience of care survey if the surveys are administered separately 
for the fee-for-service and managed care delivery systems. We encourage 
States and other entities involved in survey administration to take 
steps to deduplicate survey samples, but we are not proposing at this 
time to require States to ensure that survey samples are deduplicated 
due to the administrative complexity associated with deduplicating 
samples across potentially multiple experience of care surveys and 
entities involved in survey administration. We invite comment on 
whether we should require States to deduplicate survey samples when 
individuals may be included in the sample for multiple experience of 
care surveys.
    Based on information submitted by MFP grant recipients in their 
operational protocols describing how they intend to meet HCBS Quality 
Measure Set reporting requirements in 2026, we believe that few States 
are currently using or plan to use POM in the future to assess 
experience of care and that, where it is used, States use or plan to 
use POM to survey only a small subset of the State's overall HCBS 
population. Given this understanding, we anticipate proposing the 
removal of POM from the 2030 HCBS Quality Measure Set. We believe that 
this approach would allow us to remove survey measures that are not 
widely in use by States and, as a result, may no longer be meaningful 
for States or feasible for consistent State-level reporting, while also 
providing States that use POM with sufficient time to transition to 
other experience of care surveys. However, to maintain consistency with 
the requirements for MFP grant recipients in 2026, we are proposing to 
allow States to use POM measures to meet the HCBS Quality Measure Set 
reporting requirements in 2028, as interim measures prior to potential 
removal in 2030. We request comment on our proposal to include POM in 
the 2028 HCBS Quality Measure Set and our anticipated proposal to 
remove POM from the 2030 HCBS Quality Measure Set, particularly from 
States that currently use or plan to use POM.
    We note that two measures we are soliciting comment on as mandatory 
measures (LTSS-1 and LTSS-2) were recommended for removal by the HCBS 
Quality Measure Set Review Workgroup. We considered these 
recommendations in selecting the proposed mandatory measures for the 
2028 HCBS Quality Measure Set. However, we believe that these 
recommendations were based, in part, on differing interpretations among 
some workgroup members that LTSS-1 and LTSS-2, which focus on the 
quality and comprehensiveness of the person-centered planning process, 
are considered ``compliance'' measures rather than quality measures. We 
believe that effective State implementation of the person-centered 
planning process is integral to ensuring that HCBS systems are 
responsive to the needs and choices of beneficiaries receiving HCBS, 
maximize independence and self-direction, and provide support and 
coordination to facilitate full engagement in community life for people 
receiving HCBS. Further, we have received feedback from States; the 
U.S. Department of Health and Human Services (HHS) Office of Inspector 
General (OIG); the HHS Administration for Community Living (ACL); the 
HHS Office for Civil Rights (OCR); and other interested parties 
regarding the importance of person-centered planning and the role of 
the person-centered service plan in assuring the health and welfare of 
section 1915(c) waiver program participants.\23\ As such, the exclusion 
of measures that focus on the quality and comprehensiveness of the 
person-centered planning process would result in a critical gap in the 
HCBS Quality Measure Set, with inadequate representation of measures 
assessing service coordination and individualized care. Further, we 
note that the 41 States and territories participating in the MFP 
demonstration have made system changes, executed contracts, and taken 
other actions to be able to report on these measures. We believe that 
removing LTSS-1 and LTSS-2 and replacing them with alternative measures 
focused on the person-centered planning process would be disruptive to 
those States. We request comment on our proposal to include LTSS-1 and 
LTSS-2 as

[[Page 22830]]

mandatory measures in the 2028 HCBS Quality Measure Set.
---------------------------------------------------------------------------

    \23\ https://www.federalregister.gov/d/2024-08363/p-327.
---------------------------------------------------------------------------

    We note that the HCBS Quality Measure Set Review Workgroup 
recommended adding three NCI-AD measures and one NCI-IDD measure to the 
HCBS Quality Measure Set:
     NCI-AD: Percentage of People Who Have Access to Mental 
Health Services if They Want Them
     NCI-AD: Percentage of People Who Have Needed Assistive 
Equipment and Devices
     NCI-AD: Percentage of People Who Know Whom to Contact if 
They Have a Complaint about Their Services
     NCI-IDD: Percentage of People Who Report That They Know 
Whom to Talk to if They Want to Change Services
    We considered these recommendations in selecting the proposed 
mandatory measures for the 2028 HCBS Quality Measure Set. However, we 
are not proposing to include these measures as mandatory.
    To select the experience of care survey measures for mandatory 
reporting by MFP grant recipients in 2026, we identified experience of 
care survey measures in the following four domains based on feedback 
from measure stewards, States, and State associations: community 
inclusion, person-centered care, safety, and transportation. We believe 
that these domains are particularly important for assessing quality of 
care and beneficiary experience in HCBS programs. Further, our intent 
in selecting the mandatory measures for 2026 MFP reporting was to 
identify measures across all four surveys that are focused on similar 
measure concepts. While we agree with the HCBS Quality Measure Set 
Review Workgroup that the four survey measures recommended for addition 
are focused on areas that are important to measure in HCBS, we did not 
identify comparable measures across the surveys that are sufficiently 
aligned in concept. We believe that the inclusion of measures from 
other surveys that are focused on similar measure concepts would 
support comparability and consistency of HCBS quality data across 
States and that cross-survey alignment can help to ensure that States 
using different surveys are reporting on conceptually similar measures. 
Because the four survey measures recommended for addition do not have 
comparable measures across the other surveys that are sufficiently 
aligned in concept, and in light of our goals of promoting 
comparability while balancing reporting burden and feasibility, we are 
not proposing to include these measures in the 2028 HCBS Quality 
Measure Set (as doing so would introduce inconsistencies in reporting 
across States using different experience of care surveys). In addition, 
we seek to achieve an appropriate balance between State reporting 
burden and having a comprehensive set of evidence-based quality 
measures that are important to making significant gains in quality of 
care and outcomes for people receiving HCBS. We request comment on 
whether the measures recommended for addition by the HCBS Quality 
Measure Set Workgroup should be included as mandatory measures in the 
2028 HCBS Quality Measure Set.
    Two of the proposed mandatory measures, LTSS-1 and LTSS-2, have 
HEDIS-equivalent measures.\24\ In the informational bulletin for the 
2024 HCBS Quality Measure Set, we indicated that, for measures with a 
HEDIS equivalent, States can opt to use the HEDIS equivalent for their 
managed care and fee-for-service (FFS) populations.\25\ Consistent with 
that approach, we are soliciting comment on whether to allow States to 
report on the HEDIS equivalent of LTSS-1 and LTSS-2 to meet the 
proposed mandatory reporting requirement for those measures. We request 
comment on these proposed options for States.
---------------------------------------------------------------------------

    \24\ For more information about the technical specifications for 
the LTSS measures, see https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-quality/long-term-services-supports-quality-measures.
    \25\ CMCS Informational Bulletin, ``2024 Home and Community-
Based Services (HCBS) Quality Measure Set (QMS).'' Published April 
11, 2024. Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/cib041124.pdf.
---------------------------------------------------------------------------

    Functional Assessment Standardized Items (FASI) is a set of 
reliable, valid person-centered standardized items developed and tested 
by CMS to measure functional status and need for assistance with 
everyday activities among Medicaid HCBS participants.\26\ Two 
performance measures derived from FASI, FASI Performance Measure 1 
(FASI-1): Identifying Personal Priorities for Functional Assessment 
Standardized Items (FASI) Needs \27\ and FASI Performance Measure 2 
(FASI-2): Alignment of Person-Centered Service Plan (PCSP) with 
Functional Needs as Determined by Functional Assessment Standardized 
Items,\28\ can be used to assess State performance related to person-
centered planning. In the informational bulletin for the 2024 HCBS 
Quality Measure Set, we indicated that States have the option to report 
on FASI-1 and FASI-2 in place of LTSS-1 and LTSS-2, respectively. 
Consistent with that approach, we are soliciting comment on whether to 
allow States to report on FASI-1 and FASI-2 in place of LTSS-1 and 
LTSS-2, respectively. We request comment on these proposed options for 
States.
---------------------------------------------------------------------------

    \26\ For more information on FASI, see https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-quality/functional-assessments-quality-improvement.
    \27\ For more information on FASI-1, see https://cmit.cms.gov/cmit/#/MeasureView?variantId=5223§ionNumber=1.
    \28\ For more information on FASI-2, see https://cmit.cms.gov/cmit/#/MeasureView?variantId=5224§ionNumber=1.
---------------------------------------------------------------------------

    As shown in Table 4, we are soliciting comment on collecting the 
data on the proposed mandatory measures through several different 
methods, depending on the measure. These methods include: CMS analyses 
using T-MSIS Analytic Files; \29\ the HCBS CAHPS database; \30\ the 
Medicaid Data Collection Tool (MDCT),\31\ which we proposed to use to 
collect data on measures that are not available through existing data 
sources or that States opt to not have CMS report on their behalf using 
T-MSIS Analytic Files; NCI-AD survey data collection; and NCI-IDD 
survey data collection. Specifically, we are soliciting comment on 
whether to provide States the option to elect, for each of the three 
administrative data measures, to either self-report using a 
standardized form in MDCT or have CMS conduct analyses and report on 
the State's behalf using T-MSIS Analytic Files, consistent with Sec.  
441.312(d)(1)(iii). We are also proposing to require States that 
conduct the HCBS CAHPS survey to report the results to the HCBS CAHPS 
survey database managed by the Agency for Healthcare Research and 
Quality (AHRQ) and for CMS to work with AHRQ to obtain the survey 
results from the HCBS CAHPS database rather than through State 
reporting directly to CMS. For States that conduct NCI-AD and NCI-IDD, 
we are soliciting comment on States reporting the data through the 
existing processes for those surveys and for CMS to obtain the survey 
results directly from the measure stewards (ADvancing States and Human 
Services Research Institute (HSRI) for NCI-AD; and the National 
Association of State Directors of Developmental Disabilities Services 
(NASDDDS) and HSRI for NCI-IDD), rather than through State reporting 
directly to CMS. We believe these proposals would reduce State 
reporting

[[Page 22831]]

burden by using existing data sources for the proposed measures to the 
extent feasible. CMS currently has an inter-agency agreement with AHRQ 
that allows CMS access to HCBS CAHPS survey data. CMS plans to 
establish similar agreements with other survey stewards to access NCI-
AD and NCI-IDD data, as well as any State-level data use agreements 
that may be necessary to facilitate data sharing. For all other 
measures, we are soliciting comment on whether to require States to 
self-report the measures using a standardized form in MDCT, as we are 
not aware of existing data sources for those measures. We request 
comment on these proposals, particularly on whether there are existing 
data sources for any of the measures that States would otherwise need 
to self-report using a standardized form in MDCT.
---------------------------------------------------------------------------

    \29\ For information on T-MSIS and T-MSIS Analytic Files, see 
https://www.medicaid.gov/medicaid/data-systems/macbis/transformed-medicaid-statistical-information-system-t-msis.
    \30\ For information on the HCBS CAHPS database, see https://www.ahrq.gov/cahps/cahps-database/hcbs-database/index.html.
    \31\ For information on MDCT, see https://www.medicaid.gov/resources-for-states/medicaid-and-chip-program-portal/medicaid-data-collection-tool-mdct-portal.

                                     Table 4--Proposed Mandatory Measures in the 2028 HCBS Quality Measure Set \32\
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                  Technical                               Mandatory
            CMIT ID                Measure steward      Measure name        Type of data       specifications        Method of       stratification for
                                                                               source               \33\          reporting to CMS          2028
--------------------------------------------------------------------------------------------------------------------------------------------------------
00095-01-C-LTSS................  CMS...............  HCBS CAHPS:         Participant-        Numerator: The      HCBS CAHPS         No.
                                                      Choosing the        Reported Data/      number of survey    database.
                                                      Services That       Survey.             respondents who
                                                      Matter to You                           answered ``All''
                                                      Composite Measure.                      to Question 56
                                                                                              and the number of
                                                                                              respondents who
                                                                                              answered ``Yes''
                                                                                              to Question 57 on
                                                                                              the HCBS CAHPS
                                                                                              Survey.
                                                                                             Denominator: The
                                                                                              number of survey
                                                                                              respondents who
                                                                                              answered ``Yes''
                                                                                              to HCBS CAHPS
                                                                                              Survey screener
                                                                                              questions 4, 6,
                                                                                              8, or 11.
00095-03-C-LTSS................  CMS...............  HCBS CAHPS:         Participant-        Numerator: The      HCBS CAHPS         No.
                                                      Personal Safety &   Reported Data/      number of survey    database.
                                                      Respect Composite   Survey.             respondents who
                                                      Measure.                                gave the most
                                                                                              positive response
                                                                                              to each question,
                                                                                              such as ``Yes''
                                                                                              to question 64,
                                                                                              and ``No'' to
                                                                                              questions 65 and
                                                                                              68 on the HCBS
                                                                                              CAHPS Survey.
                                                                                             Denominator: For
                                                                                              each question in
                                                                                              the scale, the
                                                                                              denominator is
                                                                                              the total number
                                                                                              of respondents
                                                                                              who answered the
                                                                                              question.
00095-04-C-LTSS................  CMS...............  HCBS CAHPS:         Participant-        Numerator: The      HCBS CAHPS         No.
                                                      Physical Safety     Reported Data/      number of survey    database.
                                                      Single-Item         Survey.             respondents who
                                                      Measure.                                answered ``No''
                                                                                              to question 71 on
                                                                                              the HCBS CAHPS
                                                                                              Survey.
                                                                                             Denominator: The
                                                                                              total number of
                                                                                              survey
                                                                                              respondents who
                                                                                              answered the
                                                                                              question.
00095-07-C-LTSS................  CMS...............  HCBS CAHPS:         Participant-        Numerator: The      HCBS CAHPS         No.
                                                      Transportation to   Reported Data/      number of survey    database.
                                                      Medical             Survey.             respondents who
                                                      Appointments                            gave the most
                                                      Composite Measure.                      positive response
                                                                                              to each question,
                                                                                              such as
                                                                                              ``Always'' to
                                                                                              questions 59 and
                                                                                              62, and ``Yes''
                                                                                              to question 61 on
                                                                                              HCBS CAHPS.
                                                                                             Denominator: For
                                                                                              each question in
                                                                                              the scale, the
                                                                                              denominator is
                                                                                              the total number
                                                                                              of respondents
                                                                                              who answered the
                                                                                              question.
00960-01-C-LTSS (MLTSS-1) and    CMS...............  LTSS-1: Long-Term   Assessment/Case     Numerator: The      MDCT.............  Yes.
 00960-02-C-LTSS (FFS LTSS-1).                        Services and        Management System.  measure reports
                                                      Supports                                two numerators.
                                                      Comprehensive                          Rate 1: Assessment
                                                      Assessment and                          of Core Elements:
                                                      Update \34\ \35\.                       The number of
                                                                                              Medicaid LTSS
                                                                                              participants who
                                                                                              had a long-term
                                                                                              services and
                                                                                              supports
                                                                                              comprehensive
                                                                                              assessment with
                                                                                              ten core elements
                                                                                              documented within
                                                                                              90 days of
                                                                                              enrollment (for
                                                                                              new participants)
                                                                                              or during the
                                                                                              measurement year
                                                                                              (for established
                                                                                              participants).
                                                                                             Rate 2: Assessment                     ....................
                                                                                              of Supplemental
                                                                                              Elements: The
                                                                                              number of
                                                                                              Medicaid LTSS
                                                                                              participants who
                                                                                              had a long-term
                                                                                              services and
                                                                                              supports
                                                                                              comprehensive
                                                                                              assessment with
                                                                                              ten core elements
                                                                                              and at least 12
                                                                                              supplemental
                                                                                              elements
                                                                                              documented within
                                                                                              90 days of
                                                                                              enrollment (for
                                                                                              new participants)
                                                                                              or during the
                                                                                              measurement year
                                                                                              (for established
                                                                                              participants).
                                                                                             Denominator: A                         ....................
                                                                                              statistically
                                                                                              valid random
                                                                                              sample of
                                                                                              Medicaid LTSS
                                                                                              participant case
                                                                                              management
                                                                                              records drawn
                                                                                              from the eligible
                                                                                              population.

[[Page 22832]]

 
00961-01-C-LTSS (MLTSS-2) and    CMS...............  LTSS-2: Long-Term   Assessment/Case     Numerator: The      MDCT.............  Yes.
 00961-02-C-LTSS (FFS LTSS-2).                        Services and        Management System.  measure reports
                                                      Supports                                two numerators.
                                                      Comprehensive                          Rate 1: Person-
                                                      Person-Centered                         Centered Plan
                                                      Plan and Update                         with Core
                                                      \36\ \37\.                              Elements:
                                                                                              Medicaid LTSS
                                                                                              participants who
                                                                                              had a long-term
                                                                                              services and
                                                                                              supports
                                                                                              comprehensive
                                                                                              care plan with
                                                                                              ten core elements
                                                                                              documented within
                                                                                              120 days of
                                                                                              enrollment (for
                                                                                              new participants)
                                                                                              or during the
                                                                                              measurement year
                                                                                              (for established
                                                                                              participants).
                                                                                             Rate 2: Person-                        ....................
                                                                                              Centered Plan
                                                                                              with Supplemental
                                                                                              Elements
                                                                                              Documented: The
                                                                                              number of
                                                                                              Medicaid LTSS
                                                                                              participants who
                                                                                              had a long-term
                                                                                              services and
                                                                                              supports
                                                                                              comprehensive
                                                                                              care plan with
                                                                                              nine core
                                                                                              elements and at
                                                                                              least four
                                                                                              supplemental
                                                                                              elements
                                                                                              documented within
                                                                                              120 days of
                                                                                              enrollment (for
                                                                                              new participants)
                                                                                              or during the
                                                                                              measurement year
                                                                                              (for established
                                                                                              participants).
                                                                                             Denominator: A                         ....................
                                                                                              statistically
                                                                                              valid random
                                                                                              sample of
                                                                                              Medicaid LTSS
                                                                                              participant case
                                                                                              management
                                                                                              records drawn
                                                                                              from the eligible
                                                                                              population.
00020-03-C-LTSS (FFS LTSS-6)     CMS...............  LTSS-6: Long-Term   Administrative      Numerator: The      MDCT or CMS-       Yes.
 and 00020-04-C-LTSS (MLTSS-6).                       Services and        Data.               number of           analyses using T-
                                                      Supports                                facility            MSIS data.
                                                      Admission to a                          admissions (FA)
                                                      Facility from the                       from a community
                                                      Community.                              residence from
                                                                                              August 1 of the
                                                                                              year prior to the
                                                                                              measurement year
                                                                                              through July 31
                                                                                              of the
                                                                                              measurement year.
                                                                                              The following
                                                                                              three performance
                                                                                              rates are
                                                                                              reported across
                                                                                              four age groups
                                                                                              (18 to 64, 65 to
                                                                                              74, 75 to 84, and
                                                                                              85 and older).
                                                                                             Short-Term Stay:                       ....................
                                                                                              The rate of
                                                                                              admissions
                                                                                              resulting in a
                                                                                              short-term stay
                                                                                              (1 to 20 days)
                                                                                              per 1,000
                                                                                              Medicaid LTSS
                                                                                              participant
                                                                                              months.
                                                                                             Medium-Term Stay:                      ....................
                                                                                              The rate of
                                                                                              admissions
                                                                                              resulting in a
                                                                                              medium-term stay
                                                                                              (21 to 100 days)
                                                                                              per 1,000
                                                                                              Medicaid LTSS
                                                                                              participant
                                                                                              months.
                                                                                             Long-Term Stay:                        ....................
                                                                                              The rate of
                                                                                              admissions
                                                                                              resulting in a
                                                                                              long-term stay
                                                                                              (greater than or
                                                                                              equal to 101
                                                                                              days) per 1,000
                                                                                              Medicaid LTSS
                                                                                              participant
                                                                                              months.
                                                                                             Denominator:                           ....................
                                                                                              Number of
                                                                                              participant
                                                                                              months where the
                                                                                              participant was
                                                                                              residing in the
                                                                                              community for at
                                                                                              least one day of
                                                                                              the month.
00968-01-C-LTSS (MLTSS-7) and    CMS...............  LTSS-7: Long-Term   Administrative      Numerator: The      MDCT or CMS-       Yes.
 00968-01-C-LTSS (FFS LTSS-7).                        Services and        Data.               count of            analyses using T-
                                                      Supports                                discharges from a   MSIS data.
                                                      Minimizing                              facility to the
                                                      Facility Length                         community during
                                                      of Stay.                                the measurement
                                                                                              year that
                                                                                              occurred within
                                                                                              100 days or fewer
                                                                                              of admission.
                                                                                              Discharges that
                                                                                              result in death,
                                                                                              hospitalization,
                                                                                              or readmission to
                                                                                              the facility
                                                                                              within 60 days of
                                                                                              discharge from
                                                                                              the facility do
                                                                                              not meet the
                                                                                              element.
                                                                                             Denominator:                           ....................
                                                                                              Number of
                                                                                              facility
                                                                                              admissions
                                                                                              occurring during
                                                                                              the measurement
                                                                                              period, removing
                                                                                              those for which
                                                                                              the admission
                                                                                              represented a
                                                                                              transfer between
                                                                                              facilities and
                                                                                              those for which a
                                                                                              death occurred
                                                                                              while admitted
                                                                                              (on the same day
                                                                                              as the admission
                                                                                              or within one day
                                                                                              of discharge).

[[Page 22833]]

 
000414-03-C-LTSS (MLTSS-8) and   CMS...............  LTSS-8: Long-Term   Administrative      Numerator: The      MDCT or CMS-       Yes.
 000414-04-C-LTSS (FFS LTSS-8).                       Services and        Data.               count of            analyses using T-
                                                      Supports                                discharges from a   MSIS data.
                                                      Successful                              facility to the
                                                      Transition after                        community from
                                                      Long-Term                               July 1 of the
                                                      Facility Stay.                          year prior to the
                                                                                              measurement year
                                                                                              through October
                                                                                              31 of the
                                                                                              measurement year
                                                                                              that result in a
                                                                                              successful
                                                                                              transition to the
                                                                                              community for 60
                                                                                              consecutive days.
                                                                                              Discharges that
                                                                                              result in death,
                                                                                              hospitalization,
                                                                                              or readmission to
                                                                                              the facility
                                                                                              within 60 days of
                                                                                              discharge from
                                                                                              the facility do
                                                                                              not meet the
                                                                                              element.
                                                                                             Denominator:                           ....................
                                                                                              Number of
                                                                                              discharges
                                                                                              occurring during
                                                                                              the measurement
                                                                                              period, removing
                                                                                              those for which
                                                                                              the discharge
                                                                                              represented a
                                                                                              transfer between
                                                                                              facilities and
                                                                                              those for which
                                                                                              an expiration
                                                                                              occurred while
                                                                                              admitted (on the
                                                                                              same day as the
                                                                                              admission or
                                                                                              within one day of
                                                                                              discharge).
00457-05-C-MACS................  ADvancing States,   NCI-AD: Percentage  Participant-        Numerator: The      NCI-AD survey      No.
                                  Human Services      of People Who are   Reported Data/      number of           data collection.
                                  Research            as Active in        Survey.             respondents who
                                  Institute (HSRI).   Their Community                         report ``Yes'' to
                                                      as They Would                           the question.
                                                      Like to Be.                            Denominator: The
                                                                                              number of
                                                                                              respondents who
                                                                                              answered the
                                                                                              question on the
                                                                                              NCI-AD Adult
                                                                                              Consumer Survey.
00457-10-C-MACS................  ADvancing States,   NCI-AD: Percentage  Participant-        Numerator: The      NCI-AD survey      No.
                                  HSRI.               of People Who       Reported Data/      number of           data collection.
                                                      Feel Safe Around    Survey.             respondents who
                                                      Their Support                           report ``Yes, All
                                                      Staff.                                  Paid Support
                                                                                              Workers, Always
                                                                                              or Almost
                                                                                              Always.''.
                                                                                             Denominator: The
                                                                                              number of
                                                                                              respondents who
                                                                                              answered the
                                                                                              question on the
                                                                                              NCI-AD Adult
                                                                                              Consumer Survey.
00457-13-C-MACS................  ADvancing States,   NCI-AD: Percentage  Participant-        Numerator: The      NCI-AD survey      No.
                                  HSRI.               of People Who       Reported Data/      number of           data collection.
                                                      Have                Survey.             respondents who
                                                      Transportation to                       report ``Yes'' to
                                                      Get to Medical                          the question.
                                                      Appointments When                      Denominator: The
                                                      They Need to.                           number of
                                                                                              respondents who
                                                                                              answered the
                                                                                              question on the
                                                                                              NCI-AD Adult
                                                                                              Consumer Survey.
00457-14-C-MACS................  ADvancing States,   NCI-AD: Percentage  Participant-        Numerator: The      NCI-AD survey      No.
                                  HSRI.               of People Who       Reported Data/      number of           data collection.
                                                      Have                Survey.             respondents who
                                                      Transportation                          report ``Yes'' to
                                                      When They Want to                       the question.
                                                      Do Things Outside                      Denominator: The
                                                      of Their Home.                          number of
                                                                                              respondents who
                                                                                              answered the
                                                                                              question on the
                                                                                              NCI-AD Survey.
00457-17-C-MACS................  ADvancing States,   NCI-AD: Percentage  Participant-        Numerator: The      NCI-AD survey      No.
                                  HSRI.               of People Whose     Reported Data/      number of           data collection.
                                                      Service Plan        Survey.             respondents who
                                                      Includes Their                          report ``Yes, all/
                                                      Preferences and                         completely'' to
                                                      Choices.                                the question.
                                                                                             Denominator: The
                                                                                              number of
                                                                                              respondents who
                                                                                              answered the
                                                                                              question on the
                                                                                              NCI-AD Adult
                                                                                              Consumer Survey
                                                                                              optional module
                                                                                              for person-
                                                                                              centered planning.
01823-07-C-LTSS................  National            NCI-IDD PCP-5:      Participant-        Numerator of Each   NCI-IDD survey     No.
                                  Association of      Satisfaction with   Reported Data/      Constituent Item    data collection.
                                  State Directors     Community           Survey.             Score: The number
                                  of Developmental    Inclusion Scale                         of people who
                                  Disabilities        (The Proportion                         reported
                                  Services            of People Who                           satisfaction with
                                  (NASDDDS), HSRI.    Report                                  the frequency of
                                                      Satisfaction with                       their
                                                      the Level of                            participation in
                                                      Participation in                        the indicated
                                                      Community-                              activity, or the
                                                      Inclusion                               number of people
                                                      Activities).                            who report that
                                                                                              they do not want
                                                                                              to be part of
                                                                                              more community
                                                                                              groups.
                                                                                             Denominator of
                                                                                              Each Constituent
                                                                                              Item Score:
                                                                                              Number of people
                                                                                              who provided a
                                                                                              valid response.
                                                                                             Scale Calculation:                     ....................
                                                                                              Mean of the item
                                                                                              scores for
                                                                                              respondents who
                                                                                              provided valid
                                                                                              responses to at
                                                                                              least two of the
                                                                                              questions.
01823-03-C-MACS................  NASDDDS, HSRI.....  NCI-IDD CI-1:       Participant-        Numerator: The      NCI-IDD survey     No.
                                                      Social              Reported Data/      number of people    data collection.
                                                      Connectedness       Survey.             who responded
                                                      (The Proportion                         ``no.''.
                                                      of People Who                          Denominator:
                                                      Report that They                        Number of people
                                                      Do Not Feel                             who provided a
                                                      Lonely Often).                          valid response.

[[Page 22834]]

 
01823-04-C-MACS................  NASDDDS, HSRI.....  NCI-IDD CI-3:       Participant-        Numerator of Each   NCI-IDD survey     No.
                                                      Transportation      Reported Data/      Constituent Item    data collection.
                                                      Availability        Survey.             Score: The number
                                                      Scale (The                              of people with
                                                      Proportion of                           the top box score.
                                                      People Who Report                      Denominator of
                                                      Adequate                                Each Constituent
                                                      Transportation).                        Item Score:
                                                                                              Number of people
                                                                                              who provided a
                                                                                              valid response.
                                                                                             Scale Calculation:                     ....................
                                                                                              Mean of the two
                                                                                              item scores for
                                                                                              respondents who
                                                                                              provided valid
                                                                                              responses to both
                                                                                              questions.
01823-05-C-LTSS................  NASDDDS, HSRI.....  NCI-IDD HLR-1:      Participant-        Numerator of Each   NCI-IDD survey     No.
                                                      Respect for         Reported Data/      Constituent Item    data collection.
                                                      Personal Space      Survey.             Score: The number
                                                      Scale (The                              of people with
                                                      Proportion of                           the top box score.
                                                      People Who Report                      Denominator of
                                                      that Their                              Each Constituent
                                                      Personal Space is                       Item Score:
                                                      Respected in the                        Number of people
                                                      Home).                                  who provided a
                                                                                              valid response.
01823-06-C-LTSS................  NASDDDS, HSRI.....  NCI-IDD PCP 2:      Participant-        Numerator: The      NCI-IDD survey     No.
                                                      Person-Centered     Reported Data/      number of people    data collection.
                                                      Goals (The          Survey.             with the top box
                                                      Proportion of                           score.
                                                      People Who Report                      Denominator:
                                                      their Service                           Number of people
                                                      Plan Includes                           who provided a
                                                      Things that are                         valid response.
                                                      Important to
                                                      Them).
01822-01-C-LTSS................  Council on Quality  POM: People are     Participant-        Numerator: The      MDCT.............  No.
                                  and Leadership      free from abuse     Reported Data/      number of
                                  (CQL).              and neglect.        Survey.             respondents who
                                                                                              are not subjected
                                                                                              to abuse,
                                                                                              neglect,
                                                                                              mistreatment, or
                                                                                              exploitation from
                                                                                              anyone.
                                                                                             Denominator: The
                                                                                              number of survey
                                                                                              respondents
                                                                                              (people with
                                                                                              disabilities 18
                                                                                              and older) who
                                                                                              provided valid
                                                                                              answers to the
                                                                                              survey question.
01822-02-C-LTSS................  CQL...............  POM: People Choose  Participant-        Numerator: The      MDCT.............  No.
                                                      Services.           Reported Data/      number of
                                                                          Survey.             respondents who
                                                                                              choose the
                                                                                              services/supports
                                                                                              they receive,
                                                                                              their provider
                                                                                              organizations,
                                                                                              and their direct
                                                                                              support
                                                                                              professionals/
                                                                                              staff.
                                                                                             Denominator: The                       ....................
                                                                                              number of survey
                                                                                              respondents
                                                                                              (people with
                                                                                              disabilities 18
                                                                                              and older) who
                                                                                              provided valid
                                                                                              answers to the
                                                                                              survey question.
01822-06-C-LTSS................  CQL...............  POM: People         Participant-        Numerator: The      MDCT.............  No.
                                                      Participate in      Reported Data/      number of
                                                      the Life of the     Survey.             respondents who
                                                      Community.                              participate in
                                                                                              the life of the
                                                                                              community, with
                                                                                              the type and
                                                                                              frequency of
                                                                                              participation
                                                                                              they prefer.
                                                                                             Denominator: The                       ....................
                                                                                              number of survey
                                                                                              respondents
                                                                                              (people with
                                                                                              disabilities 18
                                                                                              and older) who
                                                                                              provided valid
                                                                                              answers to the
                                                                                              survey question.
01822-07-C-LTSS................  CQL...............  POM: People         Participant-        Numerator: The      MDCT.............  No.
                                                      Realize Personal    Reported Data/      number of
                                                      Goals.              Survey.             respondents who
                                                                                              accomplish goals
                                                                                              significant to
                                                                                              them.
                                                                                             Denominator: The                       ....................
                                                                                              number of survey
                                                                                              respondents
                                                                                              (people with
                                                                                              disabilities 18
                                                                                              and older) who
                                                                                              provided valid
                                                                                              answers to the
                                                                                              survey question.
--------------------------------------------------------------------------------------------------------------------------------------------------------

B. Proposed Voluntary Measures
---------------------------------------------------------------------------

    \32\ The measures listed in this table are the same as the 
measures that MFP grant recipients are expected to report on in 
2026.
    \33\ For measures with separate FFS and MLTSS versions, there 
may be some wording differences in the technical specifications for 
the FFS and/or MLTSS versions compared to the information presented 
in this table. This table is for informational purposes only for the 
ease of commenting on the proposed measures. We refer the reader to 
the detailed technical specifications maintained by the measure 
steward for the most up to date technical specifications and 
additional information on the measures.
    \34\ We are soliciting comments on whether to give States the 
option to report on the HEDIS equivalent of LTSS-1 in place of LTSS-
1.
    \35\ We are soliciting comments on whether to give States the 
option to report on FASI-1 in place of LTSS-1. For more information 
on FASI-1, see https://cmit.cms.gov/cmit/#/MeasureView?variantId=5223§ionNumber=1.
    \36\ We are soliciting comments on whether to give States the 
option to report on the HEDIS equivalent of LTSS-2 in place of LTSS-
2.
    \37\ We are soliciting comments on whether to give States the 
option to report on FASI-2 in place of LTSS-2. For more information 
on FASI-2, see https://cmit.cms.gov/cmit/#/MeasureView?variantId=5224§ionNumber=1.
---------------------------------------------------------------------------

    As discussed in sections I.A., I.C., and II.A. of this notice with 
comment period, we used the 2024 HCBS Quality Measure Set as the basis 
for the 2028 HCBS Quality Measure Set. We also considered the 
recommendations of the HCBS Quality Measure Set Review Workgroup and 
existing reporting requirements for the 41 States and territories 
participating in the MFP demonstration. LTSS-4: Reassessment

[[Page 22835]]

and Person-Centered Plan Update after Inpatient Discharge and MLTSS-5: 
Screening, Risk Assessment, and Plan of Care to Prevent Future Falls 
are included in the 2024 HCBS Quality Measure Set and are voluntary for 
MFP grant recipients to report on in 2026. We are soliciting comments 
on whether to include these two assessment/case management system 
measures as voluntary measures in the 2028 HCBS Quality Measure Set. 
These measures focus on person-centered planning after inpatient 
discharge (LTSS-4) and reducing the risk of falls (MLTSS-5). LTSS-4 
addresses the timeliness and person-centeredness of reassessments 
following a discharge, which supports continuity of care and aligns 
with the person-centered planning domain. MLTSS-5 supports fall risk 
mitigation efforts and care planning for older adults and others at 
risk of injury in the community setting, which aligns with the safety 
and wellness domain. Both measures were developed through CMS-led 
measure development efforts and are considered feasible for reporting 
using existing data sources because the required information is already 
contained in assessment and case management records. However, we also 
recognize the burden associated with quality measurement and reporting, 
particularly for measures that require assessment or case management 
records. As stated earlier in section II.A. of this notice with comment 
period, our goal is to balance the administrative burden on States with 
the need for a comprehensive, evidence-based measure set that can drive 
improvement in quality and outcomes. We believe that including these 
measures as voluntary measures in 2028 would allow States to gain 
experience implementing these measures and will provide CMS with data 
to evaluate their value and reporting feasibility before considering 
whether broader adoption is warranted. We request comment on our 
proposals to include LTSS-4 and MLTSS-5 as voluntary measures in the 
2028 HCBS Quality Measure Set.
    We are also proposing to give States the option to voluntarily 
report any HCBS CAHPS, NCI-AD, NCI-IDD, or POM measure that is not 
proposed for inclusion in the 2028 HCBS Quality Measure Set as a 
mandatory measure. Rather than proposing each such measure as a 
specific voluntary measure, we are proposing to give States this option 
generally. We believe that including all of these measures as specific 
voluntary measures would result in an excessive number of voluntary 
measures. This, in turn, could make it difficult for States to use the 
list of voluntary measures to identify measures that would be 
meaningful and useful for quality improvement purposes, and make it 
unlikely that a sufficient number of States would report on each 
measure to support public reporting or provide States with comparative 
data for quality improvement purposes. Based on our review of the 
remaining survey measures, we have not, at this time, identified a 
compelling justification for including additional voluntary measures. 
We welcome comment or additional evidence that could inform future 
selection decisions. However, we also believe that participant-reported 
survey measures are important for understanding the perspectives and 
experiences of beneficiaries and provide valuable indicators of quality 
and outcomes that often cannot be measured using other data sources. As 
a result, rather than proposing the inclusion of specific survey 
measures as voluntary measures, we are soliciting comments on whether 
to allow States to report as voluntary measures any HCBS CAHPS, NCI-AD, 
NCI-IDD, and POM measure not included as mandatory measures.\38\ We 
also welcome comments on potential uses of voluntarily reported data, 
including considerations around publication and utility for quality 
improvement. We believe that allowing States to report as voluntary 
measures any HCBS CAHPS, NCI-AD, NCI-IDD, and POM measure not included 
as mandatory measures recognizes the importance and value of 
participant-reported survey measures and provides States flexibility to 
report on survey measures that are most meaningful for their programs 
and quality improvement efforts. We request comment on this proposed 
approach.
---------------------------------------------------------------------------

    \38\ As discussed earlier in sections I.C. and II.A. of this 
notice with comment period, the HCBS Quality Measure Set Review 
Workgroup recommended adding three NCI-AD measures and one NCI-IDD 
measure to the HCBS Quality Measure Set. Based on this proposal and 
the rationale for this proposal, we are not proposing the addition 
of the NCI-AD and NCI-IDD measures recommended for addition by the 
workgroup.
---------------------------------------------------------------------------

    Table 5 provides the proposed voluntary measures in the 2028 HCBS 
Quality Measure Set. Similar to Table 4, Table 5 includes the CMIT 
ID,\39\ the measure steward, the measure name, the type of data source, 
the method of reporting to CMS, and brief technical specifications for 
each proposed measure. As with the proposed mandatory measures, the 
CMIT ID, measure steward, and measure name are provided to clearly 
identify each proposed voluntary measure. Commenters are encouraged to 
use the CMIT ID and/or the measure name as written in the table when 
referencing specific measures in comments. The type of data source 
provides information on the type of data States would need to collect 
and analyze to report on the measure, as determined by the measure 
steward. The technical specifications provide information on the 
numerator and denominator for each measure and are provided for 
informational purposes only. The method of reporting to CMS provides 
information on our proposed method for States to report the results of 
each proposed measure. More detailed information on each measure is 
available in CMIT or from the measure steward for each measure. We 
discuss the proposed method of reporting each measure later in this 
section.
---------------------------------------------------------------------------

    \39\ CMIT is available at https://cmit.cms.gov/cmit/#/.
---------------------------------------------------------------------------

    We considered whether to include, as voluntary measures in the 2028 
HCBS Quality Measure Set, five other measures that are included in the 
2024 HCBS Quality Measure Set. These include: FASI-1 and FASI-2, which 
are discussed in more detail in section II.A. of this notice with 
comment period; HCBS-10: Self-Direction of Services and Supports among 
Medicaid Beneficiaries Receiving LTSS through Managed Care 
Organizations; Plan All-Cause Readmission; and LTSS-3: Shared Person-
Centered Plan with Primary Care Provider. As discussed earlier in 
section II.A. of this notice with comment period, we are soliciting 
comments on whether to allow States to report on FASI-1 and FASI-2, in 
place of two proposed mandatory measures, LTSS-1 and LTSS-2, 
respectively. We believe there is little value in also including FASI-1 
and FASI-2 as proposed voluntary measures in the 2028 HCBS Quality 
Measure Set, as it is very unlikely that a State would report on both 
LTSS-1 and FASI-1 or both LTSS-2 and FASI-2 because the measures 
address similar aspects of person-centered planning.
    HCBS-10 is a CMS-stewarded process measure that relies on case 
management record data and assesses the offer, and selection, of self-
directed services among adult MLTSS enrollees who receive HCBS.\40\ 
While this is the only measure in the 2024 HCBS Quality Measure Set 
that is focused explicitly on self-direction in HCBS, we have received 
feedback from interested parties that it is an administratively 
burdensome measure and that it provides unclear information on quality

[[Page 22836]]

of care or outcomes. As a result, we are not proposing HCBS-10 for 
inclusion as a voluntary measure in the 2028 HCBS Quality Measure Set.
---------------------------------------------------------------------------

    \40\ For more information on HCBS-10, see https://cmit.cms.gov/cmit/#/MeasureView?variantId=13283§ionNumber=1.
---------------------------------------------------------------------------

    Plan All-Cause Readmission is a HEDIS measure that assesses the 
percentage of acute inpatient and observation stays during the 
measurement year that were followed by an unplanned acute readmission 
for any diagnosis within 30 days, for participants 65 years of age and 
older.\41\ It is available for use in managed care only, does not have 
a FFS equivalent, and is focused only on the older adult population. As 
such, we are not proposing Plan All-Cause Readmission for inclusion as 
a voluntary measure in the 2028 HCBS Quality Measure Set.
---------------------------------------------------------------------------

    \41\ For more information on the Plan All-Cause Readmission 
Measure, see https://cmit.cms.gov/cmit/#/MeasureView?variantId=13284§ionNumber=1.
---------------------------------------------------------------------------

    LTSS-3 is a CMS-stewarded measure, with a FFS and managed care 
version, that relies on case management record data and assesses the 
percentage of Medicaid LTSS participants, aged 18 and older, with a 
person-centered plan transmitted to their primary care provider (or 
other documented medical care provider) identified by the participant 
within 30 days of its development.\42\ LTSS-3 was recommended for 
removal from the HCBS Quality Measure Set by the HCBS Quality Measure 
Set Review Workgroup. The Workgroup believed that the value of this 
measure did not justify the high administrative burden States will 
experience collecting and reporting it, due to the manual effort 
associated with reviewing case management records in many States. 
Members of the Workgroup also asserted that such measures are often 
highly scored, providing limited opportunity for further improvement 
and generating few insights into actual quality of care. Given the 
proposed inclusion of other measures focused on person-centered care, 
we are not proposing to include LTSS-3 in the 2028 HCBS Quality Measure 
Set. We request comment on whether FASI-1, FASI-2, HCBS-10, Plan All-
Cause Readmission, or LTSS-3 should be included as voluntary measures 
in the 2028 HCBS Quality Measure Set.
---------------------------------------------------------------------------

    \42\ For more information on LTSS-3, see https://cmit.cms.gov/cmit/#/FamilyView?familyId=963.
---------------------------------------------------------------------------

    Consistent with our proposed approach to collecting the data for 
the proposed mandatory measures, we are soliciting comments on whether 
to collect the data on voluntary measures through several different 
methods, depending on the measure. These methods include CMS analyses 
using T-MSIS Analytic Files; \43\ the HCBS CAHPS database; the MDCT; 
\44\ NCI-AD survey data collection; and NCI-IDD survey data collection. 
Specifically, we are soliciting comments on whether to provide States 
the option to self-report administrative data measures using a 
standardized form in MDCT or for CMS to conduct analyses and report on 
the State's behalf using T-MSIS Analytic Files, consistent with Sec.  
441.312(d)(1)(iii).\45\ We are also proposing for States that conduct 
the HCBS CAHPS survey to report the results to the HCBS CAHPS survey 
database managed by AHRQ and for CMS to work with AHRQ to obtain the 
survey results from the HCBS CAHPS database rather than through State 
reporting directly to CMS. For States that conduct NCI-AD and NCI-IDD, 
we are soliciting comments on whether data should be reported through 
the existing processes for those surveys, with CMS obtaining results 
directly from the measure stewards (ADvancing States and HSRI for NCI-
AD; and NASDDDS and HSRI for NCI-IDD), rather than through State 
reporting directly to CMS. We believe these proposals would reduce 
State reporting burden by using existing data sources for the proposed 
measures to the extent feasible. For all other measures (including the 
two proposed voluntary measures, LTSS-4 and MLTSS-5), we are soliciting 
comments on whether to require States to self-report the measures using 
a standardized form in MDCT, as we are not aware of existing data 
sources for those measures. We request comment on these proposals, 
particularly related to whether there are existing data sources for 
measures for which States would need to self-report the measures using 
a standardized form in MDCT.
---------------------------------------------------------------------------

    \43\ For information on T-MSIS and T-MSIS Analytic Files, see 
https://www.medicaid.gov/medicaid/data-systems/macbis/transformed-medicaid-statistical-information-system-t-msis.
    \44\ For information on MDCT, see https://www.medicaid.gov/resources-for-states/medicaid-and-chip-program-portal/medicaid-data-collection-tool-mdct-portal.
    \45\ Although we are not proposing any administrative data 
measures for voluntary reporting, we have included our proposed 
approach to collecting data on administrative data measures in the 
event that we include administrative data measures in the 2028 HCBS 
Quality Measure Set as voluntary measures.

                                        Table 5--Proposed Voluntary Measures in the 2028 HCBS Quality Measure Set
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                             Method of reporting         Technical
             CMIT No.                    Measure steward           Measure name       Type of data source           to CMS          specifications \46\
--------------------------------------------------------------------------------------------------------------------------------------------------------
00962-01-C-LTSS (MLTSS-4) and       CMS.....................  LTSS-4: Reassessment   Assessment/Case        MDCT.................  Numerator: The
 00962-02-C-LTSS (FFS LTSS-4).                                 and Person-Centered    Management System.                            measure reports two
                                                               Plan Update after                                                    numerators.
                                                               Inpatient Discharge.                                                Rate 1: Reassessment
                                                                                                                                    after Inpatient
                                                                                                                                    Discharge. The
                                                                                                                                    percentage of
                                                                                                                                    discharges from
                                                                                                                                    inpatient facilities
                                                                                                                                    resulting in a long-
                                                                                                                                    term services and
                                                                                                                                    supports
                                                                                                                                    reassessment within
                                                                                                                                    30 days of
                                                                                                                                    discharge.
                                                                                                                                   Rate 2: Reassessment
                                                                                                                                    and Person-Centered
                                                                                                                                    Plan Update after
                                                                                                                                    Inpatient Discharge.
                                                                                                                                    The percentage of
                                                                                                                                    discharges from
                                                                                                                                    inpatient facilities
                                                                                                                                    resulting in a long-
                                                                                                                                    term services and
                                                                                                                                    supports
                                                                                                                                    reassessment and
                                                                                                                                    care plan update
                                                                                                                                    within 30 days of
                                                                                                                                    discharge.

[[Page 22837]]

 
                                                                                                                                   Denominator: A
                                                                                                                                    statistically valid
                                                                                                                                    random sample of
                                                                                                                                    inpatient discharges
                                                                                                                                    drawn from the
                                                                                                                                    eligible population.
                                                                                                                                    The denominator is
                                                                                                                                    based on discharges,
                                                                                                                                    not on participants.
                                                                                                                                    Participants may
                                                                                                                                    appear more than
                                                                                                                                    once in the sample.
01255-01-C-LTSS...................  CMS.....................  MLTSS-5: Screening,    Assessment/Case        MDCT.................  Numerator: The number
                                                               Risk Assessment, and   Management System.                            of Medicaid MLTSS
                                                               Plan of Care to                                                      participants who
                                                               Prevent Future Falls.                                                have documentation
                                                                                                                                    of an evaluation of
                                                                                                                                    whether the
                                                                                                                                    participant has
                                                                                                                                    experienced a fall
                                                                                                                                    or problems with
                                                                                                                                    balance or gait.
                                                                                                                                   Denominator: A
                                                                                                                                    statistically valid
                                                                                                                                    random sample of
                                                                                                                                    Medicaid MLTSS
                                                                                                                                    participants drawn
                                                                                                                                    from the eligible
                                                                                                                                    population.
Varies............................  Varies..................  Any HCBS CAHPS, NCI-   Participant-Reported   HCBS CAHPS database,   Varies.
                                                               AD, NCI-IDD, or POM    Data/Survey.           NCI-AD survey data
                                                               measure not included                          collection, NCI-IDD
                                                               in the proposed list                          survey data
                                                               of mandatory                                  collection, or MDCT,
                                                               measures.                                     as applicable.
--------------------------------------------------------------------------------------------------------------------------------------------------------

C. Proposed Stratification Requirements
---------------------------------------------------------------------------

    \46\ For the measure with separate FFS and MLTSS versions, there 
may be some wording differences in the technical specifications for 
the FFS and/or MLTSS versions compared to the information presented 
in this table. This table is for informational purposes only for the 
ease of commenting on the proposed measures. We refer the reader to 
the detailed technical specifications maintained by the measure 
steward for the most up to date technical specifications and 
additional information on the measures.
---------------------------------------------------------------------------

    As discussed earlier in section I.B. of this notice with comment 
period, at Sec.  441.312(f), we established a phase-in schedule for 
stratified reporting that requires States to provide stratified data 
for 25 percent of the measures in the HCBS Quality Measure Set by July 
9, 2028, 50 percent by July 9, 2030, and 100 percent by July 9, 2032. 
To meet this requirement, States are required to provide stratified 
data for 25 percent of the mandatory measures in the 2028 HCBS Quality 
Measure Set. In section II.A. of this notice with comment period, we 
indicated that we are soliciting comments on whether to include a total 
of 23 mandatory measures in the 2028 HCBS Quality Measure Set. However, 
we also clarified that we are not proposing to require States to report 
on all 23 measures. Instead, the number of measures that each State 
would need to report in 2028 would vary based on the populations served 
in the State's HCBS programs and the survey(s) selected by the State. 
We further clarified that we believe that each State would need to 
report up to 19 proposed mandatory measures in the 2028 HCBS Quality 
Measure Set. As a result, we are soliciting comments on whether to 
determine the number of proposed mandatory measures that would require 
stratification using the likely maximum number of measures that States 
would need to report, rather than the total number of proposed 
mandatory measures in the 2028 HCBS Quality Measure Set. Specifically, 
we are soliciting comments on whether to require States to report 
stratified data for five of the mandatory measures. We believe this 
approach more effectively recognizes the practical implications of the 
design of the 2028 HCBS Quality Measure Set than an approach based on 
the total number of proposed measures.
    The specific measures proposed for required stratification are 
identified in Table 4 in section II.A. of this notice with comment 
period and include two assessment and care planning measures (LTSS-1 
and LTSS-2) and three administrative data measures (LTSS-6, LTSS-7, and 
LTSS-8). We believe that these measures are feasible for States to 
stratify, and that the administrative data measures in particular would 
be relatively low burden for State reporting, particularly for States 
that opt for CMS to report the results on their behalf. Further, we are 
concerned that requiring stratified reporting of participant-reported 
measures from experience of care surveys could be difficult for States 
to implement due to small sample sizes, missing demographic 
information, and the potential need to increase sample sizes or 
oversample certain populations, which could increase survey costs and 
beneficiary burden. As discussed earlier in section I.B. of this notice 
with comment period, at Sec.  441.312(f), we established that, in 
specifying the measures and the factors by which States must report 
stratified measures, the Secretary will consider whether such 
stratified sampling can be accomplished based on valid statistical 
methods, without risking violating beneficiary privacy, and, for 
measures obtained from surveys, whether the original survey instrument 
collects the variables or factors necessary to stratify the measures. 
We believe that our proposal to not require stratified reporting of 
survey measures in the 2028 HCBS Quality Measure Set is consistent with 
Sec.  441.312(f). We request comment on our proposals, including 
whether any of the measures proposed for required stratification would 
not be feasible for States to stratify without undue burden or cost, 
whether States should be required to stratify any of the mandatory 
participant-reported survey measures, and whether the proposed 
stratification requirements would result in undue privacy risk.
    For each of the measures we are soliciting comments on whether to 
require States to stratify, we are soliciting comments on whether to 
require stratification by geography, using a minimum standard of core-
based statistical area (CBSA) \47\ with a recommendation to move 
towards Rural-Urban Commuting Area Codes.\48\ We are not proposing to 
require stratification for any other factors. We acknowledge that 
stratified data can be beneficial for identifying populations or groups 
that receive poorer quality care

[[Page 22838]]

or have worse outcomes, but we also recognize that requiring States to 
report stratified data can increase reporting burden and costs. 
Further, most States have limited experience with reporting on one or 
more of the proposed mandatory measures in the 2028 HCBS Quality 
Measure Set. In addition to feasibility and burden, privacy concerns 
may limit States' ability to stratify measures with small cell sizes. 
For the initial implementation of the HCBS Quality Measure Set 
reporting requirements at Sec.  441.311(c), we believe that it is 
important for States to focus their efforts primarily on timely and 
accurate reporting of the mandatory measures in the HCBS Quality 
Measure Set and on developing and implementing quality improvement 
strategies for the measures. We also note that direct care workforce 
shortages are particularly acute in many rural areas, beneficiaries 
have less access to HCBS in rural areas than in urban areas, and 
beneficiaries may have fewer options for both services and service 
providers in rural areas than in more urban areas.49 50 
These challenges, along with unique issues faced in rural areas (e.g., 
long travel times to reach beneficiaries which can delay timely access 
to care, lack of cell phone or broadband coverage which can reduce 
access to telehealth and remote care services), may lead to higher 
rates of unmet needs, poorer quality of care, and worse outcomes for 
people receiving HCBS in rural areas compared to those in more urban 
areas.51 52 53 54 For these reasons, we believe it is 
important to identify differences in HCBS quality based on geography.
---------------------------------------------------------------------------

    \47\ Available at https://www.census.gov/geographies/reference-maps/2020/geo/cbsa.html.
    \48\ Available at https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/.
    \49\ CMS. Strengthening the Direct Service Workforce in Rural 
Areas. Accessed at https://www.medicaid.gov/sites/default/files/2023-01/hcbs-strengthening-dsw-rural-areas.pdfhcbs-strengthening-dsw-rural-areas.pdf.
    \50\ Dill, J., C. Henning-Smith, R. Zhu, E. Vomacka. Who Will 
Care for Rural Older Adults? Measuring the Direct Care Workforce in 
Rural Areas. J Appl Gerontol. 2023 Aug;42(8):1800-1808. doi: 
10.1177/07334648231158482. Epub 2023 Feb 16. PMID: 36794536; PMCID: 
PMC10427731. Accessed at https://pmc.ncbi.nlm.nih.gov/articles/PMC10427731/.
    \51\ CMS. Strengthening the Direct Service Workforce in Rural 
Areas. Accessed at https://www.medicaid.gov/sites/default/files/2023-01/hcbs-strengthening-dsw-rural-areas.pdfhcbs-strengthening-dsw-rural-areas.pdf.
    \52\ Campbell, S., A. Del Rio Drake, R. Espinoza, K. Scales. 
2021. Caring for the future: The power and potential of America's 
direct care workforce. Bronx, NY: PHI. Accessed at http://phinational.org/wp-content/uploads/2021/01/Caring-for-the-Future-2021-PHI.pdf.
    \53\ Bauerly B.C., R.F. McCord, R. Hulkower, D. Pepin. Broadband 
Access as a Public Health Issue: The Role of Law in Expanding 
Broadband Access and Connecting Underserved Communities for Better 
Health Outcomes. J Law Med Ethics. 2019 Jun;47(2_suppl):39-42. doi: 
10.1177/1073110519857314. PMID: 31298126; PMCID: PMC6661896. 
Accessed at https://pmc.ncbi.nlm.nih.gov/articles/PMC6661896/.
    \54\ Siconolfi, D., R.A. Shih, E.M. Friedman, V.I. Kotzias, S.C. 
Ahluwali, J.L. Phillips, D. Saliba. Rural-Urban Disparities in 
Access to Home- and Community-Based Services and Supports: 
Stakeholder Perspectives From 14 States. J Am Med Dir Assoc. 2019 
Apr;20(4):503-508.e1. doi: 10.1016/j.jamda.2019.01.120. Epub 2019 
Mar 1. PMID: 30827892; PMCID: PMC6451868. Accessed at https://pmc.ncbi.nlm.nih.gov/articles/PMC6451868/.
---------------------------------------------------------------------------

    We note that States routinely collect information on geographic 
location for all beneficiaries as part of eligibility and enrollment 
processes. As a result, we believe it is feasible for States to 
stratify by geography for all of the measures we are soliciting 
comments on requiring States to stratify. CMS also has the capability, 
using T-MSIS data, to stratify the three administrative measures (LTSS-
6, LTSS-7, and LTSS-8) by geography. We are soliciting comments on both 
requiring States to stratify these measures and, for the administrative 
measures, whether to allow CMS to report results on States' behalf. In 
addition, we note that geography is one of the required factors for 
stratification of the Core Set of Adult Health Care Quality Measures 
for Medicaid (Adult Core Set), and including geographic stratification 
within the HCBS Quality Measure Set would align with that precedent.
    We request comment on this proposal, including on the feasibility 
of stratifying LTSS-1, LTSS-2, LTSS-6, LTSS-7, and LTSS-8 by geography. 
We also note that we are exploring the feasibility of requiring States 
to stratify quality measures across additional stratification 
categories. We request comment on whether we should require 
stratification by eligibility group, age, other demographic 
characteristics, or other factors.

D. Proposed Reporting Populations and Proposed Attribution Rules for 
Reporting on Beneficiaries Who Meet Criteria for More Than One HCBS 
Population

    As discussed earlier in section I.B. of this notice with comment 
period, at Sec.  441.311(c), States are required to report every other 
year, beginning July 9, 2028, on the HCBS Quality Measure Set for 
services approved and delivered under sections 1915(c), 1915(i), 
1915(j), and 1915(k) of the Act. In addition, consistent with the 
applicability of other HCBS regulatory requirements to such 
demonstration projects, the requirements for section 1915(c) waiver 
programs and for section 1915(i), (j), and (k) State plan services 
included in the rule would apply to such services included in approved 
section 1115 demonstration projects, unless we explicitly waive one or 
more of the requirements as part of the approval of the demonstration 
project.\55\ Based on the requirements finalized at Sec.  441.311(c), 
States must report on the mandatory measures in the HCBS Quality 
Measure Set for all Medicaid-funded HCBS under section 1915(c), (i), 
(j), and (k) authorities, as well as section 1115 demonstrations that 
include HCBS. Reporting must include all eligible individuals receiving 
HCBS under these authorities (or a sample of eligible individuals that 
is drawn following the technical specifications for the measure, if 
applicable).
---------------------------------------------------------------------------

    \55\ https://www.federalregister.gov/d/2024-08363/p-316.
---------------------------------------------------------------------------

    With the exception of the proposed stratification requirements 
discussed earlier in section II.A. of this notice with comment period, 
we are soliciting comments on whether State reporting on each mandatory 
measure (and each voluntary measure, if applicable) should be in the 
aggregate across all of the applicable HCBS programs subject to the 
requirements at Sec.  441.311(c). We are not proposing to require 
States to report separately for each HCBS program or authority. This 
approach is intended to reduce reporting burden, particularly during 
early implementation, and promote consistency and comparability of 
reported data across States. We are also not proposing that States 
report separately by delivery system or managed care plan. However, we 
will consider allowing States, at their option, to report at the 
program, authority, delivery system, or managed care plan level. If we 
allow optional reporting at these more granular levels, States would 
still be expected to report at the aggregate level. We request comment 
on our proposal for aggregate reporting and whether we should consider 
requiring alternative levels of reporting, such as at the program, 
authority, delivery system, or managed care plan level.
    Individuals who receive services through multiple HCBS programs, 
authorities, delivery systems, or managed care plans during the 
measurement period could be included in the denominator of a measure 
for more than one program, authority, delivery system, or managed care 
plan if a State reports at the program, authority, delivery system, or 
managed care plan level at their option. As we discuss in section II.A. 
of this notice with comment period, when individuals can be included in 
the sample for multiple experience of care surveys, we are not 
proposing to require States to

[[Page 22839]]

ensure that survey samples are deduplicated due to the administrative 
complexity of deduplicating samples across multiple experience of care 
surveys and entities involved in survey administration. However, we 
believe that States would experience less administrative complexity 
with deduplicating their results for measures that use other data 
sources than they would for survey-based measures. We also believe that 
deduplicated results would provide more accurate results than reporting 
that is not deduplicated. As a result, for all proposed mandatory 
measures that use data sources other than surveys, we are proposing to 
require States to deduplicate their results for each measure when 
reporting at the aggregate level. That is, for measures that use 
administrative data or assessment/case management system data, States 
would be required to deduplicate aggregate results where an individual 
should be counted only once in the denominator under the measure's 
technical specifications.
    In implementing the proposed requirement for States to report 
deduplicated results for measures that use administrative data or 
assessment/case management system data, States would be expected to 
follow the technical specifications of each measure, including any 
requirements related to attribution and population-specific reporting. 
If an individual receives services through multiple HCBS programs, 
authorities, delivery systems, or managed care plans and the State 
needs to establish additional attribution rules beyond those in the 
measure's technical specifications to assign an individual to a 
particular population for the purpose of deduplicating results, we are 
proposing to provide States with flexibility to set such attribution 
rules so long as each State uses a consistent approach to attribute 
individuals to a single population for purposes of reporting. We 
request comment on our proposed approach related to attribution rules 
and whether additional guidance is needed.
    We note that, in implementing our proposed requirement for States 
to report in the aggregate across all of the applicable HCBS programs 
subject to the requirements at Sec.  441.311(c), States would be 
expected to follow the technical specifications of each measure. In 
particular, States would be expected to include only the populations 
eligible for each measure and to report stratified data or multiple 
performance rates if applicable to the measure as detailed in the 
technical specifications. Further, measures such as LTSS-1, LTSS-2, 
LTSS-4, LTSS-6, LTSS-7, and LTSS-8 have separate FFS and managed care 
versions. States would be expected to report separately on the FFS and 
managed care versions of such measures, to the extent that the States 
deliver HCBS under both FFS and managed care.

E. Proposed Reporting Schedule

    Section 441.311(c) requires that States report every other year, 
beginning July 9, 2028, on the HCBS Quality Measure Set for services 
approved and delivered under sections 1915(c), 1915(i), 1915(j), and 
1915(k) of the Act. As discussed earlier in section I.B. of this notice 
with comment period, MFP grant recipients are required to report on the 
HCBS Quality Measure Set, beginning in fall 2026 and every other year 
thereafter. In establishing the reporting schedule for MFP grant 
recipients, we considered the amount of time needed for State reporting 
following the end of each calendar year. We also considered the 
timeframes for State reporting on the Adult Core Set, which generally 
opens in September and closes at the end of each calendar year. As 
discussed in sections II.A. and B. of this notice with comment period, 
we are soliciting comments on collecting data for the mandatory and 
voluntary measures in the 2028 HCBS Quality Measure Set through several 
different data sources, including State reporting in MDCT, CMS-
conducted analyses using T-MSIS Analytic Files, the HCBS CAHPS survey 
database, NCI-AD survey data collection, and NCI-IDD survey data 
collection. For measures reported using available data sources, we will 
work with the entities responsible for that data to establish data 
feeds and obtain the relevant data based on data availability. For 
measures reported in MDCT, we are soliciting comments on whether to 
establish a State reporting window, similar to that for the Adult Core 
Set, that would open September 1, 2028, and close on December 31, 2028, 
and on whether an alternate schedule would be preferred. We request 
comment on this proposal, including the feasibility of State reporting 
of relevant measures in MDCT by December 31, 2028.
    In the April 11, 2024, informational bulletin describing the HCBS 
Quality Measure Set reporting requirements for MFP grant recipients, we 
indicated that MFP grant recipients must report on the measures in the 
HCBS Quality Measure Set beginning in the fall 2026 for the 2025 
performance period (that is, reporting on data primarily collected 
during calendar year 2025). After discussions with States and measure 
stewards, we provided MFP grant recipients with additional flexibility 
on the timing of fielding experience of care surveys. This flexibility 
applies solely to survey fielding; the reporting timeline remains 
unchanged. Specifically, MFP grant recipients that conduct HCBS CAHPS 
and/or POM can field those surveys at any time during calendar year 
2024 or 2025. MFP grant recipients that conduct NCI-AD and/or NCI-IDD 
can field those surveys during the July 2024-June 2025 or July 2025-
June 2026 reporting cycles. This flexibility was intended to provide 
MFP grant recipients that conduct multiple experience of care surveys 
with flexibility to meet the reporting requirements by staggering the 
administration of the surveys, such as by conducting NCI-AD in the 
2024-2025 reporting cycle and NCI-IDD in the 2025-2026 reporting cycle. 
We have also indicated to MFP grant recipients that we plan to provide 
them with similar flexibility on the timing of experience of care 
surveys for future reporting periods. We believe that such flexibility 
can support States in budgeting for survey costs and allocating 
staffing and contract resources towards survey administration. As such, 
we are soliciting comments on whether to retain similar flexibility in 
the 2028 HCBS Quality Measure Set by allowing States that conduct HCBS 
CAHPS and/or POM to field those surveys at any time during calendar 
year 2026 or 2027, and States conducting NCI-AD and/or NCI-IDD to field 
those surveys during the July 2026-June 2027 or July 2027-June 2028 
reporting cycles. We request comment on our proposed timeframes for 
States to field experience of care surveys for the 2028 HCBS Quality 
Measure Set, including our proposed flexibility for States to conduct 
experience of care surveys during a two-year time period.
    Table 6 provides the measurement periods for the proposed 
administrative data and assessment/case management measures. For each 
proposed measure included in the table, the table provides the 
measurement period for the denominator, numerator, and continuous 
enrollment period, based on the technical specifications for each 
measure. We refer commenters to the technical specifications for each 
measure for additional information on the measurement periods. We 
welcome feedback on the measurement periods for each measure as to the 
feasibility of State reporting in 2028.

[[Page 22840]]

F. Proposed Exemption for Small Numbers

    CMS has a cell size suppression policy that is intended to protect 
the confidentiality of Medicare and Medicaid beneficiaries by avoiding 
the release of information that can be used to identify individual 
beneficiaries.\56\ The policy sets minimum thresholds for the display 
of CMS data and stipulates that no cell (for example, admissions, 
discharges, patients, or services) containing a value of 1 to 10 can be 
reported directly, nor can any cell be reported that would allow a 
value of 1 to 10 to be derived from other reported cells or 
information. While this policy specifically applies to the display of 
CMS data, we are soliciting comment on aligning State-to-CMS reporting 
with this policy by proposing to allow States to suppress any 
numerator, denominator, or other component of a measure with a value of 
1 to 10, or that would allow such a value to be derived from other 
reported cells or information. For example, larger thresholds may be 
warranted in cases where reporting data for small populations is still 
associated with substantial risk of identification despite suppression 
at the 1 to 10 level. A higher threshold may also help reduce burden 
for States that would otherwise need to redact or collapse data before 
submission. In addition, alignment with suppression practices used in 
other reporting programs may support consideration of a higher 
threshold. We request comment on this proposal, including whether we 
should allow States to suppress values larger than 10, such as up to 
25, up to 50, or up to 100, due to beneficiary privacy, State reporting 
burden, or other factors.
---------------------------------------------------------------------------

    \56\ Available at https://resdac.org/articles/cms-cell-size-suppression-policy.

 Table 6--Measurement Periods for Proposed Administrative Data and Assessment/Case Management System Measures in
                                          the 2028 Quality Measure Set
----------------------------------------------------------------------------------------------------------------
                                                            Proposed 2028 measurement period
                                      --------------------------------------------------------------------------
               Measure                                                                    Continuous enrollment
                                             Denominator               Numerator                  period
----------------------------------------------------------------------------------------------------------------
LTSS-1: Long-Term Services and         Includes participants    Event occurs within 90   August 1, 2026-December
 Supports Comprehensive Assessment      from eligible            days of enrollment for   31, 2027.
 and Update.                            population enrolled      new participants or
                                        for at least 150 days.   during the measurement
                                                                 year for established
                                                                 participants.
LTSS-2: Long-Term Services and         Not applicable.........  Event occurs within 120  August 1, 2026-December
 Supports Comprehensive Person-                                  days of enrollment for   31, 2027.
 Centered Plan and Update.                                       new participants or
                                                                 during the measurement
                                                                 year for established
                                                                 participants.
LTSS-4: Reassessment and Person-       January 1, 2027-         Not applicable.........  Enrollment in Medicaid
 Centered Plan Update after Inpatient   December 1, 2027.                                 LTSS on the date of
 Discharge.                                                                               discharge through 30
                                                                                          days following the
                                                                                          date of discharge.
MLTSS-5: Screening, Risk Assessment,   Not applicable.........  August 1, 2026-December  August 1, 2026-December
 and Plan of Care to Prevent Future                              31, 2027.                31, 2027.
 Falls.
LTSS-6: Long-Term Services and         August 1, 2026-July 31,  August 1, 2026-July 31,  August 1, 2026-July 31,
 Supports Admission to a Facility       2027.                    2027.                    2027.
 from the Community.
LTSS-7: Long-Term Services and         July 1, 2026-October     July 1, 2026-June 30,    Enrollment in Medicaid
 Supports Minimizing Facility Length    31, 2027.                2027.                    LTSS on the facility
 of Stay.                                                                                 admission date through
                                                                                          160 days following the
                                                                                          facility admission
                                                                                          date.
LTSS-8: Long-Term Services and         All participants         July 1, 2026-October     July 1, 2026-December
 Supports Successful Transition after   residing in a facility   31, 2027.                31, 2027.
 Long-Term Facility Stay.               on July 1 of the year
                                        prior to the
                                        measurement year and
                                        who were residing in
                                        the facility for at
                                        least 101 days.
----------------------------------------------------------------------------------------------------------------

III. Collection of Information Requirements

    As indicated in section V. of this notice with comment period, this 
notice does not propose any new or revised collection of information 
requirements or burden. Instead, this notice with comment period is 
intended to satisfy, in part, the provisions under Sec.  441.312(c)(4), 
which requires the Secretary to develop and update the HCBS Quality 
Measure Set using a process that allows for public input and comment.
    To develop the initial 2028 HCBS Quality Measure Set, a 
solicitation for public review on such measures was issued in July 
2024. We are using this notice with comment period for the 2028 HCBS 
Quality Measure Set and similar subsequent Federal Register notices as 
the vehicle for notifying the public of the availability to review the 
applicable version of the HCBS Quality Measure Set and of the 
opportunity to comment on such.
    As noted in section I.C. of this notice with comment period, an 
independent HCBS Quality Measure Set Review Workgroup was established 
to review each of the measures suggested through the public call for 
measures. In addition to their review, the Workgroup voted on and 
recommended measures to add/remove from the 2028 HCBS Quality Measure 
Set. The purpose of this notice with comment period is to notify the 
public of the availability of the 2028 HCBS Quality Measure Set and to 
solicit comment.
    Separate from this notice, the HCBS Quality Measure Set's reporting 
requirements and burden will be submitted to OMB for approval as 
required under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 
3501 et seq.). When ready, the requirements and burden will also be 
made available for public review and comment under the standard non-
rule PRA process which includes the publication of 60- and 30-day 
Federal Register notices. The CMS ID number for that collection of 
information request is CMS-10854 (OMB control number 0938-TBD).
    Since this would be a new collection of information request, the 
OMB control number has yet to be determined (TBD) but will be issued by 
OMB upon their approval of the 30-day version of this new collection of 
information request.

[[Page 22841]]

IV. Response to Comments

    Because of the large number of public comments, we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble, 
and, when we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.

V. Regulatory Impact Analysis

    We have examined the impacts of this notice with comment period as 
required by Executive Order 12866, ``Regulatory Planning and Review''; 
Executive Order 13132, ``Federalism''; Executive Order 13563, 
``Improving Regulation and Regulatory Review''; Executive Order 14192, 
``Unleashing Prosperity Through Deregulation''; the Regulatory 
Flexibility Act (RFA) (Pub. L. 96-354); section 1102(b) of the Social 
Security Act; and section 202 of the Unfunded Mandates Reform Act of 
1995 (Pub. L. 104-4).
    Executive Orders 12866 and 13563 direct agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select those regulatory approaches that 
maximize net benefits (including potential economic, environmental, 
public health and safety, and other advantages; distributive impacts). 
Section 3(f) of Executive Order 12866 defines a ``significant 
regulatory action'' as any regulatory action that is likely to result 
in a rule that may: (1) have an annual effect on the economy of $100 
million or more or adversely affect in a material way the economy, a 
sector of the economy, productivity, competition, jobs, the 
environment, public health or safety, or State, local, or tribal 
governments or communities; (2) create a serious inconsistency or 
otherwise interfere with an action taken or planned by another agency; 
(3) materially alter the budgetary impact of entitlements, grants, user 
fees, or loan programs or the rights and obligations of recipients 
thereof; or (4) raise novel legal or policy issues arising out of legal 
mandates, or the President's priorities.
    The RFA requires agencies to analyze options for regulatory relief 
of small entities, if a rule has a significant impact on a substantial 
number of small entities. We are not preparing an analysis for the RFA 
because we have determined, and the Secretary certifies, that this 
notice with comment period is not subject to the RFA.
    In addition, section 1102(b) of the Act requires us to prepare an 
RIA if a rule may have a significant impact on the operations of a 
substantial number of small rural hospitals. We are not preparing an 
analysis for section 1102(b) of the Act because we have determined, and 
the Secretary certifies, that this notice with comment period is not 
subject to section 1102(b).
    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. In 2026, that 
threshold is approximately $193 million. This notice with comment 
period does not mandate any requirements for State, local, or tribal 
governments, or for the private sector. Accordingly, the requirements 
of section 202 of UMRA do not apply.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. This notice with comment period does not have a 
substantial direct effect on State or local governments, preempt 
States, or otherwise have a Federalism implication.
    Mehmet Oz, Administrator of the Centers for Medicare & Medicaid 
Services, approved this document on April 14, 2026.

Robert F. Kennedy, Jr.,
Secretary, Department of Health and Human Services.
[FR Doc. 2026-08190 Filed 4-27-26; 8:45 am]
BILLING CODE 4120-01-P