[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/.
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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).
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\55\ https://www.federalregister.gov/d/2024-08363/p-316.
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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.
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\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
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Proposed 2028 measurement period
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Measure Continuous enrollment
Denominator Numerator period
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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.
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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