(a) Basis and scope. Section 1102(a) of the Act provides the Secretary of HHS with authority to make and publish rules and regulations that are necessary for the efficient administration of the Medicaid program. Section 1902(a)(6) of the Act requires State Medicaid agencies to make such reports, in such form and containing such information, as the Secretary may from time to time require, and to comply with such provisions as the Secretary may from time to time find necessary to assure the correctness and verification of such reports. This section describes the Home and Community-Based Services Quality Measure Set, which States are required to use in section 1915(c) waiver programs to promote public transparency related to the administration of Medicaid-covered HCBS, under the authority at sections 1102(a) and 1902(a)(6) of the Act.

(b) Definitions. As used in this subpart—

(1) Attribution rules means the process States use to assign beneficiaries to a specific health care program or delivery system for the purpose of calculating the measures on the Home and Community-Based Services Quality Measure Set.

(2) Home and Community-Based Services Quality Measure Set means the Home and Community-Based Services Quality Measures for Medicaid established and updated by the Secretary through a process that allows for public input and comment, including through the Federal Register, as described in paragraph (d) of this section.

(c) Responsibilities of the Secretary. The Secretary shall—

(1) 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 Home and Community-Based Services Quality Measure Set as defined in paragraph (b) of this section.

(2) Make technical updates and corrections to the Home and Community-Based Services Quality Measure Set annually as appropriate.

(3) Consult at least every other year with States and other interested parties identified in paragraph (g) of this section to—

(i) Establish priorities for the development and advancement of the Home and Community-Based Services Quality Measure Set;

(ii) Identify newly developed or other measures which should be added including to address any gaps in the measures included in the Home and Community-Based Services Quality Measure Set;

(iii) Identify measures which should be removed as they no longer strengthen the Home and Community-Based Services Quality Measure Set; and

(iv) Ensure that all measures included in the Home and Community-Based Quality Measure Set reflect an evidence-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.

(4) In consultation with States, develop and update, no more frequently than every other year, the Home and Community-Based Services Quality Measure Set Quality Measure Set using a process that allows for public input and comment as described in paragraph (d) of this section.

(d) Process for developing and updating the HCBS Quality Measure Set. The process for developing and updating the Home and Community-Based Services Quality Measure Set Quality Measure Set will address all of the following:

(1) Identification of all measures in the Home and Community-Based Services Quality Measure Set, including:

(i) Measures newly added and measures removed from the prior version of the Home and Community-Based Services Quality Measure Set;

(ii) The specific measures for which reporting is mandatory;

(iii) The measures for which the Secretary will complete reporting on behalf of States and the measures for which States may elect to have the Secretary report on their behalf; and

(iv) The measures, if any, for which the Secretary will provide States with additional time to report, as well as how much additional time the Secretary will provide, in accordance with paragraph (c) of this section.

(2) Technical information to States on how to collect and calculate the data on the Home and Community-Based Services Quality Measure Set.

(3) Standardized format and reporting schedule for reporting measure data required under this section.

(4) Procedures that State agencies must follow in reporting measure data required under this section.

(5) Identification of the populations for which States must report the measures identified by the Secretary under paragraph (e) of this section, which may include, but is not limited to beneficiaries—

(i) Receiving services through specified delivery systems, such as those enrolled in a MCO, PIHP, or PAHP as defined in § 438.2 or receiving services on a fee-for-service basis;

(ii) Who are dually eligible for Medicare and Medicaid, including beneficiaries whose medical assistance is limited to payment of Medicare premiums or cost sharing;

(iii) Who are older adults;

(iv) Who have physical disabilities;

(v) Who have intellectual and development disabilities;

(vi) Who have serious mental illness; and

(vii) Who have other health conditions.

(6) Technical information on attribution rules for determining how States must report on measures for beneficiaries who are included in more than one population, as described in paragraph (d)(5) of this section, during the reporting period.

(7) The subset of measures among the measures in the Home and Community-Based Services Quality Measure Set that must be stratified by race, ethnicity, sex, age, rural/urban status, disability, language, or such other factors as may be specified by the Secretary and informed by consultation every other year with States and interested parties in accordance with paragraphs (b)(2) and (g) of this section.

(8) Describe how to establish State performance targets for each of the measures in the Home and Community-Based Services Quality Measure Set.

(e) Phasing in of certain reporting. As part of the process that allows for developing and updating the Home and Community-Based Services Quality Measure Set described in paragraph (d) of this section, the Secretary may provide that mandatory State reporting for certain measures and reporting for certain populations of beneficiaries will be phased in over a specified period of time, taking into account the level of complexity required for such State reporting.

(f) Selection of measures for stratification. In specifying which measures, and by which factors, States must report stratified measures consistent with paragraph (d)(7) of this section, the Secretary will take into account whether stratification can be accomplished based on valid statistical methods and without risking a violation of beneficiary privacy and, for measures obtained from surveys, whether the original survey instrument collects the variables necessary to stratify the measures, and such other factors as the Secretary determines appropriate; the Secretary will require stratification of 25 percent of the measures in the Home and Community-Based Services Quality Measure Set for which the Secretary has specified that reporting should be stratified by 4 years after July 9, 2024, 50 percent of such measures by 6 years after July 9, 2024, and 100 percent of measures by 8 years after July 9, 2024.

(g) Consultation with interested parties. For purposes of paragraph (c)(2) of this section, the Secretary must consult with interested parties as described in this paragraph to include the following:

(1) State Medicaid Agencies and agencies that administer Medicaid-covered home and community-based services.

(2) Health care and home and community-based services professionals, including members of the allied health professions who specialize in the care and treatment of older adults, children and adults with disabilities, and individuals with complex medical needs.

(3) Health care and home and community-based services professionals (including members of the allied health professions), providers, and direct care workers who provide services to older adults, children and adults with disabilities, and individuals with complex medical and behavioral health care needs who live in urban and rural medically underserved communities or who are members of distinct population sub-groups at heightened risk for poor outcomes.

(4) Providers of home and community-based services.

(5) Direct care workers and national organizations representing direct care workers.

(6) Consumers and national organizations representing older adults, children and adults with disabilities, and individuals with complex medical needs.

(7) National organizations and individuals with expertise in home and community-based services quality measurement.

(8) Voluntary consensus standards setting organizations and other organizations involved in the advancement of evidence-based measures of health care.

(9) Measure development experts.

(10) Such other interested parties as the Secretary may determine appropriate.

[89 FR 40868, May 10, 2024; 89 FR 53502, June 27, 2024]