Initial Approval for 35 States' HCBS State Transition Plans

Regulation | August 14, 2017 | by Peter Notarstefano

To date 35 states have received initial approval and 4 states received final approval of their state transition plan.

Approval is granted because these states completed their systemic assessment, included the outcomes of this assessment in the STP, clearly outlined remediation strategies to rectify issues that the systemic assessment uncovered, such as legislative changes and changes to contracts, and is actively working on those remediation strategies. On a August 15th call, Melissa Harris and George Failla from CMS said that they hope to have the remaining states receive initial approval within the next 6 months. They also reported they are working on guidance for states to use on the heightened scrutiny processs, which continues to be a challenge for many states. If a provider fits the criteria related to location and sites that isolate, then the state was determine if they meet the requirements in the HCBS settings rule, and submit their findings on the provider to CMS for review. If an adult day or assisted living provider was not a provider on or before March 17, 2014, then the state can use the heightened scrutiny process to determine is they are in compliance with the rule as long as there are residents/participants being served in the setting. The residents/participants do not have to be receiving the services through Medicaid. Melissa Harris said the state has the ultimate decision on determining if a specific provider is acepted or rejected under heightened scrutiny, and the recommendation being sent to CMS. CMS is willing to schedule a call with providers/developers and state officials to review the criteria to be in compliance with the rule. Melissa Harris also stated that they plan on releasing additional guidance on non-residential settings, and that the challenge is that day programs serve a younger population that may need employment training and an older population that benefits from socialization and some medical services. They all were pleased about the deadline for completion being extended to March 17, 2022. 

CMS granted the following states initial approval of their Statewide Transition Plan (STP) to be in compliance with the federal home and community-based services (HCBS) regulations:

  1. Tennessee (both initial and final approval) April 13, 2016

  2. Kentucky June 2, 2016, Final approval on  June 13, 2017

  3. Ohio June 2, 2016

  4. Delaware July 14, 2016

  5. Iowa August 9, 2016

  6. Pennsylvania August 30, 2016

  7. Idaho, September 23, 2016

  8. Connecticut, October 21, 2016

  9. West Virginia, October 26, 2016

  10. North Dakota, November 1, 2016

  11. Oregon, November 2, 2016

  12. South Carolina, November 3, 2016

  13. Washington State, November 3, 2016

  14. Arkansas, November 7, 2016, Final approval on June 2, 2017 

  15. Indiana, November 8, 2016 

  16. Virginia, December 6, 2016

  17. Montana  December 23, 2016 

  18. Alaska December 28, 2016 

  19. Oklahoma December 28, 2016 , Final approval on August 10, 2017

  20. Rhode Island January 5, 2017

  21. Hawaii January 13, 2017

  22. New Mexico January 13, 2017

  23. Alabama February 21, 2017 

  24. Louisiana March 3, 2017

  25. Missouri   March 29, 2017 

  26. Nebraska  March 31, 2017 

  27. Utah  April 5, 2017

  28. Wyoming May 10, 2017

  29. Mississippi  May 25, 2017 

  30. Minnesota  June 2, 2017 

  31. South Dakota June 2, 2017

  32. New Hampshire July 3, 2017

  33. Wisconsin  July 13th, 2017 

  34. Maryland August 2, 2017 

  35. Michigan August 10, 2017

The StatesApproval is granted because these states completed their systemic assessment, included the outcomes of this assessment in the STP, clearly outlined remediation strategies to rectify issues that the systemic assessment uncovered, such as legislative changes and changes to contracts, and is actively working on those remediation strategies. 

To date 35 states have received initial approval and 4 states received final approval of their state transition plan. CMS is requiring states to include a crosswalk between state standards (including state housing regulations) and the HCBS settings rule. They also want the state to write a narrative of provider types that are compliant, not compliant, partially compliant, as well as any regulations that are in the federal rule, but not in state statute. This process may involve multiple state agencies. 

In their state transition plans, CMS is seeing states develop a tiered set of standards to comply with the HCBS regulations. CMS requires the states to abide by the minimal standards within the rule; however, states have the right to have more stringent standards that they believe will improve HCBS in the state. The more stringent standards may include requirements for more integration in the community for Medicaid beneficiaries. 

CMS has already stated that "reverse integration" or bringing the community into the Assisted Living, Adult Day Center is not enough. There has to be a process in place that the beneficiary has the ability to travel into the community for the services/events that they choose. CMS has introduced another challenge by saying that a Medicaid beneficiary's choice of an HCBS provider is not enough to have compliance with the HCBS rule. CMS has placed more emphasis on community integration than on consumer choice. The difficulty with the integration criteria in the rule, is that it is the most subjective criteria. 

It is important for LeadingAge members and State affiliates to work closely with their states in determining how to create a practical implementation of the HCBS rule, in order to avoid any unintentional negative consequences, such as a reduced choices of HCBS providers.