HCBS Settings Rule

The Home and Community Based Services (HCBS) Settings Rule ensures that individuals receiving services and supports through Medicaid’s HCBS programs have full access to the benefits of community living and are able to receive services in the most integrated setting. Doing so provides an opportunity to enhance the quality of HCBS and provide additional protections to individuals that receive services. Under the rule, a setting that is truly home and community based is one that:

  • Is integrated in and supports access to the greater community
  • Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources
  • Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
  • Is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting
    • Person-centered service plans document the options based on the individual’s needs, preferences; and for residential settings, the individual’s resources
  • Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint
  • Optimizes individual initiative, autonomy, and independence in making life choices
  • Facilitates individual choice regarding services and supports, and who provides them

Provider owned or controlled settings also have additional requirements they are expected to meet. States are currently at different stages in working on their state transition plans (STPs) and completing heightened scrutiny reviews for settings that are identified as “presumptively institutional.” Presumptively institutional settings are:

  • Settings in a publicly or privately-owned facility providing inpatient treatment
  • Settings on grounds of, or adjacent to, a public institution
  • Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS

The transition period comes to a close on March 17, 2023, after which settings will need to meet the requirements of the rule that have not been impacted by the COVID-19 pandemic to continue receiving Medicaid funding. For those requirements that have been impacted by the pandemic, states can submit corrective action plans (CAPs) to allow settings more time to meet those requirements.

The Importance of Public Engagement

Public engagement is the best path to realizing the promise of the Settings Rule, and people receiving services, their families, and their advocates should have a voice in this process. ACL’s network can help amplify those voices, can serve as resources, and can share important information as part of a feedback loop between states, providers, and people receiving services. Those information loops, which help paint a picture of what is happening on the ground in each setting and each state, are an essential ingredient to improving services and settings.

Public comment periods are written into the HCBS Settings Rule and responsiveness to public input a requirement. ACL believes that facilitating individual-level engagement in public comment periods for the Settings Rule, and more broadly for any state or federal program that provides programs or services for people with disabilities and older adults, is the best way to develop and implement good programs and services, and to truly achieve community integration.


ACL hosts regular webinars to help stakeholders understand and engage with the Settings Rule and provide updates on implementation. Below, you’ll find recordings of those webinars.

Strengthening Advocacy in the HCBS Settings Rule: Getting the Services You Need from the Waiver
(December 2022)

This webinar highlights why you should pay attention to the waiver application and what is in an application, with a focus on appendix C – Services. It also looks at what states have to put into the application and highlights best practices for commenting on your state’s waiver application.
View webinar here

Strengthening Advocacy in the HCBS Settings Rule: ​​​​​​The Voices of People with Disabilities and Older Adults
(September 2022)

This webinar provides participants with an opportunity to learn when and how to invite and/or provide feedback on state efforts to comply with the rule. Presenters share key dates, strategies, and examples of how powerful the voices of people with lived experience can be in creating more opportunities for choice and control in service delivery, and advancing the quality of services.
View webinar here
Passcode: V08r*Pu#

Key Updates on the HCBS Settings Rule (5/25/2022) The March 2023 end of the transition period for
implementation of the Home and Community-Based Services (HCBS) Settings Rule is fast approaching.
In this webinar, leaders from ACL and CMS discuss the current state of the transition, as well important
updates on the implementation of the Rule and expectations for states and providers moving forward.
View webinar here
Passcode: zYzB05^@

More webinars

ACL/CMS Promising Practices webinar: Rethinking Day Services: The Without Walls Approach (3/24/2022)

The COVID-19 pandemic changed the way we think about and provide services, with more and more providers shifting to a without walls approach, which more clearly complies with the intent of the HCBS Settings Rule regarding community inclusion and customized competitive employment. This webinar provides insight into how a without walls approach can be used as part of a COVID-19 response strategy, how to train staff to shift from center-based services to community-based services, and what a without walls approach looks like in practice.
View webinar here

ACL/CMS Promising Practices Training: HCBS Settings Regulation: Where Are We Now and Where Are We Going (1/27/2022)

This webinar includes an overview of the criteria for home and community-based settings and the heightened scrutiny process, as well as what is required of states to comply with the rule. It also explores how ACL and CMS are collaborating to ensure successful implementation of the rule and how ACL is supporting our networks and encouraging engagement as states work toward implementation and beyond.
View webinar here

Last modified on 03/07/2023

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