CMS Publishes 2028 Medicaid HCBS Quality Measure Set

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Notice

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

A Notice by the Centers for Medicare & Medicaid Services on 04/28/2026

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3. Document Details Published Content - Document Details Agencies Department of Health and Human Services Centers for Medicare & Medicaid Services Agency/Docket Number CMS-2453-NC Document Citation 91 FR 22823 Document Number 2026-08190 Document Type Notice Pages 22823-22841 (19 pages) Publication Date 04/28/2026 RIN 0938-ZB99 Published Content - Document Details

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Department of Health and Human Services

Centers for Medicare & Medicaid Services

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2. RIN 0938-ZB99

AGENCY:

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

ACTION:

Notice with comment period.

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.

1. 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. ]

( printed page 22824)

B. HCBS Quality Measure Set

In July 2022, we issued State Medicaid Director Letter # 22-003 ] 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 ] to update the HCBS Quality Measure Set, hereinafter referred to as the 2024 HCBS Quality Measure Set; and (2) an informational bulletin ] 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. ] 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, ] 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.

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 § 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 § 441.312(d), on measures identified in the HCBS Quality Measure Set as mandatory for States to report. At § 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 § 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 § 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 § 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 § 441.312(d)(1)(iii). Further, at § 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 § 441.311(c) beginning July 9, 2028.

Regulations at § 441.312 set requirements for developing the HCBS Quality Measure Set. Specifically, at § 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 § 441.312(c)(2), we required that the Secretary make technical updates and corrections to the HCBS Quality Measure Set annually as appropriate. At § 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 § 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; ( printed 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 § 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 § 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 § 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 § 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 § 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 ] 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). ]

Measures suggested for addition
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Health Plan Survey, Adult Version, Measures:
CAHPS Health Plan Survey, Adult Version: Enrollees' Rating of Health Plan.
National Core Indicators-Aging and Disabilities (NCI-AD TM ) 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® Intellectual and Developmental Disabilities (NCI®-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.
( printed 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.

Measures suggested for removal
Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) 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
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.

An independent HCBS Quality Measure Set Review Workgroup ] 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. ]

| Measures Recommended for Addition |
| 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. |
| Measures Recommended for Removal |
| LTSS-1: Comprehensive Assessment and Update. |
| ( printed page 22827) |
The proposed 2028 HCBS Quality Measure Set considers 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. Our intent in issuing this notice with comment period is to satisfy, in part, the requirements established at § 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).

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 ]); and Personal Outcome Measures® (POM: People Live in Integrated Environments.

The Planning Your Time and Activities composite measure is calculated using scores on six items in the HCBS CAHPS survey: ]

• 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 ( printed 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} 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) ] 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.

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® (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. ] 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. ] NCI-IDD IPS is an annual multi-State cross-sectional survey of adult recipients of State developmental disabilities systems' supports and services. ] 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. ]

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 ( printed page 22829) State's HCBS programs, if a survey is available for use with each relevant population. ] These population groups are consistent with those referenced in § 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, ] 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.

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. ] 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 ( printed page 22830) mandatory measures in the 2028 HCBS Quality Measure Set.

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. ] 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. ] 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.

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. ] Two performance measures derived from FASI, FASI Performance Measure 1 (FASI-1): Identifying Personal Priorities for Functional Assessment Standardized Items (FASI) Needs ] and FASI Performance Measure 2 (FASI-2): Alignment of Person-Centered Service Plan (PCSP) with Functional Needs as Determined by Functional Assessment Standardized Items, ] 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.

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; ] the HCBS CAHPS database; ] the Medicaid Data Collection Tool (MDCT), ] 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 § 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 ( printed 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.

| CMIT ID | Measure steward | Measure name | Type of data source | Technical specifications 33 | Method of
reporting
to CMS | Mandatory
stratification
for 2028 |
| --- | --- | --- | --- | --- | --- | --- |
| 00095-01-C-LTSS | CMS | HCBS CAHPS: Choosing the Services That Matter to You Composite Measure | Participant-Reported Data/Survey | Numerator: The number of survey respondents who answered “All” 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 | HCBS CAHPS database | No. |
| 00095-03-C-LTSS | CMS | HCBS CAHPS: Personal Safety & Respect Composite Measure | Participant-Reported Data/Survey | Numerator: The number of survey respondents who 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 | HCBS CAHPS database | No. |
| 00095-04-C-LTSS | CMS | HCBS CAHPS: Physical Safety Single-Item Measure | Participant-Reported Data/Survey | Numerator: The number of survey respondents who answered “No” to question 71 on the HCBS CAHPS Survey Denominator: The total number of survey respondents who answered the question | HCBS CAHPS database | No. |
| 00095-07-C-LTSS | CMS | HCBS CAHPS: Transportation to Medical Appointments Composite Measure | Participant-Reported Data/Survey | Numerator: The number of survey respondents who gave the most 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 | HCBS CAHPS database | No. |
| 00960-01-C-LTSS (MLTSS-1) and 00960-02-C-LTSS (FFS LTSS-1) | CMS | LTSS-1: Long-Term Services and Supports Comprehensive Assessment and Update 34 35 | Assessment/Case Management System | Numerator: The measure reports two numerators Rate 1: Assessment of Core Elements: 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) | MDCT | Yes. |
| 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 |
| ( printed page 22832) |
| 00961-01-C-LTSS (MLTSS-2) and 00961-02-C-LTSS (FFS LTSS-2) | CMS | LTSS-2: Long-Term Services and Supports Comprehensive Person-Centered Plan and Update 36 37 | Assessment/Case Management System | Numerator: The measure reports two numerators Rate 1: Person-Centered Plan with Core 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) | MDCT | Yes. |
| 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) |
| 00020-03-C-LTSS (FFS LTSS-6) and 00020-04-C-LTSS (MLTSS-6) | CMS | LTSS-6: Long-Term Services and Supports Admission to a Facility from the Community | Administrative Data | Numerator: The number of facility admissions (FA) from a 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) | MDCT or CMS-analyses using T-MSIS data | Yes. |
| 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 00968-01-C-LTSS (FFS LTSS-7) | CMS | LTSS-7: Long-Term Services and Supports Minimizing Facility Length of Stay | Administrative Data | Numerator: The count of discharges from a facility to the community during 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 | MDCT or CMS-analyses using T-MSIS data | Yes. |
| 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) |
| ( printed page 22833) |
| 000414-03-C-LTSS (MLTSS-8) and 000414-04-C-LTSS (FFS LTSS-8) | CMS | LTSS-8: Long-Term Services and Supports Successful Transition after Long-Term Facility Stay | Administrative Data | Numerator: The count of discharges from a facility to the community from July 1 of the 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 | MDCT or CMS-analyses using T-MSIS data | Yes. |
| 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, Human Services Research Institute (HSRI) | NCI-AD: Percentage of People Who are as Active in Their Community as They Would Like to Be | Participant-Reported Data/Survey | Numerator: The number of respondents who report “Yes” to the question Denominator: The number of respondents who answered the question on the NCI-AD Adult Consumer Survey | NCI-AD survey data collection | No. |
| 00457-10-C-MACS | ADvancing States, HSRI | NCI-AD: Percentage of People Who Feel Safe Around Their Support Staff | Participant-Reported Data/Survey | Numerator: The number of respondents who report “Yes, All Paid Support Workers, Always or Almost Always.” Denominator: The number of respondents who answered the question on the NCI-AD Adult Consumer Survey | NCI-AD survey data collection | No. |
| 00457-13-C-MACS | ADvancing States, HSRI | NCI-AD: Percentage of People Who Have Transportation to Get to Medical Appointments When They Need to | Participant-Reported Data/Survey | Numerator: The number of respondents who report “Yes” to the question Denominator: The number of respondents who answered the question on the NCI-AD Adult Consumer Survey | NCI-AD survey data collection | No. |
| 00457-14-C-MACS | ADvancing States, HSRI | NCI-AD: Percentage of People Who Have Transportation When They Want to Do Things Outside of Their Home | Participant-Reported Data/Survey | Numerator: The number of respondents who report “Yes” to the question Denominator: The number of respondents who answered the question on the NCI-AD Survey | NCI-AD survey data collection | No. |
| 00457-17-C-MACS | ADvancing States, HSRI | NCI-AD: Percentage of People Whose Service Plan Includes Their Preferences and Choices | Participant-Reported Data/Survey | Numerator: The number of respondents who report “Yes, all/completely” to the question Denominator: The number of respondents who answered the question on the NCI-AD Adult Consumer Survey optional module for person-centered planning | NCI-AD survey data collection | No. |
| 01823-07-C-LTSS | National Association of State Directors of Developmental Disabilities Services (NASDDDS), HSRI | NCI-IDD PCP-5: Satisfaction with Community Inclusion Scale (The Proportion of People Who Report Satisfaction with the Level of Participation in Community-Inclusion Activities) | Participant-Reported Data/Survey | Numerator of Each Constituent Item Score: The number of people who reported satisfaction with the frequency of their participation in the indicated activity, or the number of people 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 | NCI-IDD survey data collection | No. |
| 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: Social Connectedness (The Proportion of People Who Report that They Do Not Feel Lonely Often) | Participant-Reported Data/Survey | Numerator: The number of people who responded “no.” Denominator: Number of people who provided a valid response | NCI-IDD survey data collection | No. |
| ( printed page 22834) |
| 01823-04-C-MACS | NASDDDS, HSRI | NCI-IDD CI-3: Transportation Availability Scale (The Proportion of People Who Report Adequate Transportation) | Participant-Reported Data/Survey | Numerator of Each Constituent Item Score: The number of people with the top box score Denominator of Each Constituent Item Score: Number of people who provided a valid response | NCI-IDD survey data collection | No. |
| 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: Respect for Personal Space Scale (The Proportion of People Who Report that Their Personal Space is Respected in the Home) | Participant-Reported Data/Survey | Numerator of Each Constituent Item Score: The number of people with the top box score Denominator of Each Constituent Item Score: Number of people who provided a valid response | NCI-IDD survey data collection | No. |
| 01823-06-C-LTSS | NASDDDS, HSRI | NCI-IDD PCP 2: Person-Centered Goals (The Proportion of People Who Report their Service Plan Includes Things that are Important to Them) | Participant-Reported Data/Survey | Numerator: The number of people with the top box score Denominator: Number of people who provided a valid response | NCI-IDD survey data collection | No. |
| 01822-01-C-LTSS | Council on Quality and Leadership (CQL) | POM: People are free from abuse and neglect | Participant-Reported Data/Survey | Numerator: The number of 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 | MDCT | No. |
| 01822-02-C-LTSS | CQL | POM: People Choose Services | Participant-Reported Data/Survey | Numerator: The number of respondents who choose the services/supports they receive, their provider organizations, and their direct support professionals/staff | MDCT | No. |
| 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 Participate in the Life of the Community | Participant-Reported Data/Survey | Numerator: The number of respondents who participate in the life of the community, with the type and frequency of participation they prefer | MDCT | No. |
| 01822-07-C-LTSS | CQL | POM: People Realize Personal Goals | Participant-Reported Data/Survey | Numerator: The number of respondents who accomplish goals significant to them | MDCT | No. |

B. Proposed Voluntary Measures

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 ( printed 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. ] 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.

Table 5 provides the proposed voluntary measures in the 2028 HCBS Quality Measure Set. Similar to Table 4, Table 5 includes the CMIT ID, ] 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.

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. ] 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 ( printed 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.

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. ] 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.

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. ] 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.

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; ] the HCBS CAHPS database; the MDCT; ] 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 § 441.312(d)(1)(iii). ] 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.

| CMIT No. | Measure steward | Measure name | Type of data source | Method of
reporting to CMS | Technical

specifications 46
00962-01-C-LTSS (MLTSS-4) and 00962-02-C-LTSS (FFS LTSS-4)
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.
( printed 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
Denominator: A statistically valid random sample of Medicaid MLTSS participants drawn from the eligible population.
Varies

C. Proposed Stratification Requirements

As discussed earlier in section I.B. of this notice with comment period, at § 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 § 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 § 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) ] with a recommendation to move towards Rural-Urban Commuting Area Codes. ] 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 ( printed 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 § 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. ] 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. ] For these reasons, we believe it is important to identify differences in HCBS quality based on geography.

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 § 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. ] Based on the requirements finalized at § 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).

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 § 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 ( printed 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 § 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. ( printed 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. ] 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.

Measure	Proposed 2028 measurement period
Denominator	Numerator
LTSS-1: Long-Term Services and Supports Comprehensive Assessment and Update	Includes participants from eligible population enrolled for at least 150 days
LTSS-2: Long-Term Services and Supports Comprehensive Person-Centered Plan and Update	Not applicable
LTSS-4: Reassessment and Person-Centered Plan Update after Inpatient Discharge	January 1, 2027-December 1, 2027
MLTSS-5: Screening, Risk Assessment, and Plan of Care to Prevent Future Falls	Not applicable
LTSS-6: Long-Term Services and Supports Admission to a Facility from the Community	August 1, 2026-July 31, 2027
LTSS-7: Long-Term Services and Supports Minimizing Facility Length of Stay	July 1, 2026-October 31, 2027
LTSS-8: Long-Term Services and Supports Successful Transition after Long-Term Facility Stay	All participants residing in a facility on July 1 of the year prior to the measurement year and who were residing in the facility for at least 101 days

III. Collection of Information Requirements

As indicated in section V. of this notice with comment period, this notice does not propose any new or revised collection of information requirements or burden. Instead, this notice with comment period is intended to satisfy, in part, the provisions under § 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. ( printed 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.

Footnotes

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.

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.

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.

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.

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.

14.

 Available at https://www.medicaid.gov/​medicaid/​quality-of-care/​quality-of-care-performance-measurement/​cahps-home-and-community-based-services-survey.

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.

16.

 CMIT is available at https://cmit.cms.gov/​cmit/​#/.

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/.

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.

1. https://www.federalregister.gov/​d/​2024-08363/​p-327.

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.

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&​sectionNumber=​1.

28.

 For more information on FASI-2, see https://cmit.cms.gov/​cmit/​#/​MeasureView?​variantId=​5224&​sectionNumber=​1.

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.

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&​sectionNumber=​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&​sectionNumber=​1.

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.

39.

 CMIT is available at https://cmit.cms.gov/​cmit/​#/.

40.

 For more information on HCBS-10, see https://cmit.cms.gov/​cmit/​#/​MeasureView?​variantId=​13283&​sectionNumber=​1.

41.

 For more information on the Plan All-Cause Readmission Measure, see https://cmit.cms.gov/​cmit/​#/​MeasureView?​variantId=​13284&​sectionNumber=​1.

42.

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

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.

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.

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/.

1. https://www.federalregister.gov/​d/​2024-08363/​p-316.

56.

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

[FR Doc. 2026-08190 Filed 4-27-26; 8:45 am]

BILLING CODE 4120-01-P

Published Document: 2026-08190 (91 FR 22823)