Federal officials are reshaping the rules surrounding Medicaid home and community-based services for people with disabilities in an effort to improve access and strengthen the direct support professional workforce.

Under a final rule released this week, the Centers for Medicare & Medicaid Services is establishing minimum payment thresholds for direct care providers, requiring that states regularly reevaluate the needs of those receiving home and community-based services and much more.

The regulation known as “Ensuring Access to Medicaid Services,” or the Access Rule, comes in response to the increasing shift toward people with disabilities living in the community as opposed to institutions.

With the rule, CMS said it sought to address significant variations across states in terms of quality and reporting requirements while also tackling the national shortage of direct care workers.

“The Access Rule is the most consequential, comprehensive regulation related to Medicaid-funded HCBS in a decade,” said Alison Barkoff who is performing the duties of the administrator at the U.S. Department of Health and Human Services’ Administration on Community Living. “It will strengthen the HCBS that make it possible for people to live in their own homes, stay connected to friends and family, and participate in the community in ways that are meaningful to them.”

The regulation clarifies that states must reassess the needs of each person receiving home and community-based services annually and revise their service plan accordingly. In addition, states will have to maintain an electronic incident management system and respond to incidents within specified timeframes. They also will need to establish a grievance process so that beneficiaries in traditional Medicaid plans can file complaints against a provider or state if they experience issues receiving the home and community-based services called for in their plan much like the process that already exists for those with managed care plans.

Under the measure, at least 80% of Medicaid payments for homemaker, home health aide and personal care services must go toward compensation for direct care workers as opposed to administrative overhead with limited exceptions. States will have to disclose the average hourly rate paid to workers for these services. And, states will face new requirements to report on a standardized set of quality measures as well as how they establish and maintain their waiting lists and the timeliness of service delivery.

Jennifer Lav, senior attorney at the National Health Law Program, said she’s optimistic that the changes will improve the availability of services for people with disabilities.

“Nationally, there is a critical direct care workforce shortage. All too often, people eligible for HCBS, which allow people with disabilities and complex medical needs to live in their homes and communities, cannot actually find anyone to provide these essential supports,” Lav said. “The HCBS Access Rule creates a mechanism to address historically insufficient rates and establishes that a fair share of state and federal Medicaid dollars go directly to wages for direct care workers, a workforce that is largely composed of immigrants and people of color. Ultimately, we hope this will increase access to critical HCBS services that let people with disabilities live in their own communities while also improving historical inequities in how this workforce is paid.”

The new rule will take effect 60 days after it is published in the Federal Register, but states will have years to comply with many of the requirements.

In addition to the Access Rule, CMS is also finalizing regulations instituting minimum staffing standards for nursing homes and a rule imposing new requirements for managed care plans.

States will be required to survey Medicaid beneficiaries enrolled in managed care plans regularly about their experiences and they must conduct “secret shopper” surveys annually to ensure managed care plans are providing accurate provider directories and that they are complying with appointment wait time standards, among other rules.

“Everyone should have equal access to the critical care they need,” said Secretary of Health and Human Services Xavier Becerra. “We are taking important steps to strengthen care provided through Medicaid and CHIP, and establishing national staffing standards for nursing homes to enhance care for residents while improving conditions for workers. This will help ensure that millions of people have access to high-quality health care and that the dedicated workers who provide care to our loved ones are fully valued for their work.”

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