HCBS Access Rule Compliance

 
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Medicaid Related Assistance
Developmental Disabilities
 
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What you need to know

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​The HCBS Access Rule is a federal regulation finalizing a broad set of requirements related to ensuring access to Medicaid services. The Centers for Medicare and Medicaid Services (CMS) published the Access Rule in the Federal Register in May of 2024, and it became effective on July 9, 2024. 

The Access Rule aims to improve access to Medicaid services and make services better. Most provisions in the Access Rule have compliance deadlines in the future. This webpage provides information on how Nebraska is complying with the Access Rule and its timelines.

Access Rule Sections below include the dates for when the state must comply. 


Advisory Groups

Medicaid Advisory Committee (MAC) (July 9, 2025)

Requirement

States must have a Medicaid Advisory Committee (MAC) to make recommendations to Medicaid about how much to pay for services, quality of services, and serving people from diverse backgrounds, including those who speak any language.

States must establish membership requirements for the MAC. At least 25% of MAC members must be from the BAC.  

The group must meet at least four times per year. At least two MAC meetings per year must be open to the public and include a public comment period. 

States must provide staff to support MAC activities. Information about MAC activities must be publicly available, including bylaws, meeting schedules, agendas, minutes, and membership lists.

Nebraska Compliance

The Medicaid Advisory Committee (MAC) is a group that includes Medicaid beneficiaries, advocates, and providers. The committee works together to make recommendations for the Medicaid program. Visit the MAC webpage.

Beneficiary Advisory Council (BAC) (July 9, 2025)

Requirement

States must have a Beneficiary Advisory Council (BAC) including people who receive Medicaid, their families, and paid or non-paid caregivers. 

States must provide staff to support BAC activities. Information about BAC activities must be publicly available, including bylaws, meeting schedules, agendas, minutes, and membership lists.​​

Nebraska Compliance

Nebraska established a Beneficiary Advisory Committee (BAC) in July 2025​. Visit the BAC webpage.

Advisory Reports (July 9, 2026)

Requirement

States must create and publicly​ post an annual report summarizing MAC and BAC activities. 

Nebraska Compliance

A joint MAC and BAC report will be posted on the MAC​ and BAC webpages.​

Interested Parties Advisory Group (IPAG) (January 1, 2029)

Requirement 

The State agency must establish an advisory group for interested parties to advise and consult on provider rates with respect to service categories under the Medicaid State plan, 1915(c) waiver, and demonstration programs, as applicable, where payments are made to the direct care workers for the self-directed or agency-directed services.

The interested parties advisory group must include, at a minimum, direct care workers, beneficiaries, advocates, and other interested parties impacted by the services rates in question, as determined by the State.

The IPAG shall meet at least every 2 years and make recommendations to the Medicaid agency on the sufficiency of State plan, 1915(c) waiver, and demonstration direct care worker payment rates. The Medicaid agency must publish the recommendations produced by the IPAG within 1 month of when the group provides the recommendation to the agency.

Nebraska Compliance

The Interested Parties Advisory Group is a group that will include direct care workers, Medicaid beneficiaries, and advocates. Compliance is required by January 1, 2029.


Person-Centered Planning​​

Person Centered Planning Compliance Reporting (July 9, 2027)

Requirement

States must look at what each participant needs for services at least once a year. States must show CMS that they are completing needs assessments and updating person-centered plans. 

Nebraska Compliance

Percentage of participants who had their person-centered plan reviewed as reported to CMS as part of Nebraska's Annual Reports (CMS-372). 

​Waiver
​2024 Report
2023 Report 
​Aged and Disabled
86%​
​91%
​Traumatic Brain Injury
​100%
No Performance Measure
​Family Support 
Waiver Not Active
Waiver Not Active
​DD Adult Day
​99%
​99.5%
​Comprehensive DD

​99%
​99%
Performance Measure D.C. 1: Number and percent of participants reviewed whose person-centered plans were reviewed and revised on or before the annual review date.​ 


Grievances ​

Grievance System (July 9, 2026)

Requirement

States must have a way for people to make a grievance about their HCBS services. The person receiving services, or their guardian, may file grievances. Another person may help them with the process. 

The state must tell participants about their rights, give accessible directions on how to file a grievance, provide two ways to file a grievance (verbally or in writing), and help them make sure their grievance is filed correctly. The state must provide interpreters when needed. 

The state must make sure people who file a grievance are not threatened. Someone must talk to the person if they are unsatisfied about any decision related to their grievance. 

The state grievance system must include how the state responds to grievances and collects information. 

Nebraska Compliance

A participant or their representative has the right to file a grievance with DDA when they have a concern related to any aspect of their HCBS services, settings, or planning and to have the grievance addressed by DDA. 

Participants or their representatives may complete the Grievance Form on the DDA public website or directly here.

Participants may also submit a complaint by mail, telephone, or in person at a local DHHS office. DDA contact information is available here.​


Incident Management​

Incident Management Systems Assessment (July 9, 2027)

Requirement

States must clearly define all types of abuse and neglect. The Access Rule says that critical incidents include: 

  • ​Verbal abuse: name-calling, yelling, or making fun of a participant.
  • Physical abuse: hitting, shoving, or threatening to hurt a participant.
  • Sexual abuse: unwanted or forced sexual touching or activity.
  • Emotional abuse: someone controlling, frightening, or isolating a participant.
  • Neglect: not giving enough food, housing, or medical care. 
  • Exploitation: taking money or other things without asking; also when a person with a disability is paid less than other workers.
  • The use of restraint or seclusion: 
    • ​Restraint: when someone stops someone else from moving. 
    • Seclusion: when someone locks someone else in an empty room.
  • A medication error resulting in a telephone call to, or consultation with, a poison control center, an emergency department visit, an urgent care visit, hospitalization, or death.
  • An unexplained or unanticipated death.

Nebraska Compliance

These critical incidents have been incorporated into all waivers and are required to be reported (as GERs) by all HCBS providers. The Quality Team reviews all critical incidents for follow-up and resolution.

Incident Management Compliance Reporting (July 9, 2027)

Requirement

States must meet nationwide incident management system standards for monitoring HCBS programs.​

Nebraska Compliance

Compliance reporting is required by July 9, 2027.​

Electronic Incident Management System (July 9, 2029)

Requirement

States must use a computer-based system to keep track of incident reports. States must make sure providers investigate incidents and take actions in response to incidents. There are deadlines for investigating and reporting what happened during and after an incident. If reports are not filed on time, the state is responsible to conduct an investigation. States must share updates about investigations. 

Providers must report critical incidents to the state, regardless of if services were being delivered at the time of the incident. States must look at reports from other agencies, such as Adult Protective Services, to see if there are incidents that a provider did not report. 

Nebraska Compliance

Nebraska uses Therap​ as the state-mandated web-based single case management system. It is used for many things, including incident reports, billing, referrals and secure communication. 


Payment Adequacy, Transparency, and Rate Provisions​

Fee For Services (FFS) Payment Rates (July 1, 2026)

Requirement

States​ must publish all FFS Medicaid fee schedule payment rates on a publicly available and accessible website so anyone can see what Medicaid pays for a service. 

States must report the average cost of service. This includes what agency providers pay for wages and benefits to direct care workers. 

States must also publish the initial comparative payment rate analysis in effect as of July 1, 2025, for primary care services, obstetrical and gynecological services, outpatient mental health and substance abuse disorder services, and personal care, home health aide, homemaker, and habilitative services by no later than July 1, 2026 and every two years thereafter. 

Nebraska Compliance

FFS Medicaid fee schedules are available at the following locations:


Comparative rate analysis documents are available athe the following locations:

Payment Adequacy Reporting for Personal Care, Home Health Aide, and Home Maker Services (July 9, 2028)

States must report on the percentage of Medicaid payments for homemaker, home health aide, personal care, and habilitation services spent on compensation to the direct care workers furnishing these services, subject to certain exceptions.

States must establish an advisory group for direct care workers, beneficiaries, beneficiaries' authorized representatives, and other interested parties to meet at least every two years, and advise and consult on payment rates paid to direct care workers for personal care, home health aide, homemaker, and habilitation services.

Nebraska Compliance

Compliance reporting is required by July 9, 2028.

The following Nebraska waiver services are included in the requirement for homemaker, personal care, and habilitative services:

AD Waiver
TBI Waiver
FSW
DDAD Waiver
CDD Waiver
LRI Personal Care
LRI Personal Care
Child Day Habilitation
Community Inclusion
Behavioral In-Home Habilitation
Personal Care
Supported Employment - Follow-Along
Community Inclusion
Day Support
Child Day Habilitation

Supported Employment - Individual
Day Support
Employment Exploration
Community Inclusion

TBI Personal Care
Homemaker
Independent Living
Continuous Home


Independent Living
LRI Personal Care
Day Support

​LRI Personal Care
Prevocational
Employment Exploration

​Supported Family Living
Small Group Vocational Support
Homemaker

​​Supported Employment - Follow-Along
Host Home

​​Supported Employment - Individual
Independent Living


​​Supported Family Living
LRI Personal Care

​

Medical In-Home Habilitation

​​​Prevocational 

​

Shared Living

​​
Small Group Vocational Support

​​
Supported Employment - Follow-Along






Supported Employment - Individual

​​​Supported Family Living

​​​Youth Continuous Home



Payment Adequacy Minimum Performance Standard - 80/20 Rule (July 9, 2030)

At least 80% of the Medicaid money that goes to states for HCBS services must go to pay and benefits for direct care workers. Direct care workers include personal care attendants, homemakers or people who help with chores or household activities, and people who provide home health services. It does not include habilitation services or day programs.

States have the option to establish: 

  1. A hardship exemption based on a transparent state process and objective criteria for providers facing extraordinary circumstances and 
  2. A separate performance level for small providers meeting state-defined criteria based on a transparent state process and objective criteria. 

​The HCBS payment adequacy provision also exempts the Indian Health Service and Tribal health programs subject to 25 U.S.C. 1641 from complying with its requirements.


Website Transparency​

Website Transparency (July 9, 2027)

Requirement

States must have public transparency related to Medicaid HCBS through public reporting of quality, performance, and compliance measures.

Nebraska Compliance

This website provides transparency. ​


Waiting Lists and Timeliness of Access​

Wait List Reporting (July 9, 2027)

Requirement

States must report on the use of waiting lists if the state limits the size of its waiver program.

States must report on the average time from authorization to the initiation of homemaker, personal care, and habilitative services for applicants newly admitted to the waiver. States may use a statistically valid random sample of individuals admitted to the waiver within the past 12 months for this reporting.

States must report on the percentage of authorized homemaker, personal care, and habilitative service hours that are billed. States may use a statistically valid random sample of the entire participant population for this reporting.

Nebraska Compliance

Nebraska has not limited the size of its 1915(c) waivers or maintained a waitlist since the elimination of the DD Waitlist in July 2025. At this time, all eligible individuals are admitted to the waiver for which they qualify, or may choose among waivers if eligible for more than one, as soon as eligibility is determined.

To calculate the average time from authorization to the initiation of homemaker, personal care, and habilitative services for individuals newly admitted to the waiver program, the State calculates the average number of days between the date an authorization is created and the first date of service associated with that authorization. The State uses a statistically valid random sample (95% confidence level with a ±5% margin of error) of all participants initially admitted to the waiver program within the past 12 months.

To calculate the percentage of authorized homemaker, personal care, and habilitative service hours that are billed, the State calculates the ratio of total billed hours to total authorized hours for these services. This analysis is conducted using a statistically valid random sample (95% confidence level with a ±5% margin of error) of all waiver participants.​​

​

Quality Measures ​

Quality Measure Set (July 9, 2028)

Requirement

CMS has a new way to check on how good services are in each state, like a "report card." Every two years, states must give CMS their "report card" on the quality of services in their state. States must set goals to improve services and describe what they will do to make services better. 

Participants must have opportunities to tell CMS what they like and don't like about their HCBS services. 

Nebraska Compliance

​​​Nebraska uses National Core Indicators (NCI) to fulfill this requirement. NCI is a national effort to measure and improve the quality of services for aged and disabled people and individuals with intellectual and developmental disabilities and their families. For more information on the surveys Nebraska ​participates in, as well as survey results, visit our Quality Assurance webpage.