HCBS Final Settings Rule

Medicaid Related Assistance
Developmental Disabilities

What would you like to do?

What you need to know

​​​​​​​​​​​​​​​​​​​​The Centers for Medicare and Medicaid Services (CMS) published a final rule for Medicaid Home and Community Based Services effective March 17, 2014. The final rule requires states to ensure people receiving Home and Community-Based Services (HCBS) have the benefits of community living. 

Each state reviewed policies, practices, and settings where HCBS are provided. Each state was required to have a plan for review and making needed changes. 

Nebraska's Compliance

Virtual and In-Person Training

​Do you have questions about the Final Settings Rule? Do you want more information and training before CMS does on-site visits in Nebraska? The DHHS Quality Team can help!

HCBS Final Settings Rule Q&A Sessions

Starting March 31, 2023, the Division of Developmental Disabilities (DDD) offers virtual Q&A sessions about the HCBS Final Settings Rule. 

Sessions are the last Friday of every month for 12 months. Come ready to ask questions about the HCBS Final Settings Rule.

Join meetings from the DDD calendar at the bottom of the DDD homepage​.

Final Settings Videos from The Council on Quality and Leadership (CQL) 

CQL developed videos to explain the CMS Final Settings Rule. 

Heightened Scrutiny

For settings presumed to have institutional qualities, CMS requires an assessment process called “heightened scrutiny." Identified settings are required to undergo an additional review by state staff and may be included in a sample reviewed by CMS. 

Settings subject to heightened scrutiny include:

  • Settings in a publicly or privately-operated facility providing inpatient institutional treatment; 
  • Settings on the grounds of, or adjacent to, a public institution; or 
  • Settings with the effect of isolating people receiving Medicaid home and community-based services from the broader community of people not receiving services. 

Settings subject to heightened scrutiny complete a packet to determine compliance. Heightened scrutiny documentation is sent to CMS when requested. CMS makes the final determination if identified settings meet HCBS criteria.

Under CMS' definition of what constitutes heightened scrutiny, DHHS identified 66 assisted living facilities (ALFs), which required review. 

Setting Assessments - Including Heightened Scrutiny Worksheet

AD Waiver

AD Providers will have an assessment completed by their Resource Development worker when then enroll as a new provider and during their annual review. AD Providers may complete the heightened scrutiny worksheet as requested by DDD.​

DD Waivers

When a DD provider opens a new residential service setting, the provider must complete a self-assessment at least 15 business days before opening. Residential settings include group homes, centers for the developmentally disabled (CDDs), host homes, and shared living homes. 

When a DD provider opens a new non-residential site, the provider must notify DDD Provider Relations at DHHS.DDProviderRelations@nebraska.gov so an assessment can be completed at least 15 business days before opening. Non-residential settings include workshops, hubs, enclaves, and other locations where day services occur.

TBI Waiver

TBI Providers will have an assessment completed by their Resource Development worker when then enroll as a new provider and during their annual review. TBI Providers may complete the heightened scrutiny worksheet as requested by DDD. 

Other Rule Resources

Questions can be emailed to DHHS.DDProviderRelations@nebraska.gov​