HCBS Final Settings Rule

 
4
Medicaid Related Assistance
Developmental Disabilities
 
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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. 


Public Comment for HCBS Heightened Scrutiny Review

The Nebraska Department of Health and Human Services (DHHS) is seeking public feedback related to facility designation following the state's review of heightened scrutiny of settings of 1915(c) Medicaid Home and Community Based Services (HCBS). 

Documents for Review - Accura HealthCare of Franklin, LLC

The 30-day public comment period is from June 23, 2025 through July 23, 2025: 

Documents for Review - Accura HealthCare of Hartington, LLC

The 30-day public comment period is from June 24, 2025 through July 24, 2025: ​

Submitting Comments

Interested persons are invited to submit written comments to the Department. 

Public comments may be submitted:

  • To the designated email address dhhs.hcbs-fsr@nebraska.gov
  • Faxed to (402) 471-8792; or
  • Sent to DHHS – Division of Developmental Disabilities, 301 Centennial Mall South, P.O. Box 95026, Lincoln, NE 68509-5026.

Written comments must be postmarked or received by end of public comment period.


Nebraska's Compliance

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

CQL developed videos to explain the CMS Final Settings Rule. 

Training for Direct Support Professionals - January 2025

Learn about the Final Settings Rule and how it applies to providers.

  • ​Training for Direct Support Professionals (DSPs): Understanding the HCBS Final 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. 

CMS Guidance for States

Other Rule Resources


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