Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Introduction


Under Federal statute, the Centers for Medicare & Medicaid Services (CMS) have the authority to oversee and regulate states’ approaches to quality assurance for Section (§)1915(c) home and community-based services (HCBS) waiver programs (hereafter called HCBS waiver programs). Over the last 10 years, CMS has mounted a vigorous initiative to promote and enhance quality oversight of HCBS waiver programs, an initiative that has required changes by the states and CMS.2

Until 2004, Federal oversight of HCBS waiver program consisted of periodic reviews focusing on whether programmatic requirements had been met. During this period, CMS did not collect representative data on waiver system performance, nor did it require the states to collect such information for use in quality monitoring and improvement activities. Moreover, there was appreciable variation in how CMS Regional Offices conducted quality reviews.

A major impetus for increased Federal attention to quality in the HCBS waiver programs was a 2003 Government Accountability Office (GAO) report.3 The report cited as problematic the minimal information required in the waiver application about a state’s approach to monitoring quality, as well as the absence of a minimum level of routine reporting from the states to CMS. The GAO urged greater oversight by CMS and the provision of increased guidance to the states on waiver monitoring practices.

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