DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
SMD# 22-003 
RE: Home and Community-Based 
Services Quality Measure Set 
 
July 21, 2022 
 
Dear State Medicaid Director: 
 
The Centers for Medicare & Medicaid Services (CMS) and states have worked for decades to 
support increased availability and provision of high-quality Home and Community-Based 
Services (HCBS) for Medicaid beneficiaries.  HCBS provide individuals who need assistance 
with everyday activities the opportunity to receive services (such as personal care, homemaker, 
and adult day health services) in their own homes or the community as opposed to institutional 
settings.  This State Medicaid Director Letter provides information on a set of nationally 
standardized quality measures for Medicaid-funded HCBS that is intended to promote more 
common and consistent use within and across states of such nationally standardized quality 
measures in HCBS programs, create opportunities for CMS and states to have comparative 
quality data on HCBS programs, and drive improvement in quality of care and outcomes for 
people receiving HCBS. 
 
Background 
 
Millions of Americans, including children, non-elderly adults, and older adults, need long-term 
services and supports (LTSS) because of disabling conditions, chronic illness, and other factors. 
Medicaid is the primary payer across the nation for these services, although private spending 
(e.g., out-of-pocket spending by individuals and long-term care insurance) and other public 
payers (e.g., Veterans Health Administration, state and local programs, and Medicare) also 
account for some LTSS spending nationally.1  Medicaid allows for the coverage of LTSS 
through several authorities and programs and over a continuum of settingsranging from 
institutional settings, such as nursing facilities, to home and community-based settings.2   
Medicaid coverage of HCBS varies by state and can include a combination of medical and non-
medical services, such as (but not limited to) case management, homemaker, home health aide, 
personal care, adult day health, habilitation (both day and residential), and respite care services.  
HCBS programs serve a variety of targeted population groups, such as people with intellectual or 
developmental disabilities, physical disabilities, substance use disorders, and/or mental illness, 
                                                            
1 Office of the Assistant Secretary for Planning and Evaluation. February 8, 2018. An Overview of Long-Term 
Services and Supports and Medicaid: Final Report. Retrieved from https://aspe.hhs.gov/basic-report/overview-long-
term-services-and-supports-and-medicaid-final-report.  
2 See https://www.medicaid.gov/medicaid/long-term-services-supports/index.html for more information on LTSS 
and https://www.medicaid.gov/medicaid/home-community-based-services/index.html for more information on 
HCBS. 
 
  State Medicaid Director  Page 2 
and provide opportunities for Medicaid beneficiaries to receive services in their own homes and 
communities rather than in institutions. 
 
From the beginning of the Medicaid program in 1965, state Medicaid programs were required to 
provide medically necessary nursing facility care for most eligible individuals age 21 or older, 
but coverage for HCBS has been a state option.3  However, over the past several decades states 
have used several Medicaid authorities,4 as well as CMS-funded grant programs,5 to develop a 
broad range of HCBS to provide alternatives to institutionalization for eligible Medicaid 
beneficiaries and to advance person-centered care.  Consistent with many beneficiaries 
preferences for where they would like to receive their care, HCBS have become a critical 
component of the Medicaid program and are part of a larger framework of progress toward 
community integration of older adults and people with disabilities that spans efforts across the 
federal government.  Further, HCBS play an important role in states efforts to achieve 
compliance with the Americans with Disabilities Act (ADA) and the Olmstead decision, in 
which the Supreme Court held that the unjustified institutional isolation of people with 
disabilities is a form of unlawful discrimination under the ADA.6   
 
As a result of state and federal efforts to expand access to HCBS, Medicaid spending on HCBS 
now exceeds spending on institutional services.  For instance, in fiscal year (FY) 1990, HCBS 
expenditures accounted for only 13 percent of the $31 billion in federal and state expenditures 
for all Medicaid LTSS, including nursing home expenditures.7,8  By FY 2020, HCBS 
expenditures accounted for $125 billion, or 62 percent, of the $199 billion spent nationally on 
Medicaid LTSS.9,10  However, as the number of beneficiaries receiving Medicaid HCBS and 
                                                            
3 Wenzlow, Audra, Steve Eiken and Kate Sredl. 2016. Improving the Balance: The Evolution of Medicaid 
Expenditures for Long-Term Services and Supports (LTSS), FY 1981-2014. Retrieved from 
https://www.medicaid.gov/sites/default/files/2019-12/evolution-ltss-expenditures.pdf. 
4 These authorities include Medicaid state plan personal care services and Social Security Act (the Act) section 
1915(c) waivers, section 1915(i) state plan HCBS, section 1915(j) self-directed personal assistant services, and 
section 1915(k) Community First Choice. See https://www.medicaid.gov/medicaid/home-community-based-
services/home-community-based-services-authorities/index.html for more information on these authorities. Some 
states also use demonstration authority under section 1115(a) of the Act to cover and test home and community-
based service strategies. See https://www.medicaid.gov/medicaid/section-1115-demonstrations/index.html for more 
information.  
5 Federally funded grant programs, such as the Money Follows the Person demonstration, which was initially 
authorized by the Deficit Reduction Act (P.L. 109-171) and continues to operate in 36 states, and the Balancing 
Incentive Program authorized by the Patient Protection and Affordable Care Act (P.L. 111-148), which provided 
financial incentives over four years (FY 2011-2015) to 13 states to increase access to HCBS, have been designed to 
shift Medicaids long-term care spending from institutional care to HCBS. 
6 https://www.medicaid.gov/about-us/program-history/medicaid-50th-anniversary/entry/47688 
7 Wenzlow, Audra, Steve Eiken and Kate Sredl. 2016. Improving the Balance: The Evolution of Medicaid 
Expenditures for Long-Term Services and Supports (LTSS), FYs 1981-2014. Retrieved from 
https://www.medicaid.gov/sites/default/files/2019-12/evolution-ltss-expenditures.pdf. 
8 Amount is not adjusted for inflation. 
9  Murray, Caitlin, Michelle Eckstein, Debra Lipson, and Andrea Wysocki. Medicaid Long Term Services and 
Supports Annual Expenditures Report: Federal Fiscal Year 2020. Chicago, IL: Mathematica. Forthcoming. 
10 Amounts are not adjusted for inflation. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 3 
spending on HCBS has increased, so too has the need to ensure the availability and provision of 
high-quality services that promote positive outcomes and cost-effective delivery of care, while 
minimizing provider burden.  
 
Over the past decade, the Department of Health and Human Services (HHS), states, and other 
entities have taken a number of steps to strengthen the capacity of states and the federal 
government to monitor, oversee, and improve the quality and effectiveness of services, and to 
assure beneficiary health and safety.  For example, in 2014, CMS revised the quality oversight 
structure originally established in 2004 for section 1915(c) HCBS waiver programs.11  At the 
center of this framework is reporting on state-developed performance measures designed to 
reflect the operations of waiver programs across important domains that CMS defined, such as 
beneficiary health and welfare (safety), financial accountability, and service provision and 
delivery.  CMS has also promoted the development of new quality measures,12 interoperability 
standards (including electronic long-term services and supports standards), standardized tools 
and instruments,13 and other innovations related to HCBS through initiatives such as the Testing 
Experience and Functional Tools (TEFT) demonstration,14 the Balancing Incentive Program,15 
and the Medicaid Innovation Accelerator Program,16 among others.17  As another example, for 
the last seven years, HHSs Administration for Community Livings National Institute on 
Disability, Independent Living, and Rehabilitation Research (NIDILRR) has funded a 
Rehabilitation Research and Training Center grant18 to develop, cognitively and 
psychometrically test, and gain National Quality Forum (NQF)19 approval for HCBS quality 
measures.  Many states have also made substantial investments related to monitoring, 
overseeing, and improving the quality of HCBS.20 
                                                            
11 https://www.medicaid.gov/sites/default/files/2019-12/3-cmcs-quality-memo-narrative_0.pdf  
12 See https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/cahps-hcbs-survey/index.html 
and https://www.medicaid.gov/medicaid/managed-care/ltss/index.html for examples. 
13 See https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/cahps-hcbs-survey/index.html 
and https://www.medicaid.gov/medicaid/ltss/teft-program/functional-assessment-standardized-items/index.html for 
examples. 
14 https://www.medicaid.gov/medicaid/ltss/teft-program/index.html  
15 https://www.medicaid.gov/medicaid/ltss/balancing/incentive/index.html  
16 https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/index.html  
17 https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/measuring-and-improving-
quality-home-and-community-based-services-hcbs/index.html  
18 See https://acl.gov/programs/research-and-development/rehabilitation-research-and-training for more information.  
19 NQF (https://www.qualityforum.org/Home.aspx) is a private non-profit organization and is currently designated 
as the consensus-based entity (CBE) with a contract with HHS under section 1890 of the Social Security Act (the 
Act).  As required under section 1890, the CBE is required to: synthesize evidence and convene key stakeholders to 
make recommendations on an integrated national strategy and priorities for health care performance measurement in 
all applicable settings; provide for the endorsement of standardized health care performance measures; and establish 
and implement a process to ensure that measures endorsed are updated (or retired if obsolete) as new evidence is 
developed. See https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityMeasures/Downloads/CMS-RTC-Quality-Measurement-March-1-2019_508.pdf for more 
information. 
20 National Quality Forum (NQF). Quality in Home and Community-Based Services to Support Community 
Living: Addressing Gaps in Performance Measurement. Final Report. Washington, DC: NQF, September 2016. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 4 
 
Despite these and other recent advances, notable gaps and challenges related to HCBS quality 
remain. In particular, a 2016 NQF report commissioned by HHS, Quality in Home and 
Community-Based Services to Support Community Living: Addressing Gaps in Performance 
Measurement, indicates that, unlike other types of health care services, HCBS lacks any 
standardized set of quality measures...[and] consensus as to what HCBS quality entails.  The 
report recommended that HHS develop a core set of standard measures for use across the HCBS 
system, along with a menu of supplemental measures that are tailorable to the population, 
setting, and program.20  In 2020, CMS published a request for information (RFI)21 seeking 
public input on a draft set of quality measures for Medicaid-funded HCBS that was specifically 
intended to address that recommendation.  Since releasing the RFI, CMS has also engaged with a 
broad range of stakeholders, including states, managed care plans, consumer advocates, quality 
measurement experts, researchers, and other federal agencies, to receive additional feedback on 
the draft measure set and on opportunities to support states with using the measure set, including 
to meet quality measurement and reporting requirements under various Medicaid HCBS 
authorities.  As a result of these stakeholder engagement activities, CMS is releasing this first of 
two planned guidance documents to promote more common and consistent use of nationally 
standardized quality measures in their HCBS programs and to support states with improving the 
quality and outcomes of HCBS. 
 
This letter provides the first official version of the HCBS Quality Measure Set.  It includes the 
list of measures in the measure set (see attachment) and provides additional information on the 
purpose of the measure set, the measures included, measure selection criteria, organization of the 
measure set, and considerations for implementation.  The list of measures in the attachment also 
includes the NQF number (if applicable), measure steward,22 and data collection method for each 
measure, as well as information on whether each measure addresses section 1915(c) waiver 
assurances and/or can be used to assess access, LTSS rebalancing,23 and/or community 
integration and HCBS settings requirements, as defined in the HCBS Settings final rule.24    
 
A forthcoming second planned guidance document will describe how states can use the measure 
set as part of their HCBS quality measurement, reporting, and improvement activities, including 
to meet federal requirements for their HCBS programs (such as required reporting for section 
1915(c) waiver assurances and subassurances).25  
 
 
 
 
                                                            
http://www.qualityforum.org/Publications/2016/09/Quality_in_Home_and_Community-
Based_Services_to_Support_Community_Living__Addressing_Gaps_in_Performance_Measurement.aspx  
21 https://www.medicaid.gov/medicaid/quality-of-care/downloads/rfi-hcbs-recommended-measure-set.pdf 
22 The measure steward is the entity that owns the measure and is responsible for maintaining it. 
23 Rebalancing is commonly defined as achieving a more equitable balance between the share of spending and use of 
services and supports delivered in home and community-based settings relative to institutional care. 
24 See https://www.medicaid.gov/medicaid/home-community-based-services/guidance/home-community-based-
services-final-regulation/index.html for information on the HCBS Settings final rule. 
25 See https://www.medicaid.gov/sites/default/files/2019-12/3-cmcs-quality-memo-narrative_0.pdf for more 
information on required reporting for section 1915(c) waiver assurances and subassurances. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 5 
Purpose of the HCBS Quality Measure Set  
 
The HCBS Quality Measure Set is intended to promote more common and consistent use, within 
and across states, of nationally standardized quality measures in HCBS programs, and to create 
opportunities for CMS and states to have comparative quality data on HCBS programs.  In doing 
so, it is expected to support states with improving the quality and outcomes of HCBS.  It is also 
intended to reduce some of the burden that states and others may experience in identifying and 
using HCBS quality measures.  By providing states and other entities with a set of nationally 
standardized measures to assess HCBS quality and outcomes and by facilitating access to 
information on those measures, CMS may be able to reduce the time and resources expended on 
identifying, assessing, and implementing measures for use in HCBS programs.  
 
While use of this measure set is voluntary at this time, CMS plans to incorporate use of the 
measure set into the reporting requirements for specific authorities and programs, including the 
Money Follows the Person (MFP) program and future section 1115 demonstrations that include 
HCBS.  Additional information will be made available to states that are participating in the MFP 
program and that deliver HCBS through section 1115 demonstrations; states are not expected to 
make any changes to their measurement and reporting activities in their MFP programs or their 
section 1115 demonstrations until they receive additional information from CMS.  CMS also 
encourages states to use the measure set to assess quality and outcomes in HCBS programs 
authorized under other federal authorities, including section 1915(c) waiver programs, section 
1915(i) state plan services, section 1915(j) self-directed personal assistance services, and section 
1915(k) Community First Choice.  In addition, while some of the measures included in the 
measure set are applicable for only certain delivery system types, CMS encourages states to use 
the measure set, to the extent that measures are applicable to a specific HCBS program, 
regardless of delivery system type.  As noted previously, a second guidance document, which is 
forthcoming, will describe how states can use the measure set to meet federal requirements for 
their HCBS programs (such as required reporting under section 1915(c) waivers and quality 
reporting in managed care programs).   
 
Measures Included in the HCBS Quality Measure Set 
 
The HCBS Quality Measure Set is comprised of measures that assess quality across a broad 
range of domains identified as measurement priorities for HCBS.  To be included in the measure 
set, a measure must be clearly defined and expressed as a rate, proportion, or ratio that is 
calculated with: (1) a numerator that counts the target process, condition, event, or outcome 
expected for the target population, and (2) a denominator that counts the number of people 
eligible for the process or for whom the outcome is relevant.26  A measure must also have clearly 
defined exclusion criteria that can be used to identify who should be removed from the measure 
population.  
 
In addition to claims-based measures and measures that require assessment or other beneficiary 
records, the HCBS Quality Measure Set extensively leverages existing beneficiary surveys used 
                                                            
26 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/NTM-What-is-a-
Quality-Measure-SubPage.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 6 
by states to assess beneficiary experience of care, which is critical for improving the quality and 
outcomes of HCBS and ensuring that services are person-centered and support beneficiaries 
goals and preferences for care.  Specifically, the measure set includes measures derived from 
experience of care surveys (HCBS Consumer Assessment of Healthcare Providers and Systems 
(CAHPS), National Core Indicators-Intellectual and Developmental Disabilities (NCI-IDD), 
National Core Indicators-Aging and Disability (NCI-AD)TM, Personal Outcome Measures 
(POM)) which assess the experience of care of one or more population groups included in 
HCBS programs (e.g., older adults, adults with intellectual and developmental disabilities, adults 
with physical disabilities, adults with serious mental illness). The measure set also includes other 
nationally standardized and tested measures related to key areas, such as access, LTSS 
rebalancing, community integration, health and safety, and person-centered practices.  These 
areas are discussed in more detail under Organization of the HCBS Quality Measure Set 
below.  
 
Measure Selection Criteria 
 
Consistent with the CMS Measures Management System Blueprint27 and NQF measure 
evaluation criteria,28 CMS took into consideration the following criteria when selecting measures 
for inclusion in the measure set: 
  Importance to Measure and Report: Extent to which the specific measure focus is 
evidence based and important to making significant gains in healthcare quality where 
there is variation in or overall, less than optimal performance. 
  Scientific Acceptability of the Measure Properties: Extent to which the measure, as 
specified, produces consistent (reliable) and credible (valid) results, including across 
HCBS populations, when implemented. 
  Feasibility: Extent to which the specifications, including measure logic, require data that 
are readily available or that could be captured without undue burden and can be 
implemented for performance measurement. This criterion also includes whether measure 
specifications and any instruments needed to collect data are publicly available at no cost. 
  Usability and Use: Extent to which states, HCBS programs, managed LTSS (MLTSS) 
plans, or other entities are using or could use performance results for both accountability 
and performance improvement. For example, this would include whether a measure can 
be used to support the existing reporting requirements associated with the section 1915(c) 
assurances and subassurances29 or other CMS requirements. 
  Related and Competing Measures: Extent to which there are related measures (i.e., 
measures that address either the same topic or the same population) and/or competing 
measures (i.e., measures that address both the same topic and the same population) in the 
measure set. 
                                                            
27 CMS. Blueprint for the CMS Measures Management System. Version 17.0, September 2021. 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint.html.  
28 NQF. Measure Evaluation Criteria and Guidance for Evaluating Measures for Endorsement. September 2021. 
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88439. 
29 https://www.medicaid.gov/sites/default/files/2019-12/3-cmcs-quality-memo-narrative_0.pdf  
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 7 
See the CMS Measures Management System Blueprint30 and NQF measure evaluation criteria31 
for more information on these criteria.  
 
CMS also considered the type of measure (specifically: structural, process, or outcome32); the 
level at which the measure can be applied (e.g., statewide, delivery system, population level); 
and whether the measure promotes health information exchange, or the electronic sharing of 
health-related data between two or more organizations for use by a variety of stakeholders to 
inform health and care.  However, due to the limited number of HCBS quality measures that 
fully meet all of these criteria, CMS used the criteria as a guide, rather than a standard, in 
selecting the measures.  
 
As HCBS measure development continues to advance, CMS expects to update the measure set to 
address measure gaps, advance health information exchange, add newly developed measures that 
fully meet the criteria of the CMS Measures Management System Blueprint, and retire measures 
that do not meet Blueprint criteria. CMS expects to transition the measure set to include only 
measures that fully meet Blueprint criteria by 2025.  Measure stewards are encouraged to 
complete any necessary data collection and testing to demonstrate that the measures included in 
the measure set fully meet Blueprint criteria by 2024.  
 
Organization of the HCBS Quality Measure Set 
 
As shown in the attachment, CMS has organized the measures by section 1915(c)33 waiver 
assurances and subassurances, where the measures align with the assurances and subassurances.  
This organization is intended to support states with using the measure set in their HCBS 
programs.  While the current version of the measure set does not have an all-inclusive set of 
measures to demonstrate that assurances are met, CMS will continue to update the measure set to 
address gaps and identity additional measures to demonstrate that assurances are met.  The 
current version of the measure set includes measures that address the following Service Plan 
subassurances: 
                                                            
30 CMS. Blueprint for the CMS Measures Management System. Version 17.0, September 2021. 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint.html.  
31 NQF. Measure Evaluation Criteria and Guidance for Evaluating Measures for Endorsement. September 2021. 
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88439. 
32 Structural measures focus on features of a healthcare organization or provider that are relevant to the capacity to 
provide high quality care. Process measures focus on activities or steps performed for, on behalf of, or by a person 
related to their care. There should be a scientific basis for believing that the process, if executed well, will increase 
the probability of achieving a desired outcome. Process measures are the most common type of quality measure. 
Outcome measures assess the results of care. They focus on the persons health state, health status, or change in 
health status resulting from care. Some outcome measures are intermediate outcome measures that examine the 
change produced by an intervention, which leads to a longer-term outcome (e.g., an intervention that prevents falls 
and, in turn, reduces the risk of serious injury and/or mortality among the elderly). Sources: CMS. Blueprint for the 
CMS Measures Management System. Version 17.0, September 2021. https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint.html; and NQF. Measure Evaluation Criteria 
and Guidance for Evaluating Measures for Endorsement. September 2018. 
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88439.  
33 While HCBS can be provided under other Medicaid authorities, section 1915(c) waivers are most commonly used 
by states and account for about half of HCBS spending nationally.  As a result, particular emphasis was placed on 
aligning the measure set with section 1915(c) reporting requirements.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 8 
  Service plans address all participants assessed needs (including health and safety risk 
factors) and personal goals, either by waiver services or through other means; 
  Service plans are updated/revised at least annually or when warranted by changes in the 
waiver participants needs; 
  Services are delivered in accordance with the service plan, including in the type, scope, 
amount, duration, and frequency specified in the service plan; and 
  Participants are afforded choice between/among waiver services and providers.   
 
The measure set also includes measures that address the following Health and Welfare 
subassurances: 
  The state demonstrates on an ongoing basis that it identifies, addresses, and seeks to 
prevent instances of abuse, neglect, exploitation and unexplained death; and 
  The state establishes overall health care standards and monitors those standards based on 
the responsibility of the service provider as stated in the approved waiver. 
 
In addition, the measure set identifies measures that address HCBS quality and outcomes in the 
following key priority areas:   
1.  Access, which is defined for the purposes of the measure set as the level to which the 
beneficiary/family caregiver/natural support is aware of and able to access resources 
(e.g., peer support, respite, crisis support, information and referral) that support overall 
well-being.  
2.  Rebalancing, which is commonly defined as achieving a more equitable balance between 
the share of spending and use of services and supports delivered in home and community-
based settings relative to institutional care.  
3.  Community Integration, which is focused on ensuring the self-determination, 
independence, empowerment, and full inclusion of children and adults with disabilities 
and older adults in all parts of society; and HCBS Settings Requirements,34 as defined 
in the HCBS Settings final rule,35 which establishes requirements for the qualities of 
settings in which Medicaid HCBS are provided under sections 1915(c), 1915(i), and 
1915(k) of the Social Security Act.  The final rule requires that all home and community-
based settings meet certain qualifications, including:  
  The setting is integrated in and supports full access to the greater community;  
  The setting is selected by the individual from among setting options;  
  The setting ensures an individuals rights of privacy, dignity and respect, and 
freedom from coercion and restraint;  
  The setting optimizes autonomy and independence in making life choices; and 
  The setting facilitates choice regarding services and who provides them.   
 
                                                            
34 Please note that the measures related to the HCBS settings requirements are not designed to determine if a 
particular setting is fully compliant with HCBS settings requirements. Instead, the measures are included as an 
assessment of overall system performance in terms of whether people receiving HCBS have opportunities for 
community integration and the system of care is meeting the purpose and intent of the settings rule.  
35 See https://www.medicaid.gov/medicaid/home-community-based-services/guidance/home-community-based-
services-final-regulation/index.html for information on the HCBS Settings final rule. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 9 
The NQF number (if applicable), measure steward, and data collection method (e.g., survey, case 
management system) are also included for each measure.  In addition, CMS will release a 
supplement to the measure set that provides additional technical details on each measure (e.g., 
numerator, denominator, exclusion criteria).   
 
CMS notes that the draft version of the measure set released through the RFI included a different 
organization of the measures. Specifically, it was organized into two main parts: A base set of 
measures and an extended set of measures.  The base set was comprised of a relatively small 
number of measures that would be used in their entirety as a set of measures to promote 
widespread adoption of common measures and create opportunities for comparative data (e.g., 
across states, MLTSS plans, or populations).  The extended set was comprised of a larger 
number of measures from which states, managed care plans, and other entities could select to 
supplement the base set and address their priorities and needs.   CMS also proposed to organize 
the measures in both the base set and the extended set using the eleven HCBS quality domains 
described in NQFs 2016 report, Quality in Home- and Community-Based Services to Support 
Community Living: Addressing Gaps in Performance Measurement.  This organization was 
intended to help ensure that the measure set addresses a broad and diverse range of areas related 
to HCBS quality measurement priorities.36  While stakeholder feedback generally supported the 
organization of the measure set proposed through the RFI, CMS adopted a different organization 
in the final version released through this letter to support states better with using the measure set 
in their programs and to ensure that the measure set is aligned with CMS reporting requirements 
and priorities for HCBS programs.  
 
Considerations for Implementation 
 
The HCBS Quality Measure Set is designed to assess quality and outcomes across a broad range 
of key areas for HCBS.  As a result, it is intended for use in all HCBS programs except when the 
identified measures are not applicable (e.g., managed care measures for states with only fee-for-
service programs, measures derived from experience of care surveys other than those being used 
to assess beneficiary experience in the HCBS program 37).  However, states are also encouraged 
to use the measure set for specific purposes (e.g., to assess the impact of an initiative on access 
as part of the evaluation plan for a state directed payment in managed care38).  In addition, while 
some of the measures included in the measure set are applicable for only certain delivery system 
types, CMS encourages states to use the measure set, to the extent that measures are applicable to 
a specific HCBS program, regardless of delivery system type.  Most of the measures included in 
                                                            
36 The domains include: Service Delivery and Effectiveness; Person-Centered Planning and Coordination; Choice 
and Control; Community Inclusion; Caregiver Support; Workforce; Human and Legal Rights; Equity; Holistic 
Health and Functioning; System Performance and Accountability; and Consumer Leadership in System 
Development. Definitions for each NQF domain are embedded within the recommended measure set. The 
subdomains and subdomain definitions are also provided in the recommended measure set for informational 
purposes. However, because of the limited number and breadth of HCBS measures available, the measures are not 
organized by subdomain.  
37 See additional clarifying information on experience of care measures in the next paragraph. 
38 See https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd21001.pdf for more information. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 10 
the measure set have only been tested with adults and have not been tested with children and 
adolescents. As a result, the measure set may not be appropriate for use in HCBS programs that 
serve children and adolescents. 
 
As noted earlier, the HCBS Quality Measure Set extensively leverages existing beneficiary 
surveys used by states to assess beneficiary experience of care, and is designed to be used with 
one or more experience of care surveys to assess the experience of care of each of the major 
population groups included in the HCBS program (e.g., older adults, adults with intellectual and 
developmental disabilities, adults with physical disabilities, adults with serious mental illness).39  
In the measure set, CMS provides states with the choice of measures derived from the following  
experience of care surveys: HCBS CAHPS, NCI-IDD, NCI-ADTM, and POM.  States that 
adopt the measure set are not expected to conduct all of the experience of care surveys included 
in the measure set.  However, some experience of care surveys have not been tested with all 
populations enrolled in HCBS programs.  As a result, states may need to use multiple experience 
of care surveys, depending on the populations served by the states HCBS program and the 
particular survey instruments that states select to use, to ensure that all major population groups 
are assessed using the measures in the measure set.  States are only expected to use as many 
surveys as are necessary to assess the experience of care of each of the major population groups 
included in the HCBS program (e.g., older adults, adults with intellectual and developmental 
disabilities, adults with physical disabilities, adults with serious mental illness).   
 
Also, as noted earlier, while use of this measure set is voluntary at this time, CMS strongly 
encourages states to use the measures and plans to incorporate use of the measure set into the 
reporting requirements for specific authorities and programs, including the MFP program and 
section 1115 demonstrations that include HCBS. Additional information will be made available 
to states participating in the MFP program and states that deliver HCBS through section 1115 
demonstrations.  CMS also encourages states to use the measure set to assess quality and 
outcomes in their HCBS programs authorized under other federal authorities, including section 
1915(c) waiver programs, section 1915(i) state plan services, section 1915(j) self-directed 
personal assistance services, and section 1915(k) Community First Choice.  
 
States that implement the measure set are encouraged to assess their performance on the 
measures at least biannually, set performance targets, and develop a quality improvement plan to 
meet their targets.  Further, states are strongly encouraged to oversample sufficiently to produce 
results at the population (e.g., older adults, adults with intellectual and developmental 
disabilities, adults with physical disabilities, adults with serious mental illness) and delivery 
system levels, and to assess and address disparities within their HCBS programs related to 
demographic characteristics (e.g., race, ethnicity, language), health status (e.g., physical 
disability, mental illness), and social determinants of health (e.g., housing security, food security, 
literacy). Additional information on using the measure set to promote equity is provided in the 
next section.  
 
                                                            
39 Most of the measures included in the measure set have only been tested with adults and have not been tested with 
children and adolescents.  As a result, the measure set may not be appropriate for use in HCBS programs that serve 
children and adolescents.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 11 
CMS is available to provide states with technical assistance to support the implementation of the 
HCBS Quality Measure Set.  We recognize that states may need to make enhancements to their 
data and information systems or incur other costs in implementing the measure set.  We remind 
states that enhanced Federal Financial Participation (FFP) is available at a 90 percent Federal 
Medical Assistance Percentage (FMAP) rate for the design, development, or installation of 
improvements of mechanized claims processing and information retrieval systems, in accordance 
with applicable federal requirements.40  Enhanced FFP at a 75 percent FMAP rate is also 
available for operations of such systems, in accordance with applicable federal requirements.41  
Receipt of these enhanced funds is conditioned upon states meeting a series of standards and 
conditions to ensure investments are efficient and effective.42   States are also encouraged to 
advance the interoperable exchange of HCBS data and support quality improvement activities by 
adopting standards in 45 CFR Part 170 and other relevant standards identified in the 
Interoperability Standards Advisory (ISA).43 
 
CMS reminds states that they continue to have independent obligations to comply with the 
Americans with Disabilities Act, Section 1557 of the Affordable Care Act, and Section 504 of 
the Rehabilitation Act, including their requirements under Olmstead v. L.C.  Technical assistance 
on the implications of quality measurement for civil rights obligations is available from the HHS 
Office for Civil Rights and the Department of Justice Civil Rights Division.44 
 
Using the Measure Set to Promote Equity 
 
Consistent with Executive Order 13985, Advancing Racial Equity and Support for Underserved 
Communities, CMS defines health equity as the attainment of the highest level of health for all 
people, where everyone has a fair and just opportunity to attain their optimal health regardless of 
race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, 
preferred language, or other factors that affect access to care and health outcomes.  CMS is 
working to advance health equity by designing, implementing, and operationalizing policies and 
programs that support health for all the people served by our programs, eliminating avoidable 
differences in health outcomes experienced by people who are disadvantaged or underserved, 
                                                            
40 See Section 1903(a)(3)(A)(i) and  433.15(b)(3), 80 FR 75817-75843; https://www.medicaid.gov/state-resource-
center/faq-medicaid-and-chip-affordable-care-act-implementation/downloads/affordable-care-act-faq-enhanced-
funding-for-medicaid.pdf; https://www.medicaid.gov/federal-policy-guidance/downloads/SMD16004.pdf.  
41 See Section 1903(a)(3)(B) and  433.15(b)(4). 
42 See  433.112 (b, 80 FR 75841; https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-
C  
43 Relevant standards adopted by HHS and identified in the ISA include the USCDI 
(https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi), eLTSS 
(https://www.healthit.gov/isa/documenting-care-plans-person-centered-services), and Functional Assessment 
Standardized Items (https://www.healthit.gov/isa/representing-patient-functional-status-andor-disability). 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 12 
and providing the care and support that our enrollees need to thrive.45,46  The CMS Framework 
for Health Equity (2022-2032)47 includes six priorities for operationalizing health equity across 
CMS programs: Priority 1 is to expand the collection, reporting, and analysis of standardized 
data.  In support of this priority, CMS strives to improve our collection and use of 
comprehensive, interoperable, standardized individual-level demographic and social 
determinants of health data, including race, ethnicity, language, gender identity, sex, sexual 
orientation, and disability status.  By increasing our understanding of the needs of those we 
serve, including social risk factors and changes in communities needs over time, CMS can 
leverage quality improvement and other tools to ensure all individuals have access to equitable 
care and coverage. 
 
Stratification of data is necessary to use the HCBS Quality Measure Set effectively to identify 
health disparities experienced by Medicaid beneficiaries receiving HCBS, and to identify 
effectively where targeted interventions are needed to reduce inequities.  We strongly 
recommend and encourage states that implement the measure set to stratify a subset of measures 
within two years of implementing the HCBS Quality Measure Set, and to increase meaningfully 
the number of measures that they stratify over time.  Further, we strongly recommend and 
encourage states to oversample sufficiently to be able to stratify their data on key demographic 
and other beneficiary characteristics, such as race and ethnicity, sex, age, rural/urban, disability, 
and language. CMS recognizes that oversampling may be associated with increased cost of 
implementation and recommends that states consider using part of the enhanced FFP noted 
above for system improvements that will enhance their ability to collect the demographic and 
other data necessary for stratification.  
 
We encourage states to pay particular attention to measures that are disparity-sensitive,48 based 
on the prevalence and magnitude of the disparity and the actionability of the measure, when 
using the measures to address disparities in health care access, quality, and outcomes for people 
receiving HCBS.  We also encourage states to consider whether stratification can be 
accomplished based on valid statistical methods and without risking violation of beneficiary 
privacy, as states may not serve large enough HCBS populations to be able to stratify all 
measures and/or to stratify measures for all beneficiary characteristics of interest.49  In addition, 
states should consider the specific variables that are available through the survey or other data 
source in determining which measures to stratify.  We note that many key demographic 
characteristics are included as part of the United State Core Data for Interoperability (USCDI) 
standard adopted by the Office of National Coordinator for Health IT (ONC).50  This 
standardized set of health data classes can not only support stratification activities but also 
support reporting and care delivery as measures elements may align with an existing or future 
                                                            
45 Executive Order 13985: https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-
order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/  
46 Centers for Medicare and Medicaid Services, Health Equity https://www.cms.gov/pillar/health-equity  
47 Centers for Medicare and Medicaid Services, CMS Framework for Health Equity (2022-2032). 
https://www.cms.gov/files/document/cms-framework-health-equity.pdf  
48 See https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72347 for more information.    
49 Privacy issues can occur, in particular, when stratifying data for smaller and less diverse populations, as it 
becomes possible to identify individual data when there are small numbers to report. 
50 See https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 13 
national core set.  States should consider the USCDI in determining which measures to stratify in 
addition to helping to determine which measures to adopt overall.   
 
Conclusion 
 
The HCBS Quality Measure Set addresses a critical gap related to HCBS quality.  The measure 
set is intended to support states with improving the quality and outcomes of HCBS, and can play 
an important role in states efforts to promote equity in their HCBS programs.  CMS is available 
to provide technical assistance to states on the implementation of the measure set.  Additional 
guidance on how states can use the measure set to meet federal reporting requirements for HCBS 
programs, such as required reporting on section 1915(c) waiver assurances and subassurances, is 
forthcoming.  
 
We look forward to working with states on the implementation of this new HCBS Quality 
Measure Set. If you have any questions regarding the HCBS Quality Measure Set, please contact 
Jennifer Bowdoin, who is the Director of the Division of Community Systems Transformation in 
the Disabled and Elderly Health Programs Group, by email at Jennifer.Bowdoin@cms.hhs.gov.  
 
 
Sincerely, 
 
 
 
 
Daniel Tsai 
Deputy Administrator and Center Director 
 
Enclosure 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 14 
Home and Community-Based Services (HCBS) Quality Measure Set  
July 2022 
The HCBS Quality Measure Set is intended to promote more common and consistent use, within 
and across states, of nationally standardized quality measures in HCBS programs and to create 
opportunities for CMS and states to have comparative quality data on HCBS programs.  It is 
comprised of measures that assess quality across a broad range of areas identified as 
measurement priorities for HCBS.  States are encouraged to use the measure set to assess quality 
and outcomes in their HCBS programs, regardless of federal authority.   
 
The HCBS Quality Measure Set is designed to assess quality and outcomes across a broad range 
of key areas for HCBS.  As a result, it is intended for use in all HCBS programs except when the 
identified measures are not applicable (e.g., managed care measures for states with only fee-for-
service programs, measures derived from experience of care surveys other than those being used 
to assess beneficiary experience in the HCBS program1).  However, states are also encouraged to 
use the measure set for specific purposes (e.g., to assess the impact of an initiative on access as 
part of the evaluation plan for a State Directed Payment in managed care2).  In addition, while 
some of the measures included in the measure set are applicable for certain delivery system types 
only, CMS encourages states to use the measure set, to the extent that measures are applicable to 
a specific HCBS program, regardless of delivery system type. 
 
In addition to claims-based measures and measures that require assessment or other beneficiary 
records, the measure set includes measures derived from several experience of care surveys 
(HCBS CAHPS, National Core Indicators-Intellectual and Developmental Disabilities (NCI-
IDD), National Core Indicators-Aging and Disability (NCI-AD)TM, Personal Outcome Measures 
(POM)) which assess the experience of care of one or more population groups included in 
HCBS programs (e.g., older adults, adults with intellectual and developmental disabilities, adults 
with physical disabilities, adults with serious mental illness).3  States that adopt the measure set 
are not expected to conduct all of the experience of care surveys included in the measure set.  
However, some experience of care surveys have not been tested with all populations enrolled in 
HCBS programs.  As a result, states may need to use multiple experience of care surveys, 
depending on the populations served by the states HCBS programs and the particular survey 
instruments that states select to use, to ensure that all major population groups are assessed using 
the measures in the measure set.  The measure set also includes other nationally standardized and 
tested measures in key measurement areas.    
 
The measures are organized by section 1915(c) waiver assurances and subassurances, where the 
measures align with the assurances and subassurances.  While the current version of the measure 
set does not have an all-inclusive set of measures to demonstrate that assurances are met, CMS 
will continue to update the measure set to address gaps and identity additional measures to 
demonstrate that assurances are met.  The measure set currently includes measures that address 
the Service Plan section 1915(c) waiver subassurances, and some of the Health and Welfare 
section 1915(c) waiver subassurances.  The Service Plan measures are in blue shading, while the 
Health and Welfare measures are in orange shading.  Measures that are not highlighted in blue or 
orange shading have not been identified by CMS to address the section 1915(c) waiver Service 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.  State Medicaid Director  Page 15 
Plan or Health and Welfare subassurances. It is important to note that the measure set cannot be 
used, by itself, to fully meet all of the section 1915(c) waiver subassurances, because the 
measure set does not include measures that address all of the subassurances, 
 
The measure set also includes measures that address HCBS quality and outcomes in the 
following areas:   
 
1.  Access, which is defined for the purposes of the measure set as the level to which the 
beneficiary/family caregiver/natural support is aware of and able to access resources 
(e.g., peer support, respite, crisis support, information and referral) that support overall 
well-being.  
 
2.  Rebalancing, which is commonly defined as achieving a more equitable balance between 
the share of spending and use of services and supports delivered in home and community-
based settings relative to institutional care.  
 
3.  Community Integration, which is focused on ensuring the self-determination, 
independence, empowerment, and full inclusion of children and adults with disabilities 
and older adults in all parts of society; and HCBS Settings Requirements, as defined in 
the HCBS Settings final rule, which establishes requirements for the qualities of settings 
in which Medicaid HCBS are provided under sections 1915(c), 1915(i) and 1915(k) of 
the Social Security Act. The final rule requires that all home and community-based 
settings meet certain qualifications, including:  
  The setting is integrated in and supports full access to the greater community;  
  The setting is selected by the individual from among setting options;  
  The setting ensures individual rights of privacy, dignity and respect, and freedom 
from coercion and restraint;  
  The setting optimizes autonomy and independence in making life choices; and  
  The setting facilitates choice regarding services and who provides them.  
 
In addition to measure name, the measure set also includes National Quality Forum (NQF) 
number (if applicable), measure steward, and data collection method (e.g., survey, case 
management system) for each measure.  CMS will also release a supplement to the measure set 
that will provide additional technical details on each measure (e.g., numerator, denominator, 
exclusion criteria).  
 
States that implement the measure set are encouraged to assess their performance at least 
biannually, set performance targets, and develop a quality improvement plan to meet their 
targets. Further, states are strongly encouraged to oversample sufficiently to produce results at 
the population (e.g., older adults, adults with intellectual and developmental disabilities, adults 
with physical disabilities, adults with serious mental illness) and delivery system levels, and to 
use the measures in the measure set to assess and address disparities within their HCBS 
programs.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically 
incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.   
HCBS Quality Measure Set  
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
Section 1915(c) Service Plan Subassurances 
For the Service Plan subassurances, measures from multiple experience of care surveys are included. States that implement the measure set are not expected to conduct all of 
the experience of care surveys listed. Instead, states are only expected to use as many surveys as are necessary to assess the experience of care of each of the major 
population groups included in the HCBS program (e.g., older adults, adults with intellectual and developmental disabilities, adults with physical disabilities, adults with serious 
mental illness).4 Measures from the Personal Outcome Measures (POM) can also be used to address some of the Service Plan section 1915(c) waiver subassurances.  
States may use the measures from the measure set to report on their performance in meeting some section 1915(c) subassurances. In some cases, it may be necessary to 
report more than one measure to demonstrate compliance with the subassurances. Further, the measure set does not currently include sufficient measures to satisfy all of the 
subassurances.  As a result, states will need to supplement the measure set with additional measures to fully meet all of the subassurances. 
States that deliver their HCBS programs through managed LTSS (MLTSS) can use either the MLTSS measures listed or their HEDIS equivalents (if available). At a states 
option, the Functional Assessment Standardized Items (FASI) measures5 can be used in place of MLTSS-1 and MLTSS-2 for subassurance 1; FASI-1 and FASI-2 are not 
expected to be used by all states implementing the measure set and instead are included only as an option in place of MLTSS-1 and MLTSS-2. For any states opting to use the 
FASI measures, CMS will work with states to map their existing assessment instruments to the FASI.  
Work is underway to re-specify and test most of the MLTSS measures for use in fee-for-service. The measure set will be updated with relevant fee-for-service measures once 
they have been fully re-specified and tested. CMS expects to complete testing of the measures in 2022 and to make the full measure specifications available in 2023 for fee-for-
service versions of most of the MLTSS measures included in the measure set.  
Although the waiver subassurances are only required for certain HCBS authorities, states are encouraged to use the measures listed below for all of their HCBS programs, 
regardless of federal authority, given the importance of person-centered practices in HCBS programs. 
Service Plan measures are in blue shading. 
Assurance: Service Plan - The State demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.  
Subassurance: 1. Service plans address all members assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or 
through other means. 
2967  CMS  HCBS CAHPS Choosing  Participant  Assurance: Service Plan - The State demonstrates it has     
the services that matter to  Reported  designed and implemented an effective system for reviewing the     
you (Q 56, 57)6  Data/Survey  adequacy of service plans for waiver participants.  
  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
3622  NASDDDS,  NCI-IDD PCP-2: Person- Participant  Assurance: Service Plan - The State demonstrates it has     
   
HSRI  Centered Goals (The  Reported  designed and implemented an effective system for reviewing the 
proportion of people who  Data/Survey  adequacy of service plans for waiver participants.  
report their service plan  Subassurance: 1. Service plans address all members assessed 
includes things that are  needs (including health and safety risk factors) and personal 
important to them)  goals, either by the provision of waiver services or through other 
means. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
Not  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
appli- States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the     
cable  HSRI  change what kind of  Data/Survey  adequacy of service plans for waiver participants.  
(NA)  services they get  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the     
HSRI  change when and how  Data/Survey  adequacy of service plans for waiver participants.  
often they get their  Subassurance: 1. Service plans address all members assessed 
services  needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people whose service plan  Reported  designed and implemented an effective system for reviewing the     
HSRI  includes their preferences  Data/Survey  adequacy of service plans for waiver participants.  
and choices  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  CQL  POM: People realize  Paper  Assurance: Service Plan - The State demonstrates it has       
personal goals  Records,  designed and implemented an effective system for reviewing the 
Participant  adequacy of service plans for waiver participants.  
Reported  Subassurance: 1. Service plans address all members assessed 
Data/Survey  needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  CMS  MLTSS-1: LTSS  Assessment/ Assurance: Service Plan - The State demonstrates it has      
Comprehensive  Case  designed and implemented an effective system for reviewing the 
 
Assessment and Update7  Management  adequacy of service plans for waiver participants.  
  System  Subassurance: 1. Service plans address all members assessed 
HEDIS equivalent  needs (including health and safety risk factors) and personal 
available8  goals, either by the provision of waiver services or through other 
means. 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
NA  CMS  MLTSS-2: LTSS  Case  Assurance: Service Plan - The State demonstrates it has      
Comprehensive Care Plan  Management  designed and implemented an effective system for reviewing the 
 
and Update9  System  adequacy of service plans for waiver participants.  
  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
HEDIS equivalent available 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
3593  CMS  FASI-1: Identification of  Electronic  Assurance: Service Plan - The State demonstrates it has      
Person-Centered  Health  designed and implemented an effective system for reviewing the 
 
Priorities10,11  Record,  adequacy of service plans for waiver participants.  
Paper  Subassurance: 1. Service plans address all members assessed 
Records,  needs (including health and safety risk factors) and personal 
Participant  goals, either by the provision of waiver services or through other 
Reported 
means. 
Data/Survey 
3594  CMS  FASI-2: Documentation of  Electronic  Assurance: Service Plan - The State demonstrates it has      
a Person-Centered Service  Health  designed and implemented an effective system for reviewing the 
 
Plan12,13  Record,  adequacy of service plans for waiver participants.  
Paper  Subassurance: 1. Service plans address all members assessed 
Records,  needs (including health and safety risk factors) and personal 
Participant  goals, either by the provision of waiver services or through other 
Reported 
means. 
Data/Survey 
Subassurance: 2. Service plans are updated/revised at least annually or when warranted by changes in the waiver participants needs. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
2967  CMS  HCBS CAHPS Unmet  Participant  Assurance: Service Plan - The State demonstrates it has  
   
Needs Single-Item  Reported  designed and implemented an effective system for reviewing the   
Measures (Q 18, 22, 25,  Data/Survey  adequacy of service plans for waiver participants.  
27, 40)14  Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
NA  CMS  MLTSS-1: LTSS  Assessment/ Assurance: Service Plan - The State demonstrates it has      
Comprehensive  Case  designed and implemented an effective system for reviewing the 
 
Assessment and Update15  Management  adequacy of service plans for waiver participants.  
  System  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
HEDIS equivalent available 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
NA  CMS  MLTSS-2: LTSS  Case  Assurance: Service Plan - The State demonstrates it has      
Comprehensive Care Plan  Management  designed and implemented an effective system for reviewing the 
 
and Update16  System  adequacy of service plans for waiver participants.  
  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
HEDIS equivalent available 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
NA  CMS  MLTSS-4: LTSS  Assessment/ Assurance: Service Plan - The State demonstrates it has      
Reassessment/Care Plan  Case  designed and implemented an effective system for reviewing the 
 
Update after Inpatient  Management  adequacy of service plans for waiver participants.  
Discharge17  System  Subassurance: 2. Service plans are updated/revised at least 
  annually or when warranted by changes in the waiver participants 
HEDIS equivalent available  needs. 
Subassurance: 3. Services are delivered in accordance with the service plan, including the type, scope, amount, duration, and frequency specified in the service plan. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
2967  CMS  HCBS CAHPS Unmet  Participant  Assurance: Service Plan - The State demonstrates it has      
Needs Single-Item  Reported  designed and implemented an effective system for reviewing the   
Measures (Q 18, 22, 25,  Data/Survey  adequacy of service plans for waiver participants.  
27, 40)18  Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
2967   CMS  HCBS CAHPS Staff Are  Participant  Assurance: Service Plan - The State demonstrates it has      
Reliable and Helpful  Reported  designed and implemented an effective system for reviewing the   
Composite Measure (Q 13,  Data/Survey  adequacy of service plans for waiver participants.  
14, 15, 19, 37, 38)19  Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
2967  CMS  HCBS CAHPS Staff Listen  Participant  Assurance: Service Plan - The State demonstrates it has     
 
and Communicate Well  Reported  designed and implemented an effective system for reviewing the 
Composite Measure (Q 28,  Data/Survey  adequacy of service plans for waiver participants.  
29, 30, 31, 32, 33, 41, 42,  Subassurance: 3. Services are delivered in accordance with the 
43, 44, 45)20  service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
NA  NASDDDS,  NCI-IDD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
 
HSRI  people who report their  Reported  designed and implemented an effective system for reviewing the 
staff come and leave when  Data/Survey  adequacy of service plans for waiver participants.  
they are supposed to  Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
 
States,  people whose support staff  Reported  designed and implemented an effective system for reviewing the 
HSRI  do things the way they  Data/Survey  adequacy of service plans for waiver participants.  
want them done  Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has      
 
States,  people whose support staff  Reported  designed and implemented an effective system for reviewing the 
HSRI  show up and leave when  Data/Survey  adequacy of service plans for waiver participants.  
they are supposed to  Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
Subassurance: 4. Participants are afforded choice between/among waiver services and providers. 
2967   CMS  HCBS CAHPS Community  Participant  Assurance: Service Plan - The State demonstrates it has    
 
Inclusion and  Reported  designed and implemented an effective system for reviewing the 
 
Empowerment Composite  Data/Survey  adequacy of service plans for waiver participants 
Measure (Q 75, 77, 78, 79,  Subassurance: 4. Participants are afforded choice 
80, 81)21    between/among waiver services and providers. 
3622  NASDDDS,  NCI-IDD CC-4: Life  Participant  Assurance: Service Plan - The State demonstrates it has    
   
HSRI  Decision Composite  Reported  designed and implemented an effective system for reviewing the 
Measure (The proportion of  Data/Survey  adequacy of service plans for waiver participants. 
people who report making  Subassurance: 4. Participants are afforded choice 
choices (independently or 
between/among waiver services and providers. 
with help) in life decisions) 
NA  NASDDDS,  NCI-IDD: The percentage  Participant  Assurance: Service Plan - The State demonstrates it has    
   
HSRI  of people who report that  Reported  designed and implemented an effective system for reviewing the 
they helped make their  Data/Survey  adequacy of service plans for waiver participants. 
service plan  Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
   
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the 
HSRI  change what kind of  Data/Survey  adequacy of service plans for waiver participants.  
services they get  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
   
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the 
HSRI  change when and how  Data/Survey  adequacy of service plans for waiver participants.  
often they get their  Subassurance: 1. Service plans address all members assessed 
services  needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has    
   
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the 
HSRI  change their support staff  Data/Survey  adequacy of service plans for waiver participants.  
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
   
States,  people whose service plan  Reported  designed and implemented an effective system for reviewing the 
HSRI  reflects their preferences  Data/Survey  adequacy of service plans for waiver participants.  
and choices  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  CQL  POM: People choose  Paper  Assurance: Service Plan - The State demonstrates it has   
   
services  Records,  designed and implemented an effective system for reviewing the 
Participant  adequacy of service plans for waiver participants 
Reported  Subassurance: 4. Participants are afforded choice 
Data/Survey  between/among waiver services and providers. 
NA  CMS  HCBS-10: Self-direction of  Case  Assurance: Service Plan - The State demonstrates it has    
   
services and supports  Management  designed and implemented an effective system for reviewing the 
among Medicaid  System  adequacy of service plans for waiver participants 
beneficiaries receiving  Subassurance: 4. Participants are afforded choice 
LTSS through managed 
between/among waiver services and providers. 
care organizations22 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
Section 1915(c) Health and Welfare Subassurances 
For the Health and Welfare subassurances, measures from multiple experience of care surveys are included. States that implement the measure set are not expected to conduct 
all of the experience of care surveys listed. Instead, states are only expected to use as many surveys as is necessary to assess the experience of care of each of the major 
population groups included in the HCBS program (e.g., older adults, adults with intellectual and developmental disabilities, adults with physical disabilities, adults with serious 
mental illness).23  Measures from the Personal Outcome Measures (POM) can also be used to address some of the Health and Welfare section 1915(c) waiver 
subassurances. 
States may use the measures from the measure set to report on their performance in meeting some section 1915(c) subassurances. In some cases, it may be necessary to 
report more than one measure to demonstrate compliance with the subassurances. Further, the measure set does not currently include sufficient measures to satisfy all of the 
subassurances.  As a result, states will need to supplement the measure set with additional measures to fully meet all of the subassurances. 
States that deliver their HCBS programs through MLTSS can use either the MLTSS measures listed or their HEDIS equivalents (if available).  Work is underway to re-specify 
and test most of the MLTSS measures for use in fee-for-service. The measure set will be updated with relevant fee-for-service measures once they have been fully re-specified 
and tested. CMS expects to complete testing of the measures in 2022 and to make the full measure specifications available in 2023 for fee-for-service versions of most of the 
MLTSS measures included in the measure set.  
Although the waiver subassurances are only required for certain HCBS authorities, states are encouraged to use the measures listed below for all of their HCBS programs, 
regardless of federal authority, given the importance of promoting beneficiary health and welfare in HCBS programs.  
Health and Welfare measures are in orange shading. 
Assurance: Health & Welfare - The State demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare.  
Subassurance: 1. The State demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instances of abuse, neglect, exploitation and unexplained 
death. 
2967   CMS  HCBS CAHPS Personal  Participant  Assurance: Health & Welfare - The State demonstrates it has    
Safety & Respect  Reported  designed and implemented an effective system for assuring     
Composite Measure (Q 64,  Data/Survey  waiver participant health and welfare.  
65, 68)24  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
2967   CMS  HCBS CAHPS Physical  Participant  Assurance: Health & Welfare - The State demonstrates it has    
Safety Single-Item  Reported  designed and implemented an effective system for assuring     
Measure (Q 71)25  Data/Survey  waiver participant health and welfare.  
Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has      
 
States,  people who feel safe  Reported  designed and implemented an effective system for assuring 
HSRI  around their support staff  Data/Survey  waiver participant health and welfare.  
Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has      
 
States,  people who are ever  Reported  designed and implemented an effective system for assuring 
HSRI  worried for the security of  Data/Survey  waiver participant health and welfare.  
their personal belongings  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has      
 
States,  people whose money was  Reported  designed and implemented an effective system for assuring 
HSRI  taken or used without their  Data/Survey  waiver participant health and welfare.  
permission in the last 12  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
months 
abuse, neglect, exploitation and unexplained death. 
NA  CQL  POM: People are free from  Paper  Assurance: Health & Welfare - The State demonstrates it has      
 
abuse and neglect  Records,  designed and implemented an effective system for assuring 
Participant  waiver participant health and welfare.  
Reported  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
Data/Survey 
abuse, neglect, exploitation and unexplained death. 
Subassurance: 2. The State demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the 
extent possible. 
No relevant measures 
Subassurance: 3. State policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed. 
No relevant measures 
Subassurance: 4. The State establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the 
approved waiver. 
NA  NASDDDS,  NCI-IDD preventive  Participant  Assurance: Health & Welfare - The State demonstrates it has    
HSRI  screening single-item  Reported  designed and implemented an effective system for assuring     
measures: Percentage of  Data/Survey  waiver participant health and welfare.  
people who are reported to  Subassurance: 4. The State establishes overall health care 
have received preventive  standards and monitors those standards based on the 
health screenings within  responsibility of the service provider as stated in the approved 
recommended time frames  waiver.  
(physical exam, routine 
dental exam, vision 
screening, hearing test, 
mammogram, pap test, 
colorectal cancer 
screening) 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has   
States,  people who know how to  Reported  designed and implemented an effective system for assuring     
HSRI  manage their chronic  Data/Survey  waiver participant health and welfare.  
conditions  Subassurance: 4. The State establishes overall health care 
standards and monitors those standards based on the 
responsibility of the service provider as stated in the approved 
waiver.  
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has   
States,  people who had somebody  Reported  designed and implemented an effective system for assuring     
HSRI  talk or work with them to  Data/Survey  waiver participant health and welfare.  
reduce their risk of falling  Subassurance: 4. The State establishes overall health care 
standards and monitors those standards based on the 
or being unstable 
responsibility of the service provider as stated in the approved 
waiver.  
NA  CMS  MLTSS-3: LTSS Shared  Case  Assurance: Health & Welfare - The State demonstrates it has   
Care Plan with Primary  Management  designed and implemented an effective system for assuring     
Care Practitioner26  System  waiver participant health and welfare.  
Subassurance: 4. The State establishes overall health care 
 
standards and monitors those standards based on the 
HEDIS equivalent available  responsibility of the service provider as stated in the approved 
waiver.  
NA  NCQA  MLTSS-5: Screening, Risk  Case  Assurance: Service Plan - The State demonstrates it has   
   
Assessment, and Plan of  Management  designed and implemented an effective system for reviewing the 
Care to Prevent Future  System  adequacy of service plans for waiver participants.  
Falls (NCQA)  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal goals, 
either by the provision of waiver services or through other means. 
Assurance: Health & Welfare - The State demonstrates it has 
designed and implemented an effective system for assuring 
waiver participant health and welfare.  
Subassurance: 4. The State establishes overall health care 
standards and monitors those standards based on the 
responsibility of the service provider as stated in the approved 
waiver. 
NA  NCQA  MLTSS: Plan All-Cause  Administrative  Assurance: Health & Welfare - The State demonstrates it has   
designed and implemented an effective system for assuring     
Readmission (HEDIS)  Claims 
waiver participant health and welfare.  
Subassurance: 4. The State establishes overall health care 
standards and monitors those standards based on the 
responsibility of the service provider as stated in the approved 
waiver. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  NCQA  MLTSS: Flu Vaccination  Administrative  Assurance: Health & Welfare - The State demonstrates it has   
(HEDIS) (adults 18-64  Claims  designed and implemented an effective system for assuring     
waiver participant health and welfare.  
only) 
Subassurance: 4. The State establishes overall health care 
standards and monitors those standards based on the 
responsibility of the service provider as stated in the approved 
waiver. 
NA  CQL  POM: People have the  Paper  Assurance: Health & Welfare - The State demonstrates it has   
best possible health  Records,  designed and implemented an effective system for assuring     
Participant  waiver participant health and welfare.  
Reported  Subassurance: 4. The State establishes overall health care 
Data/Survey  standards and monitors those standards based on the 
responsibility of the service provider as stated in the approved 
waiver. 
Access, Rebalancing, and Community Integration/HCBS Settings Requirements  
For Access, Rebalancing, and Community Integration/HCBS Settings Requirements, measures from multiple experience of care surveys are included.  States that implement the 
measure set are not expected to conduct all of the experience of care surveys listed.  Instead, states are only expected to use as many surveys as is necessary to assess the 
experience of care of each of the major population groups included in the HCBS program (e.g., older adults, adults with intellectual and developmental disabilities, adults with 
physical disabilities, adults with serious mental illness).27  Measures from the Personal Outcome Measures (POM) can also be used to address some areas related to access, 
rebalancing, and community integration/HCBS settings requirements.   
Work is underway to re-specify and test most of the MLTSS measures listed below for use in fee-for-service.  The exception is MLTSS-6, for which a fee-for-service equivalent is 
already available (HCBS-1). The measure set will be updated with additional relevant fee-for-service measures once they have been fully re-specified and tested.  CMS expects 
to complete testing of the measures in 2022 and to make the full measure specifications available in 2023.  
Access - the level to which the beneficia ry/family caregiver/natural support is aware of and able to access resources (e.g., peer support, respite, crisis support, information and 
referral) that support overall well-being. 
2967  CMS  HCBS CAHPS Choosing  Participant  Assurance: Service Plan - The State demonstrates it has     
   
the services that matter to  Reported  designed and implemented an effective system for reviewing the 
you (Q 56, 57)28  Data/Survey  adequacy of service plans for waiver participants.  
  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
2967  CMS  HCBS CAHPS Unmet  Participant  Assurance: Service Plan - The State demonstrates it has      
 
Needs Single-Item  Reported  designed and implemented an effective system for reviewing the 
Measures (Q 18, 22, 25, 
Data/Survey  adequacy of service plans for waiver participants.  
27, 40)29 
Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
2967   CMS  HCBS CAHPS Staff Are  Participant  Assurance: Service Plan - The State demonstrates it has      
 
Reliable and Helpful  Reported  designed and implemented an effective system for reviewing the 
Composite Measure (Q 13,  Data/Survey  adequacy of service plans for waiver participants.  
14, 15, 19, 37, 38)30  Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
2967  CMS  HCBS CAHPS  Participant      
   
Transportation to Medical  Reported 
Appointments Composite  Data/Survey 
Measure (Q 59, 61, 62)31 
3622  NASDDDS,  NCI-IDD CI-3:  Participant       
HSRI  Transportation Availability  Reported     
Scale (The proportion of  Data/Survey 
people who report 
adequate transportation) 
3622  NASDDDS,  NCI-IDD PCP-2: Person- Participant  Assurance: Service Plan - The State demonstrates it has     
HSRI  Centered Goals (The  Reported  designed and implemented an effective system for reviewing the     
proportion of people who  Data/Survey  adequacy of service plans for waiver participants.  
report their service plan  Subassurance: 1. Service plans address all members assessed 
includes things that are  needs (including health and safety risk factors) and personal 
important to them)  goals, either by the provision of waiver services or through other 
means. 
NA  NASDDDS,  NCI-IDD preventive  Participant  Assurance: Health & Welfare - The State demonstrates it has    
HSRI  screening single-item  Reported  designed and implemented an effective system for assuring     
measures: Percentage of  Data/Survey  waiver participant health and welfare.  
people who are reported to  Subassurance: 4. The State establishes overall health care 
have received preventive  standards and monitors those standards based on the 
health screenings within  responsibility of the service provider as stated in the approved 
recommended time frames  waiver.  
(physical exam, routine 
dental exam, vision 
screening, hearing test, 
mammogram, pap test, 
colorectal cancer 
screening) 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has      
States,  people whose support staff  Reported  designed and implemented an effective system for reviewing the   
HSRI  show up and leave when  Data/Survey  adequacy of service plans for waiver participants.  
they are supposed to  Subassurance: 3. Services are delivered in accordance with the 
service plan, including the type, scope, amount, duration, and 
frequency specified in the service plan. 
NA  ADvancing  NCI-AD: Percentage of  Participant        
States,  non-English speaking  Reported   
HSRI  participants who receive  Data/Survey 
information about their 
services in the language 
they prefer 
NA  ADvancing  NCI-AD: Percentage of  Participant       
States,  people who have  Reported     
HSRI  transportation when they  Data/Survey 
want to do things outside of 
their home 
NA  ADvancing  NCI-AD: Percentage of  Participant        
States,  people who have  Reported   
HSRI  transportation to get to  Data/Survey 
medical appointments 
when they need to 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the     
HSRI  change what kind of  Data/Survey  adequacy of service plans for waiver participants.  
services they get  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the     
HSRI  change when and how  Data/Survey  adequacy of service plans for waiver participants.  
often they get their  Subassurance: 1. Service plans address all members assessed 
services  needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people whose service plan  Reported  designed and implemented an effective system for reviewing the     
HSRI  reflects their preferences  Data/Survey  adequacy of service plans for waiver participants.  
and choices  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  CMS  HCBS-10: Self-direction of  Case  Assurance: Service Plan - The State demonstrates it has    
   
services and supports  Management  designed and implemented an effective system for reviewing the 
among Medicaid  System  adequacy of service plans for waiver participants 
beneficiaries receiving  Subassurance: 4. Participants are afforded choice 
LTSS through managed 
between/among waiver services and providers. 
care organizations32 
Rebalancing - achieving a more equitable balance between the share of spending and use of services and supports delivered in home and community-based settings relative to 
institutional care.  
NA  ADvancing  NCI-AD: Percentage of  Participant        
States,  people who had adequate  Reported   
HSRI  follow up after being  Data/Survey 
discharged from a hospital 
or rehabilitation/nursing 
facility  
NA  CMS  MLTSS-4: LTSS  Assessment/ Assurance: Service Plan - The State demonstrates it has      
Reassessment/Care Plan  Case  designed and implemented an effective system for reviewing the 
 
Update after Inpatient  Management  adequacy of service plans for waiver participants.  
Discharge33  System  Subassurance: 2. Service plans are updated/revised at least 
  annually or when warranted by changes in the waiver participants 
HEDIS equivalent available  needs. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  CMS  MLTSS-6: LTSS Admission  Administrative        
to a Facility from the  Claims   
Community (MLTSS 
equivalent of HCBS-1) 
NA  CMS  HCBS-1: Admission to a  Administrative        
Facility from the  Claims     
Community Among 
 
Medicaid Fee-for Service 
(FFS) HCBS Users (CMS)   
(FFS equivalent of MLTSS-
 
6)34 
 
 
   
3457   CMS  MLTSS-7: LTSS  Administrative       
Minimizing Facility Length  Claims     
of Stay 
NA  CMS  MLTSS-8: LTSS  Administrative       
Successful Transition After  Claims       
Long-Term Facility Stay 
Community Integration, which is focused on ensuring the self-determination, independence, empowerment, and full inclusion of children and adults with disabilities and older 
adults in all parts of society, and HCBS Settings Requirements, as defined in the HCBS Settings final rule, which establishes requirements for the qualities of settings in which 
Medicaid HCBS are provided under sections 1915(c), 1915(i) and 1915(k) of the Social Security Act.  The final rule requires that all home and community-based settings meet 
certain qualifications, including:  
  The setting is integrated in and supports full access to the greater community;  
  The setting is selected by the individual from among setting options;  
  The setting ensures individual rights of privacy, dignity and respect, and freedom from coercion and restraint;  
  The setting optimizes autonomy and independence in making life choices; and  
  The setting facilitates choice regarding services and who provides them. 
Please note that the measures included in the measure set are not designed to determine if a particular setting is fully compliant with HCBS settings requirements. Instead, the 
measures are included as an assessment of overall system performance in terms of whether people receiving HCBS have opportunities for community integration and the 
system of care is meeting the purpose and intent of the settings rule. 
2967  CMS  HCBS CAHPS Choosing  Participant  Assurance: Service Plan - The State demonstrates it has     
   
the services that matter to  Reported  designed and implemented an effective system for reviewing the 
you (Q 56, 57)35  Data/Survey  adequacy of service plans for waiver participants.  
  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
2967   CMS  HCBS CAHPS Personal  Participant  Assurance: Health & Welfare - The State demonstrates it has    
Safety & Respect  Reported  designed and implemented an effective system for assuring     
Composite Measure (Q 64,  Data/Survey  waiver participant health and welfare.  
65, 68)36  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
2967   CMS  HCBS CAHPS Physical  Participant  Assurance: Health & Welfare - The State demonstrates it has    
Safety Single-Item  Reported  designed and implemented an effective system for assuring     
Measure (Q 71)37  Data/Survey  waiver participant health and welfare.  
Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
2967   CMS  HCBS CAHPS Community  Participant  Assurance: Service Plan - The State demonstrates it has    
 
Inclusion and  Reported  designed and implemented an effective system for reviewing the 
 
Empowerment Composite  Data/Survey  adequacy of service plans for waiver participants 
Measure (Q 75, 77, 78, 79,  Subassurance: 4. Participants are afforded choice 
80, 81)38   between/among waiver services and providers. 
3622  NASDDDS,  NCI-IDD CI-1: Social  Participant      
   
HSRI  Connectedness (The  Reported 
proportion of people who  Data/Survey 
report that they do not feel 
lonely) 
3622  NASDDDS,  NCI-IDD CI-3:  Participant       
HSRI  Transportation Availability  Reported     
Scale (The proportion of  Data/Survey 
people who report 
adequate transportation) 
NA  NASDDDS,  NCI-IDD: The percentage  Participant  Assurance: Service Plan - The State demonstrates it has    
   
HSRI  of people who report that  Reported  designed and implemented an effective system for reviewing the 
they helped make their  Data/Survey  adequacy of service plans for waiver participants. 
service plan  Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
3622  NASDDDS,  NCI-IDD CC-3: Can Stay  Participant      
   
HSRI  Home When Others Leave  Reported   
(The proportion of people  Data/Survey 
who live with others who 
report they can stay home 
if they choose when others 
in their house/home go 
somewhere) 
3622  NASDDDS,  NCI-IDD CC-4: Life  Participant  Assurance: Service Plan - The State demonstrates it has    
   
HSRI  Decision Composite  Reported  designed and implemented an effective system for reviewing the 
Measure (The proportion of  Data/Survey  adequacy of service plans for waiver participants. 
people who report making  Subassurance: 4. Participants are afforded choice 
choices (independently or 
between/among waiver services and providers. 
with help) in life decisions) 
3622  NASDDDS,  NCI-IDD PCP-2: Person- Participant  Assurance: Service Plan - The State demonstrates it has     
   
HSRI  Centered Goals (The  Reported  designed and implemented an effective system for reviewing the 
proportion of people who  Data/Survey  adequacy of service plans for waiver participants.  
report their service plan  Subassurance: 1. Service plans address all members assessed 
includes things that are  needs (including health and safety risk factors) and personal 
important to them)  goals, either by the provision of waiver services or through other 
means. 
3622  NASDDDS,  NCI-IDD PCP-5:  Participant      
   
HSRI  Satisfaction with  Reported 
Community Inclusion Scale  Data/Survey 
(The proportion of people 
who report satisfaction with 
the level of participation in 
community inclusion 
activities) 
3622  NASDDDS,  NCI-IDD HLR-1: Respect  Participant      
   
HSRI  for Personal Space Scale  Reported 
(The proportion of people  Data/Survey 
who report that their 
personal space is 
respected in the home) 
NA  ADvancing  NCI-AD: Percentage of  Participant      
   
States,  people who are as active in  Reported 
 
HSRI  their community as they  Data/Survey 
would like to be 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant      
   
States,  people who are able to see  Reported 
HSRI  or talk to their friends and  Data/Survey 
family when they want to 
NA  ADvancing  NCI-AD: Percentage of  Participant       
States,  people who have  Reported     
HSRI  transportation when they  Data/Survey 
want to do things outside of 
their home 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has      
 
States,  people who feel safe  Reported  designed and implemented an effective system for assuring 
HSRI  around their support staff  Data/Survey  waiver participant health and welfare.  
Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has      
 
States,  people who are ever  Reported  designed and implemented an effective system for assuring 
HSRI  worried for the security of  Data/Survey  waiver participant health and welfare.  
their personal belongings  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
abuse, neglect, exploitation and unexplained death. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Health & Welfare - The State demonstrates it has      
 
States,  people whose money was  Reported  designed and implemented an effective system for assuring 
HSRI  taken or used without their  Data/Survey  waiver participant health and welfare.  
permission in the last 12  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
months 
abuse, neglect, exploitation and unexplained death. 
NA  ADvancing  NCI-AD: Percentage of  Participant      
   
States,  people in group settings  Reported 
HSRI  who have enough privacy  Data/Survey 
where they live 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the     
HSRI  change what kind of  Data/Survey  adequacy of service plans for waiver participants.  
services they get  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the     
HSRI  change when and how  Data/Survey  adequacy of service plans for waiver participants.  
often they get their  Subassurance: 1. Service plans address all members assessed 
services  needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has    
   
States,  people who can choose or  Reported  designed and implemented an effective system for reviewing the 
HSRI  change their support staff  Data/Survey  adequacy of service plans for waiver participants.  
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  ADvancing  NCI-AD: Percentage of  Participant  Assurance: Service Plan - The State demonstrates it has     
States,  people whose service plan  Reported  designed and implemented an effective system for reviewing the     
HSRI  reflects their preferences  Data/Survey  adequacy of service plans for waiver participants.  
and choices  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 4. Participants are afforded choice 
between/among waiver services and providers. 
NA  CQL  POM: People are free from  Paper  Assurance: Health & Welfare - The State demonstrates it has      
 
abuse and neglect  Records,  designed and implemented an effective system for assuring 
Participant  waiver participant health and welfare.  
Reported  Subassurance: 1. The State demonstrates on an ongoing basis 
that it identifies, addresses and seeks to prevent instances of 
Data/Survey 
abuse, neglect, exploitation and unexplained death. 
NA  CQL  POM: People live in  Paper      
integrated environments   Records,     
  Participant 
Reported 
Data/Survey 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
POM: People interact with 
NA  CQL   Paper      
other members of the     
Records, 
community  
Participant 
  Reported 
Data/Survey 
NA  CQL  POM: People participate in  Paper      
the life of the community   Records,     
  Participant 
Reported 
Data/Survey 
NA  CMS  MLTSS-1: LTSS  Assessment/ Assurance: Service Plan - The State demonstrates it has      
Comprehensive  Case  designed and implemented an effective system for reviewing the 
 
Assessment and Update39  Management  adequacy of service plans for waiver participants.  
  System  Subassurance: 1. Service plans address all members assessed 
HEDIS equivalent  needs (including health and safety risk factors) and personal 
available40  goals, either by the provision of waiver services or through other 
means. 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
NA  CMS  MLTSS-2: LTSS  Case  Assurance: Service Plan - The State demonstrates it has      
Comprehensive Care Plan  Management  designed and implemented an effective system for reviewing the 
 
and Update41  System  adequacy of service plans for waiver participants.  
  Subassurance: 1. Service plans address all members assessed 
needs (including health and safety risk factors) and personal 
HEDIS equivalent available 
goals, either by the provision of waiver services or through other 
means. 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
3457   CMS  MLTSS-7: LTSS  Administrative       
Minimizing Facility Length  Claims     
of Stay 
NA  CMS  MLTSS-8: LTSS  Administrative       
Successful Transition After  Claims       
Long-Term Facility Stay 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
Community 
Integration 
and HCBS 
Assurance 
NQF  Measure  Data Collection  Settings 
#  Steward  Measure Name  Method  Subassurance  Access  Rebalancing  Requirements 
3593  CMS  FASI-1: Identification of  Electronic  Assurance: Service Plan - The State demonstrates it has      
Person-Centered  Health  designed and implemented an effective system for reviewing the 
 
Priorities42,43  Record,  adequacy of service plans for waiver participants.  
Paper  Subassurance: 1. Service plans address all members assessed 
Records,  needs (including health and safety risk factors) and personal 
Participant  goals, either by the provision of waiver services or through other 
Reported 
means. 
Data/Survey 
Subassurance: 2. Service plans are updated/revised at least 
annually or when warranted by changes in the waiver participants 
needs. 
3594  CMS  FASI-2: Documentation of  Electronic  Assurance: Service Plan - The State demonstrates it has      
a Person-Centered Service  Health  designed and implemented an effective system for reviewing the 
 
Plan44,45  Record,  adequacy of service plans for waiver participants.  
Paper  Subassurance: 1. Service plans address all members assessed 
Records,  needs (including health and safety risk factors) and personal 
Participant  goals, either by the provision of waiver services or through other 
Reported 
means. 
Data/Survey 
 
                                                            
 
1 See additional clarifying information on experience of care measures in the next paragraph. 
2 See https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd21001.pdf for more information. 
3 Most of the measures included in the measure set have only been tested with adults and have not been tested with children and adolescents.  As a result, the measure set may not 
be appropriate for use in HCBS programs that serve children and adolescents. 
4 Most of the measures included in the measure set have only been tested with adults and have not been tested with children and adolescents.  As a result, the measure set may not 
be appropriate for use in HCBS programs that serve children and adolescents. 
5 At a states option, the FASI measures may also be used with fee-for-service populations.  
6 Questions used to calculate the composite score include: 
  Q 56: In the last 3 months, did your [program-specific term for service plan] include . . . 
  Q 57: In the last 3 months, did you feel {personal assistance/behavioral health staff} knew whats on your [program-specific term for service plan], including the things that 
are important to you?  
7 Measure description: The percentage of MLTSS plan members age 18 and older who have documentation of a comprehensive assessment in a specified timeframe that includes 
documentation of core elements. For more information, see https://www.medicaid.gov/media/3396.  
8 For all measures with a HEDIS equivalent, states can opt to use the HEDIS equivalent for managed care and FFS populations. 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
                                                                                                                                                                                                                                                                                                      
 
9 Measure description: The percentage MLTSS plan members age 18 and older who have documentation of a comprehensive LTSS care plan in a specified timeframe that includes 
documentation of core elements. For more information, see https://www.medicaid.gov/media/3396. 
10 Measure description: Percentage of individuals 18 years or older who received community-based LTSS with documented needs determined by the Functional Assessment 
Standardized Items AND who have identified at least 3 personal priorities related to self-care, mobility, or IADL functional needs within the reporting period. For more information, 
see https://www.medicaid.gov/medicaid/ltss/teft-program/functional-assessment-standardized-items/index.html.  
11 At a states option, FASI-1 can be used in place of MLTSS-1; FASI-1 is not expected to be used by all states implementing the measure set and instead is included only as an 
option in place of MLTSS-1. 
12 Measure description: Percentage of individuals 18 years or older who received community-based LTSS with documented functional needs as determined by the Functional 
Assessment Standardized Items assessment AND documentation of a person-centered service plan that addressed identified functional needs within the reporting period. For more 
information, see https://www.medicaid.gov/medicaid/ltss/teft-program/functional-assessment-standardized-items/index.html.  
13 At a states option, FASI-2 can be used in place of MLTSS-2; FASI-2 is not expected to be used by all states implementing the measure set and instead is included only as an 
option in place of MLTSS-2. 
14 Questions include: 
  Q 18: Unmet need in dressing/bathing due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to help you?  
  Q 22: Unmet need in meal preparation/eating due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to help 
you?  
  Q 25: Unmet need in medication administration due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to 
help you? 
  Q 27: Unmet need in toileting due to lack of help: In the last 3 months, did you get all the help you needed with toileting from {personal assistance/behavioral health staff} 
when you needed it? 
  Q 40: Unmet need with household tasks due to lack of help: In the last 3 months, was this because there were no {homemakers} to help you? 
15 Measure description: The percentage of MLTSS plan members age 18 and older who have documentation of a comprehensive assessment in a specified timeframe that includes 
documentation of core elements. For more information, see https://www.medicaid.gov/media/3396.  
16 Measure description: The percentage MLTSS plan members age 18 and older who have documentation of a comprehensive LTSS care plan in a specified timeframe that includes 
documentation of core elements. For more information, see https://www.medicaid.gov/media/3396. 
17 Measure description: The percentage of discharges from inpatient facilities for MLTSS plan members age 18 and older for whom a reassessment and care plan update occurred 
within 30 days of discharge. For more information, see https://www.medicaid.gov/media/3396. 
18 Questions include: 
  Q 18: Unmet need in dressing/bathing due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to help you?  
  Q 22: Unmet need in meal preparation/eating due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to help 
you?  
  Q 25: Unmet need in medication administration due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to 
help you? 
  Q 27: Unmet need in toileting due to lack of help: In the last 3 months, did you get all the help you needed with toileting from {personal assistance/behavioral health staff} 
when you needed it? 
  Q 40: Unmet need with household tasks due to lack of help: In the last 3 months, was this because there were no {homemakers} to help you? 
19 Questions used to calculate the composite score include: 
  Q 13: In the last 3 months, how often did {personal assistance/behavioral health staff} come to work on time?  
  Q 14: In the last 3 months, how often did {personal assistance/behavioral health staff} work as long as they were supposed to?  
  Q 15: In the last 3 months, when staff could not come to work on a day that they were scheduled, did someone let you know that {personal assistance/behavioral health 
staff} could not come that day? 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
                                                                                                                                                                                                                                                                                                      
 
  Q 19: In the last 3 months, how often did {personal assistance/behavioral health staff} make sure you had enough personal privacy when you dressed, took a shower, or 
bathed? 
  Q 37: In the last 3 months, how often did {homemakers} come to work on time?  
  Q 38: In the last 3 months, how often did {homemakers} work as long as they were supposed to? 
20 Questions used to calculate the composite score include: 
  Q 28: In the last 3 months, how often did {personal assistance/behavioral health staff} treat you with courtesy and respect?  
  Q 29: In the last 3 months, how often were the explanations {personal assistance/behavioral health staff} gave you hard to understand because of an accent or the way 
{personal assistance/behavioral health staff} spoke English?  
  Q 30: In the last 3 months, how often did {personal assistance/behavioral health staff} treat you the way you wanted them to?  
  Q 31: In the last 3 months, how often did {personal assistance/behavioral health staff} explain things in a way that was easy to understand?  
  Q 32: In the last 3 months, how often did {personal assistance/behavioral health staff} listen carefully to you?  
  Q 33: In the last 3 months, did you feel {personal assistance/behavioral health staff} knew what kind of help you needed with everyday activities, like getting ready in the 
morning, getting groceries, or going places in your community? 
  Q 41: In the last 3 months, how often did {homemakers} treat you with courtesy and respect?  
  Q 42: In the last 3 months, how often were the explanations {homemakers} gave you hard to understand because of an accent or the way the {homemakers} spoke 
English?  
  Q 43: In the last 3 months, how often did {homemakers} treat you the way you wanted them to?  
  Q 44: In the last 3 months, how often did {homemakers} listen carefully to you?  
  Q 45: In the last 3 months, did you feel {homemakers} knew what kind of help you needed? 
21 Questions used to calculate the composite score include:   
  Q 75: In the last 3 months, when you wanted to, how often could you get together with these family members who live nearby?  
  Q 77: In the last 3 months, when you wanted to, how often could you get together with these friends who live nearby?  
  Q 78: In the last 3 months, when you wanted to, how often could you do things in the community that you like?  
  Q 79: In the last 3 months, did you need more help than you get from {personal assistance/behavioral health staff} to do things in your community?  
  Q 80: In the last 3 months, did you take part in deciding what you do with your time each day?  
  Q 81: In the last 3 months, did you take part in deciding when you do things each dayfor example, deciding when you get up, eat, or go to bed? 
22 This measure assesses the offer, and selection, of self-directed services among MLTSS adult enrollees who receive HCBS. The measure consists of two rates:  
1.  Self-direction offer rate: Percentage of HCBS users ages 18 and older enrolled in MLTSS plans and eligible for self-direction who were offered the option to self-direct their 
home and community-based services in the last 12 months.  
2.  2. Self-direction opt-in rate: Percentage of HCBS users ages 18 and older enrolled in MLTSS plans and eligible for self-direction who opted-in to self-direct their home and 
community-based services, among those who received an offer to self-direct in the last 12 months. 
23 Most of the measures included in the measure set have only been tested with adults and have not been tested with children and adolescents.  As a result, the measure set may 
not be appropriate for use in HCBS programs that serve children and adolescents. 
24 Questions used to calculate the composite score include: 
  Q 64: In the last 3 months, was there a person you could talk to if someone hurt you or did something to you that you didnt like? 
  Q 65: In the last 3 months, did any {personal assistance/behavioral health staff, homemakers, or your case managers} take your money or your things without asking you first? 
  Q 68: In the last 3 months, did any {staff} yell, swear, or curse at you? 
25 Question: In the last 3 months, did any {staff} hit you or hurt you? 
26 Measure description: The percentage of MLTSS plan members age 18 and older with a care plan that was transmitted to their primary care practitioner (PCP) or other 
documented medical care practitioner identified by the plan member within 30 days its development. For more information, see https://www.medicaid.gov/media/3396. 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
                                                                                                                                                                                                                                                                                                      
 
27 Most of the measures included in the measure set have only been tested with adults and have not been tested with children and adolescents.  As a result, the measure set may 
not be appropriate for use in HCBS programs that serve children and adolescents. 
28 Questions used to calculate the composite score include: 
  Q 56: In the last 3 months, did your [program-specific term for service plan] include . . . 
  Q 57: In the last 3 months, did you feel {personal assistance/behavioral health staff} knew whats on your [program-specific term for service plan], including the things that 
are important to you?  
29 Questions include: 
  Q 18: Unmet need in dressing/bathing due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to help you?  
  Q 22: Unmet need in meal preparation/eating due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to help 
you?  
  Q 25: Unmet need in medication administration due to lack of help: In the last 3 months, was this because there were no {personal assistance/behavioral health staff} to 
help you? 
  Q 27: Unmet need in toileting due to lack of help: In the last 3 months, did you get all the help you needed with toileting from {personal assistance/behavioral health staff} 
when you needed it? 
  Q 40: Unmet need with household tasks due to lack of help: In the last 3 months, was this because there were no {homemakers} to help you? 
30 Questions used to calculate the composite score include: 
  Q 13: In the last 3 months, how often did {personal assistance/behavioral health staff} come to work on time?  
  Q 14: In the last 3 months, how often did {personal assistance/behavioral health staff} work as long as they were supposed to?  
  Q 15: In the last 3 months, when staff could not come to work on a day that they were scheduled, did someone let you know that {personal assistance/behavioral health 
staff} could not come that day? 
  Q 19: In the last 3 months, how often did {personal assistance/behavioral health staff} make sure you had enough personal privacy when you dressed, took a shower, or 
bathed? 
  Q 37: In the last 3 months, how often did {homemakers} come to work on time?  
  Q 38: In the last 3 months, how often did {homemakers} work as long as they were supposed to? 
31 Questions used to calculate the composite score include questions 59, 61, and 62. 
32 This measure assesses the offer, and selection, of self-directed services among MLTSS adult enrollees who receive HCBS. The measure consists of two rates:  
1.  Self-direction offer rate: Percentage of HCBS users ages 18 and older enrolled in MLTSS plans and eligible for self-direction who were offered the option to self-direct their 
home and community-based services in the last 12 months.  
2.  2. Self-direction opt-in rate: Percentage of HCBS users ages 18 and older enrolled in MLTSS plans and eligible for self-direction who opted-in to self-direct their home and 
community-based services, among those who received an offer to self-direct in the last 12 months. 
33 Measure description: The percentage of discharges from inpatient facilities for MLTSS plan members age 18 and older for whom a reassessment and care plan update occurred 
within 30 days of discharge. For more information, see https://www.medicaid.gov/media/3396. 
34 For all measures with a HEDIS equivalent, states can opt to use the HEDIS equivalent for Managed Care or FFS populations. 
35 Questions used to calculate the composite score include: 
  Q 56: In the last 3 months, did your [program-specific term for service plan] include . . . 
  Q 57: In the last 3 months, did you feel {personal assistance/behavioral health staff} knew whats on your [program-specific term for service plan], including the things that 
are important to you?  
36 Questions used to calculate the composite score include: 
  Q 64: In the last 3 months, was there a person you could talk to if someone hurt you or did something to you that you didnt like? 
  Q 65: In the last 3 months, did any {personal assistance/behavioral health staff, homemakers, or your case managers} take your money or your things without asking you 
first? 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.   
                                                                                                                                                                                                                                                                                                      
 
  Q 68: In the last 3 months, did any {staff} yell, swear, or curse at you? 
37 Question: In the last 3 months, did any {staff} hit you or hurt you? 
38 Questions used to calculate the composite score include:   
  Q 75: In the last 3 months, when you wanted to, how often could you get together with these family members who live nearby?  
  Q 77: In the last 3 months, when you wanted to, how often could you get together with these friends who live nearby?  
  Q 78: In the last 3 months, when you wanted to, how often could you do things in the community that you like?  
  Q 79: In the last 3 months, did you need more help than you get from {personal assistance/behavioral health staff} to do things in your community?  
  Q 80: In the last 3 months, did you take part in deciding what you do with your time each day?  
  Q 81: In the last 3 months, did you take part in deciding when you do things each dayfor example, deciding when you get up, eat, or go to bed? 
39 Measure description: The percentage of MLTSS plan members age 18 and older who have documentation of a comprehensive assessment in a specified timeframe that includes 
documentation of core elements. For more information, see https://www.medicaid.gov/media/3396.  
40 For all measures with a HEDIS equivalent, states can opt to use the HEDIS equivalent for managed care and FFS populations. 
41 Measure description: The percentage MLTSS plan members age 18 and older who have documentation of a comprehensive LTSS care plan in a specified timeframe that includes 
documentation of core elements. For more information, see https://www.medicaid.gov/media/3396. 
42 Measure description: Percentage of individuals 18 years or older who received community-based LTSS with documented needs determined by the Functional Assessment 
Standardized Items AND who have identified at least 3 personal priorities related to self-care, mobility, or IADL functional needs within the reporting period. For more information, 
see https://www.medicaid.gov/medicaid/ltss/teft-program/functional-assessment-standardized-items/index.html.  
43 At a states option, FASI-1 can be used in place of MLTSS-1; FASI-1 is not expected to be used by all states implementing the measure set and instead is included only as an 
option in place of MLTSS-1. 
44 Measure description: Percentage of individuals 18 years or older who received community-based LTSS with documented functional needs as determined by the Functional 
Assessment Standardized Items assessment AND documentation of a person-centered service plan that addressed identified functional needs within the reporting period. For more 
information, see https://www.medicaid.gov/medicaid/ltss/teft-program/functional-assessment-standardized-items/index.html.  
45 At a states option, FASI-2 can be used in place of MLTSS-2; FASI-2 is not expected to be used by all states implementing the measure set and instead is included only as an 
option in place of MLTSS-2. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the 
public regarding existing requirements under the law.