DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
CMCS Informational Bulletin 
DATE:  April 5, 2018
FROM:  Timothy B. Hill, Acting Director 
Center for Medicaid and CHIP Services 
SUBJECT:  Compliance with Medicaid Home Health Final Regulation 
The Centers for Medicare & Medicaid Services (CMS) Medicaid Home Health final rule1 was 
published on February 2, 2016 with an effective date of July 1, 2016.  States are required to 
comply with these provisions, however, as indicated in the final rule, CMS recognizes that states 
may experience operational and budgetary implications that states need to consider as they plan to 
implement certain provisions of the final rule.  Therefore, CMS delayed compliance with the final 
rule for up to two years from the effective date, based on state legislative cycles. 
CMS Administrator Seema Verma issued a letter to the nations Governors on March 14, 20172, 
affirming the continued CMS commitment to partnership with states in the administration of the 
Medicaid program.  Through our discussions with states following the issuance of this letter, we 
recognize that there may continue to be state-specific administrative challenges associated with 
implementing certain provisions of the Medicaid Home Health final rule and that there is 
confusion surrounding state compliance deadlines.  As any modifications or changes to the 
Medicaid Home Health Final Rule will generally necessitate rulemaking as required by the 
Administrative Procedure Act (APA), CMS intends to use our enforcement discretion to focus on 
working with states to achieve compliance with provisions of the Medicaid Home Health final rule 
if states are unable to meet compliance deadlines.  This use of enforcement discretion will be 
applied based on state-specific facts and circumstances and focused on states specific needs. 
To implement this targeted enforcement discretion, states will need to identify for CMS the 
provisions of the final rule that they are unable to implement by the required date based on their 
legislative timeframes. States should work through their normal regional office processes to 
identify the specific provisions.  CMS will work with states on assessing compliance with the 
specific provisions, including (1) the specific goals and intent for the provision; (2) compliance 
with home health regulatory standards that were in effect prior to the Medicaid face- 
1 Medicaid Program; Face-to-Face Requirements for Home Health Services; 
Policy Changes and Clarifications Related to Home Health; Final Rule, 81 FR 5529 (February 2, 
2016); available at: https://www.federalregister.gov/documents/2016/02/02/2016-01585/medicaid-
program-face-to-face-requirements-for-home-health-services-policy-changes-and  
2 Letter to the nations Governors on March 14, 2017  CMCS Informational Bulletin  Page 2 
to-face rule publication in 2016; (3) alternatives the state could consider in moving toward 
compliance and strategies for how states can best mitigate specific risks and concerns with non-
compliance; and (4) developing a timeline for future compliance with the regulatory requirements. 
Notwithstanding this guidance, CMS is unable to permit flexibility for all provisions of the final 
rule for which compliance is required on or after July 1, 2016.  Specifically, we will not permit 
flexibility for certain provisions which codify longstanding Medicaid home health policy.  These 
include:  
1. The prohibition on requiring that the availability of all home health service is  contingent
upon the individual needing nursing or therapy services found in  440.70(b);
2. The requirements found at  440.70(b)(3)(v) codifying CMS long standing policy
implementing the ruling of the United States Court of Appeals for the Second Circuit  in
DeSario v. Thomas, 139 F. 3d 80 (1998).  Specifically,  a state may develop a list of pre-
approved items of medical equipment as an administrative convenience, but must provide
individuals with a reasonable and meaningful procedure for requesting items that do not
appear on such a list;  and
3. The homebound prohibition on Medicaid home health services and settings in which
individuals can receive Medicaid home health services found in 440.70(c)(1).
As articulated in the final home health regulation, the regulation sets forth a framework for 
coverage, and does not remove state flexibility to define the scope of the home health benefit.  
States continue to have flexibility to establish a reasonable service definition as long as that 
definition is consistent with the federal regulatory framework. 
Technical Assistance 
CMS will work with states on assessing compliance with the specific provisions on a case-by- case 
basis.  Please contact CMS by May 31, 2018 to request assistance so that compliance can be 
assessed and any necessary flexibility can be granted prior to July 1, 2018. 
CMS remains committed to providing technical assistance to states and other stakeholders in 
understanding the Medicaid Home Health final rule and developing implementation approaches 
that maximize the provision of Medicaid services in a manner compliant with program 
requirements.  If you have questions or would like to request technical assistance related to the 
guidance in this informational bulletin, please send an email to 
MedicaidHomeHealthRule@cms.hhs.gov. 
We look forward to continuing our partnership to deliver on our shared goals of providing high 
quality, sustainable healthcare to those who need it.