DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
CMCS Informational Bulletin 
 
 
DATE:  March 20, 2014 
 
FROM:  Cindy Mann 
Director 
     
SUBJECT:  Home and Community-Based Service (HCBS) 1915(c) Waiver and 1915(i) 
State Plan Amendment (SPA) Settings Requirements Compliance Toolkit 
 
The Centers for Medicare & Medicaid Services (CMS) is pleased to share with State Medicaid 
Agencies, Operating Agencies, and other stakeholders a Home and Community-Based (HCB) 
Settings Toolkit to assist states develop Home and Community-Based Services (HCBS) 1915(c) 
waiver and section 1915(i) state plan amendment (SPA) or renewal application(s) to comply with 
new requirements in the recently published HCBS regulations. 
The toolkit includes:  
  a summary of the regulatory requirements of fully compliant HCB settings and those 
settings that are excluded; 
  schematic drawings of the heightened scrutiny process as a part of the regular waiver 
life cycle and the HCBS 1915(c) compliance flowchart; 
  additional technical guidance on regulatory language regarding settings that isolate; 
and 
  exploratory questions that may assist states in the assessment of residential settings. 
Upon receipt of a states HCBS 1915(c) waiver and 1915(i) SPA amendment or renewal 
application(s) including compliance information with the new requirements in the recently 
published HCBS regulations, CMS will review the document and reach an agreement with the 
state about its determination of compliant HCB settings and its actions to bring other settings 
into compliance.  We expect this process to be a dialogue with states in much the same way 
CMS currently reviews and negotiates with states on the approval of their HCBS 1915(c) waiver 
actions.  If necessary, CMS staff may conduct on-site reviews to facilitate confirmation of a 
states determination of whether certain types of settings or specific settings are compliant. 
Upon completion of the federal review, CMS will communicate its decision to states, including 
whether the state must take additional steps to complete the HCBS 1915(c) waiver or SPA 
compliance plan. If the state must make substantive changes to that plan, the waiver or SPA must 
be re-posted for public comment.  Informational Bulletin  Page 2 
CMS is currently developing additional information for states with regard to non-residential 
settings for HCBS participants. Recognizing the importance of this technical guidance to state 
planning activities, we are providing additional flexibility in timeframes for states to address 
non-residential settings. While all provisions of the regulations apply, the list of potential traits of 
settings that exhibit HCB characteristics included in the toolkit, provides examples of traits states 
should consider when assessing both residential and non-residential settings.  With regard to 
non-residential settings, states should, at a minimum provide an assurance in the initial SPA or 
waiver plan for compliance that they will submit a more fully developed timeframe for bringing 
non-residential settings into compliance, after receipt of the technical guidance from CMS.  
Once CMS has communicated its decision on the SPA or waiver plan for compliance embedded 
it the HCBS 1915(c) waiver or 1915(i) SPA amendment or renewal application, the state 
Medicaid agency is expected to implement the plan for compliance. The plan for compliance in 
the HCBS 1915(c) application should be submitted in Attachment #2: HCB Settings Waiver 
Transition Plan which applies to the assessment of settings and the plan for settings not in 
compliance with 42 CFR 441.301(c)(4)-(5) at the time an amendment or renewal is submitted; 
and Appendix C-5: HCB Settings which applies to settings that comply with 42 CFR 
441.301(c)(4)-(5) 
CMS will continue to monitor the states implementation of the plan for compliance.  If a state 
fails to submit an approvable plan for compliance and/or comply with the terms of the approved 
plan for compliance, CMS may take compliance actions including, but not limited to, 
deferral/disallowance of Federal Financial Participation (FFP). 
CMS staff stand ready to assist states in the development and implementation of this critical 
regulation. We believe that our mutual success in implementation of these new requirements 
about HCB settings will accelerate Medicaid beneficiaries access to and enjoyment of those 
aspects of community inclusion and integration that we all value. 
You will find the toolkit at http://www.medicaid.gov/HCBS, along with a link to the 
hcbs@cms.hhs.gov email address to contact CMS directly.