DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-14-26 
Baltimore, Maryland  21244-1850 
 
 
 
Frequently Asked Questions: Section 12006 of the 21st Century Cures Act 
Electronic Visit Verification (EVV) Systems for Personal Care Services (PCS) and Home Health 
Care Services (HHCS) 
Provisions of the Legislation 
 
1.  Q: What does section 12006 of the 21st Century Cures Act require? 
A: Section 12006 of the 21St Century Cures Act (the Cures Act), P.L. 114-255, added Section 1903(l) 
of the Social Security Act (SSA). Section 1903(l) provides that states must require the use of an 
electronic visit verification (EVV) system for personal care services (PCS) and home health care 
services (HHCS) that require an in-home visit by a provider. 
2.  Q: Does section 1903(l) apply to the territories identified at Social Security Act 1101(a)(1) too? 
 
A: Yes. There is no definition of state unique to section 12006. Accordingly, the definition of 
state at section 1101(a)(1) of the Social Security Act also applies with respect to section 1903(l). 
That definition includes the District of Columbia, as well as the territories of Puerto Rico, the Virgin 
Islands, Guam, the Northern Mariana Islands, and American Samoa. 
 
3.  Q:  Does section 1903(l) apply to all Medicaid PCS? 
A: The section 1903(l) requirement applies to personal care services (PCS) requiring an in-home visit 
that are provided under the Medicaid state plan or under a waiver program or demonstration 
project under the following Social Security Act provisions and their implementing regulations: 
1)  SSA Section 1905(a)(24) state plan personal care benefit 
2)  SSA Section 1915(c) home and community based services waivers 
3)  SSA Section 1915(i) home and community based services state plan option 
4)  SSA Section 1915(j) self-directed personal attendant care services 
5)  SSA Section 1915(k) Community First Choice state plan option 
6)  SSA Section 1115 demonstration projects 
For purposes of the electronic visit verification (EVV) requirement under SSA section 1903(l), the 
definitions of personal care services and self-directed personal assistance services at 42 CFR  
440.167 and 441.450 apply, as do any state-specific definitions of the term or similar terms (e.g., 
personal attendant services, personal assistance services, attendant care services, etc.) in CMS- 
approved state plan amendments, waivers, and demonstration projects under section 1915(c),  (i), 
(j), or (k), and section 1115. States should also refer to descriptions of the service in CMS guidance, 
such as the State Medicaid Manual (CMS Manual Pub. #45) section 4480. The definition of personal 
care services is not uniform across all the authorities under which it can be covered as a Medicaid 
benefit, but in general, it consists of services supporting Activities of Daily Living (ADL), such as 
movement, bathing, dressing, toileting, and personal hygiene. Personal care services can also offer 
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  support for Instrumental Activities of Daily Living (IADL), such as meal preparation, money 
management, shopping, and telephone use. 
 
Personal care services that are provided to inpatients or residents of a hospital, nursing facility, 
intermediate care facility for individuals with intellectual disabilities, or an institution for mental 
diseases, and personal care services that do not require an in-home visit, are not subject to the EVV 
requirement. 
 
CMS is aware that PCS are provided in a variety of settings, including in congregate residential 
programs such as group homes, assisted living facilities, etc. Stakeholders have questioned whether 
the EVV requirements apply to PCS provided in those settings offering 24 hour service 
availability.  CMS interprets the reference in the statute to an in-home visit to exclude PCS 
provided in congregate residential settings where 24 hour service is available. This interpretation 
recognizes inherent differences in service delivery model where an employee of a congregate 
setting furnishes services to multiple individuals throughout a shift, and services provided to an 
individual during an in home visit from someone coming to a home to provide PCS as specified in 
the EVV statute. Consistent with this difference in service delivery model, typical reimbursement for 
services provided in these congregate settings utilizes a per diem methodology, rather than discrete 
per visit or per service payment structures. Therefore, CMS finds that services provided in a 
congregate residential setting are distinct from an in home visit subject to EVV requirements 
under the statute. 
 
4.  Q:  Does section 1903(l) apply to all HHCS? 
 
A: Section 1903(l) applies to home health services requiring an in-home visit that are described in 
section 1905(a)(7) of the SSA and provided under the state plan or under a waiver of the state plan 
(such as a Section 1915(c) waiver or a waiver under a Section 1115 demonstration). 
 
5.  Q: Does the EVV requirement apply to the Program of All-Inclusive Care for the Elderly (PACE) 
program? 
 
A: CMS does not interpret the EVV requirement to apply to PACE program services. In CMSs view, 
PACE is a separate Medicaid benefit listed at section 1905(a)(26) of the Social Security Act, and that 
provision is not cited in section 12006(a)(5)(C) of the Cures Act. 
6.  Q: States often choose alternate titles for personal care services or bundle them within other 
service definitions (e.g., respite, in-home living supports). Is the Cures Act definition limited to just 
those services explicitly titled personal care services in a states state plan or waiver program? 
 
A: All services requiring an in-home visit that are included in claims under the home health category 
or personal care services category on the CMS-64 form are subject to the EVV requirement. In 
addition, services furnished under waivers or demonstration projects that meet the statutory or 
regulatory definition of a home health service or personal care service must meet the EVV 
requirement, even if they are bundled into a different service or furnished through a managed care 
provider. In other words, if the service includes personal care services or home health services, even 
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  if it has a different name or also includes other services, it is subject to EVV. See question 3 for 
additional description of PCS subject to EVV requirements. 
7.  Q:  The Medicaid home health benefit is defined through regulation to include (a) nursing services, 
(b) home health aide services, (c) medical supplies, equipment, and appliances. At the states 
option, the benefit may also include physical therapy, occupational therapy, and speech 
pathology and audiology services. Is EVV required for all of the services included in a states 
home health benefit? 
 
A: SSA Section 1903(l)(1) specifies that the EVV requirement applies to personal care services or 
home health care services requiring an in-home visit by a provider that are provided under a State 
plan under this title (or under a waiver of the plan).... Similarly, section 1903(l)(5)(B) defines home 
health services for purposes of the EVV requirement to mean services described in section 
1905(a)(7) provided under a state plan under this title (or under a waiver of the plan). Therefore, 
any home health services that the state has opted to cover under the state plan or under a waiver of 
the plan, and that require an in-home visit, would be subject to the EVV requirement.  For example, 
if a medical supply is delivered through the mail, or is picked up at the pharmacy, EVV does not 
apply. However, if a medical supply requires an in-home visit for set-up, then EVV applies. This 
applies to both managed care and fee-for-service delivery systems. 
 
8.  Q:  What type of EVV system must be used? 
A: Section 12006(c)(2) provides that section 1903(l) cannot be construed to require the use of a 
particular or uniform EVV system. However, section 1903(l)(5)(A) provides that the system must be 
able to electronically verify, with respect to visits conducted as part of personal care services or 
home health care services, the following: 
1)  the type of service performed; 
2)  the individual receiving the service; 
3)  the date of the service; 
4)  the location of service delivery; 
5)  the individual providing the service; and 
6)  the time the service begins and ends 
Section 1903(l)(2) also requires states to provide for a stakeholder process to allow input into the 
states implementation of the EVV requirement from providers of PCS and home health services, 
beneficiaries, family caregivers and other stakeholders. 
9.  Q:  When do states need to comply with this requirement? 
A: An EVV system must be in place for personal care services starting January 1, 202019.  An EVV 
system must be in place for Home Health Services starting January 1, 2023  If a state demonstrates 
to the Secretary (1) that the state has made a good faith effort to comply with the EVV requirements 
(including by taking steps to adopt the technology used for an electronic visit verification system), 
and (2) that the state, in implementing such a system, has encountered unavoidable system delays, 
then the FMAP reductions shall not apply for calendar quarters in 202019 (for personal care 
services) or for calendar quarters in 2023 (for home health care services). 
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  10. Q:  What happens if a state does not implement the EVV requirement? 
A: Section 1903(l) requires a decrease in the Federal Medical Assistance Percentage (FMAP) rate if 
EVV is not implemented. For calendar quarters in 2019 and 2020, FMAP for PCS is decreased by .25 
percentage points.  FMAP is reduced by 0.5 percentage points for calendar quarters in 2021; and by 
0.75 percentage points for calendar quarters in 2022. For calendar quarters in 2023 and each year 
thereafter, FMAP is reduced by 1 percentage point. For home health care services, the same 
increments apply, but the FMAP reductions do not start until 2023. Thus, for home health care 
services, for calendar quarters in 2023 and 2024, FMAP is decreased by .25 percentage points. For 
calendar quarters in 2025, FMAP is reduced by .5 percentage points. For calendar quarters in 2026, 
FMAP is reduced by .75 percentage points. For calendar quarters in 2027 and each year thereafter, 
FMAP is reduced by 1 percentage point. 
CMS notes that the legislation exempts the FMAP reductions only for calendar quarters in 202019 
for EVV implementation in PCS and only for calendar quarters in 2023 for EVV implementation in 
HHCS for states that have made a good faith effort to comply with requirements. This good faith 
effort applies to states that have taken steps to adopt the technology used for an EVV system AND 
have encountered unavoidable system delays. States may begin submitting information to CMS in 
July 201918 to describe concerns they foresee in adhering to the January 1, 202019 effective date 
for PCS and provide justification that the state has demonstrated a good faith effort. CMS will be 
working with states on an individual basis to determine if both conditions of a good faith effort are 
present. 
State Specific Variations 
 
11. Q: Are there any implementation flexibilities for states with legislatures that only meet every two 
years, and will not meet again prior to the January 1, 202019 effective date for EVV systems in 
personal care services? Can states demonstrate a good faith effort in implementation activities 
and avoid the reduction in FMAP? 
A: Section 1903(l)(4) allows a state to demonstrate that it ``...(i) has made a good faith effort to 
comply with the requirements of paragraphs (1) and (2) (including by taking steps to adopt the 
technology used for an electronic visit verification system); and (ii) in implementing such a system, 
has encountered unavoidable system delays. If the state can make such a demonstration, FMAP will 
not be reduced for calendar quarters in 202019 (for PCS) or 2023 (for home health care services). It 
is important to note there is no extension beyond these specified quarters in these specific years. 
CMS will take variables such as legislative cycles into account when determining whether individual 
states meet the criteria for the good faith exception to the requirement. However, CMS will expect 
states to demonstrate that they have made good faith efforts to meet the dates required in the 
Cures Act; this could include, but not be limited to, the state demonstrating steps taken to adopt 
and implement the technology used for an EVV system. 
 
12. Q: How does CMS anticipate states implementing EVV requirements in frontier or rural areas? 
 
A: Section 1903(l) does not include an exception for frontier or rural areas, but does give states 
discretion in determining the type(s) of systems that would work best. States should therefore 
determine which EVV system works best for them, including for their frontier or rural areas, so long 
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  as the system captures the six verification criteria specified in the statute (i. service type; ii. 
Individual receiving the service; iii. date of service; iv. location of service delivery; v. individual 
providing the service; and vi. begin and end times of service). States may implement more than one 
EVV system to account for differences in geography, strength of cellular networks, etc. 
Implementation Flexibilities 
 
13. Q:  Must states implement a specific type of EVV system? 
 
A: No. As long as all of the statutorily mandated information is collected on personal care and home 
health care services requiring an in-home visit by a provider, states have significant discretion to 
utilize the system(s) of their choosing. CMS does not endorse one type of system over another. In a 
concurrent guidance mandated by the legislation to describe best practices of EVV system 
implementation, CMS described some examples of systems that facilitate integration of existing 
systems, along with implications for states, provider and beneficiaries when specific models of EVV 
are selected by the state. 
 
14. Q: Does an EVV system require the Medicaid beneficiary to have an Internet connection, a cell 
phone, or a land line? 
A: No. CMS notes that there are a number of options available within an EVV system. CMS believes 
there are EVV system options that meet the six verification criteria specified in the legislation 
without relying upon a Medicaid beneficiary to supply any technology, including those in which the 
provider has a phone or electronic tracker available to staff and/or the service recipient. The state 
should explore all options available and determine what best fits the needs of the state. 
15. Q: How can EVV be implemented in ways that minimize privacy concerns, particularly around the 
need to capture location information through the EVV system? 
 
A: The Cures Act does not require states to capture each location as the individual is moving 
throughout the community. Services either starting or stopping in the individuals home are subject 
to EVV requirements, and capturing the location in which the service is started and stopped is 
sufficient for meeting the minimum requirements specified in the Cures Act. CMS notes that states 
may choose to require more information as a factor to control for fraud, waste, and abuse. State 
Medicaid Agencies have a good deal of discretion in selecting the EVV system(s) that will most 
effectively meet their needs. CMS also notes that there is no requirement to use global positioning 
services (GPS), but it is one approach for implementation of the EVV requirements. A common 
alternative to GPS is Interactive Voice Response, which requires the caregiver to check-in and out 
using a landline or cellular device located at the individuals home. 
Self-Direction Implications 
 
16. Q: How can states implement EVV systems in self-directed personal care programs in ways that 
adhere to program flexibilities? 
 
A: CMS recognizes the hallmarks of self-directed programs such as beneficiary selection of service 
provider and flexibility in determining optimal service provision timeframes.  CMS encourages states 
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  to select EVV systems that facilitate accommodation of self-directed models by ensuring flexibilities 
such as fluid scheduling modifications, choice of worker, engagement in community activities, and 
proper interaction with Financial Management Services (FMS) entities. As with all programs, 
including self-directed programs, EVV systems are also encouraged to have processes for 
troubleshooting and communication of roles and responsibilities. 
Federal Funding Availability 
 
17. Q: Is federal reimbursement available for implementing an EVV system? 
A: Yes. To the extent that EVV is an automated data processing (ADP) system, the Advanced 
Planning Document (APD) requirements under 45 CFR Part 95 Subpart F would apply. If the system 
will be operated by the state or a contractor on behalf of the state  the state may apply for federal 
financial participation (FFP) for expenditures to receive 90% federal match for the design, 
development or installation of such a system, and 75 percent federal match for the operation and 
maintenance of the system. States should seek the enhanced federal through the APD process. To 
assist states in applying for federal funding, CMS will provide technical assistance to help streamline 
and expedite the review and approval process. States are encouraged to contact their Regional 
Offices to initiate this assistance. 
18. Q: Is enhanced Federal Match available to states for the implementation of a higher level system 
that unifies multiple operational vendors (e.g., for the purposes of collating data from providers 
EVV vendors at the state level, such as an aggregator system)? 
A: Yes. CMS will consider enhanced matching funds for higher level systems components and 
vendors for Medicaid enterprise IT projects that adhere to the principles and requirements 
described in Federal Policy Guidance found at SMD # 16-009 (June 27, 2016) Re: Mechanized Claims 
Processing and Information Retrieval Systems  APD Requirements; and SMD # 16-010 (August 16, 
2016) RE: CMS-2392-F Mechanized Claims Processing and Information Retrieval Systems  
Modularity. This policy guidance is available at https://www.medicaid.gov/Federal-Policy- 
Guidance/Federal-Policy-Guidance.html 
 
19. Q:  Is enhanced Federal Match available to states for buying an EVV system off the shelf? 
 
A: Yes. Certain costs associated with implementing Commercial Off the Shelf (COTS) software may 
be eligible for enhanced funding.  Such costs include: 
  At the 90 percent federal matching rate -- the initial licensing fees, and minimum 
necessary costs to analyze the suitability of COTS or hosted software, installation, 
configuration and integration of the COTS or hosted software solution, and modification 
of existing state software to ensure interoperability and coordination of operations. 
  At the 75 percent federal matching rate -- ongoing licensing fees during maintenance 
and operation, including usual and customary charges for routine software updates or 
upgrades, and any associated modifications to customization that might be required. 
Please note that the enhanced federal match under 1903(l)(6) is available only if the EVV system is 
operated by the state or a contractor on behalf of the state; thus, the costs listed above would have 
to be incurred by the state or its contractor. Please contact your RO for more information. 
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  20. Q: Is enhanced Federal Match available for administrative costs for providers or managed care 
organizations to contract with their preferred EVV vendors? 
A: No. CMS does not have authority to provide enhanced federal match for administrative costs for 
providers or managed care organizations. However, enhanced match may be available to states for 
mechanized claims processing and information retrieval systems (e.g., MMIS) in 1903(a)(3) for 
software programs or equipment interfaces necessary to receive data from managed care vendors 
into the MMIS as this will enhance states ability to use data and automation to improve efficiency 
of the Medicaid program. 
In some instances, providers may incur costs to purchase EVV devices and/or equipment 
themselves. In those instances, the costs associated with the purchase of the EVV devices and/or 
equipment could be built into the rate paid to the provider for the rendering of services. Please 
check with your RO for technical assistance on provider payment rates. 
21. Q: Is enhanced Federal Match under 1903(l)(6) available to states for costs associated with 
upgrading a states existing/current EVV system to align with Cures Act requirements? 
A: Yes. CMS will consider costs associated with upgrading a states existing/current EVV system to be 
eligible for enhanced matching rates (i.e., the 90 and 75 percent match rates) if the system is 
operated by the state or a contractor of the state. Please consult with your RO MMIS lead for 
guidance. 
22. Q: Is enhanced Federal Match available for state expenditures on tools necessary for EVV 
implementation, such as phones, internet access, fobs, tablets, etc. for providers or individuals 
receiving services? 
 
A: No. CMS does not have authority to provide enhanced federal match for administrative costs for 
providers or individuals receiving services. 
Next Steps 
 
23. Q: Will CMS require states to demonstrate the use of EVV in their MMIS as a condition for 
receiving enhanced Federal Match under 1903(l)(6)? If so, how should states ensure the necessary 
EVV data are captured? 
 
A:  EVV systems supported with enhanced federal funding should provide for the necessary 
interfaces or data exchanges that are appropriate to ensure that the MMIS provides a 
comprehensive management tool for efficient, effective, and economical administration of 
Medicaid. CMS is considering options for reviewing EVV systems as part of the Medicaid Enterprise 
Certification Toolkit (MECT) process. CMS will work with states to provide additional guidance in this 
area. 
 
24. Q: Will CMS require states to demonstrate the use of EVV systems relative to provider claims and 
tracking of services in the MMIS, as a condition for reimbursement of expenditures for PCS and 
HHCS services? 
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  A: Yes. States can demonstrate this in a variety of ways, through direct interface with the MMIS, or 
other conceptually equivalent methods or processes, including through the use of decision support 
systems and automated or ad hoc data analytics (See the State Medicaid Manual (SMM) Part 
11225). 
 
The U.S. Department of Health & Human Services (HHS) uses a variety of methods to monitor state 
claims for expenditures and for improper payments. Our reviews and determinations are 
established using several different approaches, including CMS 64 reviews, Financial Management 
reviews (FMR), CMS Payment Error Rate Measurement Program (PERM) Reviews, MMIS Data 
Reviews, Medicaid Integrity Contactor (MIC) Audits, and findings from the HHS Office of Inspector 
General (HHS OIG) and Single State Audits. Reviews start with the expenditure claim from the state 
and work back to the source documentation (e.g., provider claims and related documentation) that 
supports the claim. In the course of audits or reviews, we anticipate that EVV systems that are 
integrated with MMIS will enhance states' ability to identify, document, edit, and track claims and 
expenditures for PCS and HHCS paid through the MMIS. As an example, for a PCS claim, a state 
could obtain the number of assessment hours a client was authorized, verify the number of hours 
services were provided using the EVV system, and match that to prior authorization and payment 
activity in the MMIS. The match can occur directly in the MMIS, or through a conceptually 
equivalent method or process as mentioned above. CMS anticipates that the EVV system will help 
increase the state's ability to validate provision of services and monitor accuracy of payments to 
providers thereby detecting and addressing instances of potential fraud, waste and abuse. 
 
25. Q: How does a state describe EVV information in state plan amendment (SPA), waiver, or section 
1115 demonstration project applications? 
 
A: CMS is currently reviewing this issue and will advise states where in SPA, waiver, and demonstration 
project applications the state should reflect the states commitment to and implementation of EVV. 
We will communicate with states on an individual basis based on specific submissions. 
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