DEPARTMENT OF HEALTH & HUMAN SERVICES  
Centers for Medicare & Medicaid Services  
7500 Security Boulevard,  Mail  Stop S2-26-12  
Baltimore, Maryland    21244-1850  
CENTERS FOR MEDICARE & MEDICAID SERVICES 
  CENTER FOR MEDICAID & CHIP SERVICES 
 
 
 
CMCS Informational Bulletin  
  
DATE:   December 12, 2023  
 
FROM:   Daniel  Tsai   
Deputy Administrator and Director  
  Center for Medicaid and CHIP  Services   
 
SUBJECT:   Development and Maintenance of  Direct Support Worker Registries: Benefits of  
Utilization and Enhanced Federal  Funding Availability  
 
The Center for Medicaid and CHIP Services (CMCS) is issuing this Informational Bulletin to  
remind states and stakeholders that the use of worker management platforms, often called  
registries, is  an important strategy for  ensuring that individuals receiving Medicaid-covered  
home and community-based services  (HCBS) have awareness of and access to qualified workers  
who deliver services. Importantly, the use of these registries does not require CMCS approval. 
 
Even before the COVID-19 public health emergency (PHE), CMCS was aware of a national  
shortage in the direct support workforce (DSW), and the PHE has exacerbated this crisis.1   This  
Informational Bulletin  is part of a series of steps CMCS is taking to maximize beneficiary access  
to Medicaid services they need, recognizing the critical role direct support  workers  have in 
delivering HCBS.  
 
Background  
Worker  registries can serve as a critical bridge between individuals needing services, and  
individuals qualified and available to provide those services. Registries  can be used for personal  
care  and other  HCBS, provided under traditional  agency-delivered models and in self-directed  
delivery models. The types of workers included on a registry can vary according to state  
preference and  can include position titles such as home care worker, home  care  attendant, home  
health aide, personal care attendant, direct support  worker, direct care  worker, direct support  
professional, and others.  
 
As CMCS first discussed in 2016,2 only workers who have attained the states minimum  
requirements for education or training should be included on a registry.  This ensures that a  
worker selected off the registry is qualified to provide Medicaid-covered  HCBS immediately.  
 
1  National Core Indicators  Intellectual and Developmental  Disabilities 2021 State of the  Workforce Survey Report  
https://idd.nationalcoreindicators.org/wp-content/uploads/2023/02/2021StateoftheWorkforceReport_FINAL.pdf   
2  https://www.medicaid.gov/federal-policy-guidance/downloads/cib080316.pdf    Page 2  CMCS Informational Bulletin  
 
States should also  determine and be transparent  about reasons that would exclude a  worker from  
being reflected on the registry.  For example, state  laws could prohibit individuals with certain 
criminal histories from inclusion.  CMCS  continues to advise  states to balance these safety  
concerns  with the ability of beneficiaries to choose a qualified service provider.  
 
To ensure maximum worker buy-in, states should educate  workers about the mandatory or  
voluntary nature of participation on the registry, along with the scope of information the state  
requires for both internal  use and public reflection.   Likewise,  it is important to educate  
beneficiaries  about how the registry is to be used under the relevant service  delivery mechanisms  
to ensure maximum utility.   Worker registries  may  also  be used in the delivery of services across  
multiple Medicaid state plan and waiver authorities.  Programmatically, the use of registries does  
not require CMCS approval. 
 
Implementation of registries can  support the following functions:   
 
   Helping beneficiaries identify and employ qualified workers who meet their needs, 
including the operation of a robust electronic matching system that provides information 
about worker skills and background.  
 
   Facilitating recruitment and retention of workers in the Medicaid program to ensure an 
adequate supply of  workers, including activities such as screening workers and 
facilitating the participation of both family members and non-family members in HCBS  
programs, as well as providing access to training and other benefits. Examples of   
training can include requirements for professional certification and specialized  
experience in delivering services to populations such as individuals with dementia and 
complex behavioral conditions.  
 
   Supporting state oversight activities related to program integrity, monitoring access to 
and quality of care for beneficiaries who receive services, and  maintaining a system for  
communication with workers.  
 
Registries  often  take different forms in different states. Variation among states may reflect  
differences in, for example, states Medicaid HCBS programs, their oversight approach for the  
workforce, the use of a third party, or their  existing information technology (IT) infrastructure  
regarding services  and workers.    
 
Promising Practices  
Regardless of the state Medicaid agencys  approach for structure of the registry and (if  
applicable) its relationship with a third-party entity, registries generally preserve the  central  role  
of beneficiary decision making and autonomy in self-directed models. To that end, CMCS offers  
the following promising practices  that states may  consider  in developing a  registry  to connect  
individuals needing HCBS with individuals qualified to deliver them. CMCS will make available  
additional practices  received from continued state  implementation of registries.  
    Page 3  CMCS Informational Bulletin  
 
   Registry functions may help beneficiaries connect  to care  and support self-direction by:  
   Maintaining an electronic system to help beneficiaries identify and match with 
o
appropriate  workers, potentially including the ability for beneficiaries to sort  
available workers based  on characteristics such  as language proficiency,  
certifications, and previous experience or special skills.  
   Assisting beneficiaries  and their families in navigating the HCBS system,  
o
including specific support on self-direction.  
   Integrating financial management service (FMS) functions, such as processing 
o
payments to workers  and making tax withholdings and other deductions for  
standard employment benefits on behalf of the beneficiary. In some states, these  
functions may currently be performed by independent FMS entities. 
 
   Registry functions  can support recruitment and retention of a qualified home care  
workforce by:  
   Helping workers become HCBS Medicaid providers as well as stay enrolled as a  
o
provider. This could include worker screening, verification of qualifications, and 
assessment of skills capabilities.  
   Actively recruiting new  workers (e.g., through advertising or job fairs).  
o
   Connecting workers to training benefits and opportunities for professional  
o
development, including by contracting with training programs operated by labor-
management partnerships or other entities with experience in training direct 
support workers, and providing other opportunities to reduce rates of  worker  
turnover.  
   Facilitating access to health coverage  and other benefits, in addition to training. 
o
Subject to other applicable laws governing employment and employer-sponsored 
health coverage, the  entity operating the registry could act as an employer for the  
purchase of a group health plan for workers or, where there is a collective  
bargaining agreement in place, through contributions to a union health fund.  The 
entity may  also facilitate enrollment in Marketplace or Medicaid coverage for  
eligible workers.  
   Ensuring there is a system for communication with and support for workers, 
o
particularly in the case of health or other  emergencies (e.g., distribution of  
personal protective equipment and virus tests). 
 
   Registry functions  can support state oversight by:  
   Providing background checks. Our 2016 Program  Integrity CIB3  discusses  the 
o
important role of background checks in identifying criminal histories of  
individuals seeking to provide  HCBS  in Medicaid programs. States  are 
encouraged to adopt background checks, and in doing so, are encouraged to 
collaborate with stakeholders, including beneficiary advocates, to develop policies  
that support consumer-directed programs that allow friends and  family members  
to be recognized providers. 
   Verifying worker qualifications and identifying special skills. As we noted in the  
o
2016 Program Integrity CIB, while states have discretion in determining who is  
 
3  CMCS Informational Bulletin (medicaid.gov)   Page 4  CMCS Informational Bulletin  
 
qualified to furnish Medicaid HCBS, each state should have in place  procedures  
for ensuring that workers are in compliance with those requirements and should 
develop procedures  for documenting compliance. As a repository of information 
about qualified direct support workers  available to provide HCBS to Medicaid 
beneficiaries, the registry should only include workers when the workers  
qualifications have been  verified as meeting the States requirements to be a 
Medicaid-enrolled provider of HCBS. In addition, the workers additional  or  
special skills should also be verified in  accordance with the States established  
documentation procedures prior to publication in the registry. Such verifications  
are important so Medicaid beneficiaries may have confidence in the accuracy of  
the information in the registry and the qualifications of the workers listed therein.  
   Creating a system for  communication with workers and beneficiaries in self-
o
directed programs to facilitate communication with HCBS providers in public  
health and other  emergencies and to provide program updates and access to other  
supports. 
 
CMCS also notes that  several potential registry  functions could generate useful data for purposes  
of states monitoring of  HCBS access and quality, such as by providing data on the recruitment  
and retention of Medicaid HCBS  workers over time, as well as  on the prevalence of proficiency  
in different languages and other special skills; and providing data on total worker  compensation, 
taking into account Medicaid payments as well as  benefits. Filling gaps in data on this workforce  
is a priority for President Biden, who tasked the Department of Health and  Human Services  and  
the Department of Labor  with identifying opportunities to enhance and expand data on the HCBS  
workforce in a recent Executive Order4. 
 
Availability of Enhanced Federal Match  for Worker Registry Development and Maintenance  
State Medicaid agency  IT System costs  associated with developing and maintaining a worker  
registry  may be eligible for enhanced federal financial participation (FFP).  Approval for  
enhanced match requires  the submission of an Advanced Planning Document (APD).  A state  
may submit an APD requesting the 90/10 percent  enhanced match for the design, development, 
and implementation of their Medicaid Enterprise  Systems (MES) initiatives that contribute to the  
economic and efficient operation of the  Medicaid  and  CHIP  programs, including worker  
registries in support of HCBS.  
 
Interested states should refer to 45 C.F.R. Part 95 Subpart F  Automatic Data Processing  
Equipment and Services-Conditions for FFP  for  the specifics related to APD submission.  
 
States may also request a 75/25 percent  enhanced match for ongoing operations of CMS-
approved systems.  Interested states should refer to 42 C.F.R. Part 433 Subpart C  Mechanized  
Claims Processing and Information Retrieval Systems   for the specifics related to systems  
approval.  
 
MES projects that benefit more than one program  require  an allocation of  costs to each program  
benefiting from the project which are unique to that project.  45 C.F.R. Part 75 provides  
principles and standards for determining appropriate cost allocation.  
 
4  Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers | The White House   Page 5  CMCS Informational Bulletin  
 
  
The basic concept for cost allocating MES projects is to break the project down into its  
functional component parts, and to charge a share  of the cost of each component to only those  
programs that will directly benefit. If the  component only benefits one program, then the total 
cost of that component will be direct charged to that program. CMCS is available for technical  
assistance on cost allocation.   
 
Additional Funding Opportunity  
Section 9817 of the American Rescue Plan Act of  2021 (ARP, P.L. 117-2) provided qualifying 
states  with  a temporary 10 percentage point increase to the federal medical assistance percentage 
(FMAP) for certain Medicaid expenditures for HCBS, beginning April 1, 2021, and ending 
March 31, 2022.  The funds must be used to supplement, not supplant, existing state funds  
expended for Medicaid HCBS in effect as of April 1, 2021.  Section 9817 also requires states to 
use state funds equivalent to the amount of  federal funds attributable to the increased FMAP  
(commonly referred to  as state equivalent  funds) to enhance, expand, or strengthen HCBS  
under the Medicaid program. CMS expects states to expend such funds by March 31, 2025.  
States interested in using  the state equivalent funds under  ARP section  9817 for the development  
and maintenance of worker registries should reach out to their CMCS contacts  or 
HCBSIncreasedFMAP@cms.hhs.gov. 
 
For additional information on utilizing worker registries in Medicaid programs, please contact  
Melissa Harris, Deputy Director, Medicaid Benefits and Health Programs  Group, at  
melissa.harris@cms.hhs.gov. For additional information on enhanced federal funding for the  
development and maintenance of  worker registries, please contact Edward Dolly, Director, 
Division of State Systems, at edward.dolly@cms.hhs.gov.