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:  August 3, 2016 
FROM:  Vikki Wachino, Director                                                                                       
Center for Medicaid and CHIP Services 
SUBJECT:  Suggested Approaches for Strengthening and Stabilizing the Medicaid Home 
Care Workforce  
Introduction 
This informational bulletin highlights steps available to states, providers, and others to strengthen 
the home care workforce, the term used in this document to encompass individuals furnishing 
HCBS, consistent with advancing goals of beneficiary autonomy and self-direction of needed 
services.   
CMS and states are taking important steps to support increased access to high-quality home and 
community based care.  These steps are helping to remedy a longstanding imbalance between 
institutional and home and community-based care:  data for fiscal year 2014 showed that 53 
percent of total Medicaid long-term services and supports (LTSS) expenditures were spent on 
home and community-based services (HCBS), a marked change from 2009 when only 45 percent 
of LTSS expenditures were on HCBS1.  To continue this progress, CMS and states have moved 
forward with implementing recent regulations requiring greater community integration, adopting 
key improvements to managed LTSS, and soliciting public comment on how best to measure 
access to HCBS.  A stable workforce, engaged in the delivery of services and supports that 
address the needs and preferences of beneficiaries, is a critical element to achieving continued 
progress.  
Workforce Identity 
Home care workers may be employed by an agency, such as a home health agency or personal 
care agency, or may be employed directly by a beneficiary under self-directed service models.  
Because home care workers often deliver care on site in the homes of beneficiaries receiving 
services, and travel from home to home independently, home care workers may interact with 
their professional peers infrequently, which can promote isolation and disengagement, and make 
professional development challenging.  
Establishing an open registry of workers for public use can help strengthen the identity of the 
workforce and improve beneficiary awareness of available, qualified home care workers. To be 
most effective, the registry should include individuals who have attained any required 
educational or training standards (discussed more below), but states can use registries in different 
                                                           
1 Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2014. April 15, 2016.  
https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/long-
term-services-and-supports.html  CMCS Informational Bulletin - Page 2  
ways, including offering it as an option but not requiring beneficiaries to select home care 
workers from it.  Medicaid beneficiaries should be able to access these registries not only to 
identify workers but to also add workers, including those who are available for service provision 
under self-directed service models. Self-direction is an important component of the provision of 
HCBS, and actions taken to promote workforce stability should also support the ability of 
beneficiaries to exercise autonomy in determining how service provision can best meet their 
needs.  Registry exclusions should align with state law and policy with respect to criminal 
history.  They should also balance safety concerns with respect for the beneficiaries right to 
choose a trusted family member or friend.  This is particularly relevant in evaluating what 
training will address the individual needs of the beneficiary, and whether existing state laws 
regarding previous criminal history may prevent a beneficiary from choosing a trusted family 
member or friend.  Medicaid administrative match is available to states to help fund the 
development and maintenance of the registry.  Guidance on administrative claiming for these 
functions can be found at https://www.medicaid.gov/medicaid-chip-program-information/by-
topics/financing-and-reimbursement/downloads/qa-training-registry-costs-071015.pdf 
Professional associations or unions can also help support home care worker training and 
development.  For example, they can offer orientation programs for new home care workers on 
state requirements regarding qualifications, documentation, and billing; training in new 
requirements or best practices for the current workforce; professional support and career ladder 
opportunities; peer support; and an organized way to engage in design of the states home care 
system.  State Medicaid Agencies may, with the consent of the individual practitioner, make a 
payment on behalf of the practitioner to a third party that provides benefits to the workforce such 
as health insurance, skills training, and other benefits customary for employees (42 CFR 
447.10(g)(4)).    
Provider Qualifications and Basic Training 
HCBS differs from medical-focused services, a fact that has long been recognized by CMS, 
states, and other stakeholders. Recognizing the importance of balancing program integrity and 
self-direction, states frequently establish broad provider qualifications for HCBS provision, 
although the qualifications can vary depending on the specific service being provided.  For 
services provided primarily in the home, such as personal care services, qualifications can 
include possession of a valid drivers license, a minimum age threshold, and the receipt of any 
training required by the state.  Some states require basic competency-based training content such 
as first aid and CPR certification, etc.  But such minimum qualification requirements should not 
restrict the ability of beneficiaries to require individualized training on the specific ways to 
provide care based on their own needs and preferences. Training can be provided by professional 
home care associations, training organizations, public Workforce Investment Act programs, or 
trade unions. In many consumer directed personal care programs, much of the training can also 
be provided directly by the beneficiary.  
Wage Analyses 
Access to services is critical to ensuring that individuals get the care they need to live in the 
community, and wage thresholds help to attract dedicated and engaged workers.  CMS has issued 
several guidance documents articulating how access is to be monitored in both fee for service (in 
the November 2, 2015 final regulation entitled Methods for Assuring Access to Covered  CMCS Informational Bulletin - Page 3  
Medicaid Services) and in managed care (in the May 6, 2016 final regulation entitled Medicaid 
Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party 
Liability).  In response to a Request for Information issued on November 2, 2015, CMS is 
considering how to develop measures to monitor access to services, including home care, on an 
ongoing basis. CMS encourages states and providers to be mindful of the relationship between 
wage sufficiency, workforce health, and access to care. Wages paid to individual workers are 
often slow to be adjusted in response to inflation and economic growth, and can lag behind wage 
increases in other health and service sectors.  Analyses of how the home care industry relates to 
the larger marketplace within a state are encouraged when states establish rate-setting 
methodologies to providers, and when providers determine the wage structure for their 
employees.  This includes taking into account geographic differences in wages within a state.  
CMS notes that joint-employer relationships addressed in the Department of Labors final rule, 
Application of the Fair Labor Standards Act to Domestic Service, 78 Fed.Reg. 60453 (Oct. 1, 
2013), should be kept in mind as states determine what actions to take in the context of wage 
adequacy.   
When developing payment rates for home care services, states should also consider business 
costs incurred by a provider  whether a home care agency or an individually employed worker  
associated with the recruitment, skills training, and retention of qualified workers. Aside from 
setting appropriate rates generally for this provider group, states have the option to develop 
tiered rate structures that provide enhanced reimbursement for services rendered by workers who 
are able to serve beneficiaries with more complex needs or have other advanced skills. For 
example, the state of Washington used tiered reimbursement rates for personal attendant services 
authorized under Community First Choice based on the acuity level of the beneficiary receiving 
services. Similarly, a state may build into its payment rates the providers cost of maintaining 
status as a qualified Medicaid provider, attending Medicaid-specific pre-service orientations or 
trainings, and post-enrollment training. A providers costs for other benefits offered to workers, 
such as tuition assistance, performance-based bonus payments or higher wages for shiftwork, can 
also be built into the rate the state pays the provider for the service rendered. For additional 
information on which costs may be included in developing service rates, states may refer to 45 
CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements 
for HHS Awards. 
 
Related Prior Guidance 
Previous guidance on programs for home care workers has been issued as part of efforts of the 
National Direct Service Workforce Resource Center, created by CMS in 2006.  Additional 
information on this topic, and others such as core competencies, can be found at the following 
website:  https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-
services-and-supports/workforce/workforce-initiative.html.  In August 2013, CMS issued a 
Toolkit for State Medicaid Agencies titled Coverage of Direct Service Workforce Continuing 
Education and Training within Medicaid Policy and Rate Setting.  Aside from providing 
information on training options, the Toolkit also includes a discussion of how special features of 
self-directed delivery systems should be taken into account.  A goal of the toolkit is to provide a 
foundation for recognizing and addressing the sometimes disparate needs of beneficiaries, home 
care workers, provider agencies, professional associations, and others. Training curricula that is 
developed in partnership with beneficiaries directing their own services instills an understanding 
of the basic values and skills needed to support these individuals.    CMCS Informational Bulletin - Page 4  
As states increasingly turn to managed care to deliver Medicaid-funded HCBS, CMS 
strengthened approaches to managed long-term services and supports (MLTSS) programs and 
resulting beneficiary protections in the Medicaid managed care final rule.  For example, specific 
provisions require stakeholder engagement in the design, implementation and oversight of 
MLTSS programs. The regulation also sets standards to evaluate the adequacy of the network for 
MLTSS programs and the accessibility of providers to meet the needs of MLTSS enrollees. In 
addition, states are reminded of their obligations under Olmstead v. L.C., 527 U.S. 581 (1999) 
and the Americans with Disabilities Act. 
States interested in learning more on these topics and to request technical assistance may contact 
Melissa Harris, Senior Policy Advisor in the Disabled and Elderly Health Programs Group, at 
melissa.harris@cms.hhs.gov.