The HCBS Settings Rule: what it guarantees about living in the community

What the rule is

Medicaid waivers pay for care outside institutions. The federal home and community based services settings rule exists because paying for care outside an institution is not the same as delivering care that feels like life outside an institution.

Before the rule, a program could fund a setting that had a community address and institutional habits: fixed wake-up times, meals on a schedule nobody chose, visitors by appointment, doors that did not lock, and no realistic way to go out. The rule sets out what a setting has to be like for waiver dollars to pay for services delivered there.

The short version: the place where you get services has to be a place where you live, not a place where you are kept.

What it protects

The rule applies to every setting where waiver services are delivered, with additional requirements for provider-owned or provider-controlled residential settings.

• Privacy. Personal care and personal conversations happen privately. In a residential setting this includes a bedroom door that locks, with the resident holding a key.
• Choice of where and with whom to live. Options are presented, including a private unit where available. Where residents share a room, they have a say in who with.
• Your own schedule. When to get up, when to sleep, when and what to eat, what to do with the day. Not a routine imposed on everyone because it suits the staffing pattern.
• Visitors of your choosing, at times of your choosing. Including overnight, in a residential setting.
• Access to the community. The ability to go out, get to shops, services, work, worship and people, on the same basis as anyone who lives there without support.
• A lease-like agreement. In a provider-owned or provider-controlled residential setting, written protections comparable to a tenant’s, including notice and a route to challenge being asked to leave.
• Freedom from unnecessary restraint, and physical access to the whole of the setting.
• A say in your own plan. The person-centered plan is built with the member, and it records what they want as well as what they need.

When something can be restricted

Rights can be restricted only for a specific individual, for a specific assessed reason, and only with the work shown. That means the person-centered plan has to record:

• The specific and individualized assessed need behind the restriction
• The less intrusive things that were tried first and did not work
• What exactly is being restricted, and for how long
• Ongoing collection of evidence about whether it is still needed
• Regular review, with the aim of removing it
• The member’s informed consent

The practical test is simple. A restriction that applies to everybody in a building is not an individualized restriction – it is a house rule, and house rules that remove rights are what the settings rule exists to stop.

What this looks like in practice

• A resident who wants to sleep late can sleep late.
• A grandson can visit on Sunday evening without permission from a rota.
• Someone can keep food in their room and eat when they are hungry.
• A resident can leave the building to go to church, a shop, a job or a friend’s house.
• A person can choose not to attend an activity without it being logged as a behavior.
• A resident can close and lock their own door.

Why it exists

Because the alternative was well documented. People moved out of institutions and into settings that reproduced institutional life at a community address, and the loss of ordinary adult control – over a door, a meal, a visitor, an afternoon – turned out to matter as much as the quality of the care itself.

If a setting is not meeting these standards, raise it with the case manager first. It is squarely part of the case manager’s monitoring role. If that does not resolve it, the routes on the complaints page are open, and none of them cost anything. Where the concern is abuse, neglect or exploitation rather than a rights restriction, use the reporting page instead and do it straight away.