Reading The Signals In Cms’ Proposed 2028 Hcbs Quality Measures

When CMS announced its proposed quality measures for Medicaid home- and community-based services (HCBS) for 2028, I was a little surprised by the tone of many of the measures.

Metrics like “People Realize Personal Goals” and “People Participate in the Life of the Community” stood in contrast to the “harder” data I’ve grown accustomed to seeing, like “Minimizing Facility Length of Stay,” which fits perfectly into the industry’s long-standing narrative of cost-avoidance.

After talking with two experts to understand what the measures actually mean for HCBS providers, I came away realizing that these measures demonstrate a clear directional signal from CMS about the outcomes they’re prioritizing, and they set the scene for a transition in how services are paid for.

It’s important to note that states will report on these measures on an aggregated basis, and will gather data from sources such as consumer surveys like CAHPS, claims and encounter data and assessment records. An individual provider will not be judged on its performance on these measures – yet. But as CMS gathers this information and begins public reporting and state-level comparisons, providers will feel downstream effects.

CMS is proposing that states report data starting in 2028 and every two years after that.

The measures are a preview of how “quality” is being defined. They also set the stage for a shift in how these services are ultimately paid for, and they add yet another layer to the state-level patchwork that Medicaid providers must navigate every day.

In this week’s exclusive, members-only, HHCN+ Update, I’ll dive deeper into the proposed measures, offering analysis and key takeaways, including:

– The value-based care future that the measures have made possible

– The themes within the measure set

– How these measures will impact multi-state providers

The bridge between measurement and money

For my coverage, I talked to Bill Hanna, practice director of ATI Advisory’s payer strategy and program design practice and a former state Medicaid director. For Hanna, these measurements could represent the building blocks of value-based models. CMS has created a set of standardized measures that act as the raw material for value-based care.

“If states pair new reporting expectations with realistic timelines, technical assistance and rate and contract strategies that recognize the cost of better assessments, care planning and transitions, providers can leverage the HCBS measures to demonstrate value and improve outcomes,” Hanna told me in an email.

Hanna is pointing out that states can turn CMS’ proposed measurements into VBC infrastructure. The measures themselves don’t change payment, but they make it much easier to justify a change in payment.

States and MCOs may start paying differently based on performance, or require that providers have certain capabilities to get better rates or more referrals.

So for each state, these measures are a value-based fork in the road. They could either go with a fee-for-service mindset and stick with just reporting the data that CMS is asking for. Or, as Hanna said, they could shift to have quality expectations and financing move in tandem. The flip side of this is that “thinly capitalized home‑ and community‑based providers are asked to do more with less,” as Hanna said.

The value-based care opportunity here is why these measures matter. Right now, they don’t directly implicate margins – but they could. At a minimum, this is a signal. It’s a preview of what states, plans and CMS are starting to define as “value” in HCBS, and that’s something providers can’t afford to ignore.

Themes in the measure set

To get an initial read on what CMS is really emphasizing in this measure set, I made a word cloud. Forgive my slightly cheesy methodology – I just love a good word cloud.

It’s not perfect, and it definitely glosses over nuance, but I see this word cloud as a helpful directional tool. The bigger the word, the more frequently it appears, and, I’d argue, the more CMS is implicitly prioritizing it.

The top four words: people, transportation, community and personal.

This might not seem revelatory – this is HCBS, after all – but it strikes me that the focus here is on people and community versus more financial or clinical concepts. CMS is asking whether people are actually living the kind of lives they want to live, including how active they are in their communities. Several measures focus directly on community engagement:

– Percentage of People Who are as Active in Their Community as They Would Like to Be

– Satisfaction with Community Inclusion Scale (The Proportion of People Who Report Satisfaction with the Level of Participation in Community-Inclusion Activities)

– People Participate in the Life of the Community

Community participation is being treated as a core outcome. For providers, that could be a nudge to start measuring this more intentionally and to consider how well they understand and support the holistic goals of the people they are serving.

Transportation is the word that really surprised me.

I expected more emphasis on things like institutional utilization or cost. And yet, transportation is the second-most highlighted word in my word cloud. Transportation-focused measures include:

– Transportation to Medical Appointments Composite Measure

– Percentage of People Who Have Transportation to Get to Medical Appointments When They Need to

– Percentage of People Who Have Transportation When They Want to Do Things Outside of Their Home

– Transportation Availability Scale (The Proportion of People Who Report Adequate Transportation)

For providers, that’s worth paying attention to. Whether it means offering transportation directly, partnering with other organizations, or just better coordinating it, this is an area that could matter more in the future.

And if these measures do eventually get tied to payment, being ahead of the curve on transportation could end up being more than just a nice-to-have.

State-level variability

States will approach the new measure set differently, as they decide which, if any, voluntary measures to use, how much they delegate to MCOs, the investments they make in data and whether to use the measures as a path to value-based care.

For providers, this means yet another Medicaid measure that varies by geography. Last year, my conversations about Medicaid budget cuts in the One Big Beautiful Bill Act (OBBA) always came down to the fact that states would individually have to decide how to reallocate funds, creating the possibility for trickle-down cuts to Medicaid HCBS. In 2028, providers will face yet another state-level quandary, which obviously could create a headache for multi-state providers in particular.

Whether these become a major concern or boon to providers very much remains to be seen – but I do think providers should start thinking about these now. Not only because it shows where the Medicaid HCBS puck is moving, but also because providers in multiple states need to get their action plans ready to deal with state-level variation.

States will ultimately determine what this measure set becomes. They will decide whether to adopt additional voluntary measures, how much responsibility to push to managed care organizations, how heavily to invest in data infrastructure and whether to use these measures as the foundation for value-based care.

For providers, that means the impact of CMS’ proposal will be filtered through 50 different Medicaid programs, each making its own policy and payment decisions. The result is familiar: a growing patchwork of expectations that vary by geography.

By 2028, providers, especially multi-state providers, may be navigating not just different reimbursement structures but also different definitions of “quality” and the expectations tied to them. What looks like a standardized federal framework could translate into very different operational realities on the ground.

Whether that becomes a burden or an opportunity will depend on how aggressively states tie these measures to payment and contracting. But either way, the measure set signals what CMS, and, eventually, states and plans, will value.

Providers don’t need to overhaul their operations tomorrow. But they do need to start preparing for a world where performance on these measures is rewarded, scrutinized and paid for.

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