A congressional advisory panel is recommending enhancing access to home- and community-based services and reducing state and federal administrative burdens for providing those services.

The Medicaid and CHIP Payment and Access Commission, or MACPAC, made the proposed recommendations in its March 2025 Report to Congress on Medicaid and CHIP, released Thursday.

“This report offers recommendations and insights that both state and federal policymakers can use to enhance transparency in the Medicaid program, reduce administrative burdens and significantly improve the experience for its beneficiaries,” MACPAC Chair Verlon Johnson said in a statement.

Chapter 2 of the report examines HCBS and makes a recommendation to improve timely access to services. Specifically, the report recommends that the US Department of Health and Human Services direct the Centers for Medicare & Medicaid Services to issue guidance on how states can implement provisional plans of care, addressing policy and operational considerations under Section 1915(c) waivers, under which states primarily cover HCBS.

Those waivers are a common way that assisted living communities offer HCBS to Medicaid beneficiaries.

The chapter focuses on the use of presumptive eligibility — which allows individuals to receive services temporarily while completing the Medicaid application process — and expedited flexibilities — including accepting self-attestation of information needed to determine Medicaid eligibility — for non-modified adjusted gross income, or MAGI, population, as well as provisional care plans, or interim service plans.

The commission recommended that CMS provide additional guidance to better describe the intent and use of provisional plans of care, including state examples of how to make the policy operational.

“Guidance could explain how provisional plans of care can be used in routine situations, such as … when a resident of an assisted living facility needs to transition to Medicaid coverage after spending down their savings. In addition, one expert noted that it would be helpful to have specific guidance allowing states to offer a standard set of limited HCBS in a provisional plan of care,” the report said.

Chapter 3 analyzes the federal administrative requirements for HCBS programs and recommends extending the renewal period for HCBS programs operating under Section 1915(c) waivers and Section 1915(i) state plan amendments from five years to 10 years. 

In 2024, 46 states and the District of Columbia operated more than 250 Section 1915(c) waivers. Most states operate multiple HCBS programs, and the administrative complexity in federal statute, regulation and guidance can leave states dedicating substantial time and resources to meeting the requirements of operating Medicaid HCBS programs, according to the report. 

Section 1915(c) waivers and Section 1915(i) state plan amendments that restrict eligibility to specific populations must be renewed every five years. The report called this a “resource-intensive process” for CMS and for states, with unpredictable timelines. Feedback collected for the report supported extending the renewal period to 10 years. 

MACPAC also made recommendations on how to improve the managed care external quality review process.