Home and Community-Based Services

HCBS offers a wide array of waivers to provide care for specific circumstances. Explore the waiver program and learn more.

• For help applying for Medicaid, visit the Apply for Medicaid page to explore options.
• Or, find a local HHS office near you to work with some in-person or over the phone on your HCBS application.
• Or, contact Member Services to talk to a member of our team for help.

• Waiver Priority Need Assessment Form (#470-5795) (167.35 KB) .pdf

Search for HCBS providers on the Find a Provider webpage.

A setting is provider owned or controlledwhen the HCBS provider owns the property where the member resides, leases the property from a third party or has a direct or indirect financial relationship with the property owner that impacts either the care provided to or the financial conditions applicable to the member. The unit or dwelling is a specific physical space that can be owned, rented or occupied under a legally enforceable agreement by the member receiving services, and the member has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the state, county, city or other designated entity. For the settings in which landlord tenant laws do not apply, the state must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS member and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord/tenant law. This definition includes “daily” SCL or Home-Based Habilitation residential service settings (including Host Home models).

Site-based or group-based non-residential services include day habilitation centers, adult day care centers, sheltered workshops, small group supported employment and groups of members receiving community-based or “no-walls” day habilitation services.

Presumptively institutional is a term used to describe settings identified by the regulation as being presumed to have the qualities of an institution. The three categories of presumptively institutional settings are also the three categories requiring heightened scrutiny.

• Settings in the same building as a public or private in-patient treatment institution.
• Settings on the grounds of or adjacent to a public institution.
• Settings that have qualities that isolate Medicaid beneficiaries.

Some HCBS settings are considered institutional or “presumptively institutional.” These settings must go through a heightened scrutiny review by CMS (Centers for Medicare & Medicaid Services).

Three Categories of Heightened Scrutiny

CMS has identified three types of settings that need this review:

1. Category 1: Settings in a building that also has a public or private facility providing inpatient institutional treatment.
2. Category 2: Settings in a building on the grounds of, or right next to, a public institution.
3. Category 3: Any setting that isolates people receiving Medicaid HCBS from the broader community.

How the Review Works

When the state finds a setting that needs heightened scrutiny, it first reviews the setting and decides if the setting:

• Can meet HCBS requirements as it is,
• Can meet requirements with changes (called remediation or modifications), or
• Cannot meet requirements and must stop being an HCBS setting.

If changes are needed, the state makes sure those changes happen and then reviews the setting again.

If the setting still cannot meet requirements, it cannot be approved as an HCBS setting.

If the setting can meet requirements (with or without changes), the state will refer it to CMS for final review after getting public input.

Important Notes

Category 3 settings: After March 17, 2023, these are usually not sent to CMS because they either cannot comply or they fix the isolation issue and no longer count as Category 3.

The time between the establishment of the final rule and the deadline for all states to comply is referred to as the “transition period." The transition period ended on March 17, 2023.

Each state had to develop a plan to map out how their state would move from learning about the rule to fully complying with the HCBS setting final rule. These plans were called "statewide transition plans" or STPs.

Initial STPs were developed and submitted to CMS explaining how each state planned to carry out a discovery, assessment, remediation and monitoring process to make sure all settings in the state complied. The initial STP also described any progress made in implementation up to that point in time.

Iowa's initial STP was approved on August 9, 2016.

• Iowa’s Initial Approved STP (2016) (1.25 MB) .pdf
• Initial STP Approval Letter (2016) (1.25 MB) .pdf

Final STP were developed and submitted to CMS explaining the results of the state's discovery, assessment, remediation and monitoring processes. The final STP also outlined the state's ongoing monitoring processes.

Iowa's final STP was approved on March 17, 2023.

• Iowa’s Final Approved STP (2023) (1.62 MB) .pdf
• Final STP Approval Letter (2023) (263 KB) .pdf

Even though Iowa's final STP was approved, there was still some work that needed to be done to fully demonstrate compliance. Iowa, and many other states are working through a corrective action plan (CAP) to finish up work around heightened scrutiny and validation of results. 

Iowa's STP CAP was approved on June 23, 2023. (302.21 KB) .pdf

Starting March 17, 2023:
HCBS waiver and Habilitation providers must report and get approval for any new provider-owned or provider-controlled residential or non-residential settings before using HCBS funding in those settings. Providers must also report when they close these types of settings.

Additions or closures of settings are done through the Provider Self-Assessment (PSA) online tool. Instructions can be found in the Provider Self-Assessment Application Training as linked below.

According to guidance from the Centers for Medicare and Medicaid Services (CMS):

• Providers must show that the setting is actually operating and serving members to confirm it meets HCBS requirements.
• This is especially important for settings that may look or feel like an institution.
• If the setting does not meet requirements, providers may need to make changes before approval and before HCBS funding can be used.
• Services must be paid for with non-Medicaid funds long enough to show the setting meets requirements.

As part of our ongoing commitment to ensuring high-quality care, Iowa Medicaid's Quality Improvement Organization (QIO) Home and Community Based Services (HCBS) unit conducts quality oversight reviews of HCBS providers. These reviews help us verify the accuracy of responses on your most recent provider quality self-assessment and to ensure your compliance with current laws, rules, requirements, and best practices. Quality oversight includes, but is not limited to, annual provider self-assessment, Periodic or Certification Reviews, CNRS Reviews, Focused Reviews and review of incidents and complaints (also known as Targeted Reviews).

Periodic Reviews: All non-certified providers receive a Periodic Review at least once in a five-year cycle. During the review process, responses on the latest SA are verified to evidence found in member and personnel records and compared to other evidence such as Residential Assessments for selected members.

Certification Reviews: Certification Reviews occur 270 days after the initial enrollment of an HCBS-certified provider. Subsequent certification reviews determine the level of certification for the provider. Providers can be recertified for up to a maximum of three years. The Certification Review process is the same as the Periodic Review process but results in a score that determines the provider’s certification level.

Focused Reviews: Providers are semi-randomly selected each year to participate in a Focused Review, and all providers receive a Focused Review once in a five-year cycle. The Focused Review subject is determined annually and based on historical data and Iowa Medicaid need.

Targeted Reviews: Providers may be subject to a Targeted Review based on a complaint towards a specific provider or a serious incident or pattern of incidents. Complaints and incidents may be related to HCBS setting rule non-compliance. A Targeted Review may be completed as a desk review or an onsite review.

Corrective Action Plan Guidelines

When you receive a quality oversight review, you will get a report detailing findings related to the review. Comments will include descriptions of findings including but not limited to, any commendations for areas which the review team found to be exemplary, recommendations for suggested organization actions and areas where corrective action is required to come into compliance with current laws, rules, requirements, and best practices as well as organization policy and responses on the most recent provider quality self-assessment. When changes are required, the report will give parameters in which to develop corrective actions. You have thirty (30) calendar days from the date of this report to develop and submit a CAP.

Components of an Effective CAP

A comprehensive and acceptable CAP must contain the four essential components list below. Each component must be clearly defined, measurable, and time-bound to ensure effective implementation and sustained compliance.

1. Understanding of the Problem

• Clearly acknowledge the identified problem(s).
• Explain why it might have happened (root cause analysis).

2. Steps for Fixing the Problem

• List specific steps to solve the problem.
• Set clear deadlines for each step that align with the corrective action process.
• Spell out necessary changes to written policies, practices, or both.
  • If updating or creating a policy, submit the draft policy with the CAP.
• Name who's responsible for each task.

3. Training Your Team

• Explain how you will train or retrain affected staff on the changes.
  • It may be necessary to include information about the content of training when submitting the CAP.
• Set a training schedule that aligns with the corrective action process.
• Check that staff understand the changes.
• Plan for future training if needed.

4. Monitoring and Sustainability Plan

• Develop a plan for monitoring if the changes you make work to solve the problems (internal monitoring).
• Decide how you will know your plan is working and what kind of information you will gather.
• Set a schedule for monitoring that aligns with the corrective action process.
• Explain how you will document monitoring activities.
• Explain what you will do if new, similar problems come up.

A separate Provider Quality Self-Assessment for Community-Based Neurobehavioral Rehabilitation Services (CNRS) providers can be found on the CNRS webpage.

The HCBS Provider Quality Self-Assessment is required of all providers enrolled for the services identified, regardless of whether those services are currently being provided. The self-assessment must be completed, submitted and approved at application, annually and anytime there is a change in the provider's enrollment that warrants an updated self-assessment.

In July 2025, the Provider Self-Assessment (PSA) Application was launched to streamline communication with HCBS Quality Oversight specialists and providers. The application is accessed within the Iowa Medicaid Portal Application (IMPA). A training was developed to communicate expectations and explain functionality of the application.

• Provider Self-Assessment Application Training
• Training Slides  (1.98 MB) .pdf

Coming soon: Frequently Asked Questions (FAQ)

Coming soon: An informational letter will be available with PSA Application information, registration instructions, and a user guide. 

Minor Incidents are occurrences involving a member that are not major incidents and that:

1. Result in the application of basic first aid,

2. bruising,

3. seizure activity,

4. injury to self, to others, or to property that does not require physician or hospital treatment or

5. prescription medication error that does not require physician or hospital treatment

Minor incidents must be reported in any format determined by the HCBS provider or case management organization within 72 hours of discovery of the incident.

Minor incident reports should not be reported in IMPA.

There is no designated minor incident report template. Minor incidents can be reported in any format determined by the organization and needs to be maintained in a centralized location.

A major incident will be defined as an occurrence involving a member who is enrolled in an HCBS waiver, targeted case management, or habilitation services and that:

1. results in a physical injury to or by the member that requires treatment from a medical professional or admission to a hospital,
2. results in the death of the member, including those resulting from known and unknown medical conditions,
3. results in emergency mental health treatment for the member, (EMS, Crisis Response, ER visit, Hospitalization)
4. results in medical treatment for the member, (EMS, ER Visit, Hospitalization)
5. results in the intervention of law enforcement, including contacts, arrests, and incarcerations,
6. results in a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3,
7. constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in bullets 1- 6 above
8. involves a member’s provider staff, who are assigned protective oversight, being unable to locate the member or • involves a member leaving the program against court orders, or professional advice
9. involves the use of a restraint of any kind (physical, chemical restraint, mechanical restraint, or seclusion of the member)

Major (critical incidents) must be reported through Iowa Medicaid’s Critical Incident Reporting and Management System by the end of the next calendar day after discovery of the incident.

A new centralized, online critical incident management system was launched in July 2023.

The application is accessed through IMPA.

For access to this application within IMPA or to see the full Critical Incident Report User Guide, go to IMPA launch page at https://secureapp.dhs.state.ia.us/impa/Default.aspx.

• Critical Incident Reporting FAQ (397.95 KB) .pdf

Iowa HHS, in collaboration with the Iowa Association of Community Providers (IACP), the Iowa Coalition for Integration and Employment (ICIE) and the managed care organizations (MCOs), has developed an  Employment Matrix (238.88 KB) .pdf . This tool was created to provide an easy-to-follow guide to HCBS-funded employment services and supports. The Employment Matrix also provides guidance regarding the employment service provider staff qualifications and training requirements and the processes for service authorization for employment services for both fee-for-service (FFS) and the MCOs.

Iowa HHS, in partnership with employment stakeholders, has developed an  Employment First Guidebook. (2 MB) .pdf This Guidebook was created to provide case managers, care managers, service coordinators and Integrated Health Home (IHH) care coordinators with critical information, resources and tools to help them do the best possible job of assisting transition-age youth and working-age adults with disabilities they support to work.

Supported Community Living (SCL) services are provided within the member’s home and community, according to the individualized member need as identified in the member’s service plan. SCL services are intended to provide for the daily living needs of the member and are available as needed during any 24-hour period. The services are intended to develop, increase and maintain independent living-skills and include personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation and treatment services.

The Department has developed a Legally Responsible Persons and Legal Representatives of Supported Community Living (SCL) Guidance Document (206.38 KB) .pdf . This tool was created to provide an easy-to-follow guide to the delivery of SCL to minors and adults by legally responsible persons and legal representatives through the HCBS Brain Injury and Intellectual Disability Waivers.

The Department has developed a SCL provided in a Host Home Guidance Document (162.87 KB) .pdf . This tool was created to provide an easy-to-follow guide in the delivery of SCL in a Host Home through the HCBS Habilitation program and the HCBS Brain Injury and Intellectual Disability Waivers.  

The Department has developed a Frequently Asked Questions (86.33 KB) .pdf document related to SCL delivered in a Host Home. This tool was created to provide answers to the most frequently asked questions related to the delivery of SCL in a Host Home. 

The Department has developed a SCL delivered through the Remote Support Modality Policy (170.25 KB) .pdf . This policy was developed to provide an easy-to-follow guide in the delivery of SCL via remote support under the HCBS Brain Injury and Intellectual Disability Waivers.

The Department has developed a Frequently Asked Questions (FAQs) (123.25 KB) .pdf document related to Medical Day Care for Children and Adult Day Care delivered in the home. This tool was created to provide answers to the most frequently asked questions related to the delivery of Medical Day Care for Children and Adult Day Care in the home.