Pursuant to the authority of 42 CFR 441.301(c)(5)(v) in the final HCBS regulation and at 441.530(a)(2)(v), the Iowa Department of Health and Human Services (HHS) has an obligation to identify settings that are presumed institutional and submit the settings to the Centers for Medicare and Medicaid Services (CMS) to undergo a process of “heightened scrutiny”. Heightened scrutiny is used by states to rebut or overcome the presumption that a particular setting has the qualities of an institution.

Iowa Medicaid’s Quality Improvement Organization (QIO) has identified the settings as summarized below as requiring heightened scrutiny review.


Five providers were identified as requiring a CMS heightened scrutiny review. Those five providers may operate several settings. One provider had agency-wide, systemic issues related to HCBS settings requirements and the rest had issues in specific settings. All five have since demonstrated compliance with HCBS settings requirements or quit providing HCBS waiver or Habilitation services in the non-compliant setting. However, since these are new providers or new issues, the provider had not demonstrated compliance before July 1, 2020 and is required to be put forward for heightened scrutiny review by CMS.

Fiscal Impact

There is no fiscal impact related to the changes proposed.

Public Review and Comments

A copy of this notice is available at the following link: https://hhs.iowa.gov/sites/default/files/Public%20Notice_Heightened%20Sc....

To reach all stakeholders, non-electronic copies will be made available for review at the HHS Field Offices.

Written comments concerning this notice or the proposed amendments may be addressed to: Brian Wines, Iowa Department of Health and Human Services, Iowa Medicaid, 1305 East Walnut Street, Des Moines, Iowa 50319, or via email at HCBSSettings@dhs.state.ia.us.

Please indicate “Heightened Scrutiny” in the subject line of the email.

All comments must be received by: March 2, 2023

Additional Attachments

Submitted by:

Elizabeth Matney

Medicaid Director

Iowa Medicaid

Iowa Department of Health & Human Services