The Home Care Association of Florida (HCAF) has submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) regarding the proposed 2028 Home and Community-Based Services (HCBS) Quality Measure Set (CMS-2453-NC), raising significant concerns about the operational, workforce, and financial realities facing Florida’s Medicaid home care provider community.

The proposed HCBS Quality Measure Set is part of CMS’ broader effort to standardize quality measurement across Medicaid-funded HCBS programs nationwide. The initiative stems from the Ensuring Access to Medicaid Services rule finalized in 2024, which requires states to begin reporting HCBS quality data in 2028.

In comments submitted to CMS Administrator Dr. Mehmet Oz, HCAF expressed support for the agency’s goal of improving quality, accountability, patient outcomes, and person-centered care in Medicaid home care programs. However, the association cautioned that the success of the initiative will depend heavily on whether implementation reflects the operational realities confronting providers on the ground.

Florida Workforce Crisis Threatens Access to Care

HCAF’s comments highlight Florida’s longstanding and worsening home care workforce shortage as one of the most significant barriers to achieving the proposed quality goals.

Despite having the nation’s second-largest population of adults age 65 and older, Florida ranks last in the availability of home health and personal care aides, with only 17 aides per 1,000 seniors compared to a national average of 65 aides per 1,000 seniors.

According to HCAF, these shortages are already producing serious consequences for Medicaid beneficiaries and families across the state, including:

• Inability to fully staff authorized services
• Delays in initiating care
• Increased hospitalization and readmission risks
• Greater reliance on family caregivers
• Increased risk of institutionalization

HCAF emphasized that many of the proposed quality outcomes — including access, continuity, and patient experience — are directly dependent on workforce availability.

“Without sufficient staffing capacity, providers cannot consistently meet these expectations — regardless of intent or effort,” the association wrote.

Concerns Over Unfunded Mandates

HCAF also warned that the proposed quality framework could function as an unfunded mandate unless reimbursement rates are addressed.

Florida Medicaid home care reimbursement rates remain among the lowest in the nation, limiting providers’ ability to increase wages, recruit caregivers, expand capacity, or invest in additional infrastructure.

At the same time, CMS is proposing new expectations that may require providers to implement additional training, documentation, care coordination, reporting, and patient experience oversight processes.

HCAF urged CMS to recognize that quality improvement efforts cannot be separated from reimbursement adequacy and workforce sustainability.

“Quality measurement must be paired with sustainable policy and funding strategies to be effective,” HCAF stated in its comments.

Administrative Burden and Operational Challenges

Although the proposed measures would be reported at the state level, HCAF noted that much of the implementation burden will ultimately fall on providers.

The association cautioned that agencies will likely face increased expectations related to:

• Data collection and validation
• Documentation alignment
• Performance monitoring
• Survey participation
• Managed care reporting requirements
• Pay-for-performance initiatives

HCAF further noted that these requirements would be layered onto existing administrative burdens, including Florida’s Electronic Visit Verification (EVV) system, which providers continue to report has resulted in technical claim denials, delayed payments, and significant operational strain unrelated to direct patient care.

Risk of Reduced Provider Participation

HCAF also warned CMS about the risk of unintended consequences if implementation moves forward without adequate safeguards or funding support.

The association cautioned that additional administrative and quality reporting burdens could contribute to:

• Reduced provider participation in Medicaid
• Increased service gaps for medically complex patients
• Greater provider consolidation
• Reduced patient choice
• Additional barriers to serving hard-to-staff populations

HCAF stressed that providers operating in workforce-constrained environments should not be unfairly penalized for systemic labor shortages beyond their control.

HCAF Recommendations to CMS

In its comments, HCAF urged CMS to take several steps to support successful implementation of the HCBS Quality Measure Set, including:

1. Aligning quality expectations with reimbursement adequacy and workforce realities
2. Providing realistic implementation timelines for states and providers
3. Minimizing duplicative administrative reporting requirements
4. Recognizing workforce shortages as a structural factor affecting performance measures
5. Providing technical assistance and implementation support to states and providers

About the HCBS Quality Measure Set

The HCBS Quality Measure Set is intended to create a nationally standardized framework for evaluating quality and outcomes in Medicaid-funded home and community-based services programs.

Under the Medicaid Access Rule finalized in May 2024, states will be required to report HCBS quality data beginning in 2028. CMS is currently soliciting public comments on proposed mandatory and voluntary measures, reporting methodologies, stratification requirements, and implementation timelines.

CMS is required to finalize the HCBS Quality Measure Set by December 31, 2026.