EMI Advisors Comments on CMS 2028 Medicaid Home and Community-Based Services Quality Measure Set
The comments below were submitted to CMS 2028 Medicaid Home and Community-Based Services Quality Measure Set (CMS-2453-NC) on May 28, 2026.
EMI Advisors LLC (EMI) and contributing partner Elevations Consultation LLC appreciate the opportunity to provide comments on the proposed 2028 Medicaid Home and Community-Based Services (HCBS) Quality Measure Set (CMS-2453-NC).
Our central message is brief. The infrastructure that enables Health Level Seven International® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®)-based reporting on case-management-derived HCBS quality measures is the same infrastructure that enables real care coordination between HCBS and primary care. Centers for Medicare & Medicaid Services (CMS)’s reporting method choices in this rule will shape whether states invest in that infrastructure or not. Recognizing FHIR-based exchange as a compliant reporting pathway, in sub-regulatory guidance, is the single most consequential step CMS can take in this rulemaking to align HCBS quality measurement with the rest of the federal quality infrastructure.
We organize our comments around the questions CMS posted in the notice: whether Long-Term Services and Supports (LTSS) measures LTSS-1 and LTSS-2 should remain mandatory; whether LTSS-3 should be included as a voluntary measure; whether states should be permitted to report Healthcare Effectiveness Data and Information Set (HEDIS) equivalents or Functional Assessment Standardized Items (FASI) measures FASI-1 and FASI-2 in place of LTSS-1 and LTSS-2, and how states should collect, calculate, and report data on these measures.
Organizational Background
EMI is a digital transformation firm with more than 15 years of experience supporting federal and state agencies in designing, governing, and implementing standards-based digital ecosystems. We have supported CMS, Office of the National Coordinator for Health Information Technology (ONC), Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ), Administration for Community Living (ACL), Administration for Children and Families (ACF), and the Veterans Affairs (VA), in advancing data standards, quality measurement, and person-centered care models. Our Chief Executive Officer (CEO), Evelyn Gallego, co-founded the HL7 Gravity Project and helped develop the electronic Long-Term Services and Supports (eLTSS) dataset that now anchors FHIR-based care plan exchange for individuals with intellectual and developmental disabilities (IDD) receiving HCBS waivers in Missouri. EMI has worked on care plan interoperability standards since the Health Information Technology for Economic and Clinical Health Act (HITECH) and has helped develop and advocate for other care planning standards, including the HL7 Multiple Chronic Conditions eCare Plan FHIR Implementation Guide (Standard for Trial Use 1), the HL7 Person-Centered Outcomes FHIR Implementation Guide (IG) [1], and the Care Plan class in USCDI v6 [2].
Duane Shumate, M.Ed., is Founder of Elevations Consultation and a subcontractor to EMI Advisors on the Missouri Department of Mental Health Division of Developmental Disabilities (DMH-DDD) eLTSS Person-Centered Service Plan (PCSP) FHIR implementation. From 2014 to 2024, Mr. Shumate served as Missouri DMH-DDD’s Director for Employment and Community Engagement and helped lead Missouri’s state-side launch of Phase 1 of the eLTSS project that is now being moved into production. Elevations Consultation has worked with HCBS state agencies and/or providers related to person-centered planning and processes in Kansas, Montana, Illinois, Maryland, and Georgia, in addition to Missouri. Mr. Shumate’s contributions to this comment reflect his personal expertise and firsthand experience as a former state employee. They do not represent the current official policy position of Missouri DMH-DDD or any state agency.
The Missouri implementation supports real-time FHIR-based exchange of the PCSP for more than 48,000 Missourians with intellectual and developmental disabilities and is, to our knowledge, the first statewide FHIR-based care plan implementation in any state Medicaid HCBS program [3].
The Measures We Address
This comment addresses three measures in the Person-Centered Planning and Coordination Domain on which the HCBS Quality Measure Set Review Workgroup and CMS reached different conclusions.
LTSS-1 (Comprehensive Assessment and Update) and LTSS-2 (Comprehensive Person-Centered Plan and Update): CMS proposes to retain both as mandatory for 2028, citing the centrality of person-centered planning to HCBS quality and states’ existing investments. The Workgroup recommended removal on the grounds of burden. CMS explicitly invites comment on this disagreement.
LTSS-3 (Shared Person-Centered Plan with Primary Care Provider): CMS proposes removal entirely, accepting the Workgroup’s finding that manual case record review was prohibitively burdensome and that scores were near the ceiling. CMS nonetheless solicits comment on whether LTSS-3, along with FASI-1 and FASI-2, should be included as a voluntary measure.
We support CMS on LTSS-1 and LTSS-2. We recommend CMS reinstate LTSS-3 as a voluntary measure and recognize FHIR-based exchange as a compliant reporting pathway for all three. We also recommend that the FHIR-based pathway be available alongside and on equal footing with the HEDIS-equivalent and FASI-1/FASI-2 alternatives that CMS already proposes to permit. The remainder of this comment lays out our analysis and recommendations.
Analysis
A. The Workgroup’s critique of the burden is accurate. It is a critique of the reporting method, not of the measure.
The Workgroup’s case for removing LTSS-1, LTSS-2, and LTSS-3 was grounded in a real and important observation: manual case record review is expensive, inconsistent across states, and produces compliance scores rather than quality insight. The representative from ADvancing States correctly noted that these measures were originally designed for managed care plans and apply awkwardly in fee-for-service contexts where case management systems were not built for structured data extraction. NASDDDS observed that LTSS-1’s elements do not align with IDD support planning practice. These critiques are accurate. State agencies directly responsible for administering HCBS programs are best positioned to detail the specific operational burden of current reporting methods, and CMS should weigh those accounts carefully.
They are not, however, critiques of the measurement of person-centered planning. They are critiques of measuring it through manual review of unstructured records. The same measures, calculated from structured FHIR-based care plan data, produce a fundamentally different burden profile and a fundamentally different data quality profile. The reporting-method question and the measure-validity question are separable, and CMS can address the first without conceding the second.
B. Missouri demonstrates that a different reporting pathway is feasible.
Missouri DMH’s Division of Developmental Disabilities has implemented real-time, FHIR-based exchange of the state’s Person-Centered Service Plan using the HL7 eLTSS FHIR Implementation Guide. The plan moves as structured data from the state’s data holdings, which include a FHIR server, through the four health information networks, to HCBS providers and clinical providers. The design of this infrastructure enables the creation and sharing of standardized, digital, person-centered information for more than 48,000 individuals with IDD served by the DMH-DDD. The implementation began with a 2020 ONC Leading Edge Acceleration Projects (LEAP) grant and is now operating in production under state general revenue funding.
We want to be precise about what this means for HCBS quality measure reporting. Missouri is not producing LTSS-1, LTSS-2, or LTSS-3 reports from the FHIR infrastructure today. The immediate use case has been care coordination across the IDD provider network. The strategic intent behind the investment, however, included future reporting of digital quality measures. As one of us, Mr. Shumate*, can share from having been involved as a state employee in supporting the business case and launch of the eLTSS project, the decision to use FHIR for the eLTSS use case was made in part because FHIR infrastructure and the eLTSS data standards are scalable, extensible, and sustainable over time, including for digital quality measure reporting as that capability matures. Missouri’s broader Digital Backbone initiative, articulated in the state’s Rural Health Transformation Program project narrative, includes significant investment in FHIR-based exchange, United States Core Data for Interoperability (USCDI) alignment, interoperability for community-based access, and electronic health record (EHR) modernization to support both program operations and quality reporting [4].
*This reflects Mr. Shumate’s personal knowledge from his time in his state role and is not a statement of Missouri’s current position on the LTSS measures in this rulemaking.
C. The single most important point: care-coordination and quality-reporting infrastructure are the same infrastructure
The infrastructure required to report case-management-derived quality measures via FHIR is the same infrastructure that enables care coordination at the HCBS-primary care interface. Both depend on the care plan being available as structured, queryable data to authorized care team members.
LTSS-3 illustrates this most clearly. Under manual workflows, “shared person-centered plan with primary care provider” meant faxing a document and attesting that it was sent. Under FHIR-based exchange, a primary care physician retrieves the current care plan from the state’s health information network through their EHR, just as they may retrieve a laboratory result. The measurement signal (was the plan retrieved?) and the care coordination outcome (does the primary care physician have the plan?) become the same event. The ceiling effect that drove the Workgroup’s removal recommendation goes away because the data source is Application Programming Interface (API) transaction logs rather than caseworker attestation.
This unification matters for the broader set of measures as well. Better care plan exchange between HCBS and primary care affects facility admission rates (LTSS-6, LTSS-7, LTSS-8), chronic condition management, and access to mental health services, all of which appear elsewhere in the proposed measure set. A voluntary, FHIR-enabled LTSS-3 functions as a leading indicator for measures CMS is already committed to. Removing it altogether eliminates a measurement signal that would otherwise track the very interoperability work that improves the rebalancing outcomes the measure set already prizes.
D. Recognizing FHIR-based reporting aligns HCBS quality measurement with the rest of the federal quality ecosystem.
The direction of federal quality infrastructure is unambiguous. National Committee for Quality Assurance (NCQA) has committed to a fully HEDIS by Measurement Year 2030, with the hybrid medical record review method phased out by Measurement Year 2029 [5]. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires regulated payers to implement FHIR-based Patient Access, Provider Access, and Payer-to-Payer APIs covering care plan data. The ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model launching in July 2026 requires bidirectional health information exchange and FHIR-based outcomes submission.
Holding HCBS quality measurement to a paper-and-fax reporting paradigm while the rest of CMS’s quality infrastructure moves to FHIR creates avoidable misalignment. It also creates a perverse incentive. States that have built FHIR infrastructure, including Missouri, will face a choice between two bad options: maintain duplicative manual review processes purely for measure reporting (paying twice for the same data), or defer the FHIR-based reporting use case indefinitely. Either outcome reduces the return on existing federal and state interoperability investments and weakens the policy incentive for other states to follow Missouri’s lead. A simple recognition of FHIR-based pathways in sub-regulatory guidance prevents this.
E. FHIR-based reporting also makes the proposed stratification requirements achievable.
CMS proposes to require geographic stratification of LTSS-1, LTSS-2, LTSS-6, LTSS-7, and LTSS-8 by July 9, 2028, and recommends moving toward Rural-Urban Commuting Area Codes. Stratification at this scale is functionally impossible under manual case record review without expanding sample sizes and review burden in proportion to the number of strata. It is straightforward under structured FHIR data, where stratification is a query against fields already in the resource. This is an additional reason to make the FHIR-based pathway explicit now, before stratification requirements take effect.
F. The HEDIS-equivalent and FASI alternatives are compatible with, not substitutes for, a FHIR-based reporting pathway.
CMS solicits comment on permitting states to report HEDIS equivalents of LTSS-1 and LTSS-2, and on permitting states to report FASI-1 and FASI-2 in place of LTSS-1 and LTSS-2. We support both options, with one clarification.
The HEDIS-equivalent and FASI alternatives describe what is measured. The FHIR-based reporting pathway describes how the underlying data is captured, exchanged, and submitted. These are different questions, and the answers are not in tension. A state should be able to report LTSS-1, the LTSS-1 HEDIS equivalent, or FASI-1, and should be able to do so through structured FHIR-based data submission, whichever measure specification it uses.
The FASI option deserves particular attention because FASI and the eLTSS data standards share a single origin. Both were developed under the CMS Testing Experience and Functional Tools (TEFT) demonstration [6], which ran from 2014 to 2018, and produced, among other outputs, the functional assessment items known as FASI and the dataset that became the eLTSS FHIR IG. The two were architected together as part of a single CMS-ONC effort to enable interoperable person-centered planning and assessment in HCBS.
The practical consequence for CMS's current rulemaking is that a state implementing the eLTSS FHIR IG, as Missouri has done, is already operating on infrastructure designed to carry FASI data. Recognizing FHIR-based reporting as a compliant pathway for FASI-1 and FASI-2, specifically, in addition to LTSS-1, LTSS-2, and their HEDIS equivalents, completes a measurement and reporting architecture that CMS and ONC have already invested in building. We encourage CMS to make this alignment explicit in sub-regulatory guidance so that states do not read the measure alternatives as separable from the digital reporting question.
Recommendations
On LTSS-1 and LTSS-2 (Mandatory Status)
Retain LTSS-1 and LTSS-2 as mandatory for 2028, as proposed. Person-centered planning is foundational to HCBS quality, and removing both measures would leave a visible gap in the measure set.
Publish sub-regulatory guidance (i.e., a CMCS Informational Bulletin or technical guidance document) establishing that states implementing FHIR-based care plan data exchange may satisfy LTSS-1 and LTSS-2 reporting requirements through structured FHIR data submission. The guidance should explicitly recognize the HL7 eLTSS FHIR Implementation Guide and the FASI FHIR profiles (under the HL7 Post-Acute Care InterOperability (PACIO) Functional Status Implementation Guide) as compliant data sources, and describe acceptable evidence (such as conformance with the eLTSS IG and API transaction logs) that states can use to demonstrate compliance [7].
Begin planning for the Medicaid Data Collection Tool (MDCT) to accept structured FHIR-based submissions for LTSS-1 and LTSS-2, starting with an optional pathway. This establishes the pipeline and surfaces implementation issues before any future mandate.
Convene IDD-specific stakeholders, including NASDDDS, state IDD agencies, beneficiary advocates, providers and provider associations, researchers, measure developers, and other subject matter experts to develop core and supplemental elements designed for IDD support planning which serve as the numerator in Performance Rates 1 and 2. The existing current core and supplemental elements are inconsistent with IDD support planning workflows. This is correctable without removing the measures.
On LTSS-3 (Reinstate as Voluntary)
Reinstate LTSS-3 as a voluntary measure for 2028 rather than removing it entirely. The Workgroup’s removal recommendation was correct about manual record review being unworkable, but full removal eliminates the measurement signal and the policy incentive to build the FHIR-based exchange infrastructure that solves both the reporting problem and the underlying care coordination problem.
Recognize FHIR-based exchange (specifically via the HL7 eLTSS FHIR IG) as a permissible reporting method for LTSS-3, with API transaction logs as acceptable evidence in place of manual case record review.
Rather than committing to a specific date for mandatory status, publish the criteria CMS will use to determine when LTSS-3 should return to mandatory status. Suggested criteria: a threshold number of states with operational FHIR-based care plan exchange; demonstrated reliability of API-log-based measure calculation; and alignment with NCQA Digital HEDIS milestones. This approach preserves CMS’s timing flexibility while making the forward path more visible to states making infrastructure decisions today.
On the HEDIS-Equivalent and FASI Alternatives
Adopt the HEDIS-equivalent and FASI-1/FASI-2 options that CMS proposes to permit, and clarify that the FHIR-based reporting pathway is available across all measure variants. Questions regarding what is measured (LTSS, HEDIS equivalent, or FASI) and how it is reported (manual review, MDCT self-report, or structured FHIR submission) should be addressed independently in CMS guidance.
On How States Collect, Calculate, and Report Data (Responsive to CMS’s Solicited Question)
Explicitly state in the final rule or accompanying guidance that FHIR-based data submission is a recognized reporting pathway for case-management-derived HCBS quality measures, alongside the existing MDCT and Transformed Medicaid Statistical Information System pathways. This is the single most actionable step CMS can take in this rulemaking to align HCBS quality measurement with broader federal interoperability policy.
Coordinate with ONC on technical guidance so that the FHIR-based reporting pathway aligns with USCDI versioning (including the Care Plan class in USCDI v6), ONC Health IT Certification criteria, and Trusted Exchange Framework and Common Agreement (TEFCA)-based exchange.
Issue an Informational Bulletin in advance of the 2028 reporting cycle (we suggest no later than the first quarter of 2028) so states have time to operationalize the FHIR-based pathway before the September 1, 2028, MDCT reporting window closes.
Closing Remarks
The Workgroup was right that manual case record review is unworkable for LTSS-1, LTSS-2, and LTSS-3. CMS was right that person-centered planning is too fundamental to HCBS quality to abandon as a measurement domain. Both can be true. State commenters raising administrative burden concerns are describing a real problem with the current reporting infrastructure. We are respectfully offering a different resolution than removal for consideration: Retain LTSS-1 and LTSS-2 as mandatory, reinstate LTSS-3 as voluntary, and recognize FHIR-based exchange as a compliant reporting pathway across all three. This policy choice aligns HCBS quality measurement with the broader direction of federal quality infrastructure and strengthens the investment case for interoperability infrastructure that improves care coordination outcomes for the people served by HCBS programs and the reporting that’s needed to measure quality and outcomes.
References
Health Level Seven International / Patient Care Work Group. (2026). Person-Centered Outcomes (PCO) Implementation Guide (Version 1.0.0, STU 1). Access at https://hl7.org/fhir/us/pco/STU1/en/
Office of the National Coordinator for Health Information Technology. (n.d.). Care plans. Interoperability Standards Platform. Access at https://isp.healthit.gov/uscdi-data-class/care-plans#uscdi-v6
Gallego, E. (2026, April 21). Making the person-centered care plan the next frontier in interoperability. EMI Advisors LLC. Access at https://www.emiadvisors.net/news/making-the-person-centered-care-plan-the-next-frontier-in-interoperability
Missouri Department of Social Services. (2025, December). Missouri Rural Health Transformation Program project narrative. Access at https://mydss.mo.gov/media/pdf/rhtp-application-narrative
National Committee for Quality Assurance. (n.d.). What you need to know. Digital Quality Hub. Access at https://www.ncqa.org/digital-quality-transition/what-you-need-to-know/
Centers for Medicare & Medicaid Services. (n.d.). Testing experience & functional tools. Medicaid.gov. Access at https://www.medicaid.gov/medicaid/home-community-based-services/home-and-community-based-services-hcbs-quality/testing-experience-functional-tools
HL7 Patient Care Work Group. (2021, November 3). PACIO Functional Status Implementation Guide (Version 1.0.0, STU 1) Health Level Seven International. Access at https://build.fhir.org/ig/HL7/fhir-pacio-functional-status/
