The HCBS Settings Rule: the rights it gives, in plain language

People who receive Medicaid Home and Community-Based Services have rights written into federal regulation: privacy, visitors, food, a schedule of one's own. What the rule says and when a right may be limited.

Rights · Updated 5 October 2026 · 4 minute read

Home and Community-Based Services, usually shortened to HCBS, are Medicaid-funded supports that help people with disabilities and older adults live in their own homes and communities and not in institutions. In January 2014 the federal Centers for Medicare and Medicaid Services issued a regulation commonly called the HCBS Settings Rule. It says what a place must be like for Medicaid to pay for these services there, and it does so mostly by listing rights that belong to the person receiving them. States were required to be in full compliance by 17 March 2023.

The rule is found at title 42 of the Code of Federal Regulations, section 441.301(c)(4) and (5), with matching sections for other Medicaid programmes. What follows is a plain summary.

Rights in every setting

These apply wherever HCBS are delivered, including a day programme, a workplace and a home.

• Being part of the community. The setting must support full access to the wider community: the chance to look for paid work alongside people without disabilities, to take part in community life, to control personal money and belongings, and to use community services as anyone else would.
• Choosing the setting. The person chooses where to live and receive services from among options, and the options must include settings that are not only for people with disabilities. The choice is recorded in the person-centered service plan.
• Privacy, dignity and respect, and freedom from coercion and restraint.
• Independence in making life choices, including daily activities, physical surroundings and whom to spend time with.
• Choice about services and supports, and about who provides them.

Additional rights where the provider owns or controls the home

Group homes, adult residential facilities and similar places, where the provider owns or controls the housing, must meet further conditions. Each individual living there has:

• A lease or other legally enforceable agreement, with the same protection against eviction that other tenants have under local landlord and tenant law, or an equivalent written agreement where that law does not apply.
• Privacy in the bedroom or living unit, including a door that the individual can lock, with only appropriate staff holding keys.
• A choice of roommate where a room is shared.
• Freedom to furnish and decorate the bedroom or living unit, within the lease or agreement.
• Control of one's own schedule and activities.
• Access to food at any time.
• Visitors of one's own choosing, at any time.
• A setting that is physically accessible to the individual.

When a right may be limited

The rights in the second list, apart from physical accessibility, can be modified for a particular individual, and only under strict conditions. A house rule that applies to everyone, such as fixed visiting hours or a locked kitchen, does not meet them. A modification must be justified for that one person and written into the person-centered service plan, which has to record:

1. A specific, individually assessed need.
2. The positive interventions and supports used before any modification.
3. The less intrusive methods that were tried and did not work.
4. A clear description of the modification, in proportion to the assessed need.
5. Regular collection and review of data to measure whether it is working.
6. Set time limits for reviewing whether it is still needed or can end.
7. The informed consent of the individual.
8. An assurance that the intervention will cause the individual no harm.

In short, a restriction has to be about one person's assessed need, has to be a last resort, has to be agreed to, and has to be reviewed. Convenience for staff is not a reason the rule accepts.

The person-centered plan

The same regulation requires that services be planned through a process the individual leads as far as possible. The individual chooses who takes part, the meeting is held at a time and place convenient to the individual, information is given in plain language and in a form the individual can use, and the plan reflects the individual's own goals and preferences, not only needs identified by others. The finished plan is agreed to in writing by the individual and is reviewed at least once a year, or sooner if circumstances change or the individual asks.

Settings that cannot qualify

Nursing facilities, institutions for mental diseases, intermediate care facilities for individuals with intellectual disabilities and hospitals are not home and community-based settings. Other places that tend to isolate people from the wider community are presumed not to qualify unless a state shows otherwise through a closer review.

If a right is not being respected

• Raise it with the provider, in writing where possible, and keep a copy.
• Tell the service coordinator or case manager, and ask for a planning meeting. The plan is where rights and any limits on them must be written down.
• Use the state's complaint or grievance process. Every state Medicaid HCBS programme has one, and a decision to reduce or deny services can be appealed through a fair hearing.
• Contact the state's Protection and Advocacy organisation. Every state and territory has one, federally funded and independent of service providers, and its help is free. A long-term care ombudsman can also help residents of licensed homes.