From Policy to Practice: Socio-Ecological Challenges in Implementing the Home and Community Based Settings Rule

The 2014 U.S. Centers for Medicare and Medicaid Services “Settings Rule,” which took effect in 2023, restricts Home and Community Based Services funding for adults with intellectual disabilities to small integrated settings and person-centered supports. The Settings Rule responds to the fact that community services, mandated by the Americans with Disabilities Act (ADA) and the Supreme Court Olmstead ruling, while integrated physically, often operate as institutions. The Settings Rule is meant to create integration and individualization. I argue that the regulation cannot, on its own, accomplish these goals. The deinstitutionalization movement has had mixed outcomes—and without change across multiple socio-ecological systems, the Settings Rule will also deliver mixed results.