On March 22, 2019, the Centers for Medicare & Medicaid Services (CMS) clarified that Medicaid home- and community-based services (HCBS) settings assumed to be "presumptively institutional" will be subject to heightened scrutiny. Presumptively institutional settings are those that have the qualities of an institution and/or isolate beneficiaries receiving HCBS. Medicaid will not cover HCBS provided in institutional settings. The goal of heightened scrutiny is to determine if the setting overcomes the presumption that it is an institution, or if remediation is needed. CMS defines HCBS settings that have the qualities of an institutions as: settings that are located . . .