CMS proposed on Nov. 5, 2026, to ease several federal rules that apply to intermediate care facilities for people with intellectual disabilities, including part of the Medicaid payment-transparency reports those facilities now face. The Centers for Medicare & Medicaid Services fact sheet for the Cutting Administrative Requirements for Excellence in Patient Care proposed rule (CMS-3484-P) and the public-inspection draft scheduled for Federal Register publication on Nov. 10 spell out the ICF/IID pieces.
What the CARE rule would change for ICFs/IID
CMS says it reviewed Conditions of Participation for 21 provider types and estimates the package would save about $320 million a year and return more than 3.26 million staff hours. For ICFs/IID alone, the agency projects average annual savings of about $6.6 million, or $66 million over 10 years.
As of January 2026, CMS counts 5,215 ICFs/IID with 55,321 beds. Under the proposal, those facilities would see:
- Staff COVID-19 "educate and offer" rules dropped. CMS would remove requirements that ICFs/IID educate staff about the COVID-19 vaccine, offer it to them, and document those steps. Client-facing vaccine education and offer rules would be streamlined rather than eliminated.
- Outside-window / natural-light mandate removed. CMS would drop the requirement that patient or client care areas have access to natural light and ventilation through exterior windows or doors for ICFs/IID (and for hospitals, critical access hospitals, nursing homes and hospice inpatient units with similar rules).
- Life Safety Code updates. Facilities would move to newer National Fire Protection Association Life Safety and Health Care Facilities Code editions, with authority for CMS to allow compliance with specified newer provisions by waiver.
Payment transparency: what stays, what goes
The biggest money-and-reporting fight for I/DD institutional providers sits in the Medicaid institutional payment-transparency rules finalized in the 2024 Minimum Staffing Standards rule (42 CFR 442.43 and related managed-care text).
CMS proposes to rescind state reporting, at the facility level, of:
- the share of Medicaid nursing-facility payments spent on direct care worker compensation,
- the share of Medicaid nursing-facility payments spent on support-staff compensation, and
- the share of Medicaid ICF/IID payments spent on support-staff compensation.
CMS would keep the requirement that states report the share of Medicaid ICF/IID payments spent on direct care worker compensation. The draft argues nursing homes already generate enough federal payroll and census data to approximate wage-pass-through metrics, while ICFs/IID do not, and that ICF/IID payments are mostly Medicaid-only, so the tracking burden is lower.
The same section asks for public comment on how to ease direct care shortages inside nursing facilities and ICFs/IID — a rare federal solicitation aimed squarely at the institutional I/DD workforce, not only nursing homes.
Comment timing
Comments are due 60 days after Federal Register publication. The public-inspection header schedules publication for Nov. 10, 2026, which would put the window into early January 2027 if that date holds. Comments should cite file code CMS-3484-P.
What this means for providers and DSPs
ICF/IID operators and QIDPs should read the payment-transparency section carefully: support-staff reporting would go away, but direct care wage reporting for ICFs/IID would stay. That is a different path than nursing facilities, which would lose both metrics under the proposal. Agencies that run both nursing homes and ICFs/IID will face split compliance tracks if the rule is finalized as drafted.
Frontline DSPs and other direct care staff in ICFs/IID would no longer be covered by the federal staff COVID educate-and-offer paperwork CMS is proposing to scrap, but client protections and other Conditions of Participation remain. The workforce comment solicitation is a chance for ICF providers, unions and family groups to put institutional staffing shortages on the same federal record that already tracks HCBS wage-pass-through fights.
Nothing in the CARE package finalizes rates or staffing ratios. It is a proposed deregulatory package. Watch the Nov. 10 Federal Register text for the exact comment deadline and for any ICF/IID language that differs from the public-inspection PDF.