[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4131 Introduced in House (IH)]
<DOC>
117th CONGRESS
1st Session
H. R. 4131
To amend title XIX of the Social Security Act to expand access to home
and community-based services (HCBS) under Medicaid, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 24, 2021
Mrs. Dingell (for herself, Mr. Pallone, Ms. Schakowsky, and Ms. Matsui)
introduced the following bill; which was referred to the Committee on
Energy and Commerce
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to expand access to home
and community-based services (HCBS) under Medicaid, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Better Care Better
Jobs Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
TITLE I--EXPANDING ACCESS TO MEDICAID HOME AND COMMUNITY-BASED SERVICES
Sec. 101. HCBS infrastructure improvement planning grants.
Sec. 102. HCBS Infrastructure Improvement Program.
Sec. 103. Reports; technical assistance; other administrative
requirements.
Sec. 104. Quality measurement and improvement.
TITLE II--OTHER PROVISIONS
Sec. 201. MACPAC study and report on Appendix K emergency home and
community-based services (HCBS) 1915(c)
waivers.
Sec. 202. Making permanent the State option to extend protection under
Medicaid for recipients of home and
community-based services against spousal
impoverishment.
Sec. 203. Permanent extension of Money Follows the Person Rebalancing
demonstration.
SEC. 2. DEFINITIONS.
In this Act:
(1) Appropriate committees of congress.--The term
``appropriate committees of Congress'' means the Committee on
Energy and Commerce of the House of Representatives, the
Committee on Education and Labor of the House of
Representatives, the Committee on Finance of the Senate, the
Committee on Health, Education, Labor and Pensions of the
Senate, and the Special Committee on Aging of the Senate.
(2) Direct care worker; direct care workforce.--The terms
``direct care worker'' and ``direct care workforce'' mean--
(A) a direct support professional;
(B) a personal care attendant;
(C) a direct care worker;
(D) a home health aide; and
(E) any other relevant worker, as determined by the
Secretary.
(3) Eligible individual.--The term ``eligible individual''
means an individual who is eligible for and enrolled for
medical assistance under a State Medicaid program and includes
an individual who becomes eligible for medical assistance under
a State Medicaid program when removed from a waiting list.
(4) Health plan.--The term ``health plan'' means a group
health plan or health insurance issuer (as such terms are
defined in section 2791 of the Public Health Service Act (42
U.S.C. 300gg-91)).
(5) HCBS program improvement state.--The term ``HCBS
program improvement State'' means a State with an HCBS
infrastructure improvement plan approved by the Secretary under
section 101(d).
(6) Home and community-based services.--The term ``home and
community-based services'' means any of the following (whether
provided on a fee-for-service, risk, or other basis):
(A) Home health care services authorized under
paragraph (7) of section 1905(a) of the Social Security
Act (42 U.S.C. 1396d(a)).
(B) Personal care services authorized under
paragraph (24) of such section.
(C) PACE services authorized under paragraph (26)
of such section.
(D) Home and community-based services authorized
under subsections (b), (c), (i), (j), and (k) of
section 1915 of such Act (42 U.S.C. 1396n), such
services authorized under a waiver under section 1115
of such Act (42 U.S.C. 1315), and such services
provided through coverage authorized under section 1937
of such Act (42 U.S.C. 1396u-7).
(E) Case management services authorized under
section 1905(a)(19) of the Social Security Act (42
U.S.C. 1396d(a)(19)) and section 1915(g) of such Act
(42 U.S.C. 1396n(g)).
(F) Rehabilitative services, including those
related to behavioral health, described in section
1905(a)(13) of such Act (42 U.S.C. 1396d(a)(13)).
(G) Such other services specified by the Secretary.
(7) Institutional setting.--The term ``institutional
setting'' means--
(A) a skilled nursing facility (as defined in
section 1819(a) of the Social Security Act (42 U.S.C.
1395i-3(a)));
(B) a nursing facility (as defined in section
1919(a) of such Act (42 U.S.C. 1396r(a)));
(C) a long-term care hospital (as described in
section 1886(d)(1)(B)(iv) of such Act (42 U.S.C.
1395ww(d)(1)(B)(iv)));
(D) an institution (or distinct part thereof)
described in section 1905(d) of such Act (42 U.S.C.
1396d(d)));
(E) an institution (or distinct part thereof) which
is a psychiatric hospital (as defined in section
1861(f) of such Act (42 U.S.C. 1395x(f))) or that
provides inpatient psychiatric services in another
residential setting specified by the Secretary;
(F) an institution (or distinct part thereof)
described in section 1905(i) of such Act (42 U.S.C.
1396d(i)); and
(G) any other relevant facility, as determined by
the Secretary.
(8) Medicaid program.--The term ``Medicaid program'' means,
with respect to a State, the State program under title XIX of
the Social Security Act (42 U.S.C. 1396 et seq.) (including any
waiver or demonstration under such title or under section 1115
of such Act (42 U.S.C. 1315) relating to such title).
(9) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(10) State.--The term ``State'' has the meaning given such
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
TITLE I--EXPANDING ACCESS TO MEDICAID HOME AND COMMUNITY-BASED SERVICES
SEC. 101. HCBS INFRASTRUCTURE IMPROVEMENT PLANNING GRANTS.
(a) In General.--Not later than 12 months after the date of
enactment of this Act, the Secretary shall award planning grants to
States for the purpose of expanding access to home and community-based
services and strengthening the direct care workforce that provides such
services by developing HCBS infrastructure improvement plans that meet
the requirements of subsections (b) and (c).
(b) Content Requirements.--In order to meet the requirements of
this subsection, an HCBS infrastructure improvement plan shall include,
with respect to a State, the following:
(1) Existing medicaid hcbs landscape.--
(A) Eligibility and benefits.--A description of--
(i) the existing standards, pathways, and
methodologies for eligibility for home and
community-based services, including limits on
assets and income;
(ii) the home and community-based services
available under the State Medicaid program; and
(iii) utilization management standards for
such services.
(B) Access.--An assessment of the extent to which
home and community-based services are available to
eligible individuals in the State, including--
(i) estimates of the number of eligible
individuals who are on a waitlist for such
services;
(ii) estimates of the number of individuals
who would be eligible individuals but are not
enrolled in the State Medicaid program or on a
waitlist for such services;
(iii) a description of the home and
community-based services not available under
the State Medicaid program;
(iv) a description of the populations for
which the State is unable to provide home and
community-based services under the State
Medicaid program that are provided under the
Medicaid programs of other States; and
(v) a description of barriers to accessing
home and community-based services identified by
eligible individuals and families of such
individuals.
(C) Utilization.--An assessment of the utilization
of home and community-based services in the State.
(D) Service delivery structures.--A description of
the service delivery structures for providing home and
community-based services in the State, including with
respect to the use and models of self-direction, the
provision of services by agencies, the ownership of
service provider agencies, the use of managed care
versus fee-for-service to provide such services, and
the supports provided for family caregivers.
(E) Workforce.--A description of the
characteristics of the direct care workforce that
provides home and community-based services, including
the number of full- and part-time direct care workers,
the average and range of direct care worker wages, the
benefits provided to direct care workers, the turnover
and vacancy rates of direct care worker positions, the
membership of direct care workers in labor
organizations or professional organizations, and the
race, ethnicity, and gender of such workforce.
(F) Payment rates.--A description of the payment
rates for home and community-based services, including
when such rates were last updated, an assessment of the
extent to which authorized services are not delivered
as a result of such rates being insufficient, and the
extent to which payment rates are passed through to
direct care worker wages.
(G) Quality.--A description of how the quality of
home and community-based services is measured and
monitored, including how the State uses beneficiary and
family caregiver experience of care surveys to assess
the quality of home and community-based services
provided by the State.
(H) Long-term services and supports provided in
institutional settings.--A description of--
(i) the extent to which eligible
individuals receive long-term services and
supports in institutional settings in the
State; and
(ii) the populations provided such services
and supports.
(I) HCBS share of overall medicaid ltss spending.--
For the most recent fiscal year for which data is
available, the percentage of expenditures made by the
State under the State Medicaid program for long-term
services and supports that are for home and community-
based services.
(J) Demographic data.--Each assessment required
under subparagraphs (B) and (C), and the description
required under subparagraph (H)(ii) shall include, to
the extent available, data disaggregated by disability
status, age, income, gender, race, ethnicity,
geography, primary language, sexual orientation, gender
identity, and type of service setting.
(2) Annual measures and reports.--A description of the
State plan for--
(A) annually measuring and reporting on--
(i) the availability and utilization of
home and community-based services;
(ii) the characteristics of the direct care
workforce that provides home and community-
based services and the race, ethnicity, and
gender of such workforce;
(iii) changes in payment rates for home and
community-based services; and
(iv) progress with respect to
implementation of the activities, benchmarks,
and improvement activities provided under
subsection (jj) of section 1905 of the Social
Security Act (as added under section 102); and
(B) collecting and reporting disaggregated data by
disability status, age, income, gender, race,
ethnicity, geography, primary language, sexual
orientation, gender identity, and type of service
setting for the information required by clause (i) of
subparagraph (A).
(3) Implementation and goals for hcbs improvements.--A
description of how the State will--
(A) conduct the activities, benchmarks, and
improvement activities provided under subsection (jj)
of section 1905 of the Social Security Act (as added
under section 102), including how the State plans to
meet the benchmarks described in paragraph (5) of such
subsection and, if applicable, the additional HCBS
improvement efforts described in paragraph (3) of such
subsection;
(B) identify and reduce barriers to accessing home
and community-based services, including for individuals
in institutional settings, individuals experiencing
homelessness or housing instability, and individuals in
regions with low or no access to such services;
(C) identify and reduce disparities in access to,
and utilization of, home and community-based services
by disability status, age, income, gender, race,
ethnicity, geography, primary language, sexual
orientation, gender identity, and type of service
setting;
(D) coordinate implementation of the HCBS
infrastructure improvement plan among the State
Medicaid agency, agencies serving individuals with
disabilities, the elderly, and other relevant State and
local agencies; and
(E) facilitate access to related supports by
coordinating with State and local agencies and
organizations that provide housing, transportation,
employment, nutrition, and other services and supports.
(c) Development and Submission Requirements.--In order to meet the
requirements of this subsection, an HCBS infrastructure improvement
plan shall--
(1) be developed with input from stakeholders through a
public notice and comment process that includes consultation
with eligible individuals who are recipients of home and
community-based services, family caregivers of such recipients,
providers, health plans, direct care workers, chosen
representatives of direct care workers, and aging, disability,
and workforce advocates;
(2) be submitted for approval by the Secretary not later
than 24 months after the date on which the State was awarded
the planning grant under this section; and
(3) be publicly available in the final version submitted to
the Secretary on a State Internet website.
(d) Approval; Publication.--
(1) In general.--The Secretary shall approve an HCBS
infrastructure improvement plan if the plan--
(A) is complete; and
(B) provides assurances to the satisfaction of the
Secretary that the State will meet the requirements of
the HCBS Infrastructure Improvement Program established
under subsection (jj) of section 1905 of the Social
Security Act (42 U.S.C. 1396d), as added by section
102, and achieve the benchmarks for improvement
established by such program.
(2) Publication.--The Secretary, acting through the
Administrator of the Centers for Medicare & Medicaid Services,
shall make publicly available on an Internet website--
(A) the final version of each approved HCBS
infrastructure improvement plan; and
(B) in the case of any HCBS infrastructure
improvement plan submitted for approval that is not
approved--
(i) the submitted plan;
(ii) the decision not approving such plan;
and
(iii) information relating to why the plan
was not approved.
(e) Continuation of American Rescue Plan Act Increased FMAP for
HCBS for States Awarded a Planning Grant.--
(1) FMAP.--
(A) In general.--Notwithstanding subsections (b) or
(ff) of section 1905 of the Social Security Act (42
U.S.C. 1396d), subject to subparagraph (C), in the case
of a State that is awarded a planning grant under this
section and meets the maintenance of effort
requirements under paragraph (2), the Federal medical
assistance percentage determined for the State under
such subsection (b) (or such subsection (ff), if
applicable) and, if applicable, as increased under
subsection (y), (z), (aa), or (ii) of such section,
section 1915(k) of such Act (42 U.S.C. 1396n(k)), or
section 6008 of the Families First Coronavirus Response
Act (Public Law 116-127), shall be increased by 10
percentage points (but not to exceed 95 percent) with
respect to amounts expended by the State Medicaid
program for medical assistance for home and community-
based services that are provided during HCBS planning
period (as defined in subparagraph (B)).
(B) HCBS planning period.--In this paragraph, the
term ``HCBS planning period'' means, with respect to a
State, the period--
(i) beginning on the date on which the
State is awarded a planning grant under this
section; and
(ii) ending on the earlier of--
(I) the first day of the first
fiscal quarter for which the State is
an HCBS program improvement State; and
(II) the date that is 3 years after
the date on which the State is awarded
such a grant.
(C) Rule of application in case of overlap with
period for american rescue plan increase.--If the HCBS
planning period for a State begins during the HCBS
program improvement period (as defined under subsection
(a)(2)(A) of section 9817 of the American Rescue Plan
Act (Public Law 117-2)), and the State meets the HCBS
program requirements under subsection (b) of such
section, the increase in the Federal medical assistance
percentage that would otherwise apply to the State
under subparagraph (A) of this paragraph shall not
apply during any portion of the HCBS program
improvement period (as defined under subsection
(a)(2)(A) of section 9817 of the American Rescue Plan
Act (Public Law 117-2)) for which the State receives an
increase in the Federal medical assistance percentage
in accordance with that section.
(D) Nonapplication of territorial funding caps.--
Any payment made to Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands, or American Samoa
for expenditures on medical assistance that are subject
to the Federal medical assistance percentage increase
specified under subparagraph (A) shall not be taken
into account for purposes of applying payment limits
under subsections (f) and (g) of section 1108 of the
Social Security Act (42 U.S.C. 1308).
(2) Maintenance of effort requirements.--For purposes of
paragraph (1)(A), the requirements of this paragraph are, with
respect to the period for which a State is awarded a planning
grant under this section, the State shall not--
(A) lower the amount, duration, or scope of home
and community-based services available under the State
Medicaid program (relative to the services available
under the program as of the date on which the State was
awarded such grant); or
(B) adopt more restrictive standards,
methodologies, or procedures for determining
eligibility, benefits, or services for receipt of home
and community-based services under the State Medicaid
program, including with respect to utilization
management or cost-sharing, than the standards,
methodologies, or procedures applicable as of the date
on which the State was awarded such grant.
(f) Funding.--
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the Secretary
for purposes of awarding planning grants under this section,
$100,000,000 for fiscal year 2022, to remain available until
expended.
(2) Technical assistance and guidance.--The Secretary shall
reserve $5,000,000 of the amount appropriated under paragraph
(1) for purposes of issuing guidance and providing technical
assistance to States seeking or awarded a planning grant under
this section.
SEC. 102. HCBS INFRASTRUCTURE IMPROVEMENT PROGRAM.
(a) Enhanced FMAP for HCBS Program Improvement States.--Section
1905 of the Social Security Act (42 U.S.C. 1396d) is amended--
(1) in subsection (b), by striking ``and (ii)'' and
inserting ``(ii), and (jj)''; and
(2) by adding at the end the following new subsection:
``(jj) Enhanced Federal Medical Assistance Percentage for HCBS
Program Improvement States.--
``(1) In general.--
``(A) Increased federal financial participation.--
Subject to paragraph (5), in the case of a State that
is an HCBS program improvement State and meets the
requirements described in paragraphs (2) and (4), for
each fiscal year quarter that begins on or after the
first date on which a State is an HCBS program
improvement State--
``(i) notwithstanding subsection (b) or
(ff), subject to subparagraph (B), with respect
to amounts expended during the quarter by such
State for medical assistance for home and
community-based services, the Federal medical
assistance percentage for such State and
quarter (as determined for the State under
subsection (b) and, if applicable, increased
under subsection (y), (z), (aa), or (ii), or
section 6008(a) of the Families First
Coronavirus Response Act) shall be increased by
10 percentage points (but not to exceed 95
percent); and
``(ii) notwithstanding the per centum
specified in section 1903(a)(7), with respect
to amounts expended during the quarter and
before October 1, 2031, for administrative
costs for expanding and enhancing home and
community-based services, including for
enhancing the Medicaid data and technology
infrastructure, modifying rate setting
processes, adopting, using, and reporting
quality measures and beneficiary and family
caregiver experience surveys, adopting or
improving training programs for direct care
workers and family caregivers, and adopting,
carrying out, or enhancing programs that
register qualified direct care workers or
connect beneficiaries to qualified direct care
workers, such per centum shall be increased to
80 percent.
``(B) Additional hcbs improvement efforts.--Subject
to paragraph (5), in addition to the increase to the
Federal medical assistance percentage under
subparagraph (A)(i), with respect to amounts expended
for medical assistance during the first 4 fiscal
quarters throughout which an HCBS program improvement
State has implemented a program to support self-
directed care that meets the requirements of paragraph
(3) (in addition to meeting the requirements described
in paragraph (2)), the Federal medical assistance
percentage for such State and each such quarter with
respect to such amounts shall be further increased by 2
percentage points (but not to exceed 95 percent).
``(C) Nonapplication of territorial funding caps.--
Any payment made to Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands, or American Samoa
for expenditures that are subject to an increase in the
Federal medical assistance percentage under
subparagraph (A)(i) or (B), or an increase in an
applicable Federal matching percentage under
subparagraph (A)(ii), shall not be taken into account
for purposes of applying payment limits under
subsections (f) and (g) of section 1108.
``(2) Requirements.--The requirements described in this
paragraph, with respect to a State and a fiscal year quarter,
are the following:
``(A) Maintenance of effort.--
``(i) In general.--Except as provided under
clause (ii), the State does not--
``(I) lower the amount, duration,
or scope of home and community-based
services available under the State plan
or waiver (relative to the home and
community-based services available
under the plan or waiver as of the date
on which the State was awarded a
planning grant under section 101 of the
Better Care Better Jobs Act); or
``(II) adopt more restrictive
standards, methodologies, or procedures
for determining eligibility, benefits,
or services for receipt of home and
community-based services, including
with respect to utilization management
or cost-sharing and the amount,
duration, and scope of available home
and community-based services, than the
standards, methodologies, or procedures
applicable as of such date.
``(ii) Exception.--On or after October 1,
2028, a State may modify such standards,
methodologies, or procedures if the State
demonstrates that such modifications shall not
result in--
``(I) home and community-based
services that are less comprehensive or
lower in amount, duration, or scope;
``(II) fewer individuals (overall
and within particular beneficiary
populations) receiving home and
community-based services; or
``(III) increased cost-sharing for
home and community-based services.
``(B) Access to services.--The State enhances,
expands, or strengthens home and community-based
services by doing all of the following:
``(i) Addressing access barriers and
disparities in access or utilization identified
in the State HCBS infrastructure improvement
plan.
``(ii) Expanding financial eligibility
criteria for home and community-based services
up to Federal limits.
``(iii) Requiring coverage of personal care
services for all eligible populations receiving
home and community-based services in the State.
``(iv) Using `no wrong door' programs,
providing presumptive eligibility for home and
community-based services, and improving home
and community-based services counseling and
education programs.
``(v) Expanding access to behavioral health
services and coordination with employment,
housing, and transportation supports.
``(vi) Providing supports to family
caregivers, which shall include providing
respite care, and may include providing such
services as caregiver assessments, peer
supports, or paid family caregiving.
``(vii) Adopting, expanding eligibility
for, or improving coverage provided under a
Medicaid buy-in program authorized under
subclause (XIII), (XV), or (XVI) of section
1902(a)(10)(A)(ii).
``(C) Strengthened and expanded workforce.--
``(i) In general.--The State strengthens
and expands the direct care workforce that
provides home and community-based services by--
``(I) adopting processes to ensure
that payments for home and community-
based services are sufficient to ensure
that care and services are available to
the extent described in the State HCBS
infrastructure improvement plan; and
``(II) updating, developing, and
adopting qualification standards and
training opportunities for the
continuum of providers of home and
community-based services, including
programs for independent providers of
such services and agency direct care
workers, as well as unique programs and
resources for family caregivers.
``(ii) Payment rates.--In carrying out
clause (i)(I), the State shall--
``(I) address insufficient payment
rates for delivery of home and
community-based services, with an
emphasis on supporting the recruitment
and retention of the direct care
workforce, as identified during the
period in which the State HCBS
infrastructure improvement plan was
developed and during subsequent years;
``(II) update payment rates for
home and community-based services at
least every 2 years through a
transparent process involving
meaningful input from stakeholders,
including recipients of home and
community-based services, family
caregivers of such recipients,
providers, health plans, direct care
workers, chosen representatives of
direct care workers, and aging,
disability, and workforce advocates;
and
``(III) ensure that increases in
the payment rates for home and
community-based services are--
``(aa) at a minimum,
proportionately passed through
to direct care workers and in a
manner that is determined with
input from the stakeholders
described in subclause (II);
and
``(bb) incorporated into
payment rates for home and
community-based services
provided under this title by a
managed care entity (as defined
in section 1932(a)(1)(B)) or a
prepaid inpatient health plan
or prepaid ambulatory health
plan, as defined in section
438.2 of title 42, Code of
Federal Regulations (or any
successor regulation)), under a
contract with the State.
``(3) HCBS improvement to support self-directed models for
the delivery of services.--For purposes of paragraph (1)(B),
the requirements of this paragraph, with respect to a State and
a fiscal year quarter, are that the State establishes directly
or by contract with 1 or more non-profit entities, a program
for the performance of all of the following functions:
``(A) Registering qualified direct care workers and
assisting beneficiaries in finding direct care workers.
``(B) Undertaking activities to recruit and train
independent providers to enable beneficiaries to direct
their own care, including by providing or coordinating
training for beneficiaries on self-directed care.
``(C) Ensuring the safety of, and supporting the
quality of, care provided to beneficiaries, such as by
conducting background checks and addressing complaints
reported by recipients of home and community-based
services.
``(D) Facilitating coordination between State and
local agencies and direct care workers for matters of
public health, training opportunities, changes in
program requirements, workplace health and safety, or
related matters.
``(E) Supporting beneficiary hiring of independent
providers of home and community-based services through
an agency with choice or similar model, including by
processing applicable tax information, collecting and
processing timesheets, submitting claims and processing
payments to such providers.
``(F) To the extent a State permits beneficiaries
to hire a family member or individual with whom they
have an existing relationship to provide home and
community-based services, providing support to
beneficiaries who wish to hire a caregiver who is a
family member or individual with whom they have an
existing relationship, such as by facilitating
enrollment of such family member or individual as a
provider of home and community-based services under the
State plan or a waiver of such plan.
``(G) Ensuring that program policies and procedures
allow for cooperation with labor organizations that
bargain on behalf of direct care workers in the case of
a State in which the direct care workers in the State
have elected to join, or form, such a labor
organization, or, in the case of a State in which such
workers have not joined or formed such a labor
organization, are neutral with regard to such workers
joining or forming such a labor organization.
``(4) Quality, reporting, and oversight.--The requirements
described in this paragraph, with respect to a State and a
fiscal year quarter, are the following:
``(A) The State adopts the core quality measures
for home and community-based services developed by the
Secretary under section 104 of the Better Care Better
Jobs Act, or an alternate set of quality measures
approved by the Secretary, and, at the option of the
State, expands the use of beneficiary and family
caregiver experience surveys.
``(B) The State designates an HCBS ombudsman office
that--
``(i) operates independently from the State
Medicaid agency and managed care entities;
``(ii) provides direct assistance to
beneficiaries and their families; and
``(iii) identifies and reports systemic
problems to State officials, the public, and
the Secretary.
``(C) Beginning with the 5th fiscal year quarter
for which the State is an HCBS program improvement
State, and annually thereafter, the State reports on
the components of the existing home and community-based
services landscape reported in the State HCBS
infrastructure improvement plan, including with respect
to--
``(i) the availability and utilization of
home and community-based services,
disaggregated by disability status, age,
income, gender, race, ethnicity, geography,
primary language, sexual orientation, gender
identity, and type of service setting;
``(ii) the characteristics of the direct
care workforce that provides home and
community-based services workforce and the
race, ethnicity, and gender of such workforce;
``(iii) changes in payment rates for home
and community-based services;
``(iv) implementation of the activities to
strengthen and expand access to home and
community-based services and the direct care
workforce that provides such services in
accordance with the requirements of
subparagraphs (B) and (C) of paragraph (2);
``(v) if applicable, implementation of the
activities described in paragraph (3); and
``(vi) the progress made with respect to
meeting the benchmarks for demonstrating
improvements required in paragraph (5).
``(5) Benchmarks for demonstrating improvements.--An HCBS
program improvement State shall cease to be eligible for an
increase in the Federal medical assistance percentage under
paragraph (1)(A)(i) or (1)(B) or an increase in an applicable
Federal matching percentage under paragraph (1)(A)(ii)
beginning with the 29th fiscal year quarter that begins on or
after the first date on which a State is an HCBS program
improvement State, unless, not later than 90 days before the
first day of such fiscal year quarter, the State submits to the
Secretary a report demonstrating the following improvements:
``(A) Increased availability of home and community-
based services in the State relative to such
availability as reported in the State HCBS
infrastructure improvement plan and adjusted for
demographic changes in the State since the submission
of such plan.
``(B) Increased utilization and availability of
home and community-based services by populations with
the lowest utilization and availability of such
services (as reported in the State HCBS infrastructure
improvement plan) relative to the utilization of such
services by such populations as reported in such plan
and adjusted for demographic changes in the State since
the submission of such plan.
``(C) Evidence that a majority of direct care
workers receive competitive wages and benefits.
``(D) With respect to the percentage of
expenditures made by the State for long-term services
and supports that are for home and community-based
services, in the case of an HCBS program improvement
State for which such percentage (as reported in the
State HCBS infrastructure improvement plan) was--
``(i) less than 50 percent, the State
demonstrates that the percentage of such
expenditures has increased to at least 50
percent since the plan was approved; and
``(ii) at least 50 percent, the State
demonstrates that such percentage has not
decreased since the plan was approved.
``(6) Definitions.--In this subsection, the terms `direct
care worker', `direct care workforce', `HCBS program
improvement State', and `home and community-based services'
have the meanings given those terms in section 2 of the Better
Care Better Jobs Act.''.
SEC. 103. REPORTS; TECHNICAL ASSISTANCE; OTHER ADMINISTRATIVE
REQUIREMENTS.
(a) Reports.--The Secretary shall submit to the appropriate
committees of Congress the following reports relating to the HCBS
Infrastructure Improvement Program established under this title:
(1) Initial report.--Not later than 4 years after the date
of enactment of this Act, a report that includes the following:
(A) A description of the HCBS infrastructure
improvement plans approved by the Secretary under
section 101(d).
(B) A description of the national landscape with
respect to gaps in coverage of home and community-based
services, disparities in access to, and utilization of,
such services, and barriers to accessing such services.
(C) A description of the national landscape with
respect to the direct care workforce that provides home
and community-based services, including with respect to
compensation, benefits, and challenges to the
availability of such workers.
(2) Subsequent reports.--Not later than 7 years after the
date of enactment of this Act, and every 3 years thereafter, a
report that includes the following:
(A) The number of HCBS program improvement States.
(B) A summary of the progress being made by such
States with respect to strengthening and expanding
access to home and community-based services and the
direct care workforce that provides such services and
meeting the benchmarks for demonstrating improvements
required under section 1905(jj)(5) of the Social
Security Act (as added by section 102).
(C) A summary of outcomes related to home and
community-based services core quality measures and
beneficiary and family caregiver surveys.
(D) A summary of the challenges and best practices
reported by States in expanding access to home and
community-based services and supporting and expanding
the direct care workforce that provides such services.
(b) Technical Assistance; Guidance; Regulations.--The Secretary
shall provide HCBS program improvement States with technical assistance
related to carrying out the HCBS infrastructure improvement plans
approved by the Secretary under section 101(d) and meeting the
requirements and benchmarks for demonstrating improvements required
under section 1905(jj) of the Social Security Act (as added by section
102) and shall issue such guidance or regulations as necessary to carry
out this title and the amendments made by this title, including
guidance specifying how States shall assess and track the availability
of home and community-based services over time.
(c) Recommendations To Guide Infrastructure Improvement.--
(1) In general.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall coordinate with the
Secretary of Labor and the Administrator of the Centers for
Medicare & Medicaid Services for purposes of issuing
recommendations for the Federal Government and for States to
strengthen the direct care workforce that provides home and
community-based services, including with respect to how the
Federal Government should classify the direct care workforce,
how such Administrator and State Medicaid programs can enforce
and support the provision of competitive wages and benefits
across the direct care workforce, including for workers with
particular skills or expertise, and how State Medicaid programs
can support training opportunities and other related efforts
that support the provision of quality home and community-based
services care.
(2) Stakeholder consultation.--In developing the
recommendations required under paragraph (1), the Secretary
shall ensure that such recommendations are informed by
consultation with recipients of home and community-based
services, family caregivers of such recipients, providers,
health plans, direct care workers, chosen representatives of
direct care workers, and aging, disability, and workforce
advocates.
(d) Funding.--Out of any funds in the Treasury not otherwise
appropriated, there is appropriated to the Secretary for purposes of
carrying out this section, $10,000,000 for fiscal year 2022, to remain
available until expended.
SEC. 104. QUALITY MEASUREMENT AND IMPROVEMENT.
(a) Development and Publication of Core and Supplemental Sets of
HCBS Quality Measures.--
(1) In general.--Not later than 2 years after the date of
enactment of this Act, the Secretary shall identify and publish
for general comment a recommended core set and supplemental set
of home and community-based services quality measures for use
by State Medicaid programs, health plan and managed care
entities that enter into contracts with such programs, and
providers of items and services under such programs.
(2) Regular reviews and updates.--The Secretary shall
review and update the recommended core set and supplemental set
of home and community-based services quality measures published
under paragraph (1) not less frequently than once every year.
(3) Requirements.--
(A) Interagency collaboration; stakeholder input.--
In developing the recommended core set and supplemental
set of home and community-based services quality
measures under paragraph (1), and subsequently
reviewing and updating such core and supplemental sets,
the Secretary shall--
(i) collaborate with the Administrator of
the Centers for Medicare & Medicaid Services,
the Administrator of the Administration for
Community Living, the Director of the Agency
for Healthcare Research and Quality, and the
Administrator of the Substance Abuse and Mental
Health Services Administration; and
(ii) ensure that such core and supplemental
sets are informed by input from stakeholders,
including recipients of home and community-
based services, family caregivers of such
recipients, providers, health plans, direct
care workers, chosen representatives of direct
care workers, and aging, disability, and
workforce advocates.
(B) Reflective of full array of services.--Such
recommended core set and supplemental set of home and
community-based services quality measures shall--
(i) reflect the full array of home and
community-based services and recipients of such
services, including adults and children; and
(ii) include--
(I) outcomes-based measures;
(II) measures of availability of
services;
(III) measures of provider capacity
and availability;
(IV) measures related to person-
centered care;
(V) measures specific to self-
directed care;
(VI) measures related to
transitions to and from institutional
care; and
(VII) beneficiary and family
caregiver surveys.
(C) Demographics.--Such recommended core set and
supplemental set of home and community-based services
quality measures shall allow for the collection of data
that is disaggregated by disability status, age,
income, gender, race, ethnicity, geography, primary
language, sexual orientation, gender identity, and type
of service setting .
(4) Funding.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the Secretary
for purposes of carrying out this subsection, $5,000,000 for
fiscal year 2022, to remain available until expended.
(b) State Adoption and Reports.--
(1) In general.--Not later than 2 years after the date on
which the Secretary publishes the recommended core set and
supplemental set of home and community-based services quality
measures under subsection (a)(1), and annually thereafter, each
State Medicaid program shall use such core and supplemental
sets (or an alternative set of quality measures approved by the
Secretary) to report information to the Secretary regarding the
quality of home and community-based services provided under
such program.
(2) Process.--The information required under paragraph (1)
shall be reported using a standardized format and procedures
established by the Secretary. Such procedures shall allow a
State Medicaid program to report such information separately or
as part of the annual reports required under sections 1139A(c)
and 1139B(d) of the Social Security Act (42 U.S.C. 1320b-9a,
1320b-9b).
(3) Publication of quality measures.--Each State Medicaid
program shall periodically make the information reported to the
Secretary under paragraph (1) available to the public.
(4) Increased federal matching rate for adoption and
reporting.--Section 1903(a)(3) of the Social Security Act (42
U.S.C. 1396b(a)(3)) is amended--
(A) in subparagraph (F)(ii), by striking ``plus''
after the semicolon and inserting ``and''; and
(B) by inserting after subparagraph (F), the
following:
``(G) 80 percent of so much of the sums expended
during such quarter as are attributable to the
reporting of information regarding the quality of home
and community-based services in accordance with section
104(b) of the Better Care Better Jobs Act; and''.
TITLE II--OTHER PROVISIONS
SEC. 201. MACPAC STUDY AND REPORT ON APPENDIX K EMERGENCY HOME AND
COMMUNITY-BASED SERVICES (HCBS) 1915(C) WAIVERS.
(a) In General.--The Medicaid and CHIP Payment and Access
Commission (referred to in this section as ``MACPAC'') shall conduct a
study and submit to Congress a report on the accelerated changes and
emergency amendments to home and community-based services waivers under
section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c))
approved for States during the COVID-19 pandemic using the Appendix K
template issued by the Centers for Medicare & Medicaid Services on
March 22, 2020.
(b) Report.--The report submitted under subsection (a) shall--
(1) describe the specific types of flexibilities or other
program changes adopted by States using the Appendix K
template;
(2) evaluate the efficiency, management, and success and
failures of such flexibilities and program changes; and
(3) include recommendations for legislative and
administrative actions to continue specific flexibilities,
program changes, and innovative service delivery models that
increase access to care in home and community settings.
SEC. 202. MAKING PERMANENT THE STATE OPTION TO EXTEND PROTECTION UNDER
MEDICAID FOR RECIPIENTS OF HOME AND COMMUNITY-BASED
SERVICES AGAINST SPOUSAL IMPOVERISHMENT.
(a) In General.--Section 1924(h)(1)(A) of the Social Security Act
(42 U.S.C. 1396r-5(h)(1)(A)) is amended by striking ``is described in
section 1902(a)(10)(A)(ii)(VI)'' and inserting the following: ``is
eligible for medical assistance for home and community-based services
provided under subsection (c), (d), or (i) of section 1915, under a
waiver approved under section 1115, or who is eligible for such medical
assistance by reason of being determined eligible under section
1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the
basis of a reduction of income based on costs incurred for medical or
other remedial care, or who is eligible for medical assistance for home
and community-based attendant services and supports under section
1915(k)''.
(b) Conforming Amendment.--Section 2404 of the Patient Protection
and Affordable Care Act (42 U.S.C. 1396r-5 note) is amended by striking
``September 30, 2023'' and inserting ``the date of enactment of the
Better Care Better Jobs Act''.
SEC. 203. PERMANENT EXTENSION OF MONEY FOLLOWS THE PERSON REBALANCING
DEMONSTRATION.
(a) In General.--Section 6071(h) of the Deficit Reduction Act of
2005 (42 U.S.C. 1396a note) is amended--
(1) in paragraph (1)--
(A) in subparagraph (I), by inserting ``and'' after
the semicolon;
(B) by amending subparagraph (J) to read as
follows:
``(G) $450,000,000 for each fiscal year after
fiscal year 2021.''; and
(C) by striking subparagraph (K); and
(2) in paragraph (2), by striking ``September 30, 2023''
and inserting ``September 30 of such fiscal year''.
(b) Redistribution of Unexpended Grant Awards.--Section 6071(e)(2)
of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended
by adding at the end the following new sentence: ``Any portion of a
State grant award for a fiscal year under this section that is
unexpended by the State at the end of the fourth succeeding fiscal year
shall be rescinded by the Secretary and added to the appropriation for
the fifth succeeding fiscal year.''.
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