HCBS Access Act

[Congressional Bills 119th Congress] [From the U.S. Government Publishing Office] [S. 5321 Introduced in Senate (IS)]

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119th CONGRESS 2d Session S. 5321

To amend title XIX of the Social Security Act to require coverage of, and expand access to, home and community-based services under the Medicaid program to award grants for the creation, recruitment, training and education, retention, and advancement of the direct care workforce and to award grants to support family caregivers and for other purposes.

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IN THE SENATE OF THE UNITED STATES

August 6, 2026

Mr. Lujan (for himself, Mr. Kaine, Ms. Baldwin, Ms. Duckworth, Mrs. Gillibrand, Ms. Hassan, Mr. Blumenthal, Mr. Merkley, Mr. Sanders, Ms. Warren, Mr. Reed, Mr. Markey, Mrs. Shaheen, Mr. Fetterman, Mr. Kim, and Mrs. Murray) introduced the following bill; which was read twice and referred to the Committee on Finance

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A BILL

To amend title XIX of the Social Security Act to require coverage of, and expand access to, home and community-based services under the Medicaid program to award grants for the creation, recruitment, training and education, retention, and advancement of the direct care workforce and to award grants to support family caregivers 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 ``HCBS Access Act''. (b) Table of Contents.--The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents. Sec. 2. Definitions. TITLE I--REQUIRING AND EXPANDING ACCESS TO HCBS COVERAGE UNDER MEDICAID

Sec. 101. Purpose. Sec. 102. Requiring coverage of home and community-based services under the Medicaid program. Sec. 103. Medicaid eligibility modifications. Sec. 104. Home and community-based services implementation plan. Sec. 105. Quality of services. Sec. 106. Reports; technical assistance; other administrative requirements. Sec. 107. Quality measurement and improvement. Sec. 108. Making permanent the extended protection under medicaid for recipients of home and community-based services against spousal impoverishment. Sec. 109. Permanent extension of money follows the person rebalancing demonstration. Sec. 110. Liens, adjustments, and recoveries for medical assistance. Sec. 111. HCBS provider tax. Sec. 112. Medicare amendment. TITLE II--RECOGNIZING THE ROLE OF DIRECT SUPPORT PROFESSIONALS

Sec. 201. Findings. Sec. 202. Revision of standard occupational classification system. TITLE III--SUPPORT FOR THE DIRECT CARE WORKFORCE

Sec. 301. Definitions. Sec. 302. Authority to establish a technical assistance center for building the direct care workforce. Sec. 303. Authority to award grants. Sec. 304. Project plans. Sec. 305. Evaluations and reports; technical assistance. Sec. 306. Authorization of appropriations. TITLE IV--EVALUATION

Sec. 401. Evaluation of impact on access to HCBS.

SEC. 2. DEFINITIONS.

In this Act: (1) Demographics.--The term ``demographics'' means information relating to the races, ethnicities, genders, sexual orientations, gender identities, geographic locations, incomes, primary languages, types of service setting, and disability types represented within a particular group of individuals. (2) Secretary.--Except as otherwise provided, the term ``Secretary'' means the Secretary of Health and Human Services.

TITLE I--REQUIRING AND EXPANDING ACCESS TO HCBS COVERAGE UNDER MEDICAID

SEC. 101. PURPOSE.

It is the purpose of this title to require coverage of home and community-based services (in this section referred to as ``HCBS'') under a State plan (or waiver of such plan) under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) for the following reasons: (1) To eliminate waiting lists for HCBS, which delay access to necessary services and deny access to the promise of community inclusion guaranteed under the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.) for individuals with disabilities and older adults. (2) To build on decades of progress in serving individuals with disabilities and older adults through access to HCBS. (3) To fulfill the purposes of the Medicaid program to provide medical assistance for individuals whose income and resources are insufficient to meet the costs of necessary medical services, and to provide rehabilitation, long-term services and supports, and other services to help such individuals attain or retain capacity for independence or self- care. (4) To ensure that individuals with all kinds of disabilities and with multiple disabilities, including intellectual disabilities, cognitive disabilities, developmental disabilities, behavioral health disabilities, physical disabilities, and substance use disorders, and older adults, receive the services they need to live in their communities. (5) To streamline access to HCBS by eliminating the need for States to repeatedly apply for waivers of their respective State plans for medical assistance. (6) To continue to increase the capacity of community services to ensure individuals with disabilities and older adults have high-quality, safe, and meaningful options to receive care in their community and are not at risk of unnecessary institutionalization. (7) To act on the decades of research and practice that show that everyone, including individuals with the most severe disabilities, can live in the community with the right services and supports. (8) To eliminate the race, gender, sexual orientation, and gender identity disparities that exist in accessing information and HCBS and to prevent the unnecessary impoverishment and institutionalization of black and brown individuals with disabilities and older adults. (9) To support over 63,000,000 unpaid family caregivers, who are disproportionately women and often providing complex services and supports to older adults and individuals with disabilities because of a lack of affordable services, workforce shortages, and other inefficiencies. (10) To improve direct care quality and ensure access to services by improving workforce standards for the nearly 3,200,000 direct care workers, who are primarily women, people of color, and immigrants facing heightened risks of discrimination in employment, providing support to individuals with disabilities and older adults in their homes and communities.

SEC. 102. REQUIRING COVERAGE OF HOME AND COMMUNITY-BASED SERVICES UNDER THE MEDICAID PROGRAM.

(a) Definition of Home and Community-Based Services.-- (1) Inclusion as medical assistance.--Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended-- (A) in paragraph (31), by striking ``and'' at the end; (B) by redesignating paragraph (32) as paragraph (33); and (C) by inserting after paragraph (31) the following new paragraph: ``(32) home and community-based services (as defined in subsection (ll)); and''. (2) Home and community-based services defined.--Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection: ``(ll) Home and Community-Based Services.-- ``(1) In general.--For purposes of this title, the term `home and community-based services' means those services specified in paragraph (2) furnished to an eligible individual (as defined in paragraph (3)), based on an individualized assessment (as described in paragraph (4)) and person-centered service plan (as described in paragraph (4)(D)) for such individual, in a setting that-- ``(A) meets the qualities specified in paragraph (1) of section 441.710(a) of title 42, Code of Federal Regulations (or a successor regulation); ``(B) is not described in paragraph (2) of such section (or a successor regulation); and ``(C) meets such other qualities as the Secretary determines appropriate in line with recommendations for additional services made by the advisory panel described in paragraph (2)(B) of this subsection. ``(2) Services specified.-- ``(A) In general.--For purposes of paragraph (1), the services specified in this paragraph are services described in any of paragraphs (7), (8), (13)(C), (19), (20), (22), (24), (29), and (33) of subsection (a) of this section or in any of subsections (c)(4)(B), (c)(5), (k)(1)(A), (k)(1)(B), or (k)(1)(D) of section 1915, including the following: ``(i) Supported employment and integrated day services. ``(ii) Personal assistance, including personal care attendants, direct support professionals, home health aides, private duty nursing, homemakers and chore assistance, and companionship services. ``(iii) Services that enhance independence, inclusion, and full participation in the broader community. ``(iv) Non-emergency, non-medical transportation services to facilitate community integration. ``(v) Respite services provided in the individual's home or broader community. ``(vi) Caregiver and family support services. ``(vii) Case management, including intensive case management, fiscal intermediary, and support brokerage services. ``(viii) Services that support person- centered planning and self-direction. ``(ix) Direct support services during acute hospitalizations. ``(x) Necessary medical and nursing services not otherwise covered that are necessary in order for the individual to remain in their home and community, including hospice services. ``(xi) Home and community-based intensive behavioral health and crisis intervention services. ``(xii) Peer support services. ``(xiii) Housing support, including transitional housing or transitional support services for individuals who are unhoused, and wrap-around services. ``(xiv) Necessary home modifications and assistive technology, including those that substitute for human assistance. ``(xv) Transition services to support an individual who is transitioning from an institutional setting to the community, including appropriate services for individuals who are unhoused or at risk of becoming unhoused, and including such transition services provided while the individual resides in an institution. ``(xvi) Nutrition services. ``(xvii) Assisted living services. ``(xviii) Any other service approved by the Secretary, pursuant to the recommendation of the advisory panel convened under subparagraph (B). ``(B) Specification of recommended services.-- ``(i) In general.--Not later than 6 months after the date of the enactment of this subparagraph, and not less frequently than once every 5 years thereafter, the Secretary shall appoint an advisory panel for purposes of recommending additional services which may be included as home and community-based services under this paragraph. ``(ii) Composition.-- ``(I) Selection.--The advisory panel shall be comprised of not less than 50 members and include representatives of the following categories, with the majority of all members being selected from the categories described in items (aa), (bb), and (cc): ``(aa) Individuals with disabilities receiving home and community-based services under this title and individuals with disabilities in need of such services, including those with physical disabilities, behavioral health disabilities, or intellectual or developmental disabilities, and including older adults, that are representative of multiple States, geographical locations, races, ethnicities, and other demographic factors. ``(bb) Beneficiary-led disability rights organizations. ``(cc) Disability-led organizations. ``(dd) Disabled veterans organizations. ``(ee) Disability organizations representing families. ``(ff) Organizations serving individuals with disabilities, including intellectual or developmental disabilities. ``(gg) Organizations serving older adults. ``(hh) Direct care workers and the labor organizations that represent such workers. ``(ii) The Protection and Advocacy System. ``(jj) The Centers for Independent Living. ``(kk) Health care providers. ``(ll) The National Association of Medicaid Directors. ``(mm) The National Association of State Directors of Developmental Disabilities Services. ``(nn) The National Association of State Mental Health Program Directors. ``(oo) Advancing States. ``(pp) The Centers for Medicare & Medicaid Services. ``(qq) The Administration for Community Living of the Department of Health and Human Services. ``(rr) Members of federally recognized tribes and tribally led organizations. ``(ss) Other relevant Federal, State, and local home and community-based service systems, as determined by the Secretary. ``(II) Requirement for proportionate representation.--The Secretary shall seek to ensure proportionate representation among each category described in items (dd) through (ss) of subclause (I) in convening the advisory panel. ``(iii) Duties.-- ``(I) In general.--Not later than 2 years after an advisory panel is convened under clause (i), the advisory panel shall submit to the Secretary and to Congress a report recommending additional services which may be included as home and community-based services under this paragraph with the goal of increasing community integration and self-determination for individuals with disabilities receiving such services. ``(II) Considerations.--In developing recommendations, the advisory panel shall consider-- ``(aa) available data on coverage gaps of needed home and community-based services, including compliance reporting required by section 441.311(d) of title 42, Code of Federal Regulations; ``(bb) new technology or innovations that could promote access to home and community- based services for individuals with disabilities and older adults; ``(cc) relevant data based on the latest Home and Community-Based Services Quality Measure Set established and updated by the Secretary pursuant to section 441.312 of title 42, Code of Federal Regulations; and ``(dd) other relevant research, data, or information that will help inform the adoption of home and community- based services for individuals with disabilities and older adults. ``(iv) Implementation of recommended additional services.-- ``(I) In general.--The Secretary shall consider the recommendations made in a report submitted by the advisory panel pursuant to clause (iii)(I), and review any other relevant information, to identify additional services as home and community-based services pursuant to subparagraph (A)(xviii). ``(II) Considerations.--In determining which recommendations of the advisory panel to implement, the Secretary shall consider-- ``(aa) available data on coverage gaps of needed home and community-based services, including compliance reporting required by section 411.311(d) of title 42, Code of Federal Regulations; ``(bb) new technology or innovations that could promote access to home and community- based services for individuals with disabilities; ``(cc) relevant data based on the latest Home and Community-Based Services Quality Measure Set established and updated by the Secretary pursuant to section 441.312 of title 42, Code of Federal Regulations; ``(dd) public comment about additional home and community- based services obtained through the public notice and comment process described in subclause (III); and ``(ee) other relevant research, data, or information that will help inform the adoption of home and community- based services for individuals with disabilities. ``(III) Notice and comment.--Not later than 1 year after an advisory panel is convened under clause (i), the Secretary shall establish a process for public notice and comment, including public hearings, sufficient to ensure a meaningful level of public input. ``(IV) Notification to state medicaid directors.--Not later than 1 year after the conclusion of the notice and comment process established by the Secretary pursuant to subclause (III), the Secretary shall issue a State Medicaid Director Letter to notify States of any additional home and community-based services approved by the Secretary for purposes of subparagraph (A)(xviii). ``(C) Private duty nursing defined.--For purposes of this paragraph, the term `private duty nursing' means nursing services that are sufficient to meet the needs of an individual who requires more individualized and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or skilled nursing facility, and includes services provided to an individual in the individual's own home by a registered nurse or licensed practical nurse under the direction of a physician. ``(3) Eligible individual.-- ``(A) In general.--For purposes of paragraph (1), the term `eligible individual' means-- ``(i) an individual who is determined, on an annual basis or on a longer basis specified by the State, by a health care provider approved by the State under a process described in subparagraph (C) to have a functional impairment (as defined in subparagraph (B)) (not taking into account any items or services, or any other ameliorative measures, furnished to such individual to mitigate such impairment) that is expected to last at least 90 days; ``(ii) during the period that ends on the day before the first day of the first calendar quarter beginning on or after the date that is 5 years after the date of the enactment of this subsection, an individual who, as of such date of enactment, is receiving or has been determined to be eligible for home and community-based services under this title (or under a waiver or State plan option in effect under section 1915 or 1115, provided that the individual continues to meet any level of care requirement applicable under such waiver or State plan option); or ``(iii) an individual who is eligible under the State plan or a waiver of such plan and is under the age of 21. ``(B) Functional impairment.--For purposes of subparagraph (A)(i), the term `functional impairment' means, with respect to an individual, the inability of such individual to perform, without assistance-- ``(i) 2 or more activities of daily living (as described in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986); ``(ii) 2 or more instrumental activities of daily living (as defined for purposes of section 1915(k)(1)(A)); or ``(iii) 1 activity of daily living (as so described) and 1 instrumental activity of daily living (as so defined). ``(C) Health care provider state approval.--For purposes of subparagraph (A)(i), a process described in this subparagraph is a process established by the State to approve a health care provider to make a determination of functional impairment in accordance with such standards as the Secretary may prescribe. ``(4) Individualized assessment.-- ``(A) In general.--For purposes of paragraph (1), an individualized assessment described in this paragraph is an independent assessment, with respect to an eligible individual-- ``(i) to determine a necessary level of services and supports to be provided, consistent with the individual's physical and health condition, including any functional impairments; ``(ii) to identify needed medical and non- medical services and supports; ``(iii) to inform development of a person- centered care plan (as described in subparagraph (D)) for the individual; ``(iv) that includes each of the elements described in clauses (ii) through (v) of section 1915(i)(1)(F); and ``(v) that occurs not later than 30 days after such individual is determined to be an eligible individual. ``(B) Reassessments.--An individualized assessment shall be conducted at least once every 12 months, and as needed when the individual's support needs or circumstances change significantly, and an individual's person-centered service plan shall be revised as necessary to reflect the results of the most recent individualized assessment. ``(C) Presumption.--The individualized assessment described in subparagraph (A) shall be conducted with the presumption-- ``(i) that each eligible individual, regardless of type or level of disability or service need, can be served in the individual's own home and community; and ``(ii) at the option of the individual, that services may be self-directed (as defined in section 1915(i)(1)(G)(iii)(II)). ``(D) Person-centered care plan.--For purposes of subparagraph (A)(iii), a person-centered care plan described in this subparagraph is a written plan with respect to an individual that is developed in accordance with, and meets the requirements of, paragraphs (1) through (3) of section 441.301(c) of title 42, Code of Federal Regulations. ``(E) Standards.--An individualized assessment shall be conducted in accordance with standards specified by the Secretary to-- ``(i) safeguard against conflicts of interest; ``(ii) specify qualifications for who may perform any such assessment; ``(iii) ensure transparency in the conducting of any such assessment, including ensuring the provision of the results of the assessment and, in plain language, any information necessary to interpret the methodology and results of the assessment; ``(iv) ensure that the methodology used in any such assessment is sound and evidence- based; ``(v) require such methodology to be made available on the public website of the State and tested for reliability and validity by an independent evaluator; ``(vi) require assessment tools to include language assistance services and compliance with Federal non-discrimination requirements, including-- ``(I) the availability of such assessments in the individual's primary language or with a qualified interpreter; ``(II) accessibility for individuals who are blind or have low- vision; ``(III) accessibility for deaf and hard-of-hearing individuals; and ``(IV) accessibility for individuals who cannot rely on speech to communicate; and ``(vii) ensure that any services and supports necessary for community integration are identified, involve professionals knowledgeable about the range of services and supports available in the community, and allow individuals getting assessed to present their own independent evidence of the appropriateness of an integrated setting.''. (b) Mandatory Benefit.-- (1) In general.--Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking ``and (30)'' and inserting ``(30), and (32)''. (2) Effective date.--The amendment made by this subsection shall take effect on the first day of the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this Act. (c) Ensuring Coverage of HCBS for All Medicaid-Eligible Individuals.--Section 1902(a)(10)(D) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended-- (1) by inserting ``(i)'' after ``(D)''; (2) by adding ``and'' after the semicolon; and (3) by adding at the end the following new clause: ``(ii) beginning on the first day of the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this clause (or at such earlier date as the State may elect) for the inclusion of home and community-based services (as defined in section 1905(ll)) for any individual who-- ``(I) is eligible for medical assistance under the State plan (or waiver of such plan); ``(II) is an eligible individual (as defined in such section); and ``(III) elects to receive such services.''. (d) Federal Medical Assistance Percentage for Home and Community- Based Services.--Section 1905 of the Social Security Act (42 U.S.C. 1396d), as amended by subsection (a), is further amended-- (1) in subsection (b), by striking ``and (ii)'' and inserting ``(ii), and (mm)''; and (2) by adding at the end the following new subsections: ``(mm) Specified Federal Medical Assistance Percentage for Home and Community-Based Services.-- ``(1) In general.--Notwithstanding any other provision of law and except as provided in paragraph (3), the Federal medical assistance percentage for amounts expended for medical assistance for home and community-based services (as defined in subsection (ll)), including any such services furnished under a waiver in effect under section 1915 or 1115, on or after the date of the enactment of this subsection shall be equal to 100 percent for any State that meets the requirements of paragraph (2). ``(2) Access to essential home and community-based services.--As a condition of receiving the Federal medical assistance percentage described in paragraph (1), a State shall enhance, expand, or strengthen the level of and access to home and community-based services offered under the State plan under this title (or a waiver of such plan) as of the date of enactment of this subsection by doing each of the following: ``(A) Lowering or eliminating access barriers and disparities in access or utilization identified in the implementation plan described in section 1902(zz). ``(B) Using a program to ensure that an individual is not denied services based on the fact that the individual contacts the wrong entity (commonly referred to as a `No Wrong Door Program'), providing presumptive eligibility for home and community-based services, and improving home and community-based services counseling and education programs. ``(C) Providing supports to family caregivers, which shall include providing respite care and may include providing such services as caregiver assessments, peer supports, access to assistive technology, or paid family caregiving. ``(D) Adopting processes to ensure that payments for home and community-based services (including any payment to a direct care worker who delivers such services) are sufficient to ensure that care and services are available to the extent described in the implementation plan described in section 1902(zz). In carrying out this subparagraph, the State shall review and update payment rates for home and community-based services at least every 2 years, with an emphasis on ensuring that rates are adequate to recruit and retain a sufficient workforce to ensure access to the full set of services for eligible individuals as determined under subsection (ll) and 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. ``(E) Developing a process to ensure that increases in payment rates for home and community-based services are-- ``(i) at a minimum, proportionately passed through to direct care workers and in a manner that is determined with input from the stakeholders described in subparagraph (D); and ``(ii) 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 such terms are defined in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation), under a contract with the State. ``(F) 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. ``(G) Establishing an entity to strengthen the infrastructure supporting the delivery of home and community-based services under consumer-directed models of care in accordance with the requirements of subsection (nn). ``(3) Exception.--The Federal medical assistance percentage applicable to medical assistance for home and community-based services furnished to an individual who is only eligible for medical assistance under a State plan or waiver on the basis of section 1902(a)(10)(A)(ii)(XXIV) shall be determined without regard to this subsection. ``(4) Administrative costs.--Notwithstanding the per centum specified in section 1903(a)(7), with respect to amounts expended for the first 4 fiscal quarters during which this subsection is implemented and each of the succeeding 16 fiscal quarters, 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, 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 under subsection (nn), such per centum shall be 80 percent. ``(nn) HCBS Infrastructure To Support Self-Directed Care Models for the Delivery of Services.--For the purposes of paragraph (2)(G) of subsection (mm), the requirements of this subsection, with respect to a State and fiscal quarter, are that the State establishes, directly or by contract with 1 or more non-profit entities, a program to support self-directed models for the delivery of services for the performance of each of the following functions: ``(1) Registering qualified direct care workers and assisting beneficiaries in finding direct care workers to furnish home and community-based services. ``(2) 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. ``(3) 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. ``(4) 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. ``(5) 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. ``(6) 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. ``(7) 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.''. (e) Conforming Amendments.-- (1) In general.--Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended-- (A) in section 1905(a), in the matter preceding the first numbered paragraph-- (i) in each of clauses (xvi) and (xviii), by moving the left margin 2 ems to the left; and (ii) in clause (xvii), by inserting ``or who are described in section 1902(a)(10)(D)'' after ``a State plan amendment under such subsection''; and (B) in section 1943(b)(5), by striking ``the State'' and all that follows through the period at the end and inserting ``a determination be conducted on an annual basis (or on such longer basis as specified by the State) in accordance with section 1905(ll) for purposes of providing home and community-based services under the State plan (or waiver of such plan).''. (2) Effective date.--The amendments made by this subsection shall take effect on the first day of the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this Act.

SEC. 103. MEDICAID ELIGIBILITY MODIFICATIONS.

Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended-- (1) in subsection (a)-- (A) in paragraph (10)-- (i) in subparagraph (A)(i)-- (I) in subclause (VIII), by striking ``; or'' and inserting a semicolon; (II) in subclause (IX)(dd), by striking the semicolon at the end and inserting ``; or''; and (III) by inserting after subclause (IX) the following new subclause: ``(X) beginning with the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this subclause (or such earlier date as the State may elect), who are eligible individuals described in section 1905(ll)(3)(A) and are not described in a previous subclause of this clause and whose income does not exceed the greater of-- ``(aa) 150 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved; or ``(bb) 300 percent of the supplemental security income benefit rate established by section 1611(b)(1);''; and (ii) in subparagraph (A)(ii)-- (I) in subclause (XXII), by striking ``; or'' and inserting a semicolon; (II) in subclause (XXIII), by striking the semicolon at the end and inserting ``; or''; and (III) by inserting after subclause (XXIII) the following new subclause: ``(XXIV) who are eligible individuals who would be described in clause (i)(X) but for the fact that their income exceeds the income levels established under such clause but is less than such income level as the State may establish for purposes of this subclause;''; and (B) by amending paragraph (34) to read as follows: ``(34) provides that in the case of an individual eligible for home and community-based services (as described in section 1905(ll)(3)(A)), such services will be made available and furnished in or after the third month before the month in which such individual made application (or application was made on behalf of such individual in the case of a deceased individual) for such services if such individual was (or upon application would have been) eligible for such services at the time such services were furnished and, that if services are provided through a service plan or any similar document, including services provided under the authority of any provision of section 1115 or 1915, such services shall be available pursuant to this subsection without regard to whether the service plan or similar document was developed before or after the services were provided;''; and (2) in subsection (xx)(9)(A)(ii)-- (A) in subclause (VIII), by striking ``or'' at the end; (B) in subclause (IX), by striking the period and inserting ``; or''; and (C) by adding at the end the following new subclause: ``(X) who is described in subclause (X) of subsection (a)(10)(A)(i) or subclause (XXIV) of subsection (a)(10)(A)(ii).''.

SEC. 104. HOME AND COMMUNITY-BASED SERVICES IMPLEMENTATION PLAN.

(a) In General.--Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended-- (1) in subsection (a)-- (A) in paragraph (89), by striking ``and'' at the end; (B) in paragraph (90)(C), by striking the period at the end and inserting ``; and''; and (C) by inserting after paragraph (90) the following new paragraph: ``(91) provide that, prior to the beginning of the first calendar quarter beginning on or after the date that is 5 years after the date of the enactment of this paragraph (or such earlier date at the State may elect), the State shall submit to the Secretary the implementation plan described in subsection (zz).''; and (2) by adding at the end the following new subsection: ``(zz) Implementation Plan.--For purposes of subsection (a)(91), an implementation plan described in this subsection is a plan developed by a State that includes the following: ``(1) An explanation of how the State will operationalize the definition of an eligible individual under section 1905(ll), including the process for any determination specified in paragraph (3)(A)(i) of such section. ``(2) A description of the characteristics of the State's direct care workforce that provides home and community-based services, including the number of workers, the average and range of direct care worker wages or service payments, the health and other workplace benefits provided to direct care workers, turnover and vacancy rates, and an explanation of the State's plan to ensure a stable and high quality workforce and that compensation for individuals furnishing home and community-based services is sufficient to ensure an appropriate supply of workers to provide services to all eligible individuals and plans to identify and address any additional workforce issues. ``(3) A list of any home and community-based services provided under the State Medicaid plan (including any waiver of such plan) as of the date of enactment of this subsection, including a breakdown of use of such services by demographics (as defined in section 2 of the HCBS Access Act), compared to such services that are required under the amendments made by section 102 of such Act, and a description of numerical goals to increase access to such services that have barriers to access for populations in need of such services. ``(4) A description of how the State will incorporate existing State disability and aging agencies into the new unified provision of home and community-based services and how such State will ensure that such services address all functional impairments. ``(5) A plan for carrying out outreach and education activities with respect to the availability of such services through appropriate entities, including a program to ensure that an individual is not denied such services based on the fact that the individual contacts the wrong entity (commonly referred to as a `No Wrong Door Program'). ``(6) A plan for how such services will be coordinated with other relevant State agencies, such as housing, transportation, child welfare, food and income security, and employment agencies. ``(7) A State with federally recognized Indian tribes, Indian health programs, or urban Indian health organizations shall include a process to consult with the Indian tribes and seek advice from Indian health programs and urban Indian health organizations in the State. ``(8) A description of how the State will build capacity prior to the implementation of the requirements described in subclause (X) of subsection (a)(10)(A)(i) and subclause (XXIV) of subsection (a)(10)(A)(ii) to ensure that such services are available to every eligible individual under the State Medicaid program, how the State will ensure an adequate provider network to provide access to and choice of provider, and how the State will ensure that such services are provided in a setting that meets the requirements specified in paragraph (1) of section 1905(ll), as added by section 102 of the HCBS Access Act. ``(9) A plan for how the State will prioritize individuals who have already met eligibility requirements but are on waiting lists to receive home and community-based services and ensure those individuals do not experience an increase in the amount of time they will wait to receive such services. ``(10) In the case of a State that utilizes an alternative benefit plan, a description of how the State will ensure that all individuals who are eligible individuals (as defined in section 1905(ll)) are appropriately identified as medically frail and exempted from such plan. ``(11) How the State will coordinate eligibility for such services with other disability eligibility programs, such as disability buy-in programs. ``(12) Data and milestone requirements to ensure community integration, including such requirements with respect to utilization of such services by demographics (as defined in section 2 of the HCBS Access Act). ``(13) A description of how the State will evaluate and address disparities based on age, disability, race, ethnicity, sexual orientation, gender identity, and geographic equity.''. (b) FMAP Increase.--Section 1903(a)(3) of the Social Security Act (42 U.S.C. 1396b(a)(3)) is amended-- (1) in subparagraph (F)(ii), by striking ``plus'' at the end and inserting ``and''; and (2) by inserting after subparagraph (F)(ii) the following new subparagraph: ``(G) an amount equal to 100 percent of the sums expended during the quarter which are attributable to the costs of developing the implementation plan described in section 1902(zz); and''.

SEC. 105. QUALITY OF SERVICES.

(a) In General.-- (1) Development of metrics.-- (A) In general.--Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services, in consultation with State Medicaid Directors, shall develop standardized, State-level metrics regarding access to, and satisfaction with, providers, including primary care and specialist providers, with respect to individuals who are enrolled in a State Medicaid plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (or under a waiver of such plan), broken down by demographics (as defined in section 2) and any other category determined appropriate by the Secretary. (B) Inclusions.--The metrics developed under subparagraph (A) shall include metrics on the total number of individuals enrolled in the State plan or under a waiver of such plan during a fiscal year that required the level of care provided in a nursing facility, intermediate care facility for individuals with intellectual disabilities, institution for mental disease, or other similarly restrictive or institutional setting. (2) Process.--The Secretary shall develop the metrics described in paragraph (1) through a public process, which shall provide opportunities for stakeholders to participate. (b) Updating Metrics.--The Secretary, in consultation with the Deputy Administrator and Director for the Center for Medicaid and CHIP Services and State Medicaid Directors, shall update the metrics developed under subsection (a) not less than once every 3 years. (c) State Implementation Funding.--The Secretary may award funds, from the amount appropriated under subsection (d), to States for the purpose of implementing the metrics developed under this section. (d) Appropriation.--There is appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $200,000,000 for fiscal year 2027, to remain available until expended, for the purpose of carrying out this section.

SEC. 106. REPORTS; TECHNICAL ASSISTANCE; OTHER ADMINISTRATIVE REQUIREMENTS.

(a) Reports.--The Secretary shall submit to the Committee on Finance of the Senate, the Committee on Health, Education, Labor, and Pensions of the Senate, the Special Committee on Aging of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committee on Education and Workforce of the House of Representatives the following reports relating to the home and community-based services implementation plan established under section 104: (1) Interim report.--Not later than 2 years after the date of enactment of this Act, a report that describes-- (A) State efforts to develop their home and community-based services implementation plans as described in section 1902(zz) of the Social Security Act (42 U.S.C. 1396a(zz)) (as added by section 104); and (B) the funds awarded to States for any administrative costs associated with the development of such implementation plans. (2) First implementation 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 home and community-based services implementation plans approved by the Secretary under section 1902(zz) of the Social Security Act (42 U.S.C. 1396a(zz)) (as added by section 104). (B) A description of the national landscape with respect to gaps in coverage of home and community-based services, disparities in access to such services, 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. (3) 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 States awarded funding, and the funds awarded to such States, to develop an implementation plan described in section 1902(zz) of the Social Security Act (42 U.S.C. 1396a(zz)) (as added by section 104). (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(ll)(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 States awarded funding to develop an implementation plan described in section 1902(zz) of the Social Security Act (42 U.S.C. 1396a(zz)) (as added by section 104) with technical assistance related to carrying out the home and community-based services implementation plans approved by the Secretary under such section and meeting the requirements and benchmarks for demonstrating improvements required under section 1905(mm) 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 HCBS Implementation.-- (1) In general.--Not later than 18 months after the date of enactment of this Act, the Secretary, in coordination with the Secretary of Labor and the Administrator of the Centers for Medicare & Medicaid Services, shall issue recommendations regarding how the Federal Government and States can 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. (2) Stakeholder consultation.-- (A) In general.--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, educational agencies, and aging, disability, and workforce advocates. (B) Consultation with current and potential hcbs beneficiaries and family caregivers.--In consulting with stakeholders under subparagraph (A), the Secretary shall-- (i) hold at least 1 meeting solely with current and potential recipients of home and community-based services and family caregivers of such recipients for the purpose of developing the recommendations required under paragraph (1); and (ii) seek to achieve parity in terms of the level of participation in the development of such recommendations between-- (I) current and potential recipients of home and community-based services and family caregivers of such recipients; and (II) other categories of stakeholder described in subparagraph (A). (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 2027, to remain available until expended.

SEC. 107. QUALITY MEASUREMENT AND IMPROVEMENT.

(a) Development and Publication of Core and Supplemental Sets of HCBS Quality Measures.-- (1) In general.--The Secretary shall identify and publish a core set and supplemental set of home and community-based services quality measures for use by State Medicaid programs, health plans 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 core set and supplemental set of home and community-based services quality measures published under paragraph (1) not less frequently than annually. (3) Requirements.-- (A) Interagency collaboration; stakeholder input.-- In developing the 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 subagency heads determined appropriate by the Secretary; 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, with the goal that at least half of such input is from current and potential recipients of home and community- based services and family caregivers. (B) Reflective of full array of services.--Such 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; (VII) beneficiary and family caregiver surveys; and (VIII) measures related to outcomes by race and ethnicity, language, sex, gender identity, geography, and other demographic factors to track and reduce health disparities. (C) Demographics.--Such core set and supplemental set of home and community-based services quality measures shall allow for the collection of data that is disaggregated by demographics (as defined in section 2 and including any additional category determined by the Secretary). (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, $10,000,000 for fiscal year 2027, 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 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 annually 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)), as amended by section 104(b), is amended-- (A) in subparagraph (H)(ii), by striking ``plus'' after the semicolon and inserting ``and''; and (B) by inserting after subparagraph (H)(ii) the following new subparagraph: ``(I) 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 107(b) of the HCBS Access Act; plus''. (c) Ombudsman.--Each State shall establish a home and community- based services ombudsman office that-- (1) operates independently from the State Medicaid agency and managed care entities; (2) provides direct assistance to beneficiaries and their families with respect to accessing home and community-based services; and (3) identifies and reports systemic problems to State officials, the public, and the Secretary with respect to the provision of or access to home and community-based services.

SEC. 108. MAKING PERMANENT THE EXTENDED 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 ``(at the option of the State) is described in section 1902(a)(10)(A)(ii)(VI)'' and inserting ``is an eligible individual (as defined in section 1905(ll)(3))''. (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, 2027'' and inserting ``the date of enactment of the HCBS Access Act''.

SEC. 109. PERMANENT EXTENSION OF MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION.

Section 6071(h)(1)(L) of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended by striking ``each of fiscal years 2024 through 2027'' and inserting ``fiscal year 2024 and each fiscal year thereafter''.

SEC. 110. LIENS, ADJUSTMENTS, AND RECOVERIES FOR MEDICAL ASSISTANCE.

(a) Liens.--Section 1917(a) of the Social Security Act (42 U.S.C. 1396p(a)) is amended-- (1) in paragraph (1)-- (A) in the matter preceding subparagraph (A), by striking ``plan, except--'' and inserting ``plan, except, subject to paragraph (4)--''; and (B) in subparagraph (B), by striking ``in the case of'' and inserting ``with respect to liens imposed before the date of the enactment of the HCBS Access Act, in the case of''; and (2) by adding at the end the following: ``(4) Notwithstanding any preceding provision of this subsection, not later than 90 days after the date of the enactment of this paragraph, a State shall-- ``(A) withdraw any lien imposed under paragraph (1)(B) that is in effect as of such date; and ``(B) notify each individual (or legal representative of such individual (or of such individual's estate)) subject to such a lien so withdrawn of the withdrawal of such lien.''. (b) Adjustments and Recoveries.--Section 1917(b) of the Social Security Act (42 U.S.C. 1396p(b)) is amended-- (1) in paragraph (1), by striking ``except that'' and inserting ``except that, subject to paragraph (6),''; and (2) by adding at the end the following: ``(6) Notwithstanding any preceding provision of this subsection, no adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be initiated, maintained, or collected on or after the date of the enactment of this paragraph. Not later than 90 days after such date, a State shall-- ``(A) withdraw any lien in effect as of such date with respect to such medical assistance correctly paid; and ``(B) notify each individual (or legal representative of such individual (or of such individual's estate)) subject to such a lien so withdrawn of the withdrawal of such lien and the prohibition on adjustment or recovery under this paragraph.''.

SEC. 111. HCBS PROVIDER TAX.

Section 1903(w) of the Social Security Act (42 U.S.C. 1396b(w)) is amended-- (1) in paragraph (7)(A)-- (A) by redesignating clause (ix) as clause (x); and (B) by inserting after clause (viii) the following new clause: ``(ix) home and community-based services.''; and (2) in paragraph (4)(C)(ii), by inserting ``for a class of health care items and services other than the class described in paragraph (7)(A)(ix),'' after ``2026,''.

SEC. 112. MEDICARE AMENDMENT.

Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42 U.S.C. 1395w-114) is amended by striking ``or subsection (c) or (d) of section 1915 or under a State plan amendment under subsection (i) of such section'' and inserting ``, section 1915, 1115A, or under a State plan amendment''.

TITLE II--RECOGNIZING THE ROLE OF DIRECT SUPPORT PROFESSIONALS

SEC. 201. FINDINGS.

Congress finds the following: (1) Direct support professionals play a critical role in the care provided to children and adults with intellectual and developmental disabilities. (2) Providers of home and community-based services are experiencing difficulty hiring and retaining direct support professionals, with a national turnover rate of 39 percent as identified in a 2023 study by the National Core Indicators. (3) High turnover rates can lead to instability for individuals receiving services, and this may result in individuals not receiving enough personalized care to help them reach their goals for independent living. (4) A discrete occupational category for direct support professionals will help States and the Federal Government-- (A) better interpret the shortage in the labor market of direct support professionals; and (B) collect data on the high turnover rate of direct support professionals. (5) The Standard Occupational Classification system is designed and maintained solely for statistical purposes, and is used by Federal statistical agencies to classify workers and jobs into occupational categories for the purpose of collecting, calculating, analyzing, or disseminating data. (6) Occupations in the Standard Occupational Classification system are classified based on work performed and, in some cases, on the skills, education, or training needed to perform the work. (7) Establishing a discrete occupational category for direct support professionals will-- (A) correct an inaccurate representation in the Standard Occupational Classification system; (B) recognize these professionals for the critical and often times overlooked work that they perform for the disabled community, which work is different than the work of a home health aide or a personal care aide; and (C) better align the Standard Occupational Classification system with related classification systems.

SEC. 202. REVISION OF STANDARD OCCUPATIONAL CLASSIFICATION SYSTEM.

(a) In General.--The Director of the Office of Management and Budget (in this Act referred to as the ``Director'') shall, as part of the first revision process of the Standard Occupational Classification system occurring after the date of enactment of this Act, consider establishing a separate code for direct support professionals as a subset of healthcare support occupations. (b) Report to Congress.--If the Director decides not to establish the separate code for direct support professionals described in subsection (a), the Director shall, not later than

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