I 

118TH CONGRESS 

1ST SESSION H. R. 547 

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 

JANUARY 26, 2023 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Better Care Better Jobs Act’’. 

6 (b) TABLE OF CONTENTS.—The table of contents for 

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Definitions. 


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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. 

1 SEC. 2. DEFINITIONS. 

2 In this Act: 

3 (1) APPROPRIATE COMMITTEES OF CON4 GRESS.—The term ‘‘appropriate committees of Con5 gress’’ means the Committee on Energy and Com6 merce of the House of Representatives, the Com7 mittee on Education and the Workforce of the 

8 House of Representatives, the Committee on Fi9 nance of the Senate, the Committee on Health, Edu10 cation, Labor, and Pensions of the Senate, and the 

11 Special Committee on Aging of the Senate. 

12 (2) DIRECT CARE WORKER; DIRECT CARE

13 WORKFORCE.—The terms ‘‘direct care worker’’ and 

14 ‘‘direct care workforce’’ mean— 

15 (A) a direct support professional; 

16 (B) a personal care attendant; 

17 (C) a direct care worker; 

18 (D) a home health aide; and 


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1 (E) any other relevant worker, as deter2 mined by the Secretary. 

3 (3) ELIGIBLE INDIVIDUAL.—The term ‘‘eligible 

4 individual’’ means an individual who is eligible for 

5 and enrolled for medical assistance under a State 

6 Medicaid program and includes an individual who 

7 becomes eligible for medical assistance under a State 

8 Medicaid program when removed from a waiting list. 

9 (4) HEALTH PLAN.—The term ‘‘health plan’’ 

10 means a group health plan or health insurance 

11 issuer (as such terms are defined in section 2791 of 

12 the Public Health Service Act (42 U.S.C. 300gg– 

13 91)). 

14 (5) HCBS PROGRAM IMPROVEMENT STATE.— 

15 The term ‘‘HCBS program improvement State’’ 

16 means a State with an HCBS infrastructure im17 provement plan approved by the Secretary under 

18 section 101(d). 

19 (6) HOME AND COMMUNITY-BASED SERV20 ICES.—The term ‘‘home and community-based serv21 ices’’ means any of the following (whether provided 

22 on a fee-for-service, risk, or other basis): 

23 (A) Home health care services authorized 

24 under paragraph (7) of section 1905(a) of the 

25 Social Security Act (42 U.S.C. 1396d(a)). 


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1 (B) Personal care services authorized 

2 under paragraph (24) of such section. 

3 (C) PACE services authorized under para4 graph (26) of such section. 

5 (D) Home and community-based services 

6 authorized under subsections (b), (c), (i), (j), 

7 and (k) of section 1915 of such Act (42 U.S.C. 

8 1396n), such services authorized under a waiver 

9 under section 1115 of such Act (42 U.S.C. 

10 1315), and such services provided through cov11 erage authorized under section 1937 of such 

12 Act (42 U.S.C. 1396u–7). 

13 (E) Case management services authorized 

14 under section 1905(a)(19) of the Social Secu15 rity Act (42 U.S.C. 1396d(a)(19)) and section 

16 1915(g) of such Act (42 U.S.C. 1396n(g)). 

17 (F) Rehabilitative services, including those 

18 related to behavioral health, described in section 

19 1905(a)(13) of such Act (42 U.S.C. 

20 1396d(a)(13)). 

21 (G) Such other services specified by the 

22 Secretary. 

23 (7) INSTITUTIONAL SETTING.—The term ‘‘insti24 tutional setting’’ means— 


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1 (A) a skilled nursing facility (as defined in 

2 section 1819(a) of the Social Security Act (42 

3 U.S.C. 1395i–3(a))); 

4 (B) a nursing facility (as defined in section 

5 1919(a) of such Act (42 U.S.C. 1396r(a))); 

6 (C) a long-term care hospital (as described 

7 in section 1886(d)(1)(B)(iv) of such Act (42 

8 U.S.C. 1395ww(d)(1)(B)(iv))); 

9 (D) an institution (or distinct part thereof) 

10 described in section 1905(d) of such Act (42 

11 U.S.C. 1396d(d)); 

12 (E) an institution (or distinct part thereof) 

13 which is a psychiatric hospital (as defined in 

14 section 1861(f) of such Act (42 U.S.C. 

15 1395x(f))) or that provides inpatient psychiatric 

16 services in another residential setting specified 

17 by the Secretary; 

18 (F) an institution (or distinct part thereof) 

19 described in section 1905(i) of such Act (42 

20 U.S.C. 1396d(i)); and 

21 (G) any other relevant facility, as deter22 mined by the Secretary. 

23 (8) MEDICAID PROGRAM.—The term ‘‘Medicaid 

24 program’’ means, with respect to a State, the State 

25 program under title XIX of the Social Security Act 


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1 (42 U.S.C. 1396 et seq.) (including any waiver or 

2 demonstration under such title or under section 

3 1115 of such Act (42 U.S.C. 1315) relating to such 

4 title). 

5 (9) SECRETARY.—The term ‘‘Secretary’’ means 

6 the Secretary of Health and Human Services. 

7 (10) STATE.—The term ‘‘State’’ has the mean8 ing given such term for purposes of title XIX of the 

9 Social Security Act (42 U.S.C. 1396 et seq.). 

10 TITLE I—EXPANDING ACCESS TO 

11 MEDICAID HOME AND COM12 MUNITY-BASED SERVICES 

13 SEC. 101. HCBS INFRASTRUCTURE IMPROVEMENT PLAN14 NING GRANTS. 

15 (a) IN GENERAL.—Not later than 12 months after 

16 the date of enactment of this Act, the Secretary shall 

17 award planning grants to States for the purpose of ex18 panding access to home and community-based services and 

19 strengthening the direct care workforce that provides such 

20 services by developing HCBS infrastructure improvement 

21 plans that meet the requirements of subsections (b) and 

22 (c). 

23 (b) CONTENT REQUIREMENTS.—In order to meet the 

24 requirements of this subsection, an HCBS infrastructure 


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1 improvement plan shall include, with respect to a State, 

2 the following: 

3 (1) EXISTING MEDICAID HCBS LANDSCAPE.— 

4 (A) ELIGIBILITY AND BENEFITS.—A de5 scription of— 

6 (i) the existing standards, pathways, 

7 and methodologies for eligibility for home 

8 and community-based services, including 

9 limits on assets and income; 

10 (ii) the home and community-based 

11 services available under the State Medicaid 

12 program; and 

13 (iii) utilization management standards 

14 for such services. 

15 (B) ACCESS.—An assessment of the extent 

16 to which home and community-based services 

17 are available to eligible individuals in the State, 

18 including— 

19 (i) estimates of the number of eligible 

20 individuals who are on a waitlist for such 

21 services; 

22 (ii) estimates of the number of indi23 viduals who would be eligible individuals 

24 but are not enrolled in the State Medicaid 

25 program or on a waitlist for such services; 


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1 (iii) a description of the home and 

2 community-based services not available 

3 under the State Medicaid program; 

4 (iv) a description of the populations 

5 for which the State is unable to provide 

6 home and community-based services under 

7 the State Medicaid program that are pro8 vided under the Medicaid programs of 

9 other States; and 

10 (v) a description of barriers to access11 ing home and community-based services 

12 identified by eligible individuals and fami13 lies of such individuals. 

14 (C) UTILIZATION.—An assessment of the 

15 utilization of home and community-based serv16 ices in the State. 

17 (D) SERVICE DELIVERY STRUCTURES.—A 

18 description of the service delivery structures for 

19 providing home and community-based services 

20 in the State, including with respect to the use 

21 and models of self-direction, the provision of 

22 services by agencies, the ownership of service 

23 provider agencies, the use of managed care 

24 versus fee-for-service to provide such services, 

25 and the supports provided for family caregivers. 


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1 (E) WORKFORCE.—A description of the 

2 characteristics of the direct care workforce that 

3 provides home and community-based services, 

4 including the number of full- and part-time di5 rect care workers, the average and range of di6 rect care worker wages, the benefits provided to 

7 direct care workers, the turnover and vacancy 

8 rates of direct care worker positions, the mem9 bership of direct care workers in labor organiza10 tions or professional organizations, and the 

11 race, ethnicity, and gender of such workforce. 

12 (F) PAYMENT RATES.—A description of 

13 the payment rates for home and community14 based services, including when such rates were 

15 last updated, an assessment of the extent to 

16 which authorized services are not delivered as a 

17 result of such rates being insufficient, and the 

18 extent to which payment rates are passed 

19 through to direct care worker wages. 

20 (G) QUALITY.—A description of how the 

21 quality of home and community-based services 

22 is measured and monitored, including how the 

23 State uses beneficiary and family caregiver ex24 perience of care surveys to assess the quality of 


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1 home and community-based services provided 

2 by the State. 

3 (H) LONG-TERM SERVICES AND SUPPORTS

4 PROVIDED IN INSTITUTIONAL SETTINGS.—A de5 scription of— 

6 (i) the extent to which eligible individ7 uals receive long-term services and sup8 ports in institutional settings in the State; 

9 and 

10 (ii) the populations provided such 

11 services and supports. 

12 (I) HCBS SHARE OF OVERALL MEDICAID

13 LTSS SPENDING.—For the most recent fiscal 

14 year for which data is available, the percentage 

15 of expenditures made by the State under the 

16 State Medicaid program for long-term services 

17 and supports that are for home and community18 based services. 

19 (J) DEMOGRAPHIC DATA.—Each assess20 ment required under subparagraphs (B) and 

21 (C), and the description required under sub22 paragraph (H)(ii) shall include, to the extent 

23 available, data disaggregated by disability sta24 tus, age, income, gender, race, ethnicity, geogVerDate Sep 11 2014 04:30 Mar 09, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H547.IH H547

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1 raphy, primary language, sexual orientation, 

2 gender identity, and type of service setting. 

3 (2) ANNUAL MEASURES AND REPORTS.—A de4 scription of the State plan for— 

5 (A) annually measuring and reporting 

6 on— 

7 (i) the availability and utilization of 

8 home and community-based services; 

9 (ii) the characteristics of the direct 

10 care workforce that provides home and 

11 community-based services and the race, 

12 ethnicity, and gender of such workforce; 

13 (iii) changes in payment rates for 

14 home and community-based services; and 

15 (iv) progress with respect to imple16 mentation of the activities, benchmarks, 

17 and improvement activities provided under 

18 subsection (jj) of section 1905 of the So19 cial Security Act (as added under section 

20 102); and 

21 (B) collecting and reporting disaggregated 

22 data by disability status, age, income, gender, 

23 race, ethnicity, geography, primary language, 

24 sexual orientation, gender identity, and type of 


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1 service setting for the information required by 

2 clause (i) of subparagraph (A). 

3 (3) IMPLEMENTATION AND GOALS FOR HCBS

4 IMPROVEMENTS.—A description of how the State 

5 will— 

6 (A) conduct the activities, benchmarks, 

7 and improvement activities provided under sub8 section (jj) of section 1905 of the Social Secu9 rity Act (as added under section 102), including 

10 how the State plans to meet the benchmarks 

11 described in paragraph (5) of such subsection 

12 and, if applicable, the additional HCBS im13 provement efforts described in paragraph (3) of 

14 such subsection; 

15 (B) identify and reduce barriers to access16 ing home and community-based services, includ17 ing for individuals in institutional settings, indi18 viduals experiencing homelessness or housing 

19 instability, and individuals in regions with low 

20 or no access to such services; 

21 (C) identify and reduce disparities in ac22 cess to, and utilization of, home and commu23 nity-based services by disability status, age, in24 come, gender, race, ethnicity, geography, priVerDate Sep 11 2014 04:30 Mar 09, 2023 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H547.IH H547

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1 mary language, sexual orientation, gender iden2 tity, and type of service setting; 

3 (D) coordinate implementation of the 

4 HCBS infrastructure improvement plan among 

5 the State Medicaid agency, agencies serving in6 dividuals with disabilities, the elderly, and other 

7 relevant State and local agencies; and 

8 (E) facilitate access to related supports by 

9 coordinating with State and local agencies and 

10 organizations that provide housing, transpor11 tation, employment, nutrition, and other serv12 ices and supports. 

13 (c) DEVELOPMENT AND SUBMISSION REQUIRE14 MENTS.—In order to meet the requirements of this sub15 section, an HCBS infrastructure improvement plan 

16 shall— 

17 (1) be developed with input from stakeholders 

18 through a public notice and comment process that 

19 includes consultation with eligible individuals who 

20 are recipients of home and community-based serv21 ices, family caregivers of such recipients, providers, 

22 health plans, direct care workers, chosen representa23 tives of direct care workers, and aging, disability, 

24 and workforce advocates; 


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1 (2) be submitted for approval by the Secretary 

2 not later than 24 months after the date on which 

3 the State was awarded the planning grant under this 

4 section; and 

5 (3) be publicly available in the final version 

6 submitted to the Secretary on a State internet 

7 website. 

8 (d) APPROVAL; PUBLICATION.— 

9 (1) IN GENERAL.—The Secretary shall approve 

10 an HCBS infrastructure improvement plan if the 

11 plan— 

12 (A) is complete; and 

13 (B) provides assurances to the satisfaction 

14 of the Secretary that the State will meet the re15 quirements of the HCBS Infrastructure Im16 provement Program established under sub17 section (jj) of section 1905 of the Social Secu18 rity Act (42 U.S.C. 1396d), as added by section 

19 102, and achieve the benchmarks for improve20 ment established by such program. 

21 (2) PUBLICATION.—The Secretary, acting 

22 through the Administrator of the Centers for Medi23 care & Medicaid Services, shall make publicly avail24 able on an internet website— 


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1 (A) the final version of each approved 

2 HCBS infrastructure improvement plan; and 

3 (B) in the case of any HCBS infrastruc4 ture improvement plan submitted for approval 

5 that is not approved— 

6 (i) the submitted plan; 

7 (ii) the decision not approving such 

8 plan; and 

9 (iii) information relating to why the 

10 plan was not approved. 

11 (e) CONTINUATION OF AMERICAN RESCUE PLAN ACT

12 INCREASED FMAP FOR HCBS FOR STATES AWARDED A

13 PLANNING GRANT.— 

14 (1) FMAP.— 

15 (A) IN GENERAL.—Notwithstanding sub16 section (b) or (ff) of section 1905 of the Social 

17 Security Act (42 U.S.C. 1396d), in the case of 

18 a State that is awarded a planning grant under 

19 this section and meets the maintenance of effort 

20 requirements under paragraph (2), the Federal 

21 medical assistance percentage determined for 

22 the State under such subsection (b) (or such 

23 subsection (ff), if applicable) and, if applicable, 

24 as increased under subsection (y), (z), (aa), or 

25 (ii) of such section, section 1915(k) of such Act 


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1 (42 U.S.C. 1396n(k)), or section 6008 of the 

2 Families First Coronavirus Response Act (Pub3 lic Law 116–127), shall be increased by 10 per4 centage points (but not to exceed 95 percent) 

5 with respect to amounts expended by the State 

6 Medicaid program for medical assistance for 

7 home and community-based services that are 

8 provided during HCBS planning period (as de9 fined in subparagraph (B)). 

10 (B) HCBS PLANNING PERIOD.—In this 

11 paragraph, the term ‘‘HCBS planning period’’ 

12 means, with respect to a State, the period— 

13 (i) beginning on the date on which the 

14 State is awarded a planning grant under 

15 this section; and 

16 (ii) ending on the earlier of— 

17 (I) the first day of the first fiscal 

18 quarter for which the State is an 

19 HCBS program improvement State; 

20 and 

21 (II) the date that is 3 years after 

22 the date on which the State is award23 ed such a grant. 

24 (C) NONAPPLICATION OF TERRITORIAL

25 FUNDING CAPS.—Any payment made to Puerto 


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1 Rico, the Virgin Islands, Guam, the Northern 

2 Mariana Islands, or American Samoa for ex3 penditures on medical assistance that are sub4 ject to the Federal medical assistance percent5 age increase specified under subparagraph (A) 

6 shall not be taken into account for purposes of 

7 applying payment limits under subsections (f) 

8 and (g) of section 1108 of the Social Security 

9 Act (42 U.S.C. 1308). 

10 (2) MAINTENANCE OF EFFORT REQUIRE11 MENTS.—For purposes of paragraph (1)(A), the re12 quirements of this paragraph are, with respect to 

13 the period for which a State is awarded a planning 

14 grant under this section, the State shall not— 

15 (A) lower the amount, duration, or scope 

16 of home and community-based services available 

17 under the State Medicaid program (relative to 

18 the services available under the program as of 

19 the date on which the State was awarded such 

20 grant); or 

21 (B) adopt more restrictive standards, 

22 methodologies, or procedures for determining 

23 eligibility, benefits, or services for receipt of 

24 home and community-based services under the 

25 State Medicaid program, including with respect 


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1 to utilization management or cost-sharing, than 

2 the standards, methodologies, or procedures ap3 plicable as of the date on which the State was 

4 awarded such grant. 

5 (f) FUNDING.— 

6 (1) IN GENERAL.—Out of any funds in the 

7 Treasury not otherwise appropriated, there is appro8 priated to the Secretary for purposes of awarding 

9 planning grants under this section, $100,000,000 

10 for fiscal year 2024, to remain available until ex11 pended. 

12 (2) TECHNICAL ASSISTANCE AND GUIDANCE.— 

13 The Secretary shall reserve $5,000,000 of the 

14 amount appropriated under paragraph (1) for pur15 poses of issuing guidance and providing technical as16 sistance to States seeking or awarded a planning 

17 grant under this section. 

18 SEC. 102. HCBS INFRASTRUCTURE IMPROVEMENT PRO19 GRAM. 

20 (a) ENHANCED FMAP FOR HCBS PROGRAM IM21 PROVEMENT STATES.—Section 1905 of the Social Secu22 rity Act (42 U.S.C. 1396d) is amended— 

23 (1) in subsection (b), by striking ‘‘and (ii)’’ and 

24 inserting ‘‘(ii), and (jj)’’; and 


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1 (2) by adding at the end the following new sub2 section: 

3 ‘‘(jj) ENHANCED FEDERAL MEDICAL ASSISTANCE

4 PERCENTAGE FOR HCBS PROGRAM IMPROVEMENT

5 STATES.— 

6 ‘‘(1) IN GENERAL.— 

7 ‘‘(A) INCREASED FEDERAL FINANCIAL

8 PARTICIPATION.—Subject to paragraph (5), in 

9 the case of a State that is an HCBS program 

10 improvement State and meets the requirements 

11 described in paragraphs (2) and (4), for each 

12 fiscal year quarter that begins on or after the 

13 first date on which a State is an HCBS pro14 gram improvement State— 

15 ‘‘(i) notwithstanding subsection (b) or 

16 (ff), subject to subparagraph (B), with re17 spect to amounts expended during the 

18 quarter by such State for medical assist19 ance for home and community-based serv20 ices, the Federal medical assistance per21 centage for such State and quarter (as de22 termined for the State under subsection 

23 (b) and, if applicable, increased under sub24 section (y), (z), (aa), or (ii), or section 

25 6008(a) of the Families First Coronavirus 


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1 Response Act) shall be increased by 10 

2 percentage points (but not to exceed 95 

3 percent); and 

4 ‘‘(ii) notwithstanding the per centum 

5 specified in section 1903(a)(7), with re6 spect to amounts expended during the 

7 quarter and before October 1, 2033, for 

8 administrative costs for expanding and en9 hancing home and community-based serv10 ices, including for enhancing the Medicaid 

11 data and technology infrastructure, modi12 fying rate setting processes, adopting, 

13 using, and reporting quality measures and 

14 beneficiary and family caregiver experience 

15 surveys, adopting or improving training 

16 programs for direct care workers and fam17 ily caregivers, and adopting, carrying out, 

18 or enhancing programs that register quali19 fied direct care workers or connect bene20 ficiaries to qualified direct care workers, 

21 such per centum shall be increased to 80 

22 percent. 

23 ‘‘(B) ADDITIONAL HCBS IMPROVEMENT

24 EFFORTS.—Subject to paragraph (5), in addi25 tion to the increase to the Federal medical asVerDate Sep 11 2014 04:30 Mar 09, 2023 Jkt 039200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\H547.IH H547

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1 sistance percentage under subparagraph (A)(i), 

2 with respect to amounts expended for medical 

3 assistance during the first 4 fiscal quarters 

4 throughout which an HCBS program improve5 ment State has implemented a program to sup6 port self-directed care that meets the require7 ments of paragraph (3) (in addition to meeting 

8 the requirements described in paragraph (2)), 

9 the Federal medical assistance percentage for 

10 such State and each such quarter with respect 

11 to such amounts shall be further increased by 

12 2 percentage points (but not to exceed 95 per13 cent). 

14 ‘‘(C) NONAPPLICATION OF TERRITORIAL

15 FUNDING CAPS.—Any payment made to Puerto 

16 Rico, the Virgin Islands, Guam, the Northern 

17 Mariana Islands, or American Samoa for ex18 penditures that are subject to an increase in the 

19 Federal medical assistance percentage under 

20 subparagraph (A)(i) or (B), or an increase in 

21 an applicable Federal matching percentage 

22 under subparagraph (A)(ii), shall not be taken 

23 into account for purposes of applying payment 

24 limits under subsections (f) and (g) of section 

25 1108. 


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1 ‘‘(2) REQUIREMENTS.—The requirements de2 scribed in this paragraph, with respect to a State 

3 and a fiscal year quarter, are the following: 

4 ‘‘(A) MAINTENANCE OF EFFORT.— 

5 ‘‘(i) IN GENERAL.—Except as pro6 vided under clause (ii), the State does 

7 not— 

8 ‘‘(I) lower the amount, duration, 

9 or scope of home and community10 based services available under the 

11 State plan or waiver (relative to the 

12 home and community-based services 

13 available under the plan or waiver as 

14 of the date on which the State was 

15 awarded a planning grant under sec16 tion 101 of the Better Care Better 

17 Jobs Act); or 

18 ‘‘(II) adopt more restrictive 

19 standards, methodologies, or proce20 dures for determining eligibility, bene21 fits, or services for receipt of home 

22 and community-based services, includ23 ing with respect to utilization manage24 ment or cost-sharing and the amount, 

25 duration, and scope of available home 


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1 and community-based services, than 

2 the standards, methodologies, or pro3 cedures applicable as of such date. 

4 ‘‘(ii) EXCEPTION.—On or after Octo5 ber 1, 2030, a State may modify such 

6 standards, methodologies, or procedures if 

7 the State demonstrates that such modifica8 tions shall not result in— 

9 ‘‘(I) home and community-based 

10 services that are less comprehensive 

11 or lower in amount, duration, or 

12 scope; 

13 ‘‘(II) fewer individuals (overall 

14 and within particular beneficiary pop15 ulations) receiving home and commu16 nity-based services; or 

17 ‘‘(III) increased cost-sharing for 

18 home and community-based services. 

19 ‘‘(B) ACCESS TO SERVICES.—The State 

20 enhances, expands, or strengthens home and 

21 community-based services by doing all of the 

22 following: 

23 ‘‘(i) Addressing access barriers and 

24 disparities in access or utilization identified 


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1 in the State HCBS infrastructure improve2 ment plan. 

3 ‘‘(ii) Expanding financial eligibility 

4 criteria for home and community-based 

5 services up to Federal limits. 

6 ‘‘(iii) Requiring coverage of personal 

7 care services for all eligible populations re8 ceiving home and community-based serv9 ices in the State. 

10 ‘‘(iv) Using ‘no wrong door’ programs, 

11 providing presumptive eligibility for home 

12 and community-based services, and improv13 ing home and community-based services 

14 counseling and education programs. 

15 ‘‘(v) Expanding access to behavioral 

16 health services and coordination with em17 ployment, housing, and transportation sup18 ports. 

19 ‘‘(vi) Providing supports to family 

20 caregivers, which shall include providing 

21 respite care, and may include providing 

22 such services as caregiver assessments, 

23 peer supports, or paid family caregiving. 

24 ‘‘(vii) Adopting, expanding eligibility 

25 for, or improving coverage provided under 


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1 a Medicaid buy-in program authorized 

2 under subclause (XIII), (XV), or (XVI) of 

3 section 1902(a)(10)(A)(ii). 

4 ‘‘(C) STRENGTHENED AND EXPANDED

5 WORKFORCE.— 

6 ‘‘(i) IN GENERAL.—The State 

7 strengthens and expands the direct care 

8 workforce that provides home and commu9 nity-based services by— 

10 ‘‘(I) adopting processes to ensure 

11 that payments for home and commu12 nity-based services are sufficient to 

13 ensure that care and services are 

14 available to the extent described in the 

15 State HCBS infrastructure improve16 ment plan; and 

17 ‘‘(II) updating, developing, and 

18 adopting qualification standards and 

19 training opportunities for the con20 tinuum of providers of home and com21 munity-based services, including pro22 grams for independent providers of 

23 such services and agency direct care 

24 workers, as well as unique programs 

25 and resources for family caregivers. 


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1 ‘‘(ii) PAYMENT RATES.—In carrying 

2 out clause (i)(I), the State shall— 

3 ‘‘(I) address insufficient payment 

4 rates for delivery of home and com5 munity-based services, with an empha6 sis on supporting the recruitment and 

7 retention of the direct care workforce, 

8 as identified during the period in 

9 which the State HCBS infrastructure 

10 improvement plan was developed and 

11 during subsequent years; 

12 ‘‘(II) update payment rates for 

13 home and community-based services 

14 at least every 2 years through a trans15 parent process involving meaningful 

16 input from stakeholders, including re17 cipients of home and community18 based services, family caregivers of 

19 such recipients, providers, health 

20 plans, direct care workers, chosen rep21 resentatives of direct care workers, 

22 and aging, disability, and workforce 

23 advocates; and 


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1 ‘‘(III) ensure that increases in 

2 the payment rates for home and com3 munity-based services are— 

4 ‘‘(aa) at a minimum, propor5 tionately passed through to direct 

6 care workers and in a manner 

7 that is determined with input 

8 from the stakeholders described 

9 in subclause (II); and 

10 ‘‘(bb) incorporated into pay11 ment rates for home and commu12 nity-based services provided 

13 under this title by a managed 

14 care entity (as defined in section 

15 1932(a)(1)(B)) or a prepaid in16 patient health plan or prepaid 

17 ambulatory health plan, as de18 fined in section 438.2 of title 42, 

19 Code of Federal Regulations (or 

20 any successor regulation), under 

21 a contract with the State. 

22 ‘‘(3) HCBS IMPROVEMENT TO SUPPORT SELF23 DIRECTED MODELS FOR THE DELIVERY OF SERV24 ICES.—For purposes of paragraph (1)(B), the re25 quirements of this paragraph, with respect to a 


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1 State and a fiscal year quarter, are that the State 

2 establishes directly or by contract with 1 or more 

3 non-profit entities, a program for the performance of 

4 all of the following functions: 

5 ‘‘(A) Registering qualified direct care 

6 workers and assisting beneficiaries in finding 

7 direct care workers. 

8 ‘‘(B) Undertaking activities to recruit and 

9 train independent providers to enable bene10 ficiaries to direct their own care, including by 

11 providing or coordinating training for bene12 ficiaries on self-directed care. 

13 ‘‘(C) Ensuring the safety of, and sup14 porting the quality of, care provided to bene15 ficiaries, such as by conducting background 

16 checks and addressing complaints reported by 

17 recipients of home and community-based serv18 ices. 

19 ‘‘(D) Facilitating coordination between 

20 State and local agencies and direct care workers 

21 for matters of public health, training opportuni22 ties, changes in program requirements, work23 place health and safety, or related matters. 

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1 based services through an agency with choice or 

2 similar model, including by processing applica3 ble tax information, collecting and processing 

4 timesheets, submitting claims and processing 

5 payments to such providers. 

6 ‘‘(F) To the extent a State permits bene7 ficiaries to hire a family member or individual 

8 with whom they have an existing relationship to 

9 provide home and community-based services, 

10 providing support to beneficiaries who wish to 

11 hire a caregiver who is a family member or in12 dividual with whom they have an existing rela13 tionship, such as by facilitating enrollment of 

14 such family member or individual as a provider 

15 of home and community-based services under 

16 the State plan or a waiver of such plan. 

17 ‘‘(G) Ensuring that program policies and 

18 procedures allow for cooperation with labor or19 ganizations that bargain on behalf of direct 

20 care workers in the case of a State in which the 

21 direct care workers in the State have elected to 

22 join, or form, such a labor organization, or, in 

23 the case of a State in which such workers have 

24 not joined or formed such a labor organization, 


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1 are neutral with regard to such workers joining 

2 or forming such a labor organization. 

3 ‘‘(4) QUALITY, REPORTING, AND OVERSIGHT.— 

4 The requirements described in this paragraph, with 

5 respect to a State and a fiscal year quarter, are the 

6 following: 

7 ‘‘(A) The State adopts the core quality 

8 measures for home and community-based serv9 ices developed by the Secretary under section 

10 104 of the Better Care Better Jobs Act, or an 

11 alternate set of quality measures approved by 

12 the Secretary, and, at the option of the State, 

13 expands the use of beneficiary and family care14 giver experience surveys. 

15 ‘‘(B) The State designates an HCBS om16 budsman office that— 

17 ‘‘(i) operates independently from the 

18 State Medicaid agency and managed care 

19 entities; 

20 ‘‘(ii) provides direct assistance to 

21 beneficiaries and their families; and 

22 ‘‘(iii) identifies and reports systemic 

23 problems to State officials, the public, and 

24 the Secretary. 


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1 ‘‘(C) Beginning with the 5th fiscal year 

2 quarter for which the State is an HCBS pro3 gram improvement State, and annually there4 after, the State reports on the components of 

5 the existing home and community-based serv6 ices landscape reported in the State HCBS in7 frastructure improvement plan, including with 

8 respect to— 

9 ‘‘(i) the availability and utilization of 

10 home and community-based services, 

11 disaggregated by disability status, age, in12 come, gender, race, ethnicity, geography, 

13 primary language, sexual orientation, gen14 der identity, and type of service setting; 

15 ‘‘(ii) the characteristics of the direct 

16 care workforce that provides home and 

17 community-based services workforce and 

18 the race, ethnicity, and gender of such 

19 workforce; 

20 ‘‘(iii) changes in payment rates for 

21 home and community-based services; 

22 ‘‘(iv) implementation of the activities 

23 to strengthen and expand access to home 

24 and community-based services and the di25 rect care workforce that provides such 


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1 services in accordance with the require2 ments of subparagraphs (B) and (C) of 

3 paragraph (2); 

4 ‘‘(v) if applicable, implementation of 

5 the activities described in paragraph (3); 

6 and 

7 ‘‘(vi) the progress made with respect 

8 to meeting the benchmarks for dem9 onstrating improvements required in para10 graph (5). 

11 ‘‘(5) BENCHMARKS FOR DEMONSTRATING IM12 PROVEMENTS.—An HCBS program improvement 

13 State shall cease to be eligible for an increase in the 

14 Federal medical assistance percentage under para15 graph (1)(A)(i) or (1)(B) or an increase in an appli16 cable Federal matching percentage under paragraph 

17 (1)(A)(ii) beginning with the 29th fiscal year quar18 ter that begins on or after the first date on which 

19 a State is an HCBS program improvement State, 

20 unless, not later than 90 days before the first day 

21 of such fiscal year quarter, the State submits to the 

22 Secretary a report demonstrating the following im23 provements: 

24 ‘‘(A) Increased availability of home and 

25 community-based services in the State relative 


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1 to such availability as reported in the State 

2 HCBS infrastructure improvement plan and ad3 justed for demographic changes in the State 

4 since the submission of such plan. 

5 ‘‘(B) Increased utilization and availability 

6 of home and community-based services by popu7 lations with the lowest utilization and avail8 ability of such services (as reported in the State 

9 HCBS infrastructure improvement plan) rel10 ative to the utilization of such services by such 

11 populations as reported in such plan and ad12 justed for demographic changes in the State 

13 since the submission of such plan. 

14 ‘‘(C) Evidence that a majority of direct 

15 care workers receive competitive wages and ben16 efits. 

17 ‘‘(D) With respect to the percentage of ex18 penditures made by the State for long-term 

19 services and supports that are for home and 

20 community-based services, in the case of an 

21 HCBS program improvement State for which 

22 such percentage (as reported in the State 

23 HCBS infrastructure improvement plan) was— 

24 ‘‘(i) less than 50 percent, the State 

25 demonstrates that the percentage of such 


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1 expenditures has increased to at least 50 

2 percent since the plan was approved; and 

3 ‘‘(ii) at least 50 percent, the State 

4 demonstrates that such percentage has not 

5 decreased since the plan was approved. 

6 ‘‘(6) DEFINITIONS.—In this subsection, the 

7 terms ‘direct care worker’, ‘direct care workforce’, 

8 ‘HCBS program improvement State’, and ‘home and 

9 community-based services’ have the meanings given 

10 those terms in section 2 of the Better Care Better 

11 Jobs Act.’’. 

12 SEC. 103. REPORTS; TECHNICAL ASSISTANCE; OTHER AD13 MINISTRATIVE REQUIREMENTS. 

14 (a) REPORTS.—The Secretary shall submit to the ap15 propriate committees of Congress the following reports re16 lating to the HCBS Infrastructure Improvement Program 

17 established under this title: 

18 (1) INITIAL REPORT.—Not later than 4 years 

19 after the date of enactment of this Act, a report that 

20 includes the following: 

21 (A) A description of the HCBS infrastruc22 ture improvement plans approved by the Sec23 retary under section 101(d). 

24 (B) A description of the national landscape 

25 with respect to gaps in coverage of home and 


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1 community-based services, disparities in access 

2 to, and utilization of, such services, and bar3 riers to accessing such services. 

4 (C) A description of the national landscape 

5 with respect to the direct care workforce that 

6 provides home and community-based services, 

7 including with respect to compensation, bene8 fits, and challenges to the availability of such 

9 workers. 

10 (2) SUBSEQUENT REPORTS.—Not later than 7 

11 years after the date of enactment of this Act, and 

12 every 3 years thereafter, a report that includes the 

13 following: 

14 (A) The number of HCBS program im15 provement States. 

16 (B) A summary of the progress being 

17 made by such States with respect to strength18 ening and expanding access to home and com19 munity-based services and the direct care work20 force that provides such services and meeting 

21 the benchmarks for demonstrating improve22 ments required under section 1905(jj)(5) of the 

23 Social Security Act (as added by section 102). 

24 (C) A summary of outcomes related to 

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1 ity measures and beneficiary and family care2 giver surveys. 

3 (D) A summary of the challenges and best 

4 practices reported by States in expanding ac5 cess to home and community-based services and 

6 supporting and expanding the direct care work7 force that provides such services. 

8 (b) TECHNICAL ASSISTANCE; GUIDANCE; REGULA9 TIONS.—The Secretary shall provide HCBS program im10 provement States with technical assistance related to car11 rying out the HCBS infrastructure improvement plans ap12 proved by the Secretary under section 101(d) and meeting 

13 the requirements and benchmarks for demonstrating im14 provements required under section 1905(jj) of the Social 

15 Security Act (as added by section 102) and shall issue 

16 such guidance or regulations as necessary to carry out this 

17 title and the amendments made by this title, including 

18 guidance specifying how States shall assess and track the 

19 availability of home and community-based services over 

20 time. 

21 (c) RECOMMENDATIONS TO GUIDE INFRASTRUC22 TURE IMPROVEMENT.— 

23 (1) IN GENERAL.—Not later than 18 months 

24 after the date of enactment of this Act, the Sec25 retary shall coordinate with the Secretary of Labor 


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1 and the Administrator of the Centers for Medicare 

2 & Medicaid Services for purposes of issuing rec3 ommendations for the Federal Government and for 

4 States to strengthen the direct care workforce that 

5 provides home and community-based services, in6 cluding with respect to how the Federal Government 

7 should classify the direct care workforce, how such 

8 Administrator and State Medicaid programs can en9 force and support the provision of competitive wages 

10 and benefits across the direct care workforce, includ11 ing for workers with particular skills or expertise, 

12 and how State Medicaid programs can support 

13 training opportunities and other related efforts that 

14 support the provision of quality home and commu15 nity-based services care. 

16 (2) STAKEHOLDER CONSULTATION.—In devel17 oping the recommendations required under para18 graph (1), the Secretary shall ensure that such rec19 ommendations are informed by consultation with re20 cipients of home and community-based services, fam21 ily caregivers of such recipients, providers, health 

22 plans, direct care workers, chosen representatives of 

23 direct care workers, and aging, disability, and work24 force advocates. 


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1 (d) FUNDING.—Out of any funds in the Treasury not 

2 otherwise appropriated, there is appropriated to the Sec3 retary for purposes of carrying out this section, 

4 $10,000,000 for fiscal year 2024, to remain available until 

5 expended. 

6 SEC. 104. QUALITY MEASUREMENT AND IMPROVEMENT. 

7 (a) DEVELOPMENT AND PUBLICATION OF CORE AND

8 SUPPLEMENTAL SETS OF HCBS QUALITY MEASURES.— 

9 (1) IN GENERAL.—Not later than 2 years after 

10 the date of enactment of this Act, the Secretary 

11 shall identify and publish for general comment a rec12 ommended core set and supplemental set of home 

13 and community-based services quality measures for 

14 use by State Medicaid programs, health plan and 

15 managed care entities that enter into contracts with 

16 such programs, and providers of items and services 

17 under such programs. 

18 (2) REGULAR REVIEWS AND UPDATES.—The 

19 Secretary shall review and update the recommended 

20 core set and supplemental set of home and commu21 nity-based services quality measures published under 

22 paragraph (1) not less frequently than once every 

23 year. 

24 (3) REQUIREMENTS.— 


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1 (A) INTERAGENCY COLLABORATION; 

2 STAKEHOLDER INPUT.—In developing the rec3 ommended core set and supplemental set of 

4 home and community-based services quality 

5 measures under paragraph (1), and subse6 quently reviewing and updating such core and 

7 supplemental sets, the Secretary shall— 

8 (i) collaborate with the Administrator 

9 of the Centers for Medicare & Medicaid 

10 Services, the Administrator of the Admin11 istration for Community Living, the Direc12 tor of the Agency for Healthcare Research 

13 and Quality, and the Administrator of the 

14 Substance Abuse and Mental Health Serv15 ices Administration; and 

16 (ii) ensure that such core and supple17 mental sets are informed by input from 

18 stakeholders, including recipients of home 

19 and community-based services, family care20 givers of such recipients, providers, health 

21 plans, direct care workers, chosen rep22 resentatives of direct care workers, and 

23 aging, disability, and workforce advocates. 

24 (B) REFLECTIVE OF FULL ARRAY OF

25 SERVICES.—Such recommended core set and 


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1 supplemental set of home and community-based 

2 services quality measures shall— 

3 (i) reflect the full array of home and 

4 community-based services and recipients of 

5 such services, including adults and chil6 dren; and 

7 (ii) include— 

8 (I) outcomes-based measures; 

9 (II) measures of availability of 

10 services; 

11 (III) measures of provider capac12 ity and availability; 

13 (IV) measures related to person14 centered care; 

15 (V) measures specific to self-di16 rected care; 

17 (VI) measures related to transi18 tions to and from institutional care; 

19 and 

20 (VII) beneficiary and family care21 giver surveys. 

22 (C) DEMOGRAPHICS.—Such recommended 

23 core set and supplemental set of home and com24 munity-based services quality measures shall 

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1 gated by disability status, age, income, gender, 

2 race, ethnicity, geography, primary language, 

3 sexual orientation, gender identity, and type of 

4 service setting. 

5 (4) FUNDING.—Out of any funds in the Treas6 ury not otherwise appropriated, there is appro7 priated to the Secretary for purposes of carrying out 

8 this subsection, $5,000,000 for fiscal year 2024, to 

9 remain available until expended. 

10 (b) STATE ADOPTION AND REPORTS.— 

11 (1) IN GENERAL.—Not later than 2 years after 

12 the date on which the Secretary publishes the rec13 ommended core set and supplemental set of home 

14 and community-based services quality measures 

15 under subsection (a)(1), and annually thereafter, 

16 each State Medicaid program shall use such core 

17 and supplemental sets (or an alternative set of qual18 ity measures approved by the Secretary) to report 

19 information to the Secretary regarding the quality of 

20 home and community-based services provided under 

21 such program. 

22 (2) PROCESS.—The information required under 

23 paragraph (1) shall be reported using a standardized 

24 format and procedures established by the Secretary. 

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1 gram to report such information separately or as 

2 part of the annual reports required under sections 

3 1139A(c) and 1139B(d) of the Social Security Act 

4 (42 U.S.C. 1320b–9a, 1320b–9b). 

5 (3) PUBLICATION OF QUALITY MEASURES.— 

6 Each State Medicaid program shall periodically 

7 make the information reported to the Secretary 

8 under paragraph (1) available to the public. 

9 (4) INCREASED FEDERAL MATCHING RATE FOR

10 ADOPTION AND REPORTING.—Section 1903(a)(3) of 

11 the Social Security Act (42 U.S.C. 1396b(a)(3)) is 

12 amended— 

13 (A) in subparagraph (F)(ii), by striking 

14 ‘‘plus’’ after the semicolon and inserting ‘‘and’’; 

15 and 

16 (B) by inserting after subparagraph (F), 

17 the following: 

18 ‘‘(G) 80 percent of so much of the sums 

19 expended during such quarter as are attrib20 utable to the reporting of information regarding 

21 the quality of home and community-based serv22 ices in accordance with section 104(b) of the 

23 Better Care Better Jobs Act; and’’. 


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1 TITLE II—OTHER PROVISIONS 

2 SEC. 201. MACPAC STUDY AND REPORT ON APPENDIX K 

3 EMERGENCY HOME AND COMMUNITY-BASED 

4 SERVICES (HCBS) 1915(C) WAIVERS. 

5 (a) IN GENERAL.—The Medicaid and CHIP Payment 

6 and Access Commission (referred to in this section as 

7 ‘‘MACPAC’’) shall conduct a study and submit to Con8 gress a report on the accelerated changes and emergency 

9 amendments to home and community-based services waiv10 ers under section 1915(c) of the Social Security Act (42 

11 U.S.C. 1396n(c)) approved for States during the COVID– 

12 19 pandemic using the Appendix K template issued by the 

13 Centers for Medicare & Medicaid Services on March 22, 

14 2020. 

15 (b) REPORT.—The report submitted under subsection 

16 (a) shall— 

17 (1) describe the specific types of flexibilities or 

18 other program changes adopted by States using the 

19 Appendix K template; 

20 (2) evaluate the efficiency, management, and 

21 success and failures of such flexibilities and program 

22 changes; and 

23 (3) include recommendations for legislative and 

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1 ery models that increase access to care in home and 

2 community settings. 

3 SEC. 202. MAKING PERMANENT THE STATE OPTION TO EX4 TEND PROTECTION UNDER MEDICAID FOR 

5 RECIPIENTS OF HOME AND COMMUNITY6 BASED SERVICES AGAINST SPOUSAL IMPOV7 ERISHMENT. 

8 (a) IN GENERAL.—Section 1924(h)(1)(A) of the So9 cial Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amend10 ed by striking ‘‘is described in section 

11 1902(a)(10)(A)(ii)(VI)’’ and inserting the following: ‘‘is 

12 eligible for medical assistance for home and community13 based services provided under subsection (c), (d), or (i) 

14 of section 1915, under a waiver approved under section 

15 1115, or who is eligible for such medical assistance by rea16 son of being determined eligible under section 

17 1902(a)(10)(C) or by reason of section 1902(f) or other18 wise on the basis of a reduction of income based on costs 

19 incurred for medical or other remedial care, or who is eligi20 ble for medical assistance for home and community-based 

21 attendant services and supports under section 1915(k)’’. 

22 (b) CONFORMING AMENDMENT.—Section 2404 of the 

23 Patient Protection and Affordable Care Act (42 U.S.C. 

24 1396r–5 note) is amended by striking ‘‘September 30, 


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1 2027’’ and inserting ‘‘the date of enactment of the Better 

2 Care Better Jobs Act’’. 

3 SEC. 203. PERMANENT EXTENSION OF MONEY FOLLOWS 

4 THE PERSON REBALANCING DEMONSTRA5 TION. 

6 Subparagraph (L) of section 6071(h)(1) of the Def7 icit Reduction Act of 2005 (42 U.S.C. 1396a note), as 

8 added by section 5114 of the Health Extenders, Improving 

9 Access to Medicare, Medicaid, and CHIP, and Strength10 ening Public Health Act of 2022, is amended by striking 

11 ‘‘for each of fiscal years 2024 through 2027’’ and insert12 ing ‘‘for each fiscal year after fiscal year 2023’’. 

Æ 


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