572 
(I) School-based services when the school 
is the location for provision of services if the 
services are— 
(i) authorized under section 1905(a) 
of such Act (42 U.S.C. 1396d(a)) (or 
under a waiver under section 1915(c) or 
demonstration under section 1115) ; and 
(ii) described in another subparagraph 
of this paragraph. 
(J) Such other services specified by the 
Secretary. 
(6) INSTITUTIONAL SETTING.—The term ‘‘insti-
tutional setting’’ means— 
(A) a skilled nursing facility (as defined in 
section 1819(a) of the Social Security Act (42 
U.S.C. 1395i–3(a))); 
(B) a nursing facility (as defined in section 
1919(a) of such Act (42 U.S.C. 1396r(a))); 
(C) a long-term care hospital (as described 
in section 1886(d)(1)(B)(iv) of such Act (42 
U.S.C. 1395ww(d)(1)(B)(iv))); 
(D) a facility (or distinct part thereof) de-
scribed in section 1905(d) of such Act (42 
U.S.C. 1396d(d))); 
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(E) an institution (or distinct part thereof) 
which is a psychiatric hospital (as defined in 
section 1861(f) of such Act (42 U.S.C. 
1395x(f))) or that provides inpatient psychiatric 
services in a residential setting specified by the 
Secretary; 
(F) an institution (or distinct part thereof) 
described in section 1905(i) of such Act (42 
U.S.C. 1396d(i)); and 
(G) any other relevant facility, as deter-
mined by the Secretary. 
(7) MEDICAID
ELIGIBLE
INDIVIDUAL.—The 
term ‘‘Medicaid eligible individual’’ means an indi-
vidual who is eligible for and receiving medical as-
sistance under a State Medicaid plan or a waiver 
such plan. Such term includes an individual who 
would become eligible for medical assistance and en-
rolled under a State Medicaid plan, or waiver of 
such plan, upon removal from a waiting list. 
(8) STATE
MEDICAID
PROGRAM.—The term 
‘‘State Medicaid program’’ means, with respect to a 
State, the State program under title XIX of the So-
cial Security Act (42 U.S.C. 1396 et seq.) (including 
any waiver or demonstration under such title or 
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574 
under section 1115 of such Act (42 U.S.C. 1315) re-
lating to such title). 
(9) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(10) STATE.—The term ‘‘State’’ means each of 
the 50 States, the District of Columbia, Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Is-
lands, and American Samoa. 
SEC. 30712. HCBS IMPROVEMENT PLANNING GRANTS. 
(a) FUNDING.— 
(1) IN GENERAL.—In addition to amounts oth-
erwise available, there is appropriated to the Sec-
retary for fiscal year 2022, out of any money in the 
Treasury not otherwise appropriated, $130,000,000, 
to remain available until expended, for carrying out 
this section. 
(2) TECHNICAL ASSISTANCE AND GUIDANCE.— 
The Secretary shall reserve $5,000,000 of the 
amount appropriated under paragraph (1) for pur-
poses of issuing guidance and providing technical as-
sistance to States intending to apply for, or award-
ed, a planning grant under this section, and for 
other administrative expenses related to awarding 
planning grants under this section. 
(b) AWARD AND USE OF GRANTS.— 
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(1) DEADLINE FOR AWARD OF GRANTS.—From 
the amount appropriated under subsection (a)(1), 
the Secretary, not later than 12 months after the 
date of enactment of this Act, shall solicit State re-
quests for HCBS improvement planning grants and 
award such grants to all States that meet such re-
quirements as determined by the Secretary. 
(2) CRITERIA FOR DETERMINING AMOUNT OF 
GRANTS.—The Secretary shall take into account the 
improvements a State would propose to make, con-
sistent with the areas of focus of the HCBS im-
provement plan requirements described under sub-
section (c) in determining the amount of the plan-
ning grant to be awarded to each State that requests 
such a grant. 
(3) USE OF FUNDS.—A State awarded a plan-
ning grant under this section shall use the grant to 
carry out planning activities for purposes of devel-
oping and submitting to the Secretary an HCBS im-
provement plan for the State that meets the require-
ments of subsections (c) and (d) in order to expand 
access to home and community-based services and 
strengthen the direct care workforce that provides 
such services. A State may use planning grant funds 
to support activities related to the implementation of 
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the HCBS improvement plan for the State, collect 
and report information described in subsection (c), 
identify areas for improvement to the service deliv-
ery systems for home and community-based services, 
carry out activities related to evaluating payment 
rates for home and community-based services and 
identifying improvements to update the rate setting 
process, and for such other purposes as the Sec-
retary shall specify, including the following: 
(A) Caregiver supports. 
(B) Addressing social determinants of 
health (other than housing or homelessness). 
(C) Promoting equity and addressing 
health disparities. 
(D) Promoting community integration and 
compliance with the home and community-based 
settings rule published on January 16, 2014, or 
any successor regulation. 
(E) Building partnerships. 
(F) Infrastructure investments (such as 
case management or other information tech-
nology systems). 
(c) HCBS IMPROVEMENT PLAN REQUIREMENTS.— 
In order to meet the requirements of this subsection, an 
HCBS improvement plan developed using funds awarded 
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to a State under this section shall include, with respect 
to the State and subject to subsection (d), the following: 
(1) EXISTING MEDICAID HCBS LANDSCAPE.— 
(A) ELIGIBILITY AND BENEFITS.—A de-
scription of the existing standards, pathways, 
and methodologies for eligibility (which shall be 
delineated by the State based on eligibility 
group under the State plan or waiver of such 
plan) for home and community-based services, 
including limits on assets and income, the home 
and community-based services available under 
the State Medicaid program and the types of 
settings in which they may be provided, and 
utilization management standards for such 
services. 
(B) ACCESS.— 
(i) BARRIERS.—A description of the 
barriers to accessing home and community- 
based services in the State identified by 
Medicaid eligible individuals, the families 
of such individuals, and providers of such 
services, such as barriers for individuals 
who wish to leave institutional settings, in-
dividuals experiencing homelessness or 
housing instability, and individuals in geo-
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graphical areas of the State with low or no 
access to such services. 
(ii) AVAILABILITY; UNMET NEED.—A 
summary, in accordance with guidance 
issued by the Secretary, of the extent to 
which home and community-based services 
are available to all individuals in the State 
who would be eligible for such services 
under the State Medicaid program (includ-
ing individuals who are on a waitlist for 
such services). 
(C) UTILIZATION.—An assessment of the 
utilization of home and community-based serv-
ices in the State during such period specified by 
the Secretary. 
(D) SERVICE DELIVERY STRUCTURES AND 
SUPPORTS.—A description of the service deliv-
ery structures for providing home and commu-
nity-based services in the State, including 
whether models of self-direction are used and to 
which Medicaid eligible individuals such models 
are available, the share of total services that are 
administered by agencies, the use of managed 
care and fee-for-service to provide such services, 
and the supports provided for family caregivers. 
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(E) WORKFORCE.—A description of the di-
rect care workforce that provides home and 
community-based services, including estimates 
(and a description of the methodology used to 
develop such estimates) of the number of full- 
and part-time direct care workers, the average 
and range of direct care worker wages, the ben-
efits provided to direct care workers, the turn-
over and vacancy rates of direct care worker po-
sitions, the membership of direct care workers 
in labor organizations and, to the extent the 
State has access to such data, demographic in-
formation about such workforce, including in-
formation on race, ethnicity, and gender. 
(F) PAYMENT RATES.— 
(i) IN GENERAL.—A description of the 
payment rates for home and community- 
based services, including, to the extent ap-
plicable, how payments for such services 
are factored into the development of man-
aged care capitation rates, and when the 
State last updated payment rates for home 
and community-based services, and the ex-
tent to which payment rates are passed 
through to direct care worker wages. 
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(ii) ASSESSMENT.—An assessment of 
the relationship between payment rates for 
such services and average beneficiary wait 
times for such services, provider-to-bene-
ficiary ratios in the geographic region. 
(G) QUALITY.—A description of how the 
quality of home and community-based services 
is measured and monitored. 
(H) LONG-TERM SERVICES AND SUPPORTS 
PROVIDED IN INSTITUTIONAL SETTINGS.—A de-
scription of the number of individuals enrolled 
in the State Medicaid program who receive 
items and services for greater than 30 days in 
an institutional setting that is a nursing facility 
or intermediate care facility, and the demo-
graphic information of such individuals who are 
provided such items and services in such set-
tings. 
(I) HCBS SHARE OF OVERALL MEDICAID 
LTSS SPENDING.—For the most recent State 
fiscal year for which complete data is available, 
the percentage of expenditures made by the 
State under the State Medicaid program for 
long-term services and supports that are for 
home and community-based services. 
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(J) DEMOGRAPHIC DATA.—To the extent 
available and as applicable with respect to the 
information 
required 
under 
subparagraphs 
(B),(C), and (H), demographic data for such 
information, disaggregated by age groups, pri-
mary disability, income brackets, gender, race, 
ethnicity, geography, primary language, and 
type of service setting. 
(2) GOALS FOR HCBS IMPROVEMENTS.—A de-
scription of how the State will do the following: 
(A) Conduct the activities required under 
subsection (jj) of section 1905 of the Social Se-
curity Act(as added under section 30713). 
(B) Reduce barriers and disparities in ac-
cess or utilization of home and community- 
based services in the State. 
(C) Monitor and report (with supporting 
data to the extent available and applicable 
disaggregated by age groups, primary disability, 
income brackets, gender, race, ethnicity, geog-
raphy, primary language, and type of service 
setting, on— 
(i) access to home and community- 
based services under the State Medicaid 
program, disparities in access to such serv-
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ices, and the utilization of such services; 
and 
(ii) the amount of State Medicaid ex-
penditures for home and community-based 
services under the State Medicaid program 
as a proportion of the total amount of 
State expenditures under the State Med-
icaid program for long-term services and 
supports. 
(D) Monitor and report on wages, benefits, 
and vacancy and turnover rates for direct care 
workers. 
(E) Assess and monitor the sufficiency of 
payments under the State Medicaid program 
for the specific types of home and community- 
based services available under such program for 
purposes of supporting direct care worker re-
cruitment and retention and ensuring the avail-
ability of home and community-based services. 
(F) Coordinate implementation of the 
HCBS improvement plan among the State 
Medicaid agency, agencies serving individuals 
with disabilities, agencies serving the elderly, 
and other relevant State and local agencies and 
organizations that provide related supports, 
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such as those for housing, transportation, em-
ployment, and other services and supports. 
(d) 
DEVELOPMENT
AND
APPROVAL
REQUIRE-
MENTS.— 
(1) DEVELOPMENT REQUIREMENTS.—In order 
to meet the requirements of this subsection, a State 
awarded a planning grant under this section shall 
develop an HCBS improvement plan for the State 
with input from stakeholders through a public notice 
and comment process that includes consultation with 
Medicaid eligible individuals who are recipients of 
home and community-based services, family care-
givers of such recipients, providers, health plans, di-
rect care workers, chosen representatives of direct 
care workers, and aging, disability, and workforce 
advocates. 
(2) AUTHORITY
TO
ADJUST
CERTAIN
PLAN 
CONTENT
REQUIREMENTS.—The Secretary may 
modify the requirements for any of the information 
specified in subsection (c)(1) if a State requests a 
modification and demonstrates to the satisfaction of 
the Secretary that it is impracticable for the State 
to collect and submit the information. 
(3) SUBMISSION
AND
APPROVAL.—Not later 
than 24 months after the date on which a State is 
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SEC. 30713. HCBS IMPROVEMENT PROGRAM. 
(a) INCREASED FMAP FOR HCBS PROGRAM IM-
PROVEMENT STATES.—Section 1905 of the Social Secu-
rity Act (42 U.S.C. 1396d) is amended— 
(1) in subsection (b), by striking ‘‘and (ii)’’ and 
inserting ‘‘(ii), and (jj)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(jj) ADDITIONAL SUPPORT FOR HCBS PROGRAM 
IMPROVEMENT STATES.— 
‘‘(1) IN GENERAL.— 
‘‘(A) ADDITIONAL
SUPPORT.—Subject to 
paragraph (5), in the case of a State that is an 
HCBS program improvement State, for each 
fiscal quarter that begins on or after the first 
date on which the State is an HCBS program 
improvement State— 
‘‘(i) and for which the State meets the 
requirements described in paragraphs (2) 
and (4), notwithstanding subsection (b) or 
(ff), subject to subparagraph (B), with re-
spect to amounts expended during the 
quarter by such State for medical assist-
ance for home and community-based serv-
ices, the Federal medical assistance per-
centage for such State and quarter (as de-
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termined for the State under subsection 
(b) and, if applicable, increased under sub-
section (y), (z), (aa), or (ii), or section 
6008(a) of the Families First Coronavirus 
Response Act) shall be increased by 7 per-
centage points; and 
‘‘(ii) with respect to the State meeting 
the requirements described in paragraphs 
(2) 
and 
(4), 
notwithstanding 
section 
1903(a)(7), 1903(a)(3)(F), and 1903(t), 
with respect to amounts expended during 
the quarter and before October 1, 2031, 
for administrative costs for expanding and 
enhancing home and community-based 
services, including for enhancing Medicaid 
data and technology infrastructure, modi-
fying rate setting processes, adopting or 
improving training programs for direct 
care workers and family caregivers, and 
adopting, carrying out, or enhancing pro-
grams that register direct care workers or 
connect beneficiaries to direct care work-
ers, the per centum specified in such sec-
tion shall be increased to 80 percent. 
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In no case may the application of clause (i) re-
sult in the Federal medical assistance percent-
age determined for a State being more than 95 
percent with respect to such expenditures. In no 
case shall the application of clause (ii) result in 
a reduction to the per centum otherwise speci-
fied without application of such clause. Any in-
crease pursuant to clause (ii) shall be available 
to a State before the State meets the require-
ments of paragraphs (2) and (4). 
‘‘(B) ADDITIONAL
HCBS
IMPROVEMENT 
EFFORTS.—Subject to paragraph (5), in addi-
tion to the increase to the Federal medical as-
sistance percentage under subparagraph (A)(i) 
for amounts expended during a quarter for 
medical assistance for home and community- 
based services by an HCBS program improve-
ment State that meets the requirements of 
paragraphs (2) and (4) for the quarter, the 
Federal medical assistance percentage for 
amounts expended by the State during the 
quarter for medical assistance for home and 
community-based services shall be further in-
creased by 2 percentage points (but not to ex-
ceed 95 percent) during the first 8 fiscal quar-
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ters throughout which the State has imple-
mented and has in effect a program to support 
self-directed care that meets the requirements 
of paragraph (3). 
‘‘(C) NONAPPLICATION
OF
TERRITORIAL 
FUNDING CAPS.—Any payment made to Puerto 
Rico, the Virgin Islands, Guam, the Northern 
Mariana Islands, or American Samoa for ex-
penditures that are subject to an increase in the 
Federal medical assistance percentage under 
subparagraph (A)(i) or (B), or an increase in 
an applicable Federal matching percentage 
under subparagraph (A)(ii), shall not be taken 
into account for purposes of applying payment 
limits under subsections (f) and (g) of section 
1108. 
‘‘(D) NONAPPLICATION TO CHIP EFMAP.— 
Any increase described in subparagraph (A) (or 
payment made for expenditures on medical as-
sistance that are subject to such increase) shall 
not be taken into account in calculating the en-
hanced FMAP of a State under section 2105. 
‘‘(2) REQUIREMENTS.—As conditions for re-
ceipt of the increase under paragraph (1) to the 
Federal medical assistance percentage determined 
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for a State, with respect to a fiscal year quarter, the 
State shall meet each of the following requirements: 
‘‘(A) 
NONSUPPLANTATION.—The 
State 
uses the Federal funds attributable to the in-
crease in the Federal medical assistance per-
centage for amounts expended during a quarter 
for medical assistance for home and commu-
nity-based services under subparagraphs (A) 
and, if applicable, (B) of paragraph (1) to sup-
plement, and not supplant, the level of State 
funds expended for home and community-based 
services for eligible individuals through pro-
grams in effect as of the date the State is 
awarded a planning grant under section 30712 
of the Act titled ‘An Act to provide for rec-
onciliation pursuant to title II of S. Con. Res. 
14’. In applying this subparagraph, the Sec-
retary shall provide that a State shall have a 3- 
year period to spend any accumulated unspent 
State funds attributable to the increase de-
scribed in clause (i) in the Federal medical as-
sistance percentage. 
‘‘(B) MAINTENANCE OF EFFORT.— 
‘‘(i) IN
GENERAL.—The State does 
not— 
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‘‘(I) reduce the amount, dura-
tion, or scope of home and commu-
nity-based services available under the 
State plan or waiver (relative to the 
home and community-based services 
available under the plan or waiver as 
of the date on which the State was 
awarded a planning grant under sec-
tion 30712 of the Act titled ‘An Act 
to provide for reconciliation pursuant 
to title II of S. Con. Res. 14’; 
‘‘(II) reduce payment rates for 
home and community-based services 
lower than such rates that were in 
place as of the date described in sub-
clause (I), including, to the extent ap-
plicable, payment rates for such serv-
ices that are included in managed 
care capitation rates; or 
‘‘(III) except to the extent per-
mitted under clause (ii), adopt more 
restrictive standards, methodologies, 
or procedures for determining eligi-
bility, benefits, or services for receipt 
of home and community-based serv-
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ices, including with respect to cost- 
sharing, than the standards, meth-
odologies, or procedures applicable as 
of such date. 
‘‘(ii) FLEXIBILITY TO SUPPORT INNO-
VATIVE
MODELS.—A State may make 
modifications that would otherwise violate 
the maintenance of effort described in 
clause (i) if the State demonstrates to the 
satisfaction of the Secretary that such 
modifications shall not result in— 
‘‘(I) home and community-based 
services that are less comprehensive 
or lower in amount, duration, or 
scope; 
‘‘(II) fewer individuals (overall 
and within particular eligibility groups 
and categories) receiving home and 
community-based services; or 
‘‘(III) increased cost-sharing for 
home and community-based services. 
‘‘(C) ACCESS
TO
SERVICES.—Not later 
than an implementation date as specified by the 
Secretary after the first day of the first fiscal 
quarter for which a State receives an increase 
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592 
to the Federal medical assistance percentage or 
other applicable Federal matching percentage 
under paragraph (1), the State does all of the 
following to improve access to services: 
‘‘(i) Reduce access barriers and dis-
parities in access or utilization of home 
and community-based services, as de-
scribed in the State HCBS improvement 
plan. 
‘‘(ii) Provides coverage of personal 
care services authorized under subsection 
(a)(24) for all individuals eligible for med-
ical assistance in the State. 
‘‘(iii) Provides for navigation of home 
and community-based services through ‘no 
wrong door’ programs, provides expedited 
eligibility for home and community-based 
services, and improves home and commu-
nity-based services counseling and edu-
cation programs. 
‘‘(iv) Expands access to behavioral 
health services as defined in the State’s 
HCBS improvement plan. 
‘‘(v) Improves coordination of home 
and community-based services with em-
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ployment, housing, and transportation sup-
ports. 
‘‘(vi) Provides supports to family care-
givers, such as respite care, caregiver as-
sessments, peer supports, or paid family 
caregiving. 
‘‘(vii) Adopts, expands eligibility for, 
or expands covered items and services pro-
vided under 1 or more eligibility categories 
authorized under subclause (XIII), (XV), 
or (XVI) of section 1902(a)(10)(A)(ii). 
‘‘(D) STRENGTHENED
AND
EXPANDED 
WORKFORCE.— 
‘‘(i) 
IN
GENERAL.—The 
State 
strengthens and expands the direct care 
workforce that provides home and commu-
nity-based services by— 
‘‘(I) adopting processes to ensure 
that payments for home and commu-
nity-based services are sufficient to 
ensure that care and services are 
available to the extent described in the 
State HCBS improvement plan; and 
‘‘(II) 
updating 
qualification 
standards (as appropriate), and devel-
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oping and adopting training opportu-
nities, for the continuum of providers 
of home and community-based serv-
ices, including programs for inde-
pendent providers of such services and 
agency direct care workers, as well as 
unique programs and resources for 
family caregivers. 
‘‘(ii) PAYMENT
RATES.—In carrying 
out clause (i)(I), the State shall— 
‘‘(I) update and increase, as ap-
propriate, payment rates for delivery 
of home and community-based serv-
ices to support the recruitment and 
retention of the direct care workforce; 
‘‘(II) review and, if necessary to 
ensure sufficient access to care, in-
crease payment rates for home and 
community-based services, not less 
frequently than once every 3 years, 
through a transparent process involv-
ing meaningful input from stake-
holders, including recipients of home 
and community-based services, family 
caregivers of such recipients, pro-
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viders, health plans, direct care work-
ers, chosen representatives of direct 
care workers, and aging, disability, 
and workforce advocates; and 
‘‘(III) ensure that increases in 
the payment rates for home and com-
munity-based services— 
‘‘(aa) at a minimum, results 
in a proportionate increase to 
payments for direct care workers 
and in a manner that is deter-
mined with input from the stake-
holders described in subclause 
(II); and 
‘‘(bb) incorporate into pro-
vider 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)) a pre-
paid inpatient health plan or pre-
paid ambulatory health plan, as 
defined in section 438.2 of title 
42, Code of Federal Regulations 
(or any successor regulation)), 
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under 
a 
contract 
and 
paid 
through capitation rates with the 
State. 
‘‘(3) SELF-DIRECTED MODELS FOR THE DELIV-
ERY OF SERVICES.—As conditions for receipt of the 
increase under paragraph (1)(B) to the Federal 
medical assistance percentage determined for a 
State, with respect to a fiscal year quarter, the State 
shall establish directly, or by contract with 1 or 
more non-profit entities, including an agency with 
choice or a similar service delivery model, a program 
for the performance of all of the following functions: 
‘‘(A) Registering qualified direct care 
workers and assisting beneficiaries in finding 
direct care workers. 
‘‘(B) Undertaking activities to recruit and 
train independent providers to enable bene-
ficiaries to direct their own care, including by 
providing or coordinating training for bene-
ficiaries on self-directed care. 
‘‘(C) Ensuring the safety of, and sup-
porting the quality of, care provided to bene-
ficiaries, such as by conducting background 
checks and addressing complaints reported by 
recipients of home and community-based serv-
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