I 
117TH CONGRESS 
1ST SESSION H. R. 4131 
To amend title XIX of the Social Security Act to expand access to home 
and community-based services (HCBS) under Medicaid, and for other 
purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 24, 2021 
Mrs. DINGELL (for herself, Mr. PALLONE, Ms. SCHAKOWSKY, and Ms. MAT-
SUI) introduced the following bill; which was referred to the Committee 
on Energy and Commerce 
A BILL 
To amend title XIX of the Social Security Act to expand 
access to home and community-based services (HCBS) 
under Medicaid, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Better Care Better Jobs Act’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Definitions. 
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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 Med-
icaid for recipients of home and community-based services 
against spousal impoverishment. 
Sec. 203. Permanent extension of Money Follows the Person Rebalancing dem-
onstration. 
SEC. 2. DEFINITIONS. 
In this Act: 
(1) 
APPROPRIATE
COMMITTEES
OF
CON-
GRESS.—The term ‘‘appropriate committees of Con-
gress’’ means the Committee on Energy and Com-
merce of the House of Representatives, the Com-
mittee on Education and Labor of the House of 
Representatives, the Committee on Finance of the 
Senate, the Committee on Health, Education, Labor 
and Pensions of the Senate, and the Special Com-
mittee on Aging of the Senate. 
(2) DIRECT
CARE
WORKER; 
DIRECT
CARE 
WORKFORCE.—The terms ‘‘direct care worker’’ and 
‘‘direct care workforce’’ mean— 
(A) a direct support professional; 
(B) a personal care attendant; 
(C) a direct care worker; 
(D) a home health aide; and 
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(E) any other relevant worker, as deter-
mined by the Secretary. 
(3) ELIGIBLE INDIVIDUAL.—The term ‘‘eligible 
individual’’ means an individual who is eligible for 
and enrolled for medical assistance under a State 
Medicaid program and includes an individual who 
becomes eligible for medical assistance under a State 
Medicaid program when removed from a waiting list. 
(4) HEALTH PLAN.—The term ‘‘health plan’’ 
means a group health plan or health insurance 
issuer (as such terms are defined in section 2791 of 
the Public Health Service Act (42 U.S.C. 300gg– 
91)). 
(5) HCBS PROGRAM IMPROVEMENT STATE.— 
The term ‘‘HCBS program improvement State’’ 
means a State with an HCBS infrastructure im-
provement plan approved by the Secretary under 
section 101(d). 
(6) HOME
AND
COMMUNITY-BASED
SERV-
ICES.—The term ‘‘home and community-based serv-
ices’’ means any of the following (whether provided 
on a fee-for-service, risk, or other basis): 
(A) Home health care services authorized 
under paragraph (7) of section 1905(a) of the 
Social Security Act (42 U.S.C. 1396d(a)). 
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(B) Personal care services authorized 
under paragraph (24) of such section. 
(C) PACE services authorized under para-
graph (26) of such section. 
(D) Home and community-based services 
authorized under subsections (b), (c), (i), (j), 
and (k) of section 1915 of such Act (42 U.S.C. 
1396n), such services authorized under a waiver 
under section 1115 of such Act (42 U.S.C. 
1315), and such services provided through cov-
erage authorized under section 1937 of such 
Act (42 U.S.C. 1396u–7). 
(E) Case management services authorized 
under section 1905(a)(19) of the Social Secu-
rity Act (42 U.S.C. 1396d(a)(19)) and section 
1915(g) of such Act (42 U.S.C. 1396n(g)). 
(F) Rehabilitative services, including those 
related to behavioral health, described in section 
1905(a)(13) 
of 
such 
Act 
(42 
U.S.C. 
1396d(a)(13)). 
(G) Such other services specified by the 
Secretary. 
(7) INSTITUTIONAL SETTING.—The term ‘‘insti-
tutional setting’’ means— 
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(A) a skilled nursing facility (as defined in 
section 1819(a) of the Social Security Act (42 
U.S.C. 1395i–3(a))); 
(B) a nursing facility (as defined in section 
1919(a) of such Act (42 U.S.C. 1396r(a))); 
(C) a long-term care hospital (as described 
in section 1886(d)(1)(B)(iv) of such Act (42 
U.S.C. 1395ww(d)(1)(B)(iv))); 
(D) an institution (or distinct part thereof) 
described in section 1905(d) of such Act (42 
U.S.C. 1396d(d))); 
(E) an institution (or distinct part thereof) 
which is a psychiatric hospital (as defined in 
section 1861(f) of such Act (42 U.S.C. 
1395x(f))) or that provides inpatient psychiatric 
services in another residential setting specified 
by the Secretary; 
(F) an institution (or distinct part thereof) 
described in section 1905(i) of such Act (42 
U.S.C. 1396d(i)); and 
(G) any other relevant facility, as deter-
mined by the Secretary. 
(8) MEDICAID PROGRAM.—The term ‘‘Medicaid 
program’’ means, with respect to a State, the State 
program under title XIX of the Social Security Act 
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(42 U.S.C. 1396 et seq.) (including any waiver or 
demonstration under such title or under section 
1115 of such Act (42 U.S.C. 1315) relating to such 
title). 
(9) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(10) STATE.—The term ‘‘State’’ has the mean-
ing given such term for purposes of title XIX of the 
Social Security Act (42 U.S.C. 1396 et seq.). 
TITLE I—EXPANDING ACCESS TO 
MEDICAID HOME AND COM-
MUNITY-BASED SERVICES 
SEC. 101. HCBS INFRASTRUCTURE IMPROVEMENT PLAN-
NING GRANTS. 
(a) IN GENERAL.—Not later than 12 months after 
the date of enactment of this Act, the Secretary shall 
award planning grants to States for the purpose of ex-
panding access to home and community-based services and 
strengthening the direct care workforce that provides such 
services by developing HCBS infrastructure improvement 
plans that meet the requirements of subsections (b) and 
(c). 
(b) CONTENT REQUIREMENTS.—In order to meet the 
requirements of this subsection, an HCBS infrastructure 
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improvement plan shall include, with respect to a State, 
the following: 
(1) EXISTING MEDICAID HCBS LANDSCAPE.— 
(A) ELIGIBILITY AND BENEFITS.—A de-
scription of— 
(i) the existing standards, pathways, 
and methodologies for eligibility for home 
and community-based services, including 
limits on assets and income; 
(ii) the home and community-based 
services available under the State Medicaid 
program; and 
(iii) utilization management standards 
for such services. 
(B) ACCESS.—An assessment of the extent 
to which home and community-based services 
are available to eligible individuals in the State, 
including— 
(i) estimates of the number of eligible 
individuals who are on a waitlist for such 
services; 
(ii) estimates of the number of indi-
viduals who would be eligible individuals 
but are not enrolled in the State Medicaid 
program or on a waitlist for such services; 
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home and community-based services provided 
by the State. 
(H) LONG-TERM SERVICES AND SUPPORTS 
PROVIDED IN INSTITUTIONAL SETTINGS.—A de-
scription of— 
(i) the extent to which eligible individ-
uals receive long-term services and sup-
ports in institutional settings in the State; 
and 
(ii) the populations provided such 
services and supports. 
(I) HCBS SHARE OF OVERALL MEDICAID 
LTSS
SPENDING.—For the most recent fiscal 
year for which data is available, the percentage 
of expenditures made by the State under the 
State Medicaid program for long-term services 
and supports that are for home and community- 
based services. 
(J) DEMOGRAPHIC
DATA.—Each assess-
ment required under subparagraphs (B) and 
(C), and the description required under sub-
paragraph (H)(ii) shall include, to the extent 
available, data disaggregated by disability sta-
tus, age, income, gender, race, ethnicity, geog-
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raphy, primary language, sexual orientation, 
gender identity, and type of service setting. 
(2) ANNUAL MEASURES AND REPORTS.—A de-
scription of the State plan for— 
(A) annually measuring and reporting 
on— 
(i) the availability and utilization of 
home and community-based services; 
(ii) the characteristics of the direct 
care workforce that provides home and 
community-based services and the race, 
ethnicity, and gender of such workforce; 
(iii) changes in payment rates for 
home and community-based services; and 
(iv) progress with respect to imple-
mentation of the activities, benchmarks, 
and improvement activities provided under 
subsection (jj) of section 1905 of the So-
cial Security Act (as added under section 
102); and 
(B) collecting and reporting disaggregated 
data by disability status, age, income, gender, 
race, ethnicity, geography, primary language, 
sexual orientation, gender identity, and type of 
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service setting for the information required by 
clause (i) of subparagraph (A). 
(3) IMPLEMENTATION AND GOALS FOR HCBS 
IMPROVEMENTS.—A description of how the State 
will— 
(A) conduct the activities, benchmarks, 
and improvement activities provided under sub-
section (jj) of section 1905 of the Social Secu-
rity Act (as added under section 102), including 
how the State plans to meet the benchmarks 
described in paragraph (5) of such subsection 
and, if applicable, the additional HCBS im-
provement efforts described in paragraph (3) of 
such subsection; 
(B) identify and reduce barriers to access-
ing home and community-based services, includ-
ing for individuals in institutional settings, indi-
viduals experiencing homelessness or housing 
instability, and individuals in regions with low 
or no access to such services; 
(C) identify and reduce disparities in ac-
cess to, and utilization of, home and commu-
nity-based services by disability status, age, in-
come, gender, race, ethnicity, geography, pri-
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mary language, sexual orientation, gender iden-
tity, and type of service setting; 
(D) coordinate implementation of the 
HCBS infrastructure improvement plan among 
the State Medicaid agency, agencies serving in-
dividuals with disabilities, the elderly, and other 
relevant State and local agencies; and 
(E) facilitate access to related supports by 
coordinating with State and local agencies and 
organizations that provide housing, transpor-
tation, employment, nutrition, and other serv-
ices and supports. 
(c) DEVELOPMENT
AND
SUBMISSION
REQUIRE-
MENTS.—In order to meet the requirements of this sub-
section, an HCBS infrastructure improvement plan 
shall— 
(1) be developed with input from stakeholders 
through a public notice and comment process that 
includes consultation with eligible individuals who 
are recipients of home and community-based serv-
ices, family caregivers of such recipients, providers, 
health plans, direct care workers, chosen representa-
tives of direct care workers, and aging, disability, 
and workforce advocates; 
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(2) be submitted for approval by the Secretary 
not later than 24 months after the date on which 
the State was awarded the planning grant under this 
section; and 
(3) be publicly available in the final version 
submitted to the Secretary on a State Internet 
website. 
(d) APPROVAL; PUBLICATION.— 
(1) IN GENERAL.—The Secretary shall approve 
an HCBS infrastructure improvement plan if the 
plan— 
(A) is complete; and 
(B) provides assurances to the satisfaction 
of the Secretary that the State will meet the re-
quirements of the HCBS Infrastructure Im-
provement Program established under sub-
section (jj) of section 1905 of the Social Secu-
rity Act (42 U.S.C. 1396d), as added by section 
102, and achieve the benchmarks for improve-
ment established by such program. 
(2) 
PUBLICATION.—The 
Secretary, 
acting 
through the Administrator of the Centers for Medi-
care & Medicaid Services, shall make publicly avail-
able on an Internet website— 
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(A) the final version of each approved 
HCBS infrastructure improvement plan; and 
(B) in the case of any HCBS infrastruc-
ture improvement plan submitted for approval 
that is not approved— 
(i) the submitted plan; 
(ii) the decision not approving such 
plan; and 
(iii) information relating to why the 
plan was not approved. 
(e) CONTINUATION OF AMERICAN RESCUE PLAN ACT 
INCREASED FMAP FOR HCBS FOR STATES AWARDED A 
PLANNING GRANT.— 
(1) FMAP.— 
(A) IN
GENERAL.—Notwithstanding sub-
sections (b) or (ff) of section 1905 of the Social 
Security Act (42 U.S.C. 1396d), subject to sub-
paragraph (C), in the case of a State that is 
awarded a planning grant under this section 
and meets the maintenance of effort require-
ments under paragraph (2), the Federal med-
ical assistance percentage determined for the 
State under such subsection (b) (or such sub-
section (ff), if applicable) and, if applicable, as 
increased under subsection (y), (z), (aa), or (ii) 
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of such section, section 1915(k) of such Act (42 
U.S.C. 1396n(k)), or section 6008 of the Fami-
lies First Coronavirus Response Act (Public 
Law 116–127), shall be increased by 10 per-
centage points (but not to exceed 95 percent) 
with respect to amounts expended by the State 
Medicaid program for medical assistance for 
home and community-based services that are 
provided during HCBS planning period (as de-
fined in subparagraph (B)). 
(B) HCBS PLANNING
PERIOD.—In this 
paragraph, the term ‘‘HCBS planning period’’ 
means, with respect to a State, the period— 
(i) beginning on the date on which the 
State is awarded a planning grant under 
this section; and 
(ii) ending on the earlier of— 
(I) the first day of the first fiscal 
quarter for which the State is an 
HCBS program improvement State; 
and 
(II) the date that is 3 years after 
the date on which the State is award-
ed such a grant. 
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(C) RULE OF APPLICATION IN CASE OF 
OVERLAP WITH PERIOD FOR AMERICAN RESCUE 
PLAN INCREASE.—If the HCBS planning period 
for a State begins during the HCBS program 
improvement period (as defined under sub-
section (a)(2)(A) of section 9817 of the Amer-
ican Rescue Plan Act (Public Law 117–2)), and 
the State meets the HCBS program require-
ments under subsection (b) of such section, the 
increase in the Federal medical assistance per-
centage that would otherwise apply to the State 
under subparagraph (A) of this paragraph shall 
not apply during any portion of the HCBS pro-
gram improvement period (as defined under 
subsection (a)(2)(A) of section 9817 of the 
American Rescue Plan Act (Public Law 117– 
2)) for which the State receives an increase in 
the Federal medical assistance percentage in 
accordance with that section. 
(D) NONAPPLICATION
OF
TERRITORIAL 
FUNDING CAPS.—Any payment made to Puerto 
Rico, the Virgin Islands, Guam, the Northern 
Mariana Islands, or American Samoa for ex-
penditures on medical assistance that are sub-
ject to the Federal medical assistance percent-
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age increase specified under subparagraph (A) 
shall not be taken into account for purposes of 
applying payment limits under subsections (f) 
and (g) of section 1108 of the Social Security 
Act (42 U.S.C. 1308). 
(2) 
MAINTENANCE
OF
EFFORT
REQUIRE-
MENTS.—For purposes of paragraph (1)(A), the re-
quirements of this paragraph are, with respect to 
the period for which a State is awarded a planning 
grant under this section, the State shall not— 
(A) lower the amount, duration, or scope 
of home and community-based services available 
under the State Medicaid program (relative to 
the services available under the program as of 
the date on which the State was awarded such 
grant); or 
(B) adopt more restrictive standards, 
methodologies, or procedures for determining 
eligibility, benefits, or services for receipt of 
home and community-based services under the 
State Medicaid program, including with respect 
to utilization management or cost-sharing, than 
the standards, methodologies, or procedures ap-
plicable as of the date on which the State was 
awarded such grant. 
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(f) FUNDING.— 
(1) IN
GENERAL.—Out of any funds in the 
Treasury not otherwise appropriated, there is appro-
priated to the Secretary for purposes of awarding 
planning grants under this section, $100,000,000 
for fiscal year 2022, to remain available until ex-
pended. 
(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 seeking or awarded a planning 
grant under this section. 
SEC. 102. HCBS INFRASTRUCTURE IMPROVEMENT PRO-
GRAM. 
(a) ENHANCED 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) ENHANCED FEDERAL MEDICAL ASSISTANCE 
PERCENTAGE
FOR
HCBS PROGRAM
IMPROVEMENT 
STATES.— 
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‘‘(1) IN GENERAL.— 
‘‘(A) INCREASED
FEDERAL
FINANCIAL 
PARTICIPATION.—Subject to paragraph (5), in 
the case of a State that is an HCBS program 
improvement State and meets the requirements 
described in paragraphs (2) and (4), for each 
fiscal year quarter that begins on or after the 
first date on which a State is an HCBS pro-
gram improvement State— 
‘‘(i) 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-
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 10 
percentage points (but not to exceed 95 
percent); and 
‘‘(ii) notwithstanding the per centum 
specified in section 1903(a)(7), with re-
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spect to amounts expended during the 
quarter and before October 1, 2031, for 
administrative costs for expanding and en-
hancing home and community-based serv-
ices, including for enhancing the Medicaid 
data and technology infrastructure, modi-
fying rate setting processes, adopting, 
using, and reporting quality measures and 
beneficiary and family caregiver experience 
surveys, adopting or improving training 
programs for direct care workers and fam-
ily caregivers, and adopting, carrying out, 
or enhancing programs that register quali-
fied direct care workers or connect bene-
ficiaries to qualified direct care workers, 
such per centum shall be increased to 80 
percent. 
‘‘(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), 
with respect to amounts expended for medical 
assistance during the first 4 fiscal quarters 
throughout which an HCBS program improve-
ment State has implemented a program to sup-
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port self-directed care that meets the require-
ments of paragraph (3) (in addition to meeting 
the requirements described in paragraph (2)), 
the Federal medical assistance percentage for 
such State and each such quarter with respect 
to such amounts shall be further increased by 
2 percentage points (but not to exceed 95 per-
cent). 
‘‘(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. 
‘‘(2) REQUIREMENTS.—The requirements de-
scribed in this paragraph, with respect to a State 
and a fiscal year quarter, are the following: 
‘‘(A) MAINTENANCE OF EFFORT.— 
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‘‘(i) IN
GENERAL.—Except as pro-
vided under clause (ii), the State does 
not— 
‘‘(I) lower the amount, duration, 
or scope of home and community- 
based services available under the 
State plan or waiver (relative to the 
home and community-based services 
available under the plan or waiver as 
of the date on which the State was 
awarded a planning grant under sec-
tion 101 of the Better Care Better 
Jobs Act); or 
‘‘(II) 
adopt 
more 
restrictive 
standards, methodologies, or proce-
dures for determining eligibility, bene-
fits, or services for receipt of home 
and community-based services, includ-
ing with respect to utilization manage-
ment or cost-sharing and the amount, 
duration, and scope of available home 
and community-based services, than 
the standards, methodologies, or pro-
cedures applicable as of such date. 
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‘‘(ii) EXCEPTION.—On or after Octo-
ber 1, 2028, a State may modify such 
standards, methodologies, or procedures if 
the State demonstrates that such modifica-
tions shall not result in— 
‘‘(I) home and community-based 
services that are less comprehensive 
or lower in amount, duration, or 
scope; 
‘‘(II) fewer individuals (overall 
and within particular beneficiary pop-
ulations) receiving home and commu-
nity-based services; or 
‘‘(III) increased cost-sharing for 
home and community-based services. 
‘‘(B) ACCESS
TO
SERVICES.—The State 
enhances, expands, or strengthens home and 
community-based services by doing all of the 
following: 
‘‘(i) Addressing access barriers and 
disparities in access or utilization identified 
in the State HCBS infrastructure improve-
ment plan. 
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‘‘(ii) Expanding financial eligibility 
criteria for home and community-based 
services up to Federal limits. 
‘‘(iii) Requiring coverage of personal 
care services for all eligible populations re-
ceiving home and community-based serv-
ices in the State. 
‘‘(iv) Using ‘no wrong door’ programs, 
providing presumptive eligibility for home 
and community-based services, and improv-
ing home and community-based services 
counseling and education programs. 
‘‘(v) Expanding access to behavioral 
health services and coordination with em-
ployment, housing, and transportation sup-
ports. 
‘‘(vi) Providing supports to family 
caregivers, which shall include providing 
respite care, and may include providing 
such services as caregiver assessments, 
peer supports, or paid family caregiving. 
‘‘(vii) Adopting, expanding eligibility 
for, or improving coverage provided under 
a Medicaid buy-in program authorized 
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under subclause (XIII), (XV), or (XVI) of 
section 1902(a)(10)(A)(ii). 
‘‘(C) STRENGTHENED
AND
EXPANDED 
WORKFORCE.— 
‘‘(i) 
IN
GENERAL.—The 
State 
strengthens and expands the direct care 
workforce that provides home and 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 infrastructure improve-
ment plan; and 
‘‘(II) updating, developing, and 
adopting qualification standards and 
training opportunities for the con-
tinuum of providers of home and com-
munity-based services, including pro-
grams for independent providers of 
such services and agency direct care 
workers, as well as unique programs 
and resources for family caregivers. 
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‘‘(ii) PAYMENT
RATES.—In carrying 
out clause (i)(I), the State shall— 
‘‘(I) address insufficient payment 
rates for delivery of home and com-
munity-based services, with an empha-
sis on supporting the recruitment and 
retention of the direct care workforce, 
as identified during the period in 
which the State HCBS infrastructure 
improvement plan was developed and 
during subsequent years; 
‘‘(II) update payment rates for 
home and community-based services 
at least every 2 years through a trans-
parent process involving meaningful 
input from stakeholders, including re-
cipients of home and community- 
based services, family caregivers of 
such 
recipients, 
providers, 
health 
plans, direct care workers, chosen rep-
resentatives of direct care workers, 
and aging, disability, and workforce 
advocates; and 
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‘‘(III) ensure that increases in 
the payment rates for home and com-
munity-based services are— 
‘‘(aa) at a minimum, propor-
tionately passed through to direct 
care workers and in a manner 
that is determined with input 
from the stakeholders described 
in subclause (II); and 
‘‘(bb) incorporated into pay-
ment rates for home and commu-
nity-based 
services 
provided 
under this title by a managed 
care entity (as defined in section 
1932(a)(1)(B)) or a prepaid in-
patient health plan or prepaid 
ambulatory health plan, as de-
fined in section 438.2 of title 42, 
Code of Federal Regulations (or 
any successor regulation)), under 
a contract with the State. 
‘‘(3) HCBS IMPROVEMENT TO SUPPORT SELF- 
DIRECTED MODELS FOR THE DELIVERY OF SERV-
ICES.—For purposes of paragraph (1)(B), the re-
quirements of this paragraph, with respect to a 
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State and a fiscal year quarter, are that the State 
establishes directly or by contract with 1 or more 
non-profit entities, a program for the performance of 
all of the following functions: 
‘‘(A) Registering qualified direct care 
workers and assisting beneficiaries in finding 
direct care workers. 
‘‘(B) Undertaking activities to recruit and 
train independent providers to enable 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-
ices. 
‘‘(D) Facilitating coordination between 
State and local agencies and direct care workers 
for matters of public health, training opportuni-
ties, changes in program requirements, work-
place health and safety, or related matters. 
‘‘(E) Supporting beneficiary hiring of inde-
pendent providers of home and community- 
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based services through an agency with choice or 
similar model, including by processing applica-
ble tax information, collecting and processing 
timesheets, submitting claims and processing 
payments to such providers. 
‘‘(F) To the extent a State permits bene-
ficiaries 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 in-
dividual with whom they have an existing rela-
tionship, such as by facilitating enrollment of 
such family member or individual as a provider 
of home and community-based services under 
the State plan or a waiver of such plan. 
‘‘(G) Ensuring that program policies and 
procedures allow for cooperation with labor or-
ganizations 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, 
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are neutral with regard to such workers joining 
or forming such a labor organization. 
‘‘(4) QUALITY, REPORTING, AND OVERSIGHT.— 
The requirements described in this paragraph, with 
respect to a State and a fiscal year quarter, are the 
following: 
‘‘(A) The State adopts the core quality 
measures for home and community-based serv-
ices developed by the Secretary under section 
104 of the Better Care Better Jobs Act, or an 
alternate set of quality measures approved by 
the Secretary, and, at the option of the State, 
expands the use of beneficiary and family care-
giver experience surveys. 
‘‘(B) The State designates an HCBS om-
budsman office that— 
‘‘(i) operates independently from the 
State Medicaid agency and managed care 
entities; 
‘‘(ii) provides direct assistance to 
beneficiaries and their families; and 
‘‘(iii) identifies and reports systemic 
problems to State officials, the public, and 
the Secretary. 
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‘‘(C) Beginning with the 5th fiscal year 
quarter for which the State is an HCBS pro-
gram improvement State, and annually there-
after, the State reports on the components of 
the existing home and community-based serv-
ices landscape reported in the State HCBS in-
frastructure improvement plan, including with 
respect to— 
‘‘(i) the availability and utilization of 
home 
and 
community-based 
services, 
disaggregated by disability status, age, in-
come, gender, race, ethnicity, geography, 
primary language, sexual orientation, gen-
der identity, and type of service setting; 
‘‘(ii) the characteristics of the direct 
care workforce that provides home and 
community-based services workforce and 
the race, ethnicity, and gender of such 
workforce; 
‘‘(iii) changes in payment rates for 
home and community-based services; 
‘‘(iv) implementation of the activities 
to strengthen and expand access to home 
and community-based services and the di-
rect care workforce that provides such 
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services in accordance with the require-
ments of subparagraphs (B) and (C) of 
paragraph (2); 
‘‘(v) if applicable, implementation of 
the activities described in paragraph (3); 
and 
‘‘(vi) the progress made with respect 
to meeting the benchmarks for dem-
onstrating improvements required in para-
graph (5). 
‘‘(5) BENCHMARKS
FOR
DEMONSTRATING
IM-
PROVEMENTS.—An HCBS program improvement 
State shall cease to be eligible for an increase in the 
Federal medical assistance percentage under para-
graph (1)(A)(i) or (1)(B) or an increase in an appli-
cable Federal matching percentage under paragraph 
(1)(A)(ii) beginning with the 29th fiscal year quar-
ter that begins on or after the first date on which 
a State is an HCBS program improvement State, 
unless, not later than 90 days before the first day 
of such fiscal year quarter, the State submits to the 
Secretary a report demonstrating the following im-
provements: 
‘‘(A) Increased availability of home and 
community-based services in the State relative 
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to such availability as reported in the State 
HCBS infrastructure improvement plan and ad-
justed for demographic changes in the State 
since the submission of such plan. 
‘‘(B) Increased utilization and availability 
of home and community-based services by popu-
lations with the lowest utilization and avail-
ability of such services (as reported in the State 
HCBS infrastructure improvement plan) rel-
ative to the utilization of such services by such 
populations as reported in such plan and ad-
justed for demographic changes in the State 
since the submission of such plan. 
‘‘(C) Evidence that a majority of direct 
care workers receive competitive wages and ben-
efits. 
‘‘(D) With respect to the percentage of ex-
penditures made by the State for long-term 
services and supports that are for home and 
community-based services, in the case of an 
HCBS program improvement State for which 
such percentage (as reported in the State 
HCBS infrastructure improvement plan) was— 
‘‘(i) less than 50 percent, the State 
demonstrates that the percentage of such 
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expenditures has increased to at least 50 
percent since the plan was approved; and 
‘‘(ii) at least 50 percent, the State 
demonstrates that such percentage has not 
decreased since the plan was approved. 
‘‘(6) DEFINITIONS.—In this subsection, the 
terms ‘direct care worker’, ‘direct care workforce’, 
‘HCBS program improvement State’, and ‘home and 
community-based services’ have the meanings given 
those terms in section 2 of the Better Care Better 
Jobs Act.’’. 
SEC. 103. REPORTS; TECHNICAL ASSISTANCE; OTHER AD-
MINISTRATIVE REQUIREMENTS. 
(a) REPORTS.—The Secretary shall submit to the ap-
propriate committees of Congress the following reports re-
lating to the HCBS Infrastructure Improvement Program 
established under this title: 
(1) INITIAL REPORT.—Not later than 4 years 
after the date of enactment of this Act, a report that 
includes the following: 
(A) A description of the HCBS infrastruc-
ture improvement plans approved by the Sec-
retary under section 101(d). 
(B) A description of the national landscape 
with respect to gaps in coverage of home and 
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community-based services, disparities in access 
to, and utilization of, such services, and bar-
riers 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, bene-
fits, and challenges to the availability of such 
workers. 
(2) SUBSEQUENT REPORTS.—Not later than 7 
years after the date of enactment of this Act, and 
every 3 years thereafter, a report that includes the 
following: 
(A) The number of HCBS program im-
provement States. 
(B) A summary of the progress being 
made by such States with respect to strength-
ening and expanding access to home and com-
munity-based services and the direct care work-
force that provides such services and meeting 
the benchmarks for demonstrating improve-
ments required under section 1905(jj)(5) of the 
Social Security Act (as added by section 102). 
(C) A summary of outcomes related to 
home and community-based services core qual-
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ity measures and beneficiary and family care-
giver surveys. 
(D) A summary of the challenges and best 
practices reported by States in expanding ac-
cess to home and community-based services and 
supporting and expanding the direct care work-
force that provides such services. 
(b) TECHNICAL ASSISTANCE; GUIDANCE; REGULA-
TIONS.—The Secretary shall provide HCBS program im-
provement States with technical assistance related to car-
rying out the HCBS infrastructure improvement plans ap-
proved by the Secretary under section 101(d) and meeting 
the requirements and benchmarks for demonstrating im-
provements required under section 1905(jj) of the Social 
Security Act (as added by section 102) and shall issue 
such guidance or regulations as necessary to carry out this 
title and the amendments made by this title, including 
guidance specifying how States shall assess and track the 
availability of home and community-based services over 
time. 
(c) RECOMMENDATIONS TO GUIDE INFRASTRUC-
TURE IMPROVEMENT.— 
(1) IN GENERAL.—Not later than 18 months 
after the date of enactment of this Act, the Sec-
retary shall coordinate with the Secretary of Labor 
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and the Administrator of the Centers for Medicare 
& Medicaid Services for purposes of issuing rec-
ommendations for the Federal Government and for 
States to strengthen the direct care workforce that 
provides home and community-based services, in-
cluding with respect to how the Federal Government 
should classify the direct care workforce, how such 
Administrator and State Medicaid programs can en-
force and support the provision of competitive wages 
and benefits across the direct care workforce, includ-
ing 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 commu-
nity-based services care. 
(2) STAKEHOLDER CONSULTATION.—In devel-
oping the recommendations required under para-
graph (1), the Secretary shall ensure that such rec-
ommendations are informed by consultation with re-
cipients of home and community-based services, fam-
ily caregivers of such recipients, providers, health 
plans, direct care workers, chosen representatives of 
direct care workers, and aging, disability, and work-
force advocates. 
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(d) FUNDING.—Out of any funds in the Treasury not 
otherwise appropriated, there is appropriated to the Sec-
retary for purposes of carrying out this section, 
$10,000,000 for fiscal year 2022, to remain available until 
expended. 
SEC. 104. QUALITY MEASUREMENT AND IMPROVEMENT. 
(a) DEVELOPMENT AND PUBLICATION OF CORE AND 
SUPPLEMENTAL SETS OF HCBS QUALITY MEASURES.— 
(1) IN GENERAL.—Not later than 2 years after 
the date of enactment of this Act, the Secretary 
shall identify and publish for general comment a rec-
ommended core set and supplemental set of home 
and community-based services quality measures for 
use by State Medicaid programs, health plan and 
managed care entities that enter into contracts with 
such programs, and providers of items and services 
under such programs. 
(2) REGULAR
REVIEWS
AND
UPDATES.—The 
Secretary shall review and update the recommended 
core set and supplemental set of home and commu-
nity-based services quality measures published under 
paragraph (1) not less frequently than once every 
year. 
(3) REQUIREMENTS.— 
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(A) 
INTERAGENCY
COLLABORATION; 
STAKEHOLDER INPUT.—In developing the rec-
ommended core set and supplemental set of 
home and community-based services quality 
measures under paragraph (1), and subse-
quently reviewing and updating such core and 
supplemental sets, the Secretary shall— 
(i) collaborate with the Administrator 
of the Centers for Medicare & Medicaid 
Services, the Administrator of the Admin-
istration for Community Living, the Direc-
tor of the Agency for Healthcare Research 
and Quality, and the Administrator of the 
Substance Abuse and Mental Health Serv-
ices Administration; and 
(ii) ensure that such core and supple-
mental sets are informed by input from 
stakeholders, including recipients of home 
and community-based services, family care-
givers of such recipients, providers, health 
plans, direct care workers, chosen rep-
resentatives of direct care workers, and 
aging, disability, and workforce advocates. 
(B) REFLECTIVE
OF
FULL
ARRAY
OF 
SERVICES.—Such recommended core set and 
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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 chil-
dren; and 
(ii) include— 
(I) outcomes-based measures; 
(II) measures of availability of 
services; 
(III) measures of provider capac-
ity and availability; 
(IV) measures related to person- 
centered care; 
(V) measures specific to self-di-
rected care; 
(VI) measures related to transi-
tions to and from institutional care; 
and 
(VII) beneficiary and family care-
giver surveys. 
(C) DEMOGRAPHICS.—Such recommended 
core set and supplemental set of home and com-
munity-based services quality measures shall 
allow for the collection of data that is 
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disaggregated by disability status, age, income, 
gender, race, ethnicity, geography, primary lan-
guage, sexual orientation, gender identity, and 
type of service setting . 
(4) FUNDING.—Out of any funds in the Treas-
ury not otherwise appropriated, there is appro-
priated to the Secretary for purposes of carrying out 
this subsection, $5,000,000 for fiscal year 2022, to 
remain available until expended. 
(b) STATE ADOPTION AND REPORTS.— 
(1) IN GENERAL.—Not later than 2 years after 
the date on which the Secretary publishes the rec-
ommended 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 qual-
ity 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 pro-
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gram to report such information separately or as 
part of the annual reports required under sections 
1139A(c) and 1139B(d) of the Social Security Act 
(42 U.S.C. 1320b–9a, 1320b–9b). 
(3) PUBLICATION
OF
QUALITY
MEASURES.— 
Each State Medicaid program shall periodically 
make the information reported to the Secretary 
under paragraph (1) available to the public. 
(4) INCREASED FEDERAL MATCHING RATE FOR 
ADOPTION AND REPORTING.—Section 1903(a)(3) of 
the Social Security Act (42 U.S.C. 1396b(a)(3)) is 
amended— 
(A) in subparagraph (F)(ii), by striking 
‘‘plus’’ after the semicolon and inserting ‘‘and’’; 
and 
(B) by inserting after subparagraph (F), 
the following: 
‘‘(G) 80 percent of so much of the sums 
expended during such quarter as are attrib-
utable to the reporting of information regarding 
the quality of home and community-based serv-
ices in accordance with section 104(b) of the 
Better Care Better Jobs Act; and’’. 
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TITLE II—OTHER PROVISIONS 
SEC. 201. MACPAC STUDY AND REPORT ON APPENDIX K 
EMERGENCY HOME AND COMMUNITY-BASED 
SERVICES (HCBS) 1915(c) WAIVERS. 
(a) IN GENERAL.—The Medicaid and CHIP Payment 
and Access Commission (referred to in this section as 
‘‘MACPAC’’) shall conduct a study and submit to Con-
gress a report on the accelerated changes and emergency 
amendments to home and community-based services waiv-
ers under section 1915(c) of the Social Security Act (42 
U.S.C. 1396n(c)) approved for States during the COVID– 
19 pandemic using the Appendix K template issued by the 
Centers for Medicare & Medicaid Services on March 22, 
2020. 
(b) REPORT.—The report submitted under subsection 
(a) shall— 
(1) describe the specific types of flexibilities or 
other program changes adopted by States using the 
Appendix K template; 
(2) evaluate the efficiency, management, and 
success and failures of such flexibilities and program 
changes; and 
(3) include recommendations for legislative and 
administrative actions to continue specific flexibili-
ties, program changes, and innovative service deliv-
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ery models that increase access to care in home and 
community settings. 
SEC. 202. MAKING PERMANENT THE STATE OPTION TO EX-
TEND PROTECTION UNDER MEDICAID FOR 
RECIPIENTS OF HOME AND COMMUNITY- 
BASED SERVICES AGAINST SPOUSAL IMPOV-
ERISHMENT. 
(a) IN GENERAL.—Section 1924(h)(1)(A) of the So-
cial Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amend-
ed 
by 
striking 
‘‘is 
described 
in 
section 
1902(a)(10)(A)(ii)(VI)’’ and inserting the following: ‘‘is 
eligible for medical assistance for home and community- 
based services provided under subsection (c), (d), or (i) 
of section 1915, under a waiver approved under section 
1115, or who is eligible for such medical assistance by rea-
son 
of 
being 
determined 
eligible 
under 
section 
1902(a)(10)(C) or by reason of section 1902(f) or other-
wise on the basis of a reduction of income based on costs 
incurred for medical or other remedial care, or who is eligi-
ble for medical assistance for home and community-based 
attendant services and supports under section 1915(k)’’. 
(b) CONFORMING AMENDMENT.—Section 2404 of the 
Patient Protection and Affordable Care Act (42 U.S.C. 
1396r–5 note) is amended by striking ‘‘September 30, 
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2023’’ and inserting ‘‘the date of enactment of the Better 
Care Better Jobs Act’’. 
SEC. 203. PERMANENT EXTENSION OF MONEY FOLLOWS 
THE PERSON REBALANCING DEMONSTRA-
TION. 
(a) IN GENERAL.—Section 6071(h) of the Deficit Re-
duction Act of 2005 (42 U.S.C. 1396a note) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (I), by inserting 
‘‘and’’ after the semicolon; 
(B) by amending subparagraph (J) to read 
as follows: 
‘‘(G) $450,000,000 for each fiscal year 
after fiscal year 2021.’’; and 
(C) by striking subparagraph (K); and 
(2) in paragraph (2), by striking ‘‘September 
30, 2023’’ and inserting ‘‘September 30 of such fis-
cal year’’. 
(b) REDISTRIBUTION
OF
UNEXPENDED
GRANT 
AWARDS.—Section 6071(e)(2) of the Deficit Reduction 
Act of 2005 (42 U.S.C. 1396a note) is amended by adding 
at the end the following new sentence: ‘‘Any portion of 
a State grant award for a fiscal year under this section 
that is unexpended by the State at the end of the fourth 
succeeding fiscal year shall be rescinded by the Secretary 
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and added to the appropriation for the fifth succeeding 
fiscal year.’’. 
Æ 
VerDate Sep 11 2014 
02:15 Jul 23, 2021
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E:\BILLS\H4131.IH
H4131
pbinns on DSKJLVW7X2PROD with BILLS