I 
118TH CONGRESS 
1ST SESSION H. R. 1493 
To amend title XIX of the Social Security Act to require coverage of, and 
expand access to, home and community-based services under the Medicaid 
program; to award grants for the creation, recruitment, training and 
education, retention, and advancement of the direct care workforce and 
to award grants to support family caregivers; and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 9, 2023 
Mrs. DINGELL (for herself and Mr. BOWMAN) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committees on Education and the Workforce, and Over-
sight and Accountability, for a period to be subsequently determined by 
the Speaker, in each case for consideration of such provisions as fall with-
in the jurisdiction of the committee concerned 
A BILL 
To amend title XIX of the Social Security Act to require 
coverage of, and expand access to, home and community- 
based services under the Medicaid program; to award 
grants for the creation, recruitment, training and edu-
cation, retention, and advancement of the direct care 
workforce and to award grants to support family care-
givers; and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘HCBS Access Act’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Definitions. 
TITLE I—REQUIRING AND EXPANDING ACCESS TO HCBS 
COVERAGE UNDER MEDICAID 
Sec. 101. Purpose. 
Sec. 102. Requiring coverage of home and community-based services under the 
Medicaid program. 
Sec. 103. Medicaid eligibility modifications. 
Sec. 104. Home and community-based services implementation plan grant pro-
gram. 
Sec. 105. Quality of services. 
Sec. 106. Reports; technical assistance; other administrative requirements. 
Sec. 107. Quality measurement and improvement. 
Sec. 108. Making permanent the State option to extend protection under Med-
icaid for recipients of home and community-based services 
against spousal impoverishment. 
Sec. 109. Permanent extension of Money Follows the Person Rebalancing dem-
onstration. 
TITLE II—RECOGNIZING THE ROLE OF DIRECT SUPPORT 
PROFESSIONALS 
Sec. 201. Findings. 
Sec. 202. Definition of direct support professional. 
Sec. 203. Revision of Standard Occupational Classification System. 
TITLE III—SUPPORT FOR THE DIRECT CARE WORKFORCE 
Sec. 301. Definitions. 
Sec. 302. Authority to establish a technical assistance center for building the 
direct care workforce. 
Sec. 303. Authority to award grants. 
Sec. 304. Project plans. 
Sec. 305. Evaluations and reports; technical assistance. 
Sec. 306. Authorization of appropriations. 
TITLE IV—EVALUATION 
Sec. 401. Evaluation of impact on access to HCBS. 
SEC. 2. DEFINITIONS. 
In this Act: 
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(1) 
DEMOGRAPHICS.—The 
term 
‘‘demo-
graphics’’ means information relating to the races, 
ethnicities, genders, sexual orientations, gender iden-
tities, geographic locations, incomes, primary lan-
guages, types of service setting, and disability types 
represented within a particular group of individuals. 
(2) PRIVATE DUTY NURSING.—The term ‘‘pri-
vate duty nursing’’ means nursing services that are 
sufficient to meet the needs of an individual who re-
quires more individualized and continuous care than 
is available from a visiting nurse or routinely pro-
vided by the nursing staff of a hospital or skilled 
nursing facility, and includes services provided to an 
individual in the individual’s own home by a reg-
istered nurse or licensed practical nurse under the 
direction of a physician. 
(3) SECRETARY.—Except as otherwise provided, 
the term ‘‘Secretary’’ means the Secretary of Health 
and Human Services. 
TITLE I—REQUIRING AND EX-
PANDING ACCESS TO HCBS 
COVERAGE UNDER MEDICAID 
SEC. 101. PURPOSE. 
It is the purpose of this title to require coverage of 
home and community-based services (in this section re-
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ferred to as ‘‘HCBS’’) under a State plan (or waiver of 
such plan) under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) for the following reasons: 
(1) To eliminate waiting lists for HCBS, which 
delay access to necessary services and civil rights for 
people with disabilities and older adults. 
(2) To build on decades of progress in serving 
people with disabilities and older adults via HCBS. 
(3) To fulfill the purposes of the Medicaid pro-
gram to provide medical assistance for those whose 
income and resources are insufficient to meet the 
costs of necessary medical services, and to provide 
rehabilitation, long-term services and supports, and 
other services to help such families and individuals 
attain or retain capability for independence or self- 
care. 
(4) To ensure that people with all kinds of dis-
abilities and with multiple disabilities, including in-
tellectual disability, cognitive disabilities, develop-
mental disabilities, behavioral health disabilities, 
physical disabilities, and substance use disorders, 
and older adults, receive the services they need to 
live in their communities. 
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(5) To streamline access to HCBS by elimi-
nating the need for States to repeatedly apply for 
waivers. 
(6) To continue to increase the capacity of com-
munity services to ensure people with disabilities and 
older adults have safe and meaningful options in the 
community and are not at risk of unnecessary insti-
tutionalization. 
(7) To act on the decades of research and prac-
tice that show everyone, including people with the 
most severe disabilities, can live in the community 
with the right services and supports. 
(8) To support over 53,000,000 unpaid family 
caregivers who are often providing complex services 
and supports to older adults and people with disabil-
ities because of a lack of affordable services, work-
force shortages, and other inefficiencies. 
(9) To improve direct care quality and address 
the decades long workforce barriers, which have been 
exacerbated by the COVID–19 pandemic, for nearly 
2,600,000 direct care professionals providing sup-
port to people with disabilities and older adults in 
their homes and communities. 
(10) To eliminate the race, gender, sexual ori-
entation, and gender identity disparities that exist in 
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accessing information and HCBS and to prevent the 
unnecessary impoverishment and institutionalization 
of black and brown individuals with disabilities and 
older adults. 
SEC. 102. REQUIRING COVERAGE OF HOME AND COMMU-
NITY-BASED SERVICES UNDER THE MED-
ICAID PROGRAM. 
(a) DEFINITION OF HOME AND COMMUNITY-BASED 
SERVICES.— 
(1) IN GENERAL.—Section 1905 of the Social 
Security Act (42 U.S.C. 1396d) is amended by add-
ing at the end the following new subsection: 
‘‘(jj) HOME AND COMMUNITY-BASED SERVICES.— 
‘‘(1) IN GENERAL.—For purposes of this title, 
the term ‘home and community-based services’ 
means those services specified in paragraph (2) fur-
nished to an eligible individual (as defined in para-
graph (3)), based on an individualized assessment 
(as described in paragraph (4)) of such individual, 
in a setting that— 
‘‘(A) meets the qualities specified in para-
graph (1) of section 441.710(a) of title 42, 
Code of Federal Regulations (or a successor 
regulation); 
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‘‘(B) is not described in paragraph (2) of 
such section (or successor regulation); and 
‘‘(C) meets such other qualities as the Sec-
retary determines appropriate. 
‘‘(2) SERVICES SPECIFIED.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), the services specified in this para-
graph are services described in any of para-
graphs (7), (8), (13)(C), (19), (20), (24), and 
(29) (as applied without regard to the reference 
to ‘September 30, 2025’) of subsection (a) or in 
any of subsections (c)(4)(B), (c)(5), (k)(1)(A), 
(k)(1)(B), or (k)(1)(D) of section 1915, includ-
ing the following: 
‘‘(i) Supported employment and inte-
grated day services. 
‘‘(ii) Personal assistance, including 
personal care attendants, direct support 
professionals, home health aides, private 
duty nursing, homemakers and chore as-
sistance, and companionship services. 
‘‘(iii) Services that enhance independ-
ence, inclusion, and full participation in 
the broader community. 
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‘‘(iv) 
Non-emergency, 
non-medical 
transportation services to facilitate commu-
nity integration. 
‘‘(v) Respite services provided in the 
individual’s home or broader community. 
‘‘(vi) Caregiver and family support 
services. 
‘‘(vii) Case management, including in-
tensive case management, fiscal inter-
mediary, and support brokerage services. 
‘‘(viii) Services which support person- 
centered planning and self-direction. 
‘‘(ix) Direct support services during 
acute hospitalizations. 
‘‘(x) Necessary medical and nursing 
services not otherwise covered which are 
necessary in order for the individual to re-
main in their home and community, includ-
ing hospice services. 
‘‘(xi) Home and community-based in-
tensive behavioral health and crisis inter-
vention services. 
‘‘(xii) Peer support services. 
‘‘(xiii) Housing support, including 
transitional housing or transitional support 
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services for individuals who are unhoused, 
and wrap-around services. 
‘‘(xiv) Necessary home modifications 
and assistive technology, including those 
which substitute for human assistance. 
‘‘(xv) Transition services to support 
an individual who is transitioning from an 
institutional setting to the community, in-
cluding appropriate services for individuals 
who are unhoused or at risk of becoming 
unhoused, and including such transition 
services provided while the individual re-
sides in an institution. 
‘‘(xvi) Any other service recommended 
by the panel convened pursuant to sub-
paragraph (B). 
‘‘(B) SPECIFICATION
OF
RECOMMENDED 
SERVICES.— 
‘‘(i) IN GENERAL.—Not later than 6 
months after the date of the enactment of 
this subparagraph, and not less frequently 
than once every 5 years thereafter, the 
Secretary shall convene an advisory panel 
(in this subparagraph referred to as the 
‘panel’) for purposes of recommending ad-
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ditional services which shall be included as 
home and community-based services under 
this paragraph. 
‘‘(ii) COMPOSITION.— 
‘‘(I) 
SELECTION.—The 
panel 
shall be composed of at least one rep-
resentative (to be selected by the Sec-
retary) from each of the following: 
‘‘(aa) Individuals with dis-
abilities receiving home and com-
munity-based services under this 
title and individuals with disabil-
ities in need of such services, in-
cluding those with physical dis-
abilities, behavioral health dis-
abilities, or intellectual or devel-
opmental disabilities, and includ-
ing older adults. 
‘‘(bb) 
Beneficiary-led 
dis-
ability rights organizations. 
‘‘(cc) Disability-led organiza-
tions. 
‘‘(dd) Disabled veterans or-
ganizations. 
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‘‘(pp) Other relevant local, 
State, and Federal home and 
community-based service systems, 
as determined by the Secretary. 
‘‘(II) REQUIREMENT FOR EQUAL 
REPRESENTATION.—The 
Secretary 
shall select an equal number of rep-
resentatives from each category de-
scribed in items (aa) through (oo) of 
subclause (I) in convening the panel. 
‘‘(iii) DUTIES.—Not later than 6 
months after a panel is convened under 
clause (i), the panel shall submit to the 
Secretary and to Congress a report recom-
mending additional services which shall be 
included as home and community-based 
services under this paragraph. Such rec-
ommended services shall be so specified 
with the goal of increasing community in-
tegration and self-determination for indi-
viduals with disabilities receiving such 
services. 
‘‘(iv) 
IMPLEMENTATION
OF
REC-
OMMENDED SERVICES.— 
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‘‘(I) IN GENERAL.—Services rec-
ommended by the panel in a report 
submitted under clause (iii) shall be 
treated as services described in sub-
paragraph (A)(xvi) for calendar quar-
ters beginning on or after the date 
that is 1 year after the date of such 
submission. 
‘‘(II) NOTIFICATION.—Not later 
than 1 year after the first report is 
submitted under clause (iii), and not 
later than 1 year after the submission 
of each subsequent such report, the 
Secretary shall notify States of any 
additions or removals of home and 
community-based services based on 
services recommended under such re-
port through State Medicaid Director 
letters. 
‘‘(3) ELIGIBLE INDIVIDUAL.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph 
(1), 
the 
term 
‘eligible 
individual’ 
means— 
‘‘(i) an individual who is determined, 
on an annual basis or on a longer basis 
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specified by the State, by a health care 
provider approved by the State under a 
process described in subparagraph (C) to 
have a functional impairment (as defined 
in subparagraph (B)) (not taking into ac-
count any items or services, or any other 
ameliorative measures, furnished to such 
individual to mitigate such impairment) 
that is expected to last at least 90 days; 
‘‘(ii) during the period that ends on 
the day before the first day of the first cal-
endar quarter beginning on or after the 
date that is 5 years after the date of the 
enactment of this subsection, an individual 
who, as of such date of enactment, is re-
ceiving or has been determined to be eligi-
ble for, home and community-based serv-
ices under this title under a waiver or 
State plan option in effect under section 
1915 or 1115, provided that the individual 
continues to meet any level of care require-
ment applicable under such waiver or plan 
option; or 
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‘‘(iii) an individual who is eligible 
under the State plan or waiver and is 
under the age of 21. 
‘‘(B) 
FUNCTIONAL
IMPAIRMENT.—For 
purposes of subparagraph (A), the term ‘func-
tional impairment’ means, with respect to an 
individual the inability of such individual to 
perform, without assistance— 
‘‘(i) 2 or more activities of daily living 
(as described in section 7702B(c)(2)(B) of 
the Internal Revenue Code of 1986); 
‘‘(ii) 2 or more instrumental activities 
of daily living (as defined for purposes of 
section 1915(k)(1)(A)); or 
‘‘(iii) 1 activity of daily living (as so 
described) and 1 instrumental activity of 
daily living (as so defined). 
‘‘(C) HEALTH CARE PROVIDER STATE AP-
PROVAL.—For purposes of subparagraph (A)(i), 
a process described in this subparagraph is a 
process established by the State to approve 
health care providers to make determinations 
described in such subparagraph that meets such 
standards as the Secretary may prescribe. 
‘‘(4) INDIVIDUALIZED ASSESSMENT.— 
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‘‘(A) IN GENERAL.—For purposes of para-
graph (1), an individualized assessment de-
scribed in this paragraph is an independent as-
sessment, with respect to an eligible indi-
vidual— 
‘‘(i) to determine a necessary level of 
services and supports to be provided, con-
sistent with an individual’s functional im-
pairments, to facilitate an individual’s 
community integration, self-determination, 
and well-being; 
‘‘(ii) to prevent the provision of un-
necessary or inappropriate care; 
‘‘(iii) to establish a person-centered 
care plan (as described in subparagraph 
(C)) for the individual; 
‘‘(iv) that includes each of the ele-
ments described in clauses (ii) through (v) 
of section 1915(i)(1)(F); and 
‘‘(v) that occurs not later than 30 
days after such individual is determined to 
be an eligible individual. 
‘‘(B) PRESUMPTION.—The assessment de-
scribed in subparagraph (A) shall be conducted 
with the presumption— 
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‘‘(i) that each eligible individual, re-
gardless of type or level of disability or 
service need, can be served in the individ-
ual’s own home and community; and 
‘‘(ii) at the option of the individual, 
that services may be self-directed (as de-
fined in section 1915(i)(1)(G)(iii)(II)). 
‘‘(C) PERSON-CENTERED
CARE
PLAN.— 
For purposes of subparagraph (A)(iii), a per-
son-centered care plan described in this sub-
paragraph is a written plan with respect to an 
individual that meets the requirements of sec-
tion 1915(i)(1)(G)(ii). 
‘‘(D) STANDARDS.—An individualized as-
sessment described in subparagraph (A) shall 
be conducted in accordance with standards 
specified by the Secretary, in consultation with 
the Administration for Community Living, 
that— 
‘‘(i) safeguard against conflicts of in-
terest; 
‘‘(ii) specify qualifications for who 
may perform such assessments; 
‘‘(iii) ensure transparency in the fur-
nishing of such assessments, including en-
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suring the provision of the results of such 
assessments that includes information in 
plain language necessary to interpret the 
methodology and results of such assess-
ments; 
‘‘(iv) ensure that the methodologies 
used in such assessments are sound and 
evidence-based; and 
‘‘(v) require such methodologies to be 
made available on the public website of the 
State and tested for reliability and validity 
by an independent evaluator.’’. 
(2) INCLUSION AS MEDICAL ASSISTANCE.—Sec-
tion 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)) is amended— 
(A) in paragraph (30), by striking ‘‘; and’’ 
and inserting a semicolon; 
(B) by redesignating paragraph (31) as 
paragraph (32); and 
(C) by inserting after paragraph (30) the 
following new paragraph: 
‘‘(31) home and community-based services (as 
defined in subsection (jj)); and’’. 
(b) MANDATORY BENEFIT.— 
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‘‘(I) is eligible for medical assistance under 
the State plan (or waiver of such plan); 
‘‘(II) is an eligible individual (as defined in 
such section); and 
‘‘(III) elects to receive such services.’’. 
(d) FEDERAL MEDICAL ASSISTANCE PERCENTAGE 
FOR HOME AND COMMUNITY-BASED SERVICES.—Section 
1905 of the Social Security Act (42 U.S.C. 1396d), as 
amended by subsection (a), is further amended— 
(1) in subsection (b), by striking ‘‘and (ii)’’ and 
inserting ‘‘(ii), and (kk)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(kk) SPECIFIED FMAP FOR HOME AND COMMU-
NITY-BASED SERVICES.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law and except as provided in paragraph 
(3), the Federal medical assistance percentage for 
amounts expended for medical assistance for home 
and community-based services (as defined in sub-
section (jj)), including any such services furnished 
under a waiver in effect under section 1915, on or 
after the date of the enactment of this subsection 
shall be equal to 100 percent. 
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‘‘(2) ACCESS TO ESSENTIAL HCBS.—As a condi-
tion of receiving the Federal medical assistance per-
centage described in paragraph (1), a State shall en-
hance, expand, or strengthen the level of home and 
community-based services offered under the State 
plan under this title (or a waiver of such a plan) as 
of the date of enactment of this subsection by doing 
all of the following: 
‘‘(A) Addressing access barriers and dis-
parities in access or utilization identified in the 
State HCBS implementation plan. 
‘‘(B) Using ‘no wrong door’ programs, pro-
viding presumptive eligibility for home and com-
munity-based services, and improving home and 
community-based services counseling and edu-
cation programs. 
‘‘(C) Providing supports to family care-
givers, which shall include providing respite 
care, and may include providing such services 
as caregiver assessments, peer supports, access 
to 
assistive 
technology, 
or 
paid 
family 
caregiving. 
‘‘(D) Adopting processes to ensure that 
payments for home and community-based serv-
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ices are sufficient to ensure that such services 
are available to eligible beneficiaries. 
‘‘(3) EXCEPTION.—The Federal medical assist-
ance percentage applicable to medical assistance for 
home and community-based services furnished to an 
individual who is only eligible for medical assistance 
under a State plan or waiver on the basis of section 
1902(a)(10)(A)(ii)(XXIV) shall be determined with-
out regard to this subsection.’’. 
(e) SUNSET OF HCBS WAIVERS.—Section 1915 of 
the Social Security Act (42 U.S.C. 1396n) is amended by 
adding at the end the following new subsection: 
‘‘(m) SUNSET OF PROVISIONS RELATING TO HOME 
AND COMMUNITY-BASED SERVICES.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), the preceding provisions of this section, 
insofar as such provisions relate to a waiver for 
home and community-based services, shall not apply 
beginning with the first calendar quarter beginning 
on or after the date that is 5 years after the date 
of the enactment of this subsection. 
‘‘(2) EXCEPTION.—The Secretary may waive 
the application of paragraph (1) for a calendar quar-
ter and a State if the State requests such a waiver 
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and the Secretary determines that such a waiver is 
appropriate.’’. 
(f) CONFORMING AMENDMENTS.— 
(1) IN GENERAL.—Title XIX of the Social Se-
curity Act (42 U.S.C. 1396 et seq.) is amended— 
(A) in section 1905(a), in the matter pre-
ceding the first numbered paragraph— 
(i) in clause (xv), by striking the 
comma at the end and inserting ‘‘, or’’; 
(ii) in clause (xvi)— 
(I) by moving the left margin 2 
ems to the left; and 
(II) by striking ‘‘, or’’ and insert-
ing a comma; and 
(iii) by striking clause (xvii); and 
(B) in section 1943(b)(5), by striking ‘‘the 
State’’ and all that follows through the period 
at the end and inserting ‘‘a determination be 
conducted on an annual basis (or on such 
longer basis as specified by the State) in ac-
cordance with section 1905(jj) for purposes of 
providing home and community-based services 
under the State plan (or waiver of such plan).’’. 
(2) EFFECTIVE DATE.— 
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(A) IN GENERAL.—Except as provided in 
subparagraph (B), the amendments made by 
this subsection shall take effect on the first day 
of the first calendar quarter that begins on or 
after the date that is 5 years after the date of 
enactment of this Act. 
(B) EXCEPTION FOR STATES AUTHORIZED 
TO CONTINUE OPERATING HCBS WAIVERS.—In 
the case of a State for which the Secretary has 
waived the application of paragraph (1) of sub-
section (m) of section 1915 of the Social Secu-
rity Act (42 U.S.C. 1396n), as added by sub-
section (e), in accordance with paragraph (2) of 
such subsection (m), clause (xvii) of section 
1905(a) of the Social Security Act shall con-
tinue to have effect with respect to such State 
for so long as paragraph (1) of such subsection 
(m) does not apply to such State. 
SEC. 103. MEDICAID ELIGIBILITY MODIFICATIONS. 
Section 1902(a)(10) of the Social Security Act (42 
U.S.C. 1396a(a)(10)) is amended— 
(1) in subparagraph (A)(i)— 
(A) in subclause (VIII), by striking ‘‘; or’’ 
and inserting a semicolon; 
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05:50 Mar 29, 2023
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