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 2024, 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 disaggre-
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gated by disability status, age, income, gender, 
race, ethnicity, geography, primary language, 
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 2024, 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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