What This Bill Does
This bill requires Medicaid programs in every state to cover home and community-based services (services that help people with disabilities and older adults live in their own homes and communities instead of institutions). It also creates grants and funding to train and support direct care workers and family caregivers who provide these services.
##
Who It Affects
- People with disabilities who need long-term care services
- Older adults (age 60 and older) who need long-term care services
- Family caregivers (both paid and unpaid) caring for these individuals
- Direct care professionals (home health aides, personal care attendants, direct support professionals)
- State Medicaid programs and agencies
- Community colleges and training institutions
- Disability rights organizations and advocacy groups
##
Key Provisions
- **Medicaid must cover home and community-based services as a required benefit** for eligible individuals starting five years after the bill is enacted, including personal care assistance, day services, transportation, housing support, and behavioral health services (Sec. 102)
- **100 percent federal funding** for home and community-based services (the federal government pays the full cost to states) (Sec. 102(d))
- **States must develop implementation plans** explaining how they will provide these services, ensure stable direct care workforce wages, and eliminate service waiting lists (Sec. 104)
- **Grant programs to support direct care workers** through recruitment, training, education, and career advancement opportunities, including apprenticeships and education programs (Sec. 303)
- **Advisory panel must meet regularly** to recommend additional home and community-based services for inclusion in Medicaid coverage (Sec. 102)
- **Direct support professionals recognized as separate occupation** in the federal occupational classification system to better track workforce data (Sec. 203)
##
What Changes
If this bill becomes law, Medicaid will shift from an optional program (where states can choose to provide home and community-based services) to a required program for these services. This means:
- People with disabilities and older adults would have a guaranteed right to receive services in their homes and communities rather than being forced into nursing facilities or institutions
- States must pay for these services, but the federal government will cover the entire cost
- States must eliminate waiting lists for services
- Families caring for loved ones would receive support like respite care (temporary relief care)
- Direct care workers would have more training and career advancement opportunities
- States must develop detailed plans to ensure fair access and eliminate racial and gender disparities in who receives services
##
Important Definitions
- **Home and community-based services:** Services that help people live independently in their homes and communities, including personal care, transportation, housing support, behavioral health services, and assistance with daily activities (Sec. 102)
- **Functional impairment:** The inability to perform at least two activities of daily living (like bathing or eating) or two instrumental activities of daily living (like shopping or managing medication) without help, or one of each, expected to last at least 90 days (Sec. 102)
- **Direct support professional:** A paid worker who helps people with disabilities with daily living activities, community inclusion, employment support, and health services (Sec. 202)
- **Family caregiver:** Anyone providing unpaid or paid care to an older adult or person with a disability (Sec. 301)
- **Eligible individual:** A person with a functional impairment expected to last at least 90 days, or someone already receiving these services under current Medicaid waivers (temporary permission to provide services differently) (Sec. 102)
- **Demographics:** Information about race, ethnicity, gender, sexual orientation, gender identity, geographic location, income, language, type of service setting, and disability type (Sec. 2)
##
Effective Date
Five years after the bill is enacted (Sec. 102(b)). However, states may choose to start earlier. The advisory panel for recommending new services must meet within six months of enactment (Sec. 102).
II
118TH CONGRESS
1ST SESSION
S. 762
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 SENATE OF THE UNITED STATES
MARCH 9, 2023
Mr. CASEY (for himself, Ms. HASSAN, Mr. BROWN, Mr. KAINE, Mrs. GILLI-
BRAND, Mr. BLUMENTHAL, Mr. WELCH, Mr. FETTERMAN, Mr.
MERKLEY, Mr. SANDERS, Ms. BALDWIN, Ms. DUCKWORTH, Ms. WAR-
REN, Mr. REED, Mr. MARKEY, Mrs. SHAHEEN, and Mrs. MURRAY) intro-
duced the following bill; which was read twice and referred to the Com-
mittee on Finance
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-
1
tives of the United States of America in Congress assembled,
2
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SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
1
(a) SHORT TITLE.—This Act may be cited as the
2
‘‘HCBS Access Act’’.
3
(b) TABLE OF CONTENTS.—The table of contents of
4
this Act is as follows:
5
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.
6
In this Act:
7
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(1)
DEMOGRAPHICS.—The
term
‘‘demo-
1
graphics’’ means information relating to the races,
2
ethnicities, genders, sexual orientations, gender iden-
3
tities, geographic locations, incomes, primary lan-
4
guages, types of service setting, and disability types
5
represented within a particular group of individuals.
6
(2) PRIVATE DUTY NURSING.—The term ‘‘pri-
7
vate duty nursing’’ means nursing services that are
8
sufficient to meet the needs of an individual who re-
9
quires more individualized and continuous care than
10
is available from a visiting nurse or routinely pro-
11
vided by the nursing staff of a hospital or skilled
12
nursing facility, and includes services provided to an
13
individual in the individual’s own home by a reg-
14
istered nurse or licensed practical nurse under the
15
direction of a physician.
16
(3) SECRETARY.—Except as otherwise provided,
17
the term ‘‘Secretary’’ means the Secretary of Health
18
and Human Services.
19
TITLE I—REQUIRING AND EX-
20
PANDING ACCESS TO HCBS
21
COVERAGE UNDER MEDICAID
22
SEC. 101. PURPOSE.
23
It is the purpose of this title to require coverage of
24
home and community-based services (in this section re-
25
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•S 762 IS
ferred to as ‘‘HCBS’’) under a State plan (or waiver of
1
such plan) under title XIX of the Social Security Act (42
2
U.S.C. 1396 et seq.) for the following reasons:
3
(1) To eliminate waiting lists for HCBS, which
4
delay access to necessary services and civil rights for
5
people with disabilities and older adults.
6
(2) To build on decades of progress in serving
7
people with disabilities and older adults via HCBS.
8
(3) To fulfill the purposes of the Medicaid pro-
9
gram to provide medical assistance for those whose
10
income and resources are insufficient to meet the
11
costs of necessary medical services, and to provide
12
rehabilitation, long-term services and supports, and
13
other services to help such families and individuals
14
attain or retain capability for independence or self-
15
care.
16
(4) To ensure that people with all kinds of dis-
17
abilities and with multiple disabilities, including in-
18
tellectual disability, cognitive disabilities, develop-
19
mental disabilities, behavioral health disabilities,
20
physical disabilities, and substance use disorders,
21
and older adults, receive the services they need to
22
live in their communities.
23
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(5) To streamline access to HCBS by elimi-
1
nating the need for States to repeatedly apply for
2
waivers.
3
(6) To continue to increase the capacity of com-
4
munity services to ensure people with disabilities and
5
older adults have safe and meaningful options in the
6
community are not at risk of unnecessary institu-
7
tionalization.
8
(7) To act on the decades of research and prac-
9
tice showing that everyone, including people with the
10
most severe disabilities, can live in the community
11
with the right services and supports.
12
(8) To support over 53,000,000 unpaid family
13
caregivers who are often providing complex services
14
and supports to older adults and people with disabil-
15
ities because of a lack of affordable services, work-
16
force shortages, and other inefficiencies.
17
(9) To improve direct care quality and address
18
the decades long workforce barriers, which have been
19
exacerbated by the COVID–19 pandemic, for nearly
20
2,600,000 direct care professionals providing sup-
21
port to people with disabilities and older adults in
22
their homes and communities.
23
(10) To eliminate the race, gender, sexual ori-
24
entation, and gender identity disparities that exist in
25
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accessing information and HCBS and to prevent the
1
unnecessary impoverishment and institutionalization
2
of black and brown individuals with disabilities and
3
older adults.
4
SEC. 102. REQUIRING COVERAGE OF HOME AND COMMU-
5
NITY-BASED SERVICES UNDER THE MED-
6
ICAID PROGRAM.
7
(a) DEFINITION OF HOME AND COMMUNITY-BASED
8
SERVICES.—
9
(1) IN GENERAL.—Section 1905 of the Social
10
Security Act (42 U.S.C. 1396d) is amended by add-
11
ing at the end the following new subsection:
12
‘‘(jj) HOME AND COMMUNITY-BASED SERVICES.—
13
‘‘(1) IN GENERAL.—For purposes of this title,
14
the term ‘home and community-based services’
15
means those services specified in paragraph (2) fur-
16
nished to an eligible individual (as defined in para-
17
graph (3)), based on an individualized assessment
18
(as described in paragraph (4)) of such individual,
19
in a setting that—
20
‘‘(A) meets the qualities specified in para-
21
graph (1) of section 441.710(a) of title 42,
22
Code of Federal Regulations (or a successor
23
regulation);
24
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‘‘(B) is not described in paragraph (2) of
1
such section (or successor regulation); and
2
‘‘(C) meets such other qualities as the Sec-
3
retary determines appropriate.
4
‘‘(2) SERVICES SPECIFIED.—
5
‘‘(A) IN GENERAL.—For purposes of para-
6
graph (1), the services specified in this para-
7
graph are services described in any of para-
8
graphs (7), (8), (13)(C), (19), (20), (24), and
9
(29) (as applied without regard to the reference
10
to ‘September 30, 2025’) of subsection (a) or in
11
any of subsections (c)(4)(B), (c)(5), (k)(1)(A),
12
(k)(1)(B), or (k)(1)(D) of section 1915, includ-
13
ing the following:
14
‘‘(i) Supported employment and inte-
15
grated day services.
16
‘‘(ii) Personal assistance, including
17
personal care attendants, direct support
18
professionals, home health aides, private
19
duty nursing, homemakers and chore as-
20
sistance, and companionship services.
21
‘‘(iii) Services that enhance independ-
22
ence, inclusion, and full participation in
23
the broader community.
24
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‘‘(iv)
Non-emergency,
non-medical
1
transportation services to facilitate commu-
2
nity integration.
3
‘‘(v) Respite services provided in the
4
individual’s home or broader community.
5
‘‘(vi) Caregiver and family support
6
services.
7
‘‘(vii) Case management, including in-
8
tensive case management, fiscal inter-
9
mediary, and support brokerage services.
10
‘‘(viii) Services which support person-
11
centered planning and self-direction.
12
‘‘(ix) Direct support services during
13
acute hospitalizations.
14
‘‘(x) Necessary medical and nursing
15
services not otherwise covered which are
16
necessary in order for the individual to re-
17
main in their home and community, includ-
18
ing hospice services.
19
‘‘(xi) Home and community-based in-
20
tensive behavioral health and crisis inter-
21
vention services.
22
‘‘(xii) Peer support services.
23
‘‘(xiii) Housing support, including
24
transitional housing or transitional support
25
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services for individuals who are unhoused,
1
and wrap-around services.
2
‘‘(xiv) Necessary home modifications
3
and assistive technology, including those
4
which substitute for human assistance.
5
‘‘(xv) Transition services to support
6
an individual who is transitioning from an
7
institutional setting to the community, in-
8
cluding appropriate services for individuals
9
who are unhoused or at risk of becoming
10
unhoused, and including such transition
11
services provided while the individual re-
12
sides in an institution.
13
‘‘(xvi) Any other service recommended
14
by the panel convened pursuant to sub-
15
paragraph (B).
16
‘‘(B) SPECIFICATION
OF
RECOMMENDED
17
SERVICES.—
18
‘‘(i) IN GENERAL.—Not later than 6
19
months after the date of the enactment of
20
this subparagraph, and not less frequently
21
than once every 5 years thereafter, the
22
Secretary shall convene an advisory panel
23
(in this subparagraph referred to as the
24
‘panel’) for purposes of recommending ad-
25
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•S 762 IS
ditional services which shall be included as
1
home and community-based services under
2
this paragraph.
3
‘‘(ii) COMPOSITION.—
4
‘‘(I)
SELECTION.—The
panel
5
shall be composed of at least one rep-
6
resentative (to be selected by the Sec-
7
retary) from each of the following:
8
‘‘(aa) Individuals with dis-
9
abilities receiving home and com-
10
munity-based services under this
11
title and individuals with disabil-
12
ities in need of such services, in-
13
cluding those with physical dis-
14
abilities, behavioral health dis-
15
abilities, or intellectual or devel-
16
opmental disabilities, and includ-
17
ing older adults.
18
‘‘(bb)
Beneficiary-led
dis-
19
ability rights organizations.
20
‘‘(cc) Disability-led organiza-
21
tions.
22
‘‘(dd) Disabled veterans or-
23
ganizations.
24
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‘‘(ee)
Disability
organiza-
1
tions representing families.
2
‘‘(ff) Community-based pro-
3
vider organizations.
4
‘‘(gg) Organizations serving
5
older adults.
6
‘‘(hh) The Protection and
7
Advocacy system, the Centers for
8
Independent Living.
9
‘‘(ii) Health care providers.
10
‘‘(jj) The National Associa-
11
tion of Medicaid Directors.
12
‘‘(kk) The National Associa-
13
tion of State Directors of Devel-
14
opmental Disabilities Services.
15
‘‘(ll) The National Associa-
16
tion of State Mental Health Pro-
17
gram Directors.
18
‘‘(mm) ADvancing States.
19
‘‘(nn) The Centers for Medi-
20
care & Medicaid Services.
21
‘‘(oo) The Administration
22
for Community Living of the De-
23
partment of Health and Human
24
Services.
25
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‘‘(pp) Other relevant local,
1
State, and Federal home and
2
community-based service systems,
3
as determined by the Secretary.
4
‘‘(II) REQUIREMENT FOR EQUAL
5
REPRESENTATION.—The
Secretary
6
shall select an equal number of rep-
7
resentatives from each category de-
8
scribed in items (aa) through (oo)
9
subclause (I) in convening the panel.
10
‘‘(iii) DUTIES.—Not later than 6
11
months after a panel is convened under
12
clause (i), the panel shall submit to the
13
Secretary and to Congress a report recom-
14
mending additional services which shall be
15
included as home and community-based
16
services under this paragraph. Such rec-
17
ommended services shall be so specified
18
with the goal of increasing community in-
19
tegration and self-determination for indi-
20
viduals with disabilities receiving such
21
services.
22
‘‘(iv)
IMPLEMENTATION
OF
REC-
23
OMMENDED SERVICES.—
24
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[Text truncated for display. Full text available on Congress.gov.]