What This Bill Does
This bill expands access to home and community-based services (services that help people live in their homes and communities rather than in institutions like nursing homes) through Medicaid. States that develop and execute improvement plans receive additional federal funding to strengthen these services and the workers who provide them.
##
Who It Affects
* People eligible for Medicaid who need long-term care services
* States that operate Medicaid programs
* Direct care workers (home health aides, personal care attendants, and similar workers)
* Family caregivers
* Health plans and managed care entities
* Service providers
* The Secretary of Health and Human Services
##
Key Provisions
* States can apply for planning grants to develop home and community-based services improvement plans that assess current services, identify gaps, and plan expansions (Sec. 101)
* States with approved improvement plans receive a 10 percentage point increase in federal funding for home and community-based services, plus an additional 2 percentage points if they establish self-directed care programs (Sec. 102)
* States must maintain or expand home and community-based services eligibility and cannot make eligibility standards more restrictive while receiving enhanced federal funding (Sec. 102)
* States must update payment rates for home and community-based services at least every 2 years with stakeholder input and pass increases through to direct care workers (Sec. 102)
* States must establish programs to register qualified direct care workers, recruit and train independent providers, conduct background checks, and support beneficiaries in directing their own care (Sec. 102)
* States must adopt quality measures for home and community-based services and establish an independent ombudsman office to assist beneficiaries and report problems (Sec. 102)
* The Secretary must develop core and supplemental quality measures for home and community-based services within 2 years (Sec. 104)
##
What Changes
If this bill becomes law, states can receive substantially higher federal reimbursement for home and community-based services if they approve infrastructure improvement plans. States must expand financial eligibility for these services, require coverage of personal care services for all eligible populations, implement "no wrong door" programs (single entry points for services), and ensure presumptive eligibility (preliminary approval without full review). Payment rates must increase regularly with direct care worker involvement. States must measure quality using standardized measures and create independent oversight offices for beneficiaries. The federal government will provide funding for planning grants, technical assistance, and quality measure development.
##
Important Definitions
* **Home and community-based services**: Healthcare and support services provided in people's homes or communities, including home health care, personal care, case management, behavioral health services, and services provided through waivers
* **Direct care worker**: A direct support professional, personal care attendant, home health aide, or similar worker providing these services
* **HCBS program improvement State**: A state with an approved infrastructure improvement plan
* **Eligible individual**: Someone enrolled in a state Medicaid program or removed from a waiting list for such enrollment
* **Institutional setting**: Nursing facilities, skilled nursing facilities, long-term care hospitals, psychiatric hospitals, and similar facilities
##
Effective Date
Not specified in bill text
II
118TH CONGRESS
1ST SESSION
S. 100
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 SENATE OF THE UNITED STATES
JANUARY 26, 2023
Mr. CASEY (for himself, Mr. SCHUMER, Mr. WYDEN, Mrs. MURRAY, Ms.
DUCKWORTH, Mr. BROWN, Ms. HASSAN, Mr. SANDERS, Mr. WARNOCK,
Mr. MERKLEY, Mr. VAN HOLLEN, Mrs. GILLIBRAND, Mr. WHITEHOUSE,
Mr. BLUMENTHAL, Mr. FETTERMAN, Mr. PADILLA, Mr. KAINE, Mr.
DURBIN, Ms. BALDWIN, Ms. SMITH, Mr. MARKEY, Ms. KLOBUCHAR, Mr.
REED, Ms. WARREN, Ms. STABENOW, Ms. CANTWELL, Mr. CARDIN, Mr.
BOOKER, Mr. SCHATZ, Mr. KING, Mr. HEINRICH, Ms. HIRONO, Mrs.
SHAHEEN, Mr. WELCH, Mr. MURPHY, Mr. MENENDEZ, Mr. LUJA´N, Mrs.
FEINSTEIN, Ms. CORTEZ MASTO, and Mr. PETERS) introduced the fol-
lowing bill; which was read twice and referred to the Committee on Fi-
nance
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-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
3
(a) SHORT TITLE.—This Act may be cited as the
4
‘‘Better Care Better Jobs Act’’.
5
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
2
•S 100 IS
(b) TABLE OF CONTENTS.—The table of contents for
1
this Act is as follows:
2
Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
TITLE I—EXPANDING ACCESS TO MEDICAID HOME AND
COMMUNITY-BASED SERVICES
Sec. 101. HCBS infrastructure improvement planning grants.
Sec. 102. HCBS Infrastructure Improvement Program.
Sec. 103. Reports; technical assistance; other administrative requirements.
Sec. 104. Quality measurement and improvement.
TITLE II—OTHER PROVISIONS
Sec. 201. MACPAC study and report on Appendix K emergency home and
community-based services (HCBS) 1915(c) waivers.
Sec. 202. Making permanent the State option to extend protection under Med-
icaid for recipients of home and community-based services
against spousal impoverishment.
Sec. 203. Permanent extension of Money Follows the Person Rebalancing dem-
onstration.
SEC. 2. DEFINITIONS.
3
In this Act:
4
(1)
APPROPRIATE
COMMITTEES
OF
CON-
5
GRESS.—The term ‘‘appropriate committees of Con-
6
gress’’ means the Committee on Energy and Com-
7
merce of the House of Representatives, the Com-
8
mittee on Education and the Workforce of the
9
House of Representatives, the Committee on Fi-
10
nance of the Senate, the Committee on Health, Edu-
11
cation, Labor, and Pensions of the Senate, and the
12
Special Committee on Aging of the Senate.
13
(2) DIRECT
CARE
WORKER;
DIRECT
CARE
14
WORKFORCE.—The terms ‘‘direct care worker’’ and
15
‘‘direct care workforce’’ mean—
16
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
3
•S 100 IS
(A) a direct support professional;
1
(B) a personal care attendant;
2
(C) a direct care worker;
3
(D) a home health aide; and
4
(E) any other relevant worker, as deter-
5
mined by the Secretary.
6
(3) ELIGIBLE INDIVIDUAL.—The term ‘‘eligible
7
individual’’ means an individual who is eligible for
8
and enrolled for medical assistance under a State
9
Medicaid program and includes an individual who
10
becomes eligible for medical assistance under a State
11
Medicaid program when removed from a waiting list.
12
(4) HEALTH PLAN.—The term ‘‘health plan’’
13
means a group health plan or health insurance
14
issuer (as such terms are defined in section 2791 of
15
the Public Health Service Act (42 U.S.C. 300gg–
16
91)).
17
(5) HCBS PROGRAM IMPROVEMENT STATE.—
18
The term ‘‘HCBS program improvement State’’
19
means a State with an HCBS infrastructure im-
20
provement plan approved by the Secretary under
21
section 101(d).
22
(6) HOME
AND
COMMUNITY-BASED
SERV-
23
ICES.—The term ‘‘home and community-based serv-
24
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
4
•S 100 IS
ices’’ means any of the following (whether provided
1
on a fee-for-service, risk, or other basis):
2
(A) Home health care services authorized
3
under paragraph (7) of section 1905(a) of the
4
Social Security Act (42 U.S.C. 1396d(a)).
5
(B) Personal care services authorized
6
under paragraph (24) of such section.
7
(C) PACE services authorized under para-
8
graph (26) of such section.
9
(D) Home and community-based services
10
authorized under subsections (b), (c), (i), (j),
11
and (k) of section 1915 of such Act (42 U.S.C.
12
1396n), such services authorized under a waiver
13
under section 1115 of such Act (42 U.S.C.
14
1315), and such services provided through cov-
15
erage authorized under section 1937 of such
16
Act (42 U.S.C. 1396u–7).
17
(E) Case management services authorized
18
under section 1905(a)(19) of the Social Secu-
19
rity Act (42 U.S.C. 1396d(a)(19)) and section
20
1915(g) of such Act (42 U.S.C. 1396n(g)).
21
(F) Rehabilitative services, including those
22
related to behavioral health, described in section
23
1905(a)(13)
of
such
Act
(42
U.S.C.
24
1396d(a)(13)).
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
5
•S 100 IS
(G) Such other services specified by the
1
Secretary.
2
(7) INSTITUTIONAL SETTING.—The term ‘‘insti-
3
tutional setting’’ means—
4
(A) a skilled nursing facility (as defined in
5
section 1819(a) of the Social Security Act (42
6
U.S.C. 1395i–3(a)));
7
(B) a nursing facility (as defined in section
8
1919(a) of such Act (42 U.S.C. 1396r(a)));
9
(C) a long-term care hospital (as described
10
in section 1886(d)(1)(B)(iv) of such Act (42
11
U.S.C. 1395ww(d)(1)(B)(iv)));
12
(D) an institution (or distinct part thereof)
13
described in section 1905(d) of such Act (42
14
U.S.C. 1396d(d)));
15
(E) an institution (or distinct part thereof)
16
which is a psychiatric hospital (as defined in
17
section 1861(f) of such Act (42 U.S.C.
18
1395x(f))) or that provides inpatient psychiatric
19
services in another residential setting specified
20
by the Secretary;
21
(F) an institution (or distinct part thereof)
22
described in section 1905(i) of such Act (42
23
U.S.C. 1396d(i)); and
24
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
6
•S 100 IS
(G) any other relevant facility, as deter-
1
mined by the Secretary.
2
(8) MEDICAID PROGRAM.—The term ‘‘Medicaid
3
program’’ means, with respect to a State, the State
4
program under title XIX of the Social Security Act
5
(42 U.S.C. 1396 et seq.) (including any waiver or
6
demonstration under such title or under section
7
1115 of such Act (42 U.S.C. 1315) relating to such
8
title).
9
(9) SECRETARY.—The term ‘‘Secretary’’ means
10
the Secretary of Health and Human Services.
11
(10) STATE.—The term ‘‘State’’ has the mean-
12
ing given such term for purposes of title XIX of the
13
Social Security Act (42 U.S.C. 1396 et seq.).
14
TITLE I—EXPANDING ACCESS TO
15
MEDICAID HOME AND COM-
16
MUNITY-BASED SERVICES
17
SEC. 101. HCBS INFRASTRUCTURE IMPROVEMENT PLAN-
18
NING GRANTS.
19
(a) IN GENERAL.—Not later than 12 months after
20
the date of enactment of this Act, the Secretary shall
21
award planning grants to States for the purpose of ex-
22
panding access to home and community-based services and
23
strengthening the direct care workforce that provides such
24
services by developing HCBS infrastructure improvement
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
7
•S 100 IS
plans that meet the requirements of subsections (b) and
1
(c).
2
(b) CONTENT REQUIREMENTS.—In order to meet the
3
requirements of this subsection, an HCBS infrastructure
4
improvement plan shall include, with respect to a State,
5
the following:
6
(1) EXISTING MEDICAID HCBS LANDSCAPE.—
7
(A) ELIGIBILITY AND BENEFITS.—A de-
8
scription of—
9
(i) the existing standards, pathways,
10
and methodologies for eligibility for home
11
and community-based services, including
12
limits on assets and income;
13
(ii) the home and community-based
14
services available under the State Medicaid
15
program; and
16
(iii) utilization management standards
17
for such services.
18
(B) ACCESS.—An assessment of the extent
19
to which home and community-based services
20
are available to eligible individuals in the State,
21
including—
22
(i) estimates of the number of eligible
23
individuals who are on a waitlist for such
24
services;
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
8
•S 100 IS
(ii) estimates of the number of indi-
1
viduals who would be eligible individuals
2
but are not enrolled in the State Medicaid
3
program or on a waitlist for such services;
4
(iii) a description of the home and
5
community-based services not available
6
under the State Medicaid program;
7
(iv) a description of the populations
8
for which the State is unable to provide
9
home and community-based services under
10
the State Medicaid program that are pro-
11
vided under the Medicaid programs of
12
other States; and
13
(v) a description of barriers to access-
14
ing home and community-based services
15
identified by eligible individuals and fami-
16
lies of such individuals.
17
(C) UTILIZATION.—An assessment of the
18
utilization of home and community-based serv-
19
ices in the State.
20
(D) SERVICE DELIVERY STRUCTURES.—A
21
description of the service delivery structures for
22
providing home and community-based services
23
in the State, including with respect to the use
24
and models of self-direction, the provision of
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
9
•S 100 IS
services by agencies, the ownership of service
1
provider agencies, the use of managed care
2
versus fee-for-service to provide such services,
3
and the supports provided for family caregivers.
4
(E) WORKFORCE.—A description of the
5
characteristics of the direct care workforce that
6
provides home and community-based services,
7
including the number of full- and part-time di-
8
rect care workers, the average and range of di-
9
rect care worker wages, the benefits provided to
10
direct care workers, the turnover and vacancy
11
rates of direct care worker positions, the mem-
12
bership of direct care workers in labor organiza-
13
tions or professional organizations, and the
14
race, ethnicity, and gender of such workforce.
15
(F) PAYMENT
RATES.—A description of
16
the payment rates for home and community-
17
based services, including when such rates were
18
last updated, an assessment of the extent to
19
which authorized services are not delivered as a
20
result of such rates being insufficient, and the
21
extent to which payment rates are passed
22
through to direct care worker wages.
23
(G) QUALITY.—A description of how the
24
quality of home and community-based services
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
10
•S 100 IS
is measured and monitored, including how the
1
State uses beneficiary and family caregiver ex-
2
perience of care surveys to assess the quality of
3
home and community-based services provided
4
by the State.
5
(H) LONG-TERM SERVICES AND SUPPORTS
6
PROVIDED IN INSTITUTIONAL SETTINGS.—A de-
7
scription of—
8
(i) the extent to which eligible individ-
9
uals receive long-term services and sup-
10
ports in institutional settings in the State;
11
and
12
(ii) the populations provided such
13
services and supports.
14
(I) HCBS SHARE OF OVERALL MEDICAID
15
LTSS
SPENDING.—For the most recent fiscal
16
year for which data is available, the percentage
17
of expenditures made by the State under the
18
State Medicaid program for long-term services
19
and supports that are for home and community-
20
based services.
21
(J) DEMOGRAPHIC
DATA.—Each assess-
22
ment required under subparagraphs (B) and
23
(C), and the description required under sub-
24
paragraph (H)(ii) shall include, to the extent
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
11
•S 100 IS
available, data disaggregated by disability sta-
1
tus, age, income, gender, race, ethnicity, geog-
2
raphy, primary language, sexual orientation,
3
gender identity, and type of service setting.
4
(2) ANNUAL MEASURES AND REPORTS.—A de-
5
scription of the State plan for—
6
(A) annually measuring and reporting
7
on—
8
(i) the availability and utilization of
9
home and community-based services;
10
(ii) the characteristics of the direct
11
care workforce that provides home and
12
community-based services and the race,
13
ethnicity, and gender of such workforce;
14
(iii) changes in payment rates for
15
home and community-based services; and
16
(iv) progress with respect to imple-
17
mentation of the activities, benchmarks,
18
and improvement activities provided under
19
subsection (jj) of section 1905 of the So-
20
cial Security Act (as added under section
21
102); and
22
(B) collecting and reporting disaggregated
23
data by disability status, age, income, gender,
24
race, ethnicity, geography, primary language,
25
VerDate Sep 11 2014
19:55 Feb 03, 2023
Jkt 039200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\S100.IS
S100
pbinns on DSKJLVW7X2PROD with $$_JOB
12
•S 100 IS
sexual orientation, gender identity, and type of
1
service setting for the information required by
2
clause (i) of subparagraph (A).
3
(3) IMPLEMENTATION AND GOALS FOR HCBS
4
IMPROVEMENTS.—A description of how the State
5
will—
6
(A) conduct the activities, benchmarks,
7
and improvement activities provided under sub-
8
section (jj) of section 1905 of the Social Secu-
9
rity Act (as added under section 102), including
10
how the State plans to meet the benchmarks
11
described in paragraph (5) of such subsection
12
and, if applicable, the additional HCBS im-
13
provement efforts described in paragraph (3) of
14
such subsection;
15
(B) identify and reduce barriers to access-
16
ing home and community-based services, includ-
17
ing for individuals in institutional settings, indi-
18
viduals experiencing homelessness or housing
19
instability, and
[Text truncated for display. Full text available on Congress.gov.]