What This Bill Does
This bill gives states money and help to expand home and community-based services (services people receive at home or in their communities rather than in nursing facilities) through Medicaid. The bill aims to strengthen the workers who provide these services and improve how states organize and deliver care to more people who need it.
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Who It Affects
- People eligible for Medicaid who need long-term care services
- Direct care workers (home health aides, personal care attendants, direct support professionals)
- State Medicaid agencies
- Healthcare providers and managed care organizations
- Family caregivers
- State agencies serving elderly people and people with disabilities
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Key Provisions
- States can receive planning grants to develop plans for expanding home and community-based services and strengthening the direct care workforce (Sec. 101)
- States that approve and implement these plans receive a 10 percentage point increase in federal funding for home and community-based services, plus an additional 2 percentage point increase if they adopt self-directed care programs (Sec. 102)
- States must maintain or improve eligibility standards, service availability, and scope of services during the program period (Sec. 102)
- States must adopt quality measures for home and community-based services and establish independent ombudsman offices to help beneficiaries and report problems (Sec. 102)
- The federal government will develop core quality measures and benchmarks that states must meet to continue receiving enhanced federal funding (Sec. 104)
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What Changes
If this bill becomes law, states that participate would receive additional federal funding to pay for home and community-based services. States would be required to expand who can access these services, improve how much direct care workers earn, update payment rates regularly, and measure service quality. States would also need to create programs to help people choose and hire their own care workers. Federal agencies would develop national quality standards that states must follow.
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Important Definitions
- **Home and community-based services**: Medical care, personal care, help with activities of daily living, case management, behavioral health services, and similar support provided at home or in community settings rather than in institutions
- **Direct care worker**: Home health aides, personal care attendants, direct support professionals, and similar workers who provide direct care
- **HCBS program improvement State**: A state that submits and gets approval for a plan to improve home and community-based services
- **Institutional setting**: Nursing facilities, skilled nursing facilities, long-term care hospitals, psychiatric hospitals, and similar facilities
- **Eligible individual**: A person enrolled in a state's Medicaid program
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Effective Date
Not specified in bill text
I
118TH CONGRESS
1ST SESSION
H. R. 547
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
JANUARY 26, 2023
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-
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
(b) TABLE OF CONTENTS.—The table of contents for
6
this Act is as follows:
7
Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
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•HR 547 IH
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.
1
In this Act:
2
(1)
APPROPRIATE
COMMITTEES
OF
CON-
3
GRESS.—The term ‘‘appropriate committees of Con-
4
gress’’ means the Committee on Energy and Com-
5
merce of the House of Representatives, the Com-
6
mittee on Education and the Workforce of the
7
House of Representatives, the Committee on Fi-
8
nance of the Senate, the Committee on Health, Edu-
9
cation, Labor, and Pensions of the Senate, and the
10
Special Committee on Aging of the Senate.
11
(2) DIRECT
CARE
WORKER;
DIRECT
CARE
12
WORKFORCE.—The terms ‘‘direct care worker’’ and
13
‘‘direct care workforce’’ mean—
14
(A) a direct support professional;
15
(B) a personal care attendant;
16
(C) a direct care worker;
17
(D) a home health aide; and
18
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•HR 547 IH
(E) any other relevant worker, as deter-
1
mined by the Secretary.
2
(3) ELIGIBLE INDIVIDUAL.—The term ‘‘eligible
3
individual’’ means an individual who is eligible for
4
and enrolled for medical assistance under a State
5
Medicaid program and includes an individual who
6
becomes eligible for medical assistance under a State
7
Medicaid program when removed from a waiting list.
8
(4) HEALTH PLAN.—The term ‘‘health plan’’
9
means a group health plan or health insurance
10
issuer (as such terms are defined in section 2791 of
11
the Public Health Service Act (42 U.S.C. 300gg–
12
91)).
13
(5) HCBS PROGRAM IMPROVEMENT STATE.—
14
The term ‘‘HCBS program improvement State’’
15
means a State with an HCBS infrastructure im-
16
provement plan approved by the Secretary under
17
section 101(d).
18
(6) HOME
AND
COMMUNITY-BASED
SERV-
19
ICES.—The term ‘‘home and community-based serv-
20
ices’’ means any of the following (whether provided
21
on a fee-for-service, risk, or other basis):
22
(A) Home health care services authorized
23
under paragraph (7) of section 1905(a) of the
24
Social Security Act (42 U.S.C. 1396d(a)).
25
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•HR 547 IH
(B) Personal care services authorized
1
under paragraph (24) of such section.
2
(C) PACE services authorized under para-
3
graph (26) of such section.
4
(D) Home and community-based services
5
authorized under subsections (b), (c), (i), (j),
6
and (k) of section 1915 of such Act (42 U.S.C.
7
1396n), such services authorized under a waiver
8
under section 1115 of such Act (42 U.S.C.
9
1315), and such services provided through cov-
10
erage authorized under section 1937 of such
11
Act (42 U.S.C. 1396u–7).
12
(E) Case management services authorized
13
under section 1905(a)(19) of the Social Secu-
14
rity Act (42 U.S.C. 1396d(a)(19)) and section
15
1915(g) of such Act (42 U.S.C. 1396n(g)).
16
(F) Rehabilitative services, including those
17
related to behavioral health, described in section
18
1905(a)(13)
of
such
Act
(42
U.S.C.
19
1396d(a)(13)).
20
(G) Such other services specified by the
21
Secretary.
22
(7) INSTITUTIONAL SETTING.—The term ‘‘insti-
23
tutional setting’’ means—
24
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•HR 547 IH
(A) a skilled nursing facility (as defined in
1
section 1819(a) of the Social Security Act (42
2
U.S.C. 1395i–3(a)));
3
(B) a nursing facility (as defined in section
4
1919(a) of such Act (42 U.S.C. 1396r(a)));
5
(C) a long-term care hospital (as described
6
in section 1886(d)(1)(B)(iv) of such Act (42
7
U.S.C. 1395ww(d)(1)(B)(iv)));
8
(D) an institution (or distinct part thereof)
9
described in section 1905(d) of such Act (42
10
U.S.C. 1396d(d));
11
(E) an institution (or distinct part thereof)
12
which is a psychiatric hospital (as defined in
13
section 1861(f) of such Act (42 U.S.C.
14
1395x(f))) or that provides inpatient psychiatric
15
services in another residential setting specified
16
by the Secretary;
17
(F) an institution (or distinct part thereof)
18
described in section 1905(i) of such Act (42
19
U.S.C. 1396d(i)); and
20
(G) any other relevant facility, as deter-
21
mined by the Secretary.
22
(8) MEDICAID PROGRAM.—The term ‘‘Medicaid
23
program’’ means, with respect to a State, the State
24
program under title XIX of the Social Security Act
25
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•HR 547 IH
(42 U.S.C. 1396 et seq.) (including any waiver or
1
demonstration under such title or under section
2
1115 of such Act (42 U.S.C. 1315) relating to such
3
title).
4
(9) SECRETARY.—The term ‘‘Secretary’’ means
5
the Secretary of Health and Human Services.
6
(10) STATE.—The term ‘‘State’’ has the mean-
7
ing given such term for purposes of title XIX of the
8
Social Security Act (42 U.S.C. 1396 et seq.).
9
TITLE I—EXPANDING ACCESS TO
10
MEDICAID HOME AND COM-
11
MUNITY-BASED SERVICES
12
SEC. 101. HCBS INFRASTRUCTURE IMPROVEMENT PLAN-
13
NING GRANTS.
14
(a) IN GENERAL.—Not later than 12 months after
15
the date of enactment of this Act, the Secretary shall
16
award planning grants to States for the purpose of ex-
17
panding access to home and community-based services and
18
strengthening the direct care workforce that provides such
19
services by developing HCBS infrastructure improvement
20
plans that meet the requirements of subsections (b) and
21
(c).
22
(b) CONTENT REQUIREMENTS.—In order to meet the
23
requirements of this subsection, an HCBS infrastructure
24
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•HR 547 IH
improvement plan shall include, with respect to a State,
1
the following:
2
(1) EXISTING MEDICAID HCBS LANDSCAPE.—
3
(A) ELIGIBILITY AND BENEFITS.—A de-
4
scription of—
5
(i) the existing standards, pathways,
6
and methodologies for eligibility for home
7
and community-based services, including
8
limits on assets and income;
9
(ii) the home and community-based
10
services available under the State Medicaid
11
program; and
12
(iii) utilization management standards
13
for such services.
14
(B) ACCESS.—An assessment of the extent
15
to which home and community-based services
16
are available to eligible individuals in the State,
17
including—
18
(i) estimates of the number of eligible
19
individuals who are on a waitlist for such
20
services;
21
(ii) estimates of the number of indi-
22
viduals who would be eligible individuals
23
but are not enrolled in the State Medicaid
24
program or on a waitlist for such services;
25
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•HR 547 IH
(iii) a description of the home and
1
community-based services not available
2
under the State Medicaid program;
3
(iv) a description of the populations
4
for which the State is unable to provide
5
home and community-based services under
6
the State Medicaid program that are pro-
7
vided under the Medicaid programs of
8
other States; and
9
(v) a description of barriers to access-
10
ing home and community-based services
11
identified by eligible individuals and fami-
12
lies of such individuals.
13
(C) UTILIZATION.—An assessment of the
14
utilization of home and community-based serv-
15
ices in the State.
16
(D) SERVICE DELIVERY STRUCTURES.—A
17
description of the service delivery structures for
18
providing home and community-based services
19
in the State, including with respect to the use
20
and models of self-direction, the provision of
21
services by agencies, the ownership of service
22
provider agencies, the use of managed care
23
versus fee-for-service to provide such services,
24
and the supports provided for family caregivers.
25
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•HR 547 IH
(E) WORKFORCE.—A description of the
1
characteristics of the direct care workforce that
2
provides home and community-based services,
3
including the number of full- and part-time di-
4
rect care workers, the average and range of di-
5
rect care worker wages, the benefits provided to
6
direct care workers, the turnover and vacancy
7
rates of direct care worker positions, the mem-
8
bership of direct care workers in labor organiza-
9
tions or professional organizations, and the
10
race, ethnicity, and gender of such workforce.
11
(F) PAYMENT
RATES.—A description of
12
the payment rates for home and community-
13
based services, including when such rates were
14
last updated, an assessment of the extent to
15
which authorized services are not delivered as a
16
result of such rates being insufficient, and the
17
extent to which payment rates are passed
18
through to direct care worker wages.
19
(G) QUALITY.—A description of how the
20
quality of home and community-based services
21
is measured and monitored, including how the
22
State uses beneficiary and family caregiver ex-
23
perience of care surveys to assess the quality of
24
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•HR 547 IH
home and community-based services provided
1
by the State.
2
(H) LONG-TERM SERVICES AND SUPPORTS
3
PROVIDED IN INSTITUTIONAL SETTINGS.—A de-
4
scription of—
5
(i) the extent to which eligible individ-
6
uals receive long-term services and sup-
7
ports in institutional settings in the State;
8
and
9
(ii) the populations provided such
10
services and supports.
11
(I) HCBS SHARE OF OVERALL MEDICAID
12
LTSS
SPENDING.—For the most recent fiscal
13
year for which data is available, the percentage
14
of expenditures made by the State under the
15
State Medicaid program for long-term services
16
and supports that are for home and community-
17
based services.
18
(J) DEMOGRAPHIC
DATA.—Each assess-
19
ment required under subparagraphs (B) and
20
(C), and the description required under sub-
21
paragraph (H)(ii) shall include, to the extent
22
available, data disaggregated by disability sta-
23
tus, age, income, gender, race, ethnicity, geog-
24
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•HR 547 IH
raphy, primary language, sexual orientation,
1
gender identity, and type of service setting.
2
(2) ANNUAL MEASURES AND REPORTS.—A de-
3
scription of the State plan for—
4
(A) annually measuring and reporting
5
on—
6
(i) the availability and utilization of
7
home and community-based services;
8
(ii) the characteristics of the direct
9
care workforce that provides home and
10
community-based services and the race,
11
ethnicity, and gender of such workforce;
12
(iii) changes in payment rates for
13
home and community-based services; and
14
(iv) progress with respect to imple-
15
mentation of the activities, benchmarks,
16
and improvement activities provided under
17
subsection (jj) of section 1905 of the So-
18
cial Security Act (as added under section
19
102); and
20
(B) collecting and reporting disaggregated
21
data by disability status, age, income, gender,
22
race, ethnicity, geography, primary language,
23
sexual orientation, gender identity, and type of
24
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•HR 547 IH
service setting for the information required by
1
clause (i) of subparagraph (A).
2
(3) IMPLEMENTATION AND GOALS FOR HCBS
3
IMPROVEMENTS.—A description of how the State
4
will—
5
(A) conduct the activities, benchmarks,
6
and improvement activities provided under sub-
7
section (jj) of section 1905 of the Social Secu-
8
rity Act (as added under section 102), including
9
how the State plans to meet the benchmarks
10
described in paragraph (5) of such subsection
11
and, if applicable, the additional HCBS im-
12
provement efforts described in paragraph (3) of
13
such subsection;
14
(B) identify and reduce barriers to access-
15
ing home and community-based services, includ-
16
ing for individuals in institutional settings, indi-
17
viduals experiencing homelessness or housing
18
instability, and individuals in regions with low
19
or no access to such services;
20
(C) identify and reduce disparities in ac-
21
cess to, and utilization of, home and commu-
22
nity-based services by disability status, age, in-
23
come, gender, race, ethnicity, geography, pri-
24
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•HR 547 IH
mary language, sexual orientation, gende
[Text truncated for display. Full text available on Congress.gov.]