[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 3277 Introduced in Senate (IS)]

<DOC>






116th CONGRESS
  2d Session
                                S. 3277

    To amend title XIX of the Social Security Act to strengthen the 
   infrastructure of, access to, and reporting of Medicaid home and 
           community-based services, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 12, 2020

   Mr. Casey introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
    To amend title XIX of the Social Security Act to strengthen the 
   infrastructure of, access to, and reporting of Medicaid home and 
           community-based services, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``HCBS Infrastructure Improvement 
Act''.

SEC. 2. FINDINGS AND PURPOSE.

    (a) Findings.--Congress finds the following:
            (1) States are prioritizing funding of their Medicaid 
        programs for long-term services and supports (referred to in 
        this section as ``LTSS'') to offer a wider range of options for 
        home and community-based services (referred to in this section 
        as ``HCBS''), but gaps in HCBS remain.
            (2) In fiscal year 2016, States were spending only 57 
        percent of their total LTSS budgets on HCBS, well short of the 
        national goal of 69 percent set by the Centers for Medicare & 
        Medicaid Services.
            (3) In 2017, more than 700,000 people with disabilities, 
        older adults, and children were on waiting lists to receive 
        HCBS through existing Medicaid waver programs.
            (4) According to projections by the Bureau of the Census, 
        the number of adults over age 65 will reach 84,000,000 by mid-
        century, and the population of people 85 and older will be 
        nearly 15 million by 2040.
            (5) Absent strategic planning and investment, States will 
        experience greater difficulties as the needs of older adults 
        increase demands on State home and community-based services 
        HCBS capacity.
            (6) A one-time, targeted investment to strengthen State 
        capacity to build out Medicaid infrastructure that supports 
        multiple HCBS programs and connects to other Federal and State 
        programs, including Medicare and the Older Americans Act, will 
        improve the quality of health and daily living for the millions 
        of older adults, people with disabilities and their families.
            (7) Home and community-based services HCBS play an outsized 
        role in addressing the social determinants of health among 
        older adults and people with disabilities, who require 
        accessible housing and accessible transportation and access to 
        reliable personal care to avert costly medical crises.
    (b) Purpose.--The purpose of this Act is to establish to a one-time 
infrastructure improvement initiative for States to strengthen their 
HCBS capacity in selected target areas, including housing and 
transportation, workforce, and employment supports, in order to improve 
the cost-effectiveness of long-term service and support (LTSS) Medicaid 
programs and coordination with other programs that provide supportive 
services to older adults and people with disabilities.

SEC. 3. MEDICAID HOME AND COMMUNITY-BASED SERVICES INFRASTRUCTURE 
              IMPROVEMENT.

    Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is 
amended by adding at the end the following:

``SEC. 1947. HOME AND COMMUNITY-BASED SERVICES INFRASTRUCTURE 
              IMPROVEMENT.

    ``(a) Definitions.--In this section:
            ``(1) Direct support professional.--The term `direct 
        support professional' means a person who, in exchange for 
        compensation, provides services to a person with a disability 
        (as defined in section 3 of the Americans With Disabilities Act 
        of 1990) that promote such person's independence, including--
                    ``(A) services that enhance independence and 
                community inclusion for such person, including 
                traveling with such person, attending and assisting 
                such persons while visiting friends and family, 
                shopping, or socializing;
                    ``(B) services such as coaching and supporting such 
                person in communicating needs, achieving self-
                expression, pursuing personal goals, living 
                independently, and participating actively in employment 
                or voluntary roles in the community;
                    ``(C) services such as providing assistance with 
                activities of daily living (such as feeding, bathing, 
                toileting, and ambulation) and with tasks such as meal 
                preparation, shopping, light housekeeping, and laundry; 
                or
                    ``(D) services that support such person at home, 
                work, school, church, or other community settings.
            ``(2) Eligible hcbs expenditures.--The term `eligible HCBS 
        expenditures' means expenditures by an HCBS infrastructure 
        State on medical assistance for home and community-based 
        services that are provided under the State plan or waiver 
        during the State's HCBS infrastructure period and which aim to 
        collaborate with other programs offering support for home and 
        community-based services.
            ``(3) First mile/last mile transportation.--The term `first 
        mile/last mile transportation' means the transportation 
        necessary to--
                    ``(A) transport a person to a fixed route transit 
                system that the person could not otherwise conveniently 
                access by walking, wheelchair, walker, or other self-
                propelled mobility method; and
                    ``(B) transport a person from a fixed route transit 
                system to the person's final destination when the final 
                destination is not within a distance that the person 
                could conveniently access by walking, wheelchair, 
                walker, or other self-propelled mobility method.
            ``(4) HCBS infrastructure period.--The term `HCBS 
        infrastructure period' means, with respect to an HCBS 
        infrastructure State, the 7-fiscal year period that begins with 
        the first fiscal year that begins after the date on which the 
        State is granted approval by the Secretary under subsection (c) 
        to conduct an HCBS infrastructure program.
            ``(5) HCBS infrastructure program.--The term `HCBS 
        infrastructure program' means a demonstration program conducted 
        under this section.
            ``(6) HCBS infrastructure state.--The term `HCBS 
        infrastructure State' means a State that has been granted 
        approval by the Secretary under subsection (c) to conduct an 
        HCBS infrastructure program.
            ``(7) Home and community-based services.--The term `home 
        and community-based services' means long-term, person-centered 
        services and supports that are not provided in an institutional 
        setting, including--
                    ``(A) a home and community-based service provided 
                under subsection (c), (d), or (i) of section 1915 or 
                under a waiver under section 1115;
                    ``(B) home and community-based long-term services 
                and supports (provided in accordance with the 
                requirements for home and community-based settings 
                under sections 441.530 and 441.710 of title 42, Code of 
                Federal Regulations), including--
                            ``(i) services described in paragraphs (7), 
                        (8), (13), (19), and (24) of section 1905(a);
                            ``(ii) home and community-based services 
                        described in subsection (c)(4)(B) of section 
                        1915;
                            ``(iii) self-directed home and community-
                        based services described in subsection (i) of 
                        section 1915;
                            ``(iv) self-directed personal assistance 
                        services (as defined in subsection (j)(4)(A) of 
                        section 1915); and
                            ``(v) home and community-based attendant 
                        services and supports described in subsection 
                        (k) of section 1915;
                    ``(C) a home health care service; and
                    ``(D) a personal care service.
            ``(8) Long-term services and supports.--The term `long-term 
        services and supports' has the meaning given that term in 
        section 438.2 of title 42, Code of Federal Regulations (as of 
        the date of enactment of this section).
            ``(9) Shared living.--The term `shared living' means a 
        living arrangement involving--
                    ``(A) not more than 2 people with disabilities or 
                an older adult with a disability, except if 1 or more 
                of the people are related to each other (by blood or a 
                close association that is equivalent to a family 
                relationship);
                    ``(B) a person who--
                            ``(i) provides long-term services and 
                        supports in exchange for compensation;
                            ``(ii) lives together in a private home 
                        with the recipient of such services; and
                            ``(iii) receives a stipend or room and 
                        board as the primary form of payment for 
                        providing such services;
                    ``(C) a person receiving funding through a State 
                Medicaid program under this title or another publically 
                funded program; and
                    ``(D) the person receiving such services having the 
                final decision regarding who is the provider of such 
                services living with the person, through a consumer-
                driven matching process that includes relationship 
                building, person-centered planning as defined by the 
                Administrator of the Centers for Medicare & Medicaid 
                Services, and an assessment of individual 
                compatibility.
            ``(10) State.--The term `State' means each of the 50 
        States, the District of Columbia, the Commonwealth of Puerto 
        Rico, the United States Virgin Islands, Guam, American Samoa, 
        and the Northern Mariana Islands.
            ``(11) Universal mobility service.--The term `universal 
        mobility service' means a single platform through which people 
        with disabilities or older adults are able to--
                    ``(A) access a variety of public and private demand 
                responsive and fixed-route transportation services 
                which have the necessary vehicles and facilities to 
                meet the needs of all users, regardless of income, 
                geographic location, disability, or age;
                    ``(B) and identify their travel options and compare 
                the cost and length of trips using each such option; 
                and
                    ``(C) schedule a ride, monitor progress, and pay 
                for the trip, regardless of the number of transfers and 
                independent providers used.
    ``(b) Planning Grants.--
            ``(1) In general.--Not later than January 1 of each of 
        calendar years 2021 through 2024, from the amount appropriated 
        under paragraph (5), the Secretary shall, subject to paragraph 
        (2), award planning grants to any State that applies for such a 
        grant for the purpose of developing proposals for an HCBS 
        infrastructure program.
            ``(2) Selection, duration, and number of states.--
                    ``(A) Selection criteria.--In awarding grants for a 
                year under this subsection the Secretary shall--
                            ``(i) consider the technical merits the 
                        proposed HCBS infrastructure program of each 
                        State that is applying for a grant in such 
                        year; and
                            ``(ii) select a group of States that is 
                        diverse in terms of--
                                    ``(I) the geographic areas the 
                                group represents;
                                    ``(II) the population sizes of the 
                                States comprising the group; and
                                    ``(III) the subparagraphs of 
                                subsection (e)(2) in which each such 
                                State is described (based on data from 
                                the 2 most recent years for which data 
                                is available).
                    ``(B) Duration.--Grants awarded under this 
                subsection shall be available to States for a period of 
                1 year.
                    ``(C) Number of states.--The Secretary shall not 
                award planning grants under this subsection to more 
                than 17 States in any year, and no State may receive 
                more than 1 grant under this subsection.
            ``(3) Use of funds.--A State awarded a planning grant under 
        this subsection shall--
                    ``(A) establish a Development and Implementation 
                Council that meets the requirements described in 
                paragraph (4) to provide input into the development of 
                the proposal and, if the State receives approval to 
                conduct a demonstration program under this section, to 
                monitor the ongoing implementation of the program;
                    ``(B) with guidance from the Centers for Medicare & 
                Medicaid Services, identify populations in the State 
                for which the per capita annual expenditures under the 
                State plan or waiver of such plan on home and 
                community-based services is less than the national 
                average for that population;
                    ``(C) establish a set of standards and procedures 
                to ensure the State makes measurable progress in 
                expanding the availability of self-direction to people 
                served by home and community-based service providers;
                    ``(D) develop a plan to increase home and 
                community-based services, increase the availability of 
                providers of such service throughout the State, and 
                address at least 3 of the HCBS infrastructure priority 
                areas described in subsection (c)(3);
                    ``(E) solicit public comment to help determine what 
                the priorities of the proposed demonstration program 
                should be; and
                    ``(F) execute memoranda of understanding between 
                any State agencies that will be responsible for 
                activities under the proposed demonstration program 
                under which each such agency agrees to conduct the 
                activities for which it will be responsible and to 
                cooperate with other agencies as necessary.
            ``(4) Development and implementation council 
        requirements.--The requirements described in this paragraph 
        with respect to a Development and Implementation Council 
        established by a State (referred to in this section as a 
        `Council') are the following:
                    ``(A) The members of the Council (the majority of 
                whom shall be people with disabilities or older adults 
                who need home and community-based services) shall 
                consist of--
                            ``(i) people with disabilities or older 
                        adults who receive home and community-based 
                        services;
                            ``(ii) people with disabilities, including 
                        older adults with disabilities, who meet 
                        criteria for home and community-based services 
                        but are not receiving such services;
                            ``(iii) family caregivers;
                            ``(iv) direct support professionals;
                            ``(v) providers of home and community-based 
                        services;
                            ``(vi) one representative each from--
                                    ``(I) an organization that 
                                represents people with disabilities;
                                    ``(II) an organization that 
                                represents older adults; and
                                    ``(III) an organization that 
                                represents direct support 
                                professionals; and
                            ``(vii) representatives from State agencies 
                        that provide aging, disability, transportation, 
                        housing, employment, vocational rehabilitation, 
                        mental health, and substance use services and 
                        representatives, as appropriate, from programs 
                        providing transportation supports, housing 
                        supports, home and community-based services 
                        workforce development, family caregiver 
                        supports, and education and vocational 
                        rehabilitation services.
                    ``(B) The Council is coordinated by the Governor, 
                and any proposal of the Council shall be submitted to, 
                and reviewed by, by the Governor before it is submitted 
                to the Secretary.
                    ``(C) The Council shall conduct a public comment 
                process to collect information to inform the priorities 
                and activities identified in the grant application.
            ``(5) Funding.--
                    ``(A) In general.--Out of any funds in the Treasury 
                not otherwise appropriated, there is appropriated to 
                the Secretary for each of fiscal years 2021 through 
                2024 $100,000,000 for purposes of awarding grants under 
                this subsection.
                    ``(B) Availability.--Funds appropriated under 
                subparagraph (A) shall remain available until expended.
                    ``(C) Technical assistance.--
                            ``(i) In general.--For each of fiscal years 
                        2021 through 2024, out of the funds 
                        appropriated for such year under subparagraph 
                        (A), $3,000,000 shall be reserved for the 
                        purpose of providing technical assistance 
                        (through the Administrator of the Centers for 
                        Medicare & Medicaid Services) to States in 
                        meeting the requirements of paragraph (2).
                            ``(ii) Coordination with relevant 
                        agencies.--In providing technical assistance to 
                        States in developing plans to improve HCBS 
                        infrastructure priority areas described in 
                        subsection (c)(3), the Administrator of the 
                        Centers for Medicare & Medicaid Services shall 
                        consult with other agencies with relevant 
                        expertise in such areas, such as the Department 
                        of Transportation, the Department of Housing 
                        and Urban Development, and the Interagency 
                        Transportation Coordinating Council on Access 
                        and Mobility established under Executive Order 
                        No. 13330.
    ``(c) HCBS Infrastructure Implementation Grants.--
            ``(1) Approval of states.--Not later than 1 year after 
        awarding a planning grant to a State under subsection (b), the 
        Secretary shall, subject to paragraph (4), award to the State 
        an HCBS infrastructure implementation grant under this section 
        if the application--
                    ``(A) is developed through such planning grant; and
                    ``(B) meets the requirements of paragraph (2).
            ``(2) Grant requirements.--The requirements of this 
        paragraph with respect to a State implementation grant are the 
        following:
                    ``(A) Application.--The State submits an 
                application, using the most recent data available at 
                the time the State was awarded a planning grant under 
                subsection (b), to conduct an HCBS infrastructure 
                implementation grant to the Secretary that includes, in 
                addition to such other information as the Secretary may 
                require--
                            ``(i) targets for spending under the State 
                        plan or waiver for home and community-based 
                        services under the State plan or waiver as a 
                        percentage of all spending under the plan or 
                        waiver on long-term services and supports, and 
                        yearly milestones for such targets that--
                                    ``(I) provide States with the 
                                flexibility to focus on providing home 
                                and community-based services to certain 
                                populations; and
                                    ``(II) require the State--
                                            ``(aa) to achieve spending 
                                        targets for those populations;
                                            ``(bb) to identify 
                                        populations in the State for 
                                        which the per capita annual 
                                        expenditures under the State 
                                        plan or waiver on home and 
                                        community-based services is 
                                        less than the national average 
                                        for that population; and
                                            ``(cc) to increase the 
                                        level of expenditures on home 
                                        and community-based services 
                                        for each population described 
                                        in clause (v)(II) to a target 
                                        level proposed by the State;
                            ``(ii) a description of how the State 
                        will--
                                    ``(I) expand medical assistance for 
                                home and community-based services under 
                                the plan or waiver during the HCBS 
                                infrastructure period;
                                    ``(II) achieve the spending targets 
                                and milestones described in clause (i); 
                                and
                                    ``(III) initiate or expand self-
                                directed services, with measurable 
                                targets and milestones;
                            ``(iii) if the State limits the provision 
                        of home and community-based services to people 
                        under the plan or waiver or imposes any 
                        numerical limitation, waiting list, or similar 
                        limitation on the eligibility of people for 
                        such services, a detailed plan for how the 
                        State will reduce such limitations;
                            ``(iv) a detailed plan with measurable 
                        objectives and annual milestones for at least 3 
                        of the HCBS infrastructure priority areas 
                        described in paragraph (3); and
                            ``(v) data on the extent to which the State 
                        has already balanced the long-term services and 
                        supports system of the State, including--
                                    ``(I) the percentage of total 
                                annual expenditures under the State 
                                plan or waiver for long-term services 
                                and supports expenditures that are for 
                                home and community-based services; and
                                    ``(II) the percentage of total 
                                annual expenditures under the State 
                                plan or waiver for long-term services 
                                and supports expenditures that are for 
                                home and community-based services by 
                                population group, including--
                                            ``(aa) people with 
                                        intellectual and developmental 
                                        disabilities;
                                            ``(bb) people aged 65 and 
                                        older;
                                            ``(cc) people with physical 
                                        disabilities; and
                                            ``(dd) people with mental 
                                        health and substance use 
                                        disorders.
                    ``(B) Maintenance of eligibility requirements.--
                During the HCBS infrastructure period, the State does 
                not apply eligibility standards, methodologies, or 
                procedures for determining eligibility for medical 
                assistance for home and community-based services under 
                the plan or waiver that are more restrictive than the 
                eligibility standards, methodologies, or procedures in 
                effect for such purposes on December 31, 2019.
                    ``(C) Implementation and compliance with hcbs 
                settings rule.--The State has a final approved plan 
                to--
                            ``(i) fully comply with the Home and 
                        Community-Based Services Final Rule published 
                        by the Centers for Medicare & Medicaid Services 
                        on January 16, 2014 (79 Fed. Reg. 2947) 
                        (referred to in this section as the `HCBS 
                        Settings Rule'); and
                            ``(ii) construct the activities of the 
                        grant such that the results will be to 
                        stabilize and expand the service delivery 
                        network available in the State to provide 
                        services and supports under the State plan or 
                        waiver of such plan in a manner that complies 
                        with the HCBS Settings Rule.
                    ``(D) Use of additional funds.--The State uses any 
                additional Federal funds paid to the State as a result 
                of this section only for purposes of increasing the 
                availability and improving the quality of home and 
                community-based services in the State.
                    ``(E) Data collection.--The State collects 
                standardized data as determined by the Secretary, 
                including--
                            ``(i) services data on a per-capita or 
                        family caregiver basis and, to the extent 
                        possible, in accordance with the Transformed 
                        Medicaid Statistical Information System (T-
                        MSIS) (or a successor system);
                            ``(ii) quality data on a selected set of 
                        core home and community-based services measures 
                        determined by the Secretary, including--
                                    ``(I) measures of beneficiary and 
                                family caregiver experience;
                                    ``(II) measures for the achievement 
                                of desired outcomes appropriate to a 
                                specific beneficiary or family 
                                caregiver, including--
                                            ``(aa) community inclusion;
                                            ``(bb) choice and personal 
                                        control, including through 
                                        self-directed services; and
                                            ``(cc) person-centered 
                                        planning; and
                                    ``(III) measures for the 
                                achievement of home and community-based 
                                services infrastructure improvements, 
                                including--
                                            ``(aa) competitive, 
                                        integrated employment for 
                                        people with disabilities and 
                                        older adults;
                                            ``(bb) direct support 
                                        professional workforce 
                                        improvements, including 
                                        increased wages;
                                            ``(cc) caregiver supports;
                                            ``(dd) accessible housing 
                                        and accessible transportation 
                                        improvements; and
                                            ``(ee) non-disability-
                                        specific settings;
                            ``(iii) services data from providers of 
                        home and community-based services on a per-
                        beneficiary or family caregiver basis and in 
                        accordance with such standardized coding 
                        procedures as the State shall establish in 
                        consultation with the Secretary;
                            ``(iv) quality data on a selected set of 
                        core quality measures agreed upon by the 
                        Secretary and the State that are--
                                    ``(I) linked to population-specific 
                                outcomes measures; and
                                    ``(II) available to the public, 
                                including consumers and providers of 
                                home and community-based services; and
                            ``(v) outcomes measures data on a selected 
                        set of core population-specific outcomes 
                        measures agreed upon by the Secretary and the 
                        State that are accessible to providers and 
                        include--
                                    ``(I) measures of beneficiary and 
                                family caregiver experience with 
                                providers; and
                                    ``(II) measures for achieving 
                                desired outcomes appropriate to a 
                                specific beneficiary or family 
                                caregiver, including--
                                            ``(aa) competitive 
                                        integrated employment (as 
                                        defined in section 3(11) of the 
                                        Workforce Innovation and 
                                        Opportunity Act);
                                            ``(bb) participation in 
                                        community life;
                                            ``(cc) health stability;
                                            ``(dd) prevention of loss 
                                        in function; and
                                            ``(ee) improved family 
                                        caregiver health and wellness.
            ``(3) HCBS infrastructure priority areas.--The HCBS 
        infrastructure priority areas described in this paragraph are 
        the following:
                    ``(A) Workforce and unpaid caregiver supports.--The 
                State develops and implements, in consultation with 
                representatives of people with disabilities, 
                representatives of older adults, and representatives of 
                direct support workers--
                            ``(i) infrastructure to enhance supply and 
                        retention of the direct support workforce, 
                        including through--
                                    ``(I) enhancement of payment rates, 
                                contingent on wage increases for direct 
                                support professionals; and
                                    ``(II) training and career 
                                advancement programs for direct support 
                                professionals, including programs that 
                                facilitate the participation of direct 
                                support professionals in organizations 
                                that foster their professional 
                                development and stakeholder engagement;
                            ``(ii) infrastructure to support self-
                        direction, including--
                                    ``(I) matching service registries; 
                                and
                                    ``(II) training for consumers who 
                                want to self-direct; and
                            ``(iii) supports for family caregivers, 
                        including--
                                    ``(I) use of family caregiver 
                                assessments;
                                    ``(II) service offerings that 
                                support caregivers and may delay or 
                                ameliorate the need for more 
                                comprehensive non-institutional long-
                                term services and supports; and
                                    ``(III) implementation of evidence-
                                based caregiver supportive services, 
                                increased access to and improvements in 
                                respite care, and financial assistance 
                                to help with out-of-pocket costs 
                                incurred by family caregivers.
                    ``(B) Employment supports.--The State develops and 
                implements statewide infrastructure, subject to the 
                merit-based personnel standards and conflict of 
                interest safeguards established and maintained by the 
                State pursuant to section 1902(a)(4), to support 
                opportunities for competitive integrated employment (as 
                defined in section 3(11) of the Workforce Innovation 
                and Opportunity Act) for people with disabilities and 
                older adults, which may include--
                            ``(i) service delivery modifications and 
                        expansion; and
                            ``(ii) establishing and expanding linkages 
                        with other programs that support workers with 
                        disabilities, such as--
                                    ``(I) vocational rehabilitation;
                                    ``(II) one-stop centers described 
                                in section 121 of the Workforce 
                                Innovation and Opportunity Act; and
                                    ``(III) State departments of 
                                education.
                    ``(C) Housing supports.--The State develops and 
                implements infrastructure to increase the availability 
                of affordable, accessible housing in non-disability-
                specific settings for people with disabilities and 
                older adults receiving home and community-based 
                services, which may include--
                            ``(i) assessing the supply and availability 
                        of such housing in communities across the 
                        State;
                            ``(ii) creating or scaling incentives for 
                        State and local housing partners and developers 
                        to create more accessible housing;
                            ``(iii) developing and implementing 
                        strategies to target people with the most 
                        significant developmental and other 
                        disabilities, including people with challenging 
                        behavior, complex medical needs, people 
                        requiring round-the-clock, one-on-one support 
                        from a direct support professional, and people 
                        with very high-service needs, for housing in 
                        non-disability-specific settings;
                            ``(iv) scaling shared living within the 
                        State;
                            ``(v) home modifications and repairs that 
                        make it possible for a person to remain in the 
                        person's home or building modifications that 
                        make it possible for a person with a disability 
                        or an older adult to reside in a house or 
                        apartment; and
                            ``(vi) developing administrative 
                        infrastructure to match people with housing and 
                        provide meaningful choices among non-
                        disability-specific settings via the person-
                        centered planning process.
                    ``(D) Transportation supports.--
                            ``(i) In general.--The State develops and 
                        implements strategies to improve access for all 
                        people with disabilities and older adults 
                        (including people who are blind or visually 
                        impaired, deaf or hard of hearing, have other 
                        physical disabilities, use a wheelchair or 
                        other mobility device, use a guide animal, or 
                        have an intellectual disability) to accessible 
                        transportation options, including first mile/
                        last mile transportation, with the goal of 
                        improved community integration, in accordance 
                        with the HCBS Setting Rule, which may include--
                                    ``(I) the provision of universal 
                                mobility services (as defined in 
                                subsection (a)(11));
                                    ``(II) partnering with existing 
                                non-emergency medical transportation 
                                brokers and their networks;
                                    ``(III) partnering with demand-
                                responsive providers, non-disability-
                                specific non-profit providers, and 
                                other transportation providers;
                                    ``(IV) the targeted development of 
                                a community integration transportation 
                                system that leverages traditional and 
                                innovative transportation networks 
                                (such as on-demand application-based 
                                transportation); and
                                    ``(V) expanding the non-emergency 
                                medical transportation services offered 
                                under the State plan to include 
                                transportation to--
                                            ``(aa) employment training 
                                        and jobs;
                                            ``(bb) community-based 
                                        supportive services such as 
                                        congregate meals or independent 
                                        living centers; and
                                            ``(cc) pharmacies, grocery 
                                        stores, and other retail 
                                        establishments to assist older 
                                        adults and people with 
                                        disabilities to remain in their 
                                        homes and participate fully in 
                                        their communities.
                            ``(ii) Training requirement.--Any strategy 
                        to improve access to transportation under this 
                        subparagraph shall include the implementation 
                        of a State requirement that providers of 
                        transportation receive training on how to 
                        support people with disabilities and older 
                        adults.
                            ``(iii) Exclusion.--To the extent that any 
                        expansion, development, or financing of 
                        paratransit is required under the Americans 
                        with Disabilities Act for fixed route service, 
                        such expansion, development, or financing shall 
                        not be considered to be a strategy to improve 
                        access to transportation for purposes of this 
                        subparagraph.
                            ``(iv) Consideration of national aging and 
                        disability transportation center proposals.--A 
                        proposal for improvements described in this 
                        subparagraph shall consider and discuss the 
                        work of the National Aging and Disability 
                        Transportation Center, the `Transactional Data 
                        Specification for Demand Responsive 
                        Transportation' published by the Transportation 
                        Research Board, and best practices for the 
                        delivery of Medicaid non-emergency medical 
                        transportation services.
                    ``(E) `No wrong door single' entry point system.--
                The State develops and implements a statewide system 
                (which may include preadmission screening by nurses, 
                peer assessors, and other necessary providers to ensure 
                that the appropriate assessments with respect to any 
                person with a disability or older adult are done as 
                soon as required), subject to the merit-based personnel 
                standards and conflict of interest safeguards 
                established and maintained by the State pursuant to 
                section 1902(a)(4), to enable people enrolled in the 
                State plan or waiver to access, on a timely basis, all 
                long-term services and supports through an agency, 
                organization, coordinated network, or portal, in 
                accordance with such standards as the State shall 
                establish and that shall provide information 
                regarding--
                            ``(i) the availability of such services;
                            ``(ii) how to apply for such services;
                            ``(iii) disability benefits counseling;
                            ``(iv) referral services for services and 
                        supports otherwise available in the community; 
                        and
                            ``(v) determinations of financial and 
                        functional eligibility for such services and 
                        supports, or assistance with assessment 
                        processes for financial and functional 
                        eligibility.
            ``(4) Number of states.--The Secretary shall not grant 
        approval to more than 17 States to conduct an HCBS 
        infrastructure demonstration program under this section in any 
        year.
    ``(d) Evaluation, Oversight, and Quality.--
            ``(1) Surveys and report on direct support professional 
        compensation.--
                    ``(A) In general.--Each HCBS infrastructure State 
                shall, for each fiscal year of the State's HCBS 
                infrastructure period, conduct surveys of providers 
                that received increased rates under the HCBS 
                infrastructure program conducted by the State on the 
                compensation paid by such providers to direct support 
                professionals.
                    ``(B) Report.--Not later than 2 years after the 
                date that an HCBS infrastructure State begins to 
                conduct an HCBS infrastructure program, the State 
                submits a report to the Administrator of the Centers 
                for Medicare & Medicaid Services on the impact of the 
                rate increases on the compensation, benefits, and 
                training received by direct support professionals.
            ``(2) Evaluation.--
                    ``(A) In general.--The Secretary shall evaluate the 
                implementation and outcomes of the HCBS infrastructure 
                programs conducted by the States in the aggregate using 
                an external evaluator with experience evaluating home 
                and community-based services, disability programs, and 
                older adult programs using the criteria described in 
                each HCBS infrastructure State's application and 
                evaluating any change in HCBS service availability and 
                quality for each HCBS infrastructure State.
                    ``(B) Evaluation criteria.--The external evaluator 
                shall document and evaluate changes in access, 
                availability, and quality of HCBS services in each of 
                the priority areas described in subsection (c)(3) 
                chosen by each HCBS infrastructure State. The external 
                evaluator shall also evaluate the aggregate change 
                changes in access, availability, and quality of HCBS 
                services in each of the priorities areas described in 
                subsection (c)(3) across the HCBS infrastructure 
                States. The external evaluator shall also evaluate the 
                HCBS infrastructure programs based on (i) the impact of 
                the programs on increasing funding for home and 
                community-based services, (ii) the impact of the 
                programs on achieving targeted access, availability, 
                and quality of home and community-based services, and 
                (iii) promising practices identified by the programs 
                that increase access to, availability of, and quality 
                of home and community based services.
                    ``(C) Dissemination of evaluation findings.--The 
                Secretary shall--
                            ``(i) disseminate the findings from the 
                        evaluations of HCBS infrastructure programs 
                        conducted under this paragraph to--
                                    ``(I) all State Medicaid directors; 
                                and
                                    ``(II) the Committees on Ways and 
                                Means and Energy and Commerce of the 
                                House of Representatives, the Committee 
                                on Finance of the Senate, and the 
                                Special Committee on Aging of the 
                                Senate; and
                            ``(ii) make all evaluation findings 
                        publicly available in an accessible electronic 
                        format and any other accessible format 
                        determined appropriate by the Secretary.
                    ``(D) Oversight.--Each State awarded a grant under 
                subsection (c) shall ensure adequate oversight of the 
                expenditure of HCBS infrastructure program grant funds 
                in accordance with the Medicaid regulations, including 
                waiver 1115 and 1915 waiver regulations.
    ``(e) Financing Incentives.--
            ``(1) In general.--Notwithstanding section 1905(b), with 
        respect to each fiscal year in an HCBS infrastructure State's 
        HCBS infrastructure period, if such State meets the conditions 
        described in subsection (c)(2) for the year, the Federal 
        medical assistance percentage that would otherwise apply with 
        respect to eligible HCBS expenditures made by the State during 
        the year shall be increased (but in no case to exceed 100 
        percent) by the applicable percentage points increase 
        determined for the State and year under paragraph (2) (and as 
        increased, if applicable, under paragraph (3)).
            ``(2) Applicable percentage points increase.--The 
        applicable percentage points increase for an HCBS 
        infrastructure State and year is--
                    ``(A) in the case of a State in which, for the 2 
                years preceding the year involved, less than 35 percent 
                of the total expenditures for long-term services and 
                supports were for home and community-based services, 5 
                percentage points;
                    ``(B) in the case of a State in which, for the 2 
                years preceding the year involved, between 35 percent 
                and 50 percent of the total expenditures for long-term 
                services and supports were for home and community-based 
                services, 2 percentage points;
                    ``(C) in the case of a State in which, for the 2 
                years preceding the year involved, between 50 percent 
                and 65 percent of the total expenditures for long-term 
                services and supports were for home and community-based 
                services, 0.50 percentage points; and
                    ``(D) in the case of a State in which, for the 2 
                years preceding the year involved, 65 percent or more 
                of the total expenditures for long-term services and 
                supports were for home and community-based services, 
                0.25 percentage points.
            ``(3) Additional increase to incentivize targeting 
        underserved populations.--Beginning with the first full fiscal 
        year for which the Transformed Medicaid Statistical Information 
        System (T-MSIS) is fully operational, the applicable percentage 
        points increase determined for an HCBS infrastructure State and 
        year under paragraph (2) shall be increased by an additional--
                    ``(A) in the case of a State that is providing home 
                and community based services to 85 percent or more of 
                the people that make up the populations identified by 
                the State under subsection (b)(3)(B), 5 percentage 
                points;
                    ``(B) in the case of a State that is providing home 
                and community based services to between 75 percent and 
                85 percent of the people that make up the populations 
                identified by the State under subsection (b)(3)(B), 2 
                percentage points;
                    ``(C) in the case of a State that is providing home 
                and community based services to between 65 percent and 
                75 percent of the people that make up the populations 
                identified by the State under subsection (b)(3)(B), 0.5 
                percentage points; and
                    ``(D) in the case of a State that is providing home 
                and community based services to less than 65 percent of 
                the people that make up the populations identified by 
                the State under subsection (b)(3)(B), 0.25 percentage 
                points.
            ``(4) Exemption from limits on payments to territories.--
        The limitations on payment under subsections (f) and (g) of 
        section 1108 shall not apply to Federal payments under this 
        title that are based on the Federal medical assistance 
        percentage as increased under this subsection, and such 
        payments shall not be taken into account in applying such 
        subsections.''.
                                 <all>