[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4131 Introduced in House (IH)]

<DOC>






117th CONGRESS
  1st Session
                                H. R. 4131

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

                             June 24, 2021

Mrs. Dingell (for herself, Mr. Pallone, Ms. Schakowsky, and Ms. Matsui) 
 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 Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Better Care Better 
Jobs Act''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

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 
                            Medicaid for recipients of home and 
                            community-based services against spousal 
                            impoverishment.
Sec. 203. Permanent extension of Money Follows the Person Rebalancing 
                            demonstration.

SEC. 2. DEFINITIONS.

    In this Act:
            (1) Appropriate committees of congress.--The term 
        ``appropriate committees of Congress'' means the Committee on 
        Energy and Commerce of the House of Representatives, the 
        Committee on Education and Labor of the House of 
        Representatives, the Committee on Finance of the Senate, the 
        Committee on Health, Education, Labor and Pensions of the 
        Senate, and the Special Committee on Aging of the Senate.
            (2) Direct care worker; direct care workforce.--The terms 
        ``direct care worker'' and ``direct care workforce'' mean--
                    (A) a direct support professional;
                    (B) a personal care attendant;
                    (C) a direct care worker;
                    (D) a home health aide; and
                    (E) any other relevant worker, as determined by the 
                Secretary.
            (3) Eligible individual.--The term ``eligible individual'' 
        means an individual who is eligible for and enrolled for 
        medical assistance under a State Medicaid program and includes 
        an individual who becomes eligible for medical assistance under 
        a State Medicaid program when removed from a waiting list.
            (4) Health plan.--The term ``health plan'' means a group 
        health plan or health insurance issuer (as such terms are 
        defined in section 2791 of the Public Health Service Act (42 
        U.S.C. 300gg-91)).
            (5) HCBS program improvement state.--The term ``HCBS 
        program improvement State'' means a State with an HCBS 
        infrastructure improvement plan approved by the Secretary under 
        section 101(d).
            (6) Home and community-based services.--The term ``home and 
        community-based services'' means any of the following (whether 
        provided on a fee-for-service, risk, or other basis):
                    (A) Home health care services authorized under 
                paragraph (7) of section 1905(a) of the Social Security 
                Act (42 U.S.C. 1396d(a)).
                    (B) Personal care services authorized under 
                paragraph (24) of such section.
                    (C) PACE services authorized under paragraph (26) 
                of such section.
                    (D) Home and community-based services authorized 
                under subsections (b), (c), (i), (j), and (k) of 
                section 1915 of such Act (42 U.S.C. 1396n), such 
                services authorized under a waiver under section 1115 
                of such Act (42 U.S.C. 1315), and such services 
                provided through coverage authorized under section 1937 
                of such Act (42 U.S.C. 1396u-7).
                    (E) Case management services authorized under 
                section 1905(a)(19) of the Social Security Act (42 
                U.S.C. 1396d(a)(19)) and section 1915(g) of such Act 
                (42 U.S.C. 1396n(g)).
                    (F) Rehabilitative services, including those 
                related to behavioral health, described in section 
                1905(a)(13) of such Act (42 U.S.C. 1396d(a)(13)).
                    (G) Such other services specified by the Secretary.
            (7) Institutional setting.--The term ``institutional 
        setting'' means--
                    (A) a skilled nursing facility (as defined in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395i-3(a)));
                    (B) a nursing facility (as defined in section 
                1919(a) of such Act (42 U.S.C. 1396r(a)));
                    (C) a long-term care hospital (as described in 
                section 1886(d)(1)(B)(iv) of such Act (42 U.S.C. 
                1395ww(d)(1)(B)(iv)));
                    (D) an institution (or distinct part thereof) 
                described in section 1905(d) of such Act (42 U.S.C. 
                1396d(d)));
                    (E) an institution (or distinct part thereof) which 
                is a psychiatric hospital (as defined in section 
                1861(f) of such Act (42 U.S.C. 1395x(f))) or that 
                provides inpatient psychiatric services in another 
                residential setting specified by the Secretary;
                    (F) an institution (or distinct part thereof) 
                described in section 1905(i) of such Act (42 U.S.C. 
                1396d(i)); and
                    (G) any other relevant facility, as determined by 
                the Secretary.
            (8) Medicaid program.--The term ``Medicaid program'' means, 
        with respect to a State, the State program under title XIX of 
        the Social Security Act (42 U.S.C. 1396 et seq.) (including any 
        waiver or demonstration under such title or under section 1115 
        of such Act (42 U.S.C. 1315) relating to such title).
            (9) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (10) State.--The term ``State'' has the meaning given such 
        term for purposes of title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.).

TITLE I--EXPANDING ACCESS TO MEDICAID HOME AND COMMUNITY-BASED SERVICES

SEC. 101. HCBS INFRASTRUCTURE IMPROVEMENT PLANNING GRANTS.

    (a) In General.--Not later than 12 months after the date of 
enactment of this Act, the Secretary shall award planning grants to 
States for the purpose of expanding access to home and community-based 
services and strengthening the direct care workforce that provides such 
services by developing HCBS infrastructure improvement plans that meet 
the requirements of subsections (b) and (c).
    (b) Content Requirements.--In order to meet the requirements of 
this subsection, an HCBS infrastructure improvement plan shall include, 
with respect to a State, the following:
            (1) Existing medicaid hcbs landscape.--
                    (A) Eligibility and benefits.--A description of--
                            (i) the existing standards, pathways, and 
                        methodologies for eligibility for home and 
                        community-based services, including limits on 
                        assets and income;
                            (ii) the home and community-based services 
                        available under the State Medicaid program; and
                            (iii) utilization management standards for 
                        such services.
                    (B) Access.--An assessment of the extent to which 
                home and community-based services are available to 
                eligible individuals in the State, including--
                            (i) estimates of the number of eligible 
                        individuals who are on a waitlist for such 
                        services;
                            (ii) estimates of the number of individuals 
                        who would be eligible individuals but are not 
                        enrolled in the State Medicaid program or on a 
                        waitlist for such services;
                            (iii) a description of the home and 
                        community-based services not available under 
                        the State Medicaid program;
                            (iv) a description of the populations for 
                        which the State is unable to provide home and 
                        community-based services under the State 
                        Medicaid program that are provided under the 
                        Medicaid programs of other States; and
                            (v) a description of barriers to accessing 
                        home and community-based services identified by 
                        eligible individuals and families of such 
                        individuals.
                    (C) Utilization.--An assessment of the utilization 
                of home and community-based services in the State.
                    (D) Service delivery structures.--A description of 
                the service delivery structures for providing home and 
                community-based services in the State, including with 
                respect to the use and models of self-direction, the 
                provision of services by agencies, the ownership of 
                service provider agencies, the use of managed care 
                versus fee-for-service to provide such services, and 
                the supports provided for family caregivers.
                    (E) Workforce.--A description of the 
                characteristics of the direct care workforce that 
                provides home and community-based services, including 
                the number of full- and part-time direct care workers, 
                the average and range of direct care worker wages, the 
                benefits provided to direct care workers, the turnover 
                and vacancy rates of direct care worker positions, the 
                membership of direct care workers in labor 
                organizations or professional organizations, and the 
                race, ethnicity, and gender of such workforce.
                    (F) Payment rates.--A description of the payment 
                rates for home and community-based services, including 
                when such rates were last updated, an assessment of the 
                extent to which authorized services are not delivered 
                as a result of such rates being insufficient, and the 
                extent to which payment rates are passed through to 
                direct care worker wages.
                    (G) Quality.--A description of how the quality of 
                home and community-based services is measured and 
                monitored, including how the State uses beneficiary and 
                family caregiver experience of care surveys to assess 
                the quality of home and community-based services 
                provided by the State.
                    (H) Long-term services and supports provided in 
                institutional settings.--A description of--
                            (i) the extent to which eligible 
                        individuals receive long-term services and 
                        supports in institutional settings in the 
                        State; and
                            (ii) the populations provided such services 
                        and supports.
                    (I) HCBS share of overall medicaid ltss spending.--
                For the most recent fiscal year for which data is 
                available, the percentage of expenditures made by the 
                State under the State Medicaid program for long-term 
                services and supports that are for home and community-
                based services.
                    (J) Demographic data.--Each assessment required 
                under subparagraphs (B) and (C), and the description 
                required under subparagraph (H)(ii) shall include, to 
                the extent available, data disaggregated by disability 
                status, age, income, gender, race, ethnicity, 
                geography, primary language, sexual orientation, gender 
                identity, and type of service setting.
            (2) Annual measures and reports.--A description of the 
        State plan for--
                    (A) annually measuring and reporting on--
                            (i) the availability and utilization of 
                        home and community-based services;
                            (ii) the characteristics of the direct care 
                        workforce that provides home and community-
                        based services and the race, ethnicity, and 
                        gender of such workforce;
                            (iii) changes in payment rates for home and 
                        community-based services; and
                            (iv) progress with respect to 
                        implementation of the activities, benchmarks, 
                        and improvement activities provided under 
                        subsection (jj) of section 1905 of the Social 
                        Security Act (as added under section 102); and
                    (B) collecting and reporting disaggregated data by 
                disability status, age, income, gender, race, 
                ethnicity, geography, primary language, sexual 
                orientation, gender identity, and type of service 
                setting for the information required by clause (i) of 
                subparagraph (A).
            (3) Implementation and goals for hcbs improvements.--A 
        description of how the State will--
                    (A) conduct the activities, benchmarks, and 
                improvement activities provided under subsection (jj) 
                of section 1905 of the Social Security Act (as added 
                under section 102), including how the State plans to 
                meet the benchmarks described in paragraph (5) of such 
                subsection and, if applicable, the additional HCBS 
                improvement efforts described in paragraph (3) of such 
                subsection;
                    (B) identify and reduce barriers to accessing home 
                and community-based services, including for individuals 
                in institutional settings, individuals experiencing 
                homelessness or housing instability, and individuals in 
                regions with low or no access to such services;
                    (C) identify and reduce disparities in access to, 
                and utilization of, home and community-based services 
                by disability status, age, income, gender, race, 
                ethnicity, geography, primary language, sexual 
                orientation, gender identity, and type of service 
                setting;
                    (D) coordinate implementation of the HCBS 
                infrastructure improvement plan among the State 
                Medicaid agency, agencies serving individuals with 
                disabilities, the elderly, and other relevant State and 
                local agencies; and
                    (E) facilitate access to related supports by 
                coordinating with State and local agencies and 
                organizations that provide housing, transportation, 
                employment, nutrition, and other services and supports.
    (c) Development and Submission Requirements.--In order to meet the 
requirements of this subsection, an HCBS infrastructure improvement 
plan shall--
            (1) be developed with input from stakeholders through a 
        public notice and comment process that includes consultation 
        with eligible individuals who are recipients of home and 
        community-based services, family caregivers of such recipients, 
        providers, health plans, direct care workers, chosen 
        representatives of direct care workers, and aging, disability, 
        and workforce advocates;
            (2) be submitted for approval by the Secretary not later 
        than 24 months after the date on which the State was awarded 
        the planning grant under this section; and
            (3) be publicly available in the final version submitted to 
        the Secretary on a State Internet website.
    (d) Approval; Publication.--
            (1) In general.--The Secretary shall approve an HCBS 
        infrastructure improvement plan if the plan--
                    (A) is complete; and
                    (B) provides assurances to the satisfaction of the 
                Secretary that the State will meet the requirements of 
                the HCBS Infrastructure Improvement Program established 
                under subsection (jj) of section 1905 of the Social 
                Security Act (42 U.S.C. 1396d), as added by section 
                102, and achieve the benchmarks for improvement 
                established by such program.
            (2) Publication.--The Secretary, acting through the 
        Administrator of the Centers for Medicare & Medicaid Services, 
        shall make publicly available on an Internet website--
                    (A) the final version of each approved HCBS 
                infrastructure improvement plan; and
                    (B) in the case of any HCBS infrastructure 
                improvement plan submitted for approval that is not 
                approved--
                            (i) the submitted plan;
                            (ii) the decision not approving such plan; 
                        and
                            (iii) information relating to why the plan 
                        was not approved.
    (e) Continuation of American Rescue Plan Act Increased FMAP for 
HCBS for States Awarded a Planning Grant.--
            (1) FMAP.--
                    (A) In general.--Notwithstanding subsections (b) or 
                (ff) of section 1905 of the Social Security Act (42 
                U.S.C. 1396d), subject to subparagraph (C), in the case 
                of a State that is awarded a planning grant under this 
                section and meets the maintenance of effort 
                requirements under paragraph (2), the Federal medical 
                assistance percentage determined for the State under 
                such subsection (b) (or such subsection (ff), if 
                applicable) and, if applicable, as increased under 
                subsection (y), (z), (aa), or (ii) of such section, 
                section 1915(k) of such Act (42 U.S.C. 1396n(k)), or 
                section 6008 of the Families First Coronavirus Response 
                Act (Public Law 116-127), shall be increased by 10 
                percentage points (but not to exceed 95 percent) with 
                respect to amounts expended by the State Medicaid 
                program for medical assistance for home and community-
                based services that are provided during HCBS planning 
                period (as defined in subparagraph (B)).
                    (B) HCBS planning period.--In this paragraph, the 
                term ``HCBS planning period'' means, with respect to a 
                State, the period--
                            (i) beginning on the date on which the 
                        State is awarded a planning grant under this 
                        section; and
                            (ii) ending on the earlier of--
                                    (I) the first day of the first 
                                fiscal quarter for which the State is 
                                an HCBS program improvement State; and
                                    (II) the date that is 3 years after 
                                the date on which the State is awarded 
                                such a grant.
                    (C) Rule of application in case of overlap with 
                period for american rescue plan increase.--If the HCBS 
                planning period for a State begins during the HCBS 
                program improvement period (as defined under subsection 
                (a)(2)(A) of section 9817 of the American Rescue Plan 
                Act (Public Law 117-2)), and the State meets the HCBS 
                program requirements under subsection (b) of such 
                section, the increase in the Federal medical assistance 
                percentage that would otherwise apply to the State 
                under subparagraph (A) of this paragraph shall not 
                apply during any portion of the HCBS program 
                improvement period (as defined under subsection 
                (a)(2)(A) of section 9817 of the American Rescue Plan 
                Act (Public Law 117-2)) for which the State receives an 
                increase in the Federal medical assistance percentage 
                in accordance with that section.
                    (D) Nonapplication of territorial funding caps.--
                Any payment made to Puerto Rico, the Virgin Islands, 
                Guam, the Northern Mariana Islands, or American Samoa 
                for expenditures on medical assistance that are subject 
                to the Federal medical assistance percentage increase 
                specified under subparagraph (A) shall not be taken 
                into account for purposes of applying payment limits 
                under subsections (f) and (g) of section 1108 of the 
                Social Security Act (42 U.S.C. 1308).
            (2) Maintenance of effort requirements.--For purposes of 
        paragraph (1)(A), the requirements of this paragraph are, with 
        respect to the period for which a State is awarded a planning 
        grant under this section, the State shall not--
                    (A) lower the amount, duration, or scope of home 
                and community-based services available under the State 
                Medicaid program (relative to the services available 
                under the program as of the date on which the State was 
                awarded such grant); or
                    (B) adopt more restrictive standards, 
                methodologies, or procedures for determining 
                eligibility, benefits, or services for receipt of home 
                and community-based services under the State Medicaid 
                program, including with respect to utilization 
                management or cost-sharing, than the standards, 
                methodologies, or procedures applicable as of the date 
                on which the State was awarded such grant.
    (f) Funding.--
            (1) In general.--Out of any funds in the Treasury not 
        otherwise appropriated, there is appropriated to the Secretary 
        for purposes of awarding planning grants under this section, 
        $100,000,000 for fiscal year 2022, to remain available until 
        expended.
            (2) Technical assistance and guidance.--The Secretary shall 
        reserve $5,000,000 of the amount appropriated under paragraph 
        (1) for purposes of issuing guidance and providing technical 
        assistance to States seeking or awarded a planning grant under 
        this section.

SEC. 102. HCBS INFRASTRUCTURE IMPROVEMENT PROGRAM.

    (a) Enhanced FMAP for HCBS Program Improvement States.--Section 
1905 of the Social Security Act (42 U.S.C. 1396d) is amended--
            (1) in subsection (b), by striking ``and (ii)'' and 
        inserting ``(ii), and (jj)''; and
            (2) by adding at the end the following new subsection:
    ``(jj) Enhanced Federal Medical Assistance Percentage for HCBS 
Program Improvement States.--
            ``(1) In general.--
                    ``(A) Increased federal financial participation.--
                Subject to paragraph (5), in the case of a State that 
                is an HCBS program improvement State and meets the 
                requirements described in paragraphs (2) and (4), for 
                each fiscal year quarter that begins on or after the 
                first date on which a State is an HCBS program 
                improvement State--
                            ``(i) notwithstanding subsection (b) or 
                        (ff), subject to subparagraph (B), with respect 
                        to amounts expended during the quarter by such 
                        State for medical assistance for home and 
                        community-based services, the Federal medical 
                        assistance percentage for such State and 
                        quarter (as determined for the State under 
                        subsection (b) and, if applicable, increased 
                        under subsection (y), (z), (aa), or (ii), or 
                        section 6008(a) of the Families First 
                        Coronavirus Response Act) shall be increased by 
                        10 percentage points (but not to exceed 95 
                        percent); and
                            ``(ii) notwithstanding the per centum 
                        specified in section 1903(a)(7), with respect 
                        to amounts expended during the quarter and 
                        before October 1, 2031, for administrative 
                        costs for expanding and enhancing home and 
                        community-based services, including for 
                        enhancing the Medicaid data and technology 
                        infrastructure, modifying rate setting 
                        processes, adopting, using, and reporting 
                        quality measures and beneficiary and family 
                        caregiver experience surveys, adopting or 
                        improving training programs for direct care 
                        workers and family caregivers, and adopting, 
                        carrying out, or enhancing programs that 
                        register qualified direct care workers or 
                        connect beneficiaries to qualified direct care 
                        workers, such per centum shall be increased to 
                        80 percent.
                    ``(B) Additional hcbs improvement efforts.--Subject 
                to paragraph (5), in addition to the increase to the 
                Federal medical assistance percentage under 
                subparagraph (A)(i), with respect to amounts expended 
                for medical assistance during the first 4 fiscal 
                quarters throughout which an HCBS program improvement 
                State has implemented a program to support self-
                directed care that meets the requirements of paragraph 
                (3) (in addition to meeting the requirements described 
                in paragraph (2)), the Federal medical assistance 
                percentage for such State and each such quarter with 
                respect to such amounts shall be further increased by 2 
                percentage points (but not to exceed 95 percent).
                    ``(C) Nonapplication of territorial funding caps.--
                Any payment made to Puerto Rico, the Virgin Islands, 
                Guam, the Northern Mariana Islands, or American Samoa 
                for expenditures that are subject to an increase in the 
                Federal medical assistance percentage under 
                subparagraph (A)(i) or (B), or an increase in an 
                applicable Federal matching percentage under 
                subparagraph (A)(ii), shall not be taken into account 
                for purposes of applying payment limits under 
                subsections (f) and (g) of section 1108.
            ``(2) Requirements.--The requirements described in this 
        paragraph, with respect to a State and a fiscal year quarter, 
        are the following:
                    ``(A) Maintenance of effort.--
                            ``(i) In general.--Except as provided under 
                        clause (ii), the State does not--
                                    ``(I) lower the amount, duration, 
                                or scope of home and community-based 
                                services available under the State plan 
                                or waiver (relative to the home and 
                                community-based services available 
                                under the plan or waiver as of the date 
                                on which the State was awarded a 
                                planning grant under section 101 of the 
                                Better Care Better Jobs Act); or
                                    ``(II) adopt more restrictive 
                                standards, methodologies, or procedures 
                                for determining eligibility, benefits, 
                                or services for receipt of home and 
                                community-based services, including 
                                with respect to utilization management 
                                or cost-sharing and the amount, 
                                duration, and scope of available home 
                                and community-based services, than the 
                                standards, methodologies, or procedures 
                                applicable as of such date.
                            ``(ii) Exception.--On or after October 1, 
                        2028, a State may modify such standards, 
                        methodologies, or procedures if the State 
                        demonstrates that such modifications shall not 
                        result in--
                                    ``(I) home and community-based 
                                services that are less comprehensive or 
                                lower in amount, duration, or scope;
                                    ``(II) fewer individuals (overall 
                                and within particular beneficiary 
                                populations) receiving home and 
                                community-based services; or
                                    ``(III) increased cost-sharing for 
                                home and community-based services.
                    ``(B) Access to services.--The State enhances, 
                expands, or strengthens home and community-based 
                services by doing all of the following:
                            ``(i) Addressing access barriers and 
                        disparities in access or utilization identified 
                        in the State HCBS infrastructure improvement 
                        plan.
                            ``(ii) Expanding financial eligibility 
                        criteria for home and community-based services 
                        up to Federal limits.
                            ``(iii) Requiring coverage of personal care 
                        services for all eligible populations receiving 
                        home and community-based services in the State.
                            ``(iv) Using `no wrong door' programs, 
                        providing presumptive eligibility for home and 
                        community-based services, and improving home 
                        and community-based services counseling and 
                        education programs.
                            ``(v) Expanding access to behavioral health 
                        services and coordination with employment, 
                        housing, and transportation supports.
                            ``(vi) Providing supports to family 
                        caregivers, which shall include providing 
                        respite care, and may include providing such 
                        services as caregiver assessments, peer 
                        supports, or paid family caregiving.
                            ``(vii) Adopting, expanding eligibility 
                        for, or improving coverage provided under a 
                        Medicaid buy-in program authorized under 
                        subclause (XIII), (XV), or (XVI) of section 
                        1902(a)(10)(A)(ii).
                    ``(C) Strengthened and expanded workforce.--
                            ``(i) In general.--The State strengthens 
                        and expands the direct care workforce that 
                        provides home and community-based services by--
                                    ``(I) adopting processes to ensure 
                                that payments for home and community-
                                based services are sufficient to ensure 
                                that care and services are available to 
                                the extent described in the State HCBS 
                                infrastructure improvement plan; and
                                    ``(II) updating, developing, and 
                                adopting qualification standards and 
                                training opportunities for the 
                                continuum of providers of home and 
                                community-based services, including 
                                programs for independent providers of 
                                such services and agency direct care 
                                workers, as well as unique programs and 
                                resources for family caregivers.
                            ``(ii) Payment rates.--In carrying out 
                        clause (i)(I), the State shall--
                                    ``(I) address insufficient payment 
                                rates for delivery of home and 
                                community-based services, with an 
                                emphasis on supporting the recruitment 
                                and retention of the direct care 
                                workforce, as identified during the 
                                period in which the State HCBS 
                                infrastructure improvement plan was 
                                developed and during subsequent years;
                                    ``(II) update payment rates for 
                                home and community-based services at 
                                least every 2 years through a 
                                transparent process involving 
                                meaningful input from stakeholders, 
                                including recipients of home and 
                                community-based services, family 
                                caregivers of such recipients, 
                                providers, health plans, direct care 
                                workers, chosen representatives of 
                                direct care workers, and aging, 
                                disability, and workforce advocates; 
                                and
                                    ``(III) ensure that increases in 
                                the payment rates for home and 
                                community-based services are--
                                            ``(aa) at a minimum, 
                                        proportionately passed through 
                                        to direct care workers and in a 
                                        manner that is determined with 
                                        input from the stakeholders 
                                        described in subclause (II); 
                                        and
                                            ``(bb) incorporated into 
                                        payment rates for home and 
                                        community-based services 
                                        provided under this title by a 
                                        managed care entity (as defined 
                                        in section 1932(a)(1)(B)) or a 
                                        prepaid inpatient health plan 
                                        or prepaid ambulatory health 
                                        plan, as defined in section 
                                        438.2 of title 42, Code of 
                                        Federal Regulations (or any 
                                        successor regulation)), under a 
                                        contract with the State.
            ``(3) HCBS improvement to support self-directed models for 
        the delivery of services.--For purposes of paragraph (1)(B), 
        the requirements of this paragraph, with respect to a State and 
        a fiscal year quarter, are that the State establishes directly 
        or by contract with 1 or more non-profit entities, a program 
        for the performance of all of the following functions:
                    ``(A) Registering qualified direct care workers and 
                assisting beneficiaries in finding direct care workers.
                    ``(B) Undertaking activities to recruit and train 
                independent providers to enable beneficiaries to direct 
                their own care, including by providing or coordinating 
                training for beneficiaries on self-directed care.
                    ``(C) Ensuring the safety of, and supporting the 
                quality of, care provided to beneficiaries, such as by 
                conducting background checks and addressing complaints 
                reported by recipients of home and community-based 
                services.
                    ``(D) Facilitating coordination between State and 
                local agencies and direct care workers for matters of 
                public health, training opportunities, changes in 
                program requirements, workplace health and safety, or 
                related matters.
                    ``(E) Supporting beneficiary hiring of independent 
                providers of home and community-based services through 
                an agency with choice or similar model, including by 
                processing applicable tax information, collecting and 
                processing timesheets, submitting claims and processing 
                payments to such providers.
                    ``(F) To the extent a State permits beneficiaries 
                to hire a family member or individual with whom they 
                have an existing relationship to provide home and 
                community-based services, providing support to 
                beneficiaries who wish to hire a caregiver who is a 
                family member or individual with whom they have an 
                existing relationship, such as by facilitating 
                enrollment of such family member or individual as a 
                provider of home and community-based services under the 
                State plan or a waiver of such plan.
                    ``(G) Ensuring that program policies and procedures 
                allow for cooperation with labor organizations that 
                bargain on behalf of direct care workers in the case of 
                a State in which the direct care workers in the State 
                have elected to join, or form, such a labor 
                organization, or, in the case of a State in which such 
                workers have not joined or formed such a labor 
                organization, are neutral with regard to such workers 
                joining or forming such a labor organization.
            ``(4) Quality, reporting, and oversight.--The requirements 
        described in this paragraph, with respect to a State and a 
        fiscal year quarter, are the following:
                    ``(A) The State adopts the core quality measures 
                for home and community-based services developed by the 
                Secretary under section 104 of the Better Care Better 
                Jobs Act, or an alternate set of quality measures 
                approved by the Secretary, and, at the option of the 
                State, expands the use of beneficiary and family 
                caregiver experience surveys.
                    ``(B) The State designates an HCBS ombudsman office 
                that--
                            ``(i) operates independently from the State 
                        Medicaid agency and managed care entities;
                            ``(ii) provides direct assistance to 
                        beneficiaries and their families; and
                            ``(iii) identifies and reports systemic 
                        problems to State officials, the public, and 
                        the Secretary.
                    ``(C) Beginning with the 5th fiscal year quarter 
                for which the State is an HCBS program improvement 
                State, and annually thereafter, the State reports on 
                the components of the existing home and community-based 
                services landscape reported in the State HCBS 
                infrastructure improvement plan, including with respect 
                to--
                            ``(i) the availability and utilization of 
                        home and community-based services, 
                        disaggregated by disability status, age, 
                        income, gender, race, ethnicity, geography, 
                        primary language, sexual orientation, gender 
                        identity, and type of service setting;
                            ``(ii) the characteristics of the direct 
                        care workforce that provides home and 
                        community-based services workforce and the 
                        race, ethnicity, and gender of such workforce;
                            ``(iii) changes in payment rates for home 
                        and community-based services;
                            ``(iv) implementation of the activities to 
                        strengthen and expand access to home and 
                        community-based services and the direct care 
                        workforce that provides such services in 
                        accordance with the requirements of 
                        subparagraphs (B) and (C) of paragraph (2);
                            ``(v) if applicable, implementation of the 
                        activities described in paragraph (3); and
                            ``(vi) the progress made with respect to 
                        meeting the benchmarks for demonstrating 
                        improvements required in paragraph (5).
            ``(5) Benchmarks for demonstrating improvements.--An HCBS 
        program improvement State shall cease to be eligible for an 
        increase in the Federal medical assistance percentage under 
        paragraph (1)(A)(i) or (1)(B) or an increase in an applicable 
        Federal matching percentage under paragraph (1)(A)(ii) 
        beginning with the 29th fiscal year quarter that begins on or 
        after the first date on which a State is an HCBS program 
        improvement State, unless, not later than 90 days before the 
        first day of such fiscal year quarter, the State submits to the 
        Secretary a report demonstrating the following improvements:
                    ``(A) Increased availability of home and community-
                based services in the State relative to such 
                availability as reported in the State HCBS 
                infrastructure improvement plan and adjusted for 
                demographic changes in the State since the submission 
                of such plan.
                    ``(B) Increased utilization and availability of 
                home and community-based services by populations with 
                the lowest utilization and availability of such 
                services (as reported in the State HCBS infrastructure 
                improvement plan) relative to the utilization of such 
                services by such populations as reported in such plan 
                and adjusted for demographic changes in the State since 
                the submission of such plan.
                    ``(C) Evidence that a majority of direct care 
                workers receive competitive wages and benefits.
                    ``(D) With respect to the percentage of 
                expenditures made by the State for long-term services 
                and supports that are for home and community-based 
                services, in the case of an HCBS program improvement 
                State for which such percentage (as reported in the 
                State HCBS infrastructure improvement plan) was--
                            ``(i) less than 50 percent, the State 
                        demonstrates that the percentage of such 
                        expenditures has increased to at least 50 
                        percent since the plan was approved; and
                            ``(ii) at least 50 percent, the State 
                        demonstrates that such percentage has not 
                        decreased since the plan was approved.
            ``(6) Definitions.--In this subsection, the terms `direct 
        care worker', `direct care workforce', `HCBS program 
        improvement State', and `home and community-based services' 
        have the meanings given those terms in section 2 of the Better 
        Care Better Jobs Act.''.

SEC. 103. REPORTS; TECHNICAL ASSISTANCE; OTHER ADMINISTRATIVE 
              REQUIREMENTS.

    (a) Reports.--The Secretary shall submit to the appropriate 
committees of Congress the following reports relating to the HCBS 
Infrastructure Improvement Program established under this title:
            (1) Initial report.--Not later than 4 years after the date 
        of enactment of this Act, a report that includes the following:
                    (A) A description of the HCBS infrastructure 
                improvement plans approved by the Secretary under 
                section 101(d).
                    (B) A description of the national landscape with 
                respect to gaps in coverage of home and community-based 
                services, disparities in access to, and utilization of, 
                such services, and barriers to accessing such services.
                    (C) A description of the national landscape with 
                respect to the direct care workforce that provides home 
                and community-based services, including with respect to 
                compensation, benefits, and challenges to the 
                availability of such workers.
            (2) Subsequent reports.--Not later than 7 years after the 
        date of enactment of this Act, and every 3 years thereafter, a 
        report that includes the following:
                    (A) The number of HCBS program improvement States.
                    (B) A summary of the progress being made by such 
                States with respect to strengthening and expanding 
                access to home and community-based services and the 
                direct care workforce that provides such services and 
                meeting the benchmarks for demonstrating improvements 
                required under section 1905(jj)(5) of the Social 
                Security Act (as added by section 102).
                    (C) A summary of outcomes related to home and 
                community-based services core quality measures and 
                beneficiary and family caregiver surveys.
                    (D) A summary of the challenges and best practices 
                reported by States in expanding access to home and 
                community-based services and supporting and expanding 
                the direct care workforce that provides such services.
    (b) Technical Assistance; Guidance; Regulations.--The Secretary 
shall provide HCBS program improvement States with technical assistance 
related to carrying out the HCBS infrastructure improvement plans 
approved by the Secretary under section 101(d) and meeting the 
requirements and benchmarks for demonstrating improvements required 
under section 1905(jj) of the Social Security Act (as added by section 
102) and shall issue such guidance or regulations as necessary to carry 
out this title and the amendments made by this title, including 
guidance specifying how States shall assess and track the availability 
of home and community-based services over time.
    (c) Recommendations To Guide Infrastructure Improvement.--
            (1) In general.--Not later than 18 months after the date of 
        enactment of this Act, the Secretary shall coordinate with the 
        Secretary of Labor and the Administrator of the Centers for 
        Medicare & Medicaid Services for purposes of issuing 
        recommendations for the Federal Government and for States to 
        strengthen the direct care workforce that provides home and 
        community-based services, including with respect to how the 
        Federal Government should classify the direct care workforce, 
        how such Administrator and State Medicaid programs can enforce 
        and support the provision of competitive wages and benefits 
        across the direct care workforce, including for workers with 
        particular skills or expertise, and how State Medicaid programs 
        can support training opportunities and other related efforts 
        that support the provision of quality home and community-based 
        services care.
            (2) Stakeholder consultation.--In developing the 
        recommendations required under paragraph (1), the Secretary 
        shall ensure that such recommendations are informed by 
        consultation with recipients of home and community-based 
        services, family caregivers of such recipients, providers, 
        health plans, direct care workers, chosen representatives of 
        direct care workers, and aging, disability, and workforce 
        advocates.
    (d) Funding.--Out of any funds in the Treasury not otherwise 
appropriated, there is appropriated to the Secretary for purposes of 
carrying out this section, $10,000,000 for fiscal year 2022, to remain 
available until expended.

SEC. 104. QUALITY MEASUREMENT AND IMPROVEMENT.

    (a) Development and Publication of Core and Supplemental Sets of 
HCBS Quality Measures.--
            (1) In general.--Not later than 2 years after the date of 
        enactment of this Act, the Secretary shall identify and publish 
        for general comment a recommended core set and supplemental set 
        of home and community-based services quality measures for use 
        by State Medicaid programs, health plan and managed care 
        entities that enter into contracts with such programs, and 
        providers of items and services under such programs.
            (2) Regular reviews and updates.--The Secretary shall 
        review and update the recommended core set and supplemental set 
        of home and community-based services quality measures published 
        under paragraph (1) not less frequently than once every year.
            (3) Requirements.--
                    (A) Interagency collaboration; stakeholder input.--
                In developing the recommended core set and supplemental 
                set of home and community-based services quality 
                measures under paragraph (1), and subsequently 
                reviewing and updating such core and supplemental sets, 
                the Secretary shall--
                            (i) collaborate with the Administrator of 
                        the Centers for Medicare & Medicaid Services, 
                        the Administrator of the Administration for 
                        Community Living, the Director of the Agency 
                        for Healthcare Research and Quality, and the 
                        Administrator of the Substance Abuse and Mental 
                        Health Services Administration; and
                            (ii) ensure that such core and supplemental 
                        sets are informed by input from stakeholders, 
                        including recipients of home and community-
                        based services, family caregivers of such 
                        recipients, providers, health plans, direct 
                        care workers, chosen representatives of direct 
                        care workers, and aging, disability, and 
                        workforce advocates.
                    (B) Reflective of full array of services.--Such 
                recommended core set and supplemental set of home and 
                community-based services quality measures shall--
                            (i) reflect the full array of home and 
                        community-based services and recipients of such 
                        services, including adults and children; and
                            (ii) include--
                                    (I) outcomes-based measures;
                                    (II) measures of availability of 
                                services;
                                    (III) measures of provider capacity 
                                and availability;
                                    (IV) measures related to person-
                                centered care;
                                    (V) measures specific to self-
                                directed care;
                                    (VI) measures related to 
                                transitions to and from institutional 
                                care; and
                                    (VII) beneficiary and family 
                                caregiver surveys.
                    (C) Demographics.--Such recommended core set and 
                supplemental set of home and community-based services 
                quality measures shall allow for the collection of data 
                that is disaggregated by disability status, age, 
                income, gender, race, ethnicity, geography, primary 
                language, sexual orientation, gender identity, and type 
                of service setting .
            (4) Funding.--Out of any funds in the Treasury not 
        otherwise appropriated, there is appropriated to the Secretary 
        for purposes of carrying out this subsection, $5,000,000 for 
        fiscal year 2022, to remain available until expended.
    (b) State Adoption and Reports.--
            (1) In general.--Not later than 2 years after the date on 
        which the Secretary publishes the recommended core set and 
        supplemental set of home and community-based services quality 
        measures under subsection (a)(1), and annually thereafter, each 
        State Medicaid program shall use such core and supplemental 
        sets (or an alternative set of quality measures approved by the 
        Secretary) to report information to the Secretary regarding the 
        quality of home and community-based services provided under 
        such program.
            (2) Process.--The information required under paragraph (1) 
        shall be reported using a standardized format and procedures 
        established by the Secretary. Such procedures shall allow a 
        State Medicaid program to report such information separately or 
        as part of the annual reports required under sections 1139A(c) 
        and 1139B(d) of the Social Security Act (42 U.S.C. 1320b-9a, 
        1320b-9b).
            (3) Publication of quality measures.--Each State Medicaid 
        program shall periodically make the information reported to the 
        Secretary under paragraph (1) available to the public.
            (4) Increased federal matching rate for adoption and 
        reporting.--Section 1903(a)(3) of the Social Security Act (42 
        U.S.C. 1396b(a)(3)) is amended--
                    (A) in subparagraph (F)(ii), by striking ``plus'' 
                after the semicolon and inserting ``and''; and
                    (B) by inserting after subparagraph (F), the 
                following:
                    ``(G) 80 percent of so much of the sums expended 
                during such quarter as are attributable to the 
                reporting of information regarding the quality of home 
                and community-based services in accordance with section 
                104(b) of the Better Care Better Jobs Act; and''.

                       TITLE II--OTHER PROVISIONS

SEC. 201. MACPAC STUDY AND REPORT ON APPENDIX K EMERGENCY HOME AND 
              COMMUNITY-BASED SERVICES (HCBS) 1915(C) WAIVERS.

    (a) In General.--The Medicaid and CHIP Payment and Access 
Commission (referred to in this section as ``MACPAC'') shall conduct a 
study and submit to Congress a report on the accelerated changes and 
emergency amendments to home and community-based services waivers under 
section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)) 
approved for States during the COVID-19 pandemic using the Appendix K 
template issued by the Centers for Medicare & Medicaid Services on 
March 22, 2020.
    (b) Report.--The report submitted under subsection (a) shall--
            (1) describe the specific types of flexibilities or other 
        program changes adopted by States using the Appendix K 
        template;
            (2) evaluate the efficiency, management, and success and 
        failures of such flexibilities and program changes; and
            (3) include recommendations for legislative and 
        administrative actions to continue specific flexibilities, 
        program changes, and innovative service delivery models that 
        increase access to care in home and community settings.

SEC. 202. MAKING PERMANENT THE STATE OPTION TO EXTEND PROTECTION UNDER 
              MEDICAID FOR RECIPIENTS OF HOME AND COMMUNITY-BASED 
              SERVICES AGAINST SPOUSAL IMPOVERISHMENT.

    (a) In General.--Section 1924(h)(1)(A) of the Social Security Act 
(42 U.S.C. 1396r-5(h)(1)(A)) is amended by striking ``is described in 
section 1902(a)(10)(A)(ii)(VI)'' and inserting the following: ``is 
eligible for medical assistance for home and community-based services 
provided under subsection (c), (d), or (i) of section 1915, under a 
waiver approved under section 1115, or who is eligible for such medical 
assistance by reason of being determined eligible under section 
1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the 
basis of a reduction of income based on costs incurred for medical or 
other remedial care, or who is eligible for medical assistance for home 
and community-based attendant services and supports under section 
1915(k)''.
    (b) Conforming Amendment.--Section 2404 of the Patient Protection 
and Affordable Care Act (42 U.S.C. 1396r-5 note) is amended by striking 
``September 30, 2023'' and inserting ``the date of enactment of the 
Better Care Better Jobs Act''.

SEC. 203. PERMANENT EXTENSION OF MONEY FOLLOWS THE PERSON REBALANCING 
              DEMONSTRATION.

    (a) In General.--Section 6071(h) of the Deficit Reduction Act of 
2005 (42 U.S.C. 1396a note) is amended--
            (1) in paragraph (1)--
                    (A) in subparagraph (I), by inserting ``and'' after 
                the semicolon;
                    (B) by amending subparagraph (J) to read as 
                follows:
                    ``(G) $450,000,000 for each fiscal year after 
                fiscal year 2021.''; and
                    (C) by striking subparagraph (K); and
            (2) in paragraph (2), by striking ``September 30, 2023'' 
        and inserting ``September 30 of such fiscal year''.
    (b) Redistribution of Unexpended Grant Awards.--Section 6071(e)(2) 
of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended 
by adding at the end the following new sentence: ``Any portion of a 
State grant award for a fiscal year under this section that is 
unexpended by the State at the end of the fourth succeeding fiscal year 
shall be rescinded by the Secretary and added to the appropriation for 
the fifth succeeding fiscal year.''.
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