,,ii #aagth ,,congress #ast ,session ,s4 #bbaj ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,june #bd1 #bjba,mr4 ,casey 7for himself1 ,mr4 ,wyden1 ,mr4 ,schumer1 ,mrs4 ,murray1 ,ms4 ,duckworth1 ,mr4 ,brown1 ,ms4 ,hassan1 ,mrs4 ,gillibrand1 ,mr4 ,whitehouse1 ,mr4 ,durbin1 ,ms4 ,baldwin1 ,mr4 ,markey1 ,mr4 ,blumenthal1 ,ms4 ,warren1 ,mr4 ,reed1 ,mrs4 ,shaheen1 ,mr4 ,van ,hollen1 ,ms4 ,smith1 ,mr4 ,merkley1 ,mr4 ,booker1 ,mr4 ,leahy1 ,mr4 ,padilla1 ,mr4 ,schatz1 ,ms4 ,klobuchar1 ,mr4 ,kaine1 ,mr4 ,bennet1 ,mr4 ,warnock1 ,mr4 ,sanders1 ,mr4 ,peters1 ,mr4 ,lujn1 ,mr4 ,heinrich1 ,ms4 ,hirono1 ,ms4 ,stabenow1 ,mrs4 ,feinstein1 ,ms4 ,rosen1 ,mr4 ,cardin1 ,mr4 ,murphy1 ,ms4 ,cantwell1 ,mr4 ,menendez1 and ,mr4 ,king7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xix of the ,social ,security ,act to expand access to home and community-based services 7,,hcbs7 under ,medicaid1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,better ,care ,better ,jobs ,act4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,sec4 #b4 ,definitions4,,title ,i--,expanding ,access to ,medicaid ,home and ,community-,based ,services,sec4 #aja4 ,,hcbs infrastructure improvement planning grants4,sec4 #ajb4 ,,hcbs ,infrastructure ,improvement ,program4,sec4 #ajc4 ,reports2 technical assistance2 other administrative requirements4,sec4 #ajd4 ,quality measurement and improvement4,,title ,,ii--,other ,provisions,sec4 #bja4 ,,macpac study and report on ,appendix ,k emergency home and community-based services 7,,hcbs7 #aiae7;c7 waivers4,sec4 #bjb4 ,making permanent the ,state option to extend protection under ,medicaid for recipients of home and community-based services against spousal impoverishment4,sec4 #bjc4 ,permanent extension of ,money ,follows the ,person ,rebalancing demonstration4 #b4 ,definitions ,in this ,act3 7#a7 ,appropriate committees of congress ,the term appropriate committees of ,congress means the ,committee on ,energy and ,commerce of the ,house of ,representatives1 the ,committee on ,education and ,labor of the ,house of ,representatives1 the ,committee on ,finance of the ,senate1 the ,committee on ,health1 ,education1 ,labor and ,pensions of the ,senate1 and the ,special ,committee on ,aging of the ,senate4 7#b7 ,direct care worker2 direct care workforce ,the terms direct care worker and direct care workforce mean-- 7,a7 a direct support professional2 7,b7 a personal care attendant2 7,c7 a direct care worker2 7,d7 a home health aide2 and 7,e7 any other relevant worker1 as determined by the ,secretary4 7#c7 ,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 list4 7#d7 ,health plan ,the term health plan means a group health plan or health insurance issuer 7as such terms are defined in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia774 7#e7 ,,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 #aja7;d74 7#f7 ,home and community-based services ,the term home and community-based services means any of the following 7whether provided on a fee-for-service1 risk1 or other basis73 7,a7 ,home health care services authorized under paragraph 7#g7 of section #aije7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a774 7,b7 ,personal care services authorized under paragraph 7#bd7 of such section4 7,c7 ,,pace services authorized under paragraph 7#bf7 of such section4 7,d7 ,home and community-based services authorized under subsections 7b71 7c71 7i71 7j71 and 7k7 of section #aiae of such ,act 7#db ,u4,s4,c4 #acifn71 such services authorized under a waiver under section #aaae of such ,act 7#db ,u4,s4,c4 #acae71 and such services provided through coverage authorized under section #aicg of such ,act 7#db ,u4,s4,c4 #acifu-#g74 7,e7 ,case management services authorized under section #aije7;a77#ai7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77#ai77 and section #aiae7;g7 of such ,act 7#db ,u4,s4,c4 #acifn7g774 7,f7 ,rehabilitative services1 including those related to behavioral health1 described in section #aije7;a77#ac7 of such ,act 7#db ,u4,s4,c4 #acif;d7a77#ac774 7,g7 ,such other services specified by the ,secretary4 7#g7 ,institutional setting ,the term institutional setting means-- 7,a7 a skilled nursing facility 7as defined in section #ahai7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#c7;a7772 7,b7 a nursing facility 7as defined in section #aiai7;a7 of such ,act 7#db ,u4,s4,c4 #acifr7a7772 7,c7 a long-term care hospital 7as described in section #ahhf7;d77#a77;,b77iv7 of such ,act 7#db ,u4,s4,c4 #acieww7d77#a77;,b77iv7772 7,d7 an institution 7or distinct part thereof7 described in section #aije7;d7 of such ,act 7#db ,u4,s4,c4 #acif;d7d7772 7,e7 an institution 7or distinct part thereof7 which is a psychiatric hospital 7as defined in section #ahfa7;f7 of such ,act 7#db ,u4,s4,c4 #aciex7f777 or that provides inpatient psychiatric services in another residential setting specified by the ,secretary2 7,f7 an institution 7or distinct part thereof7 described in section #aije7;i7 of such ,act 7#db ,u4,s4,c4 #acif;d7i772 and 7,g7 any other relevant facility1 as determined by the ,secretary4 7#h7 ,medicaid program ,the term ,medicaid program means1 with respect to a ,state1 the ,state program under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7including any waiver or demonstration under such title or under section #aaae of such ,act 7#db ,u4,s4,c4 #acae7 relating to such title74 7#i7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7#aj7 ,state ,the term ,state has the meaning given such term for purposes of title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 ,i ,expanding ,access to ,medicaid ,home and ,community-,based ,services #aja4 ,,hcbs infrastructure improvement planning grants 7a7 ,in general ,not later than #ab months after the date of enactment of this ,act1 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 7b7 and 7c74 7b7 ,content requirements ,in order to meet the requirements of this subsection1 an ,,hcbs infrastructure improvement plan shall include1 with respect to a ,state1 the following3 7#a7 ,existing ,medicaid ,,hcbs landscape 7,a7 ,eligibility and benefits ,a description of-- 7i7 the existing standards1 pathways1 and methodologies for eligibility for home and community-based services1 including limits on assets and income2 7ii7 the home and community-based services available under the ,state ,medicaid program2 and 7iii7 utilization management standards for such services4 7,b7 ,access ,an assessment of the extent to which home and community-based services are available to eligible individuals in the ,state1 including-- 7i7 estimates of the number of eligible individuals who are on a waitlist for such services2 7ii7 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 services2 7iii7 a description of the home and community-based services not available under the ,state ,medicaid program2 7iv7 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 ,states2 and 7v7 a description of barriers to accessing home and community-based services identified by eligible individuals and families of such individuals4 7,c7 ,utilization ,an assessment of the utilization of home and community-based services in the ,state4 7,d7 ,service delivery structures ,a description of the service delivery structures for providing home and community-based services in the ,state1 including with respect to the use and models of self-direction1 the provision of services by agencies1 the ownership of service provider agencies1 the use of managed care versus fee-for-service to provide such services1 and the supports provided for family caregivers4 7,e7 ,workforce ,a description of the characteristics of the direct care workforce that provides home and community-based services1 including the number of full- and part-time direct care workers1 the average and range of direct care worker wages1 the benefits provided to direct care workers1 the turnover and vacancy rates of direct care worker positions1 the membership of direct care workers in labor organizations or professional organizations1 and the race1 ethnicity1 and gender of such workforce4 7,f7 ,payment rates ,a description of the payment rates for home and community-based services1 including when such rates were last updated1 an assessment of the extent to which authorized services are not delivered as a result of such rates being insufficient1 and the extent to which payment rates are passed through to direct care worker wages4 7,g7 ,quality ,a description of how the quality of home and community-based services is measured and monitored1 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 ,state4 7,h7 ,long-term services and supports provided in institutional settings ,a description of-- 7i7 the extent to which eligible individuals receive long-term services and supports in institutional settings in the ,state2 and 7ii7 the populations provided such services and supports4 7,i7 ,,hcbs share of overall ,medicaid ,,ltss spending ,for the most recent fiscal year for which data is available1 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 services4 7,j7 ,demographic data ,each assessment required under subparagraphs 7,b7 and 7,c71 and the description required under subparagraph 7,h77ii7 shall include1 to the extent available1 data disaggregated by disability status1 age1 income1 gender1 race1 ethnicity1 geography1 primary language1 sexual orientation1 gender identity1 and type of service setting4 7#b7 ,annual measures and reports ,a description of the ,state plan for-- 7,a7 annually measuring and reporting on-- 7i7 the availability and utilization of home and community-based services2 7ii7 the characteristics of the direct care workforce that provides home and community-based services and the race1 ethnicity1 and gender of such workforce2 7iii7 changes in payment rates for home and community-based services2 and 7iv7 progress with respect to implementation of the activities1 benchmarks1 and improvement activities provided under subsection 7jj7 of section #aije of the ,social ,security ,act 7as added under section #ajb72 and 7,b7 collecting and reporting disaggregated data by disability status1 age1 income1 gender1 race1 ethnicity1 geography1 primary language1 sexual orientation1 gender identity1 and type of service setting for the information required by clause 7i7 of subparagraph 7,a74 7#c7 ,implementation and goals for ,,hcbs improvements ,a description of how the ,state will-- 7,a7 conduct the activities1 benchmarks1 and improvement activities provided under subsection 7jj7 of section #aije of the ,social ,security ,act 7as added under section #ajb71 including how the ,state plans to meet the benchmarks described in paragraph 7#e7 of such subsection and1 if applicable1 the additional ,,hcbs improvement efforts described in paragraph 7#c7 of such subsection2 7,b7 identify and reduce barriers to accessing home and community-based services1 including for individuals in institutional settings1 individuals experiencing homelessness or housing instability1 and individuals in regions with low or no access to such services2 7,c7 identify and reduce disparities in access to1 and utilization of1 home and community-based services by disability status1 age1 income1 gender1 race1 ethnicity1 geography1 primary language1 sexual orientation1 gender identity1 and type of service setting2 7,d7 coordinate implementation of the ,,hcbs infrastructure improvement plan among the ,state ,medicaid agency1 agencies serving individuals with disabilities1 the elderly1 and other relevant ,state and local agencies2 and 7,e7 facilitate access to related supports by coordinating with ,state and local agencies and organizations that provide housing1 transportation1 employment1 nutrition1 and other services and supports4 7c7 ,development and submission requirements ,in order to meet the requirements of this subsection1 an ,,hcbs infrastructure improvement plan shall-- 7#a7 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 services1 family caregivers of such recipients1 providers1 health plans1 direct care workers1 chosen representatives of direct care workers1 and aging1 disability1 and workforce advocates2 7#b7 be submitted for approval by the ,secretary not later than #bd months after the date on which the ,state was awarded the planning grant under this section2 and 7#c7 be publicly available in the final version submitted to the ,secretary on a ,state ,internet website4 7d7 ,approval2 publication 7#a7 ,in general ,the ,secretary shall approve an ,,hcbs infrastructure improvement plan if the plan-- 7,a7 is complete2 and 7,b7 provides assurances to the satisfaction of the ,secretary that the ,state will meet the requirements of the ,,hcbs ,infrastructure ,improvement ,program established under subsection 7jj7 of section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d71 as added by section #ajb1 and achieve the benchmarks for improvement established by such program4 7#b7 ,publication ,the ,secretary1 acting through the ,administrator of the ,centers for ,medicare ,medicaid ,services1 shall make publicly available on an ,internet website-- 7,a7 the final version of each approved ,,hcbs infrastructure improvement plan2 and 7,b7 in the case of any ,,hcbs infrastructure improvement plan submitted for approval that is not approved-- 7i7 the submitted plan2 7ii7 the decision not approving such plan2 and 7iii7 information relating to why the plan was not approved4 7e7 ,continuation of ,american ,rescue ,plan ,act increased ,,fmap for ,,hcbs for ,states awarded a planning grant 7#a7 ,,fmap 7,a7 ,in general ,notwithstanding subsections 7b7 or 7ff7 of section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d71 subject to subparagraph 7,c71 in the case of a ,state that is awarded a planning grant under this section and meets the maintenance of effort requirements under paragraph 7#b71 the ,federal medical assistance percentage determined for the ,state under such subsection 7b7 7or such subsection 7ff71 if applicable7 and1 if applicable1 as increased under subsection 7y71 7z71 7aa71 or 7ii7 of such section1 section #aiae7k7 of such ,act 7#db ,u4,s4,c4 #acifn7k771 or section #fjjh of the ,families ,first ,coronavirus ,response ,act 7,public ,law #aaf-abg71 shall be increased by #aj percentage points 7but not to exceed #ie percent7 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 7as defined in subparagraph 7,b774 7,b7 ,,hcbs planning period ,in this paragraph1 the term ,,hcbs planning period means1 with respect to a ,state1 the period-- 7i7 beginning on the date on which the ,state is awarded a planning grant under this section2 and 7ii7 ending on the earlier of-- 7,i7 the first day of the first fiscal quarter for which the ,state is an ,,hcbs program improvement ,state2 and 7,,ii7 the date that is #c years after the date on which the ,state is awarded such a grant4 7,c7 ,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 7as defined under subsection 7a77#b77;,a7 of section #ihag of the ,american ,rescue ,plan ,act 7,public ,law #aag-b771 and the ,state meets the ,,hcbs program requirements under subsection 7b7 of such section1 the increase in the ,federal medical assistance percentage that would otherwise apply to the ,state under subparagraph 7,a7 of this paragraph shall not apply during any portion of the ,,hcbs program improvement period 7as defined under subsection 7a77#b77;,a7 of section #ihag of the ,american ,rescue ,plan ,act 7,public ,law #aag-b77 for which the ,state receives an increase in the ,federal medical assistance percentage in accordance with that section4 7,d7 ,nonapplication of territorial funding caps ,any payment made to ,puerto ,rico1 the ,virgin ,islands1 ,guam1 the ,northern ,mariana ,islands1 or ,american ,samoa for expenditures on medical assistance that are subject to the ,federal medical assistance percentage increase specified under subparagraph 7,a7 shall not be taken into account for purposes of applying payment limits under subsections 7f7 and 7g7 of section #aajh of the ,social ,security ,act 7#db ,u4,s4,c4 #acjh74 7#b7 ,maintenance of effort requirements ,for purposes of paragraph 7#a77;,a71 the requirements of this paragraph are1 with respect to the period for which a ,state is awarded a planning grant under this section1 the ,state shall not-- 7,a7 lower the amount1 duration1 or scope of home and community-based services available under the ,state ,medicaid program 7relative to the services available under the program as of the date on which the ,state was awarded such grant72 or 7,b7 adopt more restrictive standards1 methodologies1 or procedures for determining eligibility1 benefits1 or services for receipt of home and community-based services under the ,state ,medicaid program1 including with respect to utilization management or cost-sharing1 than the standards1 methodologies1 or procedures applicable as of the date on which the ,state was awarded such grant4 7f7 ,funding 7#a7 ,in general ,out of any funds in the ,treasury not otherwise appropriated1 there is appropriated to the ,secretary for purposes of awarding planning grants under this section1 #ajj1jjj1jjj for fiscal year #bjbb1 to remain available until expended4 7#b7 ,technical assistance and guidance ,the ,secretary shall reserve #e1jjj1jjj of the amount appropriated under paragraph 7#a7 for purposes of issuing guidance and providing technical assistance to ,states seeking or awarded a planning grant under this section4 #ajb4 ,,hcbs ,infrastructure ,improvement ,program 7a7 ,enhanced ,,fmap for ,,hcbs program improvement ,states ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is amended-- 7#a7 in subsection 7b71 by striking and 7ii7 and inserting 7ii71 and 7jj72 and 7#b7 by adding at the end the following new subsection3 7jj7 ,enhanced ,federal medical assistance percentage for ,,hcbs program improvement ,states 7#a7 ,in general 7,a7 ,increased federal financial participation ,subject to paragraph 7#e71 in the case of a ,state that is an ,,hcbs program improvement ,state and meets the requirements described in paragraphs 7#b7 and 7#d71 for each fiscal year quarter that begins on or after the first date on which a ,state is an ,,hcbs program improvement ,state-- 7i7 notwithstanding subsection 7b7 or 7ff71 subject to subparagraph 7,b71 with respect to amounts expended during the quarter by such ,state for medical assistance for home and community-based services1 the ,federal medical assistance percentage for such ,state and quarter 7as determined for the ,state under subsection 7b7 and1 if applicable1 increased under subsection 7y71 7z71 7aa71 or 7ii71 or section #fjjh7;a7 of the ,families ,first ,coronavirus ,response ,act7 shall be increased by #aj percentage points 7but not to exceed #ie percent72 and 7ii7 notwithstanding the per centum specified in section #aijc7;a77#g71 with respect to amounts expended during the quarter and before ,october #a1 #bjca1 for administrative costs for expanding and enhancing home and community-based services1 including for enhancing the ,medicaid data and technology infrastructure1 modifying rate setting processes1 adopting1 using1 and reporting quality measures and beneficiary and family caregiver experience surveys1 adopting or improving training programs for direct care workers and family caregivers1 and adopting1 carrying out1 or enhancing programs that register qualified direct care workers or connect beneficiaries to qualified direct care workers1 such per centum shall be increased to #hj percent4 7,b7 ,additional ,,hcbs improvement efforts ,subject to paragraph 7#e71 in addition to the increase to the ,federal medical assistance percentage under subparagraph 7,a77i71 with respect to amounts expended for medical assistance during the first #d fiscal quarters throughout which an ,,hcbs program improvement ,state has implemented a program to support self-directed care that meets the requirements of paragraph 7#c7 7in addition to meeting the requirements described in paragraph 7#b771 the ,federal medical assistance percentage for such ,state and each such quarter with respect to such amounts shall be further increased by #b percentage points 7but not to exceed #ie percent74 7,c7 ,nonapplication of territorial funding caps ,any payment made to ,puerto ,rico1 the ,virgin ,islands1 ,guam1 the ,northern ,mariana ,islands1 or ,american ,samoa for expenditures that are subject to an increase in the ,federal medical assistance percentage under subparagraph 7,a77i7 or 7,b71 or an increase in an applicable ,federal matching percentage under subparagraph 7,a77ii71 shall not be taken into account for purposes of applying payment limits under subsections 7f7 and 7g7 of section #aajh4 7#b7 ,requirements ,the requirements described in this paragraph1 with respect to a ,state and a fiscal year quarter1 are the following3 7,a7 ,maintenance of effort 7i7 ,in general ,except as provided under clause 7ii71 the ,state does not-- 7,i7 lower the amount1 duration1 or scope of home and community-based services available under the ,state plan or waiver 7relative 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 #aja of the ,better ,care ,better ,jobs ,act72 or 7,,ii7 adopt more restrictive standards1 methodologies1 or procedures for determining eligibility1 benefits1 or services for receipt of home and community-based services1 including with respect to utilization management or cost-sharing and the amount1 duration1 and scope of available home and community-based services1 than the standards1 methodologies1 or procedures applicable as of such date4 7ii7 ,exception ,on or after ,october #a1 #bjbh1 a ,state may modify such standards1 methodologies1 or procedures if the ,state demonstrates that such modifications shall not result in-- 7,i7 home and community-based services that are less comprehensive or lower in amount1 duration1 or scope2 7,,ii7 fewer individuals 7overall and within particular beneficiary populations7 receiving home and community-based services2 or 7,,iii7 increased cost-sharing for home and community-based services4 7,b7 ,access to services ,the ,state enhances1 expands1 or strengthens home and community-based services by doing all of the following3 7i7 ,addressing access barriers and disparities in access or utilization identified in the ,state ,,hcbs infrastructure improvement plan4 7ii7 ,expanding financial eligibility criteria for home and community-based services up to ,federal limits4 7iii7 ,requiring coverage of personal care services for all eligible populations receiving home and community-based services in the ,state4 7iv7 ,using no wrong door programs1 providing presumptive eligibility for home and community-based services1 and improving home and community-based services counseling and education programs4 7v7 ,expanding access to behavioral health services and coordination with employment1 housing1 and transportation supports4 7vi7 ,providing supports to family caregivers1 which shall include providing respite care1 and may include providing such services as caregiver assessments1 peer supports1 or paid family caregiving4 7vii7 ,adopting1 expanding eligibility for1 or improving coverage provided under a ,medicaid buy-in program authorized under subclause 7,,xiii71 7,,xv71 or 7,,xvi7 of section #aijb7;a77#aj77;,a77ii74 7,c7 ,strengthened and expanded workforce 7i7 ,in general ,the ,state strengthens and expands the direct care workforce that provides home and community-based services by-- 7,i7 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 plan2 and 7,,ii7 updating1 developing1 and adopting qualification standards and training opportunities for the continuum of providers of home and community-based services1 including programs for independent providers of such services and agency direct care workers1 as well as unique programs and resources for family caregivers4 7ii7 ,payment rates ,in carrying out clause 7i77,i71 the ,state shall-- 7,i7 address insufficient payment rates for delivery of home and community-based services1 with an emphasis on supporting the recruitment and retention of the direct care workforce1 as identified during the period in which the ,state ,,hcbs infrastructure improvement plan was developed and during subsequent years2 7,,ii7 update payment rates for home and community-based services at least every #b years through a transparent process involving meaningful input from stakeholders1 including recipients of home and community-based services1 family caregivers of such recipients1 providers1 health plans1 direct care workers1 chosen representatives of direct care workers1 and aging1 disability1 and workforce advocates2 and 7,,iii7 ensure that increases in the payment rates for home and community-based services are-- 7aa7 at a minimum1 proportionately passed through to direct care workers and in a manner that is determined with input from the stakeholders described in subclause 7,,ii72 and 7bb7 incorporated into payment rates for home and community-based services provided under this title by a managed care entity 7as defined in section #aicb7;a77#a77;,b77 or a prepaid inpatient health plan or prepaid ambulatory health plan1 as defined in section #dch4b of title #db1 ,code of ,federal ,regulations 7or any successor regulation771 under a contract with the ,state4 7#c7 ,,hcbs improvement to support self-directed models for the delivery of services ,for purposes of paragraph 7#a77;,b71 the requirements of this paragraph1 with respect to a ,state and a fiscal year quarter1 are that the ,state establishes directly or by contract with #a or more non-profit entities1 a program for the performance of all of the following functions3 7,a7 ,registering qualified direct care workers and assisting beneficiaries in finding direct care workers4 7,b7 ,undertaking activities to recruit and train independent providers to enable beneficiaries to direct their own care1 including by providing or coordinating training for beneficiaries on self-directed care4 7,c7 ,ensuring the safety of1 and supporting the quality of1 care provided to beneficiaries1 such as by conducting background checks and addressing complaints reported by recipients of home and community-based services4 7,d7 ,facilitating coordination between ,state and local agencies and direct care workers for matters of public health1 training opportunities1 changes in program requirements1 workplace health and safety1 or related matters4 7,e7 ,supporting beneficiary hiring of independent providers of home and community-based services through an agency with choice or similar model1 including by processing applicable tax information1 collecting and processing timesheets1 submitting claims and processing payments to such providers4 7,f7 ,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 services1 providing support to beneficiaries who wish to hire a caregiver who is a family member or individual with whom they have an existing relationship1 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 plan4 7,g7 ,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 join1 or form1 such a labor organization1 or1 in the case of a ,state in which such workers have not joined or formed such a labor organization1 are neutral with regard to such workers joining or forming such a labor organization4 7#d7 ,quality1 reporting1 and oversight ,the requirements described in this paragraph1 with respect to a ,state and a fiscal year quarter1 are the following3 7,a7 ,the ,state adopts the core quality measures for home and community-based services developed by the ,secretary under section #ajd of the ,better ,care ,better ,jobs ,act1 or an alternate set of quality measures approved by the ,secretary1 and1 at the option of the ,state1 expands the use of beneficiary and family caregiver experience surveys4 7,b7 ,the ,state designates an ,,hcbs ombudsman office that-- 7i7 operates independently from the ,state ,medicaid agency and managed care entities2 7ii7 provides direct assistance to beneficiaries and their families2 and 7iii7 identifies and reports systemic problems to ,state officials1 the public1 and the ,secretary4 7,c7 ,beginning with the #eth fiscal year quarter for which the ,state is an ,,hcbs program improvement ,state1 and annually thereafter1 the ,state reports on the components of the existing home and community-based services landscape reported in the ,state ,,hcbs infrastructure improvement plan1 including with respect to-- 7i7 the availability and utilization of home and community-based services1 disaggregated by disability status1 age1 income1 gender1 race1 ethnicity1 geography1 primary language1 sexual orientation1 gender identity1 and type of service setting2 7ii7 the characteristics of the direct care workforce that provides home and community-based services workforce and the race1 ethnicity1 and gender of such workforce2 7iii7 changes in payment rates for home and community-based services2 7iv7 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 7,b7 and 7,c7 of paragraph 7#b72 7v7 if applicable1 implementation of the activities described in paragraph 7#c72 and 7vi7 the progress made with respect to meeting the benchmarks for demonstrating improvements required in paragraph 7#e74 7#e7 ,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 7#a77;,a77i7 or 7#a77;,b7 or an increase in an applicable ,federal matching percentage under paragraph 7#a77;,a77ii7 beginning with the #bith fiscal year quarter that begins on or after the first date on which a ,state is an ,,hcbs program improvement ,state1 unless1 not later than #ij days before the first day of such fiscal year quarter1 the ,state submits to the ,secretary a report demonstrating the following improvements3 7,a7 ,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 plan4 7,b7 ,increased utilization and availability of home and community-based services by populations with the lowest utilization and availability of such services 7as reported in the ,state ,,hcbs infrastructure improvement plan7 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 plan4 7,c7 ,evidence that a majority of direct care workers receive competitive wages and benefits4 7,d7 ,with respect to the percentage of expenditures made by the ,state for long-term services and supports that are for home and community-based services1 in the case of an ,,hcbs program improvement ,state for which such percentage 7as reported in the ,state ,,hcbs infrastructure improvement plan7 was-- 7i7 less than #ej percent1 the ,state demonstrates that the percentage of such expenditures has increased to at least #ej percent since the plan was approved2 and 7ii7 at least #ej percent1 the ,state demonstrates that such percentage has not decreased since the plan was approved4 7#f7 ,definitions ,in this subsection1 the terms direct care worker1 direct care workforce1 ,,hcbs program improvement ,state1 and home and community-based services have the meanings given those terms in section #b of the ,better ,care ,better ,jobs ,act4 4 #ajc4 ,reports2 technical assistance2 other administrative requirements 7a7 ,reports ,the ,secretary shall submit to the appropriate committees of ,congress the following reports relating to the ,,hcbs ,infrastructure ,improvement ,program established under this title3 7#a7 ,initial report ,not later than #d years after the date of enactment of this ,act1 a report that includes the following3 7,a7 ,a description of the ,,hcbs infrastructure improvement plans approved by the ,secretary under section #aja7;d74 7,b7 ,a description of the national landscape with respect to gaps in coverage of home and community-based services1 disparities in access to1 and utilization of1 such services1 and barriers to accessing such services4 7,c7 ,a description of the national landscape with respect to the direct care workforce that provides home and community-based services1 including with respect to compensation1 benefits1 and challenges to the availability of such workers4 7#b7 ,subsequent reports ,not later than #g years after the date of enactment of this ,act1 and every #c years thereafter1 a report that includes the following3 7,a7 ,the number of ,,hcbs program improvement ,states4 7,b7 ,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 #aije7;jj77#e7 of the ,social ,security ,act 7as added by section #ajb74 7,c7 ,a summary of outcomes related to home and community-based services core quality measures and beneficiary and family caregiver surveys4 7,d7 ,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 services4 7b7 ,technical assistance2 guidance2 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 #aja7;d7 and meeting the requirements and benchmarks for demonstrating improvements required under section #aije7;jj7 of the ,social ,security ,act 7as added by section #ajb7 and shall issue such guidance or regulations as necessary to carry out this title and the amendments made by this title1 including guidance specifying how ,states shall assess and track the availability of home and community-based services over time4 7c7 ,recommendations ,to guide infrastructure improvement 7#a7 ,in general ,not later than #ah months after the date of enactment of this ,act1 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 services1 including with respect to how the ,federal ,government should classify the direct care workforce1 how such ,administrator and ,state ,medicaid programs can enforce and support the provision of competitive wages and benefits across the direct care workforce1 including for workers with particular skills or expertise1 and how ,state ,medicaid programs can support training opportunities and other related efforts that support the provision of quality home and community-based services care4 7#b7 ,stakeholder consultation ,in developing the recommendations required under paragraph 7#a71 the ,secretary shall ensure that such recommendations are informed by consultation with recipients of home and community-based services1 family caregivers of such recipients1 providers1 health plans1 direct care workers1 chosen representatives of direct care workers1 and aging1 disability1 and workforce advocates4 7d7 ,funding ,out of any funds in the ,treasury not otherwise appropriated1 there is appropriated to the ,secretary for purposes of carrying out this section1 #aj1jjj1jjj for fiscal year #bjbb1 to remain available until expended4 #ajd4 ,quality measurement and improvement 7a7 ,development and publication of core and supplemental sets of ,,hcbs quality measures 7#a7 ,in general ,not later than #b years after the date of enactment of this ,act1 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 programs1 health plan and managed care entities that enter into contracts with such programs1 and providers of items and services under such programs4 7#b7 ,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 7#a7 not less frequently than once every year4 7#c7 ,requirements 7,a7 ,interagency collaboration2 stakeholder input ,in developing the recommended core set and supplemental set of home and community-based services quality measures under paragraph 7#a71 and subsequently reviewing and updating such core and supplemental sets1 the ,secretary shall-- 7i7 collaborate with the ,administrator of the ,centers for ,medicare ,medicaid ,services1 the ,administrator of the ,administration for ,community ,living1 the ,director of the ,agency for ,healthcare ,research and ,quality1 and the ,administrator of the ,substance ,abuse and ,mental ,health ,services ,administration2 and 7ii7 ensure that such core and supplemental sets are informed by input from stakeholders1 including recipients of home and community-based services1 family caregivers of such recipients1 providers1 health plans1 direct care workers1 chosen representatives of direct care workers1 and aging1 disability1 and workforce advocates4 7,b7 ,reflective of full array of services ,such recommended core set and supplemental set of home and community-based services quality measures shall-- 7i7 reflect the full array of home and community-based services and recipients of such services1 including adults and children2 and 7ii7 include-- 7,i7 outcomes-based measures2 7,,ii7 measures of availability of services2 7,,iii7 measures of provider capacity and availability2 7,,iv7 measures related to person-centered care2 7,v7 measures specific to self-directed care2 7,,vi7 measures related to transitions to and from institutional care2 and 7,,vii7 beneficiary and family caregiver surveys4 7,c7 ,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 status1 age1 income1 gender1 race1 ethnicity1 geography1 primary language1 sexual orientation1 gender identity1 and type of service setting4 7#d7 ,funding ,out of any funds in the ,treasury not otherwise appropriated1 there is appropriated to the ,secretary for purposes of carrying out this subsection1 #e1jjj1jjj for fiscal year #bjbb1 to remain available until expended4 7b7 ,state adoption and reports 7#a7 ,in general ,not later than #b 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 7a77#a71 and annually thereafter1 each ,state ,medicaid program shall use such core and supplemental sets 7or an alternative set of quality measures approved by the ,secretary7 to report information to the ,secretary regarding the quality of home and community-based services provided under such program4 7#b7 ,process ,the information required under paragraph 7#a7 shall be reported using a standardized format and procedures established by the ,secretary4 ,such procedures shall allow a ,state ,medicaid program to report such information separately or as part of the annual reports required under sections #aaci;,a7c7 and #aaci;,b7d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;b-#i;a1 #acbj;b-#i;b74 7#c7 ,publication of quality measures ,each ,state ,medicaid program shall periodically make the information reported to the ,secretary under paragraph 7#a7 available to the public4 7#d7 ,increased ,federal matching rate for adoption and reporting ,section #aijc7;a77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7a77#c77 is amended-- 7,a7 in subparagraph 7,f77ii71 by striking plus after the semicolon and inserting and2 and 7,b7 by inserting after subparagraph 7,f71 the following3 7,g7 #hj 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 #ajd7;b7 of the ,better ,care ,better ,jobs ,act2 and 4 ,,ii ,other ,provisions #bja4 ,,macpac study and report on ,appendix ,k emergency home and community-based services 7,,hcbs7 #aiae7;c7 waivers 7a7 ,in general ,the ,medicaid and ,,chip ,payment and ,access ,commission 7referred to in this section as ,,macpac7 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 #aiae7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifn7c77 approved for ,states during the ,,covid-#ai pandemic using the ,appendix ,k template issued by the ,centers for ,medicare ,medicaid ,services on ,march #bb1 #bjbj4 7b7 ,report ,the report submitted under subsection 7a7 shall-- 7#a7 describe the specific types of flexibilities or other program changes adopted by ,states using the ,appendix ,k template2 7#b7 evaluate the efficiency1 management1 and success and failures of such flexibilities and program changes2 and 7#c7 include recommendations for legislative and administrative actions to continue specific flexibilities1 program changes1 and innovative service delivery models that increase access to care in home and community settings4 #bjb4 ,making permanent the ,state option to extend protection under ,medicaid for recipients of home and community-based services against spousal impoverishment 7a7 ,in general ,section #aibd7;h77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#e7;h77#a77;,a77 is amended by striking is described in section #aijb7;a77#aj77;,a77ii77,,vi7 and inserting the following3 is eligible for medical assistance for home and community-based services provided under subsection 7c71 7d71 or 7i7 of section #aiae1 under a waiver approved under section #aaae1 or who is eligible for such medical assistance by reason of being determined eligible under section #aijb7;a77#aj77;,c7 or by reason of section #aijb7;f7 or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care1 or who is eligible for medical assistance for home and community-based attendant services and supports under section #aiae7k74 7b7 ,conforming amendment ,section #bdjd of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acifr-#e note7 is amended by striking ,september #cj1 #bjbc and inserting the date of enactment of the ,better ,care ,better ,jobs ,act4 #bjc4 ,permanent extension of ,money ,follows the ,person ,rebalancing demonstration 7a7 ,in general ,subsection 7h7 of section #fjga of the ,deficit ,reduction ,act of #bjje 7#db ,u4,s4,c4 #acif;a note7 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,i71 by inserting and after the semicolon2 7,b7 by amending subparagraph 7,j7 to read as follows3 7,g7 #dej1jjj1jjj for each fiscal year after fiscal year #bjba4 2 and 7,c7 by striking subparagraph 7,k72 and 7#b7 in paragraph 7#b71 by striking ,september #cj1 #bjbc and inserting ,september #cj of such fiscal year4 7b7 ,redistribution of unexpended grant awards ,subsection 7e77#b7 of section #fjga of the ,deficit ,reduction ,act of #bjje 7#db ,u4,s4,c4 #acif;a note7 is amended by adding at the end the following new sentence3 ,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 year44