Sec. 30713. HCBS Improvement Program
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Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended— in subsection (b), by striking and
(ii)and inserting (ii), and
(jj); and by adding at the end the following new subsection: Subject to paragraph (5), in the case of a State that is an HCBS program improvement State, for each fiscal quarter that begins on or after the first date on which the State is an HCBS program improvement State— and for which the State meets the requirements described in paragraphs
(2)and (4), 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 7 percentage points; and with respect to the State meeting the requirements described in paragraphs
(2)and (4), notwithstanding section 1903(a)(7), 1903(a)(3)(F), and 1903(t), 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 Medicaid data and technology infrastructure, modifying rate setting processes, adopting or improving training programs for direct care workers and family caregivers, and adopting, carrying out, or enhancing programs that register direct care workers or connect beneficiaries to direct care workers, the per centum specified in such section shall be increased to 80 percent. In no case may the application of clause
(i)result in the Federal medical assistance percentage determined for a State being more than 95 percent with respect to such expenditures. In no case shall the application of clause
(ii)result in a reduction to the per centum otherwise specified without application of such clause. Any increase pursuant to clause
(ii)shall be available to a State before the State meets the requirements of paragraphs
(2)and (4). Subject to paragraph (5), in addition to the increase to the Federal medical assistance percentage under subparagraph (A)(i) for amounts expended during a quarter for medical assistance for home and community-based services by an HCBS program improvement State that meets the requirements of paragraphs
(2)and
(4)for the quarter, the Federal medical assistance percentage for amounts expended by the State during the quarter for medical assistance for home and community-based services shall be further increased by 2 percentage points (but not to exceed 95 percent) during the first 8 fiscal quarters throughout which the State has implemented and has in effect a program to support self-directed care that meets the requirements of paragraph (3). 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. Any increase described in subparagraph
(A)(or payment made for expenditures on medical assistance that are subject to such increase) shall not be taken into account in calculating the enhanced FMAP of a State under section 2105. As conditions for receipt of the increase under paragraph
(1)to the Federal medical assistance percentage determined for a State, with respect to a fiscal year quarter, the State shall meet each of the following requirements: The State uses the Federal funds attributable to the increase in the Federal medical assistance percentage for amounts expended during a quarter for medical assistance for home and community-based services under subparagraphs
(A)and, if applicable,
(B)of paragraph
(1)to supplement, and not supplant, the level of State funds expended for home and community-based services for eligible individuals through programs in effect as of the date the State is awarded a planning grant under section 30712 of the Act titled An Act to provide for reconciliation pursuant to title II of S. Con. Res. 14 . In applying this subparagraph, the Secretary shall provide that a State shall have a 3-year period to spend any accumulated unspent State funds attributable to the increase described in clause
(i)in the Federal medical assistance percentage. The State does not— reduce 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 30712 of the Act titled An Act to provide for reconciliation pursuant to title II of S. Con. Res. 14 ; reduce payment rates for home and community-based services lower than such rates that were in place as of the date described in subclause (I), including, to the extent applicable, payment rates for such services that are included in managed care capitation rates; or except to the extent permitted under clause (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 cost-sharing, than the standards, methodologies, or procedures applicable as of such date. A State may make modifications that would otherwise violate the maintenance of effort described in clause
(i)if the State demonstrates to the satisfaction of the Secretary that such modifications shall not result in— home and community-based services that are less comprehensive or lower in amount, duration, or scope; fewer individuals (overall and within particular eligibility groups and categories) receiving home and community-based services; or increased cost-sharing for home and community-based services. Not later than an implementation date as specified by the Secretary after the first day of the first fiscal quarter for which a State receives an increase to the Federal medical assistance percentage or other applicable Federal matching percentage under paragraph (1), the State does all of the following to improve access to services: Reduce access barriers and disparities in access or utilization of home and community-based services, as described in the State HCBS improvement plan. Provides coverage of personal care services authorized under subsection (a)(24) for all individuals eligible for medical assistance in the State. Provides for navigation of home and community-based services through no wrong door programs, provides expedited eligibility for home and community-based services, and improves home and community-based services counseling and education programs. Expands access to behavioral health services as defined in the State’s HCBS improvement plan. Improves coordination of home and community-based services with employment, housing, and transportation supports. Provides supports to family caregivers, such as respite care, caregiver assessments, peer supports, or paid family caregiving. Adopts, expands eligibility for, or expands covered items and services provided under 1 or more eligibility categories authorized under subclause (XIII), (XV), or
(XVI)of section 1902(a)(10)(A)(ii). The State strengthens and expands the direct care workforce that provides home and community-based services by— 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 improvement plan; and updating qualification standards (as appropriate), and developing and adopting 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. In carrying out clause (i)(I), the State shall— update and increase, as appropriate, payment rates for delivery of home and community-based services to support the recruitment and retention of the direct care workforce; review and, if necessary to ensure sufficient access to care, increase payment rates for home and community-based services, not less frequently than once every 3 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 ensure that increases in the payment rates for home and community-based services— at a minimum, results in a proportionate increase to payments for direct care workers and in a manner that is determined with input from the stakeholders described in subclause (II); and incorporate into provider 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)) 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 and paid through capitation rates with the State. As conditions for receipt of the increase under paragraph (1)(B) to the Federal medical assistance percentage determined for a State, with respect to a fiscal year quarter, the State shall establish directly, or by contract with 1 or more non-profit entities, including an agency with choice or a similar service delivery model, a program for the performance of all of the following functions: Registering qualified direct care workers and assisting beneficiaries in finding direct care workers. 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. 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 consistent with Fair Hearing requirements and prior notice of service reductions, including under subpart F of part 438 of title 42, Code of Federal Regulations and section 438.71(d) of such title. 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. Supporting beneficiary hiring, if selected by the beneficiary, of independent providers of home and community-based services, including by processing applicable tax information, collecting and processing timesheets, submitting claims and processing payments to such providers. 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 service, 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. Ensuring that such programs do not discriminate against labor organizations or workers who may join or decline to join a labor organization. As conditions for receipt of the increase under paragraph
(1)to the Federal medical assistance percentage determined for a State, with respect to a fiscal year quarter, the State shall meet each of the following requirements: The State designates (by a date specified by the Secretary) an HCBS ombudsman office that— operates independently from the State Medicaid agency and managed care entities; provides direct assistance to recipients of home and community-based services available under the State Medicaid program and their families; and identifies and reports systemic problems to State officials, the public, and the Secretary. Beginning with the 5th fiscal quarter for which the State is an HCBS program improvement State, and annually thereafter, the State reports to the Secretary on the state (as of the last quarter before the report) of the components of the home and community-based services landscape described in the State HCBS improvement plan, including with respect to— the availability and utilization of home and community-based services, disaggregated (to the extent available and as applicable) by age groups, primary disability, income brackets, gender, race, ethnicity, geography, primary language, and type of service setting; wages, benefits, turnover and vacancy rates for the direct care workforce; changes in payment rates for home and community-based services; 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
(C)and
(D)of paragraph (2); if applicable, implementation of the activities described in paragraph (3); State expenditures for home and community-based services under the State plan or a waiver of such plan as a proportion of the total amount of State expenditures under the plan or waiver of such plan for long-term services and supports; and the challenges in, and best practices for, expanding access to home and community-based services, reducing disparities, and supporting and expanding the direct care workforce. 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) at any time or beginning with the 29th fiscal quarter that begins on or after the first date on which a State is an HCBS program improvement State if the State is found to be out of compliance with paragraph (2)(B) or any other requirement of this subsection and, beginning with such 29th fiscal quarter, unless, not later than 90 days before the first day of such fiscal quarter, the State submits to the Secretary a report demonstrating the following improvements: Increased availability (above a marginal increase) of home and community-based services in the State relative to such availability as reported in the State HCBS improvement plan and adjusted for demographic changes in the State since the submission of such plan. Reduced disparities in the utilization and availability of home and community-based services relative to the availability and utilization of such services by such populations as reported in such plan according to age groups, primary disability, income brackets, gender, race, ethnicity, geography, primary language, and type of service setting (to the extent available and applicable), and adjusted for demographic changes in the State since the submission of such plan. Evidence that rates are sufficient to ensure access to items and services for individuals eligible for HCBS in such State. 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 improvement plan) was— 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 at least 50 percent, the State demonstrates that such percentage has not decreased since the plan was approved. In this subsection, the terms State Medicaid plan , direct care worker , HCBS program improvement State , and home and community-based services have the meaning given those terms in section 30711 of the Act titled An Act to provide for reconciliation pursuant to title II of S. Con. Res. 14 . .
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Sec. 30713
HCBS Improvement Program
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