Sec. 102. Requiring coverage of home and community-based services under the Medicaid program
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/bill/118/s/762/is/section-102·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended by adding at the end the following new subsection: For purposes of this title, the term home and community-based services means those services specified in paragraph
(2)furnished to an eligible individual (as defined in paragraph (3)), based on an individualized assessment (as described in paragraph (4)) of such individual, in a setting that— meets the qualities specified in paragraph
(1)of section 441.710(a) of title 42, Code of Federal Regulations (or a successor regulation); is not described in paragraph
(2)of such section (or successor regulation); and meets such other qualities as the Secretary determines appropriate. For purposes of paragraph (1), the services specified in this paragraph are services described in any of paragraphs (7), (8), (13)(C), (19), (20), (24), and
(29)(as applied without regard to the reference to September 30, 2025 ) of subsection
(a)or in any of subsections (c)(4)(B), (c)(5), (k)(1)(A), (k)(1)(B), or (k)(1)(D) of section 1915, including the following: Supported employment and integrated day services. Personal assistance, including personal care attendants, direct support professionals, home health aides, private duty nursing, homemakers and chore assistance, and companionship services. Services that enhance independence, inclusion, and full participation in the broader community. Non-emergency, non-medical transportation services to facilitate community integration. Respite services provided in the individual’s home or broader community. Caregiver and family support services. Case management, including intensive case management, fiscal intermediary, and support brokerage services. Services which support person-centered planning and self-direction. Direct support services during acute hospitalizations. Necessary medical and nursing services not otherwise covered which are necessary in order for the individual to remain in their home and community, including hospice services. Home and community-based intensive behavioral health and crisis intervention services. Peer support services. Housing support, including transitional housing or transitional support services for individuals who are unhoused, and wrap-around services. Necessary home modifications and assistive technology, including those which substitute for human assistance. Transition services to support an individual who is transitioning from an institutional setting to the community, including appropriate services for individuals who are unhoused or at risk of becoming unhoused, and including such transition services provided while the individual resides in an institution. Any other service recommended by the panel convened pursuant to subparagraph (B). Not later than 6 months after the date of the enactment of this subparagraph, and not less frequently than once every 5 years thereafter, the Secretary shall convene an advisory panel (in this subparagraph referred to as the panel ) for purposes of recommending additional services which shall be included as home and community-based services under this paragraph. The panel shall be composed of at least one representative (to be selected by the Secretary) from each of the following: Individuals with disabilities receiving home and community-based services under this title and individuals with disabilities in need of such services, including those with physical disabilities, behavioral health disabilities, or intellectual or developmental disabilities, and including older adults. Beneficiary-led disability rights organizations. Disability-led organizations. Disabled veterans organizations. Disability organizations representing families. Community-based provider organizations. Organizations serving older adults. The Protection and Advocacy system, the Centers for Independent Living. Health care providers. The National Association of Medicaid Directors. The National Association of State Directors of Developmental Disabilities Services. The National Association of State Mental Health Program Directors. ADvancing States. The Centers for Medicare & Medicaid Services. The Administration for Community Living of the Department of Health and Human Services. Other relevant local, State, and Federal home and community-based service systems, as determined by the Secretary. The Secretary shall select an equal number of representatives from each category described in items
(aa)through
(oo)subclause
(I)in convening the panel. Not later than 6 months after a panel is convened under clause (i), the panel shall submit to the Secretary and to Congress a report recommending additional services which shall be included as home and community-based services under this paragraph. Such recommended services shall be so specified with the goal of increasing community integration and self-determination for individuals with disabilities receiving such services. Services recommended by the panel in a report submitted under clause
(iii)shall be treated as services described in subparagraph (A)(xvi) for calendar quarters beginning on or after the date that is 1 year after the date of such submission. Not later than 1 year after the first report is submitted under clause (iii), and not later than 1 year after the submission of each subsequent such report, the Secretary shall notify States of any additions or removals of home and community-based services based on services recommended under such report through State Medicaid Director letters. For purposes of paragraph (1), the term eligible individual means— an individual who is determined, on an annual basis or on a longer basis specified by the State, by a health care provider approved by the State under a process described in subparagraph
(C)to have a functional impairment (as defined in subparagraph (B)) (not taking into account any items or services, or any other ameliorative measures, furnished to such individual to mitigate such impairment) that is expected to last at least 90 days; during the period that ends on the day before the first day of the first calendar quarter beginning on or after the date that is 5 years after the date of the enactment of this subsection, an individual who, as of such date of enactment, is receiving or has been determined to be eligible for, home and community-based services under this title under a waiver or State plan option in effect under section 1915 or 1115, provided that the individual continues to meet any level of care requirement applicable under such waiver or plan option; or an individual who is eligible under the State plan or waiver and is under the age of 21. For purposes of subparagraph (A), the term functional impairment means, with respect to an individual the inability of such individual to perform, without assistance— 2 or more activities of daily living (as described in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986); 2 or more instrumental activities of daily living (as defined for purposes of section 1915(k)(1)(A)); or 1 activity of daily living (as so described) and 1 instrumental activity of daily living (as so defined). For purposes of subparagraph (A)(i), a process described in this subparagraph is a process established by the State to approve health care providers to make determinations described in such subparagraph that meets such standards as the Secretary may prescribe. For purposes of paragraph (1), an individualized assessment described in this paragraph is an independent assessment, with respect to an eligible individual— to determine a necessary level of services and supports to be provided, consistent with an individual’s functional impairments, to facilitate an individual’s community integration, self-determination, and well-being; to prevent the provision of unnecessary or inappropriate care; to establish a person-centered care plan (as described in subparagraph (C)) for the individual; that includes each of the elements described in clauses
(ii)through
(v)of section 1915(i)(1)(F); and that occurs not later than 30 days after such individual is determined to be an eligible individual. The assessment described in subparagraph
(A)shall be conducted with the presumption— that each eligible individual, regardless of type or level of disability or service need, can be served in the individual’s own home and community; and at the option of the individual, that services may be self-directed (as defined in section 1915(i)(1)(G)(iii)(II)). For purposes of subparagraph (A)(iii), a person-centered care plan described in this subparagraph is a written plan with respect to an individual that meets the requirements of section 1915(i)(1)(G)(ii). An individualized assessment described in subparagraph
(A)shall be conducted in accordance with standards specified by the Secretary, in consultation with the Administration for Community Living, that— safeguard against conflicts of interest; specify qualifications for who may perform such assessments; ensure transparency in the furnishing of such assessments, including ensuring the provision of the results of such assessments that includes information in plain language necessary to interpret the methodology and results of such assessments; ensure that the methodologies used in such assessments are sound and evidence-based; and require such methodologies to be made available on the public website of the State and tested for reliability and validity by an independent evaluator. . Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) is amended— in paragraph (30), by striking ; and and inserting a semicolon; by redesignating paragraph
(31)as paragraph (32); and by inserting after paragraph
(30)the following new paragraph: home and community-based services (as defined in subsection (jj)); and . Section 1902(a)(10)(A) of the Social Security Act ( 42 U.S.C. 1396a(a)(10)(A) ) is amended by striking and
(30)and inserting (30), and
(31). The amendment made by this subsection shall take effect on the first day of the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this Act. Section 1902(a)(10)(D) of the Social Security Act ( 42 U.S.C. 1396a(a)(10)(A) ) is amended— by inserting
(i)after
(D); by adding and after the semicolon; and by adding at the end the following new clause: beginning on the first day of the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this clause (or at such earlier date as the State may elect) for the inclusion of home and community-based services (as defined in section 1905(jj)) for any individual who— is eligible for medical assistance under the State plan (or waiver of such plan); is an eligible individual (as defined in such section); and elects to receive such services. . Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ), as amended by subsection (a), is further amended— in subsection (b), by striking and
(ii)and inserting (ii), and
(kk); and by adding at the end the following new subsection: Notwithstanding any other provision of law and except as provided in paragraph (3), the Federal medical assistance percentage for amounts expended for medical assistance for home and community-based services (as defined in subsection (jj)), including any such services furnished under a waiver in effect under section 1915, on or after the date of the enactment of this subsection shall be equal to 100 percent. As a condition of receiving the Federal medical assistance percentage described in paragraph (1), a State shall enhance, expand, or strengthen the level of home and community-based services offered under the State plan under this title (or a waiver of such a plan) as of the date of enactment of this subsection by doing all of the following: Addressing access barriers and disparities in access or utilization identified in the State HCBS implementation plan. 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. Providing supports to family caregivers, which shall include providing respite care, and may include providing such services as caregiver assessments, peer supports, access to assistive technology, or paid family caregiving. Adopting processes to ensure that payments for home and community-based services are sufficient to ensure that such services are available to eligible beneficiaries. The Federal medical assistance percentage applicable to medical assistance for home and community-based services furnished to an individual who is only eligible for medical assistance under a State plan or waiver on the basis of section 1902(a)(10)(A)(ii)(XXIV) shall be determined without regard to this subsection. . Section 1915 of the Social Security Act ( 42 U.S.C. 1396n ) is amended by adding at the end the following new subsection: Except as provided in paragraph (2), the preceding provisions of this section, insofar as such provisions relate to a waiver for home and community-based services, shall not apply beginning with the first calendar quarter beginning on or after the date that is 5 years after the date of the enactment of this subsection. The Secretary may waive the application of paragraph
(1)for a calendar quarter and a State if the State requests such a waiver and the Secretary determines that such a waiver is appropriate. . Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ) is amended— in section 1905(a), in the matter preceding the first numbered paragraph— in clause (xv), by striking the comma at the end and inserting , or ; in clause (xvi)— by moving the left margin 2 ems to the left; and by striking , or and inserting a comma; and by striking clause (xvii); and in section 1943(b)(5), by striking the State and all that follows through the period at the end and inserting a determination be conducted on an annual basis (or on such longer basis as specified by the State) in accordance with section 1905(jj) for purposes of providing home and community-based services under the State plan (or waiver of such plan). . Except as provided in subparagraph (B), the amendments made by this subsection shall take effect on the first day of the first calendar quarter that begins on or after the date that is 5 years after the date of enactment of this Act. In the case of a State for which the Secretary has waived the application of paragraph
(1)of subsection
(m)of section 1915 of the Social Security Act ( 42 U.S.C. 1396n ), as added by subsection (e), in accordance with paragraph
(2)of such subsection (m), clause
(xvii)of section 1905(a) of the Social Security Act shall continue to have effect with respect to such State for so long as paragraph
(1)of such subsection
(m)does not apply to such State.
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Sec. 102
Requiring coverage of home and community-based services under the Medicaid program
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