S. 5321 — HCBS Access Act

This section states the purposes of requiring Medicaid coverage of home and community-based services, including eliminating waiting lists, streamlining access without repeated waivers, supporting 63 million unpaid family caregivers, and improving standards for 3.2 million direct care workers to reduce institutionalization and disparities.

This section requires states to cover home and community-based services as medical assistance under Medicaid. It defines the services to include supported employment, personal assistance, respite care, case management, housing support, transition services, assisted living, and 12 other categories, furnished to eligible individuals based on an individualized assessment and person-centered plan in community settings meeting federal qualities. It directs the Secretary to appoint a 50-member advisory panel every five years to recommend additional services.

This section expands Medicaid eligibility to include individuals described in section 1905(ll)(3)(A) whose income does not exceed the greater of 150 percent of the poverty line or 300 percent of the supplemental security income benefit rate, beginning no later than the first calendar quarter 5 years after enactment (or earlier at state option). It also extends eligibility to individuals with income above that threshold up to a higher state-established level. The section further requires states to provide retroactive home and community-based services to such individuals for up to three months before application and without regard to the timing of any service plan.

This section requires states to submit to the Secretary an implementation plan for home and community-based services prior to the first calendar quarter beginning on or after the date 5 years after enactment (or an earlier date elected by the state). The plan must address 13 elements, including direct care workforce characteristics and compensation, numerical goals to expand access, coordination with housing and other agencies, tribal consultation, capacity building to eliminate waiting lists, outreach through a No Wrong Door program, and data on community integration and disparities. It provides 100 percent federal matching for the costs of developing the plan.

This section directs the Secretary of Health and Human Services to develop, within one year and through a public process, standardized State-level metrics on access to and satisfaction with Medicaid providers, including primary care and specialists, broken down by demographics, and to update the metrics at least every three years. It appropriates $200,000,000 for fiscal year 2027, to remain available until expended, and authorizes the Secretary to award implementation funds to States.

This section requires the Secretary to submit reports on state home and community-based services implementation plans to the Senate Finance, HELP, and Aging Committees and the House Energy and Commerce and Education and Workforce Committees, including an interim report within 2 years of enactment, a first implementation report within 4 years, and subsequent reports beginning 7 years after enactment and every 3 years thereafter. It directs the Secretary to provide technical assistance and guidance to states, issue recommendations on strengthening the direct care workforce after consulting recipients, caregivers, workers, and other stakeholders, and appropriates $10 million for FY2027.

This section directs the Secretary to develop, publish, and annually update core and supplemental sets of home and community-based services quality measures for state Medicaid programs, with requirements for interagency collaboration, stakeholder input (at least half from recipients and caregivers), outcomes-based and disparity measures, and data disaggregation by demographics. It appropriates $10 million for fiscal year 2027 to carry out this development. It requires each state Medicaid program to report using these measures (or approved alternatives) within two years and annually thereafter, to publish the information publicly, and to use a standardized format that may be combined with existing reports under sections 1139A and 1139B. It increases the federal matching rate under section 1903(a)(3) of the Social Security Act to 80 percent for state expenditures on such reporting. It also requires each state to establish an independent home and community-based services ombudsman office to assist beneficiaries and report systemic problems.

This section makes permanent the protection against spousal impoverishment for Medicaid recipients of home and community-based services. It requires states to apply the rules in section 1924 to eligible individuals (as defined in section 1905(ll)(3)) rather than at state option for individuals described in section 1902(a)(10)(A)(ii)(VI), and eliminates the September 30, 2027 sunset.

This section extends the Money Follows the Person rebalancing demonstration, which helps states transition Medicaid beneficiaries from institutional care to home and community-based services, through fiscal year 2024 and each fiscal year thereafter (from fiscal years 2024 through 2027).

This section terminates the authority to impose liens on the homes of Medicaid recipients in nursing facilities or other medical institutions after the date of enactment of the HCBS Access Act. It requires states to withdraw all such existing liens within 90 days of enactment and notify affected individuals or their estates. It also prohibits any adjustment or recovery of correctly paid medical assistance on or after the date of enactment, with the same 90-day withdrawal and notification requirements.

This section adds home and community-based services to the classes of health care items and services for which states may impose provider taxes under Medicaid without violating federal matching requirements. It excludes this class from the transition restriction that applies after 2026 to all other classes.

This section expands the home and community-based services that qualify full-benefit dual eligible individuals for elimination of beneficiary coinsurance under the Medicare Part D low-income subsidy. It adds services authorized under section 1115A and broadens references to section 1915 and State plan amendments.

This section states findings on the critical role of direct support professionals in caring for children and adults with intellectual and developmental disabilities, the 39 percent national turnover rate among such workers, and the resulting instability for service recipients. It further finds that a discrete occupational category in the Standard Occupational Classification system would improve federal and state data collection on labor shortages and better recognize work distinct from that of home health aides or personal care aides.

This section directs the Director of the Office of Management and Budget to consider establishing a separate code for direct support professionals as a subset of healthcare support occupations during the next revision of the Standard Occupational Classification system. If the Director declines to establish the code, the Director must report the reasons to the Senate Committee on Homeland Security and Governmental Affairs and the House Committee on Education and Workforce within 30 days after announcing the final decision in the Federal Register.

This section defines terms used in the title, including apprenticeship program (registered under the National Apprenticeship Act), community college (public institution awarding predominantly associate’s degrees), direct care professional (compensated provider of services promoting independence for persons with disabilities or older adults age 60 or older), direct care workforce, eligible entity, employer, family caregiver, Indian Tribe, institution of higher education, person with a disability, project participant, Secretary (HHS acting through the Administrator for Community Living), and self-directed care professional.

This section establishes a national technical assistance center, in consultation with the Secretaries of Labor and Education and the Administrator of the Centers for Medicare & Medicaid Services, to support direct care workforce creation, training, recruitment, retention, and advancement, and to assist family caregivers of older adults and people with disabilities. It also creates an advisory council and authorizes the center to develop curricula recommendations, learning and dissemination strategies, data collection improvements, career pathways, and grant evaluation methods.

This section directs the Secretary of Health and Human Services, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, the Secretary of Labor, and the Secretary of Education, to award grants within 12 months of enactment to eligible entities for recruiting, retaining, or advancing direct care professionals, their managers, self-directed care professionals, and family caregivers. At least 30 percent of assisted projects must provide career pathways for professional development.

This section requires eligible entities seeking grants to submit project plans that include demographics of populations likely to need long-term care, projections of unmet need for direct care services based on waiver waiting lists and workforce data, advisory committee composition with specified stakeholders, labor market information on job openings, strategies to reduce recruitment and retention barriers with wage and safety assessments, and details of any education or training programs incorporating core competencies, rights education, apprenticeships, mentoring, and progressively increasing wage schedules.

This section requires grant recipients under this title to submit annual reports to the Secretary with data on individuals recruited, trained, and employed as direct care professionals; family caregiver participation; completions of work-based learning, apprenticeships, and mentoring; vacancy and separation rates; participant, client, and employer satisfaction; and performance indicators on employment, earnings, and credentials. It directs the Secretary to submit annual progress reports to Congress beginning 2 years after enactment and continuing until all projects end; requires the Comptroller General to submit an assessment of workforce and caregiver impacts with recommendations within 1 year after project completion; and mandates that the Secretary contract for independent evaluations of grant activities and the technical assistance center within 6 months of enactment.

This section authorizes $2 million per year for fiscal years 2029 and 2030 for the technical assistance center under section 302, and $1 billion for grants under section 303 in fiscal year 2029. Amounts remain available through September 30, 2038.

This section requires the Administrator of the Centers for Medicare & Medicaid Services, in coordination with the National Academy of Medicine, to conduct or contract for a national survey within 7 years of enactment on the effects of the Act on Medicaid home and community-based services availability, direct care workforce capacity and compensation, economic impacts on beneficiaries and families, and related access issues for non-Medicaid populations. It directs publication of a report on the survey results within 9 years, requires the Bureau of the Census to add a question on long-term services and supports needs to the American Community Survey, and authorizes necessary appropriations.