Home and Community-Based Services (HCBS) Infrastructure Improvement Act (S. 3277)

Sponsored by: Senator Bob Casey (D-PA):

Why do we need the HCBS Infrastructure Improvement Act (S. 3277)?

Medicaid serves as the nation’s primary source of coverage for long-term services and supports, funding more than 50% of care provided nationwide. In 2017, 4.6 million Americans received these supports at home—which is where they overwhelming prefer to be. Over 61 million Americans have a disability and, by the year 2060, the number of Americans ages 65 and older will reach 94.7 million. There is a significant need for long-term services and supports in homes and communities and it will only grow with time.

Through waivers and state plan options, Medicaid offers states several pathways to provide home and community-based services (HCBS). Yet, while states are shifting their Medicaid programs to offer home- based care, the need far outweighs the available services. In 2017, more than 700,000 individuals were on wait lists to receive HCBS through the most commonly used Medicaid waiver. Indeed, in 2016, states spent only 57% of their total long-term services and supports budgets on HCBS. States need resources to improve their service delivery networks to meet the needs of people with disabilities and older adults.

What would the HCBS Infrastructure Improvement Act do (S. 3277)?

Today, states lack capacity to meet current and future HCBS needs and to maintain cost-effective, person- centered HCBS delivery systems. The HCBS Infrastructure Improvement Act would provide a one-time investment of federal funding to strengthen states’ ability to improve quality of life for millions of older adults, people with disabilities, including those with intellectual and developmental disabilities, children and their families through multi-year grants to enhance their HCBS service delivery systems. States would have the flexibility to tailor funding to achieve three or more of the following goals:

  •   Expand the supply and availability of affordable, accessible housing;

  •   Provide accessible, affordable, reliable, equitable transportation options;

  •   Increase wages and benefits and support and sustain direct care professionals;

  •   Expand competitive, integrated employment for people with disabilities; and

  •   Build comprehensive, no-wrong-door application, referral and counseling systems.

    Seven-year grants would be awarded to states following a planning process informed by a state-based Development and Implementation Council comprised of people with disabilities, older adults, family caregivers, direct care support professionals, HCBS providers, state and local government representatives, and more. Grant amounts would be determined based on each states’ current spending on HCBS, with the opportunity to receive bonus payments based on a state’s ability to target services to underserved populations.

    Supporters: National Council on Aging (NCOA), SEIU, AFSCME, Association of University Centers on Disabilities (AUCD), The Arc of the United States, National Association of Home Care and Hospice (NAHC), Autistic Self Advocacy Network (ASAN), Autism Society of America (ASA), Association of Programs for Rural Independent Living (APRIL), Association of People Supporting Employment First (APSE), Association of Assistive Technology Programs (ATAP), Christopher and Dana Reeve Foundation, National Down Syndrome Congress (NDSC), Center for Public Representation (CPR), Collaboration to Promote Self Determination (CPSD), TASH, National Association of Councils on Developmental Disabilities (NACDD), Little Lobbyists, Paralyzed Veterans of America, ANCOR, National Disability Rights Network (NDRN), American Occupational Therapy Association (AOTA), National Alliance on Mental Illness (NAMI), National Association of State Directors of Developmental Disability Services (NASDDDS), National Council on Independent Living (NCIL) and the Consortium for Citizens with Disabilities Long Term Services and Supports Taskforce.

SECTION 3. Medicaid Home and Community-Based Services Infrastructure Improvement.

(b) Planning Grants. From 2021 to 2024, the U.S. Dept. of Health and Human Services (HHS) would award planning grants to states that apply to develop an HCBS infrastructure program. The Secretary would receive $100 million for the planning grants, including $3 million for technical assistance to States.

(c) HCBS Infrastructure Implementation Grants. One year after providing a planning grant to a State, the Secretary would award the State a 7-year HCBS infrastructure implementation grant. A State’s HCBS infrastructure program must include at least three of the following priority areas:

  •   Workforce and unpaid caregivers supports: States would identify a plan to enhance the supply and retention of direct support professionals through strategies such as enhanced payment rates, training and career advancement programs, self-direction programming as well as supports for family caregivers, including assessments, respite care and financial assistance.

  •   Employment supports: States would identify a plan to support opportunities for competitive, integrated employment, including service delivery modifications and expansion as well as enhanced linkages with other programming to support people with disabilities to secure and retain employment.

  •   Housing supports: States would identify a plan to increase the availability of accessible, affordable housing for people with disabilities and older adults receiving HCBS through strategies such as scaling providing home modification programming and shared living.

  •   Transportation supports: States would identify a plan to improve access to accessible transportation, including first mile/last mile transport, through strategies such as partnerships with demand-responsive providers, non-disability specific providers, and others services as well as the development of other innovative transportation networks.

  •   “No wrong door” single entry point system: States would identify a plan to develop and implement a system to ensure people with disabilities and older adults can access all long-term services and supports for which they are eligible on a timely basis.

    (d) Evaluation, Oversight and Quality. The Secretary would contract an external, independent qualified entity to conduct a comprehensive evaluation to of the HCBS infrastructure improvement programs to determine the effect of the programs on the availability, quality, and capacity of HCBS services.

    (e) Financing Incentives. Based on a funding formula that takes into account a State’s spending on HCBS services over the preceding 2 years, as well as a State’s ability to target HCBS services to underserved populations, States would receive a 0.25 – 5% percentage increase in their federal Medicaid match for spending on HCBS services.

    For additional information, contact Michael Gamel-McCormick at Michael_Gamel-McCormick@aging.senate.gov or Stacy Sanders at Stacy_Sanders@aging.senate.gov