HCBS Access Act
- Sponsor
- Rep. Dingell, Debbie [D-MI-6]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Apr 28, 2026
Bottom line
This bill fundamentally transforms Medicaid's long-term care system by prioritizing home and community-based services, investing in the direct care workforce, and removing financial barriers for beneficiaries.
What it actually does
The HCBS Access Act mandates comprehensive coverage of home and community-based services (HCBS) under Medicaid nationwide, eliminating waiting lists and expanding eligibility for older adults and people with disabilities. It also establishes grant programs to support the direct care workforce and family caregivers, revises the Standard Occupational Classification system for direct support professionals, and repeals Medicaid estate recovery requirements.
Proponents argue
Supporters argue the bill addresses decades of systemic bias towards institutional care, fulfills the promise of community inclusion for people with disabilities and older adults, and provides much-needed support and fair compensation for the predominantly female and minority direct care workforce and family caregivers. It aims to eliminate disparities and unnecessary institutionalization.
Opponents contend
Critics might raise concerns about the significant federal and state fiscal implications of mandating 100% FMAP for HCBS and expanding eligibility, potentially straining state budgets even with increased federal contributions. Concerns could also be raised about the administrative burden on states to implement the new requirements, develop comprehensive plans, and ensure a sufficient, qualified workforce within the specified timeframe.
The bill is moderately complex due to its extensive amendments to existing law and detailed programmatic requirements. Given its significant policy implications, the estimated reading time of 45-60 minutes is reasonable for an informed reader to grasp its core components.
Sec. 102(a) amending Section 1905 of the Social Security Act
Mandatory Coverage of Home and Community-Based Services (HCBS)
This provision fundamentally changes Medicaid by defining a comprehensive set of "home and community-based services" (HCBS) and making their coverage mandatory for eligible individuals under State Medicaid plans. It includes services like personal assistance, supported employment, respite care, housing support, and necessary home modifications. The Secretary is required to convene an advisory panel every five years to recommend additional services.
Supporters argue
Supporters argue this provision is crucial for fulfilling the promise of community inclusion for people with disabilities and older adults, aligning Medicaid with modern best practices, and addressing long-standing inequities in access to care. It eliminates the need for states to repeatedly apply for waivers, streamlining access.
Critics contend
Some might argue that a broad federal mandate, even with increased FMAP, could impose significant administrative and financial burdens on states, particularly smaller states or those with less developed HCBS infrastructure. Concerns could also be raised about the federal government dictating specific service definitions rather than allowing states flexibility.
Tradeoffs
Balances the federal goal of universal access to HCBS and community integration with state autonomy and fiscal capacity.
Sec. 102(d) amending Section 1905 of the Social Security Act
Enhanced Federal Medical Assistance Percentage (FMAP) for HCBS
This section establishes a 100% Federal Medical Assistance Percentage (FMAP) for amounts expended by states for home and community-based services. To receive this enhanced FMAP, states must enhance, expand, or strengthen HCBS by lowering access barriers, supporting family caregivers (including respite care), ensuring adequate payment rates for providers and direct care workers (with proportional pass-through), updating training standards, and establishing an entity to support self-directed care models. Administrative costs for expansion are increased to 80% FMAP for four years.
Sec. 103 amending Section 1902 of the Social Security Act
Medicaid Eligibility Modifications for HCBS
This section expands Medicaid eligibility for HCBS. It creates a new mandatory eligibility group for individuals with functional impairments whose income does not exceed 150% of the poverty line or 300% of the SSI benefit rate, whichever is greater. It also creates an optional eligibility group for states to cover individuals above these income limits but below a state-established threshold. Additionally, it ensures retroactive coverage for services provided up to three months before application, regardless of when a service plan was developed.
Sec. 104 amending Section 1902 of the Social Security Act
State HCBS Implementation Plan Requirement
States are required to submit an HCBS implementation plan to the Secretary prior to the mandatory coverage effective date (5 years after enactment). This plan must detail how the state will operationalize HCBS definitions, describe its direct care workforce and plans for stability, list existing HCBS and goals for increasing access, explain coordination with other state agencies (housing, transportation), and outline capacity building to ensure services are available to all eligible individuals. It also requires a plan for prioritizing individuals on waiting lists and addressing disparities. States receive 100% FMAP for developing this plan.
Sec. 107(a)
Development and Publication of HCBS Quality Measures
The Secretary of Health and Human Services is mandated to develop and publish core and supplemental sets of HCBS quality measures for use by State Medicaid programs, health plans, and providers. These measures must be reviewed and updated annually, developed through a public process with significant stakeholder input (at least half from beneficiaries/family caregivers), and reflect the full array of HCBS and recipients. They must include outcome-based measures, availability, provider capacity, person-centered care, self-direction, transitions, beneficiary surveys, and demographic disaggregation to track health disparities.
Sec. 108 amending Section 1924(h)(1)(A) of the Social Security Act
Permanent Protection Against Spousal Impoverishment for HCBS Recipients
This provision makes permanent the State option to extend protection against spousal impoverishment for recipients of home and community-based services under Medicaid. Previously, this protection was set to expire. It ensures that when one spouse receives HCBS, the other spouse's income and assets are not counted in a way that would leave them impoverished.
Sec. 109 amending Section 6071(h)(1)(L) of the Deficit Reduction Act of 2005
Permanent Extension of Money Follows the Person (MFP) Rebalancing Demonstration
This section permanently extends the Money Follows the Person (MFP) rebalancing demonstration program, which provides enhanced federal matching funds to states to help Medicaid beneficiaries transition from institutions (like nursing homes) back into the community with HCBS. The program was previously subject to periodic extensions.
Sec. 110 and Sec. 112 (identical sections) amending Section 1917 of the Social Security Act
Repeal of Medicaid Estate Recovery and Limitations on Liens
This provision repeals the requirement for states to establish Medicaid estate recovery programs, which allow states to recover the costs of Medicaid services from a deceased beneficiary's estate. It also prohibits states from imposing new liens on a Medicaid beneficiary's property for correctly paid medical assistance and requires states to withdraw any existing liens imposed for such purposes and notify affected individuals.
Sec. 111 amending Section 1903(w) of the Social Security Act
HCBS Provider Tax Exemption
This section amends the Social Security Act to include "home- and community-based services" as a class of health care items and services for which a state may impose a provider tax without violating federal requirements that such taxes be broad-based. It also clarifies that the 6% aggregate limit on provider taxes does not apply to this new class of services. This allows states to generate revenue from HCBS providers to fund their Medicaid programs, potentially drawing down additional federal matching funds.
Sec. 202
Revision of Standard Occupational Classification (SOC) System for Direct Support Professionals
This section directs the Director of the Office of Management and Budget (OMB) 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 (SOC) system. If OMB decides not to establish this code, the Director must submit a report to Congress explaining the decision.
Sec. 302
Establishment of a Technical Assistance Center for Direct Care Workforce
This section mandates the Secretary of Health and Human Services to establish a national technical assistance center. This center, in consultation with other federal agencies, will support the creation, recruitment, training, education, retention, and advancement of the direct care workforce. It will also support family caregivers. Its activities include developing training curricula, exploring data gaps, recommending career development opportunities, and assisting with grant evaluations.
Sec. 303
Grants for Direct Care Workforce and Family Caregivers
This section authorizes the Secretary to award grants to eligible entities (states, labor organizations, non-profits, tribes, community colleges) to create and carry out projects for recruiting, retaining, and advancing direct care professionals (including managers and self-directed care professionals) and for supporting family caregivers. At least 30% of projects must focus on career pathways for direct care professionals. Grant funds can be used for direct financial benefits or supportive services for participants, with limits on administrative costs.
Sec. 401
Evaluation of Impact on Access to HCBS and American Community Survey Addition
This section mandates a national survey, conducted by the Administrator of CMS in coordination with the National Academy of Medicine, to evaluate the effects of the Act on HCBS availability, direct service workforce capacity and demographics, compensation, economic effects on beneficiaries, and family caregivers. A report on the survey results is due 9 years after enactment. Additionally, the Secretary of Commerce is directed to add a question to the American Community Survey to identify the need for long-term services and supports.
HCBS settings must meet specific qualities from 42 CFR 441.710(a)(1) and not be described in 42 CFR 441.710(a)(2).
Sec. 102(a)(1) (amending 1905(ll)(1)(A) and (B))
Why it matters:Standard legislative practice to incorporate existing regulatory definitions by reference, avoiding reprinting lengthy text.
Case for: Ensures consistency with established federal standards for person-centered settings in HCBS, which promote community integration and individual rights.
Case against: Requires external research to fully understand the scope of the setting requirements, potentially reducing immediate transparency for the public.
Estimated impact: Ensures that all HCBS funded under Medicaid adhere to the "home and community-based" rule, preventing services from being provided in institutional-like settings.
Establishes an advisory panel to recommend additional HCBS, with specific requirements for composition, including a majority of members from "Individuals with disabilities receiving HCBS," "Beneficiary-led disability rights organizations," and "Disability-led organizations." It also requires proportionate representation among other categories.
Sec. 102(a)(2)(B) (amending 1905(ll)(2)(B))
Why it matters:Standard legislative practice for detailing advisory body composition. The specificity is important for ensuring genuine stakeholder representation.
Case for: Ensures that future expansions of HCBS are directly informed by the lived experience and expertise of people with disabilities and older adults, as well as their representative organizations, preventing top-down decision-making.
Case against: Some might argue that such prescriptive composition requirements could make it difficult to convene the panel or might exclude other valuable perspectives, though this is a minor concern given the broad categories.
Estimated impact: Directly influences the future scope and nature of HCBS covered under Medicaid, ensuring it remains responsive to beneficiary needs.
The mandatory benefit for HCBS and the eligibility expansion for HCBS do not take effect until "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."
Sec. 102(b)(2) and (c)(ii)
Why it matters:This is a tactical choice to provide states with a significant lead time (5 years) to prepare for the sweeping changes, build infrastructure, and address workforce issues, making the mandate more palatable.
Case for: Provides states with ample time to develop implementation plans, build provider capacity, recruit and train the direct care workforce, and make necessary system adjustments without immediate fiscal or administrative shock. This phased approach increases the likelihood of successful implementation.
Case against: Critics might argue that a 5-year delay postpones urgent access to services for individuals currently on waiting lists or facing institutionalization, prolonging inequities. They might contend that the urgency of the crisis warrants a faster transition.
Estimated impact: Delays the full realization of universal HCBS access by half a decade, but aims to ensure a more robust and sustainable system when it does take effect.
These two sections, 110 and 112, are entirely identical, both titled "Liens, Adjustments, and Recoveries for Medical Assistance" and both repealing Medicaid estate recovery and limiting liens.
Sec. 110 and Sec. 112 (identical sections)
Why it matters:This appears to be a drafting error, a copy-paste mistake, rather than a deliberate tactical maneuver. It does not change the substantive effect but highlights a lack of careful review.
Case for: The substantive policy (repealing estate recovery) is strongly supported by advocates for low-income families and people with disabilities. The duplication doesn't negate the policy's intent.
Case against: The duplication points to potential sloppiness in legislative drafting, which could raise questions about other less obvious inconsistencies or errors in the bill.
Estimated impact: The substantive impact is the repeal of estate recovery, as described in Key Provision #8. The duplicated section itself has no additional impact beyond that.