HCBS Access Act
- Sponsor
- Sen. Luján, Ben Ray [D-NM]
- Committees
- Finance Committee (primary)
- Last action
- Aug 6, 2026
Bottom line
The HCBS Access Act fundamentally reforms Medicaid long-term care by making home and community-based services a mandatory benefit, backed by substantial federal funding and workforce development initiatives.
What it actually does
This bill mandates that states provide home and community-based services (HCBS) as a required benefit under their Medicaid programs, significantly expanding eligibility and offering a 100% federal matching rate for these services to states that meet specific conditions. It also establishes a comprehensive grant program to recruit, train, and retain direct care professionals and support family caregivers, alongside measures to improve quality, data collection, and eliminate spousal impoverishment rules and estate recovery for HCBS recipients. The bill aims to shift long-term care away from institutional settings towards community-based options.
Proponents argue
Supporters argue that this bill is crucial for eliminating long-standing waiting lists for essential home and community-based services, ensuring individuals with disabilities and older adults can live independently in their communities. They contend it addresses systemic inequities in access, supports the vital but often undervalued direct care workforce through improved compensation and training, and alleviates the burden on millions of unpaid family caregivers. Proponents emphasize that community-based care is often preferred by individuals and can be more cost-effective than institutionalization.
Opponents contend
Critics may contend that mandating HCBS coverage and offering a 100% federal match represents a significant federal overreach into state Medicaid programs, potentially imposing substantial new administrative and financial burdens on states despite the enhanced federal funding. Concerns could be raised about the long-term fiscal sustainability of such a large federal commitment, the ability of states to rapidly scale up the direct care workforce to meet demand, and potential impacts on the existing balance between institutional and home-based care providers.
The bill is moderately long and dense, requiring dedicated time to understand its intricate amendments to existing law and new grant programs.
Sec. 102(a), (b), (c)
Mandatory Medicaid Coverage for Home and Community-Based Services (HCBS)
This provision amends the Social Security Act to include home and community-based services (HCBS) as a mandatory benefit under state Medicaid plans. It defines HCBS broadly, establishes criteria for eligible individuals based on functional impairment, and requires individualized assessments and person-centered care plans. The change takes effect five years after enactment, ensuring all Medicaid-eligible individuals who meet the functional impairment criteria can elect to receive these services.
Supporters argue
Supporters argue this is a monumental step towards fulfilling the promise of community inclusion, ending decades of waiting lists, and ensuring that individuals can receive care in their preferred setting, which is often more person-centered and less restrictive than institutional care.
Critics contend
Critics may argue that this federal mandate, even with enhanced funding, places an undue burden on states to rapidly restructure their long-term care systems and could lead to unforeseen implementation challenges and costs.
Tradeoffs
The provision balances the federal goal of universal HCBS access with the need for states to adapt their existing systems, potentially requiring significant investment in infrastructure and workforce development.
Sec. 102(d)
Enhanced Federal Medical Assistance Percentage (FMAP) for HCBS
This section sets the federal medical assistance percentage (FMAP) for HCBS at 100% for states that meet specific conditions, such as lowering access barriers, supporting family caregivers, updating payment rates for direct care workers, and establishing infrastructure for self-directed care. It also provides an 80% FMAP for administrative costs related to expanding and enhancing HCBS for the first 20 fiscal quarters.
Sec. 103
Medicaid Eligibility Expansion for HCBS
This section expands Medicaid eligibility for HCBS to individuals with incomes up to 150% of the federal poverty line or 300% of the supplemental security income (SSI) benefit rate, with states having the option to establish even higher income levels. It also ensures that HCBS can be covered retroactively for up to three months prior to application, regardless of when a service plan was developed.
Sec. 107
HCBS Quality Measurement and Ombudsman Offices
This section requires the Secretary of Health and Human Services to develop and publish core and supplemental sets of HCBS quality measures, updated annually, with significant stakeholder input. States must use these measures to report annually on HCBS quality, receiving an 80% FMAP for reporting costs. Additionally, each state must establish an independent HCBS ombudsman office to assist beneficiaries, address complaints, and report systemic problems.
Sec. 108, Sec. 109, Sec. 110
Permanent Protections Against Spousal Impoverishment and Estate Recovery; Money Follows the Person Extension
This bill makes permanent the extended protection against spousal impoverishment for HCBS recipients, ensuring that a spouse's income and assets are not depleted when their partner receives Medicaid HCBS. It also permanently extends the Money Follows the Person (MFP) rebalancing demonstration program. Furthermore, it prohibits states from imposing new liens on the property of HCBS recipients and requires the withdrawal of existing liens, and bans adjustments or recoveries of correctly paid medical assistance for HCBS, including the withdrawal of related liens.
Title III (Sec. 301-306)
Support for the Direct Care Workforce and Family Caregivers
This title authorizes a national technical assistance center and a $1 billion grant program for fiscal year 2029 to support the direct care workforce and family caregivers. Grants will fund projects for recruiting, training, educating, retaining, and advancing direct care professionals (including managers and self-directed care workers). At least 30% of projects must focus on career pathways. Grants also support family caregivers through educational, training, and self-care resources. The bill defines 'direct care professional' broadly and includes requirements for project plans, such as assessing wages, providing supportive services, and ensuring culturally competent training.
The definition of 'home and community-based services' (HCBS) explicitly references specific sections of title 42, Code of Federal Regulations (42 CFR 441.710(a)(1) and (2)), to define the qualities of settings where HCBS must be furnished. These regulations specify that settings must be integrated into the community, support individual choice, and not have qualities of an institution.
Sec. 102(a)(2)(ll)(1)(A) and (B)
Why it matters:This is standard legislative practice to incorporate existing regulatory definitions, ensuring consistency and leveraging established legal frameworks without repeating extensive details.
Case for: Supporters argue that by referencing existing regulations, the bill ensures that HCBS are truly provided in community-integrated settings, upholding the principles of the Americans with Disabilities Act and preventing services from being delivered in institutional-like environments.
Case against: No specific opposition is typically raised against referencing established regulations, but some might argue that relying on external regulations can make the bill's full implications less transparent to a casual reader.
Estimated impact: This provision fundamentally shapes the nature of HCBS delivery, ensuring services promote community integration and self-determination for millions of beneficiaries.
This provision requires states, as a condition of receiving the 100% enhanced FMAP for HCBS, to develop a process ensuring that increases in payment rates for HCBS are, at a minimum, proportionately passed through to direct care workers. This process must involve input from stakeholders, including direct care workers and their representatives.
Sec. 102(d) (amending 1905(mm)(2)(E))
Why it matters:This is a common legislative technique to tie specific policy outcomes (worker compensation) to federal funding incentives, ensuring that federal investment directly benefits the frontline workforce.
Case for: Proponents argue this is essential to ensure that federal investments in HCBS actually reach direct care workers, improving their wages and retention, which is critical for service quality and availability.
Case against: Some state agencies or provider groups might express concerns about the administrative complexity of tracking and enforcing 'proportionate pass-through' requirements, potentially preferring more flexible wage-setting mechanisms.
Estimated impact: This provision could significantly improve the economic well-being of millions of direct care workers, helping to stabilize the workforce and improve service quality.
As part of the required HCBS infrastructure to support self-directed care models, states must ensure that program policies and procedures allow for cooperation with labor organizations that bargain on behalf of direct care workers, or, if no such organization exists, are neutral with regard to workers joining or forming a labor organization.
Sec. 102(d) (amending 1905(nn)(7))
Why it matters:This is a strategic placement to integrate labor protections directly into the operational framework of state HCBS programs, ensuring that federal funding supports fair labor practices.
Case for: Labor advocates and proponents argue this provision is crucial for empowering direct care workers, ensuring their right to organize, and improving their working conditions through collective bargaining, which ultimately benefits service quality.
Case against: Some employer groups or states might oppose this provision, arguing it interferes with employer-employee relations or could increase labor costs and administrative complexities.
Estimated impact: This provision could significantly influence the landscape of labor relations for direct care workers, potentially leading to increased unionization and improved worker advocacy.
This section prohibits states from imposing new liens on the property of individuals receiving correctly paid medical assistance for HCBS and requires states to withdraw any existing liens. It also bans states from initiating, maintaining, or collecting adjustments or recoveries of correctly paid medical assistance for HCBS, and mandates the withdrawal of any related liens.
Sec. 110
Why it matters:While technically an amendment, the complete prohibition on estate recovery for HCBS is a substantial policy change that could be strategically placed within an existing framework to streamline legislative language, though it might obscure its full impact.
Case for: Proponents argue that estate recovery disproportionately harms low-income families and discourages individuals from seeking necessary HCBS, forcing them to impoverish themselves or their families. Eliminating it aligns with the goal of supporting community living without financial penalty.
Case against: Critics, particularly state fiscal officers, argue that estate recovery is a legitimate mechanism for states to recoup some costs of long-term care, and its elimination will result in a significant loss of state revenue, potentially impacting other state services or requiring new taxes.
Estimated impact: This provision will prevent states from recovering potentially hundreds of millions of dollars annually from the estates of Medicaid beneficiaries, significantly benefiting families but creating a fiscal gap for states.