Summary of HB 1138 (Aging With Dignity Act) — North Carolina, 2025 Session
NOTE: This summary reflects the bill text as introduced and does not reflect any amendments that may be adopted during the legislative process.
1) Purpose and overall intent
The bill aims to promote aging with dignity by:
- Strengthening home- and community-based care as a preferred setting for long-term services and supports (LTSS).
- Improving oversight of long-term care facilities.
- Supporting family caregivers and expanding the geriatric workforce.
- Making targeted state strategic investments to address the needs of North Carolina’s growing senior population.
- Reestablishing a Study Commission on Aging to assess and recommend policy changes.
The guiding rationale recognizes demographic growth (65+), home-based preferences, workforce shortages, caregiver burden, and the high costs/fragmentation of current LTSS systems.
2) Key provisions and changes
The bill is organized into five parts, with several substantive sections enacted in Part II and major investments/initiatives in Parts III–IV.
Part II — Improvements to LTSS for Medicaid Beneficiaries
1) Presumption in favor of home- and community-based services (HCBS) for LTSS
- Added § 108A-70.5A:
- Policy: Individuals aged 55+ who require LTSS funded by Medicaid should receive services in the most integrated setting feasible.
- Presumption: HCBS is presumed to be preferred unless institutional care is medically necessary.
- Medical necessity: Institutional placement allowed only if HCBS cannot meet the individual’s clinical, functional, or safety needs, with documentation requirements.
- Assessment/documentation: Standardized assessment, written clinical justification, and periodic reassessment are required.
- Individual choice: Right to institutional placement remains if informed of HCBS options.
- Department authority: DHHS may adopt rules and seek federal waivers as needed.
2) Polypharmacy review for Medicaid LTSS recipients
- Added § 108A-70.5B:
- Purpose: Reduce risks associated with multiple concurrent medications.
- Requirement: Periodic medication reviews by qualified health professionals for individuals 55+ on Medicaid LTSS.
- Scope: Review all prescribed medications, feasible OTC/supplements, drug interactions, fall/functional risk, documentation in care records.
- Deprescribing authority: Department may authorize deprescribing/medication changes with proper coordination.
- Integration: Findings incorporated into care plans and care-authorization decisions.
- Implementation: DHHS may use managed care contracts or other mechanisms; priority to high-risk individuals.
3) Integration of behavioral health and geriatric care
- Added § 108A-70.5C:
- Purpose: Ensure access to age-appropriate, dementia-capable behavioral health services to reduce hospitalizations and inappropriate pharmacologic treatments.
- Integration requirement: Behavioral health assessment, treatment, and care coordination integrated with LTSS for adults 55+ (including those with dementia).
- Scope: Screening/assessment for depression, anxiety, dementia-related symptoms; access to geriatric-trained mental health services; nonpharmacological, person-centered interventions; care coordination; crisis intervention.
- Medication practices: Prioritize nonpharmacological approaches; discourage unnecessary antipsychotics/sedatives.
- Implementation: Rules and policies to be adopted; prioritize high-risk individuals.
- Training/workforce support: May fund training to build geriatric behavioral health expertise.
4) Screening for social isolation and loneliness
- Added § 108A-70.5D:
- Purpose: Identify and address social isolation to prevent health decline.
- Screening: Authorized using approved evidence-based tools.
- Care coordination/referral: Screening results may trigger care coordination, referrals for evaluation, and inform care plans and service authorization.
- Covered services: Social isolation/ loneliness are recognized as valid factors for care coordination and referral; not coverage for room/board or nonmedical housing.
- Clinical evaluation: Screening is not a substitute for clinical evaluation; address loneliness symptoms and assess for related conditions if indicated.
- Implementation: Rules permitted; prioritize high-risk individuals.
Part III — Appropriations for Strategic State Investments
1) Integrated Senior Housing and Care Pilot Program
- Section 3.1:
- Purpose: Establish a housing-first integrated facility pilot (≤300 units) combining on-site health/behavioral health, pharmacy, rehab, and supportive services.
- Operation: Housing-first tenancy with integrated on-site or affiliated providers.
- Target population: Dual-eligible (Medicare/Medicaid) individuals; Medicaid participation is a condition of program participants and partner entities.
- Design/operations: Public-private partnership; on-site/affiliated services; aim to reduce fragmentation and avoid unnecessary transitions.
Sections 3.1.(c)–(d):
- Department authority to contract, fund, and structure partnerships.
- Funding: $120 million nonrecurring from the General Fund for 2026-2027 to support site acquisition, design, construction, and initial operations.
- Reversion: Funds not reverting at year-end; remain available until expended.
Section 3.1.(e):
- Annual reporting starting May 1, 2028, detailing occupant demographics, Medicaid/Medicare trends, hospitalizations, satisfaction, and scalability lessons.
Section 3.1.(f)–(g):
- Termination: Pilot ends when funds are expended.
2) Strengthening the Long-Term Care Ombudsman Program
- Sections 3.2(a)–(d):
- Objectives: Improve access, reduce complaint backlog, shorten response times in high-priority cases, and coordinate with other watchdog/regulatory entities.
- Staffing plan: By Jan 1, 2027, develop a regional staffing plan addressing vacancies and gaps; improve intake, investigations, resolution, and follow-up.
- Funding: $3.5 million recurring from General Fund starting 2026-2027 to hire more ombudsmen, expand access, support training and coordination, and reduce backlogs.
- Reporting: Annual report starting December 1, 2027 on complaints, response/resolution times, vacancies, referrals, fund use, and recommendations.
3) Geriatric Workforce Pipeline and Direct Care Career Advancement Program
- Section 3.3:
- Creation of § 143B-181.27:
- DHHS, in partnership with colleges and universities, to build a geriatric workforce pipeline and career ladder (including direct care staff).
- Goals: Training pathways, portable credentials, career ladders, recruitment in underserved/high-need areas, work-based learning, retention supports, potential scope-of-practice modernization, and cross-employer credential recognition.
- Funding: Recurring $10 million starting 2026-2027 to implement the program.
- Reporting: Annual reporting by Oct 1 to legislative committees, covering enrollment, credentials, vacancies filled, retention, and recommended legislative changes.
- Rules: DHHS may adopt implementing rules.
Part III (continued) — Notable
- The program emphasizes expanding capacity for Medicaid beneficiaries, individuals with dementia, family caregiver support, and rural/high-need areas.
- Credentialing and portability are prioritized to improve worker mobility and retention.
4) Family Caregiver Support Stipend Pilot Program
- Section 3.4:
- Purpose: Reduce caregiver burnout and delay institutionalization by providing Medicaid-funded stipends to eligible family caregivers, contingent on federal approval and funding appropriations.
- Eligibility and operation: DHB to implement; CMS submissions may be required; stipend up to $400 per eligible caregiver per eligible care recipient per month.
- Eligibility criteria: Care recipient is an older adult or receiving LTSS, living in home/community settings, caregiver provides substantial ADL/IADL support, and caregiver meets training/documentation requirements.
- Guardrails: Rules to limit duplication of payments, documentation, training, assessments, fraud prevention, and ensuring beneficiary safety and choice.
- Reporting: Within six months of federal approval and annually thereafter, reporting on participation, expenditures, and program outcomes (caregiver burden, beneficiary satisfaction, avoidable hospitalizations, etc.).
- Sunset: Program expires two years after enactment unless extended.
- Funding: $13.5 million recurring and $0.75 million nonrecurring starting 2026-2027; funds revert if not expended.
Part IV — Reestablishment of the Study Commission on Aging
- Creates the Aging Study Commission to study aging-related policy needs as baby boomers age.
- Duties include examining LTSS (home/community and institutional care), workforce capacity/training, family caregiver support, housing/transport/infrastructure for aging in place, healthcare access and integration (including behavioral health/dementia-capable services), financing/sustainability (Medicaid and public programs), and long-term care oversight.
- Membership: 15 voting members (6 Senate appointees, 6 House appointees, 3 public members) and 5 ex officio nonvoting members (state agencies and related offices).
- Operating rules: Meets as called; LSO provides staff; report due by Dec 31, 2027; sunset upon report unless extended.
5) Effective date
- Generally effective July 1, 2026, with various program start dates staggered (e.g., pilot program funding begins 2026-2027; ombudsman enhancements; workforce program reporting and operations; family caregiver stipend contingent on federal approval).
6) Potential impacts and considerations
For older adults and LTSS recipients:
- Stronger emphasis on aging in place with HCBS as default, potentially reducing institutional placements.
- Improved medication safety and reduced polypharmacy risks through pharmacist-led reviews and deprescribing where appropriate.
- Integrated behavioral health care aimed at reducing unnecessary sedative use and hospitalizations.
- Recognition of social isolation as a factor in care planning and service coordination.
For caregivers and the geriatric workforce:
- Expanded training pathways, credentials, and career advancement opportunities.
- Targeted recruitment and retention efforts, especially in rural/high-need areas.
- Stipend pilot to support family caregivers, with governance and spending safeguards.
For oversight and accountability:
- Expanded Ombudsman program staffing and capacity with annual reporting to legislators.
- The Integrated Senior Housing and Care pilot provides a scalable model for housing-with-health services integration.
Fiscal considerations:
- Significant one-time and recurring appropriations for pilots, workforce development, and program enhancements.
- Evaluation and reporting requirements to inform scalability and legislative decisions.
If you would like, I can provide a concise one-page briefing for policymakers or a comparison with current NC LTSS policies.
