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Page 22 – CMCS Informational Bulletin HCBS for individuals without requiring an ILOC determination. Section 71121 establishes several conditions for approval, such as that states must: 1) use needs-based criteria, subject to Secretary approval, to determine eligibility for HCBS under the new waiver option; 2) demonstrate that approval of the waiver will not result in a material increase in the average time individuals who meet ILOC criteria will need to wait to receive HCBS under any other approved 1915(c) waiver; 3) attest that the state’s average per capita Medicaid expenditures for individuals covered by the waiver will not exceed the state’s average per capita Medicaid expenditures for individuals receiving institutional care under the state plan (or waiver of such plan); and 4) agree to provide to the Secretary at least annually certain cost and utilization data, as specified under section 1915(c)(11)(B)(vii) of the Act. Under new section 1915(c)(11)(C) of the Act, states are prohibited from using Medicaid payments under this new waiver authority to pay third parties on behalf of an individual practitioner for benefits such as health insurance or skills training, if the practitioner belongs to a practitioner class for which Medicaid is the primary source of revenue. Section 71121 also appropriates $100 million in FY 2027 for payments to states to support state systems to deliver HCBS under section 1915(c) waivers or section 1115 demonstrations. The FY 2027 funds will be allotted based on the proportion of the state’s population receiving HCBS under section 1915(c) or section 1115 of the Act, as compared to all states. Section 1915(c)(11) of the Act, as added by section 71121, is applicable to all states, the District of Columbia, and the territories. Chapter 453 – Protecting Rural Hospitals and Providers Section 71401. Rural Health Transformation Program Section 71401 establishes a Rural Health Transformation (RHT) Program within Title XXI of the Act and appropriates $10 billion annually for allotments to states for fiscal years 2026 through 2030.54 The program, added as new subsection (h) in section 2105 of the Act, is administered by the CMS Administrator and provides funding to states (excluding DC and territories) with approved applications to improve rural health care access and outcomes. The total annual appropriation of $10 billion will be distributed in two ways. Half of the funds ($5 billion) will be distributed equally across all approved states. The remaining half ($5 billion) is allocated to at least 25 percent of approved states based on factors specified in the Act and by the Administrator, such as the percentage of the state’s population living in rural areas and the 53 Specifically, Chapter 4 of Subtitle B of Title VII of Public Law 119-21. 54 For more information of the RHT Program, visit https://www.cms.gov/priorities/rural-health-transformation-rht- program/rural-health-transformation-rht-program.