I 

109TH CONGRESS 

1ST SESSION H. R. 1264

To amend title XIX of the Social Security Act to provide funds to States 

to enable them to increase the wages paid to targeted direct support 

professionals in providing services to individuals with disabilities under 

the Medicaid program. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 10, 2005

Mr. TERRY (for himself, Mrs. CAPPS, and Mrs. MALONEY) introduced the 

following bill; which was referred to the Committee on Energy and Commerce 

A BILL

To amend title XIX of the Social Security Act to provide 

funds to States to enable them to increase the wages 

paid to targeted direct support professionals in providing 

services to individuals with disabilities under the Medicaid program.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; FINDINGS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Direct Support Professionals Fairness and Security Act 

6 of 2005’’. 

7 (b) FINDINGS.—Congress finds the following: 
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1 (1) Direct support professionals are the pri2 mary providers of long term care services for mil3 lions of individuals who have physical or mental dis4 abilities. Direct support professionals provide assist5 ance with activities of daily living, instrumental ac6 tivities of daily living, assistance with rehabilitation, 

7 habilitation, training needs and other tasks. All pro8 vide essential supports that help keep individuals 

9 with disabilities connected to their communities. 

10 (2) These workers who provide intimate sup11 ports are predominately female and many are the 

12 sole breadwinners of their families. Although work13 ing and paying taxes, many women in these jobs re14 main impoverished and are eligible for many of the 

15 same Federal and state public assistance programs 

16 upon which the very individuals with disabilities to 

17 whom they provide supports must depend. 

18 (3) Throughout the nation, there is a critical 

19 shortage of direct support professionals. Vacancy 

20 and turn over rates are high. In many parts of the 

21 country, individuals with disabilities are unable to 

22 access the services they need, thereby jeopardizing 

23 their health and quality of life, placing even greater 

24 burdens on their family members and informal care-
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1 givers and creating long waiting lists for community 

2 placement. 

3 (4) The crisis that the nation faces today will 

4 only get worse. Over the next 30 years, there will be 

5 a rapid rise of the population over 65 years of age. 

6 At the same time, advances in medical science and 

7 drug therapy are increasing the number of people, of 

8 all ages, living with severe disabilities. Thus, while 

9 demand for direct support professional services is in10 creasing, the pool of younger, entry level workers is 

11 shrinking. By 2010, more than 780,000 additional 

12 workers must be found to fill long-term direct sup13 port staff positions. 

14 (5) To stabilize and increase the number of di15 rect support professionals in the work force, the 

16 wages and benefits of direct support professionals 

17 must be improved and made equitable among long 

18 term support options. 

19 (6) Medicaid is the single-largest payor of long20 term supports and services for people with disabil21 ities. Enhanced Federal Medicaid matching funds 

22 should be available to assist states committed to ad23 dressing wage differentials among direct support 

24 professionals by increasing the wages of direct sup-
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1 port professionals and supporting and improving the 

2 stability of the direct support professional workforce. 

3 SEC. 2. MEDICAID AMENDMENT. 

4 (a) AUTHORIZING ESTABLISHMENT OF DIRECT SUP5 PORT PROFESSIONAL WAGE ENHANCEMENT PLANS.—

6 Title XIX of the Social Security Act is amended—

7 (1) by redesignating section 1936 as section 

8 1937; and 

9 (2) by inserting after section 1935 the following 

10 new section: 

11 ‘‘DIRECT SUPPORT PROFESSIONAL WAGE ENHANCEMENT

12 PLAN

13 ‘‘SEC. 1936. (a) STATE OPTION.—As a condition for 

14 the receipt of increased funding described in subsection 

15 (f), a State is required to provide for the implementation 

16 of a direct support professional wage enhancement plan 

17 under this section. 

18 ‘‘(b) DIRECT SUPPORT PROFESSIONAL WAGE EN19 HANCEMENT PLAN.—

20 ‘‘(1) IN GENERAL.—For purposes of this sec21 tion, the term ‘direct support professional wage en22 hancement plan’ means a plan of a State that the 

23 Secretary determines meets the following require24 ments: 

25 ‘‘(A) DEADLINE FOR SUBMISSION.—The 

26 plan is submitted to the Secretary not later 
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1 than 120 days after the date the Secretary pro2 vides notice to States under paragraph (3). 

3 ‘‘(B) CONTENTS.—

4 ‘‘(i) EQUALIZATION OF HOURLY WAGE

5 RATES.—The plan must describe how the 

6 State intends to use the funds made avail7 able under this section to increase the 

8 hourly wage rate of targeted direct support 

9 professionals so that by the end of the 5-

10 year implementation period (as defined in 

11 subsection (g)(4)) such rate is equal to the 

12 average hourly wage rate of reference di13 rect support professionals. 

14 ‘‘(ii) ADDITIONAL PROVISIONS.—The 

15 plan must include the additional informa16 tion described in subsection (c). 

17 ‘‘(C) IMPLEMENTATION.—The plan must 

18 be developed and implemented in accordance 

19 with subsection (d). 

20 ‘‘(D) ANNUAL REPORTS.—The State must 

21 provide for annual assessments and reports in 

22 accordance with subsection (e). 

23 ‘‘(2) MODIFICATION OF PLAN.—Nothing in this 

24 section shall be construed as preventing a State 

25 from time to time and with the approval of the Sec-
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1 retary from modifying a direct support professional 

2 wage enhancement plan so long as such plan, as 

3 modified, continues to meet the requirements of 

4 paragraph (1). 

5 ‘‘(3) NOTICE.—Not later than 90 days after the 

6 date of the enactment of this section, the Secretary 

7 shall provide notice to States regarding the provi8 sions of this section, including the availability of en9 hanced funding to implement direct support profes10 sional wage enhancement plans. 

11 ‘‘(c) CONTENTS OF PLAN.—A direct support profes12 sional wage enhancement plan shall include, consistent 

13 with the other requirements of this section, the following: 

14 ‘‘(1) A description of how the State intends to 

15 use funds provided under this section to meet the re16 quirement of subsection (b)(1). 

17 ‘‘(2) A description of the prevailing hourly wage 

18 rates for targeted direct support professionals before 

19 the implementation of such plan and any hourly 

20 wage rate differentials between targeted direct sup21 port professionals and reference direct support pro22 fessionals. 

23 ‘‘(3) The impact of wage differentials and labor 

24 market conditions on the recruitment and retention 
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1 of targeted direct support professionals, including 

2 current or projected labor shortages. 

3 ‘‘(4) The identification of a specific, five-year 

4 performance goal to increase the hourly wage rate of 

5 targeted direct support professionals so as to elimi6 nate any wage rate differential between targeted and 

7 reference direct support professionals and the meth8 odology to be used by the State to achieve its goal. 

9 ‘‘(5) The annual performance goals and targets 

10 that the State will monitor to track progress toward 

11 achieving its five-year performance goal. 

12 ‘‘(6) Current efforts to increase and stabilize 

13 the State’s direct support professional labor force 

14 and how the plan shall be coordinated with such ef15 forts. 

16 ‘‘(7) Methods for assuring that funds provided 

17 under this section shall be spent in accordance with 

18 such plan, and shall not be used to supplant existing 

19 funds for wages and benefits or to reduce the State’s 

20 expenditures below the amount that the State would 

21 have paid had the plan not been in effect. 

22 ‘‘(8) A description of the stakeholders and col23 laborative process used consistent with subsection 

24 (d) to develop the plan and the means by which such 
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1 collaboration shall continue during the implementa2 tion of the plan. 

3 ‘‘(9) Assurances satisfactory to the Secretary 

4 that upon the expiration of the 5-year implementa5 tion period, the State shall provide funding nec6 essary to maintain the wage rates attained under the 

7 plan for targeted direct support professionals at the 

8 five-year performance goal increased annually there9 after by a percentage that is not less than the an10 nual percent increase in the employment cost index 

11 (as published quarterly by the Bureau of Labor Sta12 tistics). 

13 ‘‘(d) DEVELOPMENT AND IMPLEMENTATION OF

14 PLAN.—A direct support professional wage enhancement 

15 plan shall be developed and implemented in collaboration 

16 with—

17 ‘‘(1) targeted individuals with disabilities and 

18 family representatives; 

19 ‘‘(2) targeted direct support professionals; 

20 ‘‘(3) agencies or provider organizations that 

21 serve targeted individuals with disabilities and em22 ploy targeted direct support professionals; and 

23 ‘‘(4) individuals and organizations representing 

24 the interests of those described in paragraphs (1) 

25 through (3). 
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1 ‘‘(e) ANNUAL ASSESSMENT AND REPORT.—

2 ‘‘(1) IN GENERAL.—A State shall—

3 ‘‘(A) perform an assessment of the 

4 operation of the direct care support profes5 sional wage enhancement plan in the State 

6 in each fiscal year; and 

7 ‘‘(B) report to the Secretary by Janu8 ary 1 following the end of the fiscal year, 

9 on the results of such assessment. 

10 ‘‘(2) CONTENTS.—Each such assessment shall 

11 include the following: 

12 ‘‘(A) An assessment of the effectiveness of 

13 the plan in increasing the wages of targeted di14 rect support professionals and reducing or 

15 eliminating the wage gap with reference direct 

16 support professionals. 

17 ‘‘(B) An assessment of the State’s progress 

18 in meeting its annual performance goals under 

19 the plan. 

20 ‘‘(C) An assessment of the effectiveness of 

21 the State’s collaboration with stakeholders on 

22 plan development and implementation issues. 

23 ‘‘(D) A review and assessment of State ac24 tivities to coordinate the plan with other activi-
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1 ties in the State to improve and stabilize the di2 rect support professional workforce. 

3 ‘‘(E) Recommendations for improving the 

4 plan. 

5 ‘‘(F) Such other information as the Sec6 retary may specify. 

7 ‘‘(f) INCREASE IN PAYMENT TO IMPLEMENT PLAN.—

8 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

9 for each calendar quarter during the 5-year imple10 mentation period in which a direct support profes11 sional wage enhancement plan is in effect under this 

12 section in a State, the amount of payment for med13 ical assistance under section 1903(a)(1) shall be in14 creased by the wage enhancement incentive percent15 age (as defined in paragraph (3)(G)) multiplied by 

16 the portion of total funds expended during the quar17 ter for the provision of direct support services to tar18 geted individuals that are attributable to the wages 

19 of targeted direct support professionals. 

20 ‘‘(2) LIMITATION.—

21 ‘‘(A) IN GENERAL.—Payments made under 

22 paragraph (1) shall be used only to increase the 

23 wages of targeted direct support professionals. 

24 ‘‘(B) TREATMENT OF EMPLOYEE BENE25 FITS AND SALARY RELATED BENEFITS.—For 
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1 purposes of subparagraph (A), payments for 

2 costs of employee benefits and other salary re3 lated benefits (including mandatory employment 

4 taxes and benefits) shall be treated as payments 

5 to increase the wages of targeted direct support 

6 professionals so long as payments attributable 

7 to such non-wage benefits do not exceed 20 per8 cent of the total amounts that increase the 

9 wages of targeted direct support professionals. 

10 ‘‘(3) DEFINITIONS.—For purposes of this sub11 section: 

12 ‘‘(A) ANNUAL RATE DIFFERENTIAL PER13 CENTAGE.—The term ‘annual rate differential 

14 percentage’ means, with respect to a State for 

15 a year in which the direct support professional 

16 wage enhancement plan is in effect, the percent 

17 of the direct support professional wage rate dif18 ferential (as defined in subparagraph (E)) to be 

19 paid under plan for the year. 

20 ‘‘(B) AVERAGE REFERENCE DIRECT SUP21 PORT PROFESSIONAL HOURLY WAGE RATE.—

22 The term ‘average reference direct support pro23 fessional hourly wage rate’ means, for a year 

24 under a direct support professional wage en25 hancement plan, the average direct support pro-
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1 fessional hourly wage rate (as defined in sub2 paragraph (D)), including any projected in3 crease, paid in the year to reference direct sup4 port professionals who are employed by the 

5 State or, if there are no such employees, to ref6 erence direct support professionals who are em7 ployed by local governments in the State, or, 

8 when necessary to meet the purpose of the plan, 

9 any other reference wage rate defined by the 

10 State and as approved by the Secretary. 

11 ‘‘(C) BASE-YEAR AVERAGE TARGETED DI12 RECT SUPPORT PROFESSIONAL HOURLY WAGE

13 RATE.—The term ‘average targeted direct sup14 port professional hourly wage rate’ means, for 

15 a State, the average direct support professional 

16 hourly wage rate (as defined in subparagraph 

17 (D)) paid to targeted direct support profes18 sionals under the State plan in the 12-month19 period immediately preceding the 5-year imple20 mentation period. 

21 ‘‘(D) DIRECT SUPPORT PROFESSIONAL

22 HOURLY WAGE RATE.—The term ‘direct sup23 port professional hourly wage rate’ means—

24 ‘‘(i) the rate of hourly wage paid to a 

25 direct support professional; plus 
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1 ‘‘(ii) mandatory employment taxes 

2 and benefits (as defined in subparagraph 

3 (F)) paid (as computed and applied on an 

4 hourly basis) with respect to such employ5 ment. 

6 ‘‘(E) DIRECT SUPPORT PROFESSIONAL

7 WAGE RATE DIFFERENTIAL.—The term ‘direct 

8 support professional wage rate differential’ 

9 means, for a State for a year, the amount by 

10 which—

11 ‘‘(i) the average reference direct sup12 port professional hourly wage rate (as de13 fined in subparagraph (B)) for the State 

14 and year, exceeds 

15 ‘‘(ii) the base-year average targeted 

16 direct support professional hourly wage 

17 rate (as defined in subparagraph (C)) for 

18 the State. 

19 ‘‘(F) MANDATORY EMPLOYMENT TAXES

20 AND BENEFITS.—The term ‘mandatory employ21 ment taxes and benefits’ means taxes under 

22 section 3111 of the Internal Revenue Code of 

23 1986 (relating to the employer share of FICA 

24 taxes) and the employer’s share of unemploy-
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1 ment compensation and worker’s compensation 

2 payments. 

3 ‘‘(G) WAGE ENHANCEMENT INCENTIVE

4 PERCENTAGE.—The term ‘wage enhancement 

5 incentive percentage’ means—

6 ‘‘(i) the product of (I) the total direct 

7 support professional wage rate differential 

8 (as defined in subparagraph (E), and (II) 

9 annual rate differential percentage (as de10 fined in subparagraph (A)); divided by 

11 ‘‘(ii) the average reference direct sup12 port professional hourly wage rate (as de13 fined in subparagraph (B)). 

14 ‘‘(g) INSPECTOR GENERAL AUDIT.—The Secretary, 

15 through the Inspector General of the Department of 

16 Health and Human Services, shall audit a sample from 

17 among the States in order to assess the effectiveness of 

18 progress made in reducing or eliminating the wage gap 

19 between targeted and reference direct support profes20 sionals through funds under this section. 

21 ‘‘(h) GAO STUDY.—

22 ‘‘(1) STUDY.—The Comptroller General of the 

23 United States shall conduct a study concerning the 

24 wage equalization and recruitment and retention of 
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1 direct support professionals who are providing serv2 ices and supports to individuals with disabilities. 

3 ‘‘(2) REPORTS.—The Comptroller General shall 

4 submit to Congress reports, in the third and fifth 

5 years in which this section is being implemented, on 

6 progress made by States, and the impact of pay7 ments under this section, on providing wage equali8 zation and in improving recruitment and retention of 

9 direct support professionals. 

10 ‘‘(i) DEFINITIONS.—For purposes of this section: 

11 ‘‘(1) DIRECT SUPPORT PROFESSIONAL.—The 

12 term ‘direct support professional’ means an indi13 vidual who, whether in a supervisory or non-super14 visory capacity, provides services and supports, as 

15 needed, to an individual with a disability to assist in 

16 acquiring, maintaining or enhancing skills necessary 

17 to perform activities of daily living or instrumental 

18 activities of daily living and health-related functions 

19 through hands-on assistance, supervision, or cueing. 

20 Such term includes, among others, individuals who 

21 may be classified as nurses aides, home health aides, 

22 home care aides, personal care aides and personal 

23 assistants, in-home support workers, homemakers, 

24 behavioral specialists, habilitation specialist, mental 

25 health rehabilitation technicians, independent living 
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1 skills specialists, crisis program workers, qualified 

2 mental health or mental retardation professionals, 

3 and educational technicians. 

4 ‘‘(2) DIRECT SUPPORT PROFESSIONAL WAGE

5 ENHANCEMENT PLAN.—The term ‘direct support 

6 professional wage enhancement plan’ is defined in 

7 subsection (b)(1). 

8 ‘‘(3) DIRECT SUPPORT SERVICES.—The term 

9 ‘direct support services’ means a range of services 

10 and supports, provided by one or more persons, de11 signed to provide support and health-related services 

12 to an individual with a disability to enable them to 

13 perform, acquire, maintain or enhance skills nec14 essary to perform activities of daily living, instru15 mental activities of daily living (IADL) and health16 related functions. Such term includes personal care 

17 services, consumer-directed personal assistance serv18 ices, rehabilitation services, habilitation services, and 

19 respite care. 

20 ‘‘(4) INDIVIDUAL WITH A DISABILITY.—The 

21 term ‘individual with a disability’ means an indi22 vidual who meets (or is regarded as meeting) the cri23 teria for being disabled under the supplemental secu24 rity income program under title XVI. Such term in25 cludes an individual who, regardless of age, is eligi-
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1 ble for and receiving medical assistance under this 

2 title for any benefits described in paragraph (i)(8). 

3 ‘‘(5) 5-YEAR IMPLEMENTATION PERIOD.—The 

4 term ‘5-year implementation period’ means, with re5 spect to a State and a direct support professional 

6 wage enhancement plan under this section, the pe7 riod of 20 calendar quarters beginning with the first 

8 full calendar quarter in which such plan is imple9 mented in the State under this section. Each of the 

10 five 4-calendar-quarter periods within such period 

11 shall be treated as a year for purposes of this sec12 tion. 

13 ‘‘(6) REFERENCE DIRECT SUPPORT PROFES14 SIONAL.—The term ‘reference direct support profes15 sional’ means a direct support professional who—

16 ‘‘(A) is employed by a State or local gov17 ernment entity; and 

18 ‘‘(B) provides direct support services to 

19 targeted individuals with disabilities under this 

20 title. 

21 ‘‘(7) TARGETED DIRECT SUPPORT PROFES22 SIONAL.—The term ‘targeted direct support profes23 sional’ means a direct support professional who—

24 ‘‘(A) is not employed by a State or local 

25 government entity; and 
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1 ‘‘(B) provides direct support services to 

2 targeted individuals with disabilities under this 

3 title. 

4 ‘‘(8) TARGETED INDIVIDUAL WITH A DIS5 ABILITY.—The term ‘targeted individual with a dis6 ability’ means an individual with a disability who is 

7 eligible for and is receiving medical assistance under 

8 this title for personal care services under section 

9 1905(a)(23), for rehabilitative services under section 

10 1905(a)(13), for home health care services, for home 

11 and community-based services under a waiver ap12 proved under section 1915(c) or section 1115, or for 

13 intermediate care facility services for the mentally 

14 retarded.’’. 

15 (b) CONFORMING AMENDMENT.—Section 1903(a)(1) 

16 of such Act (42 U.S.C. 1396b(a)(1)) is amended by insert17 ing ‘‘and section 1936(f)’’ after ‘‘1923(f)’’. 

18 (c) AUTHORIZATION OF PLANNING GRANTS.—The 

19 Secretary of Health and Human Services is authorized to 

20 award State planning grants in an amount not to exceed, 

21 in the aggregate, $3,000,000, in order to assist States in 

22 establishing direct support professional wage enhancement 

23 plans under section 1936 of the Social Security Act, as 

24 inserted by subsection (a).

Æ