I 

110TH CONGRESS 

1ST SESSION H. R. 1279 

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 1, 2007 

Mrs. CAPPS (for herself and Mr. TERRY) 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 2007’’. 

7 (b) FINDINGS.—Congress finds the following: 


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1 (1) Direct support professionals (including 

2 workers referred to as direct support workers, direct 

3 care workers, personal assistants, personal attend4 ants, paraprofessionals) are the primary providers of 

5 long term care services for millions of individuals 

6 who have physical or mental disabilities. Direct sup7 port professionals provide assistance with activities 

8 of daily living, instrumental activities of daily living, 

9 assistance with rehabilitation, habilitation, training 

10 needs and other tasks. All provide essential supports 

11 that help keep individuals with disabilities connected 

12 to their communities. 

13 (2) These workers who provide intimate sup14 ports are predominately female and many are the 

15 sole breadwinners of their families. Although work16 ing and paying taxes, many women in these jobs re17 main impoverished and are eligible for many of the 

18 same Federal and state public assistance programs 

19 upon which the very individuals with disabilities to 

20 whom they provide supports must depend. 

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

22 shortage of direct support professionals. Vacancy 

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

24 country, individuals with disabilities are unable to 

25 access the services they need, thereby jeopardizing 


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1 their health and quality of life, placing even greater 

2 burdens on their family members and informal care3 givers and creating long waiting lists for community 

4 placement. 

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

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

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

8 At the same time, advances in medical science and 

9 drug therapy are increasing the number of people, of 

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

11 demand for direct support professional services is in12 creasing, the pool of younger, entry level workers is 

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

14 workers must be found to fill long-term direct sup15 port staff positions. 

16 (5) To stabilize and increase the number of di17 rect support professionals in the work force, the 

18 wages and benefits of direct support professionals 

19 must be improved and made equitable among long 

20 term support options. 

21 (6) Medicaid is the single-largest payor of long22 term supports and services for people with disabil23 ities. Enhanced Federal Medicaid matching funds 

24 should be available to assist states committed to ad25 dressing wage differentials among direct support 


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1 professionals by increasing the wages of direct sup2 port professionals and supporting and improving the 

3 stability of the direct support professional workforce. 

4 SEC. 2. MEDICAID AMENDMENT. 

5 (a) AUTHORIZING ESTABLISHMENT OF DIRECT SUP6 PORT PROFESSIONAL WAGE ENHANCEMENT PLANS.— 

7 Title XIX of the Social Security Act is amended— 

8 (1) by redesignating section 1939 as section 

9 1940; and 

10 (2) by inserting after section 1938 the following 

11 new section: 

12 ‘‘DIRECT SUPPORT PROFESSIONAL WAGE ENHANCEMENT

13 PLAN

14 ‘‘SEC. 1939. (a) STATE OPTION.—As a condition for 

15 the receipt of increased funding described in subsection 

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

17 of a direct support professional wage enhancement plan 

18 under this section. 

19 ‘‘(b) DIRECT SUPPORT PROFESSIONAL WAGE EN20 HANCEMENT PLAN.— 

21 ‘‘(1) IN GENERAL.—For purposes of this sec22 tion, the term ‘direct support professional wage en23 hancement plan’ means a plan of a State that the 

24 Secretary determines meets the following require25 ments: 


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1 ‘‘(A) DEADLINE FOR SUBMISSION.—The 

2 plan is submitted to the Secretary not later 

3 than 120 days after the date the Secretary pro4 vides notice to States under paragraph (3). 

5 ‘‘(B) CONTENTS.— 

6 ‘‘(i) EQUALIZATION OF HOURLY WAGE

7 RATES.—The plan must describe how the 

8 State intends to use the funds made avail9 able under this section to increase the 

10 hourly wage rate of targeted direct support 

11 professionals so that by the end of the 5- 

12 year implementation period (as defined in 

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

14 average hourly wage rate of reference di15 rect support professionals. 

16 ‘‘(ii) ADDITIONAL PROVISIONS.—The 

17 plan must include the additional informa18 tion described in subsection (c). 

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

20 be developed and implemented in accordance 

21 with subsection (d). 

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

23 provide for annual assessments and reports in 

24 accordance with subsection (e). 


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

2 section shall be construed as preventing a State 

3 from time to time and with the approval of the Sec4 retary from modifying a direct support professional 

5 wage enhancement plan so long as such plan, as 

6 modified, continues to meet the requirements of 

7 paragraph (1). 

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

9 date of the enactment of this section, the Secretary 

10 shall provide notice to States regarding the provi11 sions of this section, including the availability of en12 hanced funding to implement direct support profes13 sional wage enhancement plans. 

14 ‘‘(c) CONTENTS OF PLAN.—A direct support profes15 sional wage enhancement plan shall include, consistent 

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

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

18 use funds provided under this section to meet the re19 quirement of subsection (b)(1). 

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

21 rates for targeted direct support professionals before 

22 the implementation of such plan and any hourly 

23 wage rate differentials between targeted direct sup24 port professionals and reference direct support pro25 fessionals. 


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

2 market conditions on the recruitment and retention 

3 of targeted direct support professionals, including 

4 current or projected labor shortages. 

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

6 performance goal to increase the hourly wage rate of 

7 targeted direct support professionals so as to elimi8 nate any wage rate differential between targeted and 

9 reference direct support professionals and the meth10 odology to be used by the State to achieve its goal. 

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

12 that the State will monitor to track progress toward 

13 achieving its five-year performance goal. 

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

15 the State’s direct support professional labor force 

16 and how the plan shall be coordinated with such ef17 forts. 

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

19 under this section shall be spent in accordance with 

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

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

22 expenditures below the amount that the State would 

23 have paid had the plan not been in effect. 

24 ‘‘(8) A description of the stakeholders and col25 laborative process used consistent with subsection 


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1 (d) to develop the plan and the means by which such 

2 collaboration shall continue during the implementa3 tion of the plan. 

4 ‘‘(9) Assurances satisfactory to the Secretary 

5 that upon the expiration of the 5-year implementa6 tion period, the State shall provide funding nec7 essary to maintain the wage rates attained under the 

8 plan for targeted direct support professionals at the 

9 five-year performance goal increased annually there10 after by a percentage that is not less than the an11 nual percent increase in the employment cost index 

12 (as published quarterly by the Bureau of Labor Sta13 tistics). 

14 ‘‘(d) DEVELOPMENT AND IMPLEMENTATION OF

15 PLAN.—A direct support professional wage enhancement 

16 plan shall be developed and implemented in collaboration 

17 with— 

18 ‘‘(1) targeted individuals with disabilities and 

19 family representatives; 

20 ‘‘(2) targeted direct support professionals; 

21 ‘‘(3) agencies or provider organizations that 

22 serve targeted individuals with disabilities and em23 ploy targeted direct support professionals; and 


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1 ‘‘(4) individuals and organizations representing 

2 the interests of those described in paragraphs (1) 

3 through (3). 

4 ‘‘(e) ANNUAL ASSESSMENT AND REPORT.— 

5 ‘‘(1) IN GENERAL.—A State shall— 

6 ‘‘(A) perform an assessment of the 

7 operation of the direct care support profes8 sional wage enhancement plan in the State 

9 in each fiscal year; and 

10 ‘‘(B) report to the Secretary by Janu11 ary 1 following the end of the fiscal year, 

12 on the results of such assessment. 

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

14 include the following: 

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

16 the plan in increasing the wages of targeted di17 rect support professionals and reducing or 

18 eliminating the wage gap with reference direct 

19 support professionals. 

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

21 in meeting its annual performance goals under 

22 the plan. 

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

24 the State’s collaboration with stakeholders on 

25 plan development and implementation issues. 


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1 ‘‘(D) A review and assessment of State ac2 tivities to coordinate the plan with other activi3 ties in the State to improve and stabilize the di4 rect support professional workforce. 

5 ‘‘(E) Recommendations for improving the 

6 plan. 

7 ‘‘(F) Such other information as the Sec8 retary may specify. 

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

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

11 for each calendar quarter during the 5-year imple12 mentation period in which a direct support profes13 sional wage enhancement plan is in effect under this 

14 section in a State, the amount of payment for med15 ical assistance under section 1903(a)(1) shall be in16 creased by the wage enhancement incentive percent17 age (as defined in paragraph (3)(G)) multiplied by 

18 the portion of total funds expended during the quar19 ter for the provision of direct support services to tar20 geted individuals that are attributable to the wages 

21 of targeted direct support professionals. 

22 ‘‘(2) LIMITATION.— 

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

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

25 wages of targeted direct support professionals. 


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1 ‘‘(B) TREATMENT OF EMPLOYEE BENE2 FITS AND SALARY RELATED BENEFITS.—For 

3 purposes of subparagraph (A), payments for 

4 costs of employee benefits and other salary re5 lated benefits (including mandatory employment 

6 taxes and benefits) shall be treated as payments 

7 to increase the wages of targeted direct support 

8 professionals so long as payments attributable 

9 to such non-wage benefits do not exceed 20 per10 cent of the total amounts that increase the 

11 wages of targeted direct support professionals. 

12 ‘‘(3) DEFINITIONS.—For purposes of this sub13 section: 

14 ‘‘(A) ANNUAL RATE DIFFERENTIAL PER15 CENTAGE.—The term ‘annual rate differential 

16 percentage’ means, with respect to a State for 

17 a year in which the direct support professional 

18 wage enhancement plan is in effect, the percent 

19 of the direct support professional wage rate dif20 ferential (as defined in subparagraph (E)) to be 

21 paid under plan for the year. 

22 ‘‘(B) AVERAGE REFERENCE DIRECT SUP23 PORT PROFESSIONAL HOURLY WAGE RATE.— 

24 The term ‘average reference direct support pro25 fessional hourly wage rate’ means, for a year 


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1 under a direct support professional wage en2 hancement plan, the average direct support pro3 fessional hourly wage rate (as defined in sub4 paragraph (D)), including any projected in5 crease, paid in the year to reference direct sup6 port professionals who are employed by the 

7 State or, if there are no such employees, to ref8 erence direct support professionals who are em9 ployed by local governments in the State, or, 

10 when necessary to meet the purpose of the plan, 

11 any other reference wage rate defined by the 

12 State and as approved by the Secretary. 

13 ‘‘(C) BASE-YEAR AVERAGE TARGETED DI14 RECT SUPPORT PROFESSIONAL HOURLY WAGE

15 RATE.—The term ‘average targeted direct sup16 port professional hourly wage rate’ means, for 

17 a State, the average direct support professional 

18 hourly wage rate (as defined in subparagraph 

19 (D)) paid to targeted direct support profes20 sionals under the State plan in the 12-month21 period immediately preceding the 5-year imple22 mentation period. 

23 ‘‘(D) DIRECT SUPPORT PROFESSIONAL

24 HOURLY WAGE RATE.—The term ‘direct sup25 port professional hourly wage rate’ means— 


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

2 direct support professional; plus 

3 ‘‘(ii) mandatory employment taxes 

4 and benefits (as defined in subparagraph 

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

6 hourly basis) with respect to such employ7 ment. 

8 ‘‘(E) DIRECT SUPPORT PROFESSIONAL

9 WAGE RATE DIFFERENTIAL.—The term ‘direct 

10 support professional wage rate differential’ 

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

12 which— 

13 ‘‘(i) the average reference direct sup14 port professional hourly wage rate (as de15 fined in subparagraph (B)) for the State 

16 and year, exceeds 

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

18 direct support professional hourly wage 

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

20 the State. 

21 ‘‘(F) MANDATORY EMPLOYMENT TAXES

22 AND BENEFITS.—The term ‘mandatory employ23 ment taxes and benefits’ means taxes under 

24 section 3111 of the Internal Revenue Code of 

25 1986 (relating to the employer share of FICA 


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1 taxes) and the employer’s share of unemploy2 ment compensation and worker’s compensation 

3 payments. 

4 ‘‘(G) WAGE ENHANCEMENT INCENTIVE

5 PERCENTAGE.—The term ‘wage enhancement 

6 incentive percentage’ means— 

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

8 support professional wage rate differential 

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

10 annual rate differential percentage (as de11 fined in subparagraph (A)); divided by 

12 ‘‘(ii) the average reference direct sup13 port professional hourly wage rate (as de14 fined in subparagraph (B)). 

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

16 through the Inspector General of the Department of 

17 Health and Human Services, shall audit a sample from 

18 among the States in order to assess the effectiveness of 

19 progress made in reducing or eliminating the wage gap 

20 between targeted and reference direct support profes21 sionals through funds under this section. 

22 ‘‘(h) GAO STUDY.— 

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

24 United States shall conduct a study concerning the 

25 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 (ADL), in15 strumental activities of daily living (IADL) and 

16 health-related functions. Such term includes per17 sonal care services, consumer-directed personal as18 sistance services, rehabilitation services, habilitation 

19 services, and 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 eligiVerDate Aug 31 2005 16:55 Mar 03, 2007 Jkt 059200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\H1279.IH H1279

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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 under 

11 section 1905(a)(7), for intermediate care facility 

12 services for the mentally retarded under section 

13 1905(a)(15), for home and community-based serv14 ices under a State plan option under section 1915(j), 

15 for self-directed personal assistance services under a 

16 State plan amendment option under section 1915(i), 

17 or for home and community-based services under a 

18 waiver approved under section 1915(c) or section 

19 1115.’’. 

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

21 of such Act (42 U.S.C. 1396b(a)(1)) is amended by insert22 ing ‘‘and section 1939(f)’’ after ‘‘1923(f)’’. 

23 (c) AUTHORIZATION OF PLANNING GRANTS.—The 

24 Secretary of Health and Human Services is authorized to 

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


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

2 establishing direct support professional wage enhancement 

3 plans under section 1939 of the Social Security Act, as 

4 inserted by subsection (a). 

Æ 


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