I 

118TH CONGRESS 

1ST SESSION H. R. 1493 

To amend title XIX of the Social Security Act to require coverage of, and 

expand access to, home and community-based services under the Medicaid 

program; to award grants for the creation, recruitment, training and 

education, retention, and advancement of the direct care workforce and 

to award grants to support family caregivers; and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 9, 2023 

Mrs. DINGELL (for herself and Mr. BOWMAN) introduced the following bill; 

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committees on Education and the Workforce, and Oversight and Accountability, for a period to be subsequently determined by 

the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XIX of the Social Security Act to require 

coverage of, and expand access to, home and communitybased services under the Medicaid program; to award 

grants for the creation, recruitment, training and education, retention, and advancement of the direct care 

workforce and to award grants to support family caregivers; and for other purposes. 

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


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

3 ‘‘HCBS Access Act’’. 

4 (b) TABLE OF CONTENTS.—The table of contents of 

5 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Definitions. 

TITLE I—REQUIRING AND EXPANDING ACCESS TO HCBS 

COVERAGE UNDER MEDICAID 

Sec. 101. Purpose. 

Sec. 102. Requiring coverage of home and community-based services under the 

Medicaid program. 

Sec. 103. Medicaid eligibility modifications. 

Sec. 104. Home and community-based services implementation plan grant program. 

Sec. 105. Quality of services. 

Sec. 106. Reports; technical assistance; other administrative requirements. 

Sec. 107. Quality measurement and improvement. 

Sec. 108. Making permanent the State option to extend protection under Medicaid for recipients of home and community-based services 

against spousal impoverishment. 

Sec. 109. Permanent extension of Money Follows the Person Rebalancing demonstration. 

TITLE II—RECOGNIZING THE ROLE OF DIRECT SUPPORT 

PROFESSIONALS 

Sec. 201. Findings. 

Sec. 202. Definition of direct support professional. 

Sec. 203. Revision of Standard Occupational Classification System. 

TITLE III—SUPPORT FOR THE DIRECT CARE WORKFORCE 

Sec. 301. Definitions. 

Sec. 302. Authority to establish a technical assistance center for building the 

direct care workforce. 

Sec. 303. Authority to award grants. 

Sec. 304. Project plans. 

Sec. 305. Evaluations and reports; technical assistance. 

Sec. 306. Authorization of appropriations. 

TITLE IV—EVALUATION 

Sec. 401. Evaluation of impact on access to HCBS. 

6 SEC. 2. DEFINITIONS. 

7 In this Act: 


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1 (1) DEMOGRAPHICS.—The term ‘‘demo2 graphics’’ means information relating to the races, 

3 ethnicities, genders, sexual orientations, gender iden4 tities, geographic locations, incomes, primary lan5 guages, types of service setting, and disability types 

6 represented within a particular group of individuals. 

7 (2) PRIVATE DUTY NURSING.—The term ‘‘pri8 vate duty nursing’’ means nursing services that are 

9 sufficient to meet the needs of an individual who re10 quires more individualized and continuous care than 

11 is available from a visiting nurse or routinely pro12 vided by the nursing staff of a hospital or skilled 

13 nursing facility, and includes services provided to an 

14 individual in the individual’s own home by a reg15 istered nurse or licensed practical nurse under the 

16 direction of a physician. 

17 (3) SECRETARY.—Except as otherwise provided, 

18 the term ‘‘Secretary’’ means the Secretary of Health 

19 and Human Services. 

20 TITLE I—REQUIRING AND EX21 PANDING ACCESS TO HCBS 

22 COVERAGE UNDER MEDICAID 

23 SEC. 101. PURPOSE. 

24 It is the purpose of this title to require coverage of 

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1 ferred to as ‘‘HCBS’’) under a State plan (or waiver of 

2 such plan) under title XIX of the Social Security Act (42 

3 U.S.C. 1396 et seq.) for the following reasons: 

4 (1) To eliminate waiting lists for HCBS, which 

5 delay access to necessary services and civil rights for 

6 people with disabilities and older adults. 

7 (2) To build on decades of progress in serving 

8 people with disabilities and older adults via HCBS. 

9 (3) To fulfill the purposes of the Medicaid pro10 gram to provide medical assistance for those whose 

11 income and resources are insufficient to meet the 

12 costs of necessary medical services, and to provide 

13 rehabilitation, long-term services and supports, and 

14 other services to help such families and individuals 

15 attain or retain capability for independence or self16 care. 

17 (4) To ensure that people with all kinds of dis18 abilities and with multiple disabilities, including in19 tellectual disability, cognitive disabilities, develop20 mental disabilities, behavioral health disabilities, 

21 physical disabilities, and substance use disorders, 

22 and older adults, receive the services they need to 

23 live in their communities. 


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1 (5) To streamline access to HCBS by elimi2 nating the need for States to repeatedly apply for 

3 waivers. 

4 (6) To continue to increase the capacity of com5 munity services to ensure people with disabilities and 

6 older adults have safe and meaningful options in the 

7 community and are not at risk of unnecessary insti8 tutionalization. 

9 (7) To act on the decades of research and prac10 tice that show everyone, including people with the 

11 most severe disabilities, can live in the community 

12 with the right services and supports. 

13 (8) To support over 53,000,000 unpaid family 

14 caregivers who are often providing complex services 

15 and supports to older adults and people with disabil16 ities because of a lack of affordable services, work17 force shortages, and other inefficiencies. 

18 (9) To improve direct care quality and address 

19 the decades long workforce barriers, which have been 

20 exacerbated by the COVID–19 pandemic, for nearly 

21 2,600,000 direct care professionals providing sup22 port to people with disabilities and older adults in 

23 their homes and communities. 

24 (10) To eliminate the race, gender, sexual ori25 entation, and gender identity disparities that exist in 


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1 accessing information and HCBS and to prevent the 

2 unnecessary impoverishment and institutionalization 

3 of black and brown individuals with disabilities and 

4 older adults. 

5 SEC. 102. REQUIRING COVERAGE OF HOME AND COMMU6 NITY-BASED SERVICES UNDER THE MED7 ICAID PROGRAM. 

8 (a) DEFINITION OF HOME AND COMMUNITY-BASED

9 SERVICES.— 

10 (1) IN GENERAL.—Section 1905 of the Social 

11 Security Act (42 U.S.C. 1396d) is amended by add12 ing at the end the following new subsection: 

13 ‘‘(jj) HOME AND COMMUNITY-BASED SERVICES.— 

14 ‘‘(1) IN GENERAL.—For purposes of this title, 

15 the term ‘home and community-based services’ 

16 means those services specified in paragraph (2) fur17 nished to an eligible individual (as defined in para18 graph (3)), based on an individualized assessment 

19 (as described in paragraph (4)) of such individual, 

20 in a setting that— 

21 ‘‘(A) meets the qualities specified in para22 graph (1) of section 441.710(a) of title 42, 

23 Code of Federal Regulations (or a successor 

24 regulation); 


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1 ‘‘(B) is not described in paragraph (2) of 

2 such section (or successor regulation); and 

3 ‘‘(C) meets such other qualities as the Sec4 retary determines appropriate. 

5 ‘‘(2) SERVICES SPECIFIED.— 

6 ‘‘(A) IN GENERAL.—For purposes of para7 graph (1), the services specified in this para8 graph are services described in any of para9 graphs (7), (8), (13)(C), (19), (20), (24), and 

10 (29) (as applied without regard to the reference 

11 to ‘September 30, 2025’) of subsection (a) or in 

12 any of subsections (c)(4)(B), (c)(5), (k)(1)(A), 

13 (k)(1)(B), or (k)(1)(D) of section 1915, includ14 ing the following: 

15 ‘‘(i) Supported employment and inte16 grated day services. 

17 ‘‘(ii) Personal assistance, including 

18 personal care attendants, direct support 

19 professionals, home health aides, private 

20 duty nursing, homemakers and chore as21 sistance, and companionship services. 

22 ‘‘(iii) Services that enhance independ23 ence, inclusion, and full participation in 

24 the broader community. 


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1 ‘‘(iv) Non-emergency, non-medical 

2 transportation services to facilitate commu3 nity integration. 

4 ‘‘(v) Respite services provided in the 

5 individual’s home or broader community. 

6 ‘‘(vi) Caregiver and family support 

7 services. 

8 ‘‘(vii) Case management, including in9 tensive case management, fiscal inter10 mediary, and support brokerage services. 

11 ‘‘(viii) Services which support person12 centered planning and self-direction. 

13 ‘‘(ix) Direct support services during 

14 acute hospitalizations. 

15 ‘‘(x) Necessary medical and nursing 

16 services not otherwise covered which are 

17 necessary in order for the individual to re18 main in their home and community, includ19 ing hospice services. 

20 ‘‘(xi) Home and community-based in21 tensive behavioral health and crisis inter22 vention services. 

23 ‘‘(xii) Peer support services. 

24 ‘‘(xiii) Housing support, including 

25 transitional housing or transitional support 


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1 services for individuals who are unhoused, 

2 and wrap-around services. 

3 ‘‘(xiv) Necessary home modifications 

4 and assistive technology, including those 

5 which substitute for human assistance. 

6 ‘‘(xv) Transition services to support 

7 an individual who is transitioning from an 

8 institutional setting to the community, in9 cluding appropriate services for individuals 

10 who are unhoused or at risk of becoming 

11 unhoused, and including such transition 

12 services provided while the individual re13 sides in an institution. 

14 ‘‘(xvi) Any other service recommended 

15 by the panel convened pursuant to sub16 paragraph (B). 

17 ‘‘(B) SPECIFICATION OF RECOMMENDED

18 SERVICES.— 

19 ‘‘(i) IN GENERAL.—Not later than 6 

20 months after the date of the enactment of 

21 this subparagraph, and not less frequently 

22 than once every 5 years thereafter, the 

23 Secretary shall convene an advisory panel 

24 (in this subparagraph referred to as the 

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1 ditional services which shall be included as 

2 home and community-based services under 

3 this paragraph. 

4 ‘‘(ii) COMPOSITION.— 

5 ‘‘(I) SELECTION.—The panel 

6 shall be composed of at least one rep7 resentative (to be selected by the Sec8 retary) from each of the following: 

9 ‘‘(aa) Individuals with dis10 abilities receiving home and com11 munity-based services under this 

12 title and individuals with disabil13 ities in need of such services, in14 cluding those with physical dis15 abilities, behavioral health dis16 abilities, or intellectual or devel17 opmental disabilities, and includ18 ing older adults. 

19 ‘‘(bb) Beneficiary-led dis20 ability rights organizations. 

21 ‘‘(cc) Disability-led organiza22 tions. 

23 ‘‘(dd) Disabled veterans or24 ganizations. 


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1 ‘‘(ee) Disability organiza2 tions representing families. 

3 ‘‘(ff) Community-based pro4 vider organizations. 

5 ‘‘(gg) Organizations serving 

6 older adults. 

7 ‘‘(hh) The Protection and 

8 Advocacy system, the Centers for 

9 Independent Living. 

10 ‘‘(ii) Health care providers. 

11 ‘‘(jj) The National Associa12 tion of Medicaid Directors. 

13 ‘‘(kk) The National Associa14 tion of State Directors of Devel15 opmental Disabilities Services. 

16 ‘‘(ll) The National Associa17 tion of State Mental Health Pro18 gram Directors. 

19 ‘‘(mm) ADvancing States. 

20 ‘‘(nn) The Centers for Medi21 care & Medicaid Services. 

22 ‘‘(oo) The Administration 

23 for Community Living of the De24 partment of Health and Human 

25 Services. 


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1 ‘‘(pp) Other relevant local, 

2 State, and Federal home and 

3 community-based service systems, 

4 as determined by the Secretary. 

5 ‘‘(II) REQUIREMENT FOR EQUAL

6 REPRESENTATION.—The Secretary 

7 shall select an equal number of rep8 resentatives from each category de9 scribed in items (aa) through (oo) of 

10 subclause (I) in convening the panel. 

11 ‘‘(iii) DUTIES.—Not later than 6 

12 months after a panel is convened under 

13 clause (i), the panel shall submit to the 

14 Secretary and to Congress a report recom15 mending additional services which shall be 

16 included as home and community-based 

17 services under this paragraph. Such rec18 ommended services shall be so specified 

19 with the goal of increasing community in20 tegration and self-determination for indi21 viduals with disabilities receiving such 

22 services. 

23 ‘‘(iv) IMPLEMENTATION OF REC24 OMMENDED SERVICES.— 


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1 ‘‘(I) IN GENERAL.—Services rec2 ommended by the panel in a report 

3 submitted under clause (iii) shall be 

4 treated as services described in sub5 paragraph (A)(xvi) for calendar quar6 ters beginning on or after the date 

7 that is 1 year after the date of such 

8 submission. 

9 ‘‘(II) NOTIFICATION.—Not later 

10 than 1 year after the first report is 

11 submitted under clause (iii), and not 

12 later than 1 year after the submission 

13 of each subsequent such report, the 

14 Secretary shall notify States of any 

15 additions or removals of home and 

16 community-based services based on 

17 services recommended under such re18 port through State Medicaid Director 

19 letters. 

20 ‘‘(3) ELIGIBLE INDIVIDUAL.— 

21 ‘‘(A) IN GENERAL.—For purposes of para22 graph (1), the term ‘eligible individual’ 

23 means— 

24 ‘‘(i) an individual who is determined, 

25 on an annual basis or on a longer basis 


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1 specified by the State, by a health care 

2 provider approved by the State under a 

3 process described in subparagraph (C) to 

4 have a functional impairment (as defined 

5 in subparagraph (B)) (not taking into ac6 count any items or services, or any other 

7 ameliorative measures, furnished to such 

8 individual to mitigate such impairment) 

9 that is expected to last at least 90 days; 

10 ‘‘(ii) during the period that ends on 

11 the day before the first day of the first cal12 endar quarter beginning on or after the 

13 date that is 5 years after the date of the 

14 enactment of this subsection, an individual 

15 who, as of such date of enactment, is re16 ceiving or has been determined to be eligi17 ble for, home and community-based serv18 ices under this title under a waiver or 

19 State plan option in effect under section 

20 1915 or 1115, provided that the individual 

21 continues to meet any level of care require22 ment applicable under such waiver or plan 

23 option; or 


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1 ‘‘(iii) an individual who is eligible 

2 under the State plan or waiver and is 

3 under the age of 21. 

4 ‘‘(B) FUNCTIONAL IMPAIRMENT.—For 

5 purposes of subparagraph (A), the term ‘func6 tional impairment’ means, with respect to an 

7 individual the inability of such individual to 

8 perform, without assistance— 

9 ‘‘(i) 2 or more activities of daily living 

10 (as described in section 7702B(c)(2)(B) of 

11 the Internal Revenue Code of 1986); 

12 ‘‘(ii) 2 or more instrumental activities 

13 of daily living (as defined for purposes of 

14 section 1915(k)(1)(A)); or 

15 ‘‘(iii) 1 activity of daily living (as so 

16 described) and 1 instrumental activity of 

17 daily living (as so defined). 

18 ‘‘(C) HEALTH CARE PROVIDER STATE AP19 PROVAL.—For purposes of subparagraph (A)(i), 

20 a process described in this subparagraph is a 

21 process established by the State to approve 

22 health care providers to make determinations 

23 described in such subparagraph that meets such 

24 standards as the Secretary may prescribe. 

25 ‘‘(4) INDIVIDUALIZED ASSESSMENT.— 


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1 ‘‘(A) IN GENERAL.—For purposes of para2 graph (1), an individualized assessment de3 scribed in this paragraph is an independent as4 sessment, with respect to an eligible indi5 vidual— 

6 ‘‘(i) to determine a necessary level of 

7 services and supports to be provided, con8 sistent with an individual’s functional im9 pairments, to facilitate an individual’s 

10 community integration, self-determination, 

11 and well-being; 

12 ‘‘(ii) to prevent the provision of un13 necessary or inappropriate care; 

14 ‘‘(iii) to establish a person-centered 

15 care plan (as described in subparagraph 

16 (C)) for the individual; 

17 ‘‘(iv) that includes each of the ele18 ments described in clauses (ii) through (v) 

19 of section 1915(i)(1)(F); and 

20 ‘‘(v) that occurs not later than 30 

21 days after such individual is determined to 

22 be an eligible individual. 

23 ‘‘(B) PRESUMPTION.—The assessment de24 scribed in subparagraph (A) shall be conducted 

25 with the presumption— 


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1 ‘‘(i) that each eligible individual, re2 gardless of type or level of disability or 

3 service need, can be served in the individ4 ual’s own home and community; and 

5 ‘‘(ii) at the option of the individual, 

6 that services may be self-directed (as de7 fined in section 1915(i)(1)(G)(iii)(II)). 

8 ‘‘(C) PERSON-CENTERED CARE PLAN.— 

9 For purposes of subparagraph (A)(iii), a per10 son-centered care plan described in this sub11 paragraph is a written plan with respect to an 

12 individual that meets the requirements of sec13 tion 1915(i)(1)(G)(ii). 

14 ‘‘(D) STANDARDS.—An individualized as15 sessment described in subparagraph (A) shall 

16 be conducted in accordance with standards 

17 specified by the Secretary, in consultation with 

18 the Administration for Community Living, 

19 that— 

20 ‘‘(i) safeguard against conflicts of in21 terest; 

22 ‘‘(ii) specify qualifications for who 

23 may perform such assessments; 

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1 suring the provision of the results of such 

2 assessments that includes information in 

3 plain language necessary to interpret the 

4 methodology and results of such assess5 ments; 

6 ‘‘(iv) ensure that the methodologies 

7 used in such assessments are sound and 

8 evidence-based; and 

9 ‘‘(v) require such methodologies to be 

10 made available on the public website of the 

11 State and tested for reliability and validity 

12 by an independent evaluator.’’. 

13 (2) INCLUSION AS MEDICAL ASSISTANCE.—Sec14 tion 1905(a) of the Social Security Act (42 U.S.C. 

15 1396d(a)) is amended— 

16 (A) in paragraph (30), by striking ‘‘; and’’ 

17 and inserting a semicolon; 

18 (B) by redesignating paragraph (31) as 

19 paragraph (32); and 

20 (C) by inserting after paragraph (30) the 

21 following new paragraph: 

22 ‘‘(31) home and community-based services (as 

23 defined in subsection (jj)); and’’. 

24 (b) MANDATORY BENEFIT.— 


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1 (1) IN GENERAL.—Section 1902(a)(10)(A) of 

2 the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) 

3 is amended by striking ‘‘and (30)’’ and inserting 

4 ‘‘(30), and (31)’’. 

5 (2) EFFECTIVE DATE.—The amendment made 

6 by this subsection shall take effect on the first day 

7 of the first calendar quarter that begins on or after 

8 the date that is 5 years after the date of enactment 

9 of this Act. 

10 (c) ENSURING COVERAGE OF HCBS FOR ALL MED11 ICAID-ELIGIBLE INDIVIDUALS.—Section 1902(a)(10)(D) 

12 of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) 

13 is amended— 

14 (1) by inserting ‘‘(i)’’ after ‘‘(D)’’; 

15 (2) by adding ‘‘and’’ after the semicolon; and 

16 (3) by adding at the end the following new 

17 clause: 

18 ‘‘(ii) beginning on the first day of the first cal19 endar quarter that begins on or after the date that 

20 is 5 years after the date of enactment of this clause 

21 (or at such earlier date as the State may elect) for 

22 the inclusion of home and community-based services 

23 (as defined in section 1905(jj)) for any individual 

24 who— 


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1 ‘‘(I) is eligible for medical assistance under 

2 the State plan (or waiver of such plan); 

3 ‘‘(II) is an eligible individual (as defined in 

4 such section); and 

5 ‘‘(III) elects to receive such services.’’. 

6 (d) FEDERAL MEDICAL ASSISTANCE PERCENTAGE

7 FOR HOME AND COMMUNITY-BASED SERVICES.—Section 

8 1905 of the Social Security Act (42 U.S.C. 1396d), as 

9 amended by subsection (a), is further amended— 

10 (1) in subsection (b), by striking ‘‘and (ii)’’ and 

11 inserting ‘‘(ii), and (kk)’’; and 

12 (2) by adding at the end the following new sub13 section: 

14 ‘‘(kk) SPECIFIED FMAP FOR HOME AND COMMU15 NITY-BASED SERVICES.— 

16 ‘‘(1) IN GENERAL.—Notwithstanding any other 

17 provision of law and except as provided in paragraph 

18 (3), the Federal medical assistance percentage for 

19 amounts expended for medical assistance for home 

20 and community-based services (as defined in sub21 section (jj)), including any such services furnished 

22 under a waiver in effect under section 1915, on or 

23 after the date of the enactment of this subsection 

24 shall be equal to 100 percent. 


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1 ‘‘(2) ACCESS TO ESSENTIAL HCBS.—As a condi2 tion of receiving the Federal medical assistance per3 centage described in paragraph (1), a State shall en4 hance, expand, or strengthen the level of home and 

5 community-based services offered under the State 

6 plan under this title (or a waiver of such a plan) as 

7 of the date of enactment of this subsection by doing 

8 all of the following: 

9 ‘‘(A) Addressing access barriers and dis10 parities in access or utilization identified in the 

11 State HCBS implementation plan. 

12 ‘‘(B) Using ‘no wrong door’ programs, pro13 viding presumptive eligibility for home and com14 munity-based services, and improving home and 

15 community-based services counseling and edu16 cation programs. 

17 ‘‘(C) Providing supports to family care18 givers, which shall include providing respite 

19 care, and may include providing such services 

20 as caregiver assessments, peer supports, access 

21 to assistive technology, or paid family 

22 caregiving. 

23 ‘‘(D) Adopting processes to ensure that 

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1 ices are sufficient to ensure that such services 

2 are available to eligible beneficiaries. 

3 ‘‘(3) EXCEPTION.—The Federal medical assist4 ance percentage applicable to medical assistance for 

5 home and community-based services furnished to an 

6 individual who is only eligible for medical assistance 

7 under a State plan or waiver on the basis of section 

8 1902(a)(10)(A)(ii)(XXIV) shall be determined with9 out regard to this subsection.’’. 

10 (e) SUNSET OF HCBS WAIVERS.—Section 1915 of 

11 the Social Security Act (42 U.S.C. 1396n) is amended by 

12 adding at the end the following new subsection: 

13 ‘‘(m) SUNSET OF PROVISIONS RELATING TO HOME

14 AND COMMUNITY-BASED SERVICES.— 

15 ‘‘(1) IN GENERAL.—Except as provided in para16 graph (2), the preceding provisions of this section, 

17 insofar as such provisions relate to a waiver for 

18 home and community-based services, shall not apply 

19 beginning with the first calendar quarter beginning 

20 on or after the date that is 5 years after the date 

21 of the enactment of this subsection. 

22 ‘‘(2) EXCEPTION.—The Secretary may waive 

23 the application of paragraph (1) for a calendar quar24 ter and a State if the State requests such a waiver 


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1 and the Secretary determines that such a waiver is 

2 appropriate.’’. 

3 (f) CONFORMING AMENDMENTS.— 

4 (1) IN GENERAL.—Title XIX of the Social Se5 curity Act (42 U.S.C. 1396 et seq.) is amended— 

6 (A) in section 1905(a), in the matter pre7 ceding the first numbered paragraph— 

8 (i) in clause (xv), by striking the 

9 comma at the end and inserting ‘‘, or’’; 

10 (ii) in clause (xvi)— 

11 (I) by moving the left margin 2 

12 ems to the left; and 

13 (II) by striking ‘‘, or’’ and insert14 ing a comma; and 

15 (iii) by striking clause (xvii); and 

16 (B) in section 1943(b)(5), by striking ‘‘the 

17 State’’ and all that follows through the period 

18 at the end and inserting ‘‘a determination be 

19 conducted on an annual basis (or on such 

20 longer basis as specified by the State) in ac21 cordance with section 1905(jj) for purposes of 

22 providing home and community-based services 

23 under the State plan (or waiver of such plan).’’. 

24 (2) EFFECTIVE DATE.— 


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1 (A) IN GENERAL.—Except as provided in 

2 subparagraph (B), the amendments made by 

3 this subsection shall take effect on the first day 

4 of the first calendar quarter that begins on or 

5 after the date that is 5 years after the date of 

6 enactment of this Act. 

7 (B) EXCEPTION FOR STATES AUTHORIZED

8 TO CONTINUE OPERATING HCBS WAIVERS.—In 

9 the case of a State for which the Secretary has 

10 waived the application of paragraph (1) of sub11 section (m) of section 1915 of the Social Secu12 rity Act (42 U.S.C. 1396n), as added by sub13 section (e), in accordance with paragraph (2) of 

14 such subsection (m), clause (xvii) of section 

15 1905(a) of the Social Security Act shall con16 tinue to have effect with respect to such State 

17 for so long as paragraph (1) of such subsection 

18 (m) does not apply to such State. 

19 SEC. 103. MEDICAID ELIGIBILITY MODIFICATIONS. 

20 Section 1902(a)(10) of the Social Security Act (42 

21 U.S.C. 1396a(a)(10)) is amended— 

22 (1) in subparagraph (A)(i)— 

23 (A) in subclause (VIII), by striking ‘‘; or’’ 

24 and inserting a semicolon; 


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1 (B) in subclause (IX)(dd), by striking the 

2 semicolon at the end and inserting ‘‘; or’’; and 

3 (C) by inserting after subclause (IX) the 

4 following new subclause: 

5 ‘‘(X) beginning with the first cal6 endar quarter that begins on or after 

7 the date that is 5 years after the date 

8 of enactment of this subclause (or 

9 such earlier date as the State may 

10 elect), who are eligible individuals de11 scribed in subsection (jj)(3)(A) and 

12 are not described in a previous sub13 clause of this clause and whose in14 come does not exceed the greater of— 

15 ‘‘(aa) 150 percent of the 

16 poverty line (as defined in section 

17 2110(c)(5)) applicable to a family 

18 of the size involved; and 

19 ‘‘(bb) 300 percent of the 

20 supplemental security income 

21 benefit rate established by section 

22 1611(b)(1);’’; and 

23 (2) in subparagraph (A)(ii)— 

24 (A) in subclause (XXII), by striking ‘‘; or’’ 

25 and inserting a semicolon; 


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1 (B) in subclause (XXIII), by striking the 

2 semicolon at the end and inserting ‘‘; or’’; and 

3 (C) by adding at the end the following new 

4 subclause: 

5 ‘‘(XXIV) who are eligible individ6 uals who would be described in clause 

7 (i)(X) but for the fact that their in8 come exceeds the income levels estab9 lished under such clause but is less 

10 than such income level as the State 

11 may establish for purposes of this 

12 subclause;’’. 

13 SEC. 104. HOME AND COMMUNITY-BASED SERVICES IMPLE14 MENTATION PLAN GRANT PROGRAM. 

15 (a) IN GENERAL.—Not later than 1 year after the 

16 date of the enactment of this Act, the Secretary shall 

17 award to each State a grant for purposes of enabling such 

18 State to implement the requirement to provide home and 

19 community-based services under title XIX of the Social 

20 Security Act (42 U.S.C. 1396 et seq.). 

21 (b) USE OF FUNDS.—A grant awarded under sub22 section (a) shall be used by a State to develop an imple23 mentation plan described in subsection (c) to be submitted 

24 to the Secretary for approval. 


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1 (c) IMPLEMENTATION PLAN.—An implementation 

2 plan described in this subsection is a plan developed by 

3 a State that includes the following: 

4 (1) An explanation of how the State will 

5 operationalize the definition of an eligible individual 

6 under section 1905(jj) of the Social Security Act, in7 cluding the process for determinations specified in 

8 paragraph (3)(A)(i) of such section. 

9 (2) A description of the State’s plan to ensure 

10 a stable and high quality workforce and how the 

11 State plans to ensure a living wage for individuals 

12 furnishing home and community-based services and 

13 identify and address any additional workforce issues. 

14 (3) A list of any home and community-based 

15 services provided under the State Medicaid plan (in16 cluding any waiver of such plan) as of the date of 

17 enactment of this Act, including a breakdown of use 

18 of such services by demographics (as defined in sec19 tion 2), compared to such services that are required 

20 under the amendments made by section 102, and a 

21 description of numerical goals to increase access to 

22 such services that have barriers to access for popu23 lations in need of such services. 

24 (4) A description of how the State will incor25 porate existing State disability agencies into the new 


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1 unified provision of home and community-based 

2 services and how such State will ensure that such 

3 services address all functional impairments. 

4 (5) An explanation of how the State will ensure 

5 access to such services. 

6 (6) A plan for carrying out outreach and edu7 cation activities with respect to the availability of 

8 such services through Aging and Disability Resource 

9 Centers and other similar entities (such as entities 

10 receiving funds from the Administration for Commu11 nity Living or the Substance Abuse and Mental 

12 Health Services Administration), including a pro13 gram that ensures that an individual is not denied 

14 such services based on the fact that the individual 

15 contacts the wrong entity (commonly referred to as 

16 a ‘‘No Wrong Door Program’’). 

17 (7) A plan for how such services will be coordi18 nated with other relevant State agencies, such as 

19 housing, transportation, child welfare, food and in20 come security, and employment agencies. 

21 (8) A description of how the State will build ca22 pacity prior to the implementation of the require23 ment described in subsection (a) to ensure that such 

24 services are available to every eligible individual 

25 under the Medicaid program and how the State will 


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1 ensure that such services are provided in a setting 

2 that meets the requirements specified in paragraph 

3 (1) of section 1905(jj) of the Social Security Act, as 

4 added by section 102. 

5 (9) In the case of a State that utilizes an alter6 native benefit plan, a description of how the State 

7 will ensure that all individuals who are eligible indi8 viduals (as defined in such section) are appropriately 

9 identified as medically frail and exempted from such 

10 plan. 

11 (10) How the State will coordinate eligibility for 

12 such services with other disability eligibility pro13 grams, such as disability buy-in programs. 

14 (11) Data and milestone requirements to ensure 

15 community integration, including such requirements 

16 with respect to utilization of such services by demo17 graphics (as defined in section 2). 

18 (d) STATE PLAN REQUIREMENT.—Section 1902(a) 

19 of the Social Security Act (42 U.S.C. 1396a(a)) is amend20 ed— 

21 (1) in paragraph (86), by striking ‘‘and’’ at the 

22 end; 

23 (2) in paragraph (87), by striking the period at 

24 the end and inserting ‘‘; and’’; and 


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1 (3) by adding at the end the following new 

2 paragraph: 

3 ‘‘(88) provide for the submission to the Sec4 retary of an implementation plan described in sec5 tion 104(c) of the HCBS Access Act for approval by 

6 the Secretary prior to the beginning of the first cal7 endar quarter beginning on or after the date that is 

8 5 years after the date of the enactment of this para9 graph.’’. 

10 (e) AUTHORIZATION OF APPROPRIATIONS.—There is 

11 authorized to be appropriated to the Secretary such sums 

12 as are necessary to carry out this section. 

13 (f) DEFINITIONS.—In subsections (a) through (c): 

14 (1) HOME AND COMMUNITY-BASED SERV15 ICES.—The term ‘‘home and community-based serv16 ices’’ has the meaning given such term in subsection 

17 (jj) of section 1905 of the Social Security Act (42 

18 U.S.C. 1396d), as added by section 102. 

19 (2) STATE.—The term ‘‘State’’ has the mean20 ing given that term in section 1101(1) of the Social 

21 Security Act (42 U.S.C. 1301(1)) for purposes of 

22 title XIX of such Act (42 U.S.C. 1396 et seq.). 

23 SEC. 105. QUALITY OF SERVICES. 

24 (a) IN GENERAL.— 


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1 (1) DEVELOPMENT OF METRICS.—Not later 

2 than 1 year after the date of enactment of this Act, 

3 the Director of the Agency for Healthcare Research 

4 and Quality, in consultation with State Medicaid Di5 rectors, shall develop standardized, State-level 

6 metrics of access to, and satisfaction with, providers, 

7 including primary care and specialist providers, with 

8 respect to individuals who are enrolled in State Med9 icaid plans under title XIX of the Social Security 

10 Act, broken down by demographics (as defined in 

11 section 2) and any other category determined by the 

12 Secretary. Such metrics shall include metrics on the 

13 total number of individuals enrolled in the State 

14 plan or under a waiver of the plan during a fiscal 

15 year that required the level of care provided in a 

16 nursing facility, intermediate care facility for indi17 viduals with intellectual disability, institution for 

18 mental disease, or other similarly restrictive or insti19 tutional setting. 

20 (2) PROCESS.—The Director of the Agency for 

21 Healthcare Research and Quality shall develop the 

22 metrics described in paragraph (1) through a public 

23 process, which shall provide opportunities for stake24 holders to participate. 


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1 (b) UPDATING METRICS.—The Director of the Agen2 cy for Healthcare Research and Quality, in consultation 

3 with the Deputy Administrator for the Center for Med4 icaid and CHIP Services and State Medicaid Directors, 

5 shall update the metrics developed under subsection (a) 

6 not less than once every 3 years. 

7 (c) STATE IMPLEMENTATION FUNDING.—The Direc8 tor of the Agency for Healthcare Research and Quality 

9 may award funds, from the amount appropriated under 

10 subsection (d), to States for the purpose of implementing 

11 the metrics developed under this section. 

12 (d) APPROPRIATION.—There is appropriated to the 

13 Director of the Agency for Healthcare Research and Qual14 ity, out of any funds in the Treasury not otherwise appro15 priated, $200,000,000 for fiscal year 2024, to remain 

16 available until expended, for the purpose of carrying out 

17 this section. 

18 SEC. 106. REPORTS; TECHNICAL ASSISTANCE; OTHER AD19 MINISTRATIVE REQUIREMENTS. 

20 (a) REPORTS.—The Secretary shall submit to the 

21 Committee on Energy and Commerce of the House of 

22 Representatives, the Committee on Education and Labor 

23 of the House of Representatives, the Committee on Fi24 nance of the Senate, the Committee on Health, Education, 

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1 mittee on Aging of the Senate the following reports relat2 ing to the HCBS implementation plan grant program es3 tablished under section 104: 

4 (1) INTERIM REPORT.—Not later than 2 years 

5 after the date of enactment of this Act, a report that 

6 describes— 

7 (A) State efforts to develop their HCBS 

8 implementation plans; and 

9 (B) the funds awarded to States. 

10 (2) FIRST IMPLEMENTATION REPORT.—Not 

11 later than 4 years after the date of enactment of 

12 this Act, a report that includes the following: 

13 (A) A description of the HCBS implemen14 tation plans approved by the Secretary under 

15 section 104. 

16 (B) A description of the national landscape 

17 with respect to gaps in coverage of home and 

18 community-based services, disparities in access 

19 to, and utilization of, such services, and bar20 riers to accessing such services. 

21 (C) A description of the national landscape 

22 with respect to the direct care workforce that 

23 provides home and community-based services, 

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1 fits, and challenges to the availability of such 

2 workers. 

3 (3) SUBSEQUENT REPORTS.—Not later than 7 

4 years after the date of enactment of this Act, and 

5 every 3 years thereafter, a report that includes the 

6 following: 

7 (A) The number of HCBS program im8 provement States and the funds awarded to 

9 States to develop their plans. 

10 (B) A summary of the progress being 

11 made by such States with respect to strength12 ening and expanding access to home and com13 munity-based services and the direct care work14 force that provides such services and meeting 

15 the benchmarks for demonstrating improve16 ments required under section 1905(jj)(5) of the 

17 Social Security Act (as added by section 102). 

18 (C) A summary of outcomes related to 

19 home and community-based services core qual20 ity measures and beneficiary and family care21 giver surveys. 

22 (D) A summary of the challenges and best 

23 practices reported by States in expanding ac24 cess to home and community-based services and 


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1 supporting and expanding the direct care work2 force that provides such services. 

3 (b) TECHNICAL ASSISTANCE; GUIDANCE; REGULA4 TIONS.—The Secretary shall provide HCBS program im5 provement States with technical assistance related to car6 rying out the HCBS implementation plans approved by 

7 the Secretary under section 104 and meeting the require8 ments and benchmarks for demonstrating improvements 

9 required under section 1905(jj) of the Social Security Act 

10 (as added by section 102) and shall issue such guidance 

11 or regulations as necessary to carry out this title and the 

12 amendments made by this title, including guidance speci13 fying how States shall assess and track the availability of 

14 home and community-based services over time. 

15 (c) RECOMMENDATIONS TO GUIDE HCBS IMPLE16 MENTATION.— 

17 (1) IN GENERAL.—Not later than 18 months 

18 after the date of enactment of this Act, the Sec19 retary shall coordinate with the Secretary of Labor 

20 and the Administrator of the Centers for Medicare 

21 & Medicaid Services for purposes of issuing rec22 ommendations for the Federal Government and for 

23 States to strengthen the direct care workforce that 

24 provides home and community-based services, in25 cluding with respect to how the Federal Government 


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1 should classify the direct care workforce, how such 

2 Administrator and State Medicaid programs can en3 force and support the provision of competitive wages 

4 and benefits across the direct care workforce, includ5 ing for workers with particular skills or expertise, 

6 and how State Medicaid programs can support 

7 training opportunities and other related efforts that 

8 support the provision of quality home and commu9 nity-based services care. 

10 (2) STAKEHOLDER CONSULTATION.— 

11 (A) IN GENERAL.—In developing the rec12 ommendations required under paragraph (1), 

13 the Secretary shall ensure that such rec14 ommendations are informed by consultation 

15 with recipients of home and community-based 

16 services, family caregivers of such recipients, 

17 providers, health plans, direct care workers, 

18 chosen representatives of direct care workers, 

19 and aging, disability, and workforce advocates. 

20 (B) CONSULTATION WITH CURRENT AND

21 POTENTIAL HCBS BENEFICIARIES AND FAMILY

22 CAREGIVERS.—As part of the process of devel23 oping recommendations under subparagraph 

24 (A), the Secretary shall— 


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1 (i) hold at least 1 meeting for the 

2 purpose of developing such recommenda3 tions that is solely with current and poten4 tial recipients of home and community5 based services and family caregivers of 

6 such recipients; and 

7 (ii) seek to achieve parity in terms of 

8 the level of participation in the develop9 ment of such recommendations between— 

10 (I) current and potential recipi11 ents of home and community-based 

12 services and family caregivers of such 

13 recipients; and 

14 (II) other categories of stake15 holder described in subparagraph (A). 

16 (d) FUNDING.—Out of any funds in the Treasury not 

17 otherwise appropriated, there is appropriated to the Sec18 retary for purposes of carrying out this section, 

19 $10,000,000 for fiscal year 2024, to remain available until 

20 expended. 

21 SEC. 107. QUALITY MEASUREMENT AND IMPROVEMENT. 

22 (a) DEVELOPMENT AND PUBLICATION OF CORE AND

23 SUPPLEMENTAL SETS OF HCBS QUALITY MEASURES.— 

24 (1) IN GENERAL.—The Secretary shall identify 

25 and publish a core set and supplemental set of home 


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1 and community-based services quality measures for 

2 use by State Medicaid programs, health plans and 

3 managed care entities that enter into contracts with 

4 such programs, and providers of items and services 

5 under such programs. 

6 (2) REGULAR REVIEWS AND UPDATES.—The 

7 Secretary shall review and update the core set and 

8 supplemental set of home and community-based 

9 services quality measures published under paragraph 

10 (1) not less frequently than once every year. 

11 (3) REQUIREMENTS.— 

12 (A) INTERAGENCY COLLABORATION; 

13 STAKEHOLDER INPUT.—In developing the core 

14 set and supplemental set of home and commu15 nity-based services quality measures under 

16 paragraph (1), and subsequently reviewing and 

17 updating such core and supplemental sets, the 

18 Secretary shall— 

19 (i) collaborate with the Administrator 

20 of the Centers for Medicare & Medicaid 

21 Services, the Administrator of the Admin22 istration for Community Living, the Direc23 tor of the Agency for Healthcare Research 

24 and Quality, and the Administrator of the 


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1 Substance Abuse and Mental Health Serv2 ices Administration; and 

3 (ii) ensure that such core and supple4 mental sets are informed by input from 

5 stakeholders, including recipients of home 

6 and community-based services, family care7 givers of such recipients, providers, health 

8 plans, direct care workers, chosen rep9 resentatives of direct care workers, and 

10 aging, disability, and workforce advocates, 

11 with the goal that at least half of such 

12 input is from current and potential recipi13 ents of home and community-based serv14 ices and family caregivers. 

15 (B) REFLECTIVE OF FULL ARRAY OF

16 SERVICES.—Such core set and supplemental set 

17 of home and community-based services quality 

18 measures shall— 

19 (i) reflect the full array of home and 

20 community-based services and recipients of 

21 such services, including adults and chil22 dren; and 

23 (ii) include— 

24 (I) outcomes-based measures; 


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1 (II) measures of availability of 

2 services; 

3 (III) measures of provider capac4 ity and availability; 

5 (IV) measures related to person6 centered care; 

7 (V) measures specific to self-di8 rected care; 

9 (VI) measures related to transi10 tions to and from institutional care; 

11 and 

12 (VII) beneficiary and family care13 giver surveys. 

14 (C) DEMOGRAPHICS.—Such core set and 

15 supplemental set of home and community-based 

16 services quality measures shall allow for the col17 lection of data that is disaggregated by demo18 graphics (as defined in section 2 but including 

19 any additional category determined by the Sec20 retary). 

21 (4) FUNDING.—Out of any funds in the Treas22 ury not otherwise appropriated, there is appro23 priated to the Secretary for purposes of carrying out 

24 this subsection, $10,000,000 for fiscal year 2024, to 

25 remain available until expended. 


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1 (b) STATE ADOPTION AND REPORTS.— 

2 (1) IN GENERAL.—Not later than 2 years after 

3 the date on which the Secretary publishes the core 

4 set and supplemental set of home and community5 based services quality measures under subsection 

6 (a)(1), and annually thereafter, each State Medicaid 

7 program shall use such core and supplemental sets 

8 (or an alternative set of quality measures approved 

9 by the Secretary) to report information to the Sec10 retary regarding the quality of home and commu11 nity-based services provided under such program. 

12 (2) PROCESS.—The information required under 

13 paragraph (1) shall be reported using a standardized 

14 format and procedures established by the Secretary. 

15 Such procedures shall allow a State Medicaid pro16 gram to report such information separately or as 

17 part of the annual reports required under sections 

18 1139A(c) and 1139B(d) of the Social Security Act 

19 (42 U.S.C. 1320b–9a, 1320b–9b). 

20 (3) PUBLICATION OF QUALITY MEASURES.— 

21 Each State Medicaid program shall annually make 

22 the information reported to the Secretary under 

23 paragraph (1) available to the public. 

24 (4) INCREASED FEDERAL MATCHING RATE FOR

25 ADOPTION AND REPORTING.—Section 1903(a)(3) of 


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1 the Social Security Act (42 U.S.C. 1396b(a)(3)) is 

2 amended— 

3 (A) in subparagraph (F)(ii), by striking 

4 ‘‘plus’’ after the semicolon and inserting ‘‘and’’; 

5 and 

6 (B) by inserting after subparagraph (F), 

7 the following: 

8 ‘‘(G) 80 percent of so much of the sums 

9 expended during such quarter as are attrib10 utable to the reporting of information regarding 

11 the quality of home and community-based serv12 ices in accordance with section 107(b) of the 

13 HCBS Access Act; and’’. 

14 SEC. 108. MAKING PERMANENT THE STATE OPTION TO EX15 TEND PROTECTION UNDER MEDICAID FOR 

16 RECIPIENTS OF HOME AND COMMUNITY17 BASED SERVICES AGAINST SPOUSAL IMPOV18 ERISHMENT. 

19 (a) IN GENERAL.—Section 1924(h)(1)(A) of the So20 cial Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amend21 ed by striking ‘‘is described in section 

22 1902(a)(10)(A)(ii)(VI)’’ and inserting the following: ‘‘is 

23 an eligible individual (as defined in section 1905(jj)(3))’’. 

24 (b) CONFORMING AMENDMENT.—Section 2404 of the 

25 Patient Protection and Affordable Care Act (42 U.S.C. 


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1 1396r–5 note) is amended by striking ‘‘September 30, 

2 2027’’ and inserting ‘‘the date of enactment of the HCBS 

3 Access Act’’. 

4 SEC. 109. PERMANENT EXTENSION OF MONEY FOLLOWS 

5 THE PERSON REBALANCING DEMONSTRA6 TION. 

7 Subparagraph (L) of section 6071(h)(1) of the Def8 icit Reduction Act of 2005 (42 U.S.C. 1396a note) is 

9 amended by striking ‘‘each of fiscal years 2024 through 

10 2027’’ and inserting ‘‘each fiscal year after 2023’’. 

11 TITLE II—RECOGNIZING THE 

12 ROLE OF DIRECT SUPPORT 

13 PROFESSIONALS 

14 SEC. 201. FINDINGS. 

15 Congress finds the following: 

16 (1) Direct support professionals play a critical 

17 role in the care provided to children and adults indi18 viduals with intellectual and developmental disabil19 ities. 

20 (2) Providers of home and community-based 

21 services are experiencing difficulty hiring and retain22 ing direct support professionals, with a national 

23 turnover rate of 45 percent as identified in a 2016 

24 study by the National Core Indicators. 


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1 (3) High turnover rates can lead to instability 

2 for individuals receiving services, and this may result 

3 in individuals not receiving enough personalized care 

4 to help them reach their goals for independent liv5 ing. 

6 (4) A discrete occupational category for direct 

7 support professionals will help States and the Fed8 eral Government— 

9 (A) better interpret the shortage in the 

10 labor market of direct support professionals; 

11 and 

12 (B) collect data on the high turnover rate 

13 of direct support professionals. 

14 (5) The Standard Occupational Classification 

15 system is designed and maintained solely for statis16 tical purposes, and is used by Federal statistical 

17 agencies to classify workers and jobs into occupa18 tional categories for the purpose of collecting, calcu19 lating, analyzing, or disseminating data. 

20 (6) Occupations in the Standard Occupational 

21 Classification system are classified based on work 

22 performed and, in some cases, on the skills, edu23 cation, or training needed to perform the work. 

24 (7) Establishing a discrete occupational cat25 egory for direct support professionals will— 


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1 (A) correct an inaccurate representation in 

2 the Standard Occupational Classification sys3 tem; 

4 (B) recognize these professionals for the 

5 critical and often times overlooked work that 

6 they perform for the disabled community, which 

7 work is different than the work of a home 

8 health aide or a personal care aide; and 

9 (C) better align the Standard Occupational 

10 Classification system with related classification 

11 systems. 

12 SEC. 202. DEFINITION OF DIRECT SUPPORT PROFES13 SIONAL. 

14 In this title, the term ‘‘direct support professional’’ 

15 means an individual who, in exchange for compensation, 

16 provides services to an individual with a disability (as de17 fined in section 3 of the Americans with Disabilities Act 

18 of 1990 (42 U.S.C. 12102)), including— 

19 (1) services that enhance independence and 

20 community inclusion for such individual, including 

21 traveling with such individual, attending and assist22 ing such individual while visiting friends and family, 

23 shopping, or socializing; 

24 (2) services such as coaching and supporting 

25 such individual in communicating needs, achieving 


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1 self-expression, pursuing personal goals, living inde2 pendently, and participating actively in employment 

3 or voluntary roles in the community; 

4 (3) services such as providing assistance with 

5 activities of daily living (such as feeding, bathing, 

6 toileting, and ambulation) and with tasks such as 

7 meal preparation, shopping, light housekeeping, and 

8 laundry; or 

9 (4) services that support such individual at 

10 home, work, school, or any other community setting. 

11 SEC. 203. REVISION OF STANDARD OCCUPATIONAL CLASSI12 FICATION SYSTEM. 

13 The Director of the Office of Management and Budg14 et shall, not later than 30 days after the date of enactment 

15 of this Act, revise the Standard Occupational Classifica16 tion system to establish a separate code (31–1123) for di17 rect support professionals as a healthcare support occupa18 tion. Such code shall be a subset of 31–1120, which in19 cludes home health aides and personal care aides. 

20 TITLE III—SUPPORT FOR THE 

21 DIRECT CARE WORKFORCE 

22 SEC. 301. DEFINITIONS. 

23 In this title: 

24 (1) APPRENTICESHIP PROGRAM.—The term 

25 ‘‘apprenticeship program’’ means an apprenticeship 


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1 program registered under the Act of August 16, 

2 1937 (commonly known as the ‘‘National Appren3 ticeship Act’’; 50 Stat. 664, chapter 663; 29 U.S.C. 

4 50 et seq.), including any requirement, standard, or 

5 rule promulgated under such Act. 

6 (2) COMMUNITY COLLEGE.—The term ‘‘commu7 nity college’’ means a public institution of higher 

8 education at which the highest degree that is pre9 dominantly awarded to students is an associate’s de10 gree, including Tribal Colleges or Universities receiv11 ing grants under section 316 of the Higher Edu12 cation Act of 1965 (20 U.S.C. 1059c) that offer a 

13 2-year program for completion of such degree and 

14 State public institutions of higher education that 

15 offer such a 2-year program. 

16 (3) DIRECT CARE PROFESSIONAL.—The term 

17 ‘‘direct care professional’’— 

18 (A) means an individual who, in exchange 

19 for compensation, provides services to a person 

20 with a disability or an older adult that promotes 

21 the independence of such person or individual, 

22 including— 

23 (i) services that enhance the inde24 pendence and community inclusion for 

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1 eling with such person or individual or at2 tending and assisting such person or indi3 vidual while visiting friends and family, 

4 shopping, or socializing; 

5 (ii) services such as coaching and sup6 porting such person or individual in com7 municating needs, achieving self-expres8 sion, pursuing personal goals, living inde9 pendently, and participating actively in em10 ployment or voluntary roles in the commu11 nity; 

12 (iii) services such as providing assist13 ance with activities of daily living (such as 

14 feeding, bathing, toileting, and ambulation) 

15 and with tasks such as meal preparation, 

16 shopping, light housekeeping, and laundry; 

17 (iv) services that support such person 

18 or individual at home, work, school, or in 

19 any other community setting; or 

20 (v) services that promote health and 

21 wellness, including scheduling and taking 

22 such person or individual to health care 

23 appointments, communicating with health 

24 and allied health professionals admin25 istering medications, implementing health 


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1 and behavioral health interventions and 

2 treatment plans, monitoring and recording 

3 health status and progress; and 

4 (B) may include— 

5 (i) a service provider supporting peo6 ple with intellectual disability and develop7 mental disabilities, and other disabilities; 

8 (ii) a home and community-based 

9 services manager or direct support profes10 sional manager; 

11 (iii) a self-directed care worker; 

12 (iv) a personal care service worker; 

13 (v) a direct care worker, as defined in 

14 section 799B of the Public Health Service 

15 Act (42 U.S.C. 295p); or 

16 (vi) any other position or job related 

17 to the home care or direct care workforce, 

18 such as positions or jobs in respite care, 

19 palliative care, community support, or peer 

20 support, as determined by the Secretary, in 

21 consultation with the Centers for Medicare 

22 & Medicaid Services and the Secretary of 

23 Labor. 


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1 (4) DIRECT CARE WORKFORCE.—The term ‘‘di2 rect care workforce’’ means the broad workforce of 

3 direct care professionals. 

4 (5) FAMILY CAREGIVER.—The term ‘‘family 

5 caregiver’’ has the meaning given such term in sec6 tion 2 of the RAISE Family Caregivers Act (42 

7 U.S.C. 3030s note; Public Law 115–119) and in8 cludes paid and unpaid family caregivers. 

9 (6) ELIGIBLE ENTITY.—The term ‘‘eligible enti10 ty’’ means an entity— 

11 (A) that is— 

12 (i) a State; 

13 (ii) a labor organization, joint labor14 management organization, or employer of 

15 direct care professionals; 

16 (iii) a nonprofit entity with experience 

17 in aging, disability, or supporting the 

18 rights and interests of, training of, or edu19 cating direct care professionals or family 

20 caregivers; 

21 (iv) an Indian Tribe, Tribal organiza22 tion, or Urban Indian organization; 

23 (v) a community college or other insti24 tution of higher education; or 


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1 (vi) a consortium of entities listed in 

2 any of clauses (i) through (v); 

3 (B) that agrees to include, as applicable 

4 with respect to the type of grant the entity is 

5 seeking under this title and the activities sup6 ported through such grant, older adults, people 

7 with disabilities, direct care professionals, and 

8 family caregivers, as advisors and trainers in 

9 such activities; and 

10 (C) that agrees to consult with the State 

11 Medicaid agency of the State (or each State) 

12 served by the grant on the grant activities, to 

13 the extent that such agency (or each such agen14 cy) is not the eligible entity. 

15 (7) EMPLOYER.—The terms ‘‘employ’’ and 

16 ‘‘employer’’ have the meanings given the terms in 

17 section 3 of the Fair Labor Standards Act of 1938 

18 (29 U.S.C. 203). 

19 (8) INDIAN TRIBE; TRIBAL ORGANIZATION.— 

20 The terms ‘‘Indian Tribe’’ and ‘‘Tribal organiza21 tion’’ have the meanings given such terms in section 

22 4 of the Indian Self-Determination and Education 

23 Assistance Act (25 U.S.C. 5304). 

24 (9) INSTITUTION OF HIGHER EDUCATION.—The 

25 term ‘‘institution of higher education’’ means— 


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1 (A) an institution of higher education de2 fined in section 101 of the Higher Education 

3 Act of 1965 (20 U.S.C. 1001); or 

4 (B) an institution of higher education de5 fined in section 102(a)(1)(B) of such Act (20 

6 U.S.C. 1002(a)(1)(B)). 

7 (10) OLDER ADULT.—The term ‘‘older adult’’ 

8 means an individual who is 60 years of age or older. 

9 (11) PERSON WITH A DISABILITY.—The term 

10 ‘‘person with disability’’ means an individual with a 

11 disability, as defined in section 3 of the Americans 

12 with Disabilities Act of 1990 (42 U.S.C. 12102). 

13 (12) PROJECT PARTICIPANT.—The term 

14 ‘‘project participant’’ means an individual partici15 pating in a project or activity assisted with a grant 

16 under this title, including (as applicable for the cat17 egory of the grant) a direct care professional, or an 

18 individual training to be such a professional, or a 

19 family caregiver. 

20 (13) SECRETARY.—The term ‘‘Secretary’’ 

21 means the Secretary of Health and Human Services, 

22 acting through the Administrator for Community 

23 Living. 

24 (14) SELF-DIRECTED CARE PROFESSIONAL.— 

25 The term ‘‘self-directed care professional’’ means a 


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1 direct care professional who is employed by an indi2 vidual who is an older adult, a person with a dis3 ability, or a representative of such older adult or 

4 person with a disability, and such older adult or per5 son with a disability has the decision-making author6 ity over certain supports and services provided by 

7 the direct care professional and takes direct respon8 sibility to manage those supports and services. 

9 (15) SUPPORTIVE SERVICES.—The term ‘‘sup10 portive services’’ means services that are necessary 

11 to enable an individual to participate in activities as12 sisted with a grant under this title, such as trans13 portation, child care, dependent care, housing, work14 place accommodations, employee benefits such as 

15 paid sick leave and child care, workplace health and 

16 safety protections, wages and overtime pay, and 

17 needs-related payments. 

18 (16) URBAN INDIAN ORGANIZATION.—The term 

19 ‘‘urban Indian organization’’ has the meaning given 

20 the term in section 4 of the Indian Health Care Im21 provement Act (25 U.S.C. 1603). 

22 (17) WORKFORCE INNOVATION AND OPPOR23 TUNITY ACT TERMS.—The terms ‘‘career pathway’’, 

24 ‘‘career planning’’, ‘‘in-demand industry sector or 

25 occupation’’, ‘‘individual with a barrier to employVerDate Sep 11 2014 05:50 Mar 29, 2023 Jkt 039200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\H1493.IH H1493

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1 ment’’, ‘‘local board’’, ‘‘on-the-job training’’, ‘‘recog2 nized postsecondary credential’’, ‘‘region’’, and 

3 ‘‘State board’’ have the meanings given such terms 

4 in section 3 of the Workforce Innovation and Oppor5 tunity Act (29 U.S.C. 3102). 

6 (18) WORK-BASED LEARNING.—The term 

7 ‘‘work-based learning’’ has the meaning given the 

8 term in section 3 of the Carl D. Perkins Career and 

9 Technical Education Act of 2006 (20 U.S.C. 2302). 

10 SEC. 302. AUTHORITY TO ESTABLISH A TECHNICAL ASSIST11 ANCE CENTER FOR BUILDING THE DIRECT 

12 CARE WORKFORCE. 

13 (a) PROGRAM AUTHORIZED.—The Secretary shall es14 tablish a national technical assistance center (referred to 

15 in this section as the ‘‘Center’’) for, in consultation with 

16 the Secretary of Labor, the Secretary of Education, the 

17 Administrator of the Centers for Medicare & Medicaid 

18 Services, and the heads of other entities as necessary— 

19 (1) supporting direct care workforce creation, 

20 training and education, recruitment, retention, and 

21 advancement; and 

22 (2) supporting family caregivers and activities 

23 of family caregivers as a critical part of the support 

24 team for older adults or people with disabilities. 


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1 (b) ADVISORY COUNCIL.—The Secretary shall con2 vene an advisory council to provide recommendations to 

3 the Center with respect to the duties of the Center under 

4 this section and may engage individuals and entities de5 scribed in paragraphs (3)(B), and (12), of section 304(b) 

6 (without regard to a specific project described in such 

7 paragraphs) for service on the advisory council. 

8 (c) ACTIVITIES.—The Center may— 

9 (1) develop recommendations for training and 

10 education curricula for direct care professionals, 

11 which such recommendations may include rec12 ommendations for curricula for higher education, 

13 postsecondary credentials, and programs with com14 munity colleges; 

15 (2) develop learning and dissemination strate16 gies to— 

17 (A) engage States and other entities in ac18 tivities supported under this title and best prac19 tices; and 

20 (B) distribute findings from activities sup21 ported by grants under this title; 

22 (3) develop recommendations for training and 

23 education curricula and other strategies for sup24 porting family caregivers; 


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1 (4) explore the national data gaps, workforce 

2 shortage areas, and data collection strategies for di3 rect care professionals and make recommendations 

4 to the Director of the Office of Management and 

5 Budget for an occupation category in the Standard 

6 Occupational Classification system for direct support 

7 professionals as a healthcare support occupation; 

8 (5) recommend career development and ad9 vancement opportunities for direct care profes10 sionals, which may include occupational frameworks, 

11 national standards, recruitment campaigns, pre-ap12 prenticeship and on-the-job training opportunities, 

13 apprenticeship programs, career ladders or path14 ways, specializations or certifications, or other activi15 ties; and 

16 (6) develop strategies for assisting with report17 ing and evaluation of grant activities under section 

18 305. 

19 SEC. 303. AUTHORITY TO AWARD GRANTS. 

20 (a) GRANTS.— 

21 (1) IN GENERAL.—Not later than 12 months 

22 after the date of enactment of this title, the Sec23 retary, in consultation with the Centers for Medicare 

24 & Medicaid Services, the Secretary of Labor, and the 

25 Secretary of Education, shall award grants described 


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1 in paragraph (2) to eligible entities. A grant award2 ed under this section may be in more than 1 cat3 egory described in such paragraph. 

4 (2) CATEGORIES OF GRANTS.—The categories 

5 of grants described in this paragraph are each of the 

6 following: 

7 (A) DIRECT CARE PROFESSIONAL

8 GRANTS.—Grants to eligible entities to create 

9 and carry out projects for the purposes of re10 cruiting, retaining, or providing advancement 

11 opportunities for direct care professionals who 

12 are not described in subparagraph (B) or (C), 

13 including through education or training pro14 grams for such professionals or individuals 

15 seeking to become such professionals. 

16 (B) DIRECT CARE PROFESSIONAL MAN17 AGERS GRANTS.—Grants to eligible entities to 

18 create and carry out projects for the purposes 

19 of recruiting, retaining, or providing advance20 ment opportunities for direct care professionals 

21 who are managers or supervisory staff that 

22 have coaching, training, managerial, super23 visory, or other oversight responsibilities, in24 cluding through education or training programs 


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1 for such professionals or individuals seeking to 

2 become such professionals. 

3 (C) SELF-DIRECTED CARE PROFESSIONALS

4 GRANTS.—Grants to eligible entities to create 

5 and carry out projects for the purposes of re6 cruiting, retaining, or providing advancement 

7 opportunities for self-directed care profes8 sionals, including through education or training 

9 programs for such professionals or individuals 

10 seeking to become such professionals. 

11 (D) FAMILY CAREGIVER GRANTS.—Grants 

12 to eligible entities to create and carry out 

13 projects for providing support to paid or unpaid 

14 family caregivers through educational, training, 

15 or other resources, including resources for care16 giver self-care or educational or training re17 sources for individuals newly in a caregiving 

18 role or seeking additional support in the role of 

19 a family caregiver. 

20 (3) PROJECTS FOR ADVANCEMENT OPPORTUNI21 TIES.—Not less than 30 percent of projects assisted 

22 with grants under this title shall be projects to pro23 vide career pathways that offer opportunities for 

24 professional development and advancement opportu25 nities to direct care professionals. 


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1 (b) TREATMENT OF CONTINUATION ACTIVITIES.— 

2 An eligible entity that carries out activities described in 

3 subsection (a)(2) prior to receipt of a grant under this 

4 title may use such grant to continue carrying out such 

5 activities, and, in using such grant to continue such activi6 ties, shall be treated as an eligible entity carrying out a 

7 project through a grant under this title. 

8 SEC. 304. PROJECT PLANS. 

9 (a) IN GENERAL.—An eligible entity seeking a grant 

10 under this title shall submit to the Secretary a project plan 

11 for each project to be developed and carried out (or for 

12 activities to be continued as described in section 303(b)) 

13 with the grant at such time, in such manner, and con14 taining such information as the Secretary may require. 

15 (b) CONTENTS.—A project plan submitted by an eli16 gible entity under subsection (a) shall include a descrip17 tion of information determined relevant by the Secretary 

18 for purposes of the category of the grant and the activities 

19 to be carried out through the grant. Such information may 

20 include (as applicable) the following: 

21 (1) The demographics (as defined in section 2) 

22 of the population in the State or relevant geographic 

23 area, including a description of the populations likely 

24 to need long-term care services, such as people with 

25 disabilities and older adults. 


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1 (2) Projections of unmet need for services pro2 vided by direct care professionals based on enroll3 ment waiting lists under home and community-based 

4 waivers under section 1115 of the Social Security 

5 Act (42 U.S.C. 1315) or section 1915 of such Act 

6 (42 U.S.C. 1396n) and other relevant data to the 

7 extent practicable and feasible, such as direct care 

8 workforce vacancy rates, crude separation rates, and 

9 the number of direct care professionals, including 

10 such professionals who are managers or supervisors, 

11 in the region. 

12 (3) An advisory committee to advise the eligible 

13 entity on activities to be carried out through the 

14 grant. Such advisory committee— 

15 (A) may be comprised of entities listed in 

16 paragraph (12); and 

17 (B) shall include— 

18 (i) older adults or persons with a dis19 ability; 

20 (ii) organizations representing the 

21 rights and interests of people receiving 

22 services by the direct care professionals or 

23 family caregivers targeted by the project; 

24 (iii) individuals who are direct care 

25 professionals or family caregivers targeted 


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1 by the project and organizations rep2 resenting the rights and interests of direct 

3 care professionals or family caregivers; 

4 (iv) as applicable, employers of indi5 viduals described in clause (iii) and labor 

6 organizations representing such individ7 uals; 

8 (v) representatives of the State Med9 icaid agency, the State agency defined in 

10 section 102 of the Older Americans Act of 

11 1965 (42 U.S.C. 3002), the State develop12 mental disabilities office, and the State be13 havioral health agency, in the State (or 

14 each State) to be served by the project; 

15 and 

16 (vi) representatives reflecting diverse 

17 racial, cultural, ethnic, geographic, socio18 economic, and gender identity and sexual 

19 orientation perspectives. 

20 (4) Current or projected job openings for, or 

21 relevant labor market information related to, the di22 rect care professionals targeted by the project in the 

23 State or region to be served by the project, and the 

24 geographic scope of the workforce to be served by 

25 the project. 


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1 (5) Specific efforts and strategies that the 

2 project will undertake to reduce barriers to recruit3 ment, retention, or advancement of the direct care 

4 professionals targeted by the project, including an 

5 assurance that such efforts will include— 

6 (A) an assessment of the wages or other 

7 compensation or benefits necessary to recruit 

8 and retain the direct care professionals targeted 

9 by the project; 

10 (B) a description of the project’s projected 

11 compensation or benefits for the direct care 

12 professionals targeted by the project at the 

13 State or local level, including a comparison of 

14 such projected compensation or benefits to re15 gional and national compensation or benefits 

16 and a description of how wages and benefits re17 ceived by project participants will be impacted 

18 by the participation in and completion of the 

19 project; and 

20 (C) a description of the projected impact of 

21 workplace safety issues on the recruitment and 

22 retention of direct care professionals targeted 

23 by the project, including the availability of per24 sonal protective equipment. 


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1 (6) In the case of a project offering an edu2 cation or training program for direct care profes3 sionals, a description of such program (including 

4 how the core competencies identified by the Centers 

5 for Medicare & Medicaid Services will be incor6 porated, curricula, models, and standards used 

7 under the program, and any associated recognized 

8 postsecondary credentials for which the program 

9 provides preparation, as applicable), which shall in10 clude an assurance that such program will provide to 

11 each project participant in such program— 

12 (A) relevant training regarding the rights 

13 of recipients of home and community-based 

14 services, including their rights to— 

15 (i) receive services in integrated set16 tings that provide access to the broader 

17 community; 

18 (ii) exercise self-determination; 

19 (iii) be free from all forms of abuse, 

20 neglect, or exploitation; and 

21 (iv) person-centered planning and 

22 practices, including participation in plan23 ning activities; 

24 (B) relevant training to ensure that each 

25 project participant has the necessary skills to 


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1 recognize abuse and understand their obliga2 tions with regard to reporting and responding 

3 to abuse appropriately in accordance with rel4 evant Federal and State law; 

5 (C) relevant training regarding the provi6 sion of culturally competent and disability com7 petent supports to recipients of services pro8 vided by the direct care professionals targeted 

9 by the project; 

10 (D) an apprenticeship program, work11 based learning, or on-the-job training opportu12 nities; 

13 (E) supervision or mentoring; and 

14 (F) for any on-the-job training portion of 

15 the program, a progressively increasing, clearly 

16 defined schedule of wages to be paid to each 

17 such participant that— 

18 (i) is consistent with skill gains or at19 tainment of a recognized postsecondary 

20 credential received as a result of participa21 tion in or completion of such program; and 

22 (ii) ensures the entry wage is not less 

23 than the greater of— 

24 (I) the minimum wage required 

25 under section 6(a) of the Fair Labor 


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1 Standards Act of 1938 (29 U.S.C. 

2 206(a)); or 

3 (II) the applicable wage required 

4 by other applicable Federal or State 

5 law, or a collective bargaining agree6 ment. 

7 (7) Any other innovative models or processes 

8 the eligible entity will implement to support the re9 tention and career advancement of the direct care 

10 professionals targeted by the project. 

11 (8) The supportive services and benefits to be 

12 provided to the project participants in order to sup13 port the employment, retention, or career advance14 ment of the direct care professionals targeted by the 

15 project. 

16 (9) How the eligible entity will make use of ca17 reer planning to support the identification of ad18 vancement opportunities and career pathways for 

19 the direct care professionals in the State or region 

20 to be served by the project. 

21 (10) How the eligible entity will collect and sub22 mit to the Secretary workforce data and outcomes of 

23 the project. 

24 (11) How the project— 

25 (A) will— 


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1 (i) provide adequate and safe equip2 ment and facilities for training and super3 vision, including a safe work environment 

4 free from discrimination, which may in5 clude the provision of personal protective 

6 equipment and other necessary equipment 

7 to prevent the spread of infectious disease 

8 among the direct care professionals tar9 geted by the project and recipients of serv10 ices provided by such professionals; 

11 (ii) incorporate remote training and 

12 education opportunities or technology-sup13 ported opportunities; 

14 (iii) for training and education cur15 ricula, incorporate evidenced-supported 

16 practices for adult learners and universal 

17 design for learning and ensure recipients 

18 of services provided by the direct care pro19 fessionals or family caregivers targeted by 

20 the project participate in the development 

21 and implementation of such training and 

22 education curricula; 

23 (iv) use outreach, recruitment, and re24 tention strategies designed to reach and re25 tain a diverse workforce; 


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1 (v) incorporate methods to monitor 

2 satisfaction with project activities for 

3 project participants and individuals receiv4 ing services from such participants; 

5 (vi) incorporate evidence-supported 

6 practices for family caregiver engagement; 

7 and 

8 (vii) incorporate core competencies 

9 identified by the Centers for Medicare & 

10 Medicaid Services; and 

11 (B) may incorporate continuing education 

12 programs and specialty training, with a specific 

13 focus on— 

14 (i) trauma-informed care; 

15 (ii) behavioral health, including co-oc16 curring behavioral health conditions and 

17 intellectual or developmental disabilities; 

18 (iii) Alzheimer’s and dementia care; 

19 (iv) chronic disease management; and 

20 (v) the use of supportive or assistive 

21 technology. 

22 (12) How the eligible entity will consult on the 

23 implementation of the project, or coordinate the 

24 project with, each of the following entities, to the ex25 tent that each such entity is not the eligible entity: 


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1 (A) The State Medicaid agency, State 

2 agency defined in section 102 of the Older 

3 Americans Act of 1965 (42 U.S.C. 3002), and 

4 the State developmental disabilities office for 

5 the State (or each State) to be served by the 

6 project. 

7 (B) The local board and State board for 

8 each region, or State, to be served by the 

9 project. 

10 (C) In the case of a project that carries 

11 out an education or training program, a non12 profit organization with demonstrated experi13 ence in the development or delivery of curricula 

14 or coursework. 

15 (D) A nonprofit organization, including a 

16 labor organization, that fosters the professional 

17 development and collective engagement of the 

18 direct care professionals targeted by the project. 

19 (E) Area agencies on aging, as defined in 

20 section 102 of the Older Americans Act of 1965 

21 (42 U.S.C. 3002). 

22 (F) Centers for independent living, as de23 scribed in part C of title VII of the Rehabilita24 tion Act of 1973 (29 U.S.C. 796f et seq.). 


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1 (G) The State Council on Developmental 

2 Disabilities (as such term is used in subtitle B 

3 of title I of the Developmental Disabilities As4 sistance and Bill of Rights Act of 2000 (42 

5 U.S.C. 15021 et seq.)) for the State (or each 

6 State) to be served by the project. 

7 (H) Aging and Disability Resource Centers 

8 (as defined in section 102 of the Older Ameri9 cans Act of 1965 (42 U.S.C. 3002)). 

10 (I) A nonprofit State provider association 

11 that represents providers who employ the direct 

12 care professionals targeted by the project, 

13 where such associations exist. 

14 (J) An entity that employs the direct care 

15 professionals targeted by the project. 

16 (K) University Centers for Excellence in 

17 Developmental Disabilities Education, Re18 search, and Services supported under subtitle D 

19 of title I of the Developmental Disabilities As20 sistance and Bill of Rights Act of 2000 (42 

21 U.S.C. 15061 et seq.). 

22 (L) The State protection and advocacy sys23 tem described in section 143 of such Act (42 

24 U.S.C. 15043) of the State (or each State) to 

25 be served by the project. 


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1 (M) Direct care professionals or direct care 

2 workforce organizations representing under3 served communities, including communities of 

4 color. 

5 (13) How the eligible entity will consult 

6 throughout the project with— 

7 (A) individuals employed or working as the 

8 direct care professionals or family caregivers 

9 targeted by the project; 

10 (B) representatives of such professionals or 

11 caregivers; 

12 (C) individuals assisted by such profes13 sionals or caregivers; 

14 (D) the families of such professionals or 

15 caregivers; and 

16 (E) individuals receiving education or 

17 training to become such professionals or care18 givers. 

19 (14) Outreach efforts to individuals for partici20 pation in such project, including targeted outreach 

21 efforts to— 

22 (A) individuals who are recipients of assist23 ance under a State program funded under part 

24 A of title IV of the Social Security Act (42 


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1 U.S.C. 601 et seq.) or individuals who are eligi2 ble for such assistance; and 

3 (B) individuals with barriers to employ4 ment. 

5 (c) CONSIDERATIONS.—In selecting eligible entities 

6 to receive a grant under this title, the Secretary shall en7 sure— 

8 (1) equitable geographic diversity, including by 

9 selecting recipients serving rural areas and selecting 

10 recipients serving urban areas; and 

11 (2) that selected eligible entities will serve areas 

12 where the occupation of direct care professional, or 

13 a related occupation, is an in-demand industry sec14 tor or occupation. 

15 (d) USES OF FUNDS; SUPPLEMENT, NOT SUP16 PLANT.— 

17 (1) USES OF FUNDS.— 

18 (A) IN GENERAL.—Each eligible entity re19 ceiving a grant under this title shall use the 

20 funds of such grant to carry out at least 1 

21 project described in section 303(a)(2). 

22 (B) ADMINISTRATIVE COSTS.—Each eligi23 ble entity receiving a grant under this title shall 

24 not use more than 5 percent of the funds of 


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1 such grant for costs associated with the admin2 istration of activities under this title. 

3 (C) DIRECT SUPPORT.—Each eligible enti4 ty receiving a grant under this title shall use 

5 not less than 5 percent of the funds of such 

6 grant to provide direct financial benefits or sup7 portive services to direct care professionals and 

8 paid or unpaid family caregivers to support the 

9 financial needs of such participants during the 

10 duration of the project activities. 

11 (2) SUPPLEMENT, NOT SUPPLANT.—An eligible 

12 entity receiving a grant under this title shall use 

13 such grant only to supplement, and not supplant, 

14 the amount of funds that, in the absence of such 

15 grant, would be available to address the recruitment, 

16 training and education, retention, and advancement 

17 of direct care professionals or provide support for 

18 family caregivers, in the State or region served by 

19 the eligible entity. 

20 (3) PROHIBITION.—No amounts made available 

21 under this title may be used for any activity that is 

22 subject to the reporting requirements set forth in 

23 section 203(a) of the Labor-Management Reporting 

24 and Disclosure Act of 1959 (29 U.S.C. 433(a)). 


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1 SEC. 305. EVALUATIONS AND REPORTS; TECHNICAL ASSIST2 ANCE. 

3 (a) REPORTING REQUIREMENTS BY GRANT RECIPI4 ENTS.— 

5 (1) IN GENERAL.—An eligible entity receiving a 

6 grant under this title shall cooperate with the Sec7 retary and annually provide a report to the Sec8 retary that includes any relevant data requested by 

9 the Secretary in a manner specified by the Sec10 retary. 

11 (2) CONTENTS.—The data requested by the 

12 Secretary for an annual report may include any of 

13 the following (as determined relevant by the Sec14 retary with respect to the category of the grant and 

15 each project supported through the grant): 

16 (A) The number of individuals and the de17 mographic categories (as defined in section 2) 

18 served by each project supported by the grant, 

19 including— 

20 (i) the number of individuals recruited 

21 through each such project to be employed 

22 as a direct care professional; 

23 (ii) the number of individuals who 

24 through each such project attained employ25 ment as a direct care professional; and 


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1 (iii) the number of individuals who en2 rolled in each such project and withdrew or 

3 were terminated from each such project 

4 without completing training or attaining 

5 employment as a direct care professional. 

6 (B) The number of family caregivers par7 ticipating in an education or training program 

8 through each project supported by the grant. 

9 (C) The number of project participants 

10 who through each such project participated in 

11 and completed— 

12 (i) work-based learning; 

13 (ii) on-the-job training; 

14 (iii) an apprenticeship program; or 

15 (iv) a professional development or 

16 mentoring program. 

17 (D)(i) Other services, benefits, or supports 

18 (other than the services, benefits, or supports 

19 described in subparagraph (C)) provided 

20 through each such project to assist in the re21 cruitment, retention, or advancement of direct 

22 care professionals (including through education 

23 or training for such professionals or individuals 

24 seeking to become such professionals); 


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1 (ii) the number of individuals who accessed 

2 such services, benefits, or supports; and 

3 (iii) the impact of such services, benefits, 

4 or supports. 

5 (E) The crude separation and vacancy 

6 rates of direct care professionals, and such 

7 rates for those professionals who are managers 

8 or supervisors, in the geographic region for a 

9 number of years before the grant was awarded, 

10 as determined by the Secretary, and annually 

11 thereafter for the duration of the grant period. 

12 (F) How each project supported by the 

13 grant assessed satisfaction with respect to— 

14 (i) project participants assisted by the 

15 project; 

16 (ii) individuals receiving services deliv17 ered by project participants, including— 

18 (I) any impact on the health or 

19 health outcomes of such individuals; 

20 and 

21 (II) any impact on the ability of 

22 individuals to transition to or remain 

23 in the community in an environment 

24 that meets the criteria established in 

25 the section 441.301(c)(4) of title 42, 


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1 Code of Federal Regulations (or suc2 cessor regulations); and 

3 (iii) employers of such project partici4 pants. 

5 (G) The performance of the eligible entity 

6 with respect to the indicators of performance on 

7 unsubsidized employment, median earnings, cre8 dential attainment, measurable skill gains, and 

9 employer satisfaction. 

10 (H) Any other information with respect to 

11 outcomes of the project as determined by the 

12 Secretary. 

13 (b) ANNUAL REPORT TO CONGRESS BY SEC14 RETARY.—Not later than 2 years after the date of enact15 ment of this title, and each year thereafter until all 

16 projects supported through a grant under this title are 

17 completed, the Secretary shall prepare and submit to Con18 gress an annual report on the progress of each project 

19 supported through a grant under this title and the activi20 ties of the technical assistance center established under 

21 section 302. 

22 (c) GAO REPORT.—Not later than 1 year after the 

23 date on which all projects supported through a grant 

24 under this title are completed, the Comptroller General of 


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1 the United States shall conduct a study and submit to 

2 Congress a report including— 

3 (1) an assessment of how the technical assist4 ance center established under section 302 and the 

5 projects supported through a grant under this title 

6 assisted in the creation, recruitment, training and 

7 education, retention, and advancement of the direct 

8 care workforce or in providing support for family 

9 caregivers; and 

10 (2) recommendations for such legislative or ad11 ministrative actions needed for improving the assist12 ance described in paragraph (1), as the Comptroller 

13 General determines appropriate. 

14 (d) INDEPENDENT EVALUATIONS.—Not later than 6 

15 months after the date of enactment of this title, the Sec16 retary shall enter into a contract with an independent enti17 ty to provide independent evaluations of activities sup18 ported by grants under this title and activities of the tech19 nical assistance center established under section 302. 

20 SEC. 306. AUTHORIZATION OF APPROPRIATIONS. 

21 (a) IN GENERAL.—There are authorized to be appro22 priated— 

23 (1) for the establishment and activities of the 

24 technical assistance center under section 302, 


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1 $2,000,000 for each of fiscal years 2024 through 

2 2028; and 

3 (2) for grants under section 303, 

4 $1,000,000,000 for fiscal year 2024. 

5 (b) AVAILABILITY.—Amounts made available under 

6 this title shall remain available until September 30, 2033. 

7 TITLE IV—EVALUATION 

8 SEC. 401. EVALUATION OF IMPACT ON ACCESS TO HCBS. 

9 (a) NATIONAL SURVEY ON EXPANDED HCBS AC10 CESS.—The Administrator of the Centers for Medicare & 

11 Medicaid Services, in coordination with the National Acad12 emy of Medicine, shall, not later than 7 years after the 

13 date of enactment of this Act, conduct or contract for a 

14 national survey of States, direct care professionals, family 

15 caregivers, and providers and recipients of home and com16 munity-based services, to determine the effects of the im17 plementation of this Act and the amendments made by 

18 this Act on— 

19 (1) the availability and access to home and 

20 community-based services under the Medicaid pro21 gram nationally and in each State; 

22 (2) the capacity of the direct service workforce 

23 to provide home and community-based services and 

24 information on the demographics (as defined in sec25 tion 2) of such workforce; 


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1 (3) the compensation and working conditions, 

2 including scheduling and benefits, of direct care 

3 workers; 

4 (4) the economic effects on beneficiaries and on 

5 families with a member receiving home and commu6 nity-based services through Medicaid; 

7 (5) the availability of direct care workers and 

8 services for people needing long-term services and 

9 supports who are not Medicaid eligible; 

10 (6) family caregivers; and 

11 (7) recommendations for measures to further 

12 expand and enhance access home and community13 based services. 

14 (b) REPORT.—Not later than 9 years after the date 

15 of enactment of this Act, the Administrator of the Centers 

16 for Medicare & Medicaid Services shall publish a report 

17 containing the results of the survey conducted under sub18 section (a). 

19 (c) AMERICAN COMMUNITY SURVEY ADDITION.—The 

20 Secretary of Commerce, acting through the Bureau of the 

21 Census, shall add to the American Community Survey a 

22 question designed to identify the need for long-term serv23 ices and supports by residents of the United States. 


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1 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated to the Secretary such 

3 sums as are necessary to carry out this section. 

Æ 


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