HCBS Access Act

Subjects: Health


<html><body><pre>[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 762 Introduced in Senate (IS)]

&lt;DOC&gt;






118th CONGRESS
  1st Session
                                 S. 762

 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 SENATE OF THE UNITED STATES

                             March 9, 2023

    Mr. Casey (for himself, Ms. Hassan, Mr. Brown, Mr. Kaine, Mrs. 
Gillibrand, Mr. Blumenthal, Mr. Welch, Mr. Fetterman, Mr. Merkley, Mr. 
Sanders, Ms. Baldwin, Ms. Duckworth, Ms. Warren, Mr. Reed, Mr. Markey, 
Mrs. Shaheen, and Mrs. Murray) introduced the following bill; which was 
          read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
 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.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``HCBS Access Act''.
    (b) Table of Contents.--The table of contents of 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.

SEC. 2. DEFINITIONS.

    In this Act:
            (1) Demographics.--The term ``demographics'' means 
        information relating to the races, ethnicities, genders, sexual 
        orientations, gender identities, geographic locations, incomes, 
        primary languages, types of service setting, and disability 
        types represented within a particular group of individuals.
            (2) Private duty nursing.--The term ``private duty 
        nursing'' means nursing services that are sufficient to meet 
        the needs of an individual who requires more individualized and 
        continuous care than is available from a visiting nurse or 
        routinely provided by the nursing staff of a hospital or 
        skilled nursing facility, and includes services provided to an 
        individual in the individual's own home by a registered nurse 
        or licensed practical nurse under the direction of a physician.
            (3) Secretary.--Except as otherwise provided, the term 
        ``Secretary'' means the Secretary of Health and Human Services.

TITLE I--REQUIRING AND EXPANDING ACCESS TO HCBS COVERAGE UNDER MEDICAID

SEC. 101. PURPOSE.

     It is the purpose of this title to require coverage of home and 
community-based services (in this section referred to as ``HCBS'') 
under a State plan (or waiver of such plan) under title XIX of the 
Social Security Act (42 U.S.C. 1396 et seq.) for the following reasons:
            (1) To eliminate waiting lists for HCBS, which delay access 
        to necessary services and civil rights for people with 
        disabilities and older adults.
            (2) To build on decades of progress in serving people with 
        disabilities and older adults via HCBS.
            (3) To fulfill the purposes of the Medicaid program to 
        provide medical assistance for those whose income and resources 
        are insufficient to meet the costs of necessary medical 
        services, and to provide rehabilitation, long-term services and 
        supports, and other services to help such families and 
        individuals attain or retain capability for independence or 
        self-care.
            (4) To ensure that people with all kinds of disabilities 
        and with multiple disabilities, including intellectual 
        disability, cognitive disabilities, developmental disabilities, 
        behavioral health disabilities, physical disabilities, and 
        substance use disorders, and older adults, receive the services 
        they need to live in their communities.
            (5) To streamline access to HCBS by eliminating the need 
        for States to repeatedly apply for waivers.
            (6) To continue to increase the capacity of community 
        services to ensure people with disabilities and older adults 
        have safe and meaningful options in the community are not at 
        risk of unnecessary institutionalization.
            (7) To act on the decades of research and practice showing 
        that everyone, including people with the most severe 
        disabilities, can live in the community with the right services 
        and supports.
            (8) To support over 53,000,000 unpaid family caregivers who 
        are often providing complex services and supports to older 
        adults and people with disabilities because of a lack of 
        affordable services, workforce shortages, and other 
        inefficiencies.
            (9) To improve direct care quality and address the decades 
        long workforce barriers, which have been exacerbated by the 
        COVID-19 pandemic, for nearly 2,600,000 direct care 
        professionals providing support to people with disabilities and 
        older adults in their homes and communities.
            (10) To eliminate the race, gender, sexual orientation, and 
        gender identity disparities that exist in accessing information 
        and HCBS and to prevent the unnecessary impoverishment and 
        institutionalization of black and brown individuals with 
        disabilities and older adults.

SEC. 102. REQUIRING COVERAGE OF HOME AND COMMUNITY-BASED SERVICES UNDER 
              THE MEDICAID PROGRAM.

    (a) Definition of Home and Community-Based Services.--
            (1) In general.--Section 1905 of the Social Security Act 
        (42 U.S.C. 1396d) is amended by adding at the end the following 
        new subsection:
    ``(jj) Home and Community-Based Services.--
            ``(1) In general.--For purposes of this title, the term 
        `home and community-based services' means those services 
        specified in paragraph (2) furnished to an eligible individual 
        (as defined in paragraph (3)), based on an individualized 
        assessment (as described in paragraph (4)) of such individual, 
        in a setting that--
                    ``(A) meets the qualities specified in paragraph 
                (1) of section 441.710(a) of title 42, Code of Federal 
                Regulations (or a successor regulation);
                    ``(B) is not described in paragraph (2) of such 
                section (or successor regulation); and
                    ``(C) meets such other qualities as the Secretary 
                determines appropriate.
            ``(2) Services specified.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the services specified in this paragraph are services 
                described in any of paragraphs (7), (8), (13)(C), (19), 
                (20), (24), and (29) (as applied without regard to the 
                reference to `September 30, 2025') of subsection (a) or 
                in any of subsections (c)(4)(B), (c)(5), (k)(1)(A), 
                (k)(1)(B), or (k)(1)(D) of section 1915, including the 
                following:
                            ``(i) Supported employment and integrated 
                        day services.
                            ``(ii) Personal assistance, including 
                        personal care attendants, direct support 
                        professionals, home health aides, private duty 
                        nursing, homemakers and chore assistance, and 
                        companionship services.
                            ``(iii) Services that enhance independence, 
                        inclusion, and full participation in the 
                        broader community.
                            ``(iv) Non-emergency, non-medical 
                        transportation services to facilitate community 
                        integration.
                            ``(v) Respite services provided in the 
                        individual's home or broader community.
                            ``(vi) Caregiver and family support 
                        services.
                            ``(vii) Case management, including 
                        intensive case management, fiscal intermediary, 
                        and support brokerage services.
                            ``(viii) Services which support person-
                        centered planning and self-direction.
                            ``(ix) Direct support services during acute 
                        hospitalizations.
                            ``(x) Necessary medical and nursing 
                        services not otherwise covered which are 
                        necessary in order for the individual to remain 
                        in their home and community, including hospice 
                        services.
                            ``(xi) Home and community-based intensive 
                        behavioral health and crisis intervention 
                        services.
                            ``(xii) Peer support services.
                            ``(xiii) Housing support, including 
                        transitional housing or transitional support 
                        services for individuals who are unhoused, and 
                        wrap-around services.
                            ``(xiv) Necessary home modifications and 
                        assistive technology, including those which 
                        substitute for human assistance.
                            ``(xv) Transition services to support an 
                        individual who is transitioning from an 
                        institutional setting to the community, 
                        including appropriate services for individuals 
                        who are unhoused or at risk of becoming 
                        unhoused, and including such transition 
                        services provided while the individual resides 
                        in an institution.
                            ``(xvi) Any other service recommended by 
                        the panel convened pursuant to subparagraph 
                        (B).
                    ``(B) Specification of recommended services.--
                            ``(i) In general.--Not later than 6 months 
                        after the date of the enactment of this 
                        subparagraph, and not less frequently than once 
                        every 5 years thereafter, the Secretary shall 
                        convene an advisory panel (in this subparagraph 
                        referred to as the `panel') for purposes of 
                        recommending additional services which shall be 
                        included as home and community-based services 
                        under this paragraph.
                            ``(ii) Composition.--
                                    ``(I) Selection.--The panel shall 
                                be composed of at least one 
                                representative (to be selected by the 
                                Secretary) from each of the following:
                                            ``(aa) Individuals with 
                                        disabilities receiving home and 
                                        community-based services under 
                                        this title and individuals with 
                                        disabilities in need of such 
                                        services, including those with 
                                        physical disabilities, 
                                        behavioral health disabilities, 
                                        or intellectual or 
                                        developmental disabilities, and 
                                        including older adults.
                                            ``(bb) Beneficiary-led 
                                        disability rights 
                                        organizations.
                                            ``(cc) Disability-led 
                                        organizations.
                                            ``(dd) Disabled veterans 
                                        organizations.
                                            ``(ee) Disability 
                                        organizations representing 
                                        families.
                                            ``(ff) Community-based 
                                        provider organizations.
                                            ``(gg) Organizations 
                                        serving older adults.
                                            ``(hh) The Protection and 
                                        Advocacy system, the Centers 
                                        for Independent Living.
                                            ``(ii) Health care 
                                        providers.
                                            ``(jj) The National 
                                        Association of Medicaid 
                                        Directors.
                                            ``(kk) The National 
                                        Association of State Directors 
                                        of Developmental Disabilities 
                                        Services.
                                            ``(ll) The National 
                                        Association of State Mental 
                                        Health Program Directors.
                                            ``(mm) ADvancing States.
                                            ``(nn) The Centers for 
                                        Medicare & Medicaid Services.
                                            ``(oo) The Administration 
                                        for Community Living of the 
                                        Department of Health and Human 
                                        Services.
                                            ``(pp) Other relevant 
                                        local, State, and Federal home 
                                        and community-based service 
                                        systems, as determined by the 
                                        Secretary.
                                    ``(II) Requirement for equal 
                                representation.--The Secretary shall 
                                select an equal number of 
                                representatives from each category 
                                described in items (aa) through (oo) 
                                subclause (I) in convening the panel.
                            ``(iii) Duties.--Not later than 6 months 
                        after a panel is convened under clause (i), the 
                        panel shall submit to the Secretary and to 
                        Congress a report recommending additional 
                        services which shall be included as home and 
                        community-based services under this paragraph. 
                        Such recommended services shall be so specified 
                        with the goal of increasing community 
                        integration and self-determination for 
                        individuals with disabilities receiving such 
                        services.
                            ``(iv) Implementation of recommended 
                        services.--
                                    ``(I) In general.--Services 
                                recommended by the panel in a report 
                                submitted under clause (iii) shall be 
                                treated as services described in 
                                subparagraph (A)(xvi) for calendar 
                                quarters beginning on or after the date 
                                that is 1 year after the date of such 
                                submission.
                                    ``(II) Notification.--Not later 
                                than 1 year after the first report is 
                                submitted under clause (iii), and not 
                                later than 1 year after the submission 
                                of each subsequent such report, the 
                                Secretary shall notify States of any 
                                additions or removals of home and 
                                community-based services based on 
                                services recommended under such report 
                                through State Medicaid Director 
                                letters.
            ``(3) Eligible individual.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the term `eligible individual' means--
                            ``(i) an individual who is determined, on 
                        an annual basis or on a longer basis specified 
                        by the State, by a health care provider 
                        approved by the State under a process described 
                        in subparagraph (C) to have a functional 
                        impairment (as defined in subparagraph (B)) 
                        (not taking into account any items or services, 
                        or any other ameliorative measures, furnished 
                        to such individual to mitigate such impairment) 
                        that is expected to last at least 90 days;
                            ``(ii) during the period that ends on the 
                        day before the first day of the first calendar 
                        quarter beginning on or after the date that is 
                        5 years after the date of the enactment of this 
                        subsection, an individual who, as of such date 
                        of enactment, is receiving or has been 
                        determined to be eligible for, home and 
                        community-based services under this title under 
                        a waiver or State plan option in effect under 
                        section 1915 or 1115, provided that the 
                        individual continues to meet any level of care 
                        requirement applicable under such waiver or 
                        plan option; or
                            ``(iii) an individual who is eligible under 
                        the State plan or waiver and is under the age 
                        of 21.
                    ``(B) Functional impairment.--For purposes of 
                subparagraph (A), the term `functional impairment' 
                means, with respect to an individual the inability of 
                such individual to perform, without assistance--
                            ``(i) 2 or more activities of daily living 
                        (as described in section 7702B(c)(2)(B) of the 
                        Internal Revenue Code of 1986);
                            ``(ii) 2 or more instrumental activities of 
                        daily living (as defined for purposes of 
                        section 1915(k)(1)(A)); or
                            ``(iii) 1 activity of daily living (as so 
                        described) and 1 instrumental activity of daily 
                        living (as so defined).
                    ``(C) Health care provider state approval.--For 
                purposes of subparagraph (A)(i), a process described in 
                this subparagraph is a process established by the State 
                to approve health care providers to make determinations 
                described in such subparagraph that meets such 
                standards as the Secretary may prescribe.
            ``(4) Individualized assessment.--
                    ``(A) In general.--For purposes of paragraph (1), 
                an individualized assessment described in this 
                paragraph is an independent assessment, with respect to 
                an eligible individual--
                            ``(i) to determine a necessary level of 
                        services and supports to be provided, 
                        consistent with an individual's functional 
                        impairments, to facilitate an individual's 
                        community integration, self-determination, and 
                        well-being;
                            ``(ii) to prevent the provision of 
                        unnecessary or inappropriate care;
                            ``(iii) to establish a person-centered care 
                        plan (as described in subparagraph (C)) for the 
                        individual;
                            ``(iv) that includes each of the elements 
                        described in clauses (ii) through (v) of 
                        section 1915(i)(1)(F); and
                            ``(v) that occurs not later than 30 days 
                        after such individual is determined to be an 
                        eligible individual.
                    ``(B) Presumption.--The assessment described in 
                subparagraph (A) shall be conducted with the 
                presumption--
                            ``(i) that each eligible individual, 
                        regardless of type or level of disability or 
                        service need, can be served in the individual's 
                        own home and community; and
                            ``(ii) at the option of the individual, 
                        that services may be self-directed (as defined 
                        in section 1915(i)(1)(G)(iii)(II)).
                    ``(C) Person-centered care plan.--For purposes of 
                subparagraph (A)(iii), a person-centered care plan 
                described in this subparagraph is a written plan with 
                respect to an individual that meets the requirements of 
                section 1915(i)(1)(G)(ii).
                    ``(D) Standards.--An individualized assessment 
                described in subparagraph (A) shall be conducted in 
                accordance with standards specified by the Secretary, 
                in consultation with the Administration for Community 
                Living, that--
                            ``(i) safeguard against conflicts of 
                        interest;
                            ``(ii) specify qualifications for who may 
                        perform such assessments;
                            ``(iii) ensure transparency in the 
                        furnishing of such assessments, including 
                        ensuring the provision of the results of such 
                        assessments that includes information in plain 
                        language necessary to interpret the methodology 
                        and results of such assessments;
                            ``(iv) ensure that the methodologies used 
                        in such assessments are sound and evidence-
                        based; and
                            ``(v) require such methodologies to be made 
                        available on the public website of the State 
                        and tested for reliability and validity by an 
                        independent evaluator.''.
            (2) Inclusion as medical assistance.--Section 1905(a) of 
        the Social Security Act (42 U.S.C. 1396d(a)) is amended--
                    (A) in paragraph (30), by striking ``; and'' and 
                inserting a semicolon;
                    (B) by redesignating paragraph (31) as paragraph 
                (32); and
                    (C) by inserting after paragraph (30) the following 
                new paragraph:
            ``(31) home and community-based services (as defined in 
        subsection (jj)); and''.
    (b) Mandatory Benefit.--
            (1) In general.--Section 1902(a)(10)(A) of the Social 
        Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking 
        ``and (30)'' and inserting ``(30), and (31)''.
            (2) Effective date.--The amendment made by this subsection 
        shall take effect on the first day of the first calendar 
        quarter that begins on or after the date that is 5 years after 
        the date of enactment of this Act.
    (c) Ensuring Coverage of HCBS for All Medicaid-Eligible 
Individuals.--Section 1902(a)(10)(D) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(A)) is amended--
            (1) by inserting ``(i)'' after ``(D)'';
            (2) by adding ``and'' after the semicolon; and
            (3) by adding at the end the following new clause:
            ``(ii) beginning on the first day of the first calendar 
        quarter that begins on or after the date that is 5 years after 
        the date of enactment of this clause (or at such earlier date 
        as the State may elect) for the inclusion of home and 
        community-based services (as defined in section 1905(jj)) for 
        any individual who--
                    ``(I) is eligible for medical assistance under the 
                State plan (or waiver of such plan);
                    ``(II) is an eligible individual (as defined in 
                such section); and
                    ``(III) elects to receive such services.''.
    (d) Federal Medical Assistance Percentage for Home and Community-
Based Services.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by subsection (a), is further amended--
            (1) in subsection (b), by striking ``and (ii)'' and 
        inserting ``(ii), and (kk)''; and
            (2) by adding at the end the following new subsection:
    ``(kk) Specified FMAP for Home and Community-Based Services.--
            ``(1) In general.--Notwithstanding any other provision of 
        law and except as provided in paragraph (3), the Federal 
        medical assistance percentage for amounts expended for medical 
        assistance for home and community-based services (as defined in 
        subsection (jj)), including any such services furnished under a 
        waiver in effect under section 1915, on or after the date of 
        the enactment of this subsection shall be equal to 100 percent.
            ``(2) Access to essential hcbs.--As a condition of 
        receiving the Federal medical assistance percentage described 
        in paragraph (1), a State shall enhance, expand, or strengthen 
        the level of home and community-based services offered under 
        the State plan under this title (or a waiver of such a plan) as 
        of the date of enactment of this subsection by doing all of the 
        following:
                    ``(A) Addressing access barriers and disparities in 
                access or utilization identified in the State HCBS 
                implementation plan.
                    ``(B) Using `no wrong door' programs, providing 
                presumptive eligibility for home and community-based 
                services, and improving home and community-based 
                services counseling and education programs.
                    ``(C) Providing supports to family caregivers, 
                which shall include providing respite care, and may 
                include providing such services as caregiver 
                assessments, peer supports, access to assistive 
                technology, or paid family caregiving.
                    ``(D) Adopting processes to ensure that payments 
                for home and community-based services are sufficient to 
                ensure that such services are available to eligible 
                beneficiaries.
            ``(3) Exception.--The Federal medical assistance percentage 
        applicable to medical assistance for home and community-based 
        services furnished to an individual who is only eligible for 
        medical assistance under a State plan or waiver on the basis of 
        section 1902(a)(10)(A)(ii)(XXIV) shall be determined without 
        regard to this subsection.''.
    (e) Sunset of HCBS Waivers.--Section 1915 of the Social Security 
Act (42 U.S.C. 1396n) is amended by adding at the end the following new 
subsection:
    ``(m) Sunset of Provisions Relating to Home and Community-Based 
Services.--
            ``(1) In general.--Except as provided in paragraph (2), the 
        preceding provisions of this section, insofar as such 
        provisions relate to a waiver for home and community-based 
        services, shall not apply beginning with the first calendar 
        quarter beginning on or after the date that is 5 years after 
        the date of the enactment of this subsection.
            ``(2) Exception.--The Secretary may waive the application 
        of paragraph (1) for a calendar quarter and a State if the 
        State requests such a waiver and the Secretary determines that 
        such a waiver is appropriate.''.
    (f) Conforming Amendments.--
            (1) In general.--Title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.) is amended--
                    (A) in section 1905(a), in the matter preceding the 
                first numbered paragraph--
                            (i) in clause (xv), by striking the comma 
                        at the end and inserting ``, or'';
                            (ii) in clause (xvi)--
                                    (I) by moving the left margin 2 ems 
                                to the left; and
                                    (II) by striking ``, or'' and 
                                inserting a comma; and
                            (iii) by striking clause (xvii); and
                    (B) in section 1943(b)(5), by striking ``the 
                State'' and all that follows through the period at the 
                end and inserting ``a determination be conducted on an 
                annual basis (or on such longer basis as specified by 
                the State) in accordance with section 1905(jj) for 
                purposes of providing home and community-based services 
                under the State plan (or waiver of such plan).''.
            (2) Effective date.--
                    (A) In general.--Except as provided in subparagraph 
                (B), the amendments made by this subsection shall take 
                effect on the first day of the first calendar quarter 
                that begins on or after the date that is 5 years after 
                the date of enactment of this Act.
                    (B) Exception for states authorized to continue 
                operating hcbs waivers.--In the case of a State for 
                which the Secretary has waived the application of 
                paragraph (1) of subsection (m) of section 1915 of the 
                Social Security Act (42 U.S.C. 1396n), as added by 
                subsection (e), in accordance with paragraph (2) of 
                such subsection (m), clause (xvii) of section 1905(a) 
                of the Social Security Act shall continue to have 
                effect with respect to such State for so long as 
                paragraph (1) of such subsection (m) does not apply to 
                such State.

SEC. 103. MEDICAID ELIGIBILITY MODIFICATIONS.

    Section 1902(a)(10) of the Social Security Act (42 U.S.C. 
1396a(a)(10)) is amended--
            (1) in subparagraph (A)(i)--
                    (A) in subclause (VIII), by striking ``; or'' and 
                inserting a semicolon;
                    (B) in subclause (IX)(dd), by striking the 
                semicolon at the end and inserting ``; or''; and
                    (C) by inserting after subclause (IX) the following 
                new subclause:
                                    ``(X) beginning with the first 
                                calendar quarter that begins on or 
                                after the date that is 5 years after 
                                the date of enactment of this subclause 
                                (or such earlier date as the State may 
                                elect), who are eligible individuals 
                                described in subsection (jj)(3)(A) and 
                                are not described in a previous 
                                subclause of this clause and whose 
                                income does not exceed the greater of--
                                            ``(aa) 150 percent of the 
                                        poverty line (as defined in 
                                        section 2110(c)(5)) applicable 
                                        to a family of the size 
                                        involved; and
                                            ``(bb) 300 percent of the 
                                        supplemental security income 
                                        benefit rate established by 
                                        section 1611(b)(1);''; and
            (2) in subparagraph (A)(ii)--
                    (A) in subclause (XXII), by striking ``; or'' and 
                inserting a semicolon;
                    (B) in subclause (XXIII), by striking the semicolon 
                at the end and inserting ``; or''; and
                    (C) by adding at the end the following new 
                subclause:
                                    ``(XXIV) who are eligible 
                                individuals who would be described in 
                                clause (i)(X) but for the fact that 
                                their income exceeds the income levels 
                                established under such clause but is 
                                less than such income level as the 
                                State may establish for purposes of 
                                this subclause;''.

SEC. 104. HOME AND COMMUNITY-BASED SERVICES IMPLEMENTATION PLAN GRANT 
              PROGRAM.

    (a) In General.--Not later than 1 year after the date of the 
enactment of this Act, the Secretary shall award to each State a grant 
for purposes of enabling such State to implement the requirement to 
provide home and community-based services under title XIX of the Social 
Security Act (42 U.S.C. 1396 et seq.).
    (b) Use of Funds.--A grant awarded under subsection (a) shall be 
used by a State to develop an implementation plan described in 
subsection (c) to be submitted to the Secretary for approval.
    (c) Implementation Plan.--An implementation plan described in this 
subsection is a plan developed by a State that includes the following:
            (1) An explanation of how the State will operationalize the 
        definition of an eligible individual under section 1905(jj) of 
        the Social Security Act, including the process for 
        determinations specified in paragraph (3)(A)(i) of such 
        section.
            (2) A description of the State's plan to ensure a stable 
        and high quality workforce and how the State plans to ensure a 
        living wage for individuals furnishing home and community-based 
        services and identify and address any additional workforce 
        issues.
            (3) A list of any home and community-based services 
        provided under the State Medicaid plan (including any waiver of 
        such plan) as of the date of enactment of this Act, including a 
        breakdown of use of such services by demographics (as defined 
        in section 2), compared to such services that are required 
        under the amendments made by section 102, and a description of 
        numerical goals to increase access to such services that have 
        barriers to access for populations in need of such services.
            (4) A description of how the State will incorporate 
        existing State disability agencies into the new unified 
        provision of home and community-based services and how such 
        State will ensure that such services address all functional 
        impairments.
            (5) An explanation of how the State will ensure access to 
        such services.
            (6) A plan for carrying out outreach and education 
        activities with respect to the availability of such services 
        through Aging and Disability Resource Centers and other similar 
        entities (such as entities receiving funds from the 
        Administration for Community Living or the Substance Abuse and 
        Mental Health Services Administration), including a program 
        that ensures that an individual is not denied such services 
        based on the fact that the individual contacts the wrong entity 
        (commonly referred to as a ``No Wrong Door Program'').
            (7) A plan for how such services will be coordinated with 
        other relevant State agencies, such as housing, transportation, 
        child welfare, food and income security, and employment 
        agencies.
            (8) A description of how the State will build capacity 
        prior to the implementation of the requirement described in 
        subsection (a) to ensure that such services are available to 
        every eligible individual under the Medicaid program and how 
        the State will ensure that such services are provided in a 
        setting that meets the requirements specified in paragraph (1) 
        of section 1905(jj) of the Social Security Act, as added by 
        section 102.
            (9) In the case of a State that utilizes an alternative 
        benefit plan, a description of how the State will ensure that 
        all individuals who are eligible individuals (as defined in 
        such section) are appropriately identified as medically frail 
        and exempted from such plan.
            (10) How the State will coordinate eligibility for such 
        services with other disability eligibility programs, such as 
        disability buy-in programs.
            (11) Data and milestone requirements to ensure community 
        integration, including such requirements with respect to 
        utilization of such services by demographics (as defined in 
        section 2).
    (d) State Plan Requirement.--Section 1902(a) of the Social Security 
Act (42 U.S.C. 1396a(a)) is amended--
            (1) in paragraph (86), by striking ``and'' at the end;
            (2) in paragraph (87), by striking the period at the end 
        and inserting ``; and''; and
            (3) by adding at the end the following new paragraph:
            ``(88) provide for the submission to the Secretary of an 
        implementation plan described in section 104(c) of the HCBS 
        Access Act for approval by the Secretary prior to the beginning 
        of the first calendar quarter beginning on or after the date 
        that is 5 years after the date of the enactment of this 
        paragraph.''.
    (e) Authorization of Appropriations.--There is authorized to be 
appropriated to the Secretary such sums as are necessary to carry out 
this section.
    (f) Definitions.--In subsections (a) through (c):
            (1) Home and community-based services.--The term ``home and 
        community-based services'' has the meaning given such term in 
        subsection (jj) of section 1905 of the Social Security Act (42 
        U.S.C. 1396d), as added by section 102.
            (2) State.--The term ``State'' has the meaning given that 
        term in section 1101(1) of the Social Security Act (42 U.S.C. 
        1301(1)) for purposes of title XIX of such Act (42 U.S.C. 1396 
        et seq.).

SEC. 105. QUALITY OF SERVICES.

    (a) In General.--
            (1) Development of metrics.--Not later than 1 year after 
        the date of enactment of this Act, the Director of the Agency 
        for Healthcare Research and Quality, in consultation with State 
        Medicaid Directors, shall develop standardized, State-level 
        metrics of access to, and satisfaction with, providers, 
        including primary care and specialist providers, with respect 
        to individuals who are enrolled in State Medicaid plans under 
        title XIX of the Social Security Act, broken down by 
        demographics (as defined in section 2) and any other category 
        determined by the Secretary. Such metrics shall include metrics 
        on the total number of individuals enrolled in the State plan 
        or under a waiver of the plan during a fiscal year that 
        required the level of care provided in a nursing facility, 
        intermediate care facility for individuals with intellectual 
        disability, institution for mental disease, or other similarly 
        restrictive or institutional setting.
            (2) Process.--The Director of the Agency for Healthcare 
        Research and Quality shall develop the metrics described in 
        paragraph (1) through a public process, which shall provide 
        opportunities for stakeholders to participate.
    (b) Updating Metrics.--The Director of the Agency for Healthcare 
Research and Quality, in consultation with the Deputy Administrator for 
the Center for Medicaid and CHIP Services and State Medicaid Directors, 
shall update the metrics developed under subsection (a) not less than 
once every 3 years.
    (c) State Implementation Funding.--The Director of the Agency for 
Healthcare Research and Quality may award funds, from the amount 
appropriated under subsection (d), to States for the purpose of 
implementing the metrics developed under this section.
    (d) Appropriation.--There is appropriated to the Director of the 
Agency for Healthcare Research and Quality, out of any funds in the 
Treasury not otherwise appropriated, $200,000,000 for fiscal year 2024, 
to remain available until expended, for the purpose of carrying out 
this section.

SEC. 106. REPORTS; TECHNICAL ASSISTANCE; OTHER ADMINISTRATIVE 
              REQUIREMENTS.

    (a) Reports.--The Secretary shall submit to the Committee on Energy 
and Commerce of the House of Representatives, the Committee on 
Education and Labor of the House of Representatives, the Committee on 
Finance of the Senate, the Committee on Health, Education, Labor and 
Pensions of the Senate, and the Special Committee on Aging of the 
Senate the following reports relating to the HCBS implementation plan 
grant program established under section 104:
            (1) Interim report.--Not later than 2 years after the date 
        of enactment of this Act, a report that describes--
                    (A) State efforts to develop their HCBS 
                implementation plans; and
                    (B) the funds awarded to States.
            (2) First implementation report.--Not later than 4 years 
        after the date of enactment of this Act, a report that includes 
        the following:
                    (A) A description of the HCBS implementation plans 
                approved by the Secretary under section 104.
                    (B) A description of the national landscape with 
                respect to gaps in coverage of home and community-based 
                services, disparities in access to, and utilization of, 
                such services, and barriers to accessing such services.
                    (C) A description of the national landscape with 
                respect to the direct care workforce that provides home 
                and community-based services, including with respect to 
                compensation, benefits, and challenges to the 
                availability of such workers.
            (3) Subsequent reports.--Not later than 7 years after the 
        date of enactment of this Act, and every 3 years thereafter, a 
        report that includes the following:
                    (A) The number of HCBS program improvement States 
                and the funds awarded to States to develop their plans.
                    (B) A summary of the progress being made by such 
                States with respect to strengthening and expanding 
                access to home and community-based services and the 
                direct care workforce that provides such services and 
                meeting the benchmarks for demonstrating improvements 
                required under section 1905(jj)(5) of the Social 
                Security Act (as added by section 102).
                    (C) A summary of outcomes related to home and 
                community-based services core quality measures and 
                beneficiary and family caregiver surveys.
                    (D) A summary of the challenges and best practices 
                reported by States in expanding access to home and 
                community-based services and supporting and expanding 
                the direct care workforce that provides such services.
    (b) Technical Assistance; Guidance; Regulations.--The Secretary 
shall provide HCBS program improvement States with technical assistance 
related to carrying out the HCBS implementation plans approved by the 
Secretary under section 104 and meeting the requirements and benchmarks 
for demonstrating improvements required under section 1905(jj) of the 
Social Security Act (as added by section 102) and shall issue such 
guidance or regulations as necessary to carry out this title and the 
amendments made by this title, including guidance specifying how States 
shall assess and track the availability of home and community-based 
services over time.
    (c) Recommendations To Guide HCBS Implementation.--
            (1) In general.--Not later than 18 months after the date of 
        enactment of this Act, the Secretary shall coordinate with the 
        Secretary of Labor and the Administrator of the Centers for 
        Medicare & Medicaid Services for purposes of issuing 
        recommendations for the Federal Government and for States to 
        strengthen the direct care workforce that provides home and 
        community-based services, including with respect to how the 
        Federal Government should classify the direct care workforce, 
        how such Administrator and State Medicaid programs can enforce 
        and support the provision of competitive wages and benefits 
        across the direct care workforce, including for workers with 
        particular skills or expertise, and how State Medicaid programs 
        can support training opportunities and other related efforts 
        that support the provision of quality home and community-based 
        services care.
            (2) Stakeholder consultation.--
                    (A) In general.--In developing the recommendations 
                required under paragraph (1), the Secretary shall 
                ensure that such recommendations are informed by 
                consultation with recipients of home and community-
                based services, family caregivers of such recipients, 
                providers, health plans, direct care workers, chosen 
                representatives of direct care workers, and aging, 
                disability, and workforce advocates.
                    (B) Consultation with current and potential hcbs 
                beneficiaries and family caregivers.--As part of the 
                process of developing recommendations under 
                subparagraph (A), the Secretary shall--
                            (i) hold at least 1 meeting for the purpose 
                        of developing such recommendations that is 
                        solely with current and potential recipients of 
                        home and community-based services and family 
                        caregivers of such recipients; and
                            (ii) seek to achieve parity in terms of the 
                        level of participation in the development of 
                        such recommendations between--
                                    (I) current and potential 
                                recipients of home and community-based 
                                services and family caregivers of such 
                                recipients; and
                                    (II) other categories of 
                                stakeholder described in subparagraph 
                                (A).
    (d) Funding.--Out of any funds in the Treasury not otherwise 
appropriated, there is appropriated to the Secretary for purposes of 
carrying out this section, $10,000,000 for fiscal year 2024, to remain 
available until expended.

SEC. 107. QUALITY MEASUREMENT AND IMPROVEMENT.

    (a) Development and Publication of Core and Supplemental Sets of 
HCBS Quality Measures.--
            (1) In general.--The Secretary shall identify and publish a 
        core set and supplemental set of home and community-based 
        services quality measures for use by State Medicaid programs, 
        health plans and managed care entities that enter into 
        contracts with such programs, and providers of items and 
        services under such programs.
            (2) Regular reviews and updates.--The Secretary shall 
        review and update the core set and supplemental set of home and 
        community-based services quality measures published under 
        paragraph (1) not less frequently than once every year.
            (3) Requirements.--
                    (A) Interagency collaboration; stakeholder input.--
                In developing the core set and supplemental set of home 
                and community-based services quality measures under 
                paragraph (1), and subsequently reviewing and updating 
                such core and supplemental sets, the Secretary shall--
                            (i) collaborate with the Administrator of 
                        the Centers for Medicare & Medicaid Services, 
                        the Administrator of the Administration for 
                        Community Living, the Director of the Agency 
                        for Healthcare Research and Quality, and the 
                        Administrator of the Substance Abuse and Mental 
                        Health Services Administration; and
                            (ii) ensure that such core and supplemental 
                        sets are informed by input from stakeholders, 
                        including recipients of home and community-
                        based services, family caregivers of such 
                        recipients, providers, health plans, direct 
                        care workers, chosen representatives of direct 
                        care workers, and aging, disability, and 
                        workforce advocates, with the goal that at 
                        least half of such input is from current and 
                        potential recipients of home and community-
                        based services and family caregivers.
                    (B) Reflective of full array of services.--Such 
                core set and supplemental set of home and community-
                based services quality measures shall--
                            (i) reflect the full array of home and 
                        community-based services and recipients of such 
                        services, including adults and children; and
                            (ii) include--
                                    (I) outcomes-based measures;
                                    (II) measures of availability of 
                                services;
                                    (III) measures of provider capacity 
                                and availability;
                                    (IV) measures related to person-
                                centered care;
                                    (V) measures specific to self-
                                directed care;
                                    (VI) measures related to 
                                transitions to and from institutional 
                                care; and
                                    (VII) beneficiary and family 
                                caregiver surveys.
                    (C) Demographics.--Such core set and supplemental 
                set of home and community-based services quality 
                measures shall allow for the collection of data that is 
                disaggregated by demographics (as defined in section 2 
                but including any additional category determined by the 
                Secretary).
            (4) Funding.--Out of any funds in the Treasury not 
        otherwise appropriated, there is appropriated to the Secretary 
        for purposes of carrying out this subsection, $10,000,000 for 
        fiscal year 2024, to remain available until expended.
    (b) State Adoption and Reports.--
            (1) In general.--Not later than 2 years after the date on 
        which the Secretary publishes the core set and supplemental set 
        of home and community-based services quality measures under 
        subsection (a)(1), and annually thereafter, each State Medicaid 
        program shall use such core and supplemental sets (or an 
        alternative set of quality measures approved by the Secretary) 
        to report information to the Secretary regarding the quality of 
        home and community-based services provided under such program.
            (2) Process.--The information required under paragraph (1) 
        shall be reported using a standardized format and procedures 
        established by the Secretary. Such procedures shall allow a 
        State Medicaid program to report such information separately or 
        as part of the annual reports required under sections 1139A(c) 
        and 1139B(d) of the Social Security Act (42 U.S.C. 1320b-9a, 
        1320b-9b).
            (3) Publication of quality measures.--Each State Medicaid 
        program shall annually make the information reported to the 
        Secretary under paragraph (1) available to the public.
            (4) Increased federal matching rate for adoption and 
        reporting.--Section 1903(a)(3) of the Social Security Act (42 
        U.S.C. 1396b(a)(3)) is amended--
                    (A) in subparagraph (F)(ii), by striking ``plus'' 
                after the semicolon and inserting ``and''; and
                    (B) by inserting after subparagraph (F), the 
                following:
                    ``(G) 80 percent of so much of the sums expended 
                during such quarter as are attributable to the 
                reporting of information regarding the quality of home 
                and community-based services in accordance with section 
                107(b) of the HCBS Access Act; and''.

SEC. 108. MAKING PERMANENT THE STATE OPTION TO EXTEND PROTECTION UNDER 
              MEDICAID FOR RECIPIENTS OF HOME AND COMMUNITY-BASED 
              SERVICES AGAINST SPOUSAL IMPOVERISHMENT.

    (a) In General.--Section 1924(h)(1)(A) of the Social Security Act 
(42 U.S.C. 1396r-5(h)(1)(A)) is amended by striking ``is described in 
section 1902(a)(10)(A)(ii)(VI)'' and inserting the following: ``is an 
eligible individual (as defined in section 1905(jj)(3))''.
    (b) Conforming Amendment.--Section 2404 of the Patient Protection 
and Affordable Care Act (42 U.S.C. 1396r-5 note) is amended by striking 
``September 30, 2027'' and inserting ``the date of enactment of the 
HCBS Access Act''.

SEC. 109. PERMANENT EXTENSION OF MONEY FOLLOWS THE PERSON REBALANCING 
              DEMONSTRATION.

    Subparagraph (L) of section 6071(h)(1) of the Deficit Reduction Act 
of 2005 (42 U.S.C. 1396a note) is amended by striking ``each of fiscal 
years 2024 through 2027'' and inserting ``each fiscal year after 
2023''.

     TITLE II--RECOGNIZING THE ROLE OF DIRECT SUPPORT PROFESSIONALS

SEC. 201. FINDINGS.

    Congress finds the following:
            (1) Direct support professionals play a critical role in 
        the care provided to children and adults with intellectual and 
        developmental disabilities.
            (2) Providers of home and community-based services are 
        experiencing difficulty hiring and retaining direct support 
        professionals, with a national turnover rate of 45 percent as 
        identified in a 2016 study by the National Core Indicators.
            (3) High turnover rates can lead to instability for 
        individuals receiving services, and this may result in 
        individuals not receiving enough personalized care to help them 
        reach their goals for independent living.
            (4) A discrete occupational category for direct support 
        professionals will help States and the Federal Government--
                    (A) better interpret the shortage in the labor 
                market of direct support professionals; and
                    (B) collect data on the high turnover rate of 
                direct support professionals.
            (5) The Standard Occupational Classification system is 
        designed and maintained solely for statistical purposes, and is 
        used by Federal statistical agencies to classify workers and 
        jobs into occupational categories for the purpose of 
        collecting, calculating, analyzing, or disseminating data.
            (6) Occupations in the Standard Occupational Classification 
        system are classified based on work performed and, in some 
        cases, on the skills, education, or training needed to perform 
        the work.
            (7) Establishing a discrete occupational category for 
        direct support professionals will--
                    (A) correct an inaccurate representation in the 
                Standard Occupational Classification system;
                    (B) recognize these professionals for the critical 
                and often times overlooked work that they perform for 
                the disabled community, which work is different than 
                the work of a home health aide or a personal care aide; 
                and
                    (C) better align the Standard Occupational 
                Classification system with related classification 
                systems.

SEC. 202. DEFINITION OF DIRECT SUPPORT PROFESSIONAL.

    In this title, the term ``direct support professional'' means an 
individual who, in exchange for compensation, provides services to an 
individual with a disability (as defined in section 3 of the Americans 
with Disabilities Act of 1990 (42 U.S.C. 12102)), including--
            (1) services that enhance independence and community 
        inclusion for such individual, including traveling with such 
        individual, attending and assisting such individual while 
        visiting friends and family, shopping, or socializing;
            (2) services such as coaching and supporting such 
        individual in communicating needs, achieving self-expression, 
        pursuing personal goals, living independently, and 
        participating actively in employment or voluntary roles in the 
        community;
            (3) services such as providing assistance with activities 
        of daily living (such as feeding, bathing, toileting, and 
        ambulation) and with tasks such as meal preparation, shopping, 
        light housekeeping, and laundry; or
            (4) services that support such individual at home, work, 
        school, or any other community setting.

SEC. 203. REVISION OF STANDARD OCCUPATIONAL CLASSIFICATION SYSTEM.

    The Director of the Office of Management and Budget shall, not 
later than 30 days after the date of enactment of this Act, revise the 
Standard Occupational Classification system to establish a separate 
code (31-1123) for direct support professionals as a healthcare support 
occupation. Such code shall be a subset of 31-1120, which includes home 
health aides and personal care aides.

            TITLE III--SUPPORT FOR THE DIRECT CARE WORKFORCE

SEC. 301. DEFINITIONS.

    In this title:
            (1) Apprenticeship program.--The term ``apprenticeship 
        program'' means an apprenticeship program registered under the 
        Act of August 16, 1937 (commonly known as the ``National 
        Apprenticeship Act''; 50 Stat. 664, chapter 663; 29 U.S.C. 50 
        et seq.), including any requirement, standard, or rule 
        promulgated under such Act.
            (2) Community college.--The term ``community college'' 
        means a public institution of higher education at which the 
        highest degree that is predominantly awarded to students is an 
        associate's degree, including Tribal Colleges or Universities 
        receiving grants under section 316 of the Higher Education Act 
        of 1965 (20 U.S.C. 1059c) that offer a 2-year program for 
        completion of such degree and State public institutions of 
        higher education that offer such a 2-year program.
            (3) Direct care professional.--The term ``direct care 
        professional''--
                    (A) means an individual who, in exchange for 
                compensation, provides services to a person with a 
                disability or an older adult that promotes the 
                independence of such person or individual, including--
                            (i) services that enhance the independence 
                        and community inclusion for such person or 
                        individual, including traveling with such 
                        person or individual or attending and assisting 
                        such person or individual while visiting 
                        friends and family, shopping, or socializing;
                            (ii) services such as coaching and 
                        supporting such person or individual in 
                        communicating needs, achieving self-expression, 
                        pursuing personal goals, living independently, 
                        and participating actively in employment or 
                        voluntary roles in the community;
                            (iii) services such as providing assistance 
                        with activities of daily living (such as 
                        feeding, bathing, toileting, and ambulation) 
                        and with tasks such as meal preparation, 
                        shopping, light housekeeping, and laundry;
                            (iv) services that support such person or 
                        individual at home, work, school, or in any 
                        other community setting; or
                            (v) services that promote health and 
                        wellness, including scheduling and taking such 
                        person or individual to health care 
                        appointments, communicating with health and 
                        allied health professionals administering 
                        medications, implementing health and behavioral 
                        health interventions and treatment plans, 
                        monitoring and recording health status and 
                        progress; and
                    (B) may include--
                            (i) a service provider supporting people 
                        with intellectual disability and developmental 
                        disabilities, and other disabilities;
                            (ii) a home and community-based services 
                        manager or direct support professional manager;
                            (iii) a self-directed care worker;
                            (iv) a personal care service worker;
                            (v) a direct care worker, as defined in 
                        section 799B of the Public Health Service Act 
                        (42 U.S.C. 295p); or
                            (vi) any other position or job related to 
                        the home care or direct care workforce, such as 
                        positions or jobs in respite care, palliative 
                        care, community support, or peer support, as 
                        determined by the Secretary, in consultation 
                        with the Centers for Medicare & Medicaid 
                        Services and the Secretary of Labor.
            (4) Direct care workforce.--The term ``direct care 
        workforce'' means the broad workforce of direct care 
        professionals.
            (5) Family caregiver.--The term ``family caregiver'' has 
        the meaning given such term in section 2 of the RAISE Family 
        Caregivers Act (42 U.S.C. 3030s note; Public Law 115-119) and 
        includes paid and unpaid family caregivers.
            (6) Eligible entity.--The term ``eligible entity'' means an 
        entity--
                    (A) that is--
                            (i) a State;
                            (ii) a labor organization, joint labor-
                        management organization, or employer of direct 
                        care professionals;
                            (iii) a nonprofit entity with experience in 
                        aging, disability, or supporting the rights and 
                        interests of, training of, or educating direct 
                        care professionals or family caregivers;
                            (iv) an Indian Tribe, Tribal organization, 
                        or Urban Indian organization;
                            (v) a community college or other 
                        institution of higher education; or
                            (vi) a consortium of entities listed in any 
                        of clauses (i) through (v);
                    (B) that agrees to include, as applicable with 
                respect to the type of grant the entity is seeking 
                under this title and the activities supported through 
                such grant, older adults, people with disabilities, 
                direct care professionals, and family caregivers, as 
                advisors and trainers in such activities; and
                    (C) that agrees to consult with the State Medicaid 
                agency of the State (or each State) served by the grant 
                on the grant activities, to the extent that such agency 
                (or each such agency) is not the eligible entity.
            (7) Employer.--The terms ``employ'' and ``employer'' have 
        the meanings given the terms in section 3 of the Fair Labor 
        Standards Act of 1938 (29 U.S.C. 203).
            (8) Indian tribe; tribal organization.--The terms ``Indian 
        Tribe'' and ``Tribal organization'' have the meanings given 
        such terms in section 4 of the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 5304).
            (9) Institution of higher education.--The term 
        ``institution of higher education'' means--
                    (A) an institution of higher education defined in 
                section 101 of the Higher Education Act of 1965 (20 
                U.S.C. 1001); or
                    (B) an institution of higher education defined in 
                section 102(a)(1)(B) of such Act (20 U.S.C. 
                1002(a)(1)(B)).
            (10) Older adult.--The term ``older adult'' means an 
        individual who is 60 years of age or older.
            (11) Person with a disability.--The term ``person with a 
        disability'' means an individual with a disability, as defined 
        in section 3 of the Americans with Disabilities Act of 1990 (42 
        U.S.C. 12102).
            (12) Project participant.--The term ``project participant'' 
        means an individual participating in a project or activity 
        assisted with a grant under this title, including (as 
        applicable for the category of the grant) a direct care 
        professional, or an individual training to be such a 
        professional, or a family caregiver.
            (13) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services, acting through the Administrator 
        for Community Living.
            (14) Self-directed care professional.--The term ``self-
        directed care professional'' means a direct care professional 
        who is employed by an individual who is an older adult, a 
        person with a disability, or a representative of such older 
        adult or person with a disability, and such older adult or 
        person with a disability has the decision-making authority over 
        certain supports and services provided by the direct care 
        professional and takes direct responsibility to manage those 
        supports and services.
            (15) Supportive services.--The term ``supportive services'' 
        means services that are necessary to enable an individual to 
        participate in activities assisted with a grant under this 
        title, such as transportation, child care, dependent care, 
        housing, workplace accommodations, employee benefits such as 
        paid sick leave and child care, workplace health and safety 
        protections, wages and overtime pay, and needs-related 
        payments.
            (16) Urban indian organization.--The term ``urban Indian 
        organization'' has the meaning given the term in section 4 of 
        the Indian Health Care Improvement Act (25 U.S.C. 1603).
            (17) Workforce innovation and opportunity act terms.--The 
        terms ``career pathway'', ``career planning'', ``in-demand 
        industry sector or occupation'', ``individual with a barrier to 
        employment'', ``local board'', ``on-the-job training'', 
        ``recognized postsecondary credential'', ``region'', and 
        ``State board'' have the meanings given such terms in section 3 
        of the Workforce Innovation and Opportunity Act (29 U.S.C. 
        3102).
            (18) Work-based learning.--The term ``work-based learning'' 
        has the meaning given the term in section 3 of the Carl D. 
        Perkins Career and Technical Education Act of 2006 (20 U.S.C. 
        2302).

SEC. 302. AUTHORITY TO ESTABLISH A TECHNICAL ASSISTANCE CENTER FOR 
              BUILDING THE DIRECT CARE WORKFORCE.

    (a) Program Authorized.--The Secretary shall establish a national 
technical assistance center (referred to in this section as the 
``Center'') for, in consultation with the Secretary of Labor, the 
Secretary of Education, the Administrator of the Centers for Medicare & 
Medicaid Services, and the heads of other entities as necessary--
            (1) supporting direct care workforce creation, training and 
        education, recruitment, retention, and advancement; and
            (2) supporting family caregivers and activities of family 
        caregivers as a critical part of the support team for older 
        adults or people with disabilities.
    (b) Advisory Council.--The Secretary shall convene an advisory 
council to provide recommendations to the Center with respect to the 
duties of the Center under this section and may engage individuals and 
entities described in paragraphs (3)(B), and (12), of section 304(b) 
(without regard to a specific project described in such paragraphs) for 
service on the advisory council.
    (c) Activities.--The Center may--
            (1) develop recommendations for training and education 
        curricula for direct care professionals, which such 
        recommendations may include recommendations for curricula for 
        higher education, postsecondary credentials, and programs with 
        community colleges;
            (2) develop learning and dissemination strategies to--
                    (A) engage States and other entities in activities 
                supported under this title and best practices; and
                    (B) distribute findings from activities supported 
                by grants under this title;
            (3) develop recommendations for training and education 
        curricula and other strategies for supporting family 
        caregivers;
            (4) explore the national data gaps, workforce shortage 
        areas, and data collection strategies for direct care 
        professionals and make recommendations to the Director of the 
        Office of Management and Budget for an occupation category in 
        the Standard Occupational Classification system for direct 
        support professionals as a healthcare support occupation;
            (5) recommend career development and advancement 
        opportunities for direct care professionals, which may include 
        occupational frameworks, national standards, recruitment 
        campaigns, pre-apprenticeship and on-the-job training 
        opportunities, apprenticeship programs, career ladders or 
        pathways, specializations or certifications, or other 
        activities; and
            (6) develop strategies for assisting with reporting and 
        evaluation of grant activities under section 305.

SEC. 303. AUTHORITY TO AWARD GRANTS.

    (a) Grants.--
            (1) In general.--Not later than 12 months after the date of 
        enactment of this title, the Secretary, in consultation with 
        the Centers for Medicare & Medicaid Services, the Secretary of 
        Labor, and the Secretary of Education, shall award grants 
        described in paragraph (2) to eligible entities. A grant 
        awarded under this section may be in more than 1 category 
        described in such paragraph.
            (2) Categories of grants.--The categories of grants 
        described in this paragraph are each of the following:
                    (A) Direct care professional grants.--Grants to 
                eligible entities to create and carry out projects for 
                the purposes of recruiting, retaining, or providing 
                advancement opportunities for direct care professionals 
                who are not described in subparagraph (B) or (C), 
                including through education or training programs for 
                such professionals or individuals seeking to become 
                such professionals.
                    (B) Direct care professional managers grants.--
                Grants to eligible entities to create and carry out 
                projects for the purposes of recruiting, retaining, or 
                providing advancement opportunities for direct care 
                professionals who are managers or supervisory staff 
                that have coaching, training, managerial, supervisory, 
                or other oversight responsibilities, including through 
                education or training programs for such professionals 
                or individuals seeking to become such professionals.
                    (C) Self-directed care professionals grants.--
                Grants to eligible entities to create and carry out 
                projects for the purposes of recruiting, retaining, or 
                providing advancement opportunities for self-directed 
                care professionals, including through education or 
                training programs for such professionals or individuals 
                seeking to become such professionals.
                    (D) Family caregiver grants.--Grants to eligible 
                entities to create and carry out projects for providing 
                support to paid or unpaid family caregivers through 
                educational, training, or other resources, including 
                resources for caregiver self-care or educational or 
                training resources for individuals newly in a 
                caregiving role or seeking additional support in the 
                role of a family caregiver.
            (3) Projects for advancement opportunities.--Not less than 
        30 percent of projects assisted with grants under this title 
        shall be projects to provide career pathways that offer 
        opportunities for professional development and advancement 
        opportunities to direct care professionals.
    (b) Treatment of Continuation Activities.--An eligible entity that 
carries out activities described in subsection (a)(2) prior to receipt 
of a grant under this title may use such grant to continue carrying out 
such activities, and, in using such grant to continue such activities, 
shall be treated as an eligible entity carrying out a project through a 
grant under this title.

SEC. 304. PROJECT PLANS.

    (a) In General.--An eligible entity seeking a grant under this 
title shall submit to the Secretary a project plan for each project to 
be developed and carried out (or for activities to be continued as 
described in section 303(b)) with the grant at such time, in such 
manner, and containing such information as the Secretary may require.
    (b) Contents.--A project plan submitted by an eligible entity under 
subsection (a) shall include a description of information determined 
relevant by the Secretary for purposes of the category of the grant and 
the activities to be carried out through the grant. Such information 
may include (as applicable) the following:
            (1) The demographics (as defined in section 2) of the 
        population in the State or relevant geographic area, including 
        a description of the populations likely to need long-term care 
        services, such as people with disabilities and older adults.
            (2) Projections of unmet need for services provided by 
        direct care professionals based on enrollment waiting lists 
        under home and community-based waivers under section 1115 of 
        the Social Security Act (42 U.S.C. 1315) or section 1915 of 
        such Act (42 U.S.C. 1396n) and other relevant data to the 
        extent practicable and feasible, such as direct care workforce 
        vacancy rates, crude separation rates, and the number of direct 
        care professionals, including such professionals who are 
        managers or supervisors, in the region.
            (3) An advisory committee to advise the eligible entity on 
        activities to be carried out through the grant. Such advisory 
        committee--
                    (A) may be comprised of entities listed in 
                paragraph (12); and
                    (B) shall include--
                            (i) older adults or persons with a 
                        disability;
                            (ii) organizations representing the rights 
                        and interests of people receiving services by 
                        the direct care professionals or family 
                        caregivers targeted by the project;
                            (iii) individuals who are direct care 
                        professionals or family caregivers targeted by 
                        the project and organizations representing the 
                        rights and interests of direct care 
                        professionals or family caregivers;
                            (iv) as applicable, employers of 
                        individuals described in clause (iii) and labor 
                        organizations representing such individuals;
                            (v) representatives of the State Medicaid 
                        agency, the State agency defined in section 102 
                        of the Older Americans Act of 1965 (42 U.S.C. 
                        3002), the State developmental disabilities 
                        office, and the State behavioral health agency, 
                        in the State (or each State) to be served by 
                        the project; and
                            (vi) representatives reflecting diverse 
                        racial, cultural, ethnic, geographic, 
                        socioeconomic, and gender identity and sexual 
                        orientation perspectives.
            (4) Current or projected job openings for, or relevant 
        labor market information related to, the direct care 
        professionals targeted by the project in the State or region to 
        be served by the project, and the geographic scope of the 
        workforce to be served by the project.
            (5) Specific efforts and strategies that the project will 
        undertake to reduce barriers to recruitment, retention, or 
        advancement of the direct care professionals targeted by the 
        project, including an assurance that such efforts will 
        include--
                    (A) an assessment of the wages or other 
                compensation or benefits necessary to recruit and 
                retain the direct care professionals targeted by the 
                project;
                    (B) a description of the project's projected 
                compensation or benefits for the direct care 
                professionals targeted by the project at the State or 
                local level, including a comparison of such projected 
                compensation or benefits to regional and national 
                compensation or benefits and a description of how wages 
                and benefits received by project participants will be 
                impacted by the participation in and completion of the 
                project; and
                    (C) a description of the projected impact of 
                workplace safety issues on the recruitment and 
                retention of direct care professionals targeted by the 
                project, including the availability of personal 
                protective equipment.
            (6) In the case of a project offering an education or 
        training program for direct care professionals, a description 
        of such program (including how the core competencies identified 
        by the Centers for Medicare & Medicaid Services will be 
        incorporated, curricula, models, and standards used under the 
        program, and any associated recognized postsecondary 
        credentials for which the program provides preparation, as 
        applicable), which shall include an assurance that such program 
        will provide to each project participant in such program--
                    (A) relevant training regarding the rights of 
                recipients of home and community based services, 
                including their rights to--
                            (i) receive services in integrated settings 
                        that provide access to the broader community;
                            (ii) exercise self-determination;
                            (iii) be free from all forms of abuse, 
                        neglect, or exploitation; and
                            (iv) person-centered planning and 
                        practices, including participation in planning 
                        activities;
                    (B) relevant training to ensure that each project 
                participant has the necessary skills to recognize abuse 
                and understand their obligations with regard to 
                reporting and responding to abuse appropriately in 
                accordance with relevant Federal and State law;
                    (C) relevant training regarding the provision of 
                culturally competent and disability competent supports 
                to recipients of services provided by the direct care 
                professionals targeted by the project;
                    (D) an apprenticeship program, work-based learning, 
                or on-the-job training opportunities;
                    (E) supervision or mentoring; and
                    (F) for any on-the-job training portion of the 
                program, a progressively increasing, clearly defined 
                schedule of wages to be paid to each such participant 
                that--
                            (i) is consistent with skill gains or 
                        attainment of a recognized postsecondary 
                        credential received as a result of 
                        participation in or completion of such program; 
                        and
                            (ii) ensures the entry wage is not less 
                        than the greater of--
                                    (I) the minimum wage required under 
                                section 6(a) of the Fair Labor 
                                Standards Act of 1938 (29 U.S.C. 
                                206(a)); or
                                    (II) the applicable wage required 
                                by other applicable Federal or State 
                                law, or a collective bargaining 
                                agreement.
            (7) Any other innovative models or processes the eligible 
        entity will implement to support the retention and career 
        advancement of the direct care professionals targeted by the 
        project.
            (8) The supportive services and benefits to be provided to 
        the project participants in order to support the employment, 
        retention, or career advancement of the direct care 
        professionals targeted by the project.
            (9) How the eligible entity will make use of career 
        planning to support the identification of advancement 
        opportunities and career pathways for the direct care 
        professionals in the State or region to be served by the 
        project.
            (10) How the eligible entity will collect and submit to the 
        Secretary workforce data and outcomes of the project.
            (11) How the project--
                    (A) will--
                            (i) provide adequate and safe equipment and 
                        facilities for training and supervision, 
                        including a safe work environment free from 
                        discrimination, which may include the provision 
                        of personal protective equipment and other 
                        necessary equipment to prevent the spread of 
                        infectious disease among the direct care 
                        professionals targeted by the project and 
                        recipients of services provided by such 
                        professionals;
                            (ii) incorporate remote training and 
                        education opportunities or technology-supported 
                        opportunities;
                            (iii) for training and education curricula, 
                        incorporate evidenced-supported practices for 
                        adult learners and universal design for 
                        learning and ensure recipients of services 
                        provided by the direct care professionals or 
                        family caregivers targeted by the project 
                        participate in the development and 
                        implementation of such training and education 
                        curricula;
                            (iv) use outreach, recruitment, and 
                        retention strategies designed to reach and 
                        retain a diverse workforce;
                            (v) incorporate methods to monitor 
                        satisfaction with project activities for 
                        project participants and individuals receiving 
                        services from such participants;
                            (vi) incorporate evidence-supported 
                        practices for family caregiver engagement; and
                            (vii) incorporate core competencies 
                        identified by the Centers for Medicare & 
                        Medicaid Services; and
                    (B) may incorporate continuing education programs 
                and specialty training, with a specific focus on--
                            (i) trauma-informed care;
                            (ii) behavioral health, including co-
                        occurring behavioral health conditions and 
                        intellectual or developmental disabilities;
                            (iii) Alzheimer's and dementia care;
                            (iv) chronic disease management; and
                            (v) the use of supportive or assistive 
                        technology.
            (12) How the eligible entity will consult on the 
        implementation of the project, or coordinate the project with, 
        each of the following entities, to the extent that each such 
        entity is not the eligible entity:
                    (A) The State Medicaid agency, State agency defined 
                in section 102 of the Older Americans Act of 1965 (42 
                U.S.C. 3002), and the State developmental disabilities 
                office for the State (or each State) to be served by 
                the project.
                    (B) The local board and State board for each 
                region, or State, to be served by the project.
                    (C) In the case of a project that carries out an 
                education or training program, a nonprofit organization 
                with demonstrated experience in the development or 
                delivery of curricula or coursework.
                    (D) A nonprofit organization, including a labor 
                organization, that fosters the professional development 
                and collective engagement of the direct care 
                professionals targeted by the project.
                    (E) Area agencies on aging, as defined in section 
                102 of the Older Americans Act of 1965 (42 U.S.C. 
                3002).
                    (F) Centers for independent living, as described in 
                part C of title VII of the Rehabilitation Act of 1973 
                (29 U.S.C. 796f et seq.).
                    (G) The State Council on Developmental Disabilities 
                (as such term is used in subtitle B of title I of the 
                Developmental Disabilities Assistance and Bill of 
                Rights Act of 2000 (42 U.S.C. 15021 et seq.)) for the 
                State (or each State) to be served by the project.
                    (H) Aging and Disability Resource Centers (as 
                defined in section 102 of the Older Americans Act of 
                1965 (42 U.S.C. 3002)).
                    (I) A nonprofit State provider association that 
                represents providers who employ the direct care 
                professionals targeted by the project, where such 
                associations exist.
                    (J) An entity that employs the direct care 
                professionals targeted by the project.
                    (K) University Centers for Excellence in 
                Developmental Disabilities Education, Research, and 
                Services supported under subtitle D of title I of the 
                Developmental Disabilities Assistance and Bill of 
                Rights Act of 2000 (42 U.S.C. 15061 et seq.).
                    (L) The State protection and advocacy system 
                described in section 143 of such Act (42 U.S.C. 15043) 
                of the State (or each State) to be served by the 
                project.
                    (M) Direct care professionals or direct care 
                workforce organizations representing underserved 
                communities, including communities of color.
            (13) How the eligible entity will consult throughout the 
        project with--
                    (A) individuals employed or working as the direct 
                care professionals or family caregivers targeted by the 
                project;
                    (B) representatives of such professionals or 
                caregivers;
                    (C) individuals assisted by such professionals or 
                caregivers;
                    (D) the families of such professionals or 
                caregivers; and
                    (E) individuals receiving education or training to 
                become such professionals or caregivers.
            (14) Outreach efforts to individuals for participation in 
        such project, including targeted outreach efforts to--
                    (A) individuals who are recipients of assistance 
                under a State program funded under part A of title IV 
                of the Social Security Act (42 U.S.C. 601 et seq.) or 
                individuals who are eligible for such assistance; and
                    (B) individuals with barriers to employment.
    (c) Considerations.--In selecting eligible entities to receive a 
grant under this title, the Secretary shall ensure--
            (1) equitable geographic diversity, including by selecting 
        recipients serving rural areas and selecting recipients serving 
        urban areas; and
            (2) that selected eligible entities will serve areas where 
        the occupation of direct care professional, or a related 
        occupation, is an in-demand industry sector or occupation.
    (d) Uses of Funds; Supplement, Not Supplant.--
            (1) Uses of funds.--
                    (A) In general.--Each eligible entity receiving a 
                grant under this title shall use the funds of such 
                grant to carry out at least 1 project described in 
                section 303(a)(2).
                    (B) Administrative costs.--Each eligible entity 
                receiving a grant under this title shall not use more 
                than 5 percent of the funds of such grant for costs 
                associated with the administration of activities under 
                this title.
                    (C) Direct support.--Each eligible entity receiving 
                a grant under this title shall use not less than 5 
                percent of the funds of such grant to provide direct 
                financial benefits or supportive services to direct 
                care professionals and paid or unpaid family caregivers 
                to support the financial needs of such participants 
                during the duration of the project activities.
            (2) Supplement, not supplant.--An eligible entity receiving 
        a grant under this title shall use such grant only to 
        supplement, and not supplant, the amount of funds that, in the 
        absence of such grant, would be available to address the 
        recruitment, training and education, retention, and advancement 
        of direct care professionals or provide support for family 
        caregivers, in the State or region served by the eligible 
        entity.
            (3) Prohibition.--No amounts made available under this 
        title may be used for any activity that is subject to the 
        reporting requirements set forth in section 203(a) of the 
        Labor-Management Reporting and Disclosure Act of 1959 (29 
        U.S.C. 433(a)).

SEC. 305. EVALUATIONS AND REPORTS; TECHNICAL ASSISTANCE.

    (a) Reporting Requirements by Grant Recipients.--
            (1) In general.--An eligible entity receiving a grant under 
        this title shall cooperate with the Secretary and annually 
        provide a report to the Secretary that includes any relevant 
        data requested by the Secretary in a manner specified by the 
        Secretary.
            (2) Contents.--The data requested by the Secretary for an 
        annual report may include any of the following (as determined 
        relevant by the Secretary with respect to the category of the 
        grant and each project supported through the grant):
                    (A) The number of individuals and the demographic 
                categories (as defined in section 2) served by each 
                project supported by the grant, including--
                            (i) the number of individuals recruited 
                        through each such project to be employed as a 
                        direct care professional;
                            (ii) the number of individuals who through 
                        each such project attained employment as a 
                        direct care professional; and
                            (iii) the number of individuals who 
                        enrolled in each such project and withdrew or 
                        were terminated from each such project without 
                        completing training or attaining employment as 
                        a direct care professional.
                    (B) The number of family caregivers participating 
                in an education or training program through each 
                project supported by the grant.
                    (C) The number of project participants who through 
                each such project participated in and completed--
                            (i) work-based learning;
                            (ii) on-the-job training;
                            (iii) an apprenticeship program; or
                            (iv) a professional development or 
                        mentoring program.
                    (D)(i) Other services, benefits, or supports (other 
                than the services, benefits, or supports described in 
                subparagraph (C)) provided through each such project to 
                assist in the recruitment, retention, or advancement of 
                direct care professionals (including through education 
                or training for such professionals or individuals 
                seeking to become such professionals);
                    (ii) the number of individuals who accessed such 
                services, benefits, or supports; and
                    (iii) the impact of such services, benefits, or 
                supports.
                    (E) The crude separation and vacancy rates of 
                direct care professionals, and such rates for those 
                professionals who are managers or supervisors, in the 
                geographic region for a number of years before the 
                grant was awarded, as determined by the Secretary, and 
                annually thereafter for the duration of the grant 
                period.
                    (F) How each project supported by the grant 
                assessed satisfaction with respect to--
                            (i) project participants assisted by the 
                        project;
                            (ii) individuals receiving services 
                        delivered by project participants, including--
                                    (I) any impact on the health or 
                                health outcomes of such individuals; 
                                and
                                    (II) any impact on the ability of 
                                individuals to transition to or remain 
                                in the community in an environment that 
                                meets the criteria established in the 
                                section 441.301(c)(4) of title 42, Code 
                                of Federal Regulations (or successor 
                                regulations); and
                            (iii) employers of such project 
                        participants.
                    (G) The performance of the eligible entity with 
                respect to the indicators of performance on 
                unsubsidized employment, median earnings, credential 
                attainment, measurable skill gains, and employer 
                satisfaction.
                    (H) Any other information with respect to outcomes 
                of the project as determined by the Secretary.
    (b) Annual Report to Congress by Secretary.--Not later than 2 years 
after the date of enactment of this title, and each year thereafter 
until all projects supported through a grant under this title are 
completed, the Secretary shall prepare and submit to Congress an annual 
report on the progress of each project supported through a grant under 
this title and the activities of the technical assistance center 
established under section 302.
    (c) GAO Report.--Not later than 1 year after the date on which all 
projects supported through a grant under this title are completed, the 
Comptroller General of the United States shall conduct a study and 
submit to Congress a report including--
            (1) an assessment of how the technical assistance center 
        established under section 302 and the projects supported 
        through a grant under this title assisted in the creation, 
        recruitment, training and education, retention, and advancement 
        of the direct care workforce or in providing support for family 
        caregivers; and
            (2) recommendations for such legislative or administrative 
        actions needed for improving the assistance described in 
        paragraph (1), as the Comptroller General determines 
        appropriate.
    (d) Independent Evaluations.--Not later than 6 months after the 
date of enactment of this title, the Secretary shall enter into a 
contract with an independent entity to provide independent evaluations 
of activities supported by grants under this title and activities of 
the technical assistance center established under section 302.

SEC. 306. AUTHORIZATION OF APPROPRIATIONS.

    (a) In General.--There are authorized to be appropriated--
            (1) for the establishment and activities of the technical 
        assistance center under section 302, $2,000,000 for each of 
        fiscal years 2024 through 2028; and
            (2) for grants under section 303, $1,000,000,000 for fiscal 
        year 2024.
    (b) Availability.--Amounts made available under this title shall 
remain available until September 30, 2033.

                          TITLE IV--EVALUATION

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

    (a) National Survey on Expanded HCBS Access.--The Administrator of 
the Centers for Medicare & Medicaid Services, in coordination with the 
National Academy of Medicine, shall, not later than 7 years after the 
date of enactment of this Act, conduct or contract for a national 
survey of States, direct care professionals, family caregivers, and 
providers and recipients of home and community-based services, to 
determine the effects of the implementation of this Act and the 
amendments made by this Act on--
            (1) the availability and access to home and community-based 
        services under the Medicaid program nationally and in each 
        State;
            (2) the capacity of the direct service workforce to provide 
        home and community-based services and information on the 
        demographics (as defined in section 2) of such workforce;
            (3) the compensation and working conditions, including 
        scheduling and benefits, of direct care workers;
            (4) the economic effects on beneficiaries and on families 
        with a member receiving home and community-based services 
        through Medicaid;
            (5) the availability of direct care workers and services 
        for people needing long-term services and supports who are not 
        Medicaid eligible;
            (6) family caregivers; and
            (7) recommendations for measures to further expand and 
        enhance access home and community-based services.
    (b) Report.--Not later than 9 years after the date of enactment of 
this Act, the Administrator of the Centers for Medicare & Medicaid 
Services shall publish a report containing the results of the survey 
conducted under subsection (a).
    (c) American Community Survey Addition.--The Secretary of Commerce, 
acting through the Bureau of the Census, shall add to the American 
Community Survey a question designed to identify the need for long-term 
services and supports by residents of the United States.
    (d) Authorization of Appropriations.--There are authorized to be 
appropriated to the Secretary such sums as are necessary to carry out 
this section.
                                 &lt;all&gt;
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