(1) Direct support professionals (including 
workers referred to as direct support workers, direct 
care workers, personal assistants, personal attend-
ants, paraprofessionals) are the primary providers of 
long term care services for millions of individuals 
who have physical or mental disabilities. Direct sup-
port professionals provide assistance with activities 
of daily living, instrumental activities of daily living, 
assistance with rehabilitation, habilitation, training 
needs and other tasks. All provide essential supports 
that help keep individuals with disabilities connected 
to their communities. 
(2) These workers who provide intimate sup-
ports are predominately female and many are the 
sole breadwinners of their families. Although work-
ing and paying taxes, many women in these jobs re-
main impoverished and are eligible for many of the 
same Federal and State public assistance programs 
upon which the very individuals with disabilities to 
whom they provide supports must depend. 
(3) Throughout the nation, there is a critical 
shortage of direct support professionals. Vacancy 
and turn over rates are high. In many parts of the 
country, individuals with disabilities are unable to 
access the services they need, thereby jeopardizing 
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their health and quality of life, placing even greater 
burdens on their family members and informal care-
givers and creating long waiting lists for community 
placement. 
(4) The crisis that the nation faces today will 
only get worse. Over the next 30 years, there will be 
a rapid rise of the population over 65 years of age. 
At the same time, advances in medical science and 
drug therapy are increasing the number of people, of 
all ages, living with severe disabilities. Thus, while 
demand for direct support professional services is in-
creasing, the pool of younger, entry level workers is 
shrinking. By 2010, more than 780,000 additional 
workers must be found to fill long-term direct sup-
port staff positions. 
(5) To stabilize and increase the number of di-
rect support professionals in the work force, the 
wages and benefits of direct support professionals 
must be improved and made equitable among long 
term support options. 
(6) Medicaid is the single-largest payor of long- 
term supports and services for people with disabil-
ities. Enhanced Federal Medicaid matching funds 
should be available to assist States committed to ad-
dressing wage differentials among direct support 
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professionals by increasing the wages of direct sup-
port professionals and supporting and improving the 
stability of the direct support professional workforce. 
SEC. 2. MEDICAID AMENDMENT. 
(a) AUTHORIZING ESTABLISHMENT OF DIRECT SUP-
PORT PROFESSIONAL WAGE ENHANCEMENT PLANS.— 
Title XIX of the Social Security Act is amended by adding 
at the end the following new section: 
‘‘DIRECT SUPPORT PROFESSIONAL WAGE ENHANCEMENT 
PLAN 
‘‘SEC. 1942. (a) STATE OPTION.—As a condition for 
the receipt of increased funding described in subsection 
(f), a State is required to provide for the implementation 
of a direct support professional wage enhancement plan 
under this section. 
‘‘(b) DIRECT SUPPORT PROFESSIONAL WAGE EN-
HANCEMENT PLAN.— 
‘‘(1) IN GENERAL.—For purposes of this sec-
tion, the term ‘direct support professional wage en-
hancement plan’ means a plan of a State that the 
Secretary determines meets the following require-
ments: 
‘‘(A) DEADLINE
FOR
SUBMISSION.—The 
plan is submitted to the Secretary not later 
than 120 days after the date the Secretary pro-
vides notice to States under paragraph (3). 
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‘‘(B) CONTENTS.— 
‘‘(i) EQUALIZATION OF HOURLY WAGE 
RATES.—The plan must describe how the 
State intends to use the funds made avail-
able under this section to increase the 
hourly wage rate of targeted direct support 
professionals so that by the end of the 5- 
year implementation period (as defined in 
subsection (g)(4)) such rate is equal to the 
average hourly wage rate of reference di-
rect support professionals. 
‘‘(ii) ADDITIONAL
PROVISIONS.—The 
plan must include the additional informa-
tion described in subsection (c). 
‘‘(C) IMPLEMENTATION.—The plan must 
be developed and implemented in accordance 
with subsection (d). 
‘‘(D) ANNUAL REPORTS.—The State must 
provide for annual assessments and reports in 
accordance with subsection (e). 
‘‘(2) MODIFICATION OF PLAN.—Nothing in this 
section shall be construed as preventing a State 
from time to time and with the approval of the Sec-
retary from modifying a direct support professional 
wage enhancement plan so long as such plan, as 
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modified, continues to meet the requirements of 
paragraph (1). 
‘‘(3) NOTICE.—Not later than 90 days after the 
date of the enactment of this section, the Secretary 
shall provide notice to States regarding the provi-
sions of this section, including the availability of en-
hanced funding to implement direct support profes-
sional wage enhancement plans. 
‘‘(c) CONTENTS OF PLAN.—A direct support profes-
sional wage enhancement plan shall include, consistent 
with the other requirements of this section, the following: 
‘‘(1) A description of how the State intends to 
use funds provided under this section to meet the re-
quirement of subsection (b)(1). 
‘‘(2) A description of the prevailing hourly wage 
rates for targeted direct support professionals before 
the implementation of such plan and any hourly 
wage rate differentials between targeted direct sup-
port professionals and reference direct support pro-
fessionals. 
‘‘(3) The impact of wage differentials and labor 
market conditions on the recruitment and retention 
of targeted direct support professionals, including 
current or projected labor shortages. 
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‘‘(4) The identification of a specific, five-year 
performance goal to increase the hourly wage rate of 
targeted direct support professionals so as to elimi-
nate any wage rate differential between targeted and 
reference direct support professionals and the meth-
odology to be used by the State to achieve its goal. 
‘‘(5) The annual performance goals and targets 
that the State will monitor to track progress toward 
achieving its five-year performance goal. 
‘‘(6) Current efforts to increase and stabilize 
the State’s direct support professional labor force 
and how the plan shall be coordinated with such ef-
forts. 
‘‘(7) Methods for assuring that funds provided 
under this section shall be spent in accordance with 
such plan, and shall not be used to supplant existing 
funds for wages and benefits or to reduce the State’s 
expenditures below the amount that the State would 
have paid had the plan not been in effect. 
‘‘(8) A description of the stakeholders and col-
laborative process used consistent with subsection 
(d) to develop the plan and the means by which such 
collaboration shall continue during the implementa-
tion of the plan. 
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‘‘(9) Assurances satisfactory to the Secretary 
that upon the expiration of the 5-year implementa-
tion period, the State shall provide funding nec-
essary to maintain the wage rates attained under the 
plan for targeted direct support professionals at the 
five-year performance goal increased annually there-
after by a percentage that is not less than the an-
nual percent increase in the employment cost index 
(as published quarterly by the Bureau of Labor Sta-
tistics). 
‘‘(d) DEVELOPMENT
AND
IMPLEMENTATION
OF 
PLAN.—A direct support professional wage enhancement 
plan shall be developed and implemented in collaboration 
with— 
‘‘(1) targeted individuals with disabilities and 
family representatives; 
‘‘(2) targeted direct support professionals; 
‘‘(3) agencies or provider organizations that 
serve targeted individuals with disabilities and em-
ploy targeted direct support professionals; and 
‘‘(4) individuals and organizations representing 
the interests of those described in paragraphs (1) 
through (3). 
‘‘(e) ANNUAL ASSESSMENT AND REPORT.— 
‘‘(1) IN GENERAL.—A State shall— 
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‘‘(A) perform an assessment of the 
operation of the direct care support profes-
sional wage enhancement plan in the State 
in each fiscal year; and 
‘‘(B) report to the Secretary by Janu-
ary 1 following the end of the fiscal year, 
on the results of such assessment. 
‘‘(2) CONTENTS.—Each such assessment shall 
include the following: 
‘‘(A) An assessment of the effectiveness of 
the plan in increasing the wages of targeted di-
rect support professionals and reducing or 
eliminating the wage gap with reference direct 
support professionals. 
‘‘(B) An assessment of the State’s progress 
in meeting its annual performance goals under 
the plan. 
‘‘(C) An assessment of the effectiveness of 
the State’s collaboration with stakeholders on 
plan development and implementation issues. 
‘‘(D) A review and assessment of State ac-
tivities to coordinate the plan with other activi-
ties in the State to improve and stabilize the di-
rect support professional workforce. 
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‘‘(E) Recommendations for improving the 
plan. 
‘‘(F) Such other information as the Sec-
retary may specify. 
‘‘(f) INCREASE IN PAYMENT TO IMPLEMENT PLAN.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
for each calendar quarter during the 5-year imple-
mentation period in which a direct support profes-
sional wage enhancement plan is in effect under this 
section in a State, the amount of payment for med-
ical assistance under section 1903(a)(1) shall be in-
creased by the wage enhancement incentive percent-
age (as defined in paragraph (3)(G)) multiplied by 
the portion of total funds expended during the quar-
ter for the provision of direct support services to tar-
geted individuals that are attributable to the wages 
of targeted direct support professionals. 
‘‘(2) LIMITATION.— 
‘‘(A) IN GENERAL.—Payments made under 
paragraph (1) shall be used only to increase the 
wages of targeted direct support professionals. 
‘‘(B) TREATMENT
OF
EMPLOYEE
BENE-
FITS
AND
SALARY
RELATED
BENEFITS.—For 
purposes of subparagraph (A), payments for 
costs of employee benefits and other salary re-
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lated benefits (including mandatory employment 
taxes and benefits) shall be treated as payments 
to increase the wages of targeted direct support 
professionals so long as payments attributable 
to such non-wage benefits do not exceed 20 per-
cent of the total amounts that increase the 
wages of targeted direct support professionals. 
‘‘(3) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) ANNUAL RATE DIFFERENTIAL PER-
CENTAGE.—The term ‘annual rate differential 
percentage’ means, with respect to a State for 
a year in which the direct support professional 
wage enhancement plan is in effect, the percent 
of the direct support professional wage rate dif-
ferential (as defined in subparagraph (E)) to be 
paid under plan for the year. 
‘‘(B) AVERAGE REFERENCE DIRECT SUP-
PORT
PROFESSIONAL
HOURLY
WAGE
RATE.— 
The term ‘average reference direct support pro-
fessional hourly wage rate’ means, for a year 
under a direct support professional wage en-
hancement plan, the average direct support pro-
fessional hourly wage rate (as defined in sub-
paragraph (D)), including any projected in-
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crease, paid in the year to reference direct sup-
port professionals who are employed by the 
State or, if there are no such employees, to ref-
erence direct support professionals who are em-
ployed by local governments in the State, or, 
when necessary to meet the purpose of the plan, 
any other reference wage rate defined by the 
State and as approved by the Secretary. 
‘‘(C) BASE-YEAR AVERAGE TARGETED DI-
RECT SUPPORT PROFESSIONAL HOURLY WAGE 
RATE.—The term ‘average targeted direct sup-
port professional hourly wage rate’ means, for 
a State, the average direct support professional 
hourly wage rate (as defined in subparagraph 
(D)) paid to targeted direct support profes-
sionals under the State plan in the 12-month- 
period immediately preceding the 5-year imple-
mentation period. 
‘‘(D) DIRECT
SUPPORT
PROFESSIONAL 
HOURLY WAGE RATE.—The term ‘direct sup-
port professional hourly wage rate’ means— 
‘‘(i) the rate of hourly wage paid to a 
direct support professional; plus 
‘‘(ii) mandatory employment taxes 
and benefits (as defined in subparagraph 
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(F)) paid (as computed and applied on an 
hourly basis) with respect to such employ-
ment. 
‘‘(E) DIRECT
SUPPORT
PROFESSIONAL 
WAGE RATE DIFFERENTIAL.—The term ‘direct 
support professional wage rate differential’ 
means, for a State for a year, the amount by 
which— 
‘‘(i) the average reference direct sup-
port professional hourly wage rate (as de-
fined in subparagraph (B)) for the State 
and year, exceeds 
‘‘(ii) the base-year average targeted 
direct support professional hourly wage 
rate (as defined in subparagraph (C)) for 
the State. 
‘‘(F) MANDATORY
EMPLOYMENT
TAXES 
AND BENEFITS.—The term ‘mandatory employ-
ment taxes and benefits’ means taxes under 
section 3111 of the Internal Revenue Code of 
1986 (relating to the employer share of FICA 
taxes) and the employer’s share of unemploy-
ment compensation and worker’s compensation 
payments. 
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