(3) by adding at the end the following new 
paragraph: 
‘‘(88) provide for the submission to the Sec-
retary of an implementation plan described in sec-
tion 104(c) of the HCBS Access Act for approval by 
the Secretary prior to the beginning of the first cal-
endar quarter beginning on or after the date that is 
5 years after the date of the enactment of this para-
graph.’’. 
(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
SERV-
ICES.—The term ‘‘home and community-based serv-
ices’’ 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 mean-
ing 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.— 
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(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 Di-
rectors, 
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 Med-
icaid 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 indi-
viduals with intellectual disability, institution for 
mental disease, or other similarly restrictive or insti-
tutional 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 stake-
holders to participate. 
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(b) UPDATING METRICS.—The Director of the Agen-
cy for Healthcare Research and Quality, in consultation 
with the Deputy Administrator for the Center for Med-
icaid 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 Direc-
tor 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 Qual-
ity, out of any funds in the Treasury not otherwise appro-
priated, $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 AD-
MINISTRATIVE 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 Fi-
nance of the Senate, the Committee on Health, Education, 
Labor and Pensions of the Senate, and the Special Com-
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mittee on Aging of the Senate the following reports relat-
ing to the HCBS implementation plan grant program es-
tablished 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 implemen-
tation 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 bar-
riers 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, bene-
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fits, 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 im-
provement 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 strength-
ening and expanding access to home and com-
munity-based services and the direct care work-
force that provides such services and meeting 
the benchmarks for demonstrating improve-
ments 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 qual-
ity measures and beneficiary and family care-
giver surveys. 
(D) A summary of the challenges and best 
practices reported by States in expanding ac-
cess to home and community-based services and 
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supporting and expanding the direct care work-
force that provides such services. 
(b) TECHNICAL ASSISTANCE; GUIDANCE; REGULA-
TIONS.—The Secretary shall provide HCBS program im-
provement States with technical assistance related to car-
rying out the HCBS implementation plans approved by 
the Secretary under section 104 and meeting the require-
ments 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 speci-
fying how States shall assess and track the availability of 
home and community-based services over time. 
(c) RECOMMENDATIONS TO GUIDE HCBS IMPLE-
MENTATION.— 
(1) IN GENERAL.—Not later than 18 months 
after the date of enactment of this Act, the Sec-
retary shall coordinate with the Secretary of Labor 
and the Administrator of the Centers for Medicare 
& Medicaid Services for purposes of issuing rec-
ommendations for the Federal Government and for 
States to strengthen the direct care workforce that 
provides home and community-based services, in-
cluding with respect to how the Federal Government 
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should classify the direct care workforce, how such 
Administrator and State Medicaid programs can en-
force and support the provision of competitive wages 
and benefits across the direct care workforce, includ-
ing 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 commu-
nity-based services care. 
(2) STAKEHOLDER CONSULTATION.— 
(A) IN GENERAL.—In developing the rec-
ommendations required under paragraph (1), 
the Secretary shall ensure that such rec-
ommendations 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 devel-
oping recommendations under subparagraph 
(A), the Secretary shall— 
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(i) hold at least 1 meeting for the 
purpose of developing such recommenda-
tions that is solely with current and poten-
tial 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 develop-
ment of such recommendations between— 
(I) current and potential recipi-
ents of home and community-based 
services and family caregivers of such 
recipients; and 
(II) other categories of stake-
holder described in subparagraph (A). 
(d) FUNDING.—Out of any funds in the Treasury not 
otherwise appropriated, there is appropriated to the Sec-
retary 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 
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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 commu-
nity-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 Admin-
istration for Community Living, the Direc-
tor of the Agency for Healthcare Research 
and Quality, and the Administrator of the 
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Substance Abuse and Mental Health Serv-
ices Administration; and 
(ii) ensure that such core and supple-
mental sets are informed by input from 
stakeholders, including recipients of home 
and community-based services, family care-
givers of such recipients, providers, health 
plans, direct care workers, chosen rep-
resentatives 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 recipi-
ents of home and community-based serv-
ices 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 chil-
dren; and 
(ii) include— 
(I) outcomes-based measures; 
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(II) measures of availability of 
services; 
(III) measures of provider capac-
ity and availability; 
(IV) measures related to person- 
centered care; 
(V) measures specific to self-di-
rected care; 
(VI) measures related to transi-
tions to and from institutional care; 
and 
(VII) beneficiary and family care-
giver surveys. 
(C) DEMOGRAPHICS.—Such core set and 
supplemental set of home and community-based 
services quality measures shall allow for the col-
lection of data that is disaggregated by demo-
graphics (as defined in section 2 but including 
any additional category determined by the Sec-
retary). 
(4) FUNDING.—Out of any funds in the Treas-
ury not otherwise appropriated, there is appro-
priated to the Secretary for purposes of carrying out 
this subsection, $10,000,000 for fiscal year 2024, to 
remain available until expended. 
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(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 Sec-
retary regarding the quality of home and commu-
nity-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 pro-
gram 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 
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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 attrib-
utable to the reporting of information regarding 
the quality of home and community-based serv-
ices in accordance with section 107(b) of the 
HCBS Access Act; and’’. 
SEC. 108. MAKING PERMANENT THE STATE OPTION TO EX-
TEND PROTECTION UNDER MEDICAID FOR 
RECIPIENTS OF HOME AND COMMUNITY- 
BASED SERVICES AGAINST SPOUSAL IMPOV-
ERISHMENT. 
(a) IN GENERAL.—Section 1924(h)(1)(A) of the So-
cial Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amend-
ed 
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. 
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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 DEMONSTRA-
TION. 
Subparagraph (L) of section 6071(h)(1) of the Def-
icit 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 indi-
viduals with intellectual and developmental disabil-
ities. 
(2) Providers of home and community-based 
services are experiencing difficulty hiring and retain-
ing direct support professionals, with a national 
turnover rate of 45 percent as identified in a 2016 
study by the National Core Indicators. 
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(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 liv-
ing. 
(4) A discrete occupational category for direct 
support professionals will help States and the Fed-
eral 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 statis-
tical purposes, and is used by Federal statistical 
agencies to classify workers and jobs into occupa-
tional categories for the purpose of collecting, calcu-
lating, 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, edu-
cation, or training needed to perform the work. 
(7) Establishing a discrete occupational cat-
egory for direct support professionals will— 
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(A) correct an inaccurate representation in 
the Standard Occupational Classification sys-
tem; 
(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 PROFES-
SIONAL. 
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 de-
fined 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 assist-
ing such individual while visiting friends and family, 
shopping, or socializing; 
(2) services such as coaching and supporting 
such individual in communicating needs, achieving 
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self-expression, pursuing personal goals, living inde-
pendently, 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 CLASSI-
FICATION SYSTEM. 
The Director of the Office of Management and Budg-
et shall, not later than 30 days after the date of enactment 
of this Act, revise the Standard Occupational Classifica-
tion system to establish a separate code (31–1123) for di-
rect support professionals as a healthcare support occupa-
tion. Such code shall be a subset of 31–1120, which in-
cludes 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 
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