119 HR 8540 IH: HCBS Access Act
U.S. House of Representatives
2026-04-28
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EN
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1.Short title; table of contents(a)This Act may be cited as the HCBS Access Act
.(b)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 MedicaidSec. 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.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.Sec. 110. Liens, adjustments, and recoveries for medical assistance.Sec. 111. HCBS provider tax.Sec. 112. Repealing the requirement that States establish a Medicaid estate recovery program and limit the circumstances in which a State may place a lien on a Medicaid beneficiary’s property.Sec. 113. Medicare amendment.Title II—Recognizing the Role of Direct Support ProfessionalsSec. 201. Findings.Sec. 202. Revision of standard occupational classification system.Title III—Support for the Direct Care WorkforceSec. 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—EvaluationSec. 401. Evaluation of impact on access to HCBS.2.In this Act:(1)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)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)Except as otherwise provided, the term Secretary means the Secretary of Health and Human Services.<enum>I</enum><header>Requiring and Expanding Access to HCBS Coverage Under Medicaid</header><section id="H0E346AFB95B644149DE984DFB53F44F7"><enum>101.</enum><header>Purpose</header><text display-inline="no-display-inline">It is the purpose of this title to require coverage of home and community-based services (in this section referred to as <quote>HCBS</quote>) under a State plan (or waiver of such plan) under title XIX of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396">42 U.S.C. 1396 et seq.</external-xref>) for the following reasons:</text><paragraph id="HC58534DA91874A8B865229C81DFF8D18"><enum>(1)</enum><text>To eliminate waiting lists for HCBS, which delay access to necessary services and deny access to the promise of community inclusion guaranteed under the Americans with Disabilities Act for people with disabilities and older adults.</text></paragraph><paragraph id="HD1805A2644EC478F8FE632365269569C"><enum>(2)</enum><text>To build on decades of progress in serving people with disabilities and older adults via HCBS.</text></paragraph><paragraph id="HE6A02C48F6284AF58980C55E12B1C57B"><enum>(3)</enum><text>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 capacity for independence or self-care.</text></paragraph><paragraph id="H66F52A07E3264C798C22448359A4AD41"><enum>(4)</enum><text>To ensure that people with all kinds of disabilities and with multiple disabilities, including intellectual disabilities, 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.</text></paragraph><paragraph id="H7789AC15BE814E56A1C7DBBED8F10B84"><enum>(5)</enum><text>To streamline access to HCBS by eliminating the need for States to repeatedly apply for waivers.</text></paragraph><paragraph id="HF6F499A9BBF14D4B899BEB82F4C96AB0"><enum>(6)</enum><text>To continue to increase the capacity of community services to ensure people with disabilities and older adults have high-quality, safe and meaningful options in the community and are not at risk of unnecessary institutionalization.</text></paragraph><paragraph id="H18251F67AB8D4C5D8170F92E23C9C876"><enum>(7)</enum><text>To act on the decades of research and practice that show everyone, including people with the most severe disabilities, can live in the community with the right services and supports.</text></paragraph><paragraph id="H38D6962E405240D8AA50502292C90A0C"><enum>(8)</enum><text>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.</text></paragraph><paragraph id="HC1A601F05F734566A14B182DDFFB192F"><enum>(9)</enum><text>To support over 63,000,000 unpaid family caregivers, who are disproportionately women, 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.</text></paragraph><paragraph id="HC3DA0AFDCF8C4955B544D393D6AFD67C"><enum>(10)</enum><text>To improve direct care quality and ensure access to services by improving workforce standards for the nearly 3,200,000 direct care workers—who are primarily women, people of color, and immigrants who face heightened risks of discrimination in employment—providing support to people with disabilities and older adults in their homes and communities.</text></paragraph></section><section id="HC8E0E3AE781F4419819C417491AE0972"><enum>102.</enum><header>Requiring coverage of home and community-based services under the Medicaid program</header><subsection id="H83AC09D6D195486A9F286E6F2B8C4884"><enum>(a)</enum><header>Definition of home and community-Based services</header><paragraph id="HE426924B8668423886F914BB88FE8C17"><enum>(1)</enum><header>In general</header><text>Section 1905 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d</external-xref>) is amended by adding at the end the following new subsection:</text><quoted-block style="OLC" id="H755D9F83944E46AC8966A9A5C33EAA1F" display-inline="no-display-inline"><subsection id="HE6C020F80069402CAA33B10B37BF8773"><enum>(ll)</enum><header>Home and community-Based services</header><paragraph id="H4AFC2FF59EDD4550B5C0BD1AB5771D05"><enum>(1)</enum><header>In general</header><text>For purposes of this title, the term <term>home and community-based services</term> 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)) and person-centered service plan (as described in paragraph (4)(D)) for such individual, in a setting that—</text><subparagraph id="HF5DEE96F56994C79B11B429A93DE70E5"><enum>(A)</enum><text>meets the qualities specified in paragraph (1) of section 441.710(a) of title 42, Code of Federal Regulations (or a successor regulation);</text></subparagraph><subparagraph id="HB55B84A9B9BC4E608606912D693F438D"><enum>(B)</enum><text>is not described in paragraph (2) of such section (or successor regulation); and</text></subparagraph><subparagraph id="HB3CA9FA89D074ADAB66345CE1CAB18FF" commented="no"><enum>(C)</enum><text>meets such other qualities as the Secretary determines appropriate in line with recommendations for additional services made by the panel described in paragraph (2)(B).</text></subparagraph></paragraph><paragraph id="H430240846AD347D28C47BC451C6BFFF9"><enum>(2)</enum><header>Services specified</header><subparagraph id="H395009DCF6B546938F6ADDC1EC779971"><enum>(A)</enum><header>In general</header><text>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), (29), and (31) 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:</text><clause id="H7BCAC2EE684A431D929B49A480F2F706"><enum>(i)</enum><text>Supported employment and integrated day services.</text></clause><clause id="H1D259817901B4A6BB45DE454B15022CD"><enum>(ii)</enum><text>Personal assistance, including personal care attendants, direct support professionals, home health aides, private duty nursing, homemakers and chore assistance, and companionship services.</text></clause><clause id="H874FEB1583A14CD0846F1D47B447CA93"><enum>(iii)</enum><text>Services that enhance independence, inclusion, and full participation in the broader community.</text></clause><clause id="HF0B163E1EEE34E8ABFB5594F5BD65F54"><enum>(iv)</enum><text>Non-emergency, non-medical transportation services to facilitate community integration.</text></clause><clause id="HCB83C2703BCE4509B536EB0B7E398F4C"><enum>(v)</enum><text>Respite services provided in the individual’s home or broader community.</text></clause><clause id="H62F52C59DF1F4CE4A4EA13DA6C2E4B46"><enum>(vi)</enum><text>Caregiver and family support services.</text></clause><clause id="H3CD39284C4604CDC99D09494F6359824"><enum>(vii)</enum><text>Case management, including intensive case management, fiscal intermediary, and support brokerage services.</text></clause><clause id="HD2E13E7DB2A24567960967ADCF117715"><enum>(viii)</enum><text>Services that support person-centered planning and self-direction.</text></clause><clause id="H3877530170DC46CE91E2A1F76A5F49A8"><enum>(ix)</enum><text>Direct support services during acute hospitalizations.</text></clause><clause id="H6298F36727764CE0BB6C8898DE3F424A"><enum>(x)</enum><text>Necessary medical and nursing services not otherwise covered that are necessary in order for the individual to remain in their home and community, including hospice services.</text></clause><clause id="H7FBE226725774F6D8A6B905CFF2EC73A"><enum>(xi)</enum><text>Home and community-based intensive behavioral health and crisis intervention services.</text></clause><clause id="HE0EC6A66D5B4433EAB30B57A7979F5FA"><enum>(xii)</enum><text>Peer support services.</text></clause><clause id="H831FBC7EA3C54E5DBF4EFA854DB01328"><enum>(xiii)</enum><text>Housing support, including transitional housing or transitional support services for individuals who are unhoused, and wrap-around services.</text></clause><clause id="HD5C90CE5CED04A2B8811523BC2461905"><enum>(xiv)</enum><text>Necessary home modifications and assistive technology, including those that substitute for human assistance.</text></clause><clause id="H57AA8E7DC2594907BA018596DDF9952D"><enum>(xv)</enum><text>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.</text></clause><clause id="HDCF6C311703F4590AAC8A421FB4F2AE5"><enum>(xvi)</enum><text>Nutrition Services.</text></clause><clause id="H92EDEF623F1E4D518A63FA670B1B3CA8"><enum>(xvii)</enum><text>Assisted living services.</text></clause><clause id="HE9BEC227F07742079811B9857DF113CC"><enum>(xviii)</enum><text>Any other service approved by the Secretary, pursuant to the recommendation of the panel convened pursuant to subparagraph (B).</text></clause></subparagraph><subparagraph id="H990800A500C64C7CAD87C9EBAFFF43BD"><enum>(B)</enum><header>Specification of recommended services</header><clause id="H2E104C881B44490397231AB86A162B5D"><enum>(i)</enum><header>In general</header><text display-inline="yes-display-inline">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 the Secretary shall appoint an advisory panel (in this subparagraph referred to as the ‘panel’) for purposes of recommending additional services which may be included as home and community-based services under this paragraph.</text></clause><clause id="HC8F2A6DF576040FE95942184AD83CF3F"><enum>(ii)</enum><header>Composition</header><subclause id="H48998F8D222C4E478ACCB8CFF7E1DC66"><enum>(I)</enum><header>Selection</header><text display-inline="yes-display-inline">The members shall be selected from categories (aa) through (rr), with the majority of all members from the categories described in items (aa), (bb), and (cc):</text><item id="HCA55EAE405D94E6B90AF786500EB4561"><enum>(aa)</enum><text>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. The individuals should be representative of multiple states, geography, race, and ethnicity and other demographic factors.</text></item><item id="H4456B9715D7A4E23B29B9BCF9A25F869"><enum>(bb)</enum><text>Beneficiary-led disability rights organizations.</text></item><item id="H3A5A248203F4496F9E91A6C9438DBF96"><enum>(cc)</enum><text>Disability-led organizations.</text></item><item id="HF4A5B8622CC74F198DD178600536D4DB"><enum>(dd)</enum><text>Disabled veterans organizations.</text></item><item id="H115D11EECDE447A4B7C8F34B85812118"><enum>(ee)</enum><text>Disability organizations representing families.</text></item><item id="H53CEB21794AA4CA1B05FC1012EFBD28A"><enum>(ff)</enum><text>Organizations serving people with people with disabilities, including intellectual or developmental disabilities.</text></item><item id="H0E940F6173964872941F9314DEFC35A9"><enum>(gg)</enum><text>Organizations serving older adults.</text></item><item id="H6D9C12EA96DB4153B5754059CF6BE597"><enum>(hh)</enum><text>Direct care workers and the labor organizations that represent them.</text></item><item id="H030BAB9AE3BE4A42916167D14F24D054"><enum>(ii)</enum><text>The Protection and Advocacy system, the Centers for Independent Living.</text></item><item id="HF8981D16256F4558ABDC46269B84337F"><enum>(jj)</enum><text>Health care providers.</text></item><item id="H0641EC30E9BB44AD974AD2B0D983ADB8"><enum>(kk)</enum><text>The National Association of Medicaid Directors.</text></item><item id="HB3E32574B7AC46D5AFCB549B5E841C2D"><enum>(ll)</enum><text display-inline="yes-display-inline">The National Association of State Directors of Developmental Disabilities Services.</text></item><item id="HFCF94E20DDD64880B266CF09898CBD11"><enum>(mm)</enum><text>The National Association of State Mental Health Program Directors.</text></item><item id="HA9BB6FDD62474AC59AEA709838BC21CD"><enum>(nn)</enum><text>Advancing States.</text></item><item id="H3D1D1AA2C1964060A5F3A52B67D5E6FC"><enum>(oo)</enum><text>The Centers for Medicare & Medicaid Services.</text></item><item id="HCF465D247B9C4CCB8B3617CF288138D8"><enum>(pp)</enum><text>The Administration for Community Living of the Department of Health and Human Services.</text></item><item id="HDFB7266D6FEE4A2992A2B01DDCB35B11"><enum>(qq)</enum><text>Other relevant local, State, and Federal home and community-based service systems, as determined by the Secretary.</text></item><item id="H4BC2B164BFA64D398EF4113AFF3BD8A1"><enum>(rr)</enum><text>Members of federally-recognized tribes and tribally-led organizations.</text></item></subclause><subclause id="HD6BA51BDC29E47AFB7F2072522DCFB4C"><enum>(II)</enum><header>Requirement for equal proportionate
representation</header><text>The Secretary shall seek to ensure proportionate representation among each category described in items (dd) through (oo) of subclause (I), in convening the panel. The majority of all members shall be from the categories described in items (aa), (bb), and (cc) of subclause (I).</text></subclause></clause><clause id="HDB24FB7CD6B44C08A454BAFC263BB7CD"><enum>(iii)</enum><header>Duties</header><subclause id="HCBDA6EAB34F942F58C4713DDA85A21FA">
<enum>(I)</enum>
<header>In general</header>
<text>Not later than 2 years 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.</text>
</subclause><subclause id="HD198DD14C9E649199EFDB4BA9A9563BA"><enum>(II)</enum><header>Considerations</header><text>In developing recommendations, the panel must consider—</text><item id="HD5B0984666D243D39BAD90A140989E9D"><enum>(aa)</enum><text>available data on coverage gaps of needed home and community based services, including compliance reporting required by section 441.311(d) of title 42, Code of Federal Regulations;</text></item><item id="H868D6BD7EB4844F39BBF9208F6E6B64C"><enum>(bb)</enum><text>new technology or innovations that could promote access to home and community based services for people with disabilities and older adults;</text></item><item id="HA2FB33BE161C4BEF9F0DA2D63B839BE3"><enum>(cc)</enum><text>relevant data based on the latest HCBS quality measures sets;</text></item><item id="H2C1CB652FD5B4CAF9E5D77C39D891ACA"><enum>(dd)</enum><text>public comment about additional home and community based services; and</text></item><item id="H479505DA9950402785C6931006BF360D"><enum>(ee)</enum><text>other relevant research, data, or information that will help inform the adoption of home and community based services for people with disabilities and older adults.</text></item></subclause><subclause id="HB71B6D4EF43F44D6B3D4902685ABA377"><enum>(III)</enum><header>Notice and comment</header><text>The Secretary shall establish a process for public notice and comment, including public hearings, sufficient to ensure a meaningful level of public input, no less than one year prior to the issuance of the panel’s report.</text></subclause></clause><clause id="H8B49E460CA224DD6A849E90FEDE65260"><enum>(iv)</enum><header>Implementation of recommended services</header><subclause id="H75F6FE39637549F6AD0B2855049A0CE8"><enum>(I)</enum><header>In general</header><text>The Secretary shall consider recommendations in the panel’s report, and review any public comment and other relevant information, to identify additional services to specific as home and community-based services, pursuant to section 1905(ll)(2)(a)(xvi).</text></subclause><subclause id="H6CF85192CE7040558A934213E71AC88C"><enum>(II)</enum><header>Considerations</header><text>In developing recommendations, the panel must consider—</text><item id="H630BEDC52CA94B36B85016CB393ACA96"><enum>(aa)</enum><text>available data on coverage gaps of needed home and community based services, including compliance reporting required by section 411.311(d) of title 42, Code of Federal Regulations;</text></item><item id="H763F9A473EA34F9C8A3374966A621659"><enum>(bb)</enum><text>new technology or innovations that could promote access to home and community based services for people with disabilities;</text></item><item id="H6445B5B928C1404984B885F6154E78A1"><enum>(cc)</enum><text>relevant data based on the latest HCBS quality measures sets;</text></item><item id="H3DBF493C73D247E3BF379D55F0CCD3E4"><enum>(dd)</enum><text>public comment about additional home and community based services; and</text></item><item id="HE5238A001C824B14B03D369CE81D9589" commented="no"><enum>(ee)</enum><text>other relevant research, data, or information that will help inform the adoption of home and community based services for people with disabilities.</text></item></subclause><subclause id="H3996262E048D49ED8C7E0A486F091B07"><enum>(III)</enum><header>Notice and comment</header><text>The Secretary shall establish a process for public notice and comment, including public hearings, sufficient to ensure a meaningful level of public input, not less than one year prior to the issuance of the panel’s report.</text></subclause><subclause id="H652AED7D6C2E4E6F8991618BCD6A5197"><enum>(IV)</enum><header>Notification</header><text>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 of home and community-based services based on services recommended under such report through State Medicaid Director letters.</text></subclause></clause></subparagraph></paragraph><paragraph id="HDF3E312B6D2D413B928D70EEE8E8860C"><enum>(3)</enum><header>Eligible individual</header><subparagraph id="H6D7266D4B26143E6B76162567916AC2F"><enum>(A)</enum><header>In general</header><text>For purposes of paragraph (1), the term <term>eligible individual</term> means—</text><clause id="H75A3466CFE88420182E492059CADF224"><enum>(i)</enum><text>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;</text></clause><clause id="H47EF73637BFF4D5692BAFA4550169BAB"><enum>(ii)</enum><text>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</text></clause><clause id="H27B7E6A7C2D849A791CC8DB574D2808F"><enum>(iii)</enum><text>an individual who is eligible under the State plan or waiver and is under the age of 21.</text></clause></subparagraph><subparagraph id="H59A3A5F894FD498FB669DCFFC0EF06CE"><enum>(B)</enum><header>Functional impairment</header><text>For purposes of subparagraph (A), the term <term>functional impairment</term> means, with respect to an individual the inability of such individual to perform, without assistance—</text><clause id="H5C9E4F49C86D4884A5BF59620C063B91"><enum>(i)</enum><text>2 or more activities of daily living (as described in <external-xref legal-doc="usc" parsable-cite="usc/26/7702B">section 7702B(c)(2)(B)</external-xref> of the Internal Revenue Code of 1986);</text></clause><clause id="HA84F0EECE9F14F8CB2B8E0DB620236AF"><enum>(ii)</enum><text>2 or more instrumental activities of daily living (as defined for purposes of section 1915(k)(1)(A)); or</text></clause><clause id="H025EEA2F426D4168AE4E2C4BFC200F0E"><enum>(iii)</enum><text>1 activity of daily living (as so described) and 1 instrumental activity of daily living (as so defined).</text></clause></subparagraph><subparagraph id="H305829043E6040E0B9968016983EBBFF"><enum>(C)</enum><header>Health care provider State approval</header><text>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.</text></subparagraph></paragraph><paragraph id="H2C652759038C431E8B2C58545A3B84FB"><enum>(4)</enum><header>Individualized assessment</header><subparagraph id="HE265B078CFDF45E9815012DCB42CD4B8"><enum>(A)</enum><header>In general</header><text>For purposes of paragraph (1), an individualized assessment described in this paragraph is an independent assessment, with respect to an eligible individual—</text><clause id="H6EE0E00A023948398DA5768A3BC78BAE"><enum>(i)</enum><text>to determine a necessary level of services and supports to be provided, consistent with an individual’s physical and health condition, including any functional impairments;</text></clause><clause id="H976C7C09C0D14492899A65CB3F699B92"><enum>(ii)</enum><text>identify needed services;</text></clause><clause id="H1CF3B141C3DD4235A1F5C6C7B5BFC29B"><enum>(iii)</enum><text>to inform development of a person-centered care plan (as described in subparagraph (C)) for the individual;</text></clause><clause id="H2D81A916236A41F0B6DB890415DD4B10"><enum>(iv)</enum><text>that includes each of the elements described in clauses (ii) through (v) of section 1915(i)(1)(F); and</text></clause><clause id="H91FDEF28CB1049D28816194E495EC202"><enum>(v)</enum><text>that occurs not later than 30 days after such individual is determined to be an eligible individual.</text></clause></subparagraph><subparagraph id="HF03DDBB4C5B64458B158167D4488797B"><enum>(B)</enum><header>Reassessments</header><text>The independent assessment of need must be conducted at least every 12 months and as needed when the individual’s support needs or circumstances change significantly, in order to revise the person-centered service plan.</text></subparagraph><subparagraph id="H30D483777A5E449EA54F0C267ABCD7FA"><enum>(C)</enum><header>Presumption</header><text>The assessment described in subparagraph (A) shall be conducted with the presumption—</text><clause id="H0A80AE35DC4C41B49BB0787BE207BA53"><enum>(i)</enum><text>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</text></clause><clause id="H8FD03F0CA5744D7A9EA9F564BD3C33FD"><enum>(ii)</enum><text>at the option of the individual, that services may be self-directed (as defined in section 1915(i)(1)(G)(iii)(II)).</text></clause></subparagraph><subparagraph id="H7B74FF40D09D4BA8A5E44BE674DA0A4F" commented="no"><enum>(D)</enum><header>Person-centered care plan</header><text>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 is developed in accordance with and meets the requirements of paragraphs (1) through (3) of section 441.301(c) of title 42, Code of Federal Regulations.</text></subparagraph><subparagraph id="H7B50E841C51C4074A119F37A4ED528F1" commented="no"><enum>(E)</enum><header>Standards</header><text>An individualized assessment described in subparagraph (A) shall be conducted in accordance with standards specified by the Secretary—</text><clause id="H573A261DA66F423FA0EA151C8FEC7766" commented="no"><enum>(i)</enum><text>safeguard against conflicts of interest;</text></clause><clause id="HE63573F469AA46EBBB545146D89F26A8" commented="no"><enum>(ii)</enum><text>specify qualifications for who may perform such assessments;</text></clause><clause id="HD906FFA698214A3090A76154462C7FCC" commented="no"><enum>(iii)</enum><text>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;</text></clause><clause id="H139C3EB27E2F47CEBAF00792D1048BC5" commented="no"><enum>(iv)</enum><text>ensure that the methodologies used in such assessments are sound and evidence-based;</text></clause><clause id="HB684512CF9054E3FA1B84DCC33235FD9" commented="no"><enum>(v)</enum><text>require such methodologies to be made available on the public website of the State and tested for reliability and validity by an independent evaluator;</text></clause><clause id="H00E57B6B69134AF29B54B3B06989D0E8" commented="no"><enum>(vi)</enum><text>require assessment tools to include language assistance services and compliance with Federal non-discrimination requirements, including—</text><subclause id="HC7C81D61FB004B6A9A59A573DD9DDA2C" commented="no"><enum>(I)</enum><text>availability of such assessments in the individual’s primary language or with a qualified interpreter;</text></subclause><subclause id="HBBACA60323AD426AB20B6BFC174159B6" commented="no"><enum>(II)</enum><text>accessibility for individuals who are blind or have low-vision;</text></subclause><subclause id="HD004F62E9FFB46EAA041F196895245A2" commented="no"><enum>(III)</enum><text>accessibility for deaf and hard-of-hearing individuals; and</text></subclause><subclause id="H33957D6CE6C442AFB11EBBF2895476DA" commented="no"><enum>(IV)</enum><text>accessibility for individuals who cannot rely on speech to communicate; and</text></subclause></clause><clause id="H17147664DC0D4F7AB9FA1A3CBF55C28D" commented="no"><enum>(vii)</enum><text>ensure that the assessment identifies services and supports necessary for community integration are identified, involves professionals knowledgeable about the range of supports and services available in the community, and allows individuals getting assessed to present their own independent evidence of the appropriateness of an integrated setting.</text></clause></subparagraph></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph><paragraph id="H9E0F53EA8CEC4991BAE3AB8664628FD0"><enum>(2)</enum><header>Inclusion as medical assistance</header><text>Section 1905(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d(a)</external-xref>) is amended—</text><subparagraph id="H35209685E5294067AB9AF436C14B67EE"><enum>(A)</enum><text>by redesignating paragraphs (31) and (32) as paragraphs (32) and (33) respectively; and</text></subparagraph><subparagraph id="H56DC32C6ECD744E28954B47E5A3FCD68"><enum>(B)</enum><text>by inserting after paragraph (30) the following new paragraph:</text><quoted-block id="HD7150F19E2A34C4692667346DB3141E7" style="OLC"><paragraph id="HFA174912DF5342B59AA588BF14A3DF67"><enum>(31)</enum><text>home and community-based services (as defined in subsection (ll));</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection><subsection id="HD544EE3B32D94A6BB279606D4327B19A"><enum>(b)</enum><header>Mandatory benefit</header><paragraph id="H3382951159D0452A9410DBF1613C0C63"><enum>(1)</enum><header>In general</header><text>Section 1902(a)(10)(A) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396a">42 U.S.C. 1396a(a)(10)(A)</external-xref>) is amended by striking <quote>and (30)</quote> and inserting <quote>(30), and (31)</quote>.</text></paragraph><paragraph id="HCDC0BF1A307B4F11A213493169317221"><enum>(2)</enum><header>Effective date</header><text>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.</text></paragraph></subsection><subsection id="H760CC90E4C7645EE840EC3B64E6462E5"><enum>(c)</enum><header>Ensuring coverage of HCBS for all medicaid-Eligible individuals</header><text>Section 1902(a)(10)(D) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396a">42 U.S.C. 1396a(a)(10)(A)</external-xref>) is amended—</text><paragraph id="HAFBD4D773D4546DD8B9062452C87FAF6"><enum>(1)</enum><text>by inserting <quote>(i)</quote> after <quote>(D)</quote>;</text></paragraph><paragraph id="H7C3CE7ECD1A84084B7A162138CE526CC"><enum>(2)</enum><text>by adding <quote>and</quote> after the semicolon; and</text></paragraph><paragraph id="H6EDBF7A1FA8149CBAF857476765CDEC8"><enum>(3)</enum><text>by adding at the end the following new clause:</text><quoted-block id="H541F6FE015F04BB3994B7E02698FFBBA" style="OLC"><clause id="HB4AA9158D9264681AE76069D04E56B60"><enum>(ii)</enum><text>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(ll)) for any individual who—</text><subclause id="H7B6AA569AA444EEF9A858D6C2F97494E"><enum>(I)</enum><text>is eligible for medical assistance under the State plan (or waiver of such plan);</text></subclause><subclause id="H32F5715FB87D456191EAED1B2AA2E2C6"><enum>(II)</enum><text>is an eligible individual (as defined in such section); and</text></subclause><subclause id="H6302E16BD94841D5938D5F79CE13C40A"><enum>(III)</enum><text>elects to receive such services.</text></subclause></clause><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H8F3EC7E904FC4FC8A20732984855C336"><enum>(d)</enum><header>Federal medical assistance percentage for home and community-Based services</header><text>Section 1905 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d</external-xref>), as amended by subsection (a), is further amended—</text><paragraph id="H93C11ED6E63B4DF195BFA8EFD38241FB"><enum>(1)</enum><text>in subsection (b), by striking <quote>and (ii)</quote> and inserting <quote>(ii), and (mm)</quote>; and</text></paragraph><paragraph id="HF6F9452665064E9CA97C4A3A5BB49B9A"><enum>(2)</enum><text>by adding at the end the following new subsections:</text><quoted-block id="H40180E2E3AA5410CB875D64D23623C1F" style="OLC"><subsection id="H7567C9CFCD3E42D6A5B2D0401F7578D8"><enum>(mm)</enum><header>Specified Federal medical assistance percentage for home and community-Based services</header><paragraph id="H8A664CBD4AB1428F84A56A1612CF4374"><enum>(1)</enum><header>In general</header><text>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 (ll)), 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.</text></paragraph><paragraph id="HEDE4E61719B0439B96156D3B09A3C89A"><enum>(2)</enum><header>Access to essential HCBS</header><text>As a condition of receiving the Federal medical assistance percentage described in paragraph (1), a State shall enhance, expand, or strengthen the level of and access to 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:</text><subparagraph id="H583D4210CF554C3597B49FF935A0B1FF"><enum>(A)</enum><text>Lowering or eliminating access barriers and disparities in access or utilization identified in the State HCBS implementation plan.</text></subparagraph><subparagraph id="HB1BD883C6CF54ADF96544FC368FE3DB5"><enum>(B)</enum><text>Using <quote>no wrong door</quote> programs, providing presumptive eligibility for home and community-based services, and improving home and community-based services counseling and education programs.</text></subparagraph><subparagraph id="H202A05B28DCA47B2B43E7A49E66CD53B"><enum>(C)</enum><text>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.</text></subparagraph><subparagraph id="H942954A86C754272A42D384DE56631EE">
<enum>(D)</enum>
<text>Adopting processes to ensure that payments for home and community-based services and to the direct care workers who deliver them are sufficient to ensure that care and services are available to the extent described in the State HCBS implementation plan, In carrying out this paragraph the State shall review and update payment rates for home- and community-based services at least every 2 years, with an emphasis on ensuring that rates are adequate to recruit and retain a sufficient workforce to ensure access to the full set of services for eligible individuals as determined under subsection (ll) and through a transparent process involving meaningful 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.</text>
</subparagraph><subparagraph id="H63FACFC4D76D4710ABC7F84623885C8B"><enum>(E)</enum><text>Developing a process to ensure that increases in payment rates for home and community-based services are—</text><clause id="HB852DDA980A544DEA83E8517FBE9FD5B"><enum>(i)</enum><text>at a minimum, proportionately passed through to direct care workers and in a manner that is determined with input from the stakeholders described in paragraph (D); and</text></clause><clause id="H45F8AF0AA98B433A938385BE521AACB6"><enum>(ii)</enum><text>incorporated into payment rates for home and community-based services provided under this title by a managed care entity (as defined in section 1932(a)(1)(B)) or a prepaid inpatient health plan or prepaid ambulatory health plan, as defined in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation), under a contract with the State.</text></clause></subparagraph><subparagraph id="HB6ACD6B91664404B9572AAF909E16E7F"><enum>(F)</enum><text>Updating, developing, and adopting qualification standards and training opportunities for the continuum of providers of home and community-based services, including programs for independent providers of such services and agency direct care workers, as well as unique programs and resources for family caregivers.</text></subparagraph><subparagraph id="H6B0DFF0BA7914F1D8EADB1577BC73A4C"><enum>(G)</enum><text>Establishing an entity to strengthen the infrastructure supporting the delivery of service under consumer-directed models of care, as defined in section (nn).</text></subparagraph></paragraph><paragraph id="HA08F5CA308C74198BAE7E67B5BD381D9"><enum>(3)</enum><header>Exception</header><text>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.</text></paragraph><paragraph id="H8250CE7440604B81982375B7C7A82F78"><enum>(4)</enum><header>Administrative costs</header><text>Notwithstanding the per centum specified in section 1903(a)(7), with respect to amounts expended a year before the implementation of this subsection and for four years after, for administrative costs for expanding and enhancing home and community-based services, including for enhancing the Medicaid data and technology infrastructure, modifying rate setting processes, adopting, using, and reporting quality measures adopting or improving training programs for direct care workers and family caregivers, and adopting, carrying out, or enhancing programs that register qualified direct care workers or connect beneficiaries to qualified direct care workers under section (nn), such per centum shall be increased to 80 percent.</text></paragraph></subsection><subsection id="HA27D98D3FE8941F3B7475AA9C4E5411D"><enum>(nn)</enum><header>HCBS infrastructure To support self-Directed care models for
the delivery of services</header><text>For the purposes of paragraph (2)(G) of section (mm), the requirements of this paragraph, with respect to a State and fiscal year quarter, are that the State establishes directly or by contract with 1 or more non-profit entities, a program to support self-directed models for the delivery of services for the performance of all of the following functions:</text><paragraph id="H0763F7F05DD647C29A69C3540EEF986B"><enum>(1)</enum><text>Registering qualified direct care workers and assisting beneficiaries in finding direct care workers.</text></paragraph><paragraph id="H129F21A3A37645F294FAD96D18CAA7B6"><enum>(2)</enum><text>Undertaking activities to recruit and train independent providers to enable beneficiaries to direct their own care, including by providing or coordinating training for beneficiaries on self-directed care.</text></paragraph><paragraph id="H79F46031128246988D2F531505E8BAFD"><enum>(3)</enum><text>Ensuring the safety of, and supporting the quality of, care provided to beneficiaries, such as by conducting background checks and addressing complaints reported by recipients of home and community-based services.</text></paragraph><paragraph id="H66741228F4DF4CEE91B7CA117684749B"><enum>(4)</enum><text>Facilitating coordination between State and local agencies and direct care workers for matters of public health, training opportunities, changes in program requirements, workplace health and safety, or related matters.</text></paragraph><paragraph id="HB677F1397C5644BCB59D62123EC797EE"><enum>(5)</enum><text>Supporting beneficiary hiring of independent providers of home and community-based services through an agency with choice or similar model, including by processing applicable tax information, collecting and processing timesheets, submitting claims and processing payments to such providers.</text></paragraph><paragraph id="HB128053D99304D8EBF8892B9B8D35673"><enum>(6)</enum><text>To the extent a State permits beneficiaries to hire a family member or individual with whom they have an existing relationship to provide home and community-based services, providing support to beneficiaries who wish to hire a caregiver who is a family member or individual with whom they have an existing relationship, such as by facilitating enrollment of such family member or individual as a provider of home and community-based services under the State plan or a waiver of such plan.</text></paragraph><paragraph id="HA78545CCEC5D4005B9ABB5CF94346812"><enum>(7)</enum><text>Ensuring that program policies and procedures allow for cooperation with labor organizations that bargain on behalf of direct care workers in the case of a State in which the direct care workers in the State have elected to join, or form, such a labor organization, or, in the case of a State in which such workers have not joined or formed such a labor organization, are neutral with regard to such workers joining or forming such a labor organization.</text></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="HDD80319B16154761AF61BBFC9F90280D"><enum>(e)</enum><header>Conforming amendments</header><paragraph id="H79F3BC0E40B649BE9FB351EF2E3E571A"><enum>(1)</enum><header>In general</header><text>Title XIX of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396">42 U.S.C. 1396 et seq.</external-xref>) is amended—</text><subparagraph id="HB2BA28DAEA5743DF92F572D274515B4A"><enum>(A)</enum><text>in section 1905(a), in the matter preceding the first numbered paragraph—</text><clause id="H1B4D0491387A4CE69C44DD050983BD58"><enum>(i)</enum><text>in clause (xv), by striking the comma at the end and inserting <quote>, or</quote>;</text></clause><clause id="H50F69A11A1404F32A2A52BD59FA42FB4"><enum>(ii)</enum><text>in clause (xvi)—</text><subclause id="H0EA14A5071A946B8A39938D8262D3159"><enum>(I)</enum><text>by moving the left margin 2 ems to the left; and</text></subclause><subclause id="H517C09C9893042AFB6A54E3B59F1673E"><enum>(II)</enum><text>by striking <quote>, or</quote> and inserting a comma; and</text></subclause></clause><clause id="H9D9E0BD13FD94320AA7785DF192851B8"><enum>(iii)</enum><text>by striking clause (xvii); and</text></clause></subparagraph><subparagraph id="H545DA6B951064438B4A77DA5C97F5E6C"><enum>(B)</enum><text>in section 1943(b)(5), by striking <quote>the State</quote> and all that follows through the period at the end and inserting <quote>a determination be conducted on an annual basis (or on such longer basis as specified by the State) in accordance with section 1905(ll) for purposes of providing home and community-based services under the State plan (or waiver of such plan).</quote>.</text></subparagraph></paragraph><paragraph id="HFC168CD23FC641B58882061787155D39"><enum>(2)</enum><header>Effective date</header><subparagraph id="HF2197904595842BDAAF1243CA4885833"><enum>(A)</enum><header>In general</header><text>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.</text></subparagraph><subparagraph id="H5C830120FAEF43A7A7519F531DE8B564"><enum>(B)</enum><header>Exception for States authorized to continue operating HCBS waivers</header><text>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 (<external-xref legal-doc="usc" parsable-cite="usc/42/1396n">42 U.S.C. 1396n</external-xref>), 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.</text></subparagraph></paragraph></subsection></section><section id="H7945FA4E4F964540AB5B9324677881CF" commented="no"><enum>103.</enum><header>Medicaid eligibility modifications</header><text display-inline="no-display-inline">Section 1902 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396a">42 U.S.C. 1396a</external-xref>) is amended—</text><paragraph id="HF8C959CCE1A64F3B883A828BAACCC306"><enum>(1)</enum><text>in subsection (a)—</text><subparagraph id="H8A42D05D828740FBBB435985BE6D6822" commented="no"><enum>(A)</enum><text>in paragraph (10)—</text><clause id="HAE8185E57BA24FA3B8D1040CAC504EBE" commented="no"><enum>(i)</enum><text>in subparagraph (A)(i)—</text><subclause id="H754E5725CF654B5BB71DACCE6C3D47EF" commented="no"><enum>(I)</enum><text>in subclause (VIII), by striking <quote>; or</quote> and inserting a semicolon;</text></subclause><subclause id="HFACE4C88C6834C948197175C3CA46A39" commented="no"><enum>(II)</enum><text>in subclause (IX)(dd), by striking the semicolon at the end and inserting <quote>; or</quote>; and</text></subclause><subclause id="H1FCCB3FC4ADA4D4C88ED2B4A20D72777" commented="no"><enum>(III)</enum><text>by inserting after subclause (IX) the following new subclause:</text><quoted-block id="HEF8FE6B3E42D45BBA7B2F6B086BC03AA" style="OLC"><subclause id="H94F06984C4BC4427B09E89C0472E92C8" commented="no"><enum>(X)</enum><text>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 (ll)(3)(A) and are not described in a previous subclause of this clause and whose income does not exceed the greater of—</text><item id="HE9B9223B4BC24D0CBAF9295CC5092DFC" commented="no"><enum>(aa)</enum><text>150 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved; and</text></item><item id="H343C43A96F1446C6809575201ABCBC62" commented="no"><enum>(bb)</enum><text>300 percent of the supplemental security income benefit rate established by section 1611(b)(1);</text></item></subclause><after-quoted-block>; and</after-quoted-block></quoted-block></subclause></clause><clause id="HC534A3F599834C14805734AD9688F4A8" commented="no"><enum>(ii)</enum><text>in subparagraph (A)(ii)—</text><subclause id="H4EE5CBC3C815495084EE6A2A55D882C7" commented="no"><enum>(I)</enum><text>in subclause (XXII), by striking <quote>; or</quote> and inserting a semicolon;</text></subclause><subclause id="H832B1D025E494CB18AA5486A460FF119" commented="no"><enum>(II)</enum><text>in subclause (XXIII), by striking the semicolon at the end and inserting <quote>; or</quote>; and</text></subclause><subclause id="H92108929F7D04A4A9E2D37483D2A6D4B" commented="no"><enum>(III)</enum><text>by adding at the end the following new subclause:</text><quoted-block id="H21EBA5E4BC7245B4AE4A0B9429134160" style="OLC"><subclause id="H3CA823DDD2DD4A2C80B43229979CF261" commented="no"><enum>(XXIV)</enum><text>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;</text></subclause><after-quoted-block>; and </after-quoted-block></quoted-block></subclause></clause></subparagraph><subparagraph id="H26D22C0E026D4EB59B4BBAC3E3518A7B" commented="no"><enum>(B)</enum><text>by amending paragraph (34) to read as follows:</text><quoted-block style="OLC" id="HC41C9F1AD9424BCA8276BE847D2BEC99" display-inline="no-display-inline"><paragraph id="H9485B74A6832453DA5FBD75FC6454022" commented="no"><enum>(34)</enum><text display-inline="yes-display-inline">provides that in the case of any individual who has been determined to be eligible for medical assistance under the plan, such assistance will be made available to him for care and services included under the plan and furnished in or after the third month before the month in which he made application (or application was made on his behalf in the case of a deceased individual) for such assistance if such individual was (or upon application would have been) eligible for such assistance at the time such care and services were furnished and, that if care or services are provided through a service plan or any similar document, including services provided under the authority of any provision of section 1115 or 1915, medical assistance must be available pursuant to this subsection without regard to whether the service plan or similar document was developed before or after the care or services were provided;</text></paragraph><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph id="H06E3A4A1EDAA4F62B3D33BE11B7B3141"><enum>(2)</enum><text>in subsection (xx)(9)(A)(ii)—</text><subparagraph id="HE0EBC513E32F43ADBCDBD1906900C3F8"><enum>(A)</enum><text>in subclause (VIII), by striking <quote>or</quote> at the end;</text></subparagraph><subparagraph id="HB38D07D7A0194D40A7F6A637BE6FF600"><enum>(B)</enum><text>in subclause (IX), by striking the period and inserting <quote>; or</quote>; and</text></subparagraph><subparagraph id="H1064F73E25DB44CD9A7E8A0CD2CA8D29"><enum>(C)</enum><text>by adding at the end the following new subclause:</text><quoted-block style="OLC" id="H945A4CE73B6442D291586D1623E7B20D" display-inline="no-display-inline"><subclause id="HCA9ABBCC6DE5440296D1864131BDFBE5"><enum>(X)</enum><text display-inline="yes-display-inline">who is described in subclause (X) of subsection (a)(10)(A)(i) or subclause (XXIV) of subsection (a)(10)(A)(ii).</text></subclause><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></section><section id="H45DF78F62C2D416DBD049CC285AEC0CE"><enum>104.</enum><header>Home and community-based services implementation plan</header><subsection id="HE01E2B47B5CD498FA5811986E7F8134D" commented="no"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Section 1902 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396a">42 U.S.C. 1396a</external-xref>) is amended—</text><paragraph id="H30D7CC587FF6491C90ECFDE0AB700093" commented="no"><enum>(1)</enum><text>in subsection (a)—</text><subparagraph id="HF586C052B8374FE1A5DDE451209744BE" commented="no"><enum>(A)</enum><text>in paragraph (88), by striking <quote>and</quote> at the end;</text></subparagraph><subparagraph id="H54A305A2700E433195BBF71A0056E99B" commented="no"><enum>(B)</enum><text>in paragraph (89), by striking the period and inserting <quote>; and</quote>; and</text></subparagraph><subparagraph id="H2F50476A060A4BC48441098641B89452" commented="no"><enum>(C)</enum><text>by inserting after paragraph (89) the following new paragraph:</text><quoted-block style="OLC" id="HA7AB5241B9C94083A3EA8293A8F36349" display-inline="no-display-inline"><paragraph id="H34E82336C7E548009B8DE4AB0506488C" commented="no"><enum>(90)</enum><text display-inline="yes-display-inline">provide that, 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, the State shall submit to the Secretary the implementation plan described in subsection (yy).</text></paragraph><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph id="H6803057F2EDC4AC3A293A3646A73BBAD" commented="no"><enum>(2)</enum><text>by adding at the end the following new subsection:</text><quoted-block style="OLC" id="H232458F512A14B55B5752D053B557110" display-inline="no-display-inline"><subsection id="HB39D2668AD434D0EB6E00FE8884C26A7"><enum>(yy)</enum><header>Implementation plan</header><text>For purposes of subsection (a)(90), an implementation plan described in this subsection is a plan developed by a State that includes the following:</text><paragraph id="HCCED7AE36BFC444EBD47CE2F1FEA290C"><enum>(1)</enum><text>An explanation of how the State will operationalize the definition of an eligible individual under section 1905(ll), including the process for determinations specified in paragraph (3)(A)(i) of such section.</text></paragraph><paragraph id="H70FBA61AFDC246F69EA406477BD0625F"><enum>(2)</enum><text>A description of the characteristics of the State’s direct care workforce that provides home- and community-based services, including the number of workers, the average and range of direct care worker wages or service payments, the health and other workplace benefits provided to workers, turnover and vacancy rates, and an explanation of the State’s plan to ensure a stable and high quality workforce and how the State plans to ensure that compensation for individuals furnishing home and community-based services is sufficient to ensure a sufficient supply of workers to provide services to all eligible individuals and plans to identify and address any additional workforce issues.</text></paragraph><paragraph id="H081A56134A7C4237B99E084559410FAB"><enum>(3)</enum><text>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 subsection, including a breakdown of use of such services by demographics (as defined in section 2 of the HCBS Access Act), compared to such services that are required under the amendments made by section 102 of such Act, and a description of numerical goals to increase access to such services that have barriers to access for populations in need of such services.</text></paragraph><paragraph id="HD5993383E5CF4D858E8578C3B02E3C09"><enum>(4)</enum><text>A description of how the State will incorporate existing State disability and aging 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.</text></paragraph><paragraph id="HC389DF4E16054ACF999C83B56E10876D" commented="no"><enum>(5)</enum><text>A plan for carrying out outreach and education activities with respect to the availability of such services through appropriate entities, 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 <quote>No Wrong Door Program</quote>).</text></paragraph><paragraph id="HC732040BC4EC426BAE5093C35B9D255C"><enum>(6)</enum><text>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.</text></paragraph><paragraph id="HADB2D010C61B4A139CEDAE7016CA48FE"><enum>(7)</enum><text>A State with federally-recognized Indian tribes, Indian health programs, and/or urban Indian health organizations shall include a process to consult with the Indian tribes, and seek advice from Indian Health programs and urban Indian health organizations in the State.</text></paragraph><paragraph id="HDFCEB96A9AC842D8BD6BE801611253A6"><enum>(8)</enum><text>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, how the State will ensure an adequate provider network to provide access to and choice of provider, 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(ll), as added by section 102 of the HCBS Access Act.</text></paragraph><paragraph id="HD67834E1901643B380FD3E5C484240C9"><enum>(9)</enum><text>A plan for how the State will prioritize individuals who have already met eligibility requirements but are on waiting lists to receive HCBS and ensure those individuals do not experience an increase in the amount of time they will wait to receive services.</text></paragraph><paragraph id="HA1B9A93227364486BB0CFFB6F0BB7EFF"><enum>(10)</enum><text>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.</text></paragraph><paragraph id="H41F2A828AAD046D589CC234E27FB6D9E"><enum>(11)</enum><text>How the State will coordinate eligibility for such services with other disability eligibility programs, such as disability buy-in programs.</text></paragraph><paragraph id="H25DC477288804BC2AD17648FC16FB5E3"><enum>(12)</enum><text>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 of the HCBS Access Act).</text></paragraph><paragraph id="HDB4B11657AAD41349CC9896208309582"><enum>(13)</enum><text>A description of how the State will evaluate and address disparities based on age, disability, race, ethnicity, sexual orientation, gender identity, and geographic equity.</text></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H5F5A937F246746B28450DDD3419CB696"><enum>(b)</enum><header>FMAP increase</header><text>Section 1903(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396b">42 U.S.C. 1396b(a)</external-xref>) is amended—</text><paragraph id="HC083D7E7C00445888A84CA58A95E53B3"><enum>(1)</enum><text>in paragraph (6), by striking <quote>plus</quote> at the end;</text></paragraph><paragraph id="H038FF248F7D342028B0800AF9F48653D"><enum>(2)</enum><text>by redesignating paragraph (7) as paragraph (8); and</text></paragraph><paragraph id="H9C2FCCF157E749C7A9E04F32EB920AF2"><enum>(3)</enum><text>by inserting after paragraph (6) the following new paragraph:</text><quoted-block style="OLC" id="H4EB4E5CE80554CD98318F2CE11B9B271" display-inline="no-display-inline"><paragraph id="H815C3963C0EE4094946222F10A8A8CC5"><enum>(7)</enum><text display-inline="yes-display-inline">an amount equal to 100 percent of the sums expended during the quarter which are attributable to the costs of developing the implementation plan described in section 1902(yy); plus</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="HC12285BACB03420989807D30EF59CEF0"><enum>105.</enum><header>Quality of services</header><subsection id="H261C9859222046BB9CA90ACA6DE99DFE"><enum>(a)</enum><header>In general</header><paragraph id="H0D2E09A162B74DD4891942DF149B133C"><enum>(1)</enum><header>Development of metrics</header><text>Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services, 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.</text></paragraph><paragraph id="H304E56414C1A4878B9F446DCC1F0AC25"><enum>(2)</enum><header>Process</header><text>The Secretary shall develop the metrics described in paragraph (1) through a public process, which shall provide opportunities for stakeholders to participate.</text></paragraph></subsection><subsection id="HC37D0008E34941FFAEA8EE68995134BD"><enum>(b)</enum><header>Updating metrics</header><text>The Secretary, 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.</text></subsection><subsection id="H922C41895F2B43B1AED80F5B5A9601F3"><enum>(c)</enum><header>State implementation funding</header><text>The Secretary may award funds, from the amount appropriated under subsection (d), to States for the purpose of implementing the metrics developed under this section.</text></subsection><subsection id="HA304DD29E9DB4969A2532BA946E181A8"><enum>(d)</enum><header>Appropriation</header><text>There is appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $200,000,000 for fiscal year 2026, to remain available until expended, for the purpose of carrying out this section.</text></subsection></section><section id="HF1F9D934E5684D2FA812152048F296B1"><enum>106.</enum><header>Reports; technical assistance; other administrative requirements</header><subsection id="H7316C093F1F9431AA7E770E672A9409B"><enum>(a)</enum><header>Reports</header><text>The Secretary shall submit to the Committee on Energy and Commerce of the House of Representatives, the Committee on Education and Workforce 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:</text><paragraph id="HC46FF564EB734C35864290940014E822"><enum>(1)</enum><header>Interim report</header><text>Not later than 2 years after the date of enactment of this Act, a report that describes—</text><subparagraph id="HE4790B1B4E70413292DA33442FC5A04F"><enum>(A)</enum><text>State efforts to develop their HCBS implementation plans; and</text></subparagraph><subparagraph id="HFDBBF8A7575A4510B80FD54A64F5694F"><enum>(B)</enum><text>the funds awarded to States.</text></subparagraph></paragraph><paragraph id="HC5E74E58186B464DA358F3B41C3CEE6B"><enum>(2)</enum><header>First implementation report</header><text>Not later than 4 years after the date of enactment of this Act, a report that includes the following:</text><subparagraph id="H3689FF88DD784A588A89ADCBD40CF169"><enum>(A)</enum><text>A description of the HCBS implementation plans approved by the Secretary under section 104.</text></subparagraph><subparagraph id="H644C2AFC42D34E30ADA065D5E6EA0B40"><enum>(B)</enum><text>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.</text></subparagraph><subparagraph id="H12169B0C3736420D865FC3C54BE57708"><enum>(C)</enum><text>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.</text></subparagraph></paragraph><paragraph id="H1238E20E271343D5A790E2E9150AD3B6"><enum>(3)</enum><header>Subsequent reports</header><text>Not later than 7 years after the date of enactment of this Act, and every 3 years thereafter, a report that includes the following:</text><subparagraph id="H94CA2DB780194338B6B1305120B93656"><enum>(A)</enum><text>The number of HCBS program improvement States and the funds awarded to States to develop their plans.</text></subparagraph><subparagraph id="H6BE331B039A545FFB6F850524078F0EA"><enum>(B)</enum><text>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(ll)(5) of the Social Security Act (as added by section 102).</text></subparagraph><subparagraph id="H1C180F2FE1954A2D96775A6275ECE7DC"><enum>(C)</enum><text>A summary of outcomes related to home and community-based services core quality measures and beneficiary and family caregiver surveys.</text></subparagraph><subparagraph id="HABB42903B0104675A1499601D3802463"><enum>(D)</enum><text>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.</text></subparagraph></paragraph></subsection><subsection id="HCFAC74AA590242D98F2554DCB9DCA824"><enum>(b)</enum><header>Technical assistance; guidance; regulations</header><text>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(mm) 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.</text></subsection><subsection id="H2D659DFD0DF140629B9B709F5AB45899"><enum>(c)</enum><header>Recommendations To guide HCBS implementation</header><paragraph id="HD6BB5B5D18BC41E7A1FC11B44C20159E"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph><paragraph id="HE59B2026C67E44B5B01C270DF4524BAE"><enum>(2)</enum><header>Stakeholder consultation</header><subparagraph id="HDC2B09517B1747F9A18BE0C8E6AC1A73"><enum>(A)</enum><header>In general</header><text>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, educational agencies, and aging, disability, and workforce advocates.</text></subparagraph><subparagraph id="H871995D47D384E0E910BC628D5D3DE2B"><enum>(B)</enum><header>Consultation with current and potential HCBS beneficiaries and
family caregivers</header><text>As part of the process of developing recommendations under subparagraph (A), the Secretary shall—</text><clause id="H88849608AC784ECBA69DC01D273BD931"><enum>(i)</enum><text>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</text></clause><clause id="H135B6185464F4DF290E2A3CC92E81361"><enum>(ii)</enum><text>seek to achieve parity in terms of the level of participation in the development of such recommendations between—</text><subclause id="H89C253643C29487296617F1903EFE5F8"><enum>(I)</enum><text>current and potential recipients of home and community-based services and family caregivers of such recipients; and</text></subclause><subclause id="H2A73674F000F41DF93B1E305F564F4B3"><enum>(II)</enum><text>other categories of stakeholder described in subparagraph (A).</text></subclause></clause></subparagraph></paragraph></subsection><subsection id="H6C8A777CDB1E4AF888843CE9C1C46F29"><enum>(d)</enum><header>Funding</header><text>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 2026, to remain available until expended.</text></subsection></section><section id="HC1142B7D54034EE996808CF43E6C8CC8"><enum>107.</enum><header>Quality measurement and improvement</header><subsection id="H73B6F8E9FC2E447EAF75B66C80E47B16" commented="no"><enum>(a)</enum><header>Development and publication of core and supplemental sets of HCBS quality measures</header><paragraph id="HAC1F60A3C7264451BFE30C12AAC4FB6F" commented="no"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph><paragraph id="H4E8E6BA0F9AC4B0DBB95AAD2FD5D78AF" commented="no"><enum>(2)</enum><header>Regular reviews and updates</header><text>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.</text></paragraph><paragraph id="H23D80A8EB9E64C91A35CDFC5F48F206B" commented="no"><enum>(3)</enum><header>Requirements</header><subparagraph id="HD48A6BEEED114D5D888BF5B55F6A36D1" commented="no"><enum>(A)</enum><header>Interagency collaboration; stakeholder input</header><text>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—</text><clause id="H351E5360AB8C4F1F8C15A6744CAC0C09" commented="no"><enum>(i)</enum><text>collaborate with subagency heads determined appropriate by the Secretary; and</text></clause><clause id="H132FF739FD3948B382F628C1195299DD" commented="no"><enum>(ii)</enum><text>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.</text></clause></subparagraph><subparagraph id="HA3A2340F7EE34D75903FD559D7FD9604" commented="no"><enum>(B)</enum><header>Reflective of full array of services</header><text>Such core set and supplemental set of home and community-based services quality measures shall—</text><clause id="H316B5F5396E743B6915FD7E49FB01C63" commented="no"><enum>(i)</enum><text>reflect the full array of home and community-based services and recipients of such services, including adults and children; and</text></clause><clause id="H200F8EADCB8747B3BCCCE0173994D0AF" commented="no"><enum>(ii)</enum><text>include—</text><subclause id="HDCC1DBD9C7054017988F06D8519A5168" commented="no"><enum>(I)</enum><text>outcomes-based measures;</text></subclause><subclause id="H418F17898ADD464C987FA066D018326A" commented="no"><enum>(II)</enum><text>measures of availability of services;</text></subclause><subclause id="H46C6255C256E4F32AD8AF19D1BD7C83D" commented="no"><enum>(III)</enum><text>measures of provider capacity and availability;</text></subclause><subclause id="H58547C4317BD46F9860F8E7E37B4C932" commented="no"><enum>(IV)</enum><text>measures related to person-centered care;</text></subclause><subclause id="H625CF6B5F00645739EC30A24B1135D49" commented="no"><enum>(V)</enum><text>measures specific to self-directed care;</text></subclause><subclause id="H04AF6D33051D46BCBD5CDE4BF9A240EB" commented="no"><enum>(VI)</enum><text>measures related to transitions to and from institutional care;</text></subclause><subclause id="H5D2E0F96A2CC4D879299B78DE11E8800" commented="no"><enum>(VII)</enum><text>beneficiary and family caregiver surveys; and</text></subclause><subclause id="H5AB6E5A0AFA843E28E8261183EDF38B4" commented="no"><enum>(VIII)</enum><text>measures related to outcomes by race/ethnicity, language, sex, gender identity, geography, and other demographic factors to track and reduce health disparities.</text></subclause></clause></subparagraph><subparagraph id="H98BF7E130495440692846F848FBA79FF" commented="no"><enum>(C)</enum><header>Demographics</header><text>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).</text></subparagraph></paragraph><paragraph id="HD8B15D3572AE414D8DF1A097F998039B" commented="no"><enum>(4)</enum><header>Funding</header><text>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 2026, to remain available until expended.</text></paragraph></subsection><subsection id="H44D9F112F4224F7BAED8B9CE119C3FF7"><enum>(b)</enum><header>State adoption and reports</header><paragraph id="H01487CC399E243328CD2ED21149AA5FB"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph><paragraph id="HE78D7ECDE5DD4CAEBA4A5177075701FB"><enum>(2)</enum><header>Process</header><text>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).</text></paragraph><paragraph id="H40E4DD518EF64AF2892E267837B48E46"><enum>(3)</enum><header>Publication of quality measures</header><text>Each State Medicaid program shall annually make the information reported to the Secretary under paragraph (1) available to the public.</text></paragraph><paragraph id="HC1927E89B3F84F6D8EEB7E4901B0BF63"><enum>(4)</enum><header>Increased Federal matching rate for adoption and reporting</header><text>Section 1903(a)(3) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396b">42 U.S.C. 1396b(a)(3)</external-xref>) is amended—</text><subparagraph id="HA6356675CD2F4B1D830718026B41FC51"><enum>(A)</enum><text>in subparagraph (F)(ii), by striking <quote>plus</quote> after the semicolon and inserting <quote>and</quote>; and</text></subparagraph><subparagraph id="HCC507191716A4DAC936844505992C1B6"><enum>(B)</enum><text>by inserting after subparagraph (F), the following:</text><quoted-block id="HE0CCAD7BD2C34B799399D38497F60CAF" style="OLC"><subparagraph id="H0090D8AA776F442A939FF1D56D009424"><enum>(G)</enum><text>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</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection><subsection id="H44B4A1C9B4F04330AEB936E47F493C18"><enum>(c)</enum><header>Ombudsman</header><text display-inline="yes-display-inline">Each State shall establish an HCBS ombudsman office that—</text><paragraph id="H4095747E555B4D048CB02EAF30AA1B60"><enum>(1)</enum><text display-inline="yes-display-inline">operates independently from the State Medicaid agency and managed care entities;</text></paragraph><paragraph id="H330635F7A264401EBCD1E97FE8ACD634"><enum>(2)</enum><text display-inline="yes-display-inline">provides direct assistance to beneficiaries and their families; and</text></paragraph><paragraph id="HD178ED4F29E1443F8A82DCB6B6B525EF"><enum>(3)</enum><text display-inline="yes-display-inline">identifies and reports systemic problems to State officials, the public, and the Secretary.</text></paragraph></subsection></section><section id="HFC423C7CDCB54EDC9563653D34636C94"><enum>108.</enum><header>Making permanent the State option to extend protection under medicaid for recipients of home and community-based services against spousal impoverishment</header><subsection id="H5BBB5D7FF6204D3B8B073B3D1943D395"><enum>(a)</enum><header>In general</header><text>Section 1924(h)(1)(A) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r-5">42 U.S.C. 1396r–5(h)(1)(A)</external-xref>) is amended by striking <quote>is described in section 1902(a)(10)(A)(ii)(VI)</quote> and inserting <quote>is an eligible individual (as defined in section 1905(ll)(3))</quote>.</text></subsection><subsection id="H45D6DA1D87DA4ACFAF2EDB55F1BFB78D"><enum>(b)</enum><header>Conforming amendment</header><text>Section 2404 of the Patient Protection and Affordable Care Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r-5">42 U.S.C. 1396r–5</external-xref> note) is amended by striking <quote>September 30, 2027</quote> and inserting <quote>the date of enactment of the HCBS Access Act</quote>.</text></subsection></section><section id="H4C332CB7E49648879B5749F140DEF3B1" commented="no"><enum>109.</enum><header>Permanent extension of money follows the person rebalancing demonstration</header><text display-inline="no-display-inline">Section 6071(h)(1)(L) of the Deficit Reduction Act of 2005 (<external-xref legal-doc="usc" parsable-cite="usc/42/1396a">42 U.S.C. 1396a</external-xref> note(h)(1)(L)) is amended by striking <quote>each of fiscal years 2024 through 2027</quote> and inserting <quote>each fiscal year after 2025</quote>.</text></section><section id="HEF372AE618C844019859371C4AA04B4C" display-inline="no-display-inline"><enum>110.</enum><header>Liens, adjustments, and recoveries for medical assistance</header><subsection id="HC93546E9B0564EC596DCA8C8C98FE517"><enum>(a)</enum><header>Liens</header><text display-inline="yes-display-inline">Section 1917(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396p">42 U.S.C. 1396p(a)</external-xref>) is amended—</text><paragraph id="H054DEB81CA434266B23670432444FA4E"><enum>(1)</enum><text>in paragraph (1)—</text><subparagraph id="HD9CF33F22CCE4C8AA7993ED79BFE70C4"><enum>(A)</enum><text>in the matter preceding subparagraph (A), by striking <quote>plan, except—</quote> and inserting <quote>plan, except, subject to paragraph (4)—</quote>; and</text></subparagraph><subparagraph id="HD211E3B542B84CC4BF2B16C3CA2AEF80"><enum>(B)</enum><text display-inline="yes-display-inline">in subparagraph (B), by striking <quote>in the case of</quote> and inserting <quote>with respect to liens imposed before the date of the enactment of the Stop Unfair Medicaid Recoveries Act, in the case of</quote>; and</text></subparagraph></paragraph><paragraph id="HAE6C318C7FF44465ACA26423BC03B8AA"><enum>(2)</enum><text>by adding at the end the following:</text><quoted-block style="OLC" id="HAC1D1C6A9D9C4198AE49CDF77A06F4D9" display-inline="no-display-inline"><paragraph id="H72B559FB6323469EB750C6A29BD7EEBA" indent="up1"><enum>(4)</enum><text display-inline="yes-display-inline">Notwithstanding any preceding provision of this subsection, not later than 90 days after the date of the enactment of this paragraph, a State shall—</text><subparagraph id="HD39B808443374D1B9435D84C0CE9995E"><enum>(A)</enum><text>withdraw any lien imposed under paragraph (1)(B) that is in effect as of such date; and</text></subparagraph><subparagraph id="HE5208930E1B848A395F7D2CE231B0B58"><enum>(B)</enum><text display-inline="yes-display-inline">notify each individual (or legal representative of such individual (or of such individual’s estate)) subject to such a lien so withdrawn of the withdrawal of such lien.</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H68654865A0CC48EB9D2393D10DBA8BC2"><enum>(b)</enum><header>Adjustments and recoveries</header><text display-inline="yes-display-inline">Section 1917(b) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396p">42 U.S.C. 1396p(b)</external-xref>) is amended—</text><paragraph id="H964E1CEF8FFA499281A7A351A0F74916"><enum>(1)</enum><text>in paragraph (1), by striking <quote>except that</quote> and inserting <quote>except that, subject to paragraph (6),</quote>; and</text></paragraph><paragraph id="HCE18334F9E85401185396AF657DB3F68"><enum>(2)</enum><text>by adding at the end the following:</text><quoted-block style="OLC" id="HE44EF527668246A498804ED33A201F74" display-inline="no-display-inline"><paragraph id="H58BE3EAB11334046B43F2BF57512AE92" indent="up1"><enum>(6)</enum><text display-inline="yes-display-inline">Notwithstanding any preceding provision of this subsection, no adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be initiated, maintained, or collected on or after the date of the enactment of this paragraph. Not later than 90 days after such date, a State shall—</text><subparagraph id="HB2D493638C8F46C991EC18D8F37C5F4F"><enum>(A)</enum><text>withdraw any lien in effect as of such date with respect to such medical assistance correctly paid; and</text></subparagraph><subparagraph id="HC04130C8088D4ED6B2A728FBCD7445E5"><enum>(B)</enum><text>notify each individual (or legal representative of such individual (or of such individual’s estate)) subject to such a lien so withdrawn of the withdrawal of such lien and the prohibition on adjustment or recovery under this paragraph.</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="HCDAFBBDF84E342B8A3933F134D67ADB5" commented="no"><enum>111.</enum><header>HCBS provider tax</header><text display-inline="no-display-inline">Section 1903(w) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396b">42 U.S.C. 1396b(w)</external-xref>) is amended—</text><paragraph id="H106D9892981D4EBB980A7A986E77B985" commented="no"><enum>(1)</enum><text display-inline="yes-display-inline">in paragraph (7)(A)—</text><subparagraph id="HEF8F797625A546F9A281A12C6FA899AF"><enum>(A)</enum><text>by redesignating clause (ix) as clause (x); and</text></subparagraph><subparagraph id="HC1A1CF7243584C3BB84B4706EE4B9D51"><enum>(B)</enum><text>by inserting after clause (viii) the following new clause:</text><quoted-block style="OLC" id="HF8F87E56B15B413CB018FD4516C22CAE" display-inline="no-display-inline"><clause id="H3286294B863B4BFBB85BB84919FF44A3" commented="no"><enum>(ix)</enum><text display-inline="yes-display-inline">home- and community-based services.</text></clause><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph id="HC3EFB43D0DEC418E8D67C582F6754BF2" commented="no"><enum>(2)</enum><text display-inline="yes-display-inline">in paragraph (4)(C)(ii), by inserting <quote>for a class of health care items and services other than the class described in paragraph (7)(A)(ix),</quote> after <quote>2026,</quote>.</text></paragraph></section><section id="H6B1CF67E7D814EE2B49658E851CF9E92"><enum>112.</enum><header>Repealing the requirement that States establish a Medicaid estate recovery program and limit the circumstances in which a State may place a lien on a Medicaid beneficiary’s property</header><subsection id="H3A4D01B2DAE14F208E7639183034DF5F"><enum>(a)</enum><header>Liens</header><text>Section 1917(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396p">42 U.S.C. 1396p(a)</external-xref>) is amended—</text><paragraph id="HD701CA2EE703472D8712A25C2E0215AD"><enum>(1)</enum><text>in paragraph (1)—</text><subparagraph id="HC2A684FA232A464F8DD3894ECD3E3372"><enum>(A)</enum><text>in the matter preceding subparagraph (A), by striking <quote>plan, except—</quote> and inserting <quote>plan, except, subject to paragraph (4)—</quote>; and</text></subparagraph><subparagraph id="H8C42AADD7C174C30A127C61C26792CAB"><enum>(B)</enum><text>in subparagraph (B), by striking <quote>in the case of</quote> and inserting <quote>with respect to liens imposed before the date of the enactment of the Stop Unfair Medicaid Recoveries Act, in the case of</quote>; and</text></subparagraph></paragraph><paragraph id="H00C88223EE7D4B2E80C75CD97EAADCF0"><enum>(2)</enum><text>by adding at the end the following:</text><quoted-block id="HC41BBE3CBE1E4334A8B838F2F1D8BDB6" style="OLC"><paragraph id="H317C2F7692AA4B1196A5761CB7E31658"><enum>(4)</enum><text>Notwithstanding any preceding provision of this subsection, not later than 90 days after the date of the enactment of this paragraph, a State shall—</text><subparagraph id="H3A5155608405441A9FA446847E321380"><enum>(A)</enum><text>withdraw any lien imposed under paragraph (1)(B) that is in effect as of such date; and</text></subparagraph><subparagraph id="HECFD1BCA6D9249589B730C38FB134F2E"><enum>(B)</enum><text>notify each individual (or legal representative of such individual (or of such individual’s estate)) subject to such a lien so withdrawn of the withdrawal of such lien.</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H1F1656309C314E4BAA48A1C7C9B5DBBE"><enum>(b)</enum><header>Adjustments and recoveries</header><text>Section 1917(b) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396p">42 U.S.C. 1396p(b)</external-xref>) is amended—</text><paragraph id="HC87CDD9152564BBF837BC9E7052E791E"><enum>(1)</enum><text>in paragraph (1), by striking <quote>except that</quote> and inserting <quote>except that, subject to paragraph (6),</quote>; and</text></paragraph><paragraph id="H23AB8D57ED0241C8BC5AB81E63DCA362"><enum>(2)</enum><text>by adding at the end the following:</text><quoted-block id="H61EB0E2BBCD84815AEB85996D4D3B00A" style="OLC"><paragraph id="HA7722A15448A491C8434E7A6416CFBED"><enum>(6)</enum><text>Notwithstanding any preceding provision of this subsection, no adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be initiated, maintained, or collected on or after the date of the enactment of this paragraph. Not later than 90 days after such date, a State shall—</text><subparagraph id="H38391560BCD247D391259CA3363B4EF7"><enum>(A)</enum><text>withdraw any lien in effect as of such date with respect to such medical assistance correctly paid; and</text></subparagraph><subparagraph id="H93DF74B118D640D8807863F8B023AFED"><enum>(B)</enum><text>notify each individual (or legal representative of such individual (or of such individual’s estate)) subject to such a lien so withdrawn of the withdrawal of such lien and the prohibition on adjustment or recovery under this paragraph.</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="HFC4131C7D7984216818EDE09B5A9D213" commented="no"><enum>113.</enum><header>Medicare amendment</header><text display-inline="no-display-inline">Section 1860D–14(a)(1)(D)(i) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395w-114">42 U.S.C. 1395w–114</external-xref>) is amended by striking <quote>or subsection (c) or (d) of section 1915 or under a State plan amendment under subsection (i) of such section</quote> and inserting <quote>, section 1915, 1115A, or under a State plan amendment</quote>.</text></section><enum>II</enum><header>Recognizing the Role of Direct Support Professionals</header><section id="HD40BD32A08DE4051BD1AA7FF9770A44C"><enum>201.</enum><header>Findings</header><text display-inline="no-display-inline">Congress finds the following:</text><paragraph id="H17A870336B374A95B67B5CF650F2A2AD"><enum>(1)</enum><text>Direct support professionals play a critical role in the care provided to children and adults with intellectual and developmental disabilities.</text></paragraph><paragraph id="HA0ECBADFE8884FC7992F9ED8C913D08E"><enum>(2)</enum><text>Providers of home and community-based services are experiencing difficulty hiring and retaining direct support professionals, with a national turnover rate of 39 percent as identified in a 2023 study by the National Core Indicators.</text></paragraph><paragraph id="HFA36051748964624977596BA9E365369"><enum>(3)</enum><text>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.</text></paragraph><paragraph id="HBE131307F3094FEE97BB3AA302762ECC"><enum>(4)</enum><text>A discrete occupational category for direct support professionals will help States and the Federal Government—</text><subparagraph id="H5D719985CC6E4A0CBD0A576903349259"><enum>(A)</enum><text>better interpret the shortage in the labor market of direct support professionals; and</text></subparagraph><subparagraph id="H25473634F4294BBC86F830C78E17C425"><enum>(B)</enum><text>collect data on the high turnover rate of direct support professionals.</text></subparagraph></paragraph><paragraph id="H4ED7045B0E304D27BB2A722DAB8A2850"><enum>(5)</enum><text>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.</text></paragraph><paragraph id="HBBD69A63F0CF42B9953961AEC8DC6903"><enum>(6)</enum><text>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.</text></paragraph><paragraph id="H2EB6FD298C6542CB8736BB8BABB99BD3"><enum>(7)</enum><text>Establishing a discrete occupational category for direct support professionals will—</text><subparagraph id="HE8F85BB795284508975B2D7F41F09FDA"><enum>(A)</enum><text>correct an inaccurate representation in the Standard Occupational Classification system;</text></subparagraph><subparagraph id="HADFD3AF65A4D4C0E9FFC86822D8F4EF0"><enum>(B)</enum><text>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</text></subparagraph><subparagraph id="H66EB87642060447E9ADDD2B388B03F50"><enum>(C)</enum><text>better align the Standard Occupational Classification system with related classification systems.</text></subparagraph></paragraph></section><section id="H95256CE9407748EA9DA4246D78CC3B43"><enum>202.</enum><header>Revision of standard occupational classification system</header><subsection id="H8FBFAC1B4C104362AACB19B7BAFE3789"><enum>(a)</enum><header>In general</header><text>The Director of the Office of Management and Budget (in this Act referred to as the <quote>Director</quote>) shall, as part of the first revision process of the Standard Occupational Classification system occurring after the date of enactment of this Act, consider establishing a separate code for direct support professionals as a subset of healthcare support occupations.</text></subsection><subsection id="HF4B8E465A51E4434A3CC9F3D7A5F0D88"><enum>(b)</enum><header>Report to Congress</header><text>If the Director decides not to establish the separate code for direct support professionals described in subsection (a), the Director shall, not later than 30 days after the Director announces in the Federal Register the final decision of the revision process described in such subsection, submit to the Committee on Homeland Security and Governmental Affairs of the Senate and the Committee on Education and Workforce of the House of Representatives a report explaining why such separate code was not established.</text></subsection></section><enum>III</enum><header>Support for the Direct Care Workforce</header><section id="H4A04B6AFC6FF490EB485FC83CE6B7455"><enum>301.</enum><header>Definitions</header><text display-inline="no-display-inline">In this title:</text><paragraph id="H13A6AE2C03114B64907A1ED380F74604"><enum>(1)</enum><header>Apprenticeship program</header><text>The term <term>apprenticeship program</term> means an apprenticeship program registered under the Act of August 16, 1937 (commonly known as the <quote>National Apprenticeship Act</quote>; 50 Stat. 664, chapter 663; <external-xref legal-doc="usc" parsable-cite="usc/29/50">29 U.S.C. 50 et seq.</external-xref>), including any requirement, standard, or rule promulgated under such Act.</text></paragraph><paragraph id="HABAF84A1E4D542F28BA85CFF204FE947"><enum>(2)</enum><header>Community college</header><text>The term <term>community college</term> 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 (<external-xref legal-doc="usc" parsable-cite="usc/20/1059c">20 U.S.C. 1059c</external-xref>) 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.</text></paragraph><paragraph id="HFB939E8FC62544B58CEA65D8926BFFF7"><enum>(3)</enum><header>Direct care professional</header><text>The term <term>direct care professional</term>—</text><subparagraph id="H0A01F72BC8E9485C9348ACB896768D09"><enum>(A)</enum><text>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—</text><clause id="HE433CDB6C5E143E496ADCFFAF4870735"><enum>(i)</enum><text>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;</text></clause><clause id="HC2FEC2F5472F49DC9AE133D1FE502884"><enum>(ii)</enum><text>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;</text></clause><clause id="H292DEB8D4C4642BD854FC992D4A20708"><enum>(iii)</enum><text>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;</text></clause><clause id="HE551370053054184BCF7B32343FF78A7"><enum>(iv)</enum><text>services that support such person or individual at home, work, school, or in any other community setting; or</text></clause><clause id="HF891DEEDD02F4E6C83698F5172B50205"><enum>(v)</enum><text>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</text></clause></subparagraph><subparagraph id="HCF0C7DA04BE9441AB79BB672183A235E"><enum>(B)</enum><text>may include—</text><clause id="HC831A6217F884802A5BB347FC9FCBE7A"><enum>(i)</enum><text>a service provider supporting people with intellectual disability and developmental disabilities, and other disabilities;</text></clause><clause id="H8D1A4B96A69D49068B1C67044E7D4044"><enum>(ii)</enum><text>a home and community-based services manager or direct support professional manager;</text></clause><clause id="H162D0355C9304ABB9F052A8D6E83D420"><enum>(iii)</enum><text>a self-directed care worker;</text></clause><clause id="H9493993B48BC4D2EAF3D8669D35F68FB"><enum>(iv)</enum><text>a personal care service worker;</text></clause><clause id="H083E620EC99D420E844AF9181215E370"><enum>(v)</enum><text>a direct care worker, as defined in section 799B of the Public Health Service Act (<external-xref legal-doc="usc" parsable-cite="usc/42/295p">42 U.S.C. 295p</external-xref>); or</text></clause><clause id="H8C766DBD24474530AA3282460FE2485B"><enum>(vi)</enum><text>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.</text></clause></subparagraph></paragraph><paragraph id="H8CA81B5BC34E4372AA6592C4D19A689F"><enum>(4)</enum><header>Direct care workforce</header><text>The term <term>direct care workforce</term> means the broad workforce of direct care professionals.</text></paragraph><paragraph id="HE547D28119DF46C2941FE713991C99BA"><enum>(5)</enum><header>Eligible entity</header><text>The term <term>eligible entity</term> means an entity—</text><subparagraph id="HF5B1369F6706421AAF86A16E7B61614A"><enum>(A)</enum><text>that is—</text><clause id="HC30CC2483B7D45C081B1B3DC1E98CDC9"><enum>(i)</enum><text>a State;</text></clause><clause id="H8D1A1BEEDEE74A1DB7B3A00F64B3ED6A"><enum>(ii)</enum><text>a labor organization, joint labor-management organization, or employer of direct care professionals;</text></clause><clause id="H97EF8307B178445B8D75FCAE19D1585D"><enum>(iii)</enum><text>an organization or 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;</text></clause><clause id="HE72AA88C8CA14FF7B8C7BB0BBE2F4CBA"><enum>(iv)</enum><text>an Indian Tribe, Tribal organization, or Urban Indian organization;</text></clause><clause id="H484FB9807FE048E786EA2C344BF5B8FE"><enum>(v)</enum><text>a community college or other institution of higher education; or</text></clause><clause id="HFC3A1C065DE74DB8841CCDE6D1FAB47E"><enum>(vi)</enum><text>a consortium of entities listed in any of clauses (i) through (v);</text></clause></subparagraph><subparagraph id="H9E3F64A73899424598F4F59A3D6B91C8"><enum>(B)</enum><text>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</text></subparagraph><subparagraph id="HD6D8CFC83DD54EBBBA1DECFB5E791FE7"><enum>(C)</enum><text>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.</text></subparagraph></paragraph><paragraph id="H3FBE99EA4B544C938EE2423D9D28F035"><enum>(6)</enum><header>Employer</header><text>The terms <term>employ</term> and <term>employer</term> have the meanings given the terms in section 3 of the Fair Labor Standards Act of 1938 (<external-xref legal-doc="usc" parsable-cite="usc/29/203">29 U.S.C. 203</external-xref>).</text></paragraph><paragraph id="HE16B79BC35BF4BF982A694F04DDEBA1E"><enum>(7)</enum><header>Family caregiver</header><text>The term <term>family caregiver</term> has the meaning given such term in section 2 of the RAISE Family Caregivers Act (<external-xref legal-doc="usc" parsable-cite="usc/42/3030s">42 U.S.C. 3030s</external-xref> note; <external-xref legal-doc="public-law" parsable-cite="pl/115/119">Public Law 115–119</external-xref>) and includes paid and unpaid family caregivers.</text></paragraph><paragraph id="HA64F5E9C00934225BCC12A32BE8C99FB"><enum>(8)</enum><header>Indian tribe; tribal organization</header><text>The terms <term>Indian Tribe</term> and <term>Tribal organization</term> have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act (<external-xref legal-doc="usc" parsable-cite="usc/25/5304">25 U.S.C. 5304</external-xref>).</text></paragraph><paragraph id="H5963B4487A7141D78368A1C8F264D31D"><enum>(9)</enum><header>Institution of higher education</header><text>The term <term>institution of higher education</term> means—</text><subparagraph id="HC97FA352D8EF44CE89A5BEB4F925B001"><enum>(A)</enum><text>an institution of higher education defined in section 101 of the Higher Education Act of 1965 (<external-xref legal-doc="usc" parsable-cite="usc/20/1001">20 U.S.C. 1001</external-xref>); or</text></subparagraph><subparagraph id="H826850EE7F744008ACD691C7543D4F2A"><enum>(B)</enum><text>an institution of higher education defined in section 102(a)(1)(B) of such Act (<external-xref legal-doc="usc" parsable-cite="usc/20/1002">20 U.S.C. 1002(a)(1)(B)</external-xref>).</text></subparagraph></paragraph><paragraph id="HFA1998175A5848E09B5F9B226F56800F"><enum>(10)</enum><header>Older adult</header><text>The term <term>older adult</term> means an individual who is 60 years of age or older.</text></paragraph><paragraph id="H2C4F55FE1EF140C4A679D5FFC9E07B25"><enum>(11)</enum><header>Person with a disability</header><text>The term <term>person with disability</term> means an individual with a disability, as defined in section 3 of the Americans with Disabilities Act of 1990 (<external-xref legal-doc="usc" parsable-cite="usc/42/12102">42 U.S.C. 12102</external-xref>).</text></paragraph><paragraph id="HF449D420182A4EE79339D6A70BFA7E9A"><enum>(12)</enum><header>Project participant</header><text>The term <term>project participant</term> 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.</text></paragraph><paragraph id="H8F31D0F0E4CC4243ADB2E963D104EA1F"><enum>(13)</enum><header>Secretary</header><text>The term <term>Secretary</term> means the Secretary of Health and Human Services, acting through the Administrator for Community Living.</text></paragraph><paragraph id="H8F4A3D0C017A4CED82ADF836CF00921B"><enum>(14)</enum><header>Self-directed care professional</header><text>The term <term>self-directed care professional</term> 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.</text></paragraph><paragraph id="HE39F5F8EC31C487EA7D31116B68C2E36"><enum>(15)</enum><header>Supportive services</header><text>The term <term>supportive services</term> 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.</text></paragraph><paragraph id="HDB62BF67D7E145A384705057760E93FD"><enum>(16)</enum><header>Urban Indian organization</header><text>The term <term>urban Indian organization</term> has the meaning given the term in section 4 of the Indian Health Care Improvement Act (<external-xref legal-doc="usc" parsable-cite="usc/25/1603">25 U.S.C. 1603</external-xref>).</text></paragraph><paragraph id="HB00D4F6C85DA4406920574B5CE01ED63"><enum>(17)</enum><header>Workforce innovation and opportunity act terms</header><text>The terms <term>career pathway</term>, <term>career planning</term>, <term>in-demand industry sector or occupation</term>, <term>individual with a barrier to employment</term>, <term>local board</term>, <term>on-the-job training</term>, <term>recognized postsecondary credential</term>, <term>region</term>, and <term>State board</term> have the meanings given such terms in section 3 of the Workforce Innovation and Opportunity Act (<external-xref legal-doc="usc" parsable-cite="usc/29/3102">29 U.S.C. 3102</external-xref>).</text></paragraph><paragraph id="HDDD347CE29E34D6AAB476AB07803C96B"><enum>(18)</enum><header>Work-based learning</header><text>The term <term>work-based learning</term> has the meaning given the term in section 3 of the Carl D. Perkins Career and Technical Education Act of 2006 (<external-xref legal-doc="usc" parsable-cite="usc/20/2302">20 U.S.C. 2302</external-xref>).</text></paragraph></section><section id="H9AFA4B3AFB6A402DBD525E589E67A120"><enum>302.</enum><header>Authority to establish a technical assistance center for building the direct care workforce</header><subsection id="H1EF8645D7E9B468B8A4A0298590DCFBE"><enum>(a)</enum><header>Program authorized</header><text>The Secretary shall establish a national technical assistance center (referred to in this section as the <quote>Center</quote>) 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—</text><paragraph id="HCA01382B92554D15AF39C6FDF4FA64CA"><enum>(1)</enum><text>supporting direct care workforce creation, training and education, recruitment, retention, and advancement; and</text></paragraph><paragraph id="H8A495789E5E749A3BD237F8E4DE5AA5C"><enum>(2)</enum><text>supporting family caregivers and activities of family caregivers as a critical part of the support team for older adults or people with disabilities.</text></paragraph></subsection><subsection id="H6B06F70B74A54BE2ADE0C6F106E473BD"><enum>(b)</enum><header>Advisory council</header><text>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.</text></subsection><subsection id="HD4082457B6DB43BF91F11003742321DD"><enum>(c)</enum><header>Activities</header><text>The Center may—</text><paragraph id="H0599A83B41AF44DC9889E8A545D0689B"><enum>(1)</enum><text>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;</text></paragraph><paragraph id="H96DE8504B8434F4283AF2A09C95DD429"><enum>(2)</enum><text>develop learning and dissemination strategies to—</text><subparagraph id="H0537BC9FF5144711845A54A291F8CF4E"><enum>(A)</enum><text>engage States and other entities in activities supported under this title and best practices; and</text></subparagraph><subparagraph id="HC4E3767414CD4DE18D876A1D130DC508"><enum>(B)</enum><text>distribute findings from activities supported by grants under this title;</text></subparagraph></paragraph><paragraph id="H9BDDB48DC4A6476E9CEA668E4C25BB8E"><enum>(3)</enum><text>develop recommendations for training and education curricula and other strategies for supporting family caregivers;</text></paragraph><paragraph id="H6EC6091890494B0BBA2F6CA5C4E557C0"><enum>(4)</enum><text>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;</text></paragraph><paragraph id="H9CC5EEA1E0164B018EF27E26CD9B974E"><enum>(5)</enum><text>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</text></paragraph><paragraph id="H866B937F3F5D472ABE0FBF8DEEFEE473"><enum>(6)</enum><text>develop strategies for assisting with reporting and evaluation of grant activities under section 305.</text></paragraph></subsection></section><section id="HD0D2E634269C4E2DB9E32E24CB54F481"><enum>303.</enum><header>Authority to award grants</header><subsection id="H5C922E67BE9744918D451690B776FD31"><enum>(a)</enum><header>Grants</header><paragraph id="H5005BF6262E9478D9818DDF91550B081"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph><paragraph id="HCA7BE0D0DDB6451E9435CF15E5A7C2A4"><enum>(2)</enum><header>Categories of grants</header><text>The categories of grants described in this paragraph are each of the following:</text><subparagraph id="H8B492848B3E2409CB58DB2DD39CBECCD"><enum>(A)</enum><header>Direct care professional grants</header><text>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.</text></subparagraph><subparagraph id="HCF1C8B49854C4210A4F51B86F293DB33"><enum>(B)</enum><header>Direct care professional managers grants</header><text>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.</text></subparagraph><subparagraph id="H74C5A93696254F4896ACFC795FDF32AF"><enum>(C)</enum><header>Self-directed care professionals grants</header><text>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.</text></subparagraph><subparagraph id="H8FEAAEE7DA6643968F025E0F89233058"><enum>(D)</enum><header>Family caregiver grants</header><text>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.</text></subparagraph></paragraph><paragraph id="H1165080C71E04A4B923C97406A33D753"><enum>(3)</enum><header>Projects for advancement opportunities</header><text>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.</text></paragraph></subsection><subsection id="H3A3DCA10C8384239B184EA91A908A247"><enum>(b)</enum><header>Treatment of continuation activities</header><text>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.</text></subsection></section><section id="H83445E11F44F4A6A8D77D9FDD04ED248"><enum>304.</enum><header>Project plans</header><subsection id="HDFAD8A28391A4CF59EED78F7E013EDB6"><enum>(a)</enum><header>In general</header><text>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.</text></subsection><subsection id="H130C9B5BFDF4438B90F506D46C4CC709"><enum>(b)</enum><header>Contents</header><text>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:</text><paragraph id="HDFAF76C875A940398B9FB30E2327DEAD"><enum>(1)</enum><text>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.</text></paragraph><paragraph id="H8ACA9A126A4E4889949E405259FA17A8"><enum>(2)</enum><text>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 (<external-xref legal-doc="usc" parsable-cite="usc/42/1315">42 U.S.C. 1315</external-xref>) or section 1915 of such Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396n">42 U.S.C. 1396n</external-xref>) 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.</text></paragraph><paragraph id="H9040301B0110434D9AE55B03FF9C8661"><enum>(3)</enum><text>An advisory committee to advise the eligible entity on activities to be carried out through the grant. Such advisory committee—</text><subparagraph id="H953200C7F4A34699A9957C50BD65A980"><enum>(A)</enum><text>may be comprised of entities listed in paragraph (12); and</text></subparagraph><subparagraph id="HFDAAF83A4D4D4BA0BE56EA98BCA2E4B3"><enum>(B)</enum><text>shall include—</text><clause id="H98363E0B41F64F279671DC33E1071E7A"><enum>(i)</enum><text>older adults or persons with a disability;</text></clause><clause id="H1035D75C97E94BF8B79FB40F1544E06E"><enum>(ii)</enum><text>organizations representing the rights and interests of people receiving services by the direct care professionals or family caregivers targeted by the project;</text></clause><clause id="H8D52194A68314371953CDE26D38725FD"><enum>(iii)</enum><text>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;</text></clause><clause id="HA7EA5C156C084BE1A6ABBCCE39B4716F"><enum>(iv)</enum><text>as applicable, employers of individuals described in clause (iii) and labor organizations representing such individuals;</text></clause><clause id="HE5D053043AF641CD8A2FD687EA197FFA"><enum>(v)</enum><text>representatives of the State Medicaid agency, the State agency defined in section 102 of the Older Americans Act of 1965 (<external-xref legal-doc="usc" parsable-cite="usc/42/3002">42 U.S.C. 3002</external-xref>), the State developmental disabilities office, and the State behavioral health agency, in the State (or each State) to be served by the project; and</text></clause><clause id="H84C857F54242493EA0CE1174367FFBF2"><enum>(vi)</enum><text>representatives reflecting diverse racial, cultural, ethnic, geographic, socioeconomic, and gender identity and sexual orientation perspectives.</text></clause></subparagraph></paragraph><paragraph id="H44C3F55980CC40AFA5B172C915065357"><enum>(4)</enum><text>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.</text></paragraph><paragraph id="H0EEB91FF5D1A451FA73E89D5471E5671"><enum>(5)</enum><text>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—</text><subparagraph id="H3E91C3D4BE1A4C3E9227B83B1567A843"><enum>(A)</enum><text>an assessment of the wages or other compensation or benefits necessary to recruit and retain the direct care professionals targeted by the project;</text></subparagraph><subparagraph id="H68CC8655BD474888A976C122645E2D1F"><enum>(B)</enum><text>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</text></subparagraph><subparagraph id="H3A0F6EE6965241C39E0D0E4E8564279B"><enum>(C)</enum><text>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.</text></subparagraph></paragraph><paragraph id="HF15F3541EFDB428B96520EC4B281068F"><enum>(6)</enum><text>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—</text><subparagraph id="HF9017169E0E04B70AC0C0C2A8B00DCEF"><enum>(A)</enum><text>relevant training regarding the rights of recipients of home and community-based services, including their rights to—</text><clause id="HE8DFE67ABA8A4E8E8E9344CBBCF4EBA5"><enum>(i)</enum><text>receive services in integrated settings that provide access to the broader community;</text></clause><clause id="HFE877953292B4889AB05BF511CFD2A84"><enum>(ii)</enum><text>exercise self-determination;</text></clause><clause id="H6CE679FE157E4BC69332DB3CCEF8F3C7"><enum>(iii)</enum><text>be free from all forms of abuse, neglect, or exploitation; and</text></clause><clause id="HC14BA30DE6DD4BFDA336911A3830B985"><enum>(iv)</enum><text>person-centered planning and practices, including participation in planning activities;</text></clause></subparagraph><subparagraph id="H5471F8CB4CE34CBF8C33CDA5945F1433"><enum>(B)</enum><text>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;</text></subparagraph><subparagraph id="H1E41C918D53C4CD0BCDA020B08241FB1"><enum>(C)</enum><text>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;</text></subparagraph><subparagraph id="H6A651E6906244B2B8C97F47C16C5EDD1"><enum>(D)</enum><text>an apprenticeship program, work-based learning, or on-the-job training opportunities;</text></subparagraph><subparagraph id="H7727F520306C432080D7418282E73448"><enum>(E)</enum><text>supervision or mentoring; and</text></subparagraph><subparagraph id="H93C75D54B9F54544B44B5B984184EA0B"><enum>(F)</enum><text>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—</text><clause id="H186744662AF64D7988205825F9FDD458"><enum>(i)</enum><text>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</text></clause><clause id="HF1F30A566BAC4A0B86428D4D370C46DC"><enum>(ii)</enum><text>ensures the entry wage is not less than the greater of—</text><subclause id="H0EED2EC8E5D04EE2A411894E2B51893E"><enum>(I)</enum><text>the minimum wage required under section 6(a) of the Fair Labor Standards Act of 1938 (<external-xref legal-doc="usc" parsable-cite="usc/29/206">29 U.S.C. 206(a)</external-xref>); or</text></subclause><subclause id="HC0A79272841C4906873FD66540BF7412"><enum>(II)</enum><text>the applicable wage required by other applicable Federal or State law, or a collective bargaining agreement.</text></subclause></clause></subparagraph></paragraph><paragraph id="H4C7D9818235D4D5F935DFADD4FAA3C70"><enum>(7)</enum><text>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.</text></paragraph><paragraph id="HF6D98EBE1C854C25B65D1C2FE77EAF54"><enum>(8)</enum><text>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.</text></paragraph><paragraph id="H7246EDEC05024C10B22A53782EFF36C8"><enum>(9)</enum><text>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.</text></paragraph><paragraph id="H2E2380E817A549F2AA604B2D8C1F6A3C"><enum>(10)</enum><text>How the eligible entity will collect and submit to the Secretary workforce data and outcomes of the project.</text></paragraph><paragraph id="H4F0C28E2AF9D44D2B397F6C897371C14"><enum>(11)</enum><text>How the project—</text><subparagraph id="HDE56220ECB1B44C9929D655FC19D87F2"><enum>(A)</enum><text>will—</text><clause id="H6414D54589B1432D832F16B1BAE7279F"><enum>(i)</enum><text>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;</text></clause><clause id="HCBDD80E1CCE74E14A8A72F09A390B5B7"><enum>(ii)</enum><text>incorporate remote training and education opportunities or technology-supported opportunities;</text></clause><clause id="H80ABFF1292274EED8D1E8601714AF155"><enum>(iii)</enum><text>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;</text></clause><clause id="H658DD921C3434A49BECE91FA51B64D09"><enum>(iv)</enum><text>use outreach, recruitment, and retention strategies designed to reach and retain a diverse workforce;</text></clause><clause id="HF67D598018EA47B3812B7840A43617B4"><enum>(v)</enum><text>incorporate methods to monitor satisfaction with project activities for project participants and individuals receiving services from such participants;</text></clause><clause id="HB8AA778DF0F844B3A5EE430774BB37D1"><enum>(vi)</enum><text>incorporate evidence-supported practices for family caregiver engagement; and</text></clause><clause id="H3F7B47E4AE9C4F7A91FEBD311C49D17E"><enum>(vii)</enum><text>incorporate core competencies identified by the Centers for Medicare & Medicaid Services; and</text></clause></subparagraph><subparagraph id="HDF508C28916D48C3B93F5EA2131930BC"><enum>(B)</enum><text>may incorporate continuing education programs and specialty training, with a specific focus on—</text><clause id="HBB440B28A87F4877825C2D5D5A1C5F52"><enum>(i)</enum><text>trauma-informed care;</text></clause><clause id="HEF76D6B66A6C4634A86C282AEFC090AB"><enum>(ii)</enum><text>behavioral health, including co-occurring behavioral health conditions and intellectual or developmental disabilities;</text></clause><clause id="H5C59C835CCD14457BFCCB66DC8327D13"><enum>(iii)</enum><text>Alzheimer’s and dementia care;</text></clause><clause id="H2D8A3F4D42E6442797858B612AA74CCD"><enum>(iv)</enum><text>chronic disease management; and</text></clause><clause id="H8925C9825B08429284DA675DEC773B12"><enum>(v)</enum><text>the use of supportive or assistive technology.</text></clause></subparagraph></paragraph><paragraph id="H1FEE3100BA924B3AADD3F53323831778"><enum>(12)</enum><text>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:</text><subparagraph id="H26169D9A3F024A4CA43F79BE390F8BDC"><enum>(A)</enum><text>The State Medicaid agency, State agency defined in section 102 of the Older Americans Act of 1965 (<external-xref legal-doc="usc" parsable-cite="usc/42/3002">42 U.S.C. 3002</external-xref>), and the State developmental disabilities office for the State (or each State) to be served by the project.</text></subparagraph><subparagraph id="HF0261CFE0BFF4F678F8B7102D135D9F3"><enum>(B)</enum><text>The local board and State board for each region, or State, to be served by the project.</text></subparagraph><subparagraph id="H6131B54844CC4A84B3858A0AE0045117"><enum>(C)</enum><text>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.</text></subparagraph><subparagraph id="HDF7B91D395974972A82FCF75B416555D"><enum>(D)</enum><text>A nonprofit organization, including a labor organization, that fosters the professional development and collective engagement of the direct care professionals targeted by the project.</text></subparagraph><subparagraph id="HC127DA39423F43FB9266DBD3E99E28FF"><enum>(E)</enum><text>Area agencies on aging, as defined in section 102 of the Older Americans Act of 1965 (<external-xref legal-doc="usc" parsable-cite="usc/42/3002">42 U.S.C. 3002</external-xref>).</text></subparagraph><subparagraph id="H5F5EE692167A4486BFE47263A1B6C4DF"><enum>(F)</enum><text>Centers for independent living, as described in part C of title VII of the Rehabilitation Act of 1973 (<external-xref legal-doc="usc" parsable-cite="usc/29/796f">29 U.S.C. 796f et seq.</external-xref>).</text></subparagraph><subparagraph id="H0EF48405AEC34DCB9FFF06936FFB48D0"><enum>(G)</enum><text>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 (<external-xref legal-doc="usc" parsable-cite="usc/42/15021">42 U.S.C. 15021 et seq.</external-xref>)) for the State (or each State) to be served by the project.</text></subparagraph><subparagraph id="H9DF0E9D021B7454F9EB174BD99A14403"><enum>(H)</enum><text>Aging and Disability Resource Centers (as defined in section 102 of the Older Americans Act of 1965 (<external-xref legal-doc="usc" parsable-cite="usc/42/3002">42 U.S.C. 3002</external-xref>)).</text></subparagraph><subparagraph id="H07E603C03A3446038E345A09649EC50F"><enum>(I)</enum><text>A nonprofit State provider association that represents providers who employ the direct care professionals targeted by the project, where such associations exist.</text></subparagraph><subparagraph id="H88BD0268456C4E058B8C49000374F90D"><enum>(J)</enum><text>An entity that employs the direct care professionals targeted by the project.</text></subparagraph><subparagraph id="HEA95D961708346D39DC4F475E4E6B44A"><enum>(K)</enum><text>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 (<external-xref legal-doc="usc" parsable-cite="usc/42/15061">42 U.S.C. 15061 et seq.</external-xref>).</text></subparagraph><subparagraph id="H58CA3AE43D7E49A3AB7D9A6F47B7205C"><enum>(L)</enum><text>The State protection and advocacy system described in section 143 of such Act (<external-xref legal-doc="usc" parsable-cite="usc/42/15043">42 U.S.C. 15043</external-xref>) of the State (or each State) to be served by the project.</text></subparagraph><subparagraph id="H46F3210E24D843CD8F71F50DA496D672"><enum>(M)</enum><text>Direct care professionals or direct care workforce organizations representing underserved communities, including communities of color.</text></subparagraph></paragraph><paragraph id="H705E1333E57047F7A8F7E5A922A6FF53"><enum>(13)</enum><text>How the eligible entity will consult throughout the project with—</text><subparagraph id="H911B7425EB6D42C6909C0B87A40C5236"><enum>(A)</enum><text>individuals employed or working as the direct care professionals or family caregivers targeted by the project;</text></subparagraph><subparagraph id="HE4661582F4704E4E86ABEAE55EA60288"><enum>(B)</enum><text>representatives of such professionals or caregivers;</text></subparagraph><subparagraph id="HED1F889AE22743B0A6DF2DFABD7F1CCC"><enum>(C)</enum><text>individuals assisted by such professionals or caregivers;</text></subparagraph><subparagraph id="HF249401FD0ED41159FB48BE821502393"><enum>(D)</enum><text>the families of such professionals or caregivers; and</text></subparagraph><subparagraph id="HF13EBAC2623F412F9C5DFBE218498531"><enum>(E)</enum><text>individuals receiving education or training to become such professionals or caregivers.</text></subparagraph></paragraph><paragraph id="HBA46ACC3E2D04130976EA5693F0692DB"><enum>(14)</enum><text>Outreach efforts to individuals for participation in such project, including targeted outreach efforts to—</text><subparagraph id="HB2144D39D9C84A36ACA605ACABC1AA4C"><enum>(A)</enum><text>individuals who are recipients of assistance under a State program funded under part A of title IV of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/601">42 U.S.C. 601 et seq.</external-xref>) or individuals who are eligible for such assistance; and</text></subparagraph><subparagraph id="H5C99FD5EEFAD428D8455DBFAD7FEA345"><enum>(B)</enum><text>individuals with barriers to employment.</text></subparagraph></paragraph></subsection><subsection id="H5395B9707F734480A058E797FD311956"><enum>(c)</enum><header>Considerations</header><text>In selecting eligible entities to receive a grant under this title, the Secretary shall ensure—</text><paragraph id="H1FDEA474C71E4244B9745C1295ACBDEB"><enum>(1)</enum><text>equitable geographic diversity, including by selecting recipients serving rural areas and selecting recipients serving urban areas; and</text></paragraph><paragraph id="HCD8CD566BEE7429D8C5EDA6A5E3AFD36"><enum>(2)</enum><text>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.</text></paragraph></subsection><subsection id="H3BBE09DBBADF4A9DAB8D00BE7CCBE529"><enum>(d)</enum><header>Uses of funds; supplement, not supplant</header><paragraph id="HBBEB6B19168B4469AB6CDA7DE4C8D5CB"><enum>(1)</enum><header>Uses of funds</header><subparagraph id="H8DAABBA9A3E14BAD9A64B6733D0DC363"><enum>(A)</enum><header>In general</header><text>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).</text></subparagraph><subparagraph id="H29EF96D9B74F4D5DBDF793E82E3AE5B0"><enum>(B)</enum><header>Administrative costs</header><text>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.</text></subparagraph><subparagraph id="H6165B82E08384679B65A3225AB5951B1"><enum>(C)</enum><header>Direct support</header><text>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.</text></subparagraph></paragraph><paragraph id="HA9FEBC2B8EA044C3943E05F8E0242154"><enum>(2)</enum><header>Supplement, not supplant</header><text>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.</text></paragraph><paragraph id="H7DC37272F0964F8D8A48BE616D4E3FCE"><enum>(3)</enum><header>Prohibition</header><text>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 (<external-xref legal-doc="usc" parsable-cite="usc/29/433">29 U.S.C. 433(a)</external-xref>).</text></paragraph></subsection></section><section id="H4AADFB44D4794BF9A943AA53024CB757"><enum>305.</enum><header>Evaluations and reports; technical assistance</header><subsection id="H6C79248E1A304A7790F4381E1D4925D6"><enum>(a)</enum><header>Reporting requirements by grant recipients</header><paragraph id="HAE89BE4B399B41DEBA3BA5B5D38F805B"><enum>(1)</enum><header>In general</header><text>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.</text></paragraph><paragraph id="H92FB968C4DB14CC5AD807EC955FC1CFA"><enum>(2)</enum><header>Contents</header><text>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):</text><subparagraph id="H5BA1CAE5F65B497F92243220DC3E121D"><enum>(A)</enum><text>The number of individuals and the demographic categories (as defined in section 2) served by each project supported by the grant, including—</text><clause id="HB8A03F680CDA484CB3D908BF9189FF50"><enum>(i)</enum><text>the number of individuals recruited through each such project to be employed as a direct care professional;</text></clause><clause id="HC8882A8149CB4C70878165CDC7D413A8"><enum>(ii)</enum><text>the number of individuals who through each such project attained employment as a direct care professional; and</text></clause><clause id="H4DE103839936488ABB834BB0DF984BDF"><enum>(iii)</enum><text>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.</text></clause></subparagraph><subparagraph id="HF3D76CFFD6B24D9A97A3E5682C7071E9"><enum>(B)</enum><text>The number of family caregivers participating in an education or training program through each project supported by the grant.</text></subparagraph><subparagraph id="HA79FB8E858D54CC3B0F425D9817C0C97"><enum>(C)</enum><text>The number of project participants who through each such project participated in and completed—</text><clause id="H2A0E492792684F4296C4EB9DFC2226BF"><enum>(i)</enum><text>work-based learning;</text></clause><clause id="H4D4871CD80B3494995E32D4C5533834D"><enum>(ii)</enum><text>on-the-job training;</text></clause><clause id="HC266DC2FE5DD4F81936D557A582C74C3"><enum>(iii)</enum><text>an apprenticeship program; or</text></clause><clause id="H78DEDDD865534F2399CEBBC0761618DE"><enum>(iv)</enum><text>a professional development or mentoring program.</text></clause></subparagraph><subparagraph id="HEBC3A29A6E64438C8B51F5F41A43C6E4"><enum>(D)</enum><clause commented="no" display-inline="yes-display-inline" id="HE9218273FE2A443FB3998139ABB6B67E"><enum>(i)</enum><text>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);</text></clause><clause id="HFF7EA83DA71043679A7DE0870BDA9A8C"><enum>(ii)</enum><text>the number of individuals who accessed such services, benefits, or supports; and</text></clause><clause id="H4DA77755FF71486B99BD0DFBE0265E03"><enum>(iii)</enum><text>the impact of such services, benefits, or supports.</text></clause></subparagraph><subparagraph id="H6EDDF8EBAC8C49AABAA52EF7329F4A8A"><enum>(E)</enum><text>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.</text></subparagraph><subparagraph id="H6AB1A39129784ACC8660375DF2967D5A"><enum>(F)</enum><text>How each project supported by the grant assessed satisfaction with respect to—</text><clause id="HF485BE347C644089A68A837EEE89AC4F"><enum>(i)</enum><text>project participants assisted by the project;</text></clause><clause id="H2695054E7FC74B6BBF3E51466820E1A3"><enum>(ii)</enum><text>individuals receiving services delivered by project participants, including—</text><subclause id="H7383A0D5BDC1400E9869DEA12097C505"><enum>(I)</enum><text>any impact on the health or health outcomes of such individuals; and</text></subclause><subclause id="H68972EBDB58D4C5AB88F4EFA6F78C87F"><enum>(II)</enum><text>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</text></subclause></clause><clause id="HB4AE837E08FA4788AB1FDBDA0DFE7172"><enum>(iii)</enum><text>employers of such project participants.</text></clause></subparagraph><subparagraph id="HA339D780A9DE4BE7A2BF3DB5447ABDA2"><enum>(G)</enum><text>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.</text></subparagraph><subparagraph id="HB9F47DC18C524EDE86B6A64522D29A66"><enum>(H)</enum><text>Any other information with respect to outcomes of the project as determined by the Secretary.</text></subparagraph></paragraph></subsection><subsection id="HD7F37983D73848E3833E8D0303025D7F"><enum>(b)</enum><header>Annual report to Congress by Secretary</header><text>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.</text></subsection><subsection id="H3ACDA73C4BBE46DCBC6B4A97AD789863"><enum>(c)</enum><header>GAO report</header><text>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—</text><paragraph id="H6C3DE8DC8A094348AC93D5AB3D865772"><enum>(1)</enum><text>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</text></paragraph><paragraph id="H6F7CE65CF3194A66A72E51EFB5916176"><enum>(2)</enum><text>recommendations for such legislative or administrative actions needed for improving the assistance described in paragraph (1), as the Comptroller General determines appropriate.</text></paragraph></subsection><subsection id="HA078E25652B74D74B58AF02B0AF03D8A"><enum>(d)</enum><header>Independent evaluations</header><text>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.</text></subsection></section><section id="HF86DB6B1275A4BEC81639E60D444537B"><enum>306.</enum><header>Authorization of appropriations</header><subsection id="H8EE5F3DF5C684AABB908B76FB3BBF193"><enum>(a)</enum><header>In general</header><text>There are authorized to be appropriated—</text><paragraph id="HEA113F8C75EA45298AD3422F1011DF11"><enum>(1)</enum><text>for the establishment and activities of the technical assistance center under section 302, $2,000,000 for each of fiscal years 2029 through 2030; and</text></paragraph><paragraph id="H054EF05D86334B7FAC1B5E12F68E5FDD"><enum>(2)</enum><text>for grants under section 303, $1,000,000,000 for fiscal year 2029.</text></paragraph></subsection><subsection id="H20CDD11EC4234E19A50A4FBC97397331"><enum>(b)</enum><header>Availability</header><text>Amounts made available under this title shall remain available until September 30, 2038.</text></subsection></section><enum>IV</enum><header>Evaluation</header><section id="H03CCDC2BE50B4715BC46F79D8881B405"><enum>401.</enum><header>Evaluation of impact on access to HCBS</header><subsection id="HFA42DCF7EDB44673A8187CB5A525D008"><enum>(a)</enum><header>National survey on expanded HCBS access</header><text>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—</text><paragraph id="HC318B328B7B6470887B25CBEA22DCAFA"><enum>(1)</enum><text>the availability and access to home and community-based services under the Medicaid program nationally and in each State;</text></paragraph><paragraph id="H446EA98AD32346B4BA92B15E0C149856"><enum>(2)</enum><text>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;</text></paragraph><paragraph id="H8F03480A431A48BA9AC48BF35BF425C0"><enum>(3)</enum><text>the compensation and working conditions, including scheduling and benefits, of direct care workers;</text></paragraph><paragraph id="HFA976FCF77454502B59411B7C1CB0864"><enum>(4)</enum><text>the economic effects on beneficiaries and on families with a member receiving home and community-based services through Medicaid;</text></paragraph><paragraph id="H276E0DA6EB21414DA87DB1177C0E61B6"><enum>(5)</enum><text>the availability of direct care workers and services for people needing long-term services and supports who are not Medicaid eligible;</text></paragraph><paragraph id="H24B4C9BD1A1B4B5EAF3704227A82DA8C"><enum>(6)</enum><text>family caregivers; and</text></paragraph><paragraph id="H920CBC9BA573463EBBE760E63F569245"><enum>(7)</enum><text>recommendations for measures to further expand and enhance access home and community-based services.</text></paragraph></subsection><subsection id="H25554F30BD6241D389EB75BFB6F647F9"><enum>(b)</enum><header>Report</header><text>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).</text></subsection><subsection id="H95EEFB7C880A40CEBA02AECD39C3277B"><enum>(c)</enum><header>American community survey addition</header><text>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.</text></subsection><subsection id="H7475479C43644EABB68A5150CC1BD81A"><enum>(d)</enum><header>Authorization of appropriations</header><text>There are authorized to be appropriated to the Secretary such sums as are necessary to carry out this section.</text></subsection></section>