HCBS Access Act
This bill expands coverage of home- and community-based services (HCBS) under Medicaid. It also establishes programs and requirements to support providers who furnish HCBS.
Specifically, the bill requires state Medicaid programs to cover HCBS for individuals who (1) are determined to have a functional impairment that affects daily living and that is expected to last at least 90 days, (2) during the five-year period after the bill is enacted, are already receiving HCBS through Medicaid under a demonstration waiver or other state option, or (3) are under the age of 21 and are otherwise eligible. Covered services include home health care services, private nursing services, homemaking assistance, non-emergency and non-medical transportation, and caregiver support.
The bill also requires the Office of Management and Budget to revise the Standard Occupational Classification system so that the occupation of direct support professional (i.e., a professional who provides services for individuals with disabilities) is classified under a separate code as a healthcare support occupation. Additionally, the Administration for Community Living must establish a technical assistance center and award grants to government, nonprofit, educational entities, and relevant employers to support training, recruitment, and retention of direct support professionals.
The Centers for Medicare & Medicaid Services must study the effects of the bill's implementation on HCBS beneficiaries and the direct care workforce.
[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 762 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
1st Session
S. 762
To amend title XIX of the Social Security Act to require coverage of,
and expand access to, home and community-based services under the
Medicaid program, to award grants for the creation, recruitment,
training and education, retention, and advancement of the direct care
workforce and to award grants to support family caregivers, and for
other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 9, 2023
Mr. Casey (for himself, Ms. Hassan, Mr. Brown, Mr. Kaine, Mrs.
Gillibrand, Mr. Blumenthal, Mr. Welch, Mr. Fetterman, Mr. Merkley, Mr.
Sanders, Ms. Baldwin, Ms. Duckworth, Ms. Warren, Mr. Reed, Mr. Markey,
Mrs. Shaheen, and Mrs. Murray) introduced the following bill; which was
read twice and referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to require coverage of,
and expand access to, home and community-based services under the
Medicaid program, to award grants for the creation, recruitment,
training and education, retention, and advancement of the direct care
workforce and to award grants to support family caregivers, and for
other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``HCBS Access Act''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
TITLE I--REQUIRING AND EXPANDING ACCESS TO HCBS COVERAGE UNDER MEDICAID
Sec. 101. Purpose.
Sec. 102. Requiring coverage of home and community-based services under
the Medicaid program.
Sec. 103. Medicaid eligibility modifications.
Sec. 104. Home and community-based services implementation plan grant
program.
Sec. 105. Quality of services.
Sec. 106. Reports; technical assistance; other administrative
requirements.
Sec. 107. Quality measurement and improvement.
Sec. 108. Making permanent the State option to extend protection under
Medicaid for recipients of home and
community-based services against spousal
impoverishment.
Sec. 109. Permanent extension of Money Follows the Person Rebalancing
demonstration.
TITLE II--RECOGNIZING THE ROLE OF DIRECT SUPPORT PROFESSIONALS
Sec. 201. Findings.
Sec. 202. Definition of direct support professional.
Sec. 203. Revision of Standard Occupational Classification System.
TITLE III--SUPPORT FOR THE DIRECT CARE WORKFORCE
Sec. 301. Definitions.
Sec. 302. Authority to establish a technical assistance center for
building the direct care workforce.
Sec. 303. Authority to award grants.
Sec. 304. Project plans.
Sec. 305. Evaluations and reports; technical assistance.
Sec. 306. Authorization of appropriations.
TITLE IV--EVALUATION
Sec. 401. Evaluation of impact on access to HCBS.
SEC. 2. DEFINITIONS.
In this Act:
(1) Demographics.--The term ``demographics'' means
information relating to the races, ethnicities, genders, sexual
orientations, gender identities, geographic locations, incomes,
primary languages, types of service setting, and disability
types represented within a particular group of individuals.
(2) Private duty nursing.--The term ``private duty
nursing'' means nursing services that are sufficient to meet
the needs of an individual who requires more individualized and
continuous care than is available from a visiting nurse or
routinely provided by the nursing staff of a hospital or
skilled nursing facility, and includes services provided to an
individual in the individual's own home by a registered nurse
or licensed practical nurse under the direction of a physician.
(3) Secretary.--Except as otherwise provided, the term
``Secretary'' means the Secretary of Health and Human Services.
TITLE I--REQUIRING AND EXPANDING ACCESS TO HCBS COVERAGE UNDER MEDICAID
SEC. 101. PURPOSE.
It is the purpose of this title to require coverage of home and
community-based services (in this section referred to as ``HCBS'')
under a State plan (or waiver of such plan) under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.) for the following reasons:
(1) To eliminate waiting lists for HCBS, which delay access
to necessary services and civil rights for people with
disabilities and older adults.
(2) To build on decades of progress in serving people with
disabilities and older adults via HCBS.
(3) To fulfill the purposes of the Medicaid program to
provide medical assistance for those whose income and resources
are insufficient to meet the costs of necessary medical
services, and to provide rehabilitation, long-term services and
supports, and other services to help such families and
individuals attain or retain capability for independence or
self-care.
(4) To ensure that people with all kinds of disabilities
and with multiple disabilities, including intellectual
disability, cognitive disabilities, developmental disabilities,
behavioral health disabilities, physical disabilities, and
substance use disorders, and older adults, receive the services
they need to live in their communities.
(5) To streamline access to HCBS by eliminating the need
for States to repeatedly apply for waivers.
(6) To continue to increase the capacity of community
services to ensure people with disabilities and older adults
have safe and meaningful options in the community are not at
risk of unnecessary institutionalization.
(7) To act on the decades of research and practice showing
that everyone, including people with the most severe
disabilities, can live in the community with the right services
and supports.
(8) To support over 53,000,000 unpaid family caregivers who
are often providing complex services and supports to older
adults and people with disabilities because of a lack of
affordable services, workforce shortages, and other
inefficiencies.
(9) To improve direct care quality and address the decades
long workforce barriers, which have been exacerbated by the
COVID-19 pandemic, for nearly 2,600,000 direct care
professionals providing support to people with disabilities and
older adults in their homes and communities.
(10) To eliminate the race, gender, sexual orientation, and
gender identity disparities that exist in accessing information
and HCBS and to prevent the unnecessary impoverishment and
institutionalization of black and brown individuals with
disabilities and older adults.
SEC. 102. REQUIRING COVERAGE OF HOME AND COMMUNITY-BASED SERVICES UNDER
THE MEDICAID PROGRAM.
(a) Definition of Home and Community-Based Services.--
(1) In general.--Section 1905 of the Social Security Act
(42 U.S.C. 1396d) is amended by adding at the end the following
new subsection:
``(jj) Home and Community-Based Services.--
``(1) In general.--For purposes of this title, the term
`home and community-based services' means those services
specified in paragraph (2) furnished to an eligible individual
(as defined in paragraph (3)), based on an individualized
assessment (as described in paragraph (4)) of such individual,
in a setting that--
``(A) meets the qualities specified in paragraph
(1) of section 441.710(a) of title 42, Code of Federal
Regulations (or a successor regulation);
``(B) is not described in paragraph (2) of such
section (or successor regulation); and
``(C) meets such other qualities as the Secretary
determines appropriate.
``(2) Services specified.--
``(A) In general.--For purposes of paragraph (1),
the services specified in this paragraph are services
described in any of paragraphs (7), (8), (13)(C), (19),
(20), (24), and (29) (as applied without regard to the
reference to `September 30, 2025') of subsection (a) or
in any of subsections (c)(4)(B), (c)(5), (k)(1)(A),
(k)(1)(B), or (k)(1)(D) of section 1915, including the
following:
``(i) Supported employment and integrated
day services.
``(ii) Personal assistance, including
personal care attendants, direct support
professionals, home health aides, private duty
nursing, homemakers and chore assistance, and
companionship services.
``(iii) Services that enhance independence,
inclusion, and full participation in the
broader community.
``(iv) Non-emergency, non-medical
transportation services to facilitate community
integration.
``(v) Respite services provided in the
individual's home or broader community.
``(vi) Caregiver and family support
services.
``(vii) Case management, including
intensive case management, fiscal intermediary,
and support brokerage services.
``(viii) Services which support person-
centered planning and self-direction.
``(ix) Direct support services during acute
hospitalizations.
``(x) Necessary medical and nursing
services not otherwise covered which are
necessary in order for the individual to remain
in their home and community, including hospice
services.
``(xi) Home and community-based intensive
behavioral health and crisis intervention
services.
``(xii) Peer support services.
``(xiii) Housing support, including
transitional housing or transitional support
services for individuals who are unhoused, and
wrap-around services.
``(xiv) Necessary home modifications and
assistive technology, including those which
substitute for human assistance.
``(xv) Transition services to support an
individual who is transitioning from an
institutional setting to the community,
including appropriate services for individuals
who are unhoused or at risk of becoming
unhoused, and including such transition
services provided while the individual resides
in an institution.
``(xvi) Any other service recommended by
the panel convened pursuant to subparagraph
(B).
``(B) Specification of recommended services.--
``(i) In general.--Not later than 6 months
after the date of the enactment of this
subparagraph, and not less frequently than once
every 5 years thereafter, the Secretary shall
convene an advisory panel (in this subparagraph
referred to as the `panel') for purposes of
recommending additional services which shall be
included as home and community-based services
under this paragraph.
``(ii) Composition.--
``(I) Selection.--The panel shall
be composed of at least one
representative (to be selected by the
Secretary) from each of the following:
``(aa) Individuals with
disabilities receiving home and
community-based services under
this title and individuals with
disabilities in need of such
services, including those with
physical disabilities,
behavioral health disabilities,
or intellectual or
developmental disabilities, and
including older adults.
``(bb) Beneficiary-led
disability rights
organizations.
``(cc) Disability-led
organizations.
``(dd) Disabled veterans
organizations.
``(ee) Disability
organizations representing
families.
``(ff) Community-based
provider organizations.
``(gg) Organizations
serving older adults.
``(hh) The Protection and
Advocacy system, the Centers
for Independent Living.
``(ii) Health care
providers.
``(jj) The National
Association of Medicaid
Directors.
``(kk) The National
Association of State Directors
of Developmental Disabilities
Services.
``(ll) The National
Association of State Mental
Health Program Directors.
``(mm) ADvancing States.
``(nn) The Centers for
Medicare & Medicaid Services.
``(oo) The Administration
for Community Living of the
Department of Health and Human
Services.
``(pp) Other relevant
local, State, and Federal home
and community-based service
systems, as determined by the
Secretary.
``(II) Requirement for equal
representation.--The Secretary shall
select an equal number of
representatives from each category
described in items (aa) through (oo)
subclause (I) in convening the panel.
``(iii) Duties.--Not later than 6 months
after a panel is convened under clause (i), the
panel shall submit to the Secretary and to
Congress a report recommending additional
services which shall be included as home and
community-based services under this paragraph.
Such recommended services shall be so specified
with the goal of increasing community
integration and self-determination for
individuals with disabilities receiving such
services.
``(iv) Implementation of recommended
services.--
``(I) In general.--Services
recommended by the panel in a report
submitted under clause (iii) shall be
treated as services described in
subparagraph (A)(xvi) for calendar
quarters beginning on or after the date
that is 1 year after the date of such
submission.
``(II) Notification.--Not later
than 1 year after the first report is
submitted under clause (iii), and not
later than 1 year after the submission
of each subsequent such report, the
Secretary shall notify States of any
additions or removals of home and
community-based services based on
services recommended under such report
through State Medicaid Director
letters.
``(3) Eligible individual.--
``(A) In general.--For purposes of paragraph (1),
the term `eligible individual' means--
``(i) an individual who is determined, on
an annual basis or on a longer basis specified
by the State, by a health care provider
approved by the State under a process described
in subparagraph (C) to have a functional
impairment (as defined in subparagraph (B))
(not taking into account any items or services,
or any other ameliorative measures, furnished
to such individual to mitigate such impairment)
that is expected to last at least 90 days;
``(ii) during the period that ends on the
day before the first day of the first calendar
quarter beginning on or after the date that is
5 years after the date of the enactment of this
subsection, an individual who, as of such date
of enactment, is receiving or has been
determined to be eligible for, home and
community-based services under this title under
a waiver or State plan option in effect under
section 1915 or 1115, provided that the
individual continues to meet any level of care
requirement applicable under such waiver or
plan option; or
``(iii) an individual who is eligible under
the State plan or waiver and is under the age
of 21.
``(B) Functional impairment.--For purposes of
subparagraph (A), the term `functional impairment'
means, with respect to an individual the inability of
such individual to perform, without assistance--
``(i) 2 or more activities of daily living
(as described in section 7702B(c)(2)(B) of the
Internal Revenue Code of 1986);
``(ii) 2 or more instrumental activities of
daily living (as defined for purposes of
section 1915(k)(1)(A)); or
``(iii) 1 activity of daily living (as so
described) and 1 instrumental activity of daily
living (as so defined).
``(C) Health care provider state approval.--For
purposes of subparagraph (A)(i), a process described in
this subparagraph is a process established by the State
to approve health care providers to make determinations
described in such subparagraph that meets such
standards as the Secretary may prescribe.
``(4) Individualized assessment.--
``(A) In general.--For purposes of paragraph (1),
an individualized assessment described in this
paragraph is an independent assessment, with respect to
an eligible individual--
``(i) to determine a necessary level of
services and supports to be provided,
consistent with an individual's functional
impairments, to facilitate an individual's
community integration, self-determination, and
well-being;
``(ii) to prevent the provision of
unnecessary or inappropriate care;
``(iii) to establish a person-centered care
plan (as described in subparagraph (C)) for the
individual;
``(iv) that includes each of the elements
described in clauses (ii) through (v) of
section 1915(i)(1)(F); and
``(v) that occurs not later than 30 days
after such individual is determined to be an
eligible individual.
``(B) Presumption.--The assessment described in
subparagraph (A) shall be conducted with the
presumption--
``(i) that each eligible individual,
regardless of type or level of disability or
service need, can be served in the individual's
own home and community; and
``(ii) at the option of the individual,
that services may be self-directed (as defined
in section 1915(i)(1)(G)(iii)(II)).
``(C) Person-centered care plan.--For purposes of
subparagraph (A)(iii), a person-centered care plan
described in this subparagraph is a written plan with
respect to an individual that meets the requirements of
section 1915(i)(1)(G)(ii).
``(D) Standards.--An individualized assessment
described in subparagraph (A) shall be conducted in
accordance with standards specified by the Secretary,
in consultation with the Administration for Community
Living, that--
``(i) safeguard against conflicts of
interest;
``(ii) specify qualifications for who may
perform such assessments;
``(iii) ensure transparency in the
furnishing of such assessments, including
ensuring the provision of the results of such
assessments that includes information in plain
language necessary to interpret the methodology
and results of such assessments;
``(iv) ensure that the methodologies used
in such assessments are sound and evidence-
based; and
``(v) require such methodologies to be made
available on the public website of the State
and tested for reliability and validity by an
independent evaluator.''.
(2) Inclusion as medical assistance.--Section 1905(a) of
the Social Security Act (42 U.S.C. 1396d(a)) is amended--
(A) in paragraph (30), by striking ``; and'' and
inserting a semicolon;
(B) by redesignating paragraph (31) as paragraph
(32); and
(C) by inserting after paragraph (30) the following
new paragraph:
``(31) home and community-based services (as defined in
subsection (jj)); and''.
(b) Mandatory Benefit.--
(1) In general.--Section 1902(a)(10)(A) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking
``and (30)'' and inserting ``(30), and (31)''.
(2) Effective date.--The amendment made by this subsection
shall take effect on the first day of the first calendar
quarter that begins on or after the date that is 5 years after
the date of enactment of this Act.
(c) Ensuring Coverage of HCBS for All Medicaid-Eligible
Individuals.--Section 1902(a)(10)(D) of the Social Security Act (42
U.S.C. 1396a(a)(10)(A)) is amended--
(1) by inserting ``(i)'' after ``(D)'';
(2) by adding ``and'' after the semicolon; and
(3) by adding at the end the following new clause:
``(ii) beginning on the first day of the first calendar
quarter that begins on or after the date that is 5 years after
the date of enactment of this clause (or at such earlier date
as the State may elect) for the inclusion of home and
community-based services (as defined in section 1905(jj)) for
any individual who--
``(I) is eligible for medical assistance under the
State plan (or waiver of such plan);
``(II) is an eligible individual (as defined in
such section); and
``(III) elects to receive such services.''.
(d) Federal Medical Assistance Percentage for Home and Community-
Based Services.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by subsection (a), is further amended--
(1) in subsection (b), by striking ``and (ii)'' and
inserting ``(ii), and (kk)''; and
(2) by adding at the end the following new subsection:
``(kk) Specified FMAP for Home and Community-Based Services.--
``(1) In general.--Notwithstanding any other provision of
law and except as provided in paragraph (3), the Federal
medical assistance percentage for amounts expended for medical
assistance for home and community-based services (as defined in
subsection (jj)), including any such services furnished under a
waiver in effect under section 1915, on or after the date of
the enactment of this subsection shall be equal to 100 percent.
``(2) Access to essential hcbs.--As a condition of
receiving the Federal medical assistance percentage described
in paragraph (1), a State shall enhance, expand, or strengthen
the level of home and community-based services offered under
the State plan under this title (or a waiver of such a plan) as
of the date of enactment of this subsection by doing all of the
following:
``(A) Addressing access barriers and disparities in
access or utilization identified in the State HCBS
implementation plan.
``(B) Using `no wrong door' programs, providing
presumptive eligibility for home and community-based
services, and improving home and community-based
services counseling and education programs.
``(C) Providing supports to family caregivers,
which shall include providing respite care, and may
include providing such services as caregiver
assessments, peer supports, access to assistive
technology, or paid family caregiving.
``(D) Adopting processes to ensure that payments
for home and community-based services are sufficient to
ensure that such services are available to eligible
beneficiaries.
``(3) Exception.--The Federal medical assistance percentage
applicable to medical assistance for home and community-based
services furnished to an individual who is only eligible for
medical assistance under a State plan or waiver on the basis of
section 1902(a)(10)(A)(ii)(XXIV) shall be determined without
regard to this subsection.''.
(e) Sunset of HCBS Waivers.--Section 1915 of the Social Security
Act (42 U.S.C. 1396n) is amended by adding at the end the following new
subsection:
``(m) Sunset of Provisions Relating to Home and Community-Based
Services.--
``(1) In general.--Except as provided in paragraph (2), the
preceding provisions of this section, insofar as such
provisions relate to a waiver for home and community-based
services, shall not apply beginning with the first calendar
quarter beginning on or after the date that is 5 years after
the date of the enactment of this subsection.
``(2) Exception.--The Secretary may waive the application
of paragraph (1) for a calendar quarter and a State if the
State requests such a waiver and the Secretary determines that
such a waiver is appropriate.''.
(f) Conforming Amendments.--
(1) In general.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended--
(A) in section 1905(a), in the matter preceding the
first numbered paragraph--
(i) in clause (xv), by striking the comma
at the end and inserting ``, or'';
(ii) in clause (xvi)--
(I) by moving the left margin 2 ems
to the left; and
(II) by striking ``, or'' and
inserting a comma; and
(iii) by striking clause (xvii); and
(B) in section 1943(b)(5), by striking ``the
State'' and all that follows through the period at the
end and inserting ``a determination be conducted on an
annual basis (or on such longer basis as specified by
the State) in accordance with section 1905(jj) for
purposes of providing home and community-based services
under the State plan (or waiver of such plan).''.
(2) Effective date.--
(A) In general.--Except as provided in subparagraph
(B), the amendments made by this subsection shall take
effect on the first day of the first calendar quarter
that begins on or after the date that is 5 years after
the date of enactment of this Act.
(B) Exception for states authorized to continue
operating hcbs waivers.--In the case of a State for
which the Secretary has waived the application of
paragraph (1) of subsection (m) of section 1915 of the
Social Security Act (42 U.S.C. 1396n), as added by
subsection (e), in accordance with paragraph (2) of
such subsection (m), clause (xvii) of section 1905(a)
of the Social Security Act shall continue to have
effect with respect to such State for so long as
paragraph (1) of such subsection (m) does not apply to
such State.
SEC. 103. MEDICAID ELIGIBILITY MODIFICATIONS.
Section 1902(a)(10) of the Social Security Act (42 U.S.C.
1396a(a)(10)) is amended--
(1) in subparagraph (A)(i)--
(A) in subclause (VIII), by striking ``; or'' and
inserting a semicolon;
(B) in subclause (IX)(dd), by striking the
semicolon at the end and inserting ``; or''; and
(C) by inserting after subclause (IX) the following
new subclause:
``(X) beginning with the first
calendar quarter that begins on or
after the date that is 5 years after
the date of enactment of this subclause
(or such earlier date as the State may
elect), who are eligible individuals
described in subsection (jj)(3)(A) and
are not described in a previous
subclause of this clause and whose
income does not exceed the greater of--
``(aa) 150 percent of the
poverty line (as defined in
section 2110(c)(5)) applicable
to a family of the size
involved; and
``(bb) 300 percent of the
supplemental security income
benefit rate established by
section 1611(b)(1);''; and
(2) in subparagraph (A)(ii)--
(A) in subclause (XXII), by striking ``; or'' and
inserting a semicolon;
(B) in subclause (XXIII), by striking the semicolon
at the end and inserting ``; or''; and
(C) by adding at the end the following new
subclause:
``(XXIV) who are eligible
individuals who would be described in
clause (i)(X) but for the fact that
their income exceeds the income levels
established under such clause but is
less than such income level as the
State may establish for purposes of
this subclause;''.
SEC. 104. HOME AND COMMUNITY-BASED SERVICES IMPLEMENTATION PLAN GRANT
PROGRAM.
(a) In General.--Not later than 1 year after the date of the
enactment of this Act, the Secretary shall award to each State a grant
for purposes of enabling such State to implement the requirement to
provide home and community-based services under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.).
(b) Use of Funds.--A grant awarded under subsection (a) shall be
used by a State to develop an implementation plan described in
subsection (c) to be submitted to the Secretary for approval.
(c) Implementation Plan.--An implementation plan described in this
subsection is a plan developed by a State that includes the following:
(1) An explanation of how the State will operationalize the
definition of an eligible individual under section 1905(jj) of
the Social Security Act, including the process for
determinations specified in paragraph (3)(A)(i) of such
section.
(2) A description of the State's plan to ensure a stable
and high quality workforce and how the State plans to ensure a
living wage for individuals furnishing home and community-based
services and identify and address any additional workforce
issues.
(3) A list of any home and community-based services
provided under the State Medicaid plan (including any waiver of
such plan) as of the date of enactment of this Act, including a
breakdown of use of such services by demographics (as defined
in section 2), compared to such services that are required
under the amendments made by section 102, and a description of
numerical goals to increase access to such services that have
barriers to access for populations in need of such services.
(4) A description of how the State will incorporate
existing State disability agencies into the new unified
provision of home and community-based services and how such
State will ensure that such services address all functional
impairments.
(5) An explanation of how the State will ensure access to
such services.
(6) A plan for carrying out outreach and education
activities with respect to the availability of such services
through Aging and Disability Resource Centers and other similar
entities (such as entities receiving funds from the
Administration for Community Living or the Substance Abuse and
Mental Health Services Administration), including a program
that ensures that an individual is not denied such services
based on the fact that the individual contacts the wrong entity
(commonly referred to as a ``No Wrong Door Program'').
(7) A plan for how such services will be coordinated with
other relevant State agencies, such as housing, transportation,
child welfare, food and income security, and employment
agencies.
(8) A description of how the State will build capacity
prior to the implementation of the requirement described in
subsection (a) to ensure that such services are available to
every eligible individual under the Medicaid program and how
the State will ensure that such services are provided in a
setting that meets the requirements specified in paragraph (1)
of section 1905(jj) of the Social Security Act, as added by
section 102.
(9) In the case of a State that utilizes an alternative
benefit plan, a description of how the State will ensure that
all individuals who are eligible individuals (as defined in
such section) are appropriately identified as medically frail
and exempted from such plan.
(10) How the State will coordinate eligibility for such
services with other disability eligibility programs, such as
disability buy-in programs.
(11) Data and milestone requirements to ensure community
integration, including such requirements with respect to
utilization of such services by demographics (as defined in
section 2).
(d) State Plan Requirement.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)) is amended--
(1) in paragraph (86), by striking ``and'' at the end;
(2) in paragraph (87), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following new paragraph:
``(88) provide for the submission to the Secretary of an
implementation plan described in section 104(c) of the HCBS
Access Act for approval by the Secretary prior to the beginning
of the first calendar quarter beginning on or after the date
that is 5 years after the date of the enactment of this
paragraph.''.
(e) Authorization of Appropriations.--There is authorized to be
appropriated to the Secretary such sums as are necessary to carry out
this section.
(f) Definitions.--In subsections (a) through (c):
(1) Home and community-based services.--The term ``home and
community-based services'' has the meaning given such term in
subsection (jj) of section 1905 of the Social Security Act (42
U.S.C. 1396d), as added by section 102.
(2) State.--The term ``State'' has the meaning given that
term in section 1101(1) of the Social Security Act (42 U.S.C.
1301(1)) for purposes of title XIX of such Act (42 U.S.C. 1396
et seq.).
SEC. 105. QUALITY OF SERVICES.
(a) In General.--
(1) Development of metrics.--Not later than 1 year after
the date of enactment of this Act, the Director of the Agency
for Healthcare Research and Quality, in consultation with State
Medicaid Directors, shall develop standardized, State-level
metrics of access to, and satisfaction with, providers,
including primary care and specialist providers, with respect
to individuals who are enrolled in State Medicaid plans under
title XIX of the Social Security Act, broken down by
demographics (as defined in section 2) and any other category
determined by the Secretary. Such metrics shall include metrics
on the total number of individuals enrolled in the State plan
or under a waiver of the plan during a fiscal year that
required the level of care provided in a nursing facility,
intermediate care facility for individuals with intellectual
disability, institution for mental disease, or other similarly
restrictive or institutional setting.
(2) Process.--The Director of the Agency for Healthcare
Research and Quality shall develop the metrics described in
paragraph (1) through a public process, which shall provide
opportunities for stakeholders to participate.
(b) Updating Metrics.--The Director of the Agency for Healthcare
Research and Quality, in consultation with the Deputy Administrator for
the Center for Medicaid and CHIP Services and State Medicaid Directors,
shall update the metrics developed under subsection (a) not less than
once every 3 years.
(c) State Implementation Funding.--The Director of the Agency for
Healthcare Research and Quality may award funds, from the amount
appropriated under subsection (d), to States for the purpose of
implementing the metrics developed under this section.
(d) Appropriation.--There is appropriated to the Director of the
Agency for Healthcare Research and Quality, out of any funds in the
Treasury not otherwise appropriated, $200,000,000 for fiscal year 2024,
to remain available until expended, for the purpose of carrying out
this section.
SEC. 106. REPORTS; TECHNICAL ASSISTANCE; OTHER ADMINISTRATIVE
REQUIREMENTS.
(a) Reports.--The Secretary shall submit to the Committee on Energy
and Commerce of the House of Representatives, the Committee on
Education and Labor of the House of Representatives, the Committee on
Finance of the Senate, the Committee on Health, Education, Labor and
Pensions of the Senate, and the Special Committee on Aging of the
Senate the following reports relating to the HCBS implementation plan
grant program established under section 104:
(1) Interim report.--Not later than 2 years after the date
of enactment of this Act, a report that describes--
(A) State efforts to develop their HCBS
implementation plans; and
(B) the funds awarded to States.
(2) First implementation report.--Not later than 4 years
after the date of enactment of this Act, a report that includes
the following:
(A) A description of the HCBS implementation plans
approved by the Secretary under section 104.
(B) A description of the national landscape with
respect to gaps in coverage of home and community-based
services, disparities in access to, and utilization of,
such services, and barriers to accessing such services.
(C) A description of the national landscape with
respect to the direct care workforce that provides home
and community-based services, including with respect to
compensation, benefits, and challenges to the
availability of such workers.
(3) Subsequent reports.--Not later than 7 years after the
date of enactment of this Act, and every 3 years thereafter, a
report that includes the following:
(A) The number of HCBS program improvement States
and the funds awarded to States to develop their plans.
(B) A summary of the progress being made by such
States with respect to strengthening and expanding
access to home and community-based services and the
direct care workforce that provides such services and
meeting the benchmarks for demonstrating improvements
required under section 1905(jj)(5) of the Social
Security Act (as added by section 102).
(C) A summary of outcomes related to home and
community-based services core quality measures and
beneficiary and family caregiver surveys.
(D) A summary of the challenges and best practices
reported by States in expanding access to home and
community-based services and supporting and expanding
the direct care workforce that provides such services.
(b) Technical Assistance; Guidance; Regulations.--The Secretary
shall provide HCBS program improvement States with technical assistance
related to carrying out the HCBS implementation plans approved by the
Secretary under section 104 and meeting the requirements and benchmarks
for demonstrating improvements required under section 1905(jj) of the
Social Security Act (as added by section 102) and shall issue such
guidance or regulations as necessary to carry out this title and the
amendments made by this title, including guidance specifying how States
shall assess and track the availability of home and community-based
services over time.
(c) Recommendations To Guide HCBS Implementation.--
(1) In general.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall coordinate with the
Secretary of Labor and the Administrator of the Centers for
Medicare & Medicaid Services for purposes of issuing
recommendations for the Federal Government and for States to
strengthen the direct care workforce that provides home and
community-based services, including with respect to how the
Federal Government should classify the direct care workforce,
how such Administrator and State Medicaid programs can enforce
and support the provision of competitive wages and benefits
across the direct care workforce, including for workers with
particular skills or expertise, and how State Medicaid programs
can support training opportunities and other related efforts
that support the provision of quality home and community-based
services care.
(2) Stakeholder consultation.--
(A) In general.--In developing the recommendations
required under paragraph (1), the Secretary shall
ensure that such recommendations are informed by
consultation with recipients of home and community-
based services, family caregivers of such recipients,
providers, health plans, direct care workers, chosen
representatives of direct care workers, and aging,
disability, and workforce advocates.
(B) Consultation with current and potential hcbs
beneficiaries and family caregivers.--As part of the
process of developing recommendations under
subparagraph (A), the Secretary shall--
(i) hold at least 1 meeting for the purpose
of developing such recommendations that is
solely with current and potential recipients of
home and community-based services and family
caregivers of such recipients; and
(ii) seek to achieve parity in terms of the
level of participation in the development of
such recommendations between--
(I) current and potential
recipients of home and community-based
services and family caregivers of such
recipients; and
(II) other categories of
stakeholder described in subparagraph
(A).
(d) Funding.--Out of any funds in the Treasury not otherwise
appropriated, there is appropriated to the Secretary for purposes of
carrying out this section, $10,000,000 for fiscal year 2024, to remain
available until expended.
SEC. 107. QUALITY MEASUREMENT AND IMPROVEMENT.
(a) Development and Publication of Core and Supplemental Sets of
HCBS Quality Measures.--
(1) In general.--The Secretary shall identify and publish a
core set and supplemental set of home and community-based
services quality measures for use by State Medicaid programs,
health plans and managed care entities that enter into
contracts with such programs, and providers of items and
services under such programs.
(2) Regular reviews and updates.--The Secretary shall
review and update the core set and supplemental set of home and
community-based services quality measures published under
paragraph (1) not less frequently than once every year.
(3) Requirements.--
(A) Interagency collaboration; stakeholder input.--
In developing the core set and supplemental set of home
and community-based services quality measures under
paragraph (1), and subsequently reviewing and updating
such core and supplemental sets, the Secretary shall--
(i) collaborate with the Administrator of
the Centers for Medicare & Medicaid Services,
the Administrator of the Administration for
Community Living, the Director of the Agency
for Healthcare Research and Quality, and the
Administrator of the Substance Abuse and Mental
Health Services Administration; and
(ii) ensure that such core and supplemental
sets are informed by input from stakeholders,
including recipients of home and community-
based services, family caregivers of such
recipients, providers, health plans, direct
care workers, chosen representatives of direct
care workers, and aging, disability, and
workforce advocates, with the goal that at
least half of such input is from current and
potential recipients of home and community-
based services and family caregivers.
(B) Reflective of full array of services.--Such
core set and supplemental set of home and community-
based services quality measures shall--
(i) reflect the full array of home and
community-based services and recipients of such
services, including adults and children; and
(ii) include--
(I) outcomes-based measures;
(II) measures of availability of
services;
(III) measures of provider capacity
and availability;
(IV) measures related to person-
centered care;
(V) measures specific to self-
directed care;
(VI) measures related to
transitions to and from institutional
care; and
(VII) beneficiary and family
caregiver surveys.
(C) Demographics.--Such core set and supplemental
set of home and community-based services quality
measures shall allow for the collection of data that is
disaggregated by demographics (as defined in section 2
but including any additional category determined by the
Secretary).
(4) Funding.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the Secretary
for purposes of carrying out this subsection, $10,000,000 for
fiscal year 2024, to remain available until expended.
(b) State Adoption and Reports.--
(1) In general.--Not later than 2 years after the date on
which the Secretary publishes the core set and supplemental set
of home and community-based services quality measures under
subsection (a)(1), and annually thereafter, each State Medicaid
program shall use such core and supplemental sets (or an
alternative set of quality measures approved by the Secretary)
to report information to the Secretary regarding the quality of
home and community-based services provided under such program.
(2) Process.--The information required under paragraph (1)
shall be reported using a standardized format and procedures
established by the Secretary. Such procedures shall allow a
State Medicaid program to report such information separately or
as part of the annual reports required under sections 1139A(c)
and 1139B(d) of the Social Security Act (42 U.S.C. 1320b-9a,
1320b-9b).
(3) Publication of quality measures.--Each State Medicaid
program shall annually make the information reported to the
Secretary under paragraph (1) available to the public.
(4) Increased federal matching rate for adoption and
reporting.--Section 1903(a)(3) of the Social Security Act (42
U.S.C. 1396b(a)(3)) is amended--
(A) in subparagraph (F)(ii), by striking ``plus''
after the semicolon and inserting ``and''; and
(B) by inserting after subparagraph (F), the
following:
``(G) 80 percent of so much of the sums expended
during such quarter as are attributable to the
reporting of information regarding the quality of home
and community-based services in accordance with section
107(b) of the HCBS Access Act; and''.
SEC. 108. MAKING PERMANENT THE STATE OPTION TO EXTEND PROTECTION UNDER
MEDICAID FOR RECIPIENTS OF HOME AND COMMUNITY-BASED
SERVICES AGAINST SPOUSAL IMPOVERISHMENT.
(a) In General.--Section 1924(h)(1)(A) of the Social Security Act
(42 U.S.C. 1396r-5(h)(1)(A)) is amended by striking ``is described in
section 1902(a)(10)(A)(ii)(VI)'' and inserting the following: ``is an
eligible individual (as defined in section 1905(jj)(3))''.
(b) Conforming Amendment.--Section 2404 of the Patient Protection
and Affordable Care Act (42 U.S.C. 1396r-5 note) is amended by striking
``September 30, 2027'' and inserting ``the date of enactment of the
HCBS Access Act''.
SEC. 109. PERMANENT EXTENSION OF MONEY FOLLOWS THE PERSON REBALANCING
DEMONSTRATION.
Subparagraph (L) of section 6071(h)(1) of the Deficit Reduction Act
of 2005 (42 U.S.C. 1396a note) is amended by striking ``each of fiscal
years 2024 through 2027'' and inserting ``each fiscal year after
2023''.
TITLE II--RECOGNIZING THE ROLE OF DIRECT SUPPORT PROFESSIONALS
SEC. 201. FINDINGS.
Congress finds the following:
(1) Direct support professionals play a critical role in
the care provided to children and adults with intellectual and
developmental disabilities.
(2) Providers of home and community-based services are
experiencing difficulty hiring and retaining direct support
professionals, with a national turnover rate of 45 percent as
identified in a 2016 study by the National Core Indicators.
(3) High turnover rates can lead to instability for
individuals receiving services, and this may result in
individuals not receiving enough personalized care to help them
reach their goals for independent living.
(4) A discrete occupational category for direct support
professionals will help States and the Federal Government--
(A) better interpret the shortage in the labor
market of direct support professionals; and
(B) collect data on the high turnover rate of
direct support professionals.
(5) The Standard Occupational Classification system is
designed and maintained solely for statistical purposes, and is
used by Federal statistical agencies to classify workers and
jobs into occupational categories for the purpose of
collecting, calculating, analyzing, or disseminating data.
(6) Occupations in the Standard Occupational Classification
system are classified based on work performed and, in some
cases, on the skills, education, or training needed to perform
the work.
(7) Establishing a discrete occupational category for
direct support professionals will--
(A) correct an inaccurate representation in the
Standard Occupational Classification system;
(B) recognize these professionals for the critical
and often times overlooked work that they perform for
the disabled community, which work is different than
the work of a home health aide or a personal care aide;
and
(C) better align the Standard Occupational
Classification system with related classification
systems.
SEC. 202. DEFINITION OF DIRECT SUPPORT PROFESSIONAL.
In this title, the term ``direct support professional'' means an
individual who, in exchange for compensation, provides services to an
individual with a disability (as defined in section 3 of the Americans
with Disabilities Act of 1990 (42 U.S.C. 12102)), including--
(1) services that enhance independence and community
inclusion for such individual, including traveling with such
individual, attending and assisting such individual while
visiting friends and family, shopping, or socializing;
(2) services such as coaching and supporting such
individual in communicating needs, achieving self-expression,
pursuing personal goals, living independently, and
participating actively in employment or voluntary roles in the
community;
(3) services such as providing assistance with activities
of daily living (such as feeding, bathing, toileting, and
ambulation) and with tasks such as meal preparation, shopping,
light housekeeping, and laundry; or
(4) services that support such individual at home, work,
school, or any other community setting.
SEC. 203. REVISION OF STANDARD OCCUPATIONAL CLASSIFICATION SYSTEM.
The Director of the Office of Management and Budget shall, not
later than 30 days after the date of enactment of this Act, revise the
Standard Occupational Classification system to establish a separate
code (31-1123) for direct support professionals as a healthcare support
occupation. Such code shall be a subset of 31-1120, which includes home
health aides and personal care aides.
TITLE III--SUPPORT FOR THE DIRECT CARE WORKFORCE
SEC. 301. DEFINITIONS.
In this title:
(1) Apprenticeship program.--The term ``apprenticeship
program'' means an apprenticeship program registered under the
Act of August 16, 1937 (commonly known as the ``National
Apprenticeship Act''; 50 Stat. 664, chapter 663; 29 U.S.C. 50
et seq.), including any requirement, standard, or rule
promulgated under such Act.
(2) Community college.--The term ``community college''
means a public institution of higher education at which the
highest degree that is predominantly awarded to students is an
associate's degree, including Tribal Colleges or Universities
receiving grants under section 316 of the Higher Education Act
of 1965 (20 U.S.C. 1059c) that offer a 2-year program for
completion of such degree and State public institutions of
higher education that offer such a 2-year program.
(3) Direct care professional.--The term ``direct care
professional''--
(A) means an individual who, in exchange for
compensation, provides services to a person with a
disability or an older adult that promotes the
independence of such person or individual, including--
(i) services that enhance the independence
and community inclusion for such person or
individual, including traveling with such
person or individual or attending and assisting
such person or individual while visiting
friends and family, shopping, or socializing;
(ii) services such as coaching and
supporting such person or individual in
communicating needs, achieving self-expression,
pursuing personal goals, living independently,
and participating actively in employment or
voluntary roles in the community;
(iii) services such as providing assistance
with activities of daily living (such as
feeding, bathing, toileting, and ambulation)
and with tasks such as meal preparation,
shopping, light housekeeping, and laundry;
(iv) services that support such person or
individual at home, work, school, or in any
other community setting; or
(v) services that promote health and
wellness, including scheduling and taking such
person or individual to health care
appointments, communicating with health and
allied health professionals administering
medications, implementing health and behavioral
health interventions and treatment plans,
monitoring and recording health status and
progress; and
(B) may include--
(i) a service provider supporting people
with intellectual disability and developmental
disabilities, and other disabilities;
(ii) a home and community-based services
manager or direct support professional manager;
(iii) a self-directed care worker;
(iv) a personal care service worker;
(v) a direct care worker, as defined in
section 799B of the Public Health Service Act
(42 U.S.C. 295p); or
(vi) any other position or job related to
the home care or direct care workforce, such as
positions or jobs in respite care, palliative
care, community support, or peer support, as
determined by the Secretary, in consultation
with the Centers for Medicare & Medicaid
Services and the Secretary of Labor.
(4) Direct care workforce.--The term ``direct care
workforce'' means the broad workforce of direct care
professionals.
(5) Family caregiver.--The term ``family caregiver'' has
the meaning given such term in section 2 of the RAISE Family
Caregivers Act (42 U.S.C. 3030s note; Public Law 115-119) and
includes paid and unpaid family caregivers.
(6) Eligible entity.--The term ``eligible entity'' means an
entity--
(A) that is--
(i) a State;
(ii) a labor organization, joint labor-
management organization, or employer of direct
care professionals;
(iii) a nonprofit entity with experience in
aging, disability, or supporting the rights and
interests of, training of, or educating direct
care professionals or family caregivers;
(iv) an Indian Tribe, Tribal organization,
or Urban Indian organization;
(v) a community college or other
institution of higher education; or
(vi) a consortium of entities listed in any
of clauses (i) through (v);
(B) that agrees to include, as applicable with
respect to the type of grant the entity is seeking
under this title and the activities supported through
such grant, older adults, people with disabilities,
direct care professionals, and family caregivers, as
advisors and trainers in such activities; and
(C) that agrees to consult with the State Medicaid
agency of the State (or each State) served by the grant
on the grant activities, to the extent that such agency
(or each such agency) is not the eligible entity.
(7) Employer.--The terms ``employ'' and ``employer'' have
the meanings given the terms in section 3 of the Fair Labor
Standards Act of 1938 (29 U.S.C. 203).
(8) Indian tribe; tribal organization.--The terms ``Indian
Tribe'' and ``Tribal organization'' have the meanings given
such terms in section 4 of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 5304).
(9) Institution of higher education.--The term
``institution of higher education'' means--
(A) an institution of higher education defined in
section 101 of the Higher Education Act of 1965 (20
U.S.C. 1001); or
(B) an institution of higher education defined in
section 102(a)(1)(B) of such Act (20 U.S.C.
1002(a)(1)(B)).
(10) Older adult.--The term ``older adult'' means an
individual who is 60 years of age or older.
(11) Person with a disability.--The term ``person with a
disability'' means an individual with a disability, as defined
in section 3 of the Americans with Disabilities Act of 1990 (42
U.S.C. 12102).
(12) Project participant.--The term ``project participant''
means an individual participating in a project or activity
assisted with a grant under this title, including (as
applicable for the category of the grant) a direct care
professional, or an individual training to be such a
professional, or a family caregiver.
(13) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Administrator
for Community Living.
(14) Self-directed care professional.--The term ``self-
directed care professional'' means a direct care professional
who is employed by an individual who is an older adult, a
person with a disability, or a representative of such older
adult or person with a disability, and such older adult or
person with a disability has the decision-making authority over
certain supports and services provided by the direct care
professional and takes direct responsibility to manage those
supports and services.
(15) Supportive services.--The term ``supportive services''
means services that are necessary to enable an individual to
participate in activities assisted with a grant under this
title, such as transportation, child care, dependent care,
housing, workplace accommodations, employee benefits such as
paid sick leave and child care, workplace health and safety
protections, wages and overtime pay, and needs-related
payments.
(16) Urban indian organization.--The term ``urban Indian
organization'' has the meaning given the term in section 4 of
the Indian Health Care Improvement Act (25 U.S.C. 1603).
(17) Workforce innovation and opportunity act terms.--The
terms ``career pathway'', ``career planning'', ``in-demand
industry sector or occupation'', ``individual with a barrier to
employment'', ``local board'', ``on-the-job training'',
``recognized postsecondary credential'', ``region'', and
``State board'' have the meanings given such terms in section 3
of the Workforce Innovation and Opportunity Act (29 U.S.C.
3102).
(18) Work-based learning.--The term ``work-based learning''
has the meaning given the term in section 3 of the Carl D.
Perkins Career and Technical Education Act of 2006 (20 U.S.C.
2302).
SEC. 302. AUTHORITY TO ESTABLISH A TECHNICAL ASSISTANCE CENTER FOR
BUILDING THE DIRECT CARE WORKFORCE.
(a) Program Authorized.--The Secretary shall establish a national
technical assistance center (referred to in this section as the
``Center'') for, in consultation with the Secretary of Labor, the
Secretary of Education, the Administrator of the Centers for Medicare &
Medicaid Services, and the heads of other entities as necessary--
(1) supporting direct care workforce creation, training and
education, recruitment, retention, and advancement; and
(2) supporting family caregivers and activities of family
caregivers as a critical part of the support team for older
adults or people with disabilities.
(b) Advisory Council.--The Secretary shall convene an advisory
council to provide recommendations to the Center with respect to the
duties of the Center under this section and may engage individuals and
entities described in paragraphs (3)(B), and (12), of section 304(b)
(without regard to a specific project described in such paragraphs) for
service on the advisory council.
(c) Activities.--The Center may--
(1) develop recommendations for training and education
curricula for direct care professionals, which such
recommendations may include recommendations for curricula for
higher education, postsecondary credentials, and programs with
community colleges;
(2) develop learning and dissemination strategies to--
(A) engage States and other entities in activities
supported under this title and best practices; and
(B) distribute findings from activities supported
by grants under this title;
(3) develop recommendations for training and education
curricula and other strategies for supporting family
caregivers;
(4) explore the national data gaps, workforce shortage
areas, and data collection strategies for direct care
professionals and make recommendations to the Director of the
Office of Management and Budget for an occupation category in
the Standard Occupational Classification system for direct
support professionals as a healthcare support occupation;
(5) recommend career development and advancement
opportunities for direct care professionals, which may include
occupational frameworks, national standards, recruitment
campaigns, pre-apprenticeship and on-the-job training
opportunities, apprenticeship programs, career ladders or
pathways, specializations or certifications, or other
activities; and
(6) develop strategies for assisting with reporting and
evaluation of grant activities under section 305.
SEC. 303. AUTHORITY TO AWARD GRANTS.
(a) Grants.--
(1) In general.--Not later than 12 months after the date of
enactment of this title, the Secretary, in consultation with
the Centers for Medicare & Medicaid Services, the Secretary of
Labor, and the Secretary of Education, shall award grants
described in paragraph (2) to eligible entities. A grant
awarded under this section may be in more than 1 category
described in such paragraph.
(2) Categories of grants.--The categories of grants
described in this paragraph are each of the following:
(A) Direct care professional grants.--Grants to
eligible entities to create and carry out projects for
the purposes of recruiting, retaining, or providing
advancement opportunities for direct care professionals
who are not described in subparagraph (B) or (C),
including through education or training programs for
such professionals or individuals seeking to become
such professionals.
(B) Direct care professional managers grants.--
Grants to eligible entities to create and carry out
projects for the purposes of recruiting, retaining, or
providing advancement opportunities for direct care
professionals who are managers or supervisory staff
that have coaching, training, managerial, supervisory,
or other oversight responsibilities, including through
education or training programs for such professionals
or individuals seeking to become such professionals.
(C) Self-directed care professionals grants.--
Grants to eligible entities to create and carry out
projects for the purposes of recruiting, retaining, or
providing advancement opportunities for self-directed
care professionals, including through education or
training programs for such professionals or individuals
seeking to become such professionals.
(D) Family caregiver grants.--Grants to eligible
entities to create and carry out projects for providing
support to paid or unpaid family caregivers through
educational, training, or other resources, including
resources for caregiver self-care or educational or
training resources for individuals newly in a
caregiving role or seeking additional support in the
role of a family caregiver.
(3) Projects for advancement opportunities.--Not less than
30 percent of projects assisted with grants under this title
shall be projects to provide career pathways that offer
opportunities for professional development and advancement
opportunities to direct care professionals.
(b) Treatment of Continuation Activities.--An eligible entity that
carries out activities described in subsection (a)(2) prior to receipt
of a grant under this title may use such grant to continue carrying out
such activities, and, in using such grant to continue such activities,
shall be treated as an eligible entity carrying out a project through a
grant under this title.
SEC. 304. PROJECT PLANS.
(a) In General.--An eligible entity seeking a grant under this
title shall submit to the Secretary a project plan for each project to
be developed and carried out (or for activities to be continued as
described in section 303(b)) with the grant at such time, in such
manner, and containing such information as the Secretary may require.
(b) Contents.--A project plan submitted by an eligible entity under
subsection (a) shall include a description of information determined
relevant by the Secretary for purposes of the category of the grant and
the activities to be carried out through the grant. Such information
may include (as applicable) the following:
(1) The demographics (as defined in section 2) of the
population in the State or relevant geographic area, including
a description of the populations likely to need long-term care
services, such as people with disabilities and older adults.
(2) Projections of unmet need for services provided by
direct care professionals based on enrollment waiting lists
under home and community-based waivers under section 1115 of
the Social Security Act (42 U.S.C. 1315) or section 1915 of
such Act (42 U.S.C. 1396n) and other relevant data to the
extent practicable and feasible, such as direct care workforce
vacancy rates, crude separation rates, and the number of direct
care professionals, including such professionals who are
managers or supervisors, in the region.
(3) An advisory committee to advise the eligible entity on
activities to be carried out through the grant. Such advisory
committee--
(A) may be comprised of entities listed in
paragraph (12); and
(B) shall include--
(i) older adults or persons with a
disability;
(ii) organizations representing the rights
and interests of people receiving services by
the direct care professionals or family
caregivers targeted by the project;
(iii) individuals who are direct care
professionals or family caregivers targeted by
the project and organizations representing the
rights and interests of direct care
professionals or family caregivers;
(iv) as applicable, employers of
individuals described in clause (iii) and labor
organizations representing such individuals;
(v) representatives of the State Medicaid
agency, the State agency defined in section 102
of the Older Americans Act of 1965 (42 U.S.C.
3002), the State developmental disabilities
office, and the State behavioral health agency,
in the State (or each State) to be served by
the project; and
(vi) representatives reflecting diverse
racial, cultural, ethnic, geographic,
socioeconomic, and gender identity and sexual
orientation perspectives.
(4) Current or projected job openings for, or relevant
labor market information related to, the direct care
professionals targeted by the project in the State or region to
be served by the project, and the geographic scope of the
workforce to be served by the project.
(5) Specific efforts and strategies that the project will
undertake to reduce barriers to recruitment, retention, or
advancement of the direct care professionals targeted by the
project, including an assurance that such efforts will
include--
(A) an assessment of the wages or other
compensation or benefits necessary to recruit and
retain the direct care professionals targeted by the
project;
(B) a description of the project's projected
compensation or benefits for the direct care
professionals targeted by the project at the State or
local level, including a comparison of such projected
compensation or benefits to regional and national
compensation or benefits and a description of how wages
and benefits received by project participants will be
impacted by the participation in and completion of the
project; and
(C) a description of the projected impact of
workplace safety issues on the recruitment and
retention of direct care professionals targeted by the
project, including the availability of personal
protective equipment.
(6) In the case of a project offering an education or
training program for direct care professionals, a description
of such program (including how the core competencies identified
by the Centers for Medicare & Medicaid Services will be
incorporated, curricula, models, and standards used under the
program, and any associated recognized postsecondary
credentials for which the program provides preparation, as
applicable), which shall include an assurance that such program
will provide to each project participant in such program--
(A) relevant training regarding the rights of
recipients of home and community based services,
including their rights to--
(i) receive services in integrated settings
that provide access to the broader community;
(ii) exercise self-determination;
(iii) be free from all forms of abuse,
neglect, or exploitation; and
(iv) person-centered planning and
practices, including participation in planning
activities;
(B) relevant training to ensure that each project
participant has the necessary skills to recognize abuse
and understand their obligations with regard to
reporting and responding to abuse appropriately in
accordance with relevant Federal and State law;
(C) relevant training regarding the provision of
culturally competent and disability competent supports
to recipients of services provided by the direct care
professionals targeted by the project;
(D) an apprenticeship program, work-based learning,
or on-the-job training opportunities;
(E) supervision or mentoring; and
(F) for any on-the-job training portion of the
program, a progressively increasing, clearly defined
schedule of wages to be paid to each such participant
that--
(i) is consistent with skill gains or
attainment of a recognized postsecondary
credential received as a result of
participation in or completion of such program;
and
(ii) ensures the entry wage is not less
than the greater of--
(I) the minimum wage required under
section 6(a) of the Fair Labor
Standards Act of 1938 (29 U.S.C.
206(a)); or
(II) the applicable wage required
by other applicable Federal or State
law, or a collective bargaining
agreement.
(7) Any other innovative models or processes the eligible
entity will implement to support the retention and career
advancement of the direct care professionals targeted by the
project.
(8) The supportive services and benefits to be provided to
the project participants in order to support the employment,
retention, or career advancement of the direct care
professionals targeted by the project.
(9) How the eligible entity will make use of career
planning to support the identification of advancement
opportunities and career pathways for the direct care
professionals in the State or region to be served by the
project.
(10) How the eligible entity will collect and submit to the
Secretary workforce data and outcomes of the project.
(11) How the project--
(A) will--
(i) provide adequate and safe equipment and
facilities for training and supervision,
including a safe work environment free from
discrimination, which may include the provision
of personal protective equipment and other
necessary equipment to prevent the spread of
infectious disease among the direct care
professionals targeted by the project and
recipients of services provided by such
professionals;
(ii) incorporate remote training and
education opportunities or technology-supported
opportunities;
(iii) for training and education curricula,
incorporate evidenced-supported practices for
adult learners and universal design for
learning and ensure recipients of services
provided by the direct care professionals or
family caregivers targeted by the project
participate in the development and
implementation of such training and education
curricula;
(iv) use outreach, recruitment, and
retention strategies designed to reach and
retain a diverse workforce;
(v) incorporate methods to monitor
satisfaction with project activities for
project participants and individuals receiving
services from such participants;
(vi) incorporate evidence-supported
practices for family caregiver engagement; and
(vii) incorporate core competencies
identified by the Centers for Medicare &
Medicaid Services; and
(B) may incorporate continuing education programs
and specialty training, with a specific focus on--
(i) trauma-informed care;
(ii) behavioral health, including co-
occurring behavioral health conditions and
intellectual or developmental disabilities;
(iii) Alzheimer's and dementia care;
(iv) chronic disease management; and
(v) the use of supportive or assistive
technology.
(12) How the eligible entity will consult on the
implementation of the project, or coordinate the project with,
each of the following entities, to the extent that each such
entity is not the eligible entity:
(A) The State Medicaid agency, State agency defined
in section 102 of the Older Americans Act of 1965 (42
U.S.C. 3002), and the State developmental disabilities
office for the State (or each State) to be served by
the project.
(B) The local board and State board for each
region, or State, to be served by the project.
(C) In the case of a project that carries out an
education or training program, a nonprofit organization
with demonstrated experience in the development or
delivery of curricula or coursework.
(D) A nonprofit organization, including a labor
organization, that fosters the professional development
and collective engagement of the direct care
professionals targeted by the project.
(E) Area agencies on aging, as defined in section
102 of the Older Americans Act of 1965 (42 U.S.C.
3002).
(F) Centers for independent living, as described in
part C of title VII of the Rehabilitation Act of 1973
(29 U.S.C. 796f et seq.).
(G) The State Council on Developmental Disabilities
(as such term is used in subtitle B of title I of the
Developmental Disabilities Assistance and Bill of
Rights Act of 2000 (42 U.S.C. 15021 et seq.)) for the
State (or each State) to be served by the project.
(H) Aging and Disability Resource Centers (as
defined in section 102 of the Older Americans Act of
1965 (42 U.S.C. 3002)).
(I) A nonprofit State provider association that
represents providers who employ the direct care
professionals targeted by the project, where such
associations exist.
(J) An entity that employs the direct care
professionals targeted by the project.
(K) University Centers for Excellence in
Developmental Disabilities Education, Research, and
Services supported under subtitle D of title I of the
Developmental Disabilities Assistance and Bill of
Rights Act of 2000 (42 U.S.C. 15061 et seq.).
(L) The State protection and advocacy system
described in section 143 of such Act (42 U.S.C. 15043)
of the State (or each State) to be served by the
project.
(M) Direct care professionals or direct care
workforce organizations representing underserved
communities, including communities of color.
(13) How the eligible entity will consult throughout the
project with--
(A) individuals employed or working as the direct
care professionals or family caregivers targeted by the
project;
(B) representatives of such professionals or
caregivers;
(C) individuals assisted by such professionals or
caregivers;
(D) the families of such professionals or
caregivers; and
(E) individuals receiving education or training to
become such professionals or caregivers.
(14) Outreach efforts to individuals for participation in
such project, including targeted outreach efforts to--
(A) individuals who are recipients of assistance
under a State program funded under part A of title IV
of the Social Security Act (42 U.S.C. 601 et seq.) or
individuals who are eligible for such assistance; and
(B) individuals with barriers to employment.
(c) Considerations.--In selecting eligible entities to receive a
grant under this title, the Secretary shall ensure--
(1) equitable geographic diversity, including by selecting
recipients serving rural areas and selecting recipients serving
urban areas; and
(2) that selected eligible entities will serve areas where
the occupation of direct care professional, or a related
occupation, is an in-demand industry sector or occupation.
(d) Uses of Funds; Supplement, Not Supplant.--
(1) Uses of funds.--
(A) In general.--Each eligible entity receiving a
grant under this title shall use the funds of such
grant to carry out at least 1 project described in
section 303(a)(2).
(B) Administrative costs.--Each eligible entity
receiving a grant under this title shall not use more
than 5 percent of the funds of such grant for costs
associated with the administration of activities under
this title.
(C) Direct support.--Each eligible entity receiving
a grant under this title shall use not less than 5
percent of the funds of such grant to provide direct
financial benefits or supportive services to direct
care professionals and paid or unpaid family caregivers
to support the financial needs of such participants
during the duration of the project activities.
(2) Supplement, not supplant.--An eligible entity receiving
a grant under this title shall use such grant only to
supplement, and not supplant, the amount of funds that, in the
absence of such grant, would be available to address the
recruitment, training and education, retention, and advancement
of direct care professionals or provide support for family
caregivers, in the State or region served by the eligible
entity.
(3) Prohibition.--No amounts made available under this
title may be used for any activity that is subject to the
reporting requirements set forth in section 203(a) of the
Labor-Management Reporting and Disclosure Act of 1959 (29
U.S.C. 433(a)).
SEC. 305. EVALUATIONS AND REPORTS; TECHNICAL ASSISTANCE.
(a) Reporting Requirements by Grant Recipients.--
(1) In general.--An eligible entity receiving a grant under
this title shall cooperate with the Secretary and annually
provide a report to the Secretary that includes any relevant
data requested by the Secretary in a manner specified by the
Secretary.
(2) Contents.--The data requested by the Secretary for an
annual report may include any of the following (as determined
relevant by the Secretary with respect to the category of the
grant and each project supported through the grant):
(A) The number of individuals and the demographic
categories (as defined in section 2) served by each
project supported by the grant, including--
(i) the number of individuals recruited
through each such project to be employed as a
direct care professional;
(ii) the number of individuals who through
each such project attained employment as a
direct care professional; and
(iii) the number of individuals who
enrolled in each such project and withdrew or
were terminated from each such project without
completing training or attaining employment as
a direct care professional.
(B) The number of family caregivers participating
in an education or training program through each
project supported by the grant.
(C) The number of project participants who through
each such project participated in and completed--
(i) work-based learning;
(ii) on-the-job training;
(iii) an apprenticeship program; or
(iv) a professional development or
mentoring program.
(D)(i) Other services, benefits, or supports (other
than the services, benefits, or supports described in
subparagraph (C)) provided through each such project to
assist in the recruitment, retention, or advancement of
direct care professionals (including through education
or training for such professionals or individuals
seeking to become such professionals);
(ii) the number of individuals who accessed such
services, benefits, or supports; and
(iii) the impact of such services, benefits, or
supports.
(E) The crude separation and vacancy rates of
direct care professionals, and such rates for those
professionals who are managers or supervisors, in the
geographic region for a number of years before the
grant was awarded, as determined by the Secretary, and
annually thereafter for the duration of the grant
period.
(F) How each project supported by the grant
assessed satisfaction with respect to--
(i) project participants assisted by the
project;
(ii) individuals receiving services
delivered by project participants, including--
(I) any impact on the health or
health outcomes of such individuals;
and
(II) any impact on the ability of
individuals to transition to or remain
in the community in an environment that
meets the criteria established in the
section 441.301(c)(4) of title 42, Code
of Federal Regulations (or successor
regulations); and
(iii) employers of such project
participants.
(G) The performance of the eligible entity with
respect to the indicators of performance on
unsubsidized employment, median earnings, credential
attainment, measurable skill gains, and employer
satisfaction.
(H) Any other information with respect to outcomes
of the project as determined by the Secretary.
(b) Annual Report to Congress by Secretary.--Not later than 2 years
after the date of enactment of this title, and each year thereafter
until all projects supported through a grant under this title are
completed, the Secretary shall prepare and submit to Congress an annual
report on the progress of each project supported through a grant under
this title and the activities of the technical assistance center
established under section 302.
(c) GAO Report.--Not later than 1 year after the date on which all
projects supported through a grant under this title are completed, the
Comptroller General of the United States shall conduct a study and
submit to Congress a report including--
(1) an assessment of how the technical assistance center
established under section 302 and the projects supported
through a grant under this title assisted in the creation,
recruitment, training and education, retention, and advancement
of the direct care workforce or in providing support for family
caregivers; and
(2) recommendations for such legislative or administrative
actions needed for improving the assistance described in
paragraph (1), as the Comptroller General determines
appropriate.
(d) Independent Evaluations.--Not later than 6 months after the
date of enactment of this title, the Secretary shall enter into a
contract with an independent entity to provide independent evaluations
of activities supported by grants under this title and activities of
the technical assistance center established under section 302.
SEC. 306. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--There are authorized to be appropriated--
(1) for the establishment and activities of the technical
assistance center under section 302, $2,000,000 for each of
fiscal years 2024 through 2028; and
(2) for grants under section 303, $1,000,000,000 for fiscal
year 2024.
(b) Availability.--Amounts made available under this title shall
remain available until September 30, 2033.
TITLE IV--EVALUATION
SEC. 401. EVALUATION OF IMPACT ON ACCESS TO HCBS.
(a) National Survey on Expanded HCBS Access.--The Administrator of
the Centers for Medicare & Medicaid Services, in coordination with the
National Academy of Medicine, shall, not later than 7 years after the
date of enactment of this Act, conduct or contract for a national
survey of States, direct care professionals, family caregivers, and
providers and recipients of home and community-based services, to
determine the effects of the implementation of this Act and the
amendments made by this Act on--
(1) the availability and access to home and community-based
services under the Medicaid program nationally and in each
State;
(2) the capacity of the direct service workforce to provide
home and community-based services and information on the
demographics (as defined in section 2) of such workforce;
(3) the compensation and working conditions, including
scheduling and benefits, of direct care workers;
(4) the economic effects on beneficiaries and on families
with a member receiving home and community-based services
through Medicaid;
(5) the availability of direct care workers and services
for people needing long-term services and supports who are not
Medicaid eligible;
(6) family caregivers; and
(7) recommendations for measures to further expand and
enhance access home and community-based services.
(b) Report.--Not later than 9 years after the date of enactment of
this Act, the Administrator of the Centers for Medicare & Medicaid
Services shall publish a report containing the results of the survey
conducted under subsection (a).
(c) American Community Survey Addition.--The Secretary of Commerce,
acting through the Bureau of the Census, shall add to the American
Community Survey a question designed to identify the need for long-term
services and supports by residents of the United States.
(d) Authorization of Appropriations.--There are authorized to be
appropriated to the Secretary such sums as are necessary to carry out
this section.
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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