H.R. 8540

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8540 Introduced in House (IH)]

<DOC>

119th CONGRESS
2d Session
H. R. 8540

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 HOUSE OF REPRESENTATIVES

April 28, 2026

Mrs. Dingell (for herself and Ms. Schakowsky) introduced the following 
bill; which was referred to the Committee on Energy and Commerce, and 
in addition to the Committees on Education and Workforce, Oversight and 
Government Reform, and Ways and Means, for a period to be subsequently 
determined by the Speaker, in each case for consideration of such 
provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

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.
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 PROFESSIONALS

Sec. 201. Findings.
Sec. 202. 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 deny access to the promise of 
community inclusion guaranteed under the Americans with 
Disabilities Act 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 capacity for independence or self-
care.
(4) 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.
(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 high-quality, safe and meaningful options in the community 
and are not at risk of unnecessary institutionalization.
(7) 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.
(8) 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.
(9) 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.
(10) 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.

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:
``(ll) 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)) and person-centered 
service plan (as described in paragraph (4)(D)) for 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 in line with recommendations for 
additional services made by the panel described in 
paragraph (2)(B).
``(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), (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:
``(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 that support person-
centered planning and self-direction.
``(ix) Direct support services during acute 
hospitalizations.
``(x) 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.
``(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 that 
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) Nutrition Services.
``(xvii) Assisted living services.
``(xviii) Any other service approved by the 
Secretary, pursuant to the recommendation of 
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 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.
``(ii) Composition.--
``(I) Selection.--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):
``(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. The 
individuals should be 
representative of multiple 
states, geography, race, and 
ethnicity and other demographic 
factors.
``(bb) Beneficiary-led 
disability rights 
organizations.
``(cc) Disability-led 
organizations.
``(dd) Disabled veterans 
organizations.
``(ee) Disability 
organizations representing 
families.
``(ff) Organizations 
serving people with people with 
disabilities, including 
intellectual or developmental 
disabilities.
``(gg) Organizations 
serving older adults.
``(hh) Direct care workers 
and the labor organizations 
that represent them.
``(ii) The Protection and 
Advocacy system, the Centers 
for Independent Living.
``(jj) Health care 
providers.
``(kk) The National 
Association of Medicaid 
Directors.
``(ll) The National 
Association of State Directors 
of Developmental Disabilities 
Services.
``(mm) The National 
Association of State Mental 
Health Program Directors.
``(nn) Advancing States.
``(oo) The Centers for 
Medicare & Medicaid Services.
``(pp) The Administration 
for Community Living of the 
Department of Health and Human 
Services.
``(qq) Other relevant 
local, State, and Federal home 
and community-based service 
systems, as determined by the 
Secretary.
``(rr) Members of 
federally-recognized tribes and 
tribally-led organizations.
``(II) Requirement for equal 
proportionate representation.--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).
``(iii) Duties.--
``(I) In general.--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.
``(II) Considerations.--In 
developing recommendations, the panel 
must consider--
``(aa) 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;
``(bb) new technology or 
innovations that could promote 
access to home and community 
based services for people with 
disabilities and older adults;
``(cc) relevant data based 
on the latest HCBS quality 
measures sets;
``(dd) public comment about 
additional home and community 
based services; and
``(ee) 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.
``(III) Notice and comment.--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.
``(iv) Implementation of recommended 
services.--
``(I) In general.--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).
``(II) Considerations.--In 
developing recommendations, the panel 
must consider--
``(aa) 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;
``(bb) new technology or 
innovations that could promote 
access to home and community 
based services for people with 
disabilities;
``(cc) relevant data based 
on the latest HCBS quality 
measures sets;
``(dd) public comment about 
additional home and community 
based services; and
``(ee) other relevant 
research, data, or information 
that will help inform the 
adoption of home and community 
based services for people with 
disabilities.
``(III) Notice and comment.--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.
``(IV) 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 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 physical and 
health condition, including any functional 
impairments;
``(ii) identify needed services;
``(iii) to inform development of 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) Reassessments.--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.
``(C) 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)).
``(D) 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 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.
``(E) Standards.--An individualized assessment 
described in subparagraph (A) shall be conducted in 
accordance with standards specified by the Secretary--
``(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;
``(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;
``(vi) require assessment tools to include 
language assistance services and compliance 
with Federal non-discrimination requirements, 
including--
``(I) availability of such 
assessments in the individual's primary 
language or with a qualified 
interpreter;
``(II) accessibility for 
individuals who are blind or have low-
vision;
``(III) accessibility for deaf and 
hard-of-hearing individuals; and
``(IV) accessibility for 
individuals who cannot rely on speech 
to communicate; and
``(vii) 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.''.
(2) Inclusion as medical assistance.--Section 1905(a) of 
the Social Security Act (42 U.S.C. 1396d(a)) is amended--
(A) by redesignating paragraphs (31) and (32) as 
paragraphs (32) and (33) respectively; and
(B) by inserting after paragraph (30) the following 
new paragraph:
``(31) home and community-based services (as defined in 
subsection (ll));''.
(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(ll)) 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 (mm)''; and
(2) by adding at the end the following new subsections:
``(mm) Specified Federal Medical Assistance Percentage 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 (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.
``(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 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:
``(A) Lowering or eliminating 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 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.
``(E) Developing a process to ensure that increases 
in payment rates for home and community-based services 
are--
``(i) 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
``(ii) 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.
``(F) 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.
``(G) Establishing an entity to strengthen the 
infrastructure supporting the delivery of service under 
consumer-directed models of care, as defined in section 
(nn).
``(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.
``(4) Administrative costs.--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.
``(nn) HCBS Infrastructure To Support Self-Directed Care Models for 
the Delivery of Services.--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:
``(1) Registering qualified direct care workers and 
assisting beneficiaries in finding direct care workers.
``(2) 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.
``(3) 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.
``(4) 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.
``(5) 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.
``(6) 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.
``(7) 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.''.
(e) 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(ll) 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 of the Social Security Act (42 U.S.C. 1396a) is 
amended--
(1) in subsection (a)--
(A) in paragraph (10)--
(i) in subparagraph (A)(i)--
(I) in subclause (VIII), by 
striking ``; or'' and inserting a 
semicolon;
(II) in subclause (IX)(dd), by 
striking the semicolon at the end and 
inserting ``; or''; and
(III) 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 (ll)(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
(ii) in subparagraph (A)(ii)--
(I) in subclause (XXII), by 
striking ``; or'' and inserting a 
semicolon;
(II) in subclause (XXIII), by 
striking the semicolon at the end and 
inserting ``; or''; and
(III) 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;''; and
(B) by amending paragraph (34) to read as follows:
``(34) 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;''; and
(2) in subsection (xx)(9)(A)(ii)--
(A) in subclause (VIII), by striking ``or'' at the 
end;
(B) in subclause (IX), by striking the period and 
inserting ``; or''; and
(C) by adding at the end the following new 
subclause:
``(X) who is described in subclause 
(X) of subsection (a)(10)(A)(i) or 
subclause (XXIV) of subsection 
(a)(10)(A)(ii).''.

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

(a) In General.--Section 1902 of the Social Security Act (42 U.S.C. 
1396a) is amended--
(1) in subsection (a)--
(A) in paragraph (88), by striking ``and'' at the 
end;
(B) in paragraph (89), by striking the period and 
inserting ``; and''; and
(C) by inserting after paragraph (89) the following 
new paragraph:
``(90) 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).''; and
(2) by adding at the end the following new subsection:
``(yy) Implementation Plan.--For purposes of subsection (a)(90), 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(ll), including the process for determinations specified in 
paragraph (3)(A)(i) of such section.
``(2) 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.
``(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 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.
``(4) 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.
``(5) 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 `No Wrong Door Program').
``(6) 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.
``(7) 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.
``(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, 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.
``(9) 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.
``(10) 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.
``(11) How the State will coordinate eligibility for such 
services with other disability eligibility programs, such as 
disability buy-in programs.
``(12) 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).
``(13) A description of how the State will evaluate and 
address disparities based on age, disability, race, ethnicity, 
sexual orientation, gender identity, and geographic equity.''.
(b) FMAP Increase.--Section 1903(a) of the Social Security Act (42 
U.S.C. 1396b(a)) is amended--
(1) in paragraph (6), by striking ``plus'' at the end;
(2) by redesignating paragraph (7) as paragraph (8); and
(3) by inserting after paragraph (6) the following new 
paragraph:
``(7) 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''.

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 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.
(2) Process.--The Secretary shall develop the metrics 
described in paragraph (1) through a public process, which 
shall provide opportunities for stakeholders to participate.
(b) Updating Metrics.--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.
(c) State Implementation Funding.--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.
(d) Appropriation.--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.

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 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:
(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(ll)(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(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.
(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, educational 
agencies, 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 2026, 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 subagency heads 
determined appropriate by the Secretary; 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;
(VII) beneficiary and family 
caregiver surveys; and
(VIII) measures related to outcomes 
by race/ethnicity, language, sex, 
gender identity, geography, and other 
demographic factors to track and reduce 
health disparities.
(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 2026, 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''.
(c) Ombudsman.--Each State shall establish an HCBS ombudsman office 
that--
(1) operates independently from the State Medicaid agency 
and managed care entities;
(2) provides direct assistance to beneficiaries and their 
families; and
(3) identifies and reports systemic problems to State 
officials, the public, and the Secretary.

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 ``is an eligible 
individual (as defined in section 1905(ll)(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.

Section 6071(h)(1)(L) of the Deficit Reduction Act of 2005 (42 
U.S.C. 1396a note(h)(1)(L)) is amended by striking ``each of fiscal 
years 2024 through 2027'' and inserting ``each fiscal year after 
2025''.

SEC. 110. LIENS, ADJUSTMENTS, AND RECOVERIES FOR MEDICAL ASSISTANCE.

(a) Liens.--Section 1917(a) of the Social Security Act (42 U.S.C. 
1396p(a)) is amended--
(1) in paragraph (1)--
(A) in the matter preceding subparagraph (A), by 
striking ``plan, except--'' and inserting ``plan, 
except, subject to paragraph (4)--''; and
(B) in subparagraph (B), by striking ``in the case 
of'' and inserting ``with respect to liens imposed 
before the date of the enactment of the Stop Unfair 
Medicaid Recoveries Act, in the case of''; and
(2) by adding at the end the following:
``(4) Notwithstanding any preceding provision of this subsection, 
not later than 90 days after the date of the enactment of this 
paragraph, a State shall--
``(A) withdraw any lien imposed under paragraph (1)(B) that 
is in effect as of such date; and
``(B) 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.''.
(b) Adjustments and Recoveries.--Section 1917(b) of the Social 
Security Act (42 U.S.C. 1396p(b)) is amended--
(1) in paragraph (1), by striking ``except that'' and 
inserting ``except that, subject to paragraph (6),''; and
(2) by adding at the end the following:
``(6) 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--
``(A) withdraw any lien in effect as of such date with 
respect to such medical assistance correctly paid; and
``(B) 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.''.

SEC. 111. HCBS PROVIDER TAX.

Section 1903(w) of the Social Security Act (42 U.S.C. 1396b(w)) is 
amended--
(1) in paragraph (7)(A)--
(A) by redesignating clause (ix) as clause (x); and
(B) by inserting after clause (viii) the following 
new clause:
``(ix) home- and community-based 
services.''; and
(2) in paragraph (4)(C)(ii), by inserting ``for a class of 
health care items and services other than the class described 
in paragraph (7)(A)(ix),'' after ``2026,''.

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.

(a) Liens.--Section 1917(a) of the Social Security Act (42 U.S.C. 
1396p(a)) is amended--
(1) in paragraph (1)--
(A) in the matter preceding subparagraph (A), by 
striking ``plan, except--'' and inserting ``plan, 
except, subject to paragraph (4)--''; and
(B) in subparagraph (B), by striking ``in the case 
of'' and inserting ``with respect to liens imposed 
before the date of the enactment of the Stop Unfair 
Medicaid Recoveries Act, in the case of''; and
(2) by adding at the end the following:
``(4) Notwithstanding any preceding provision of this 
subsection, not later than 90 days after the date of the 
enactment of this paragraph, a State shall--
``(A) withdraw any lien imposed under paragraph 
(1)(B) that is in effect as of such date; and
``(B) 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.''.
(b) Adjustments and Recoveries.--Section 1917(b) of the Social 
Security Act (42 U.S.C. 1396p(b)) is amended--
(1) in paragraph (1), by striking ``except that'' and 
inserting ``except that, subject to paragraph (6),''; and
(2) by adding at the end the following:
``(6) 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--
``(A) withdraw any lien in effect as of such date 
with respect to such medical assistance correctly paid; 
and
``(B) 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.''.

SEC. 113. MEDICARE AMENDMENT.

Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42 U.S.C. 
1395w-114) is amended by striking ``or subsection (c) or (d) of section 
1915 or under a State plan amendment under subsection (i) of such 
section'' and inserting ``, section 1915, 1115A, or under a State plan 
amendment''.

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 39 percent as 
identified in a 2023 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. REVISION OF STANDARD OCCUPATIONAL CLASSIFICATION SYSTEM.

(a) In General.--The Director of the Office of Management and 
Budget (in this Act referred to as the ``Director'') 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.
(b) Report to Congress.--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.

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) 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) 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;
(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.
(6) 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).
(7) 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.
(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 
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 2029 through 2030; and
(2) for grants under section 303, $1,000,000,000 for fiscal 
year 2029.
(b) Availability.--Amounts made available under this title shall 
remain available until September 30, 2038.

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.
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