Long-Term Care Workforce Support Act

[Congressional Bills 119th Congress] [From the U.S. Government Publishing Office] [H.R. 8541 Introduced in House (IH)]

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119th CONGRESS 2d Session H. R. 8541

To support the direct care professional workforce, and for other purposes.

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IN THE HOUSE OF REPRESENTATIVES

April 28, 2026

Mrs. Dingell (for herself and Ms. Matsui) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, Ways and Means, the Judiciary, House Administration, and Oversight and Government Reform, 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

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A BILL

To support the direct care professional workforce, 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) In General.--This Act may be cited as the ``Long-Term Care Workforce Support Act''. (b) Table of Contents.--The table of contents for this Act is as follows:

Sec. 1. Short title; table of contents. Sec. 2. Findings and purposes. Sec. 3. Definitions. TITLE I--IMPROVING REIMBURSEMENT

Sec. 101. Additional support for Medicaid long-term care services provided by direct care professionals. Sec. 102. Additional support for Medicaid long-term care services and direct care professionals. Sec. 103. Making permanent the State option to extend protection under Medicaid for recipients of home and community-based services against spousal impoverishment. Sec. 104. Permanent extension of money follows the person rebalancing demonstration. TITLE II--TRAINING, RECRUITMENT, CAREER ADVANCEMENT, AND WORKER SUPPORTS

Subtitle A--Improving Workforce Training

Chapter 1--Grants for Supporting the Direct Care Professional Workforce

Sec. 201. Definitions. Sec. 202. Authority to award grants. Sec. 203. Project plans. Sec. 204. Uses of funds; supplement, not supplant. Chapter 2--Other Workforce Training Grants

Sec. 205. Workforce investment activities grants for domestic workers. Sec. 206. Direct care professional career advancement demonstration projects. Sec. 207. Pathways to health careers. Sec. 208. Increasing workforce diversity in allied health professionals and direct support professionals. Subtitle B--Improving Workforce Recruitment

Sec. 211. Technical assistance center for building the direct care professional workforce. Sec. 212. Report on efforts to enhance the direct care professional workforce. Sec. 213. Comprehensive geriatric education. Sec. 214. Review of the availability and quality of apprenticeship programs in long-term care settings. Sec. 215. Rural health workforce grant program. Subtitle C--Providing Career Advancement Opportunities; Assessment of Worker Well-being

Sec. 221. Assessment of direct care professional well-being. Sec. 222. National Direct Care Professional Training Standards Commission. Subtitle D--Increasing Supports for the Existing Direct Care Professional Workforce

Sec. 231. Mental health services. Sec. 232. Dissemination of best practices with respect to mental health of direct care professionals. Sec. 233. Education and awareness initiative encouraging use of mental health and substance use disorder services by direct care professionals. Sec. 234. Direct care professional training grants. Sec. 235. Credit for certain health care professionals. Sec. 236. Direct Care Professional Workforce Equity Technical Assistance Center. TITLE III--WORKFORCE LABOR PROTECTIONS

Subtitle A--Long-term Care Workforce Wage Theft Prevention and Wage Recovery Act

Sec. 301. Definitions. Sec. 302. Direct care professional workforce wage theft prevention and wage recovery grant program. Subtitle B--Direct Care Professional Rights

Sec. 311. Definitions. Sec. 312. Written agreements. Sec. 313. Fair scheduling practices. Sec. 314. Right to request and receive temporary changes to scheduled work hours due to personal events. Sec. 315. Privacy. Sec. 316. Breaks for meals and rest. Sec. 317. Prohibited acts. Sec. 318. Enforcement authority. Sec. 319. Effect on existing employment benefits and other laws. Subtitle C--Workplace Violence Prevention for Health Care and Social Services Workers Act

Sec. 321. Workplace Violence Prevention Standard. Sec. 322. Scope and application. Sec. 323. Requirements for Workplace Violence Prevention Standard. Sec. 324. Rules of construction. Sec. 325. Definitions. Sec. 326. Application of the Workplace Violence Prevention Standard to certain facilities receiving Medicare funds. Subtitle D--Improving Access to Job Benefits

Sec. 331. Definitions. Sec. 332. Paid sick time. Sec. 333. Notice requirement. Sec. 334. Prohibited acts. Sec. 335. Enforcement authority. Sec. 336. Education and outreach. Sec. 337. Effect on existing employment benefits. Sec. 338. Encouragement of more generous leave policies. Sec. 339. Regulations. Sec. 339A. Effective date. Sec. 339B. Collection of data and further study. TITLE IV--NATIONAL DIRECT CARE PROFESSIONAL COMPENSATION STRATEGY

Sec. 401. Definitions. Sec. 402. National Direct Care Professional Compensation Strategy. Sec. 403. National Direct Care Professional Compensation Advisory Council. Sec. 404. Sunset provision. TITLE V--IMPROVING OVERSIGHT AND ACCOUNTABILITY

Sec. 501. Evaluation of implementation and outcomes.

SEC. 2. FINDINGS AND PURPOSES.

(a) Findings.--Congress finds the following: (1) The nearly 5,000,000 direct care professionals in the United States play a vital role in supporting the health, well- being, and independence of older individuals and people with disabilities. (2) The United States faces a growing crisis in its direct care professional workforce at the same time that demand for services is rising at unprecedented rates. (3) There will be an estimated 9,300,000 total direct care professional job openings from 2021 to 2031, including new jobs to support the growing number of people who need care and to fill the jobs of such professionals leaving the direct care professional workforce. (4) Workforce turnover and shortages have a direct impact on older individuals, people with disabilities, and their families who suffer because they cannot get the high-quality care that they need and deserve. (5) The median hourly wage for all direct care professionals in 2022 was only $15.43, with home care workers earning the least. (6) One in 8 direct care professionals live in poverty and three quarters earn less than the average living wage in their State. (7) Forty-six percent of direct care professionals rely on public assistance, such as Medicaid, food and nutrition assistance, or cash assistance. (8) Direct care professionals report high levels of burnout and professional fatigue from their physically and emotionally demanding work, lack of respect for the essential, skilled care they provide, and lasting trauma from battling the COVID-19 pandemic, all of which further drives high turnover. (9) The long-term care industry is struggling to hire and retain direct care professionals, with a national turnover rate between 77 to nearly 100 percent. (10) Ninety-two percent of nursing home respondents and nearly 70 percent of assisted living facilities surveyed report significant or severe workforce shortages. (11) More than half of nursing homes surveyed in 2022 reported that they limited new patient admissions due to staffing shortages. (12) A survey of State home and community-based services (referred to in this section as ``HCBS'') programs showed that every State reports a shortage of workers, and in 43 States, some HCBS providers have closed permanently. (13) The low-quality of direct care professional jobs reflects and perpetuates the racial and gender inequities faced by direct care professionals, who are disproportionately women, immigrants, and people of color. (14) Efforts to support the direct care professional workforce have focused on specific care settings, even though these issues are widespread across the long-term care landscape and direct care professionals across settings face similar challenges of low wages, few benefits, limited training and support, worker exploitation, and a lack of meaningful career ladders. (15) Stabilizing, growing, and supporting the direct care professional workforce across the continuum of long-term care is essential to ensuring a strong, qualified pipeline of workers, and improving the lives of direct care professionals and the older individuals, people with disabilities, and the families and communities that they support. (b) Purposes.--The purposes of this Act are as follows: (1) To increase the capacity of the direct care professional workforce to ensure that older individuals, people with disabilities, and their families receive the services they need in the settings of their choice as they deserve to live healthy, independent lives. (2) To increase compensation so that direct care professionals are paid a living wage and have access to essential job benefits, and so that direct care professional jobs are good jobs. (3) To ensure that direct care professionals are treated with respect, provided with a safe working environment, protected from exploitation, and fairly compensated for the skilled work they do. (4) To improve access to and quality of long-term care, including collecting meaningful and actionable data on the direct care professional workforce and the people they support. (5) To eliminate the race, gender, sexual orientation, age, and gender identity disparities that exist across the direct care professional workforce. (6) To strengthen the direct care professional workforce in order to support the 53,000,000 unpaid family caregivers who are often providing complex services and supports to their loved ones who are older individuals and people with disabilities in their homes, communities, and residential settings.

SEC. 3. DEFINITIONS.

In this Act: (1) Activities of daily living.--The term ``activities of daily living'' means basic, personal, everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (2) Aging and disability resource center.--The term ``Aging and Disability Resource Center'' has the meaning given such term in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002). (3) 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. (4) Appropriate committees of congress.--The term ``appropriate committees of Congress'' means-- (A) the Committee on Finance of the Senate; (B) the Committee on Health, Education, Labor, and Pensions of the Senate; (C) the Special Committee on Aging of the Senate; (D) the Committee on Ways and Means of the House of Representatives; (E) the Committee on Energy and Commerce of the House of Representatives; and (F) the Committee on Education and Workforce of the House of Representatives. (5) Area agency on aging.--The term ``area agency on aging'' has the meaning given such term in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002). (6) Assisted living facility.--The term ``assisted living facility'' means an adult care facility that-- (A) is a residential care setting licensed and regulated by the State in which the facility is located (or, if there is no State law providing for such licensing and regulation by the State, by the municipality or other political subdivision in which the facility is located); (B)(i) makes available to residents supportive services to assist the residents in carrying out activities of daily living; (ii) provides 24-hour on-site monitoring, personal care planning, food services, and personal care; and (iii) may make available to residents home health care services, such as nursing and therapy; and (C) provides dwelling units for residents, each of which may contain a full kitchen, bedroom, and bathroom, and which includes common rooms and other facilities appropriate for the provision of supportive services to the residents of the facility. (7) Certified nursing assistant.--The term ``certified nursing assistant'' means a nurse aide who has completed a State-approved training and competency evaluation program. (8) Commerce.--Except as provided in section 331, the term ``commerce'' has the meaning given such term in section 3 of the Fair Labor Standards Act of 1938 (29 U.S.C. 203). (9) Community or technical college.--The term ``community or technical 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. (10) Developmental disability.--The term ``developmental disability'' has the meaning given such term in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002). (11) Direct care professional.--The term ``direct care professional'' means-- (A) a personal or home care aide; (B) a home and community-based services worker; (C) a direct support professional; (D) a certified nursing assistant; (E) a nurse aide or nursing assistant; (F) a respite care provider; (G) a paid family caregiver; (H) a home health aide; (I) a private duty nurse; or (J) any other individual providing relevant services (as determined by the Secretary of Health and Human Services) for compensation, in the course of the profession of such individual, at a long-term care setting to a resident of such setting. (12) Direct care professional manager.--The term ``direct care professional manager'' means a person who is a manager, or supervisory staff, with coaching, training, managerial, supervisory, or other oversight responsibilities of direct care professionals. (13) Direct care professional workforce.--The term ``direct care professional workforce'' means the broad workforce of direct care professionals across all long-term care settings. (14) Disability.--The term ``disability'', except as provided in paragraph (10), has the meaning given such term in section 3 of the Americans with Disabilities Act of 1990 (42 U.S.C. 12102). (15) Domestic partner.-- (A) In general.--The term ``domestic partner'', with respect to an individual, means another individual with whom the individual is in a committed relationship. (B) Committed relationship defined.--The term ``committed relationship'' for purposes of subparagraph (A)-- (i) means a relationship between 2 individuals, each at least 18 years of age, in which both individuals share responsibility for a significant measure of each other's common welfare; and (ii) includes any such relationship between 2 individuals, including individuals of the same sex, that is granted legal recognition by a State or political subdivision of a State as a marriage or analogous relationship, including a civil union or domestic partnership. (16) Employ.--The term ``employ'' has the meaning given the term in section 3 of the Fair Labor Standards Act of 1938 (29 U.S.C. 203). (17) Employee; employer.--Except as provided in section 331, the terms ``employee'' and ``employer'' have the meanings given such terms in section 3 of such Act. (18) Home and community-based services.--The term ``home and community-based services'' means any of the following (whether provided on a fee-for-service, risk, or other basis): (A) Home health care services authorized under paragraph (7) of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)). (B) Personal care services authorized under paragraph (24) of such section. (C) PACE services authorized under paragraph (26) of such section. (D) Home and community-based services authorized under subsections (b), (c), (i), (j), and (k) of section 1915 of such Act (42 U.S.C. 1396n), such services authorized under a waiver under section 1115 of such Act (42 U.S.C. 1315), and such services provided through coverage authorized under section 1937 of such Act (42 U.S.C. 1396u-7). (E) Case management services authorized under section 1905(a)(19) of the Social Security Act (42 U.S.C. 1396d(a)(19)) and section 1915(g) of such Act (42 U.S.C. 1396n(g)). (F) Rehabilitative services, including those related to behavioral health, described in section 1905(a)(13) of such Act (42 U.S.C. 1396d(a)(13)). (G) Such other services specified by the Secretary of Health and Human Services. (19) Home and community-based services setting.--The term ``home and community-based services setting'' means a setting where home and community-based services authorized under State options described in subsection (c) or (i) of section 1915 of the Social Security Act (42 U.S.C. 1396n) or, as relevant, demonstration projects authorized under section 1115 of such Act (42 U.S.C. 1315), are provided to individuals enrolled for medical assistance under a State plan under title XIX (or under a waiver of such a plan). (20) Home and community-based services worker.--The term ``home and community-based services worker''-- (A) means an individual who provides home and community-based services for compensation; and (B) may include individuals described in subparagraph (A) who are physical therapists, occupational therapists, or speech or language therapists. (21) 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). (22) 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)). (23) Instrumental activities of daily living.--The term ``instrumental activities of daily living'' means tasks that are not necessary for fundamental functioning, but allow an individual to live independently in a community of daily living. Such tasks include-- (A) housekeeping and room cleaning; (B) meal preparation; (C) taking medications; (D) laundry; (E) transportation; (F) shopping for groceries, clothing, or other items; (G) managing communications, such as using the telephone; (H) managing finances; (I) writing letters; and (J) obtaining appointments. (24) Local educational agency.--The term ``local educational agency'' has the meaning given the term in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801). (25) Long-term care services.--The term ``long-term care services'' means any services provided by a direct care professional in a long-term care setting. (26) Long-term care setting.--The term ``long-term care setting'' means-- (A) a nursing home; (B) a home and community-based services setting; (C) an assisted living facility; (D) an intermediate care facility; (E) a State home, as defined in section 101(19) of title 38, United States Code; (F) a Tribal nursing home operated pursuant to an Indian health program (as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)); (G) a private home; (H) a respite setting; or (I) any other setting in which an individual provides relevant services (as determined by the Secretary of Health and Human Services), in the course of the profession of such individual, to a resident of such setting. (27) Medicaid program.--The term ``Medicaid program'' means, with respect to a State, the State program under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (including any waiver or demonstration under such title or under section 1115 of such Act (42 U.S.C. 1315) relating to such title). (28) Nurse aide.--The term ``nurse aide'' has the meaning given such term in section 1919(b)(5) of the Social Security Act (42 U.S.C. 1396r(b)(5)). (29) Nursing assistant.--The term ``nursing assistant'' means an individual who provides or assists with the basic care or support of a patient under the direction of onsite licensed nursing staff, which may include performing duties such as-- (A) monitoring of the health status, feeding, bathing, dressing, grooming, toileting, or ambulation of patients or residents in a health facility or nursing home; and (B) medication administration and other health- related tasks of patients in a health facility or nursing home. (30) Nursing home.--The term ``nursing home'' means-- (A) a nursing facility as defined in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)); or (B) a skilled nursing facility as defined in section 1819(a) of such Act (42 U.S.C. 1395i-3(a)). (31) Older individual.--The term ``older individual'' has the meaning given the term in section 102 of the Older Americans Act of 1965 (42 U.S.C. 3002). (32) Personal or home care aide.-- (A) In general.--The term ``personal or home care aide'' means an individual who helps older individuals and people with serious illness, physical disability, cognitive impairment (including Alzheimer's disease or other dementias, a developmental disability, or another disability involving a mental impairment) to live in their own home or a residential care facility (such as a nursing home, assisted living facility, or any other facility the Secretary of Health and Human Services determines appropriate that is not described in subparagraph (B)(i)) by providing personal care services for compensation. (B) Personal care services.--For purposes of subparagraph (A), the term ``personal care services'' means assistance or services-- (i) provided to an individual who is not an inpatient or resident of a hospital or institution for mental disease; and (ii) that enable the recipient to accomplish activities of daily living or instrumental activities of daily living. (33) Secondary school.--The term ``secondary school'' has the meaning given such term in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801). (34) Self-directed care professional.--The term ``self- directed care professional'' (also known as an ``independent provider'')-- (A) means a direct care professional who is employed by an individual who is an older individual, a person with a disability, or a representative of such older individual or person with a disability, and such older individual 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; and (B) includes paid family caregivers. (35) State.--The term ``State'', except as otherwise provided in this Act, has the meaning given such term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). (36) State educational agency.--The term ``State educational agency'' has the meaning given the term in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801). (37) 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). (38) 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). (39) Work-based learning.--The term ``work-based learning'' has the meaning given such term in section 3 of the Carl D. Perkins Career and Technical Education Act of 2006 (20 U.S.C. 2302).

TITLE I--IMPROVING REIMBURSEMENT

SEC. 101. ADDITIONAL SUPPORT FOR MEDICAID LONG-TERM CARE SERVICES PROVIDED BY DIRECT CARE PROFESSIONALS.

Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended-- (1) in subsection (b), by striking ``and (ii)'' and inserting ``(ii), and (kk)''; and (2) by adding at the end the following new subsection: ``(kk) Additional Support for Long-Term Care Services Provided by Direct Care Professionals.-- ``(1) In general.--Notwithstanding subsections (b) and (ff), in the case of a State that satisfies the conditions described in paragraph (2), for each fiscal quarter during the period of fiscal years 2026 through 2035, the Federal medical assistance percentage otherwise determined for such State under such subsection (b) or (ff) shall, after the application of any other increase to the Federal medical assistance percentage for the State and quarter applicable under any other provision of law, be increased by 10 percentage points (but not to exceed 95 percent) with respect to amounts expended by the State for medical assistance for long-term care services that are provided by direct care professionals during such quarter. ``(2) Requirements.--As a condition for receipt of the increase under paragraph (1) to the Federal medical assistance percentage determined for a State, the State shall submit to the Secretary, at such time and in such manner as specified by the Secretary, an application that includes, in addition to such other information as the Secretary shall require-- ``(A) a description of which activities described in paragraph (4) that a State plans to implement and a description of how it plans to implement such activities; ``(B) assurances that all Federal funds attributable to the increase under paragraph (1) will be-- ``(i) expended by the State in accordance with this subsection not later than September 30, 2037; and ``(ii) used-- ``(I) to implement the activities described in paragraph (4); ``(II) to supplement, and not supplant, the level of State funds expended for long-term care services provided by direct care professionals under the State plan (or under a waiver of such plan) as of the date of enactment of this subsection; and ``(III) to increase reimbursement rates for long-term care services provided by direct care professionals under the State plan (or under a waiver of such plan) to a level that will support recruitment and retention of a sufficient workforce to provide such services under the State plan (or waiver); ``(C) assurances that the State will use a portion of the Federal funds attributable to the increase under paragraph (1) to ensure greater service capacity, including reducing waiting lists and improving compensation, benefits, working conditions, and training for direct care professionals and direct care managers; and ``(D) assurances that the State will conduct adequate oversight and ensure the validity of such data as may be required by the Secretary. ``(3) Approval of application.--Not later than 90 days after the date of submission of an application of a State under paragraph (2), the Secretary shall certify if the application is complete. Upon certification that an application of a State is complete, the application shall be deemed to be approved for purposes of this section. ``(4) Activities to improve the direct care professional workforce.-- ``(A) In general.--A State shall work with community partners such as Area Agencies on Aging, centers for independent living, as described in part C of title VII of the Rehabilitation Act of 1973, nonprofit long-term care services providers, and other entities to implement some or all of the purposes described in subparagraph (B). ``(B) Focused areas of improvement.--The purposes described in this paragraph, with respect to a State, are the following: ``(i) To increase rates for service provider agencies that employ direct care professionals (including independent providers in a self-directed or consumer-directed model) to provide long-term care services under the State plan (or under a waiver of such plan), provided that any service provider agency or individual that receives payment under such an increased rate increases the compensation it pay its direct care professionals. ``(ii) To provide paid sick leave, paid family leave, and paid medical leave for direct care professionals. ``(iii) To provide hazard pay, overtime pay, and shift differential pay for direct care professionals. ``(iv) To improve stability of direct care professional jobs, including consistent hours, scheduling, pay, and benefit eligibility. ``(v) To provide home and community-based services to individuals who are on waiting lists for programs approved under sections 1115 or 1915. ``(vi) To purchase emergency supplies and equipment, which may include items not typically covered under the State plan (or under a waiver of such plan), such as personal protective equipment, necessary to enhance access to services and to protect the health and well-being of direct care professionals. ``(vii) To pay for the travel of direct care professionals to conduct their job responsibilities. ``(viii) To recruit new direct care professionals. ``(ix) To pay for training for direct care professionals, including apprenticeship programs. ``(x) To pay for assistive technologies, staffing, and training to facilitate eligible individuals' communication, and other costs incurred in order to facilitate community integration and ensure an individual's person- centered service plan is fully implemented. ``(xi) To prepare information and public health and educational materials in accessible formats (including formats accessible to people with low literacy or intellectual disabilities about prevention, treatment, recovery, and other aspects of communicable diseases and threats to the health of individuals who are enrolled for medical assistance under the State plan (or under a waiver of such plan)), their families, and the general community served by agencies described in clause (i). ``(xii) To protect the health and safety of direct care professionals during public health emergencies and natural disasters. ``(xiii) To pay for interpreters to assist in providing long-term care services to individuals under the State plan (or under a waiver of such plan) and to inform the general public about communicable diseases and other public health threats. ``(xiv) To pay for other expenses deemed appropriate by the Secretary to enhance, expand, or strengthen long-term care services under the State plan (or under a waiver of such plan). ``(5) Reporting requirements.-- ``(A) State reporting requirements.--Not later than December 31, 2028, and every 2 years thereafter until December 31, 2040, any State with respect to which an application is approved by the Secretary pursuant to paragraph (3) shall submit a report to the Secretary that contains the following information: ``(i) Activities and programs that were funded using Federal funds attributable to the increase to the Federal medical assistance percentage of the State under paragraph (1). ``(ii) The number of individuals enrolled under the State plan (or under a waiver of such plan) who were served by such activities and programs. ``(iii) A detailed accounting of all spending of funds attributable to the increase to the Federal medical assistance percentage of the State under paragraph (1) by the State and by any providers with whom the State entered into contracts or agreements to fulfill the requirements of this subsection. ``(B) Non-application of the paperwork reduction act.--Chapter 35 of title 44, United States Code (commonly referred to as the `Paperwork Reduction Act of 1995'), shall not apply to the provisions of this subsection. ``(6) Enforcement.-- ``(A) In general.--If the Secretary determines that a State with respect to which an application is approved pursuant to paragraph (3) has failed to comply with the requirements of this subsection (including the requirement that all Federal funds attributable to the increase to the Federal medical assistance percentage of the State under paragraph (1) be spent in accordance with paragraph (4)) for any quarter during the period of fiscal years described in paragraph (1), the Secretary may reduce the number of percentage points by which the Federal medical assistance percentage for the State and quarter would otherwise be increased under paragraph (1) for such quarter. ``(B) Penalty based on severity of failure.--The Secretary shall impose reductions under this paragraph based on the degree to which a State has failed to comply with the requirements of this subsection. ``(7) Evaluation.--Not later than 2028 and annually until 2037, the Secretary, in conjunction with the Secretary of Labor, shall evaluate the implementation and outcomes of this subsection on the availability of staff to cover shifts in all long-term care settings serving, worker credentials and skills, and worker compensation through a contract with an external evaluator who has experience with evaluation related to people with disabilities and older individuals. ``(8) Definitions.--In this subsection: ``(A) Direct care professional.--The term `direct care professional' has the meaning given such term in section 3 of the Long-Term Care Workforce Support Act. ``(B) Home and community-based services.--The term `home and community-based services' means any of the following: ``(i) Home health care services authorized under paragraph (7) of subsection (a). ``(ii) Personal care services authorized under paragraph (24) of such subsection. ``(iii) PACE services authorized under paragraph (26) of such subsection. ``(iv) Home and community-based services authorized under subsections (b), (c), (i), (j), and (k) of section 1915, such services authorized under a waiver under section 1115, and such services through coverage authorized under section 1937. ``(v) Case management services authorized under subsection (a)(19) of this section and section 1915(g). ``(vi) Rehabilitative services, including those related to behavioral health, described in subsection (a)(13) of this section. ``(vii) Such other services specified by the Secretary.''.

SEC. 102. ADDITIONAL SUPPORT FOR MEDICAID LONG-TERM CARE SERVICES AND DIRECT CARE PROFESSIONALS.

(a) In General.--Not later than 18 months after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this section as the ``Secretary'') shall award grants to States for the purpose of supporting and strengthening services provided by direct care professionals across direct care settings and improving recruitment, compensation, and retention of the direct care professional workforce. (b) Application.--Not later than 6 months after the date of enactment of this Act, each State that seeks to receive a grant under this section shall submit an application, in such form and manner as the Secretary shall require, to the Secretary that includes-- (1) information on how the State will use grant funds to improve long-term care services and the recruitment, compensation, and retention of direct care professionals in a manner that maximizes the independence of people with disabilities and older individuals, limits unnecessary institutionalization, and supports people living in residential settings; (2) specifies the proportion of grant funds that the State plans to spend on activities to support long-term professional care workers in nursing homes, home health settings, and home and community-based services settings, respectively; (3) a plan for sustaining the work at the conclusion of the grant period; and (4) such other information as the Secretary shall require. (c) Grant Amounts.--The Secretary shall award each State that submits an application to the Secretary that meets the requirements of subsection (b) a 5-year grant in an amount that bears the same proportion to the amount appropriated under subsection (e) as-- (1) the number of individuals who are enrolled for medical assistance under the Medicaid program of the State involved (as determined by the Secretary using the most recent data available as of the date of enactment of this Act); bears to (2) the total number of individuals who are enrolled for medical assistance under the Medicaid programs of all States that submit to the Secretary an application that meets the requirements of subsection (b). (d) Use of Grant Funds.-- (1) In general.--A State that receives a grant under this section shall use the funds of such grant in accordance with the requirements of this subsection. (2) Supplement, not supplant.--A State shall use funds from a grant awarded under this section to supplement, and not supplant, the level of State funds expended for services in long-term care settings through programs in effect as of January 1, 2026. (3) Required implementation of certain activities.--The State shall use funds from a grant awarded under this section to implement and evaluate, or supplement the implementation of, activities (which shall include the activities described in paragraph (4)) to enhance, expand, or strengthen long-term care services and to improve compensation to the workforce that provides such services. (4) Activities to strengthen and expand the direct care professional workforce.-- (A) In general.--The State strengthens and expands the direct care professional workforce that provides services across long-term care settings by-- (i) adopting a salary review process to ensure that the rates payable for long-term care services under the State Medicaid program are sufficient to ensure access to such services under such program; (ii) requiring that a percentage of all payments for long-term care services that are made under the State Medicaid program, including base payments and supplemental payments, improve compensation, benefits, working conditions, and training for direct care professionals and direct care managers; and (iii) updating, developing, and adopting qualification standards and training opportunities for the continuum of direct care professionals, including programs for independent direct care professionals and agency direct care professionals, as well as unique programs. (B) Payment rates.--In carrying out subparagraph (A)(i), the State shall-- (i) address insufficient payment rates under the State Medicaid program for delivery of long-term care services with an emphasis on supporting the recruitment and retention of direct care professionals; (ii) update payment rates under the State Medicaid program for long-term care services, including home and community-based services, nursing home services, skilled nursing facility services, and intermediate care facility services at least every 2 years through a transparent process involving meaningful input from stakeholders, in which the majority of stakeholders are recipients of such services, families, direct care professionals, family caregivers, chosen representatives of direct care workers, aging, disability, and workforce advocates, long-term care providers, and may also include health plans; and (iii) ensure that, with respect to any increases in the payment rates under the State Medicaid program for long-term care services-- (I) at a minimum, increases in the payment rates for long-term care services are proportionately passed through to direct care professionals and direct care professional managers who provide such services and in a manner that is determined with input from the stakeholders described in clause (ii); (II) such payment rate increases are incorporated into payment rates for such services provided under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) by a managed care entity (as defined in section 1932(a)(1)(B) of the Social Security Act (42 U.S.C. 1396u-2(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; (III) such payment rate increases are appropriately distributed across settings, populations, and services so as to promote independence of people with disabilities and older individuals, not result in increased institutionalization, and assists in the facilitation of rebalancing the Medicaid program towards the least restrictive settings appropriate for individuals receiving services; and (IV) such payment rate increases are prioritized toward home and community-based service workers in States that have a waiting list for home and community based services and have been determined by the Centers for Medicare & Medicaid Service to have inadequate capacity for such services. (e) Appropriation.--There is appropriated to the Secretary for awarding grants under this section an amount equal to $100,000,000,000. (f) Evaluation of Impact on HCBS Waiting Lists.--The Secretary shall evaluate the implementation and outcomes of this title on State Medicaid program waiting lists for home and community-based services through a contract with an external evaluator who has experience with evaluation related to people with disabilities and older individuals.

SEC. 103. MAKING PERMANENT THE STATE OPTION TO EXTEND PROTECTION UNDER MEDICAID FOR RECIPIENTS OF HOME AND COMMUNITY-BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT.

(a) In General.--Section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r-5(h)(1)(A)) is amended by striking ``is described in section 1902(a)(10)(A)(ii)(VI)'' and inserting the following: ``is eligible for medical assistance for home and community-based services provided under subsection (c), (d), or (i) of section 1915, under a waiver approved under section 1115, or who is eligible for such medical assistance by reason of being determined eligible under section 1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care, or who is eligible for medical assistance for home and community-based attendant services and supports under section 1915(k)''. (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 Long-Term Care Workforce Support Act''.

SEC. 104. PERMANENT EXTENSION OF MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION.

(a) In General.--Subsection (h)(1) of section 6071 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended-- (1) in subparagraph (K), by striking ``; and'' and inserting a semicolon; (2) in subparagraph (L), by striking ``through 2027.'' and inserting ``through 2026; and''; and (3) by adding at the end the following new subparagraph: ``(M) $500,000,000 for each fiscal year after fiscal year 2026.''. (b) Redistribution of Unexpended Grant Awards.--Subsection (e)(2) of section 6071 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended by adding at the end the following new sentence: ``Any portion of a State grant award for a fiscal year under this section that is unexpended by the State at the end of the fourth succeeding fiscal year shall be rescinded by the Secretary and added to the appropriation for the fifth succeeding fiscal year for grants under this section.''.

TITLE II--TRAINING, RECRUITMENT, CAREER ADVANCEMENT, AND WORKER SUPPORTS

Subtitle A--Improving Workforce Training

CHAPTER 1--GRANTS FOR SUPPORTING THE DIRECT CARE PROFESSIONAL WORKFORCE

SEC. 201. DEFINITIONS.

In this chapter: (1) Eligible entity.--The term ``eligible entity'' means an entity-- (A) that is-- (i) a State; (ii) a labor organization, joint labor- management organization, or employer of direct care professionals; (iii) a nonprofit entity with experience in aging, disability, or supporting the rights and interests of, the training of, or educating direct care professionals; (iv) an Indian Tribe, Tribal organization, or Urban Indian organization; (v) a community or technical college or other institution of higher education; or (vi) a consortium of entities listed in any of clauses (i) through (v); (B) that agrees, as applicable with respect to the type of grant the entity is seeking under this chapter and the activities supported through such grant, to include as advisors and trainers in such activities-- (i) older individuals; (ii) people with disabilities; (iii) direct care professionals; and (iv) family members of such individuals, persons, or professionals; 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. (2) Project participant.--The term ``project participant'' means an individual participating in a project or activity assisted with a grant under this chapter, including (as applicable for the category of the grant) a direct care professional or an individual training to be such a professional. (3) Secretary.--The term ``Secretary'' means the Secretary of Health and Human Services. (4) 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 chapter, 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.

SEC. 202. AUTHORITY TO AWARD GRANTS.

(a) Grants.-- (1) In general.--Not later than 12 months after the date of enactment of this Act, the Secretary, in consultation with the Administrator of 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 professionals 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), (C), or (D), 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 professional managers, including through education or training programs for such managers or individuals seeking to become such managers. (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) Home and community-based services grants.-- Grants to eligible entities to create and carry out projects to recruit, retain, or provide advancement opportunities for home and community-based services workers providing services and supports to older individuals, or people with disabilities, who are eligible for coverage under a State Medicaid program. (3) Projects for advancement opportunities.--Not less than 30 percent of projects assisted with grants under this chapter 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 chapter 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 chapter.

SEC. 203. PROJECT PLANS.

(a) In General.--An eligible entity seeking a grant under this chapter shall submit to the Secretary a project plan for each project to be developed and carried out (including for activities to be continued as described in section 202(b)) with the grant. Such project plan shall be submitted 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) Demographic information regarding the population in the State, city or municipality, or region to be served by the project, including a description of the populations likely to need services provided by direct care professionals, such as people with disabilities and older individuals. (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(c) of such Act (42 U.S.C. 1396n(c)) and other relevant data to the extent practicable and feasible, such as direct care professional workforce vacancy rates and crude separation rates and the number of direct care professionals, including such professionals who are managers or supervisors, in the State or region to be served by the project. (3) An advisory committee to advise the eligible entity on activities to be carried out through the grant. Such advisory committee-- (A) shall include-- (i) older individuals and people with disabilities receiving services from the direct care professionals targeted by the project; (ii) organizations representing the rights and interests of people receiving services by the direct care professionals targeted by the project; (iii) individuals who are direct care professionals targeted by the project and organizations representing the rights and interests of such direct care professionals; (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 mental health agency, in the State (or each State) to be served by the project; (vi) parents or caregivers of children with disabilities or chronic conditions; and (vii) representatives reflecting diverse racial, cultural, ethnic, geographic, socioeconomic, and gender identity and sexual orientation perspectives; and (B) may include any other individuals or entities listed in paragraph (12). (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 long-term care 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; (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 minimum wage required by other applicable Federal or State law, or a collective bargaining agreement; and (iii) does not use a certificate under section 14(c) of the Fair Labor Standards Act of 1938 (29 U.S.C. 214(c)). (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 direct care professional 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 evidence-supported practices for adult learners and universal design for learning and ensure recipients of services provided by the direct care professionals 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; and (vi) 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; (iii) developmental disabilities or other disabilities involving mental impairment; (iv) co-occurring behavioral health conditions and a disability described in clause (iii); (v) Alzheimer's and dementia care; (vi) infection prevention and control measures; (vii) chronic disease management; (viii) age-related conditions; and (ix) the use of supportive or assistive technology. (12) How the eligible entity will consult throughout the implementation of the project, or coordinate the project with, each of the following: (A) Older individuals and people with disabilities. (B) The State Medicaid agency, the 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. (C) The local board and State board for each region, or State, to be served by the project. (D) 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. (E) A nonprofit organization, including a labor organization, that fosters the professional development and collective engagement of the direct care professionals targeted by the project. (F) Organizations representing the rights and interests of people receiving services by the direct care professionals targeted by the project. (G) Area agencies on aging. (H) Centers for independent living, as described in part C of chapter I of title VII of the Rehabilitation Act of 1973 (29 U.S.C. 796f et seq.). (I) 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. (J) Aging and Disability Resource Centers. (K) A nonprofit State provider association that represents providers who employ the direct care professionals targeted by the project, where such associations exist. (L) An entity that employs the direct care professionals targeted by the project. (M) University Centers for Excellence in Developmental Disabilities Education, Research, and Service 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.). (N) 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. (O) Direct care professionals, and direct care professional workforce organizations, representi

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