,,ii #aaith ,,congress #b;d ,session ,s4 #cief ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,march #b1 #bjbf,mr4 ,sanders introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend the ,internal ,revenue ,code of #aihf to impose an annual tax on the net value of assets held by a taxpayer1 and for other purposes4 #a4 ,short title1 etc 7a7 ,short title ,this ,act may be cited as the ,make ,billionaires ,pay ,their ,fair ,share ,act4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title1 etc4,,title ,i--,wealth tax,sec4 #aja4 ,imposition of tax on net value of assets4,sec4 #ajb4 ,enforcement4,,title ,,ii--,affordability ,rebates,sec4 #bja4 ,affordability rebates4,,title ,,iii--,health care provisions,sec4 #cja4 ,repeal of reconciliation health provisions4,sec4 #cjb4 ,increase in eligibility for premium tax credit4,,title ,,iv--,medicare ,dental1 ,hearing1 and ,vision ,expansion,sec4 #dja4 ,short title4,sec4 #djb4 ,coverage of dental and oral health care4,sec4 #djc4 ,providing coverage for hearing care under the ,medicare program4,sec4 #djd4 ,providing coverage for vision care under the ,medicare program4,sec4 #dje4 ,phase-in of impact of dental and oral health coverage on part ,b premiums4,,title ,v--,housing ,trust ,fund,sec4 #eja4 ,authorization of appropriations4,,title ,,vi--,affordable ,child ,care for ,working ,families,sec4 #fja4 ,birth through five child care and early learning entitlement4,,title ,,vii--,establishing a #fj1jjj a year minimum salary for every public school teacher in the ,united ,states,sec4 #gja4 ,purposes4,sec4 #gjb4 ,definitions4,sec4 #gjc4 ,ensuring teachers are paid a livable and competitive wage4,sec4 #gjd4 ,collective bargaining and related rules4,,title ,,viii--,investments in ,home and ,community-,based ,services and ,long-,term ,care ,quality and ,workforce,sec4 #hja4 ,,hcbs improvement planning grants4,sec4 #hjb4 ,,hcbs ,improvement ,program4,sec4 #hjc4 ,funding for ,federal activities related to ,medicaid ,,hcbs4,sec4 #hjd4 ,funding for ,,hcbs quality measurement and improvement4,sec4 #hje4 ,permanent extension of ,medicaid protections against spousal impoverishment for recipients of home and community-based services4,sec4 #hjf4 ,permanent extension of ,money ,follows the ,person ,rebalancing demonstration4 ,i ,wealth tax #aja4 ,imposition of tax on net value of assets 7a7 ,in general ,the ,internal ,revenue ,code of #aihf is amended by inserting after subtitle ,b the following new subtitle3 ,b-#a ,wealth tax ,chapter #ah--;,determination of wealth tax #ah ,determination of wealth tax ,sec4 #bija4 ,imposition of tax4,sec4 #bijb4 ,net value of assets4,sec4 #bijc4 ,special rules4,sec4 #bijd4 ,administrative provisions4 #bija4 ,imposition of tax 7a7 ,in general ,in the case of an applicable taxpayer1 there is hereby imposed a tax computed equal to #e percent of the net value of assets held by the taxpayer for the calendar year4 7b7 ,applicable taxpayer 7#a7 ,in general ,for purposes of this chapter1 the term applicable taxpayer means any individual or trust if the net value of all assets held by the taxpayer for the calendar year exceeds #a1jjj1jjj1jjj4 7#b7 ,inflation adjustment 7,a7 ,in general ,in the case of any calendar year after #bjbf1 the #a1jjj1jjj1jjj amount under paragraph 7#a7 shall be increased by an amount equal to-- 7i7 such dollar amount1 multiplied by 7ii7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year in which the taxable year begins1 determined by substituting in subparagraph 7,a77ii7 thereof calendar year #bjbe for calendar year #bjaf4 7,b7 ,rounding ,if any amount as adjusted under subparagraph 7,a7 is not a multiple of #a1jjj1jjj1 such dollar amount shall be rounded to the next lowest multiple of #a1jjj1jjj4 7c7 ,treatment of married individuals ,for purposes of this section1 individuals who are married 7as defined in section #ggjc7 shall be treated as one taxpayer4 #bijb4 ,net value of assets 7a7 ,in general ,the net value of assets held by an applicable taxpayer for any calendar year shall be the excess of-- 7#a7 the value of all property of the taxpayer1 real or personal1 tangible or intangible1 wherever situated1 on the last day of such calendar year 7computed without regard to any debt owed by the taxpayer and secured by the property71 over 7#b7 the amount of any debt owed by the taxpayer on the last day of such calendar year4 7b7 ,inclusion of property of related children ,for purposes of this subtitle1 any property of an individual who is a child of the taxpayer 7as defined in section #aeb7;f77#a77 and has not attained the age of #ah shall be treated as property held by the taxpayer for any calendar year before the year in which such individual attains the age of #ah4 7c7 ,establishment of valuation rules 7#a7 ,authority of ,secretary ,the ,secretary shall establish rules and methods for determining the value of any asset for purposes of this subtitle4 7#b7 ,general rules ,except as otherwise provided in this paragraph1 the rules and methods established under paragraph 7#a7 may be similar to the rules of part ,,iii of subchapter ,a of chapter #aa 7other than the rules of sections #bjca7;c71 #bjcb;,a1 #bjce1 and #bjdd74 7#c7 ,rules for assets the value of which is not readily ascertainable 7,a7 ,in general ,in the case of any property the value of which is not readily ascertainable1 the ,secretary may allow the taxpayer to elect to use a value which is equal to the most recent readily ascertainable value of such property increased by an average rate of appreciation applicable to assets of a similar class4 7,b7 ,limitation ,the ,secretary may not allow a taxpayer to make an election under this paragraph for any calendar year if the taxpayer made an election under this paragraph for the preceding calendar year4 #bijc4 ,special rules 7a7 ,deceased individuals ,in the case of any individual who dies during a calendar year-- 7#a7 section #bija shall be applied as if the calendar year ended on the day of the individual's death1 and 7#b7 the amount of the tax imposed under such section shall be reduced by an amount which bears the same ratio to such amount 7determined without regard to this subsection7 as-- 7,a7 the number of days in the calendar year after the date of the individual's death1 bears to 7,b7 #cfe4 7b7 ,trusts 7#a7 ,grantor trusts ,if a grantor or another person is treated as the owner of any portion of a trust under subpart ,e of part ,i of subchapter ,j of chapter #a1 then the grantor or such other person shall be treated as holding that portion of the assets of such trust1 and any remaining portion shall be subject to tax as provided in section #bija4 7#b7 ,incomplete gifts ,in the case of any person who makes a transfer of property to a trust which is not treated as a gift for purposes of chapter #aa1 the portion of such trust attributable to such property shall be treated as the property of the person making the transfer and not the property of such trust4 7#c7 ,aggregation rules ,the rules of section #fdc7;f7 shall apply for purposes of this subtitle4 7c7 ,application to nonresidents 7#a7 ,in general ,in the case of any taxpayer who is a non resident and not a citizen of the ,united ,states1 section #bija7;a7 shall be applied by substituting net value of domestic assets for net value of all assets4 7#b7 ,net value of domestic assets ,for purposes of this subtitle1 the term net value of domestic assets means-- 7,a7 the value of all property of the taxpayer1 real or personal1 tangible or intangible1 situated in the ,united ,states 7determined under rules similar to the rules under subchapter ,b of chapter #aa71 on the last day of such calendar year 7computed without regard to any debt owed by the taxpayer and secured by the property71 over 7,b7 the amount of any debt owed by the taxpayer and secured by assets described in subparagraph 7,a71 determined as of the last day of such calendar year4 7#c7 ,treatment of married individuals ,in the case of married individuals1 this subsection shall only apply if both individuals are non residents and not citizens of the ,united ,states4 7d7 ,application to covered expatriates 7#a7 ,in general ,in the case of an applicable taxpayer who is a covered expatriate the expatriation date of which occurs during the calendar year-- 7,a7 section #bija shall be applied as if the calendar year ended on the day before the expatriation1 and 7,b7 the rate of tax under #bija7;a7 for such calendar year shall be #fj percent4 7#b7 ,covered expatriate2 expatriation date ,for purposes of this subsection-- 7,a7 ,covered expatriate ,the term covered expatriate has the meaning given such term under section #hgg;,a1 except that in the case of married individuals1 such taxpayer shall be treated as a covered expatriate only if neither individual is a ,united ,states citizen or lawful permanent resident of the ,united ,states 7within the meaning of section #ggja7;b77#f774 7,b7 ,expatriation date ,the term expatriation date has the meaning given such term under section #hgg;,a7g77#c74 #bijd4 ,administrative provisions 7a7 ,wealth registry ,the ,secretary shall establish a registry of ownership for assets taken into account under section #bijb7;a77#a71 including publicly traded securities1 digital assets1 shares of closely held businesses1 and real estate within the ,united ,states4 ,for purposes of establishing and maintaining the registry under the preceding sentence1 the ,secretary shall-- 7#a7 rely on existing sources of information1 including central depositories for securities and ,state1 local1 and foreign real property records2 and 7#b7 require timely reporting of newly acquired assets in conjunction with information required under existing information reporting requirements4 7b7 ,information reporting 7#a7 ,in general ,the ,secretary shall by regulations require the reporting of information concerning the value of assets1 including-- 7,a7 the value of any accounts which pay interest reportable under section #fjdi1 7,b7 the value of publicly traded stock with respect to which dividends are reported under section #fjdb1 7,c7 the value of any applicable privately held business1 7,d7 the value of any assets held through mutual funds or brokerage accounts1 7,e7 the value of any assets held in eligible retirement plans 7as defined in section #djb7;c77#h77;,b771 and 7,f7 such other assets as the ,secretary determines is appropriate4 7#b7 ,method of reporting ,the ,secretary shall1 where appropriate1 require the reporting made under paragraph 7#a7 to be made as a part of existing income reporting requirements4 7#c7 ,applicable privately held business ,for purposes of this subsection1 the term applicable privately held business means any trade or businesses-- 7,a7 which does not meet the gross receipts test under section #ddh7;c7 for the taxable year ending with or within the calendar year1 7,b7 in which an individual who was an applicable taxpayer 7other than a covered expatriate1 as defined in section #bijc7;d77#b77 for the preceding calendar year holds 7directly or indirectly7 #e percent or more of the ownership interests 7by value71 and 7,c7 to which paragraph 7#a77;,b7 does not apply4 7c7 ,time for payment of tax ,the due date for returns with respect to the tax imposed under this subtitle shall be not later than the latest due date for which a return of tax under subtitle ,a would be due if the taxpayer's taxable year ended on ,december #ca and the taxpayer owed tax for such taxable year4 4 7b7 ,no deduction from income taxes ,section #bge of the ,internal ,revenue ,code of #aihf is amended by inserting after paragraph 7#f7 the following new paragraph3 7#g7 ,taxes imposed by chapter #ah4 4 7c7 ,information reporting penalties ,section #fgbd7;d77#a7 of the ,internal ,revenue ,code of #aihf is amended by striking and at the end of subparagraph 7,c71 by striking the period at the end of subparagraph 7,d7 and inserting 1 and1 and by inserting after subparagraph 7,d7 the following new subparagraph3 7,e7 any statement or return required to be filed under section #bijd7;b7 which is not reported under any other provision of this paragraph4 4 7d7 ,clerical amendment ,the table of subtitles of the ,internal ,revenue ,code of #aihf is amended by inserting after the item relating to subtitle ,b the following new item3 ,subtitle ,b-#a--,wealth tax 4 7e7 ,effective date ,the amendments made by this section shall apply to calendar years beginning after the date of the enactment of this ,act4 #ajb4 ,enforcement 7a7 ,standard ,the ,secretary of the ,treasury shall audit not less than #ej percent of taxpayers required to pay the tax imposed under section #bija of the ,internal ,revenue ,code of #aihf 7as added by section #aja7 in each calendar year4 7b7 ,funding ,there is hereby appropriated to each fiscal year ending after the date of the enactment of this ,act1 out of any moneys in the ,treasury not otherwise appropriated1 amounts equivalent to #a percent of the revenues attributable to the tax imposed under section #bija of the ,internal ,revenue ,code of #aihf 7as added by section #aja7 for necessary expenses for enforcement activities of the ,internal ,revenue ,service to determine and collect taxes owed under such section4 ,,ii ,affordability ,rebates #bja4 ,affordability rebates 7a7 ,in general ,section #fdbh;,b of the ,internal ,revenue ,code of #aihf is amended-- 7#a7 in the heading1 by striking #bjba recovery rebates to individuals and inserting affordability rebates1 7#b7 in subsection 7a71 by striking #bjba an amount equal to the #bjba rebate amount and inserting #bjbf an amount equal to the affordability rebate amount1 7#c7 by striking subsection 7b7 and inserting the following3 7b7 ,affordability rebate amount ,for purposes of this section1 the term affordability rebate amount means1 with respect to any taxpayer for any taxable year1 the sum of-- 7#a7 #c1jjj 7#f1jjj in the case of a joint return71 plus 7#b7 #c1jjj multiplied by the number of dependents of the taxpayer for such taxable year4 1 7#d7 in subsection 7e77#b7-- 7,a7 in subparagraph 7,a71 by striking #a1djj and inserting #c1jjj1 and 7,b7 in subparagraph 7,b7-- 7i7 in the matter preceding clause 7i71 by striking #b1hjj and inserting #f1jjj1 and 7ii7 in clause 7i71 by striking #a1djj and inserting #c1jjj1 and 7#e7 in subsection 7g7-- 7,a7 in paragraph 7#a71 by striking #bjai and inserting #bjbd1 7,b7 in paragraph 7#b77;,b71 by striking ,january #a1 #bjba each place it appears and inserting ,january #a1 #bjbf1 7,c7 in paragraph 7#c71 by striking ,december #ca1 #bjba and inserting ,december #ca1 #bjbf1 7,d7 in paragraph 7#e7-- 7i7 in the heading1 by striking #bjbj and inserting #bjbe1 7ii7 in subparagraph 7,a7-- 7,i7 in the heading1 by striking #bjbj and inserting #bjbe1 and 7,,ii7 by striking beginning in #bjbj1 paragraph 7#a7 shall be applied with respect to such individual by substituting #bjbj for #bjai and inserting beginning in #bjbe1 paragraph 7#a7 shall be applied with respect to such individual by substituting #bjbe for #bjbd1 and 7iii7 in subparagraph 7,b7-- 7,i7 in clause 7i71 by striking #bjbj and inserting #bjbe1 7,,ii7 in clause 7ii7-- 7aa7 in subclause 7,i71 by striking #bjbj and inserting #bjbe1 and 7bb7 in subclause 7,,ii71 by striking #bjba and inserting #bjbf1 and 7,,iii7 in clause 7iii7-- 7aa7 in the heading1 by striking #bjbj and inserting #bjbe1 and 7bb7 by striking #bjbj each place it appears and inserting #bjbe1 and 7,e7 in the heading of paragraph 7#f71 by striking #bjai or #bjbj and inserting #bjbd or #bjbe4 7b7 ,conforming amendment ,the table of sections for subchapter ,b of chapter #fe of the ,internal ,revenue ,code of #aihf is amended by striking the item relating to section #fdbh;,b and inserting the following new item3 ,sec4 #fdbh;,b4 ,affordability rebates44 ,,iii ,health care provisions #cja4 ,repeal of reconciliation health provisions 7a7 ,in general ,except as provided in subsection 7b71 subtitle ,b of title ,,vii of ,an ,act to provide for reconciliation pursuant to title ,,ii of ,h4 ,con4 ,res4 #ad 7,public ,law #aai-ba7 is repealed and any law or regulation referred to in such subtitle shall be applied as if such subtitle and the amendments made by such subtitle had not been enacted4 7b7 ,exceptions 7#a7 ,in general ,subsection 7a7 shall not apply to the provisions of and amendments made by sections #gabjb1 #gacjf1 and #gadja of such ,act4 7#b7 ,availability of funds allocated under the rural health transformation program ,section #baje7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7h771 as added by ,public ,law #aai-ba1 is amended-- 7,a7 in paragraph 7#a77;,b7-- 7i7 in the subparagraph heading by striking ,unexpended or unobligated and inserting ,availability of2 7ii7 by striking clauses 7i7 through 7iii7 and inserting the following3 7i7 ,in general ,subject to clause 7ii71 funds allocated to a ,state from amounts appropriated under subparagraph 7,a7 shall remain available until expended4 2 and 7iii7 by redesignating clause 7iv7 as clause 7ii72 and 7,b7 in paragraph 7#b77;,c71 by striking paragraph 7#a77;,b77iv7 and inserting paragraph 7#a77;,b77ii74 #cjb4 ,increase in eligibility for premium tax credit 7a7 ,in general ,subparagraph 7,a7 of section #cf;,b7c77#a7 of the ,internal ,revenue ,code of #aihf is amended by striking but does not exceed #djj percent4 7b7 ,applicable percentages 7#a7 ,in general ,subparagraph 7,a7 of section #cf;,b7b77#c7 of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7,a7 ,applicable percentage ,the applicable percentage for any taxable year shall be the percentage such that the applicable percentage for any taxpayer whose household income is within an income tier specified in the following table shall increase1 on a sliding scale in a linear manner1 from the initial premium percentage to the final premium percentage specified in such table for such income tier3 ,in the case of household income 7expressed as a percent of poverty line7 within the following income tier3,the initial premium percentage is--,the final premium percentage is--,up to #aej percent#jjaej percent up to #bjj percent#jb4jbjj percent up to #bej percent#b4jd4jbej percent up to #cjj percent#d4jf4jcjj percent up to #djj percent#f4jh4edjj percent and higher#h4eh4e4 4 7#b7 ,conforming amendments relating to affordability of coverage 7,a7 ,paragraph 7#a7 of section #cf;,b7c7 of such ,code is amended by striking subparagraph 7,e74 7,b7 ,subparagraph 7,c7 of section #cf;,b7c77#b7 of such ,code is amended by striking clause 7iv74 7,c7 ,paragraph 7#d7 of section #cf;,b7c7 of such ,code is amended by striking subparagraph 7,f74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjbe4 ,,iv ,medicare ,dental1 ,hearing1 and ,vision ,expansion #dja4 ,short title ,this title may be cited as the ,medicare ,dental1 ,hearing1 and ,vision ,expansion ,act of #bjbf4 #djb4 ,coverage of dental and oral health care 7a7 ,coverage ,section #ahfa7s77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77 is amended-- 7#a7 in subparagraph 7,,jj71 by striking and at the end2 7#b7 in subparagraph 7,,kk71 by inserting and after the semicolon2 and 7#c7 by adding at the end the following new subparagraph3 7,,ll7 dental and oral health services 7as defined in subsection 7ooo772 4 7b7 ,dental and oral health services defined ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended by adding at the end the following new subsection3 7ooo7 ,dental and oral health services 7#a7 ,in general ,except as provided in paragraph 7#b71 the term dental and oral health services means the following items and services that are furnished by a doctor of dental surgery or of dental medicine 7as described in subsection 7r77#b77 or an oral health professional 7as defined in paragraph 7#c77 on or after ,january #a1 #bjbh 7or ,january #a1 #bjbg1 in the case of dentures73 7,a7 ,preventive and screening services ,preventive and screening services1 including oral exams1 dental cleanings1 dental x-rays1 and fluoride treatments4 7,b7 ,procedures and treatment services ,services to address oral disease1 including services such as restorative services1 prosthodontic and endodontic services1 including fillings1 bridges1 crowns1 and root canals1 periodontal maintenance1 periodontal scaling and root planing1 tooth extractions1 therapeutic pulpotomy1 and other related items and services4 7,c7 ,dentures and dental prosthetics ,complete dentures1 partial dentures1 and implants1 including related items and services4 7#b7 ,exclusions ,such term does not include items and services for which1 as of the date of the enactment of this subsection1 coverage was permissible under section #ahfb7;a77#ab7 and cosmetic services not otherwise covered under section #ahfb7;a77#aj74 7#c7 ,oral health professional ,the term oral health professional means1 with respect to dental and oral health services1 a health professional 7other than a doctor of dental surgery or of dental medicine 7as described in subsection 7r77#b777 who is licensed to furnish such services1 acting within the scope of such license1 by the ,state in which such services are furnished4 4 7c7 ,payment2 coinsurance2 and limitations 7#a7 ,in general ,section #ahcc7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is amended-- 7,a7 in subparagraph 7,n71 by inserting and dental and oral health services 7as defined in section #ahfa7ooo77 after section #ahfa7;hhh77#a772 7,b7 by striking and before 7,,hh72 and 7,c7 by inserting before the semicolon at the end the following3 and 7,,ii7 with respect to dental and oral health services 7as defined in section #ahfa7ooo771 the amount paid shall be the payment amount specified under section #ahcd7;bb74 7#b7 ,payment and limits specified ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is amended by adding at the end the following new subsection3 7bb7 ,payment and limits for dental and oral health services 7#a7 ,payment ,the payment amount under this part for dental and oral health services 7as defined in section #ahfa7ooo77 shall be1 subject to paragraphs 7#c7 and 7#d71 #hj percent 7or #ajj percent1 in the case of preventive and screening services described in section #ahfa7ooo77#a77;,a77 of the lesser of-- 7,a7 the actual charge for the service2 or 7,b7 7i7 in the case of such services furnished by a doctor of dental surgery or of dental medicine 7as described in section #ahfa7r77#b771 the amount determined under the fee schedule established under paragraph 7#b72 or 7ii7 in the case of such services furnished by an oral health professional 7as defined in section #ahfa7ooo77#c771 #he percent of the amount determined under the fee schedule established under paragraph 7#b74 7#b7 ,establishment of fee schedule for dental and oral health services 7,a7 ,establishment 7i7 ,in general ,the ,secretary shall establish a fee schedule for dental and oral health services furnished in #bjbh 7or #bjbg1 in the case of dentures7 and subsequent years4 ,the fee schedule amount for a dental or oral health service shall be equal to #gj percent of the national median fee 7as determined under subparagraph 7,b77 for the service or a similar service for the year 7or1 in the case of dentures1 at the bundled payment amount under clause 7iv7 of such subparagraph71 adjusted by the geographic adjustment factor established under section #ahdh7;e77#b7 for the area for the year4 7ii7 ,consultation ,in carrying out this paragraph1 the ,secretary shall consult annually with organizations representing dentists and other providers who furnish dental and oral health services and shall share with such providers the data and data analysis used to determine fee schedule amounts under this paragraph4 7,b7 ,determination of national median fee 7i7 ,in general ,for purposes of subparagraph 7,a71 the ,secretary shall apply the national median fee for a dental or oral health service for #bjbh 7or #bjbg1 in the case of dentures7 and subsequent years in accordance with this subparagraph4 7ii7 ,use of #bjbj dental fee survey 7,i7 ,in general ,except as provided in clause 7iii7 and clause 7iv71 the national median fee for a dental or oral health service shall be equal to-- 7aa7 for #bjbh 7or #bjbg1 in the case of dentures71 the median fee for the service in the table titled ,general ,practitioners-,national of the #bjbj ,survey of ,dental ,fees published by the ,american ,dental ,association1 increased by the applicable percent increase for the year determined under subclause 7,,ii71 as reduced by the productivity adjustment under subclause 7,,iii72 and 7bb7 for #bjbi 7or #bjbh1 in the case of dentures7 and subsequent years1 the amount determined under this subclause for the preceding year1 updated pursuant to subparagraph 7,c77i74 7,,ii7 ,applicable percent increase ,the applicable percent increase determined under this subclause for a year is an amount equal to the percentage increase between-- 7aa7 the consumer price index for all urban consumers 7,united ,states city average7 ending with ,june of the previous year2 and 7bb7 the consumer price index for all urban consumers 7,united ,states city average7 ending with ,june of #bjbg 7or #bjbf1 in the case of dentures74 7,,iii7 ,productivity adjustment ,after determining the applicable percentage increase under subclause 7,,ii7 for a year1 the ,secretary shall reduce such percentage increase by the productivity adjustment described in section #ahhf7;b77#c77;,b77xi77,,ii74 7iii7 ,determination if insufficient survey data ,if the ,secretary determines there is insufficient data under the ,survey described in clause 7ii7 with respect to a dental or oral health service1 the national median fee for the service for a year shall be equal to an amount established for the service using #a or more of the following methods1 as determined appropriate by the ,secretary3 7,i7 ,the payment basis determined under section #ahdh4 7,,ii7 ,fee schedules for dental and oral health services which shall include1 as practicable1 fee schedules-- 7aa7 under ,medicare ,advantage plans under part ,c2 7bb7 under ,state plans 7or waivers of such plans7 under title ,,xix2 and 7cc7 established by other health care payers4 7iv7 ,special rule for dentures 7,i7 ,in general ,the ,secretary shall make payment for dentures and associated professional services as a bundled payment as determined by the ,secretary4 7,,ii7 ,payment considerations ,in establishing such bundled payment1 the ,secretary shall consider the national median fee for the service for the year determined under clause 7ii7 or 7iii7 and the rate determined for such dentures under the ,federal ,supply ,schedule of the ,general ,services ,administration1 as published by such ,administration in #bjba1 updated to the year involved using the applicable percent increase for the year determined under clause 7ii77,,ii71 as reduced by the productivity adjustment under clause 7ii77,,iii71 and shall ensure that the payment component for dentures under such bundled payment does not exceed the maximum rate determined for such dentures under the ,federal ,supply ,schedule1 as so published and updated to the year involved4 7,c7 ,annual update and adjustments 7i7 ,annual update ,the ,secretary shall update payment amounts determined under the fee schedule from year to year beginning in #bjbi 7or #bjbh1 in the case of dentures7 by increasing such amounts from the prior year by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 for the #ab-month period ending with ,june of the preceding year1 reduced by the productivity adjustment described in section #ahhf7;b77#c77;,b77xi77,,ii74 7ii7 ,adjustments 7,i7 ,in general ,the ,secretary shall1 to the extent the ,secretary determines to be necessary and subject to subclause 7,,ii71 adjust the amounts determined under the fee schedule established under this paragraph for #bjbi 7or #bjbh1 in the case of dentures7 and subsequent years to take into account changes in dental practice1 coding changes1 new data on work1 practice1 or malpractice expenses1 or the addition of new procedures4 7,,ii7 ,limitation on annual adjustments ,the adjustments under subclause 7,i7 for a year shall not cause the amount of expenditures under this part for the year to differ by more than #bj1jjj1jjj from the amount of expenditures under this part that would have been made if such adjustments had not been made4 7#c7 ,limitations ,with respect to dental and oral health services that are preventive and screening services described in paragraph 7#a77;,a7 of section #ahfa7ooo7-- 7,a7 payment shall be made under this part for-- 7i7 not more than #b oral exams in a year2 7ii7 not more than #b dental cleanings in a year2 7iii7 not more than #a fluoride treatment in a year2 and 7iv7 not more than #a full-mouth series of x-rays as part of a preventive and screening oral exam every #c years2 and 7,b7 in the case of preventive and screening services not described in subparagraph 7,a71 payment shall be made under this part only at such frequencies determined appropriate by the ,secretary4 7#d7 ,incentives for rural providers ,in the case of dental and oral health services furnished by a doctor of dental surgery or of dental medicine 7as described in section #ahfa7r77#b77 or an oral health professional 7as defined in section #ahfa7ooo77#c77 who predominantly furnishes such services under this part in an area that is designated by the ,secretary 7under section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act7 as a health professional shortage area1 in addition to the amount of payment that would otherwise be made for such services under this subsection1 there also shall be paid an amount equal to #aj percent of the payment amount for the service under this subsection for such doctor or professional4 7#e7 ,limitation on beneficiary liability ,the provisions of section #ahdh7;g7 shall apply to a nonparticipating doctor of dental surgery or of dental medicine 7as described in section #ahfa7r77#b77 who does not accept payment on an assignment-related basis for dental and oral health services furnished with respect to an individual enrolled under this part in the same manner as such provisions apply with respect to a physician's service4 7#f7 ,establishment of dental administrator ,the ,secretary shall designate #a or more 7not to exceed #d7 medicare administrative contractors under section #ahgd;,a to establish coverage policies and establish such policies and process claims for payment for dental and oral health services1 as determined appropriate by the ,secretary4 4 7d7 ,inclusion of oral health professionals as certain practitioners ,section #ahdb7;b77#ah77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#ah77;,c77 is amended by adding at the end the following new clause3 7ix7 ,with respect to #bjbi and each subsequent year1 an oral health professional 7as defined in section #ahfa7ooo77#c774 4 7e7 ,exclusion modifications ,section #ahfb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,o71 by striking and at the end2 7,b7 in subparagraph 7,p71 by striking the semicolon at the end and inserting 1 and2 and 7,c7 by adding at the end the following new subparagraph3 7,q7 in the case of dental and oral health services 7as defined in section #ahfa7ooo77 for which a limitation is applicable under section #ahcd7;bb77#c71 which are furnished more frequently than is provided under such section2 2 and 7#b7 in paragraph 7#ab71 by inserting before the semicolon at the end the following3 and except that payment shall be made under part ,b for dental and oral health services that are covered under section #ahfa7s77#b77,,ll74 7f7 ,inclusion as excepted medical treatment ,section #ahba7;b77#e77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#e7;b77#e77;,a77 is amended-- 7#a7 in clause 7ii71 by striking or at the end2 7#b7 in clause 7iii71 by striking the period and inserting 1 or2 and 7#c7 by adding at the end the following new clause3 7iv7 consisting of dental and oral health services 7as defined in subsection 7ooo7 of section #ahfa7 that are payable under part ,b as a result of the amendments made by the ,medicare ,dental1 ,hearing1 and ,vision ,expansion ,act of #bjbf4 4 7g7 ,rural health clinics and federally qualified health centers 7#a7 ,coverage of dental and oral health services ,section #ahfa7;aa7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa771 is amended-- 7,a7 in paragraph 7#a7-- 7i7 in subparagraph 7,c71 by striking and at the end2 7ii7 in subparagraph 7,d71 by inserting and after the comma at the end2 and 7iii7 by inserting after subparagraph 7,d7 the following new subparagraph3 7,e7 dental and oral health services 7as defined in subsection 7ooo77 furnished by a doctor of dental surgery or of dental medicine 7as described in subsection 7r77#b77 or an oral health professional 7as defined in subsection 7ooo77#c77 who is employed by or working under contract with a rural health clinic if such rural health clinic furnishes such services1 2 and 7,b7 in paragraph 7#c77;,a71 by striking 7,d7 and inserting 7,e74 7#b7 ,temporary payment rates for certain services under the ,,rhc ,,air and ,,fqhc ,,pps 7,a7 ,,air ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended-- 7i7 in subsection 7a77#c77;,a71 by inserting 7which shall1 in the case of dental and oral health services 7as defined in section #ahfa7ooo7771 in lieu of any limits on reasonable costs otherwise applicable1 be based on the rates payable for such services under the payment basis determined under section #ahdh until such time as the ,secretary determines sufficient data has been collected to otherwise apply such limits 7or ,january #a1 #bjca1 if no such determination has been made as of such date77 after may prescribe in regulations2 and 7ii7 by adding at the end the following new subsection3 7ee7 ,disregard of costs attributable to certain services from calculation of ,,rhc ,,air ,payments for rural health clinic services other than dental and oral health services 7as defined in section #ahfa7ooo77 under the methodology for all-inclusive rates 7established by the ,secretary7 under subsection 7a77#c7 shall not take into account the costs of such services while rates for such services are based on rates payable for such services under the payment basis established under section #ahdh4 4 7,b7 ,,pps ,section #ahcd7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7o77 is amended by adding at the end the following new paragraph3 7#f7 ,temporary payment rates based on pfs for certain services ,the ,secretary shall1 in establishing payment rates for dental and oral health services 7as defined in section #ahfa7ooo77 that are federally qualified health center services under the prospective payment system established under this subsection1 in lieu of the rates otherwise applicable under such system1 base such rates on rates payable for such services under the payment basis established under section #ahdh until such time as the ,secretary determines sufficient data has been collected to otherwise establish rates for such services under such system 7or ,january #a1 #bjca1 if no such determination has been made as of such date74 ,payments for federally qualified health center services other than such dental and oral health services under such system shall not take into account the costs of such services while rates for such services are based on rates payable for such services under the payment basis established under section #ahdh4 4 7h7 ,implementation ,in addition to amounts otherwise available1 there is appropriated to the ,secretary of ,health and ,human ,services for fiscal year #bjbf1 out of any money in the ,treasury not otherwise appropriated1 #ijj1jjj1jjj1 to remain available until expended1 for purposes of implementing the amendments made by this section during the period beginning on ,january #a1 #bjbf1 and ending on ,september #cj1 #bjce4 #djc4 ,providing coverage for hearing care under the ,medicare program 7a7 ,provision of audiology services by qualified audiologists and hearing aid examination services by qualified hearing aid professionals 7#a7 ,in general ,section #ahfa7ll7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ll77 is amended-- 7,a7 in paragraph 7#c7-- 7i7 by inserting 7,a7 after 7#c72 7ii7 in subparagraph 7,a71 as added by clause 7i7 of this subparagraph-- 7,i7 by striking means such hearing and balance assessment services and inserting 8means-- 7i7 such hearing and balance assessment services and1 beginning ,january #a1 #bjbh1 such hearing aid examination services and treatment services 7including aural rehabilitation1 vestibular rehabilitation1 and cerumen management7 2 7,,ii7 in clause 7i71 as added by subclause 7,i7 of this clause1 by striking the period at the end and inserting 2 and2 and 7,,iii7 by adding at the end the following new clause3 7ii7 beginning ,january #a1 #bjbh1 such hearing aid examination services furnished by a qualified hearing aid professional 7as defined in paragraph 7#d77;,c77 as the professional is legally authorized to perform under ,state law 7or the ,state regulatory mechanism provided by ,state law71 as would otherwise be covered if furnished by a physician4 2 and 7iii7 by adding at the end the following new subparagraph3 7,b7 ,beginning ,january #a1 #bjbh1 audiology services described in subparagraph 7,a77i7 shall be furnished without a requirement for an order from a physician or practitioner4 2 and 7,b7 in paragraph 7#d71 by adding at the end the following new subparagraph3 7,c7 ,the term qualified hearing aid professional means an individual who-- 7i7 is licensed or registered as a hearing aid dispenser1 hearing aid specialist1 hearing instrument dispenser1 or related professional by the ,state in which the individual furnishes such services2 and 7ii7 is accredited by the ,national ,board for ,certification in ,hearing ,instrument ,sciences or meets such other requirements as the ,secretary determines appropriate 7including requirements relating to educational certifications or accreditations7 taking into account any additional relevant requirements for hearing aid specialists1 hearing aid dispensers1 and hearing instrument dispensers established by ,medicare ,advantage organizations under part ,c1 ,state plans 7or waivers of such plans7 under title ,,xix1 and group health plans and health insurance issuers 7as such terms are defined in section #bgia of the ,public ,health ,service ,act74 4 7#b7 ,payment for qualified hearing aid professionals ,section #ahcc7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a771 as amended by section #djb7;c77#a71 is amended-- 7,a7 by striking and before 7,,ii72 and 7,b7 by inserting before the semicolon at the end the following3 and 7,,jj7 with respect to hearing aid examination services 7as described in paragraph 7#c77;,a77ii7 of section #ahfa7ll77 furnished by a qualified hearing aid professional 7as defined in paragraph 7#d77;,c7 of such section71 the amounts paid shall be equal to #hj percent of the lesser of the actual charge for such services or #he percent of the amount for such services determined under the payment basis determined under section #ahdh4 7#c7 ,inclusion of qualified audiologists and qualified hearing aid professionals as certain practitioners to receive payment on an assignment-related basis 7,a7 ,qualified audiologists ,section #ahdb7;b77#ah77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#ah77;,c771 as amended by section #djb7;d71 is amended by adding at the end the following new clause3 7x7 ,beginning on ,january #a1 #bjbh1 a qualified audiologist 7as defined in section #ahfa7ll77#d77;,b774 4 7,b7 ,qualified hearing aid professionals ,section #ahdb7;b77#ah7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#ah77 is amended-- 7i7 in each of subparagraphs 7,a7 and 7,b71 by striking subparagraph 7,c7 and inserting subparagraph 7,c7 or1 beginning on ,january #a1 #bjbh1 subparagraph 7,e72 and 7ii7 by adding at the end the following new subparagraph3 7,e7 ,a practitioner described in this subparagraph is a qualified hearing aid professional 7as defined in section #ahfa7ll77#d77;,c774 4 7b7 ,coverage of hearing aids 7#a7 ,inclusion of hearing aids as prosthetic devices ,section #ahfa7s77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#h77 is amended by inserting 1 and including hearing aids 7as described in section #ahcd7;h77#g77 furnished on or after ,january #a1 #bjbh1 to individuals with moderately severe1 severe1 or profound hearing loss before the semicolon at the end4 7#b7 ,payment limitations for hearing aids ,section #ahcd7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7h77 is amended by adding at the end the following new paragraphs3 7#f7 ,payment only on an assignment-related basis ,payment for hearing aids for which payment may be made under this part may be made only on an assignment-related basis4 ,the provisions of subparagraphs 7,a7 and 7,b7 of section #ahdb7;b77#ah7 shall apply to hearing aids in the same manner as they apply to services furnished by a practitioner described in subparagraph 7,c7 of such section4 7#g7 ,limitations for hearing aids 7,a7 ,in general ,payment may be made under this part with respect to an individual1 with respect to hearing aids furnished by a qualified hearing aid supplier 7as defined in subparagraph 7,c77 on or after ,january #a1 #bjbh-- 7i7 not more than once per ear during a #e-year period2 7ii7 only for types of such hearing aids that are determined appropriate by the ,secretary2 and 7iii7 only if furnished pursuant to a written order of a physician1 qualified audiologist 7as defined in section #ahfa7ll77#d771 qualified hearing aid professional 7as defined in subparagraph 7,c7 of such section71 physician assistant1 nurse practitioner1 or clinical nurse specialist4 7,b7 ,special rule ,the payment basis determined under this subsection 7including after application of paragraph 7#a77;,h71 relating to application of competitive acquisition7 for hearing aids furnished by a qualified hearing aid supplier on or after ,january #a1 #bjbh1 shall not exceed the rate determined for such hearing aids under the ,federal ,supply ,schedule of the ,general ,services ,administration1 as published by such ,administration in #bjba1 updated to the year involved using the applicable percent increase for the year4 7,c7 ,definitions ,in this subsection3 7i7 ,hearing aid ,the term hearing aid means the item and related services including selection1 fitting1 adjustment1 and patient education and training4 7ii7 ,qualified hearing aid supplier ,the term qualified hearing aid supplier means-- 7,i7 a qualified audiologist2 7,,ii7 a physician 7as defined in section #ahfa7r77#a772 7,,iii7 a physician assistant1 nurse practitioner1 or clinical nurse specialist2 7,,iv7 a qualified hearing aid professional 7as defined in section #ahfa7ll77#d77;,c772 and 7,v7 other suppliers as determined by the ,secretary4 4 7#c7 ,application of competitive acquisition 7,a7 ,in general ,section #ahcd7;h77#a77;,h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7h77#a77;,h77 is amended-- 7i7 in the header1 by inserting and hearing aids after orthotics2 7ii7 in the matter preceding clause 7i71 by inserting or of hearing aids described in paragraph 7#b77;,e7 of such section1 after #bjaa12 and 7iii7 in clause 7i71 by inserting or such hearing aids after such orthotics4 7,b7 ,conforming amendments 7i7 ,in general ,section #ahdg7;a77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77#b77 is amended by adding at the end the following new subparagraph3 7,e7 ,hearing aids ,hearing aids described in section #ahfa7s77#h7 for which payment would otherwise be made under section #ahcd7;h74 4 7ii7 ,exemption of certain items from competitive acquisition ,section #ahdg7;a77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77#g77 is amended by adding at the end the following new subparagraph3 7,c7 ,certain hearing aids ,those items and services described in paragraph 7#b77;,e7 if furnished by a physician or other practitioner 7as defined by the ,secretary7 to the physician's or practitioner's own patients as part of the physician's or practitioner's professional service4 4 7iii7 ,implementation ,section #ahdg7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77 is amended by adding at the end the following new paragraph3 7#h7 ,competition with respect to hearing aids ,not later than ,january #a1 #bjca1 the ,secretary shall begin the competition with respect to the items and services described in paragraph 7#b77;,e74 4 7#d7 ,physician self-referral law ,section #ahgg7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acienn7b77 is amended by adding at the end the following new paragraph3 7#f7 ,hearing aids and services ,in the case of hearing aid examination services and hearing aids-- 7,a7 furnished on or after ,january #a1 #bjbh1 and before ,january #a1 #bjcj2 and 7,b7 furnished on or after ,january #a1 #bjcj1 if the financial relationship specified in subsection 7a77#b7 meets such requirements the ,secretary imposes by regulation to protect against program or patient abuse4 4 7c7 ,exclusion modification ,section #ahfb7;a77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77#g77 is amended by inserting 7except such hearing aids or examinations therefor as described in and otherwise allowed under section #ahfa7s77#h77 after hearing aids or examinations therefor4 7d7 ,inclusion as excepted medical treatment ,section #ahba7;b77#e77;,a77iv7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#e7;b77#e77;,a77iv771 as added by section #djb7;f71 is amended by inserting 1 audiology services described in subsection 7ll77#c7 of such section1 or hearing aids described in subsection 7s77#h7 of such section after section #ahfa74 7e7 ,rural health clinics and federally qualified health centers 7#a7 ,clarifying coverage of audiology services as physicians' services ,section #ahfa7;aa77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa77#a77;,a77 is amended by inserting 7including audiology services 7as defined in subsection 7ll77#c777 after physicians' services4 7#b7 ,inclusion of qualified audiologists and qualified hearing aid professionals as ,,rhc and ,,fqhc practitioners ,section #ahfa7;aa77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa77#a77;,b77 is amended by inserting or by a qualified audiologist or a qualified hearing aid professional 7as such terms are defined in subsection 7ll771 after 7as defined in subsection 7hh77#a7714 7#c7 ,temporary payment rates for certain services under the ,,rhc ,,air and ,,fqhc ,,pps 7,a7 ,,air ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel71 as amended by section #djb7;g77#b77;,a71 is amended-- 7i7 in subsection 7a77#c77;,a71 by inserting or audiology services 7as defined in section #ahfa7ll77#c77 after 7as defined in section #ahfa7ooo772 and 7ii7 in subsection 7ee71 by inserting or audiology services 7as defined in section #ahfa7ll77#c77 after 7as defined in section #ahfa7ooo774 7,b7 ,,pps ,section #ahcd7o77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7o77#f771 as added by section #djb7;g77#b77;,b71 is amended-- 7i7 in the first sentence1 by inserting or audiology services 7as defined in section #ahfa7ll77#c77 after 7as defined in section #ahfa7ooo772 and 7ii7 in the second sentence1 by inserting or such audiology services after such dental and oral health services4 7f7 ,expediting implementation ,the ,secretary of ,health and ,human ,services shall implement this section for #bjbh and #bjbi through program instruction or other forms of program guidance4 7g7 ,funding ,in addition to amounts otherwise available1 there is appropriated to the ,secretary of ,health and ,human ,services for fiscal year #bjbf1 out of any money in the ,treasury not otherwise appropriated1 #cgj1jjj1jjj1 to remain available until expended1 for purposes of implementing the amendments made by this section during the period beginning on ,january #a1 #bjbg1 and ending on ,september #cj1 #bjcf4 #djd4 ,providing coverage for vision care under the ,medicare program 7a7 ,coverage ,section #ahfa7s77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b771 as amended by section #djb7;a71 is amended-- 7#a7 in subparagraph 7,,kk71 by striking and at the end2 7#b7 in subparagraph 7,,ll71 by inserting and after the semicolon2 and 7#c7 by adding at the end the following new subparagraph3 7,,mm7 vision services 7as defined in subsection 7ppp772 4 7b7 ,vision services defined ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex71 as amended by section #djb7;b71 is amended by adding at the end the following new subsection3 7ppp7 ,vision services ,the term vision services means routine eye examinations to determine the refractive state of the eyes1 including procedures performed during the course of such examination1 furnished on or after ,january #a1 #bjbh1 by or under the direct supervision of an ophthalmologist or optometrist who is legally authorized to furnish such examinations or procedures 7as applicable7 under ,state law 7or the ,state regulatory mechanism provided by ,state law7 of the ,state in which the examinations or procedures are furnished4 4 7c7 ,payment limitations ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem71 as amended by section #djb7;c77#b71 is amended by adding at the end the following new subsection3 7cc7 ,limitation for vision services ,with respect to vision services 7as defined in section #ahfa7ppp77 and an individual1 payment shall be made under this part for only #a routine eye examination described in such subsection during a #b-year period4 4 7d7 ,payment under physician fee schedule ,section #ahdh7;j77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;j77#c77 is amended by inserting 7#b77,,mm71 before 7#c74 7e7 ,coverage of conventional eyeglasses ,section #ahfa7s77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#h771 as amended by section #djc7;b77#a71 is amended by striking 1 and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens and inserting 1 including #a pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens1 if furnished before ,january #a1 #bjbh1 and including conventional eyeglasses 7as described in section #ahcd7;h77#h771 whether or not furnished subsequent to such a surgery1 if furnished on or after ,january #a1 #bjbh4 7f7 ,special payment rules for eyeglasses 7#a7 ,limitations ,section #ahcd7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7h771 as amended by section #djc7;b77#b71 is amended by adding at the end the following new paragraph3 7#h7 ,payment limitations for eyeglasses 7,a7 ,in general ,with respect to conventional eyeglasses furnished to an individual on or after ,january #a1 #bjbh1 subject to subparagraph 7,b71 payment shall be made under this part only during a #b-year period1 for #a pair of eyeglasses 7including lenses and the frame74 7,b7 ,exception ,with respect to a #b-year period described in subparagraph 7,a71 in the case of an individual who receives cataract surgery with insertion of an intraocular lens1 payment shall be made under this part for #a pair of conventional eyeglasses furnished subsequent to such cataract surgery during such period4 7,c7 ,special rule ,the payment basis determined under this subsection 7including after application of paragraph 7#a77;,h71 relating to application of competitive acquisition7 for conventional eyeglasses furnished to an individual on or after ,january #a1 #bjbh1 shall not exceed the rate determined for such eyeglasses under the ,federal ,supply ,schedule of the ,general ,services ,administration1 as published by such ,administration in #bjba1 updated to the year involved using the applicable percent increase for the year4 7,d7 ,no coverage of certain items ,payment shall not be made under this part for deluxe eyeglasses or conventional reading glasses4 4 7#b7 ,application of competitive acquisition 7,a7 ,in general ,section #ahcd7;h77#a77;,h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7h77#a77;,h771 as amended by section #djc7;b77#c77;,a71 is amended-- 7i7 in the heading1 by striking and hearing aids and inserting hearing aids1 and eyeglasses2 7ii7 in the matter preceding clause 7i7-- 7,i7 by striking or of hearing aids and inserting of hearing aids2 and 7,,ii7 by inserting or of eyeglasses described in paragraph 7#b77;,f7 of such section1 after paragraph 7#b77;,e7 of such section12 and 7iii7 in clause 7i71 by striking or such hearing aids and inserting 1 such hearing aids1 or such eyeglasses4 7,b7 ,conforming amendment ,section #ahdg7;a77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a77#b771 as amended by section #djc7;b77#c77;,b77i71 is amended by adding at the end the following new subparagraph3 7,f7 ,eyeglasses ,eyeglasses described in section #ahfa7s77#h7 for which payment would otherwise be made under section #ahcd7;h74 4 7,c7 ,implementation ,section #ahdg7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c7;a771 as amended by section #djc7;b77#c77;,b77iii71 is amended by adding at the end the following new paragraph3 7#i7 ,competition with respect to eyeglasses ,not later than ,january #a1 #bjcj1 the ,secretary shall begin the competition with respect to the items and services described in paragraph 7#b77;,f74 4 7g7 ,exclusion modifications ,section #ahfb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a771 as amended by section #djb7;e71 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,p71 by striking and at the end2 7,b7 in subparagraph 7,q71 by striking the semicolon at the end and inserting 1 and2 and 7,c7 by adding at the end the following new subparagraph3 7,r7 in the case of vision services 7as defined in section #ahfa7ppp77 that are routine eye examinations as described in such section1 which are furnished more frequently than once during a #b-year period2 2 and 7#b7 in paragraph 7#g7-- 7,a7 by inserting 7other than such an examination that is a vision service that is covered under section #ahfa7s77#b77,,mm77 after eye examinations2 and 7,b7 by inserting 7other than such a procedure that is a vision service that is covered under section #ahfa7s77#b77,,mm77 after refractive state of the eyes4 7h7 ,inclusion as excepted medical treatment ,section #ahba7;b77#e77;,a77iv7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#e7;b77#e77;,a77iv771 as added by section #djb7;f7 and amended by section #djc7;d71 is amended-- 7#a7 by striking or hearing aids and inserting hearing aids2 and 7#b7 by inserting 1 or vision services 7as defined in subsection 7ppp7 of such section7 after subsection 7s77#h7 of such section4 7i7 ,rural ,health ,clinics and ,federally ,qualified ,health ,centers 7#a7 ,clarifying coverage of vision services as physicians' services ,section #ahfa7;aa77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa77#a77;,a771 as amended by section #djc7;e77#a71 is amended by inserting and vision services 7as defined in subsection 7ppp77 after 7as defined in subsection 7ll77#c774 7#b7 ,temporary payment rates for certain services under the ,,rhc ,,air and ,,fqhc ,,pps 7,a7 ,,air ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel71 as amended by sections #djb7;g77#b77;,a7 and #djc7;e77#c77;,a71 is amended-- 7i7 in subsection 7a77#c77;,a7-- 7,i7 by striking or audiology and inserting 1 audiology2 and 7,,ii7 by inserting 1 or vision services 7as defined in section #ahfa7ppp77 after 7as defined in section #ahfa7ll77#c772 and 7ii7 in subsection 7ee7-- 7,i7 by striking or audiology and inserting 1 audiology2 and 7,,ii7 by inserting 1 or vision services 7as defined in section #ahfa7ppp77 after 7as defined in section #ahfa7ll77#c774 7,b7 ,,pps ,section #ahcd7o77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7o77#f771 as added by section #djb7;g77#b77;,b7 and amended by section #djc7;e77#c77;,b71 is amended-- 7i7 in the first sentence-- 7,i7 by striking or audiology and inserting 1 audiology2 and 7,,ii7 by inserting 1 or vision services 7as defined in section #ahfa7ppp77 after 7as defined in section #ahfa7ll77#c772 and 7ii7 in the second sentence1 by striking or such audiology services and inserting 1 such audiology services1 or such vision services4 7j7 ,expediting implementation ,the ,secretary of ,health and ,human ,services shall implement this section for #bjbh and #bjbi through program instruction or other forms of program guidance4 7k7 ,funding ,in addition to amounts otherwise available1 there is appropriated to the ,secretary of ,health and ,human ,services for fiscal year #bjbf1 out of any money in the ,treasury not otherwise appropriated1 #ejj1jjj1jjj1 to remain available until expended1 for purposes of implementing the amendments made by this section during the period beginning on ,january #a1 #bjbg1 and ending on ,september #cj1 #bjce4 #dje4 ,phase-in of impact of dental and oral health coverage on part ,b premiums ,section #ahci7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acier7a77 is amended-- 7#a7 in the second sentence of paragraph 7#a71 by striking and 7#g7 and inserting 7#g71 and 7#h72 7#b7 in paragraph 7#c71 by striking ,the ,secretary and inserting ,subject to paragraph 7#h77;,c71 the ,secretary2 and 7#c7 by adding at the end the following3 7#h7 ,special rule for #bjbg through #bjca 7,a7 ,determination of alternative monthly actuarial rate for each of #bjbg through #bjca ,for each of #bjbg through #bjca1 the ,secretary shall1 at the same time as and in addition to the determination of the monthly actuarial rate for enrollees age #fe and over determined in each of #bjbf through #bjcj for the succeeding calendar year according to paragraph 7#a71 determine an alternative monthly actuarial rate for enrollees age #fe and over for the year as described in subparagraph 7,b74 7,b7 ,alternative monthly actuarial rate described 7i7 ,in general ,the alternative monthly actuarial rate described in this subparagraph is-- 7,i7 for #bjbg and #bjbh1 the monthly actuarial rate for enrollees age #fe and over for the year1 determined as if the amendments made by section #djb of the ,medicare ,dental1 ,hearing1 and ,vision ,expansion ,act of #bjbf did not apply2 and 7,,ii7 for #bjbi1 #bjcj1 and #bjca1 the monthly actuarial rate for enrollees age #fe and over for the year1 determined as if the amendments made by such section #djb did not apply1 plus the applicable percent of the amount by which-- 7aa7 the monthly actuarial rate for enrollees age #fe and over for the year determined according to paragraph 7#a72 exceeds 7bb7 the monthly actuarial rate for enrollees age #fe and over for the year1 determined as if the amendments made by such section #djb did not apply4 7ii7 ,definition of applicable percent ,for purposes of this subparagraph1 the term applicable percent means-- 7,i7 for #bjbi1 #be percent2 7,,ii7 for #bjcj1 #ej percent2 and 7,,iii7 for #bjca1 #ge percent4 7,c7 ,application to part b premium and other provisions of this part ,for each of #bjbg through #bjca1 the ,secretary shall use the alternative monthly actuarial rate for enrollees age #fe and over for the year determined under subparagraph 7,a71 in lieu of the monthly actuarial rate for such enrollees for the year determined according to paragraph 7#a71 when determining the monthly premium rate for the year under paragraph 7#c7 and subsection 7j71 the part ,b deductible under section #ahcc7;b71 and the premium subsidy and monthly adjustment amount under subsection 7i74 4 ,v ,housing ,trust ,fund #eja4 ,authorization of appropriations ,section #acch7;a7 of the ,federal ,housing ,enterprises ,financial ,safety and ,soundness ,act of #aiib 7#ab ,u4,s4,c4 #defh7;a77 is amended by adding at the end the following3 7#c7 ,authorization of appropriations ,there is authorized to be appropriated to the ,housing ,trust ,fund #he1fdg1jjj1jjj for each of fiscal years #bjbf through #bjce4 4 ,,vi ,affordable ,child ,care for ,working ,families #fja4 ,birth through five child care and early learning entitlement 7a7 ,child care definitions ,the definitions in section #feh,p of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #ihehn7 shall apply to this section1 except as provided in subsection 7b7 and as otherwise specified4 7b7 ,additional definitions ,in this section3 7#a7 ,child care certificate 7,a7 ,in general ,the term child care certificate means a certificate 7that may be a check or other disbursement7 that is issued by a ,state1 tribal1 territorial1 or local government under this section directly to a parent who shall use such certificate only as payment for child care services or as a deposit for child care services if such a deposit is required of other children being cared for by the provider4 7,b7 ,rule ,nothing in this section shall preclude the use of such certificates for sectarian child care services if freely chosen by the parent4 ,for the purposes of this section1 child care certificates shall be considered indirect ,federal financial assistance to the provider4 7#b7 ,child experiencing homelessness ,the term child experiencing homelessness means an individual who is a homeless child or youth under section #gbe of the ,mc,kinney-,vento ,homeless ,assistance ,act 7#db ,u4,s4,c4 #aadcd;a74 7#c7 ,eligible activity ,the term eligible activity1 with respect to a parent1 shall include1 at minimum1 activities consisting of-- 7,a7 full-time or part-time employment2 7,b7 self-employment2 7,c7 job search activities2 7,d7 job training2 7,e7 secondary1 postsecondary1 or adult education1 including education through a program of high school classes1 a course of study at an institution of higher education1 classes towards an equivalent of a high school diploma recognized by ,state law1 or ,english as a second language classes2 7,f7 health treatment 7including mental health and substance use treatment7 for a condition that prevents the parent from participating in other eligible activities2 7,g7 activities to prevent child abuse and neglect1 or family violence prevention or intervention activities2 7,h7 employment and training activities under the supplemental nutrition assistance program established under section #f7;d77#d7 the ,food and ,nutrition ,act of #bjjh 7#g ,u4,s4,c4 #bjae7;d77#d772 7,i7 employment and training activities under the ,workforce ,innovation and ,opportunity ,act 7#bi ,u4,s4,c4 #caja et seq472 7,j7 a work activity described in subsection 7d7 of section #djg of the ,social ,security ,act 7#db ,u4,s4,c4 #fjg7 for which1 consistent with clauses 7ii7 and 7iii7 of section #djb7;a77#a77;,a7 of such ,act 7#db ,u4,s4,c4 #fjb7;a77#a77;,a771 a parent or caretaker is treated as being engaged in work for a month in a fiscal year for purposes of the program of block grants to ,states for temporary assistance for needy families established under part ,a of title ,,iv of the ,social ,security ,act 7#db ,u4,s4,c4 #fja et seq472 and 7,k7 taking leave under the ,family and ,medical ,leave ,act of #aiic 7#bi ,u4,s4,c4 #bfja et seq47 7or equivalent provisions for ,federal employees71 a ,state or local paid or unpaid leave law1 or a program of employer-provided leave4 7#d7 ,eligible child 7,a7 ,in general ,the term eligible child means an individual-- 7i7 who is less than #f years of age2 7ii7 who is not yet in kindergarten2 7iii7 whose family income does not exceed #bej percent of the ,state median income for a family of the same size for the fiscal year involved1 for each fiscal year beginning with fiscal year #bjbf2 and 7iv7 who-- 7,i7 resides with a parent or parents who are participating in an eligible activity2 7,,ii7 is included in a population of vulnerable children identified by the lead agency involved1 which at a minimum shall include children with disabilities1 infants and toddlers with disabilities1 children experiencing homelessness1 children in foster care1 children in kinship care1 and children who are receiving1 or need to receive1 child protective services2 or 7,,iii7 resides with a parent who is more than #fe years of age4 7,b7 ,longer-term period eligibility ,for purposes of determining eligibility under this paragraph1 an individual who is determined to be an eligible child shall continue to be considered an eligible child and shall not be required to reverify eligibility for purposes of this section during the period-- 7i7 that begins on the date of the determination2 and 7ii7 that ends on the earlier of the date the individual becomes #f years of age or the date the individual enters kindergarten4 7#e7 ,eligible child care provider 7,a7 ,in general ,the term eligible child care provider means a center-based child care provider1 a family child care provider1 or other provider of child care services for compensation that-- 7i7 is licensed to provide child care services under ,state law applicable to the child care services it provides or1 in the case of an ,indian ,tribe or tribal organization1 meets the rules set by the ,secretary2 7ii7 participates in the ,state's tiered system for measuring and supporting the quality of eligible child care providers described in subsection 7f77#c77;,b71 or1 in the case of an ,indian ,tribe or tribal organization1 meets the rules set by the ,secretary-- 7,i7 not later than #c years after the ,state first receives funds under this section2 and 7,,ii7 for the remainder of the period for which the provider receives funds under this section2 and 7iii7 satisfies the ,state and local requirements1 including those requirements described in section #feh;,e7c77#b77;,i7 of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheh;c7c77#b77;,i771 applicable to the child care services it provides4 7,b7 ,special rule ,a child care provider who is eligible to provide child care services in a ,state for children receiving assistance under the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheg et seq47 on the date the ,state submits an application for funds under this section1 and remains in compliance with any licensing or registration standards1 or regulations1 of the ,state1 shall be deemed to be an eligible child care provider under this section for #c years after the ,state first receives funds under this section4 7#f7 ,,fmap ,the term ,,fmap has the meaning given the term ,federal medical assistance percentage in the first sentence of section #aije7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7b774 7#g7 ,family child care provider ,the term family child care provider means one or more individuals who provide child care services1 in a private residence other than the residences of the children involved1 for less than #bd hours per day per child1 or for #bd hours per day per child due to the nature of the work of the parent involved4 7#h7 ,inclusive care ,the term inclusive1 with respect to care 7including child care71 means care provided by an eligible child care provider-- 7,a7 for whom the percentage of children served by the provider who are children with disabilities or infants or toddlers with disabilities reflects the prevalence of children with disabilities and infants and toddlers with disabilities 7whichever the provider serves7 among children within the ,state involved2 and 7,b7 that provides care and full participation for children with disabilities and infants and toddlers with disabilities 7whichever the provider serves7 alongside children who are-- 7i7 not children with disabilities2 and 7ii7 not infants and toddlers with disabilities4 7#i7 ,infant or toddler ,the term infant or toddler means an individual who is less than #c years of age4 7#aj7 ,infant or toddler with a disability ,the term infant or toddler with a disability has the meaning given the term in section #fcb of the ,individuals with ,disabilities ,education ,act 7#bj ,u4,s4,c4 #adcb74 7#aa7 ,lead agency ,the term lead agency means the agency designated under subsection 7e74 7#ab7 ,provider type ,the term provider type means a type that is-- 7,a7 a center-based child care provider2 7,b7 a family child care provider2 or 7,c7 another non-center-based child care provider4 7#ac7 ,staffed family child care network ,the term staffed family child care network means a nonprofit organization or nonprofit cooperative-- 7,a7 that may be a component of a child care resource and referral organization2 7,b7 that has at least one paid staff member2 and 7,c7 that offers evidence-based professional development1 quality improvement support1 business support1 and technical assistance1 including on achieving licensure as a child care provider1 to family child care providers4 7#ad7 ,state ,the term ,state means any of the #ej ,states and the ,district of ,columbia4 7#ae7 ,territory ,the term territory means the ,commonwealth of ,puerto ,rico1 the ,virgin ,islands of the ,united ,states1 ,guam1 ,american ,samoa1 and the ,commonwealth of the ,northern ,mariana ,islands4 7c7 ,appropriations 7#a7 ,states1 ,indian ,tribes and tribal organizations1 and territories entitlement ,in addition to amounts otherwise available1 there is appropriated to the ,department of ,health and ,human ,services for fiscal year #bjbf and each subsequent fiscal year1 out of any money in the ,treasury not otherwise appropriated1 such sums as may be necessary for payments to ,states1 territories1 and ,indian ,tribes and tribal organizations for carrying out the child care program described in this section 7other than carrying out activities described in paragraph 7#b7 or 7#c774 7#b7 ,grants to localities2 awards to ,head ,start agencies ,in addition to amounts otherwise available1 there is appropriated to the ,department of ,health and ,human ,services for fiscal year #bjbf1 out of any money in the ,treasury not otherwise appropriated #bj1jjj1jjj1jjj1 to carry out the program of grants to localities1 and the program of awards to ,head ,start agencies1 described in subsection 7i74 7#c7 ,federal administration ,notwithstanding paragraph 7#a7 or 7#b71 of the funds appropriated under this section for a fiscal year1 the ,secretary of ,health and ,human ,services may reserve an amount equal to not more than #j4e percent of the funds appropriated under this section for the prior fiscal year1 for purposes of ,federal administration of this section4 7d7 ,establishment of birth through five child care and early learning entitlement program 7#a7 ,in general ,the ,secretary is authorized to administer a child care and early learning entitlement program under which an eligible child1 in a ,state1 territory1 or ,indian ,tribe1 or served by a tribal organization1 with an approved application under subsection 7f7 or 7g71 shall be provided an opportunity to obtain high-quality child care services1 subject to the requirements of this section4 7#b7 ,assistance for every eligible child ,beginning on ,october #a1 #bjbf1 every child who applies for assistance under this section1 who is in a ,state with an approved application under subsection 7f71 or in a territory or ,indian ,tribe or served by a tribal organization with an approved application under subsection 7g71 and who is determined1 by a lead agency 7or other entity designated by a lead agency7 for the ,state1 territory1 ,indian ,tribe1 or tribal organization involved1 following standards and procedures established by the ,secretary by rule1 to be an eligible child1 shall be offered assistance for and shall be entitled to receive direct child care services in accordance with and subject to the requirements and limitations of this section4 7e7 ,lead agency ,the ,governor of a ,state or the head of a territory or ,indian ,tribe1 desiring for the ,state1 territory1 or ,indian tribe or a related tribal organization to receive a payment under this section1 shall designate a lead agency 7such as a ,state agency or joint interagency office7 to administer the child care program carried out under this section4 7f7 ,applications and ,state plans 7#a7 ,application ,to be eligible to receive assistance under this section1 a ,state shall prepare and submit to the ,secretary for approval an application containing a ,state plan that meets the requirements under paragraph 7#c7 and contains such information as the ,secretary may require4 7#b7 ,period covered by plan ,a ,state plan contained in the application shall be designed to be implemented during a period of not more than #c years4 7#c7 ,requirements for ,state plans ,the ,secretary shall award funds under this section to ,states with an approved application that contains a ,state plan1 submitted under paragraph 7#a71 at such time1 in such manner1 and containing such information as the ,secretary shall by rule require1 including1 at a minimum1 the following3 7,a7 ,payment rates and cost estimation 7i7 ,payment rates ,the ,state plan shall certify that payment rates for the provision of direct child care services for which assistance is provided in accordance with this section for the period covered by the plan1 within #c years after the ,state first receives funds under this section-- 7,i7 will be sufficient to meet the cost of child care 7including fixed costs such as rent or mortgage1 and salaries71 and set 7with pay being paid7 in accordance with a cost estimation model or cost study described in clause 7ii7 that is approved by the ,secretary2 and 7,,ii7 will correspond to differences in quality 7including improved quality7 based on the ,state's tiered system for measuring and supporting the quality of eligible child care providers described in subparagraph 7,b74 7ii7 ,cost estimation ,such ,state plan shall-- 7,i7 demonstrate that the ,state has1 after consulting with relevant entities and stakeholders1 developed and uses a statistically valid and reliable cost estimation model or cost study for the payment rates for direct child care services in the ,state that are sufficient to cover providers' fixed costs and reflect the cost of child care at each of the tiers of the ,state's tiered system for measuring and supporting the quality of eligible child care providers described in subparagraph 7,b71 and variations in the cost of direct child care services by geographic area1 provider type1 and age of child1 and the additional costs associated with providing inclusive care2 7,,ii7 certify that the entities and stakeholders consulted included the ,state ,advisory ,council on ,early ,childhood ,education and ,care designated or established in section #fdb;,b7b77#a77;,a77i7 of the ,head ,start ,act 7#db ,u4,s4,c4 #ihcg;b7b77#a77;,a77i77 7including ,state ,directors of ,head ,start ,collaboration71 administrators of local child care programs and ,head ,start agencies1 organizations representing child care directors1 teachers1 and other staff1 local child care resource and referral organizations1 organizations representing parents of children with disabilities and parents of infants and toddlers with disabilities1 the ,state interagency coordinating council established under section #fda of the ,individuals with ,disabilities ,education ,act 7#bj ,u4,s4,c4 #adda71 the ,state advisory panel established under section #fab7;a77#ba7 of the ,individuals with ,disabilities ,education ,act 7#bj ,u4,s4,c4 #adab7;a77#ba771 organizations and labor organizations representing child care providers1 and other appropriate entities2 7,,iii7 certify that the ,state-- 7aa7 not later than #cj days after finalizing the cost estimation model or cost study1 published a detailed report containing the child care costs estimated with the cost estimation model or cost study1 and including an explanation detailing how the wage requirements described in subclause 7,,iv77cc7 were applied in the estimation of such costs2 and 7bb7 not later than #fj days after publishing the report described in item 7aa71 established a system to receive public comment on the report on the subject of making changes to the cost estimation model or cost study1 provided an opportunity for the public to comment on the report through that system1 and submitted the report to the ,secretary2 7,,iv7 certify that the ,state's payment rates for direct child care services for which assistance is provided in accordance with this section-- 7aa7 are set 7with pay being paid7 in accordance with the most recent estimates from the most recent cost estimation model or cost study under subclause 7,i71 so that providers at each tier of the tiered system for measuring and supporting the quality of eligible child care providers described in subparagraph 7,b7 receive a payment that is sufficient to fully meet the requirements of such tier2 7bb7 are set so as to provide payments to providers not at the top tier of the tiered system that are sufficient to enable the providers to increase quality to meet the requirements for the next tier2 7cc7 ensure adequate wages for staff of child care providers providing such direct child care services that-- 7,,aa7 at a minimum1 provide a living wage for all staff of such child care providers2 and 7,,bb7 are equivalent to wages for elementary educators with similar credentials and experience in the ,state2 and 7dd7 are adjusted on an annual basis for cost of living increases to ensure those payment rates remain sufficient to meet the requirements of this section2 7,v7 certify that the ,state will update1 not less often than once every #c years1 the cost estimation model or cost study described in subclause 7,i72 and 7,,vi7 certify that the ,state has established a system for appeals of the determination of child care costs estimated with the cost estimation model or cost study4 7iii7 ,payment practices ,such ,state plan shall include an assurance that the ,state will implement payment practices that support the fixed costs of providing direct child care services4 7,b7 ,tiered system for measuring and supporting the quality of eligible child care providers ,such ,state plan shall certify that the ,state has implemented1 or assure that the ,state will implement within #c years after first receiving funds under this section1 with input 7from early childhood education and development experts1 from a diverse group of child care providers of a variety of provider types1 from families1 and from organizations representing child care directors1 teachers1 and other staff71 a tiered system for measuring and supporting the quality of eligible child care providers who provide child care services for which assistance is made available under this section4 ,such tiered system shall-- 7i7 include a set of standards1 for determining the tier of quality of a child care provider1 that-- 7,i7 uses standards for a highest tier that at a minimum are equivalent to ,head ,start program performance standards described in section #fda;,a7a77#a77;,b7 of the ,head ,start ,act 7#db ,u4,s4,c4 #ihcf;a7a77#a77;,b77 or other equivalent evidence-based standards approved by the ,secretary2 and 7,,ii7 includes quality indicators and thresholds that are appropriate for child development from child care providers of a variety of provider types1 including child care centers and the settings of family child care providers1 and are appropriate for providers serving different age groups 7including mixed age groups7 of children2 7ii7 include a different set of standards that includes indicators1 when appropriate1 for care during nontraditional hours of operation2 and 7iii7 provide for sufficient resources and supports for child care providers at tiers lower than the highest tier to facilitate progression toward meeting higher quality standards4 7,c7 ,achieving high quality for all children ,such ,state plan shall certify the ,state has implemented1 or will implement within #c years after first receiving funds under this section1 policies and financing practices that will ensure all eligible children can choose to attend child care1 with services provided by eligible child care providers from any of a variety of provider types including family child care providers1 at the highest quality tier within #f years after the date of enactment of this ,act4 7,d7 ,compensation ,such plan shall provide a certification that the ,state has or will have within #c years after first receiving funds under this section1 a wage ladder for staff of eligible child care providers receiving assistance under this section1 including a certification that wages for such staff1 at a minimum1 will meet the requirements of subparagraph 7,a77ii77,,iv77cc74 7,e7 ,sliding fee scale for copayments 7i7 ,in general ,except as provided in clause 7ii77,i71 the ,state plan shall provide an assurance that the ,state will for the period covered by the plan use a sliding fee scale described in clause 7ii7 to determine a copayment for a family receiving assistance under this section 7or1 for a family receiving part-time care1 a reduced copayment that is the proportionate amount of the full copayment74 7ii7 ,sliding fee scale ,a full copayment described in clause 7i7 shall use a sliding fee scale that provides that1 for a family with a family income-- 7,i7 of not more than #he percent of ,state median income for a family of the same size1 the family shall not pay a copayment1 toward the cost of the child care involved for all eligible children in the family2 7,,ii7 of more than #he percent but not more than #ajj percent of ,state median income for a family of the same size1 the copayment shall be more than #j but not more than #b percent of that family income1 toward such cost for all such children2 7,,iii7 of more than #ajj percent but not more than #abe percent of ,state median income for a family of the same size1 the copayment shall be more than #b but not more than #d percent of that family income1 toward such cost for all such children2 7,,iv7 of more than #abe percent but not more than #aej percent of ,state median income for a family of the same size1 the copayment shall be more than #d but not more than #g percent of that family income1 toward such cost for all such children2 and 7,v7 of more than #aej percent but not more than #bej percent of the ,state median income for a family of the same size1 the copayment shall be #g percent of that family income1 toward such cost for all such children4 7,f7 ,prohibition on charging more than copayment ,the ,state plan shall certify that1 after the ,state develops and begins using the cost estimation model or cost study described in subparagraph 7,a77ii71 the ,state will not permit a child care provider receiving financial assistance under this section to charge1 for direct child care services for an eligible child1 more than the total of-- 7i7 the financial assistance provided for the child under this section2 and 7ii7 any applicable copayment pursuant to subparagraph 7,e74 7,g7 ,eligibility ,the ,state plan shall assure that each child who receives assistance under this section will be considered to meet all eligibility requirements for such assistance1 and will receive such assistance1 for not less than #ab months unless the child has aged out of the program1 and the child's eligibility determination and redetermination1 including any determination based on the ,state's definition of eligible activities1 shall be implemented in a manner that supports child well-being and reduces barriers to enrollment1 including continuity of services4 7,h7 ,policies to support access to child care for underserved populations ,the ,state plan shall demonstrate that the ,state will prioritize increasing access to1 and the quality and the supply of1 child care in the ,state for underserved populations1 including at a minimum1 low-income children1 children in underserved areas1 infants and toddlers1 children with disabilities and infants and toddlers with disabilities1 children who are dual language learners1 children experiencing homelessness1 children in foster or kinship care1 children who receive care during nontraditional hours1 and vulnerable children as defined by the lead agency pursuant to subsection 7b77#d77;,a77iv77,,ii74 7,i7 ,policies ,the ,state plan shall include a certification that the ,state will apply1 under this section1 the policies and procedures described in subparagraphs 7,a71 7,b71 7,i71 7,j71 7,k77i71 7,r71 and 7,u7 of section #feh;,e7c77#b7 of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheh;c7c77#b771 and the policies and procedures described in section #feh;,h of such ,act 7#db ,u4,s4,c4 #iheh;f71 to child care services provided under this section4 7,j7 ,licensing ,the ,state plan shall demonstrate that the ,state has consulted or will consult with organizations 7including labor organizations and child care and early learning organizations7 representing eligible child care providers 7including family child care providers71 child care associations1 child care directors1 teachers1 and other staff 7including child care directors1 teachers1 and other staff serving higher proportions of underserved populations as identified under subparagraph 7,h771 early childhood education and development experts1 maternal and child health experts1 and families to develop1 within #b4e years after first receiving funds under this section1 licensing standards appropriate for child care providers and a pathway to such licensure that is available to and appropriate for child care providers in a variety of settings1 that will offer providers eligible under the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheg et seq47 a reasonable pathway to become eligible providers under this section1 and that will assure an adequate supply of child care4 ,such plan shall describe the timeline the ,state will use to ensure sufficient time for providers described in subsection 7b77#e77;,b7 to comply with such licensing standards in order to remain eligible providers after #c4e years after the ,state first receives funding under this section4 7,k7 ,financial support for providers ,such plan shall describe how the ,state will use funds reserved under subsection 7h77#a77;,c7 to enable eligible child care providers from a variety of provider types to achieve licensure1 including paying for the costs of required background checks1 health screening1 and initial and ongoing training1 and other costs associated with achieving licensure4 7,l7 ,prohibition on suspensions1 expulsions1 and aversive behavioral interventions ,the ,state plan shall provide an assurance that the ,state will-- 7i7 provide assistance to carry out this section only to eligible child care providers that prohibit-- 7,i7 the use of suspension and expulsion of children2 and 7,,ii7 the use of aversive behavioral interventions2 and 7ii7 provide training resources to eligible child care providers and information to families to support the prohibition of practices described in subclauses 7,i7 and 7,,ii7 of clause 7i74 7g7 ,payments 7#a7 ,in general ,for each fiscal year3 7,a7 ,child care assistance for eligible children 7i7 ,in general ,the ,secretary shall pay to each ,state with an approved application under subsection 7f71 and that ,state shall be entitled to1 an amount for each quarter equal to #ij percent of expenditures 7which shall be the ,federal share of such expenditures7 in the quarter for direct child care services described under subsection 7h77#a77;,b7 for eligible children4 7ii7 ,exception ,funds reserved from the total under subsection 7h77#a77;,c7 shall be subject to subparagraph 7,b74 7iii7 ,prohibition ,activities described in subparagraph 7,b7 and subparagraph 7,c7 may not be included in the cost of direct child care services described in this subparagraph4 7,b7 ,activities to improve the quality and supply of child care services ,the ,secretary shall pay to each ,state with such an approved application1 and that ,state shall be entitled to1 an amount equal to the ,,fmap of expenditures 7which shall be the ,federal share of such expenditures7 to carry out activities to improve the quality and supply of child care services under subsection 7h77#a77;,c7 subject to the limit specified in clause 7i7 of such subsection4 7,c7 ,administration ,the ,secretary shall pay to each ,state with such an approved application1 and that ,state shall be entitled to1 an amount equal to #ej percent of expenditures 7which shall be the ,federal share of such expenditures7 for the costs of administration incurred by the ,state-- 7i7 which shall include costs incurred by the ,state in carrying out the child care program established in this section2 and 7ii7 which may include1 at the option of the ,state1 costs associated with carrying out requirements1 policies1 and procedures described in section #feh;,h of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheh;f74 7#b7 ,advance payment2 retrospective adjustment ,for each fiscal year1 the ,secretary shall make payments under this subsection for a period on the basis of advance estimates of expenditures submitted by the ,state and such other investigation as the ,secretary may find necessary1 and shall reduce or increase the payments as necessary to adjust for any overpayment or underpayment for previous periods4 ,no interest shall be charged or paid on any amount due because of an overpayment or underpayment for previous periods4 7#c7 ,territories and tribes 7,a7 ,in general ,for each fiscal year1 from amounts appropriated under subsection 7c77#a71 the ,secretary shall make payments to territories1 and ,indian ,tribes and tribal organizations1 as the case may be1 with applications submitted as described in subparagraph 7,b71 and approved by the ,secretary for the purpose of carrying out the child care program described in this section1 consistent1 to the extent practicable as determined by the ,secretary 7subject to subsection 7d77#b771 with the requirements applicable to ,states4 7,b7 ,applications 7i7 ,territories ,a territory seeking a payment under this paragraph shall submit an application to the ,secretary at such time1 in such manner1 and containing such information as the ,secretary may specify4 7ii7 ,indian ,tribes and tribal organizations ,an ,indian ,tribe or a tribal organization seeking a payment under this paragraph shall submit an application to the ,secretary at such time1 in such manner1 and containing such information as the ,secretary may specify4 7,c7 ,costs ,the ,secretary shall make the payments to such territories1 ,indian ,tribes1 and tribal organizations on the basis of their relative need4 ,each entity that is such a territory1 ,indian ,tribe1 or tribal organization shall be entitled to such a payment as may be necessary to pay for #ajj percent of the expenses of carrying out the activities described in subsection 7h77#a71 and to pay for #ajj percent of the costs of administration incurred by the entity1 which shall include costs incurred by the entity in carrying out the child care program1 and which may include1 at the option of the entity1 costs associated with carrying out requirements1 policies1 and procedures described in section #feh;,h of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheh;f74 7h7 ,use of funds 7#a7 ,use of funds 7,a7 ,in general ,starting on ,october #a1 #bjbf1 a ,state shall use amounts provided to the ,state under subsection 7g77#a7 for direct child care services 7provided on a sliding fee scale basis71 activities to improve the quality and supply of child care services consistent with subparagraph 7,c71 and ,state administration consistent with subsection 7g77#a77;,c74 7,b7 ,child care assistance for eligible children 7i7 ,in general ,for fiscal year #bjbf and each subsequent fiscal year1 from payments made to the ,state under subsection 7g77#a7 for that particular fiscal year1 the ,state shall ensure that parents of eligible children can access direct child care services provided by an eligible child care provider under this section through a grant or contract as described in clause 7ii7 or a certificate as described in clause 7iii74 7ii7 ,grants and contracts ,the ,state shall award grants or contracts to eligible child care providers1 consistent with the requirements under this section1 for the provision of child care services for eligible children under this section that1 at a minimum-- 7,i7 support providers' operating expenses to meet and sustain health1 safety1 quality1 licensing1 and wage standards required under this section2 and 7,,ii7 address underserved populations described in subsection 7f77#c77;,h74 7iii7 ,certificates ,the ,state shall issue a child care certificate directly to a parent who shall use such certificate only as payment for direct child care services or as a deposit for direct child care services if such a deposit is required of other children being cared for by the provider1 consistent with the requirements under this section4 7,c7 ,activities to improve the quality and supply of child care services 7i7 ,quality child care activities 7,i7 ,amount ,for fiscal year #bjbf and each subsequent fiscal year1 from the total of the payments made to the ,state for a particular fiscal year1 the ,state shall reserve and use a quality child care amount equal to not less than #e percent and not more than #aj percent of the amount made available to the ,state through such payments for the previous fiscal year4 7,,ii7 ,use of quality child care amount ,each ,state shall use the quality child care amount described in subclause 7,i7 to implement activities described in this subparagraph to improve the quality and supply of child care services by eligible child care providers1 and increase the number of available slots in the ,state for child care services funded under this section1 prioritizing assistance for child care providers who are in underserved communities and who are providing1 or are seeking to provide1 child care services for underserved populations identified in subsection 7f77#c77;,h74 7,,iii7 ,administration ,activities funded under this subparagraph may be administered-- 7aa7 directly by the lead agency2 or 7bb7 through other ,state government agencies1 local or regional child care resource and referral organizations1 community development financial institutions1 other intermediaries with experience supporting child care providers1 or other appropriate entities that enter into a contract with the ,state to provide such assistance4 7ii7 ,quality and supply activities ,activities funded under the quality child care amount described in clause 7i7 shall include each of the following3 7,i7 ,startup grants and supply expansion grants 7aa7 ,in general ,from a portion of the quality child care amount1 a ,state shall make startup and supply expansion grants to support child care providers who are providing1 or seeking to provide1 child care services to children receiving assistance under this section1 with priority for providers providing or seeking to provide child care in underserved communities and for underserved populations identified in subsection 7f77#c77;,h71 to-- 7,,aa7 support startup and expansion costs2 and 7,,bb7 assist such providers in meeting health and safety requirements1 achieving licensure1 conducting background checks1 and meeting requirements in the ,state's tiered system for measuring and supporting the quality of eligible child care providers4 7bb7 ,requirement ,as a condition of receiving a startup or supply expansion grant under this subclause1 a child care provider shall commit to meeting the requirements of an eligible provider under this section1 and providing child care services to children receiving assistance under this section on an ongoing basis4 7,,ii7 ,quality grants ,from a portion of the quality child care amount1 a ,state shall provide quality grants to support eligible child care providers in providing child care services to children receiving assistance under this section to improve the quality of such providers1 including-- 7aa7 supporting such providers in meeting or making progress toward the requirements for the highest tier of the ,state's tiered system for measuring and supporting the quality of eligible child care providers under subsection 7f77#c77;,b72 and 7bb7 supporting such providers in sustaining child care quality1 including supporting increased wages for staff and supporting payment of fixed costs4 7,,iii7 ,facilities grants 7aa7 ,in general ,from a portion of the quality child care amount1 a ,state shall provide support1 including through awarding facilities grants1 for remodeling1 renovation1 or repair of a building or facility to the extent permitted under section #feh;,f7b7 of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheh;d7b774 7bb7 ,additional uses ,for fiscal year #bjbf and subsequent fiscal years1 a ,state may award such facilities grants for construction1 permanent improvement1 or major renovation of a building or facility primarily used for providing direct child care services1 in accordance with the following3 7,,aa7 ,federal interest provisions will not apply to the renovation or rebuilding of privately owned family child care homes under this subclause4 7,,bb7 ,eligible child care providers may not use funds for buildings or facilities that are used primarily for sectarian instruction or religious worship4 7,,cc7 ,the ,secretary shall develop parameters on the use of funds under this subclause for family child care homes4 7,,dd7 ,the ,secretary shall not retain ,federal interest after a period of #aj years in any facility built1 renovated1 or repaired with funds awarded under this subclause4 7,,iv7 ,state activities to improve the quality of child care services ,a ,state shall use a portion of the quality child care amount to improve the quality of child care services available for this program1 which shall include-- 7aa7 supporting the training and professional development of the early childhood workforce1 including supporting degree attainment1 continued education1 and credentialing for early childhood educators2 7bb7 developing1 implementing1 or enhancing the ,state's tiered system for measuring and supporting the quality of eligible child care providers under subsection 7f77#c77;,b72 7cc7 improving the supply and quality of developmentally appropriate and inclusive child care programs and services for underserved populations described in subsection 7f77#c77;,h72 7dd7 improving access to child care services for vulnerable children as defined by the lead agency pursuant to subsection 7b77#d77;,a77iv77,,ii72 7ee7 providing outreach and enrollment support for families of eligible children2 7ff7 supporting eligible child care providers to eliminate use of suspensions1 expulsions1 and aversive behavioral interventions1 including through adaptations and interventions by special educators1 mental health consultants1 and other community resource personnel1 such as behavior coaches1 psychologists1 and other appropriate specialists1 and through the provision of mental health services for the providers2 7gg7 improving coordination between ,states and local government with respect to licensing and other regulatory requirements for eligible child care providers2 and 7hh7 establishing or supporting a system of local or regional child care resource and referral organizations that is coordinated1 to the extent determined appropriate by the ,state1 by a statewide public or private nonprofit1 community-based or regionally based1 lead child care resource and referral organization1 as described in section #feh;,e7c77#c77;,b77iii7 of the ,child ,care and ,development ,block ,grant ,act of #aiij 7#db ,u4,s4,c4 #iheh;c7c77#c77;,b77iii774 7,v7 ,technical assistance ,from a portion of the quality child care amount1 the ,state1 in coordination with local governments and staffed family child care networks as appropriate1 shall provide technical assistance to increase the supply and quality of eligible child care providers who are providing1 or seeking to provide1 child care services to children receiving assistance under this section1 including providing support to enable providers to achieve licensure4 7i7 ,grants to localities and awards to ,head ,start programs 7#a7 ,eligible locality defined ,in this subsection1 the term eligible locality means a city1 county1 or other unit of general local government4 7#b7 ,grants to localities 7,a7 ,in general ,after reserving a portion of the funds appropriated under subsection 7c77#b71 the ,secretary shall use the portion to award local ,birth ,through ,five ,child ,care and ,early ,learning ,grants1 as determined by the ,secretary1 to eligible localities located in ,states that have not received payments under subsection 7g74 ,the ,secretary shall award the grants to eligible localities in such a ,state from the allotment made for that ,state under subparagraph 7,b74 7,b7 ,allotments 7i7 ,poverty line defined ,in this subparagraph1 the term poverty line means the poverty line defined and revised as described in section #fgc of the ,community ,services ,block ,grant ,act 7#db ,u4,s4,c4 #iijb74 7ii7 ,general authority ,for each ,state described in subparagraph 7,a71 the ,secretary shall allot for the ,state for a fiscal year an amount that bears the same relationship to the portion described in subparagraph 7,a7 for the fiscal year as the number of children from families with family incomes that are at or below #bjj percent of the poverty line1 and who are under the age of #f1 in the ,state bears to the total number of all such children in all ,states described in subparagraph 7,a74 7,c7 ,application ,to receive a grant from the corresponding ,state allotment under subparagraph 7,b71 an eligible locality shall submit an application to the ,secretary at such time1 in such manner1 and containing such information as the ,secretary may require4 ,the requirements for the application shall1 to the greatest extent practicable1 be consistent with the ,state plan requirements applicable to ,states under subsection 7f74 7,d7 ,requirements ,the ,secretary shall specify the requirements for an eligible locality to provide access to child care1 which child care requirements shall1 to the greatest extent practicable1 be consistent with the requirements applicable to ,states under this section4 7,e7 ,recoupment of unused funds ,notwithstanding any other provision of this section1 for each of fiscal years #bjbf through #bjcj1 the ,secretary shall have the authority to recoup any unused funds allotted under subparagraph 7,b7 for awards under paragraph 7#c77;,a7 to ,head ,start agencies in accordance with paragraph 7#c74 7#c7 ,head ,start expansion in nonparticipating ,states 7,a7 ,in general ,the ,secretary shall use funds appropriated under subsection 7c77#b7 and not reserved under paragraph 7#b77;,a7 and funds recouped under paragraph 7#b7 to make awards to ,head ,start agencies in a ,state described in paragraph 7#b77;,a7 to carry out the purposes of the ,head ,start ,act 7#db ,u4,s4,c4 #ihca et seq47 in such ,state4 7,b7 ,rule ,for purposes of carrying out the ,head ,start ,act in circumstances not involving awards under this paragraph1 funds awarded under subparagraph 7,a7 shall not be included in the calculation of a base grant as such term is defined in section #fdj7;a77#g77;,a7 of the ,head ,start ,act 7#db ,u4,s4,c4 #ihce7;a77#g77;,a774 7,c7 ,definition ,in this paragraph1 the term ,head ,start agency means an entity designated or eligible to be designated as a ,head ,start agency under section #fda7;a77#a7 of the ,head ,start ,act 7#db ,u4,s4,c4 #ihcf7;a77#a77 or as an ,early ,head ,start agency 7by receiving a grant7 under section #fde;,a7a7 of such ,act 7#db ,u4,s4,c4 #ihdj;a7a77#a774 7#d7 ,priority for serving underserved populations ,in making determinations to award a grant or make an award under this subsection1 the ,secretary shall give priority to entities serving a high percentage of individuals from underserved populations described in subsection 7f77#c77;,h74 7j7 ,program requirements 7#a7 ,prohibition on additional eligibility requirements ,no individual shall be determined1 by the ,secretary1 a ,state1 or another recipient of funds under this section1 to be ineligible for child care services provided under this section1 except on the basis of eligibility requirements specified in or under this section4 7#b7 ,maintenance of effort 7,a7 ,in general ,a ,state that receives payments under this section for a fiscal year1 in using the funds made available through the payments1 shall maintain the expenditures of the ,state for child care services at the average level of such expenditures by the ,state for the #c preceding fiscal years4 7,b7 ,counting rule ,state expenditures counted for purposes of meeting the requirement in subparagraph 7,a7 may also be counted for purposes of meeting the requirement to provide a non-,federal share under subparagraph 7,a71 7,b71 or 7,c71 as appropriate1 of subsection 7g77#a74 7#c7 ,supplement not supplant ,funds received under this section shall be used to supplement and not supplant other ,federal1 ,state1 and local public funds expended to provide child care services in the ,state on the date of enactment of this ,act1 calculated as the average amount of such ,federal1 ,state1 and local public funds expended for fiscal year #bjbf and each subsequent fiscal year that ended before the date on which the average is calculated4 7#d7 ,allowable sources of non-,federal share ,for purposes of providing the non-,federal share required under subsection 7g77#a71 a ,state's non-,federal share-- 7,a7 for direct child care services described in subsection 7g77#a77;,a7-- 7i7 shall not include contributions being used as a non-,federal share or match for another ,federal award2 and 7ii7 shall be provided from ,state or local sources1 contributions from philanthropy or other private organizations1 or a combination of such sources and contributions2 and 7,b7 for activities to improve the quality and supply of child care services described in subsection 7g77#a77;,b71 and administration described in subsection 7g77#a77;,c7-- 7i7 shall not include contributions being used as a non-,federal share or match for another ,federal award2 7ii7 shall be provided from ,state or local sources1 contributions from philanthropy or other private organizations1 or a combination of such sources and contributions2 and 7iii7 may be in cash or in-kind1 fairly evaluated1 including facilities or property1 equipment1 or services4 7#e7 ,reports ,a ,state1 ,indian ,tribe1 tribal organization1 or territory receiving funds under this section shall provide to the ,secretary such periodic reports1 providing a detailed accounting of the uses of the funds received under this section1 as the ,secretary may require for the administration of this section4 ,the ,state1 ,indian ,tribe1 tribal organization1 or territory shall begin to provide the reports beginning not later than #fj days after its initial receipt of a payment under subsection 7g74 7k7 ,monitoring and enforcement 7#a7 ,review of compliance with requirements and ,state plan ,the ,secretary shall review and monitor compliance of ,states1 territories1 tribal entities1 and local entities with this section and ,state compliance with the ,state plan described in subsection 7f77#c74 7#b7 ,issuance of rule ,the ,secretary shall establish by rule procedures for-- 7,a7 receiving1 processing1 and determining the validity of complaints or findings concerning any failure of a ,state to comply with the ,state plan or any other requirement of this section2 7,b7 notifying a ,state when the ,secretary has determined there has been a failure by the ,state to comply with a requirement of this section2 and 7,c7 imposing sanctions under this subsection for such a failure4 7l7 ,federal administration ,using funds reserved under subsection 7c77#c71 the ,secretary shall carry out administration of this section1 shall provide 7including through the use of grants or cooperative agreements7 technical assistance to ,states1 territories1 ,indian ,tribes1 and tribal organizations1 and shall carry out research1 and evaluations related to this section4 7m7 ,nonpostsecondary education program ,for purposes of section #dja of the ,personal ,responsibility and ,work ,opportunity ,reconciliation ,act of #aiif 7#h ,u4,s4,c4 #afaa71 the program carried out under this section shall be considered to be a program of nonpostsecondary education4 ,,vii ,establishing a #fj1jjj a year minimum salary for every public school teacher in the ,united ,states #gja4 ,purposes ,the purposes of this title are to-- 7#a7 ensure public elementary and secondary school teachers earn a livable and competitive salary that-- 7,a7 includes a starting annual base salary of not less than #fj1jjj2 and 7,b7 increases regularly throughout a teacher's career2 7#b7 increase ,federal investments in public schools2 and 7#c7 call upon ,states and local governments to increase investments in public education in order to ensure that every public school student is taught by a qualified teacher4 #gjb4 ,definitions 7a7 ,definitions ,in this title3 7#a7 ,,esea ,terms ,the terms elementary school1 outlying area1 and secondary school have the meanings given those terms in section #haja of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #ghja74 7#b7 ,annual adjustment percentage ,the term annual adjustment percentage1 with respect to a fiscal year1 means a percentage equal to the estimated percentage change in the ,consumer ,price ,index1 as determined by the ,secretary1 for the most recent calendar year ending prior to the beginning of such fiscal year4 7#c7 ,annual base salary ,the term annual base salary-- 7,a7 means the base salary1 calculated as an annual rate of pay1 of a full-time teacher2 and 7,b7 excludes-- 7i7 any additional compensation earned by the teacher for taking on additional responsibilities 7such as coaching or teaching during the summer or after school72 and 7ii7 bonuses1 stipends1 and awards4 7#d7 ,average teacher salary baselines ,the term average teacher salary baselines means1 for each of the following years of service as teachers1 the average annual base salaries of all full-time teachers employed by local educational agencies in the ,state3 7,a7 #j years1 or starting teacher salaries4 7,b7 #c years4 7,c7 #e years4 7,d7 #aj years4 7,e7 #ae years4 7,f7 #bj years4 7,g7 #be years4 7#e7 ,consumer price index ,the term ,consumer ,price ,index has the meaning given the term in section #dgh7;f7 of the ,higher ,education ,act of #aife 7#bj ,u4,s4,c4 #ajhgrr7f774 7#f7 ,minimum salary for teachers ,the term minimum salary for teachers means an amount1 determined by the ,state1 that all full-time teachers employed by a local educational agency are1 at a minimum1 required by the ,state to be compensated by such agency as their annual base salary1 and which-- 7,a7 for teachers in their first year of teaching1 shall be an annual rate of pay that is not less than the amount described in subsection 7b72 and 7,b7 for teachers with more than #b years of experience1 shall be an annual rate of pay that-- 7i7 is greater than the amount described in subsection 7b72 and 7ii7 increases as the experience of a teacher increases4 7#g7 ,secretary ,the term ,secretary means the ,secretary of ,education4 7#h7 ,teacher ,the term teacher means-- 7,a7 an employee of a local educational agency-- 7i7 with a primary duty of teaching and who is employed and engaged in teaching in a public elementary school or secondary school served by such agency and is not a substitute teacher2 7ii7 who fully meets all applicable public elementary school or secondary school teacher certification and licensure requirements of the ,state in which the school is located2 and 7iii7 if the teacher is a special education teacher1 who meets the qualifications described in section #fab7;a77#ad77;,c7 of the ,individuals with ,disabilities ,education ,act2 and 7,b7 other full-time public elementary school or secondary school personnel employed by a local educational agency whose annual base salary is determined in accordance with such agency's salary schedule or system for a full-time teacher4 7b7 ,special rules 7#a7 ,in general ,for each fiscal year1 the amount described in subsection 7a77#f77;,a7 shall be determined under this subsection4 7#b7 ,fiscal years #bjbg through #bjca ,for each of fiscal years #bjbg through #bjca1 the amount described in subsection 7a77#f77;,a7 is #fj1jjj4 7#c7 ,fiscal years #bjcb and after 7,a7 ,in general ,for the fiscal year period #bjcb through #bjcf and for each subsequent #e fiscal year period1 the amount described in subsection 7a77#f77;,a7 shall be adjusted for inflation as described in subparagraph 7,b74 7,b7 ,determination ,the amount shall be equal to the amount applicable for the previous #e fiscal year period1 increased by the greater of-- 7i7 the aggregate annual adjustment percentage over the previous #e fiscal years2 or 7ii7 #b percent of the amount applicable under this subsection for the previous #e fiscal year period4 #gjc4 ,ensuring teachers are paid a livable and competitive wage 7a7 ,authorization and appropriations for states 7#a7 ,in general ,there are authorized to be appropriated to carry out this section such sums as may be necessary for fiscal year #bjbg and each succeeding fiscal year4 7#b7 ,appropriations for states ,in addition to amounts otherwise available to carry out this section1 there are appropriated1 out of any money in the ,treasury not otherwise appropriated1 to the ,secretary to carry out this section-- 7,a7 for fiscal year #bjbg1 #ad1ejj1jjj1jjj2 and 7,b7 for each succeeding fiscal year1 the amount appropriated under this section for the preceding fiscal year1 increased by the annual adjustment percentage4 7b7 ,program authorized 7#a7 ,in general ,from amounts made available to carry out this section1 and after making the reservations described in paragraph 7#b71 the ,secretary shall award grants1 through allotments described in paragraph 7#c71 to ,states to enable ,states to guarantee that all teachers employed by local educational agencies in the ,state are compensated with a livable and competitive salary1 which shall be an amount that-- 7,a7 is at least the minimum salary for teachers2 7,b7 increases throughout each teacher's career2 and 7,c7 is1 to the greatest extent practicable1 commensurate with annual salaries for college-educated and similarly experienced professionals in the region in which such agencies are located1 as determined in accordance with procedures and requirements established by the ,secretary4 7#b7 ,reservations 7,a7 ,in ,general ,from the amount appropriated under subsection 7a7 for a fiscal year1 the ,secretary shall reserve-- 7i7 one-half of #a percent for allotments for payments to the outlying areas1 to be distributed among those outlying areas on the basis of their relative need1 as determined by the ,secretary1 to ensure that teachers are paid a livable and competitive salary1 in accordance with the purposes of this title2 7ii7 one-half of #a percent for the ,secretary of the ,interior to be allocated by the ,director of the ,bureau of ,indian ,education for programs or activities operated or funded by the ,bureau for ,bureau-funded schools 7as defined in section #aada of the ,education ,amendments of #aigh 7#be ,u4,s4,c4 #bjba77 to ensure teachers are paid a livable and competitive salary1 in accordance with the purposes of this title2 and 7iii7 #a percent for program administration1 technical assistance1 and data collection for the program under this section4 7,b7 ,special rule ,notwithstanding any other provision of this title1 the requirements of this section and section #gjb shall not apply to recipients described in clause 7i7 and 7ii7 of subparagraph 7,a71 except that such recipients shall use funds described in this paragraph to ensure that teachers are paid a livable and competitive salary4 7#c7 ,allotments 7,a7 ,in general ,after making the reservations under paragraph 7#b71 the ,secretary shall allot #ej percent of the remaining amount appropriated under subsection 7a7 in accordance with subparagraph 7,b7 and allot the other #ej percent of such remaining amount in accordance with subparagraph 7,c74 7,b7 ,targeted formula ,from an amount equal to #ej percent of the amounts appropriated under subsection 7a7 and remaining after the reservations of funds under paragraph 7#b7 7referred to in this section as the targeted formula amounts71 the ,secretary shall allot to each ,state having a plan approved by the ,secretary under subsection 7d7 an amount that bears the same relationship to such targeted formula amounts as the total amount that local educational agencies in the ,state received under section #aabe of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #fcce7 for the preceding fiscal year bears to the amount all local educational agencies in all ,states received under such section for the preceding fiscal year4 7,c7 ,,efig formula ,from an amount equal to #ej percent of the amounts appropriated under subsection 7a7 and remaining after the reservations of funds under paragraph 7#b7 7referred to in this section as the ,,efig formula amounts71 the ,secretary shall allot to each ,state having a plan approved by the ,secretary under subsection 7d7 an amount that bears the same relationship to such ,,efig formula amounts as the amount the ,state received under section #aabe;,a of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #bj ,u4,s4,c4 #fccg7 for the preceding fiscal year bears to the amount all ,states received under such section for the preceding fiscal year4 7,d7 ,final allotments ,for the purposes of this section1 a ,state's allotment shall be the sum of a ,state's allotments calculated under subparagraph 7,b7 and subparagraph 7,c74 7c7 ,improving teacher salaries 7#a7 ,in general ,subject to paragraph 7#c71 a ,state that receives an allotment under this section shall ensure that the annual base salary of a full-time teacher employed by a local educational agency in the ,state is an amount that-- 7,a7 is at least the minimum salary for teachers2 7,b7 increases throughout each teacher's career2 and 7,c7 is1 to the greatest extent practicable1 commensurate with annual salaries for college-educated and similarly experienced professionals in the region in which such agencies are located1 as determined in accordance with procedures and requirements established by the ,secretary4 7#b7 ,compliance ,to comply with paragraph 7#a71 a ,state shall adopt one or more of the following laws or policies to ensure that every full-time teacher employed by a local educational agency in the ,state receives an annual base salary that is not less than the minimum salary for teachers3 7,a7 ,a statewide salary schedule that ensures that the salary of every full-time teacher employed by a local educational agency in the ,state is-- 7i7 an amount not less than the minimum salary for teachers established by the ,state under subsection 7d77#a77;,a72 and 7ii7 increases as the experience of a teacher increases4 7,b7 ,a statewide minimum annual base salary for teachers who are in their first year of teaching that not less than the minimum salary for teachers established by the ,state under subsection 7d77#a77;,a74 7,c7 ,a ,state law to increase salaries for teachers4 7#c7 ,timing ,the ,secretary shall ensure that1 not later than #c years after a ,state receives an allotment under this section1 each such ,state meets the teacher salary requirements described in paragraph 7#a74 7d7 ,state plan 7#a7 ,in general ,in order to receive an allotment under subsection 7b77#c71 a ,state shall submit a ,state plan to the ,secretary at such time1 in such manner1 and containing such information as the ,secretary may reasonably require4 ,such ,state plan shall include1 at a minimum each of the following3 7,a7 ,a description of the ,state's minimum salary for teachers1 including the ,state's plan to ensure that the ,state will meet the requirements of subsection 7c77#a7 not later than #c years after the ,state receives an allotment under this section4 7,b7 ,a description of the ,state's plan to increase the ,state's per-pupil expenditures or the aggregate expenditures of the ,state with respect to the provision of free public education in the ,state1 in a manner that-- 7i7 supports local educational agencies in increasing salaries or wages for teachers1 paraprofessionals1 specialized instructional support personnel1 classified school employees1 principals1 other school leaders1 school librarians1 school bus drivers1 and other staff across their careers1 including through providing increased resources to local educational agencies2 and 7ii7 does not-- 7,i7 increase average class sizes or student to full-time equivalent teacher ratios at the ,state1 local educational agency1 or school level2 7,,ii7 reduce planning time2 or 7,,iii7 require teachers to teach additional classes4 7,c7 ,an identification1 with respect to the average teacher salary baselines in the most recent fiscal year1 of the statewide average and the average in each local educational agency in the ,state4 7,d7 ,an identification of the number and percentage of teachers employed by local educational agencies in the ,state who earn a salary of less than #fj1jjj annually1 disaggregated by each period of service specified in the average teacher salary baselines1 across the ,state and in each such local educational agency4 7,e7 ,a description of the ,state's plan to comply with the equitable distribution of teachers requirement under section #aaaa7;g77#a77;,b7 of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #fcaa7;g77#a77;,b774 7#b7 ,public comment ,each ,state shall make the ,state plan publicly available for public comment for a period of not less than #cj days1 by electronic means and in an easily accessible format1 prior to submission to the ,secretary for approval under this subsection4 ,upon submission1 the ,state plan shall include a summary of the comments submitted to the ,secretary1 with a description of how the ,state addressed the comments1 and make such summary with description publicly available on the website of the ,state educational agency4 7e7 ,state use of funds ,each ,state that receives an allotment under subsection 7b7 shall-- 7#a7 reserve not more than #a percent of the amounts allotted to the ,state under subsection 7b77#c77;,d7 to provide technical assistance and conduct monitoring to ensure that all local educational agencies meet the requirements described in subsection 7c72 7#b7 reserve not more than #d percent of the amounts allotted to the ,state under subsection 7b77#c77;,d7 to conduct statewide efforts to-- 7,a7 increase teacher compensation across the ,state in accordance with in subsection 7c72 7,b7 identify and reform policies and practices at the ,state1 local educational agency1 and school-level to promote excellent teaching for all students1 particularly subgroups of students2 and 7,c7 address structural and organizational challenges in the teaching profession1 in order to-- 7i7 raise the standards1 status1 and salaries of the teaching profession2 and 7ii7 attract and retain promising and talented young people to teaching2 and 7#c7 from the amounts allotted to the ,state under subsection 7b77#c77;,d7 that are remaining after reserving amounts under paragraphs 7#a7 and 7#b71 allocate-- 7,a7 #ej percent of such remaining amounts to local educational agencies in the ,state in accordance with the targeted formula described in section #aabe7;b7 of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #fcce7;b772 and 7,b7 #ej percent of such remaining amounts to local educational agencies in the ,state in accordance with the formula described in section #aabe;,a7d7 of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #fccg7;d774 7f7 ,reporting requirements ,not later than #a year after receiving an allotment under this section and annually thereafter1 a ,state that receives an allotment under this section shall submit a report to the ,secretary and publish such report in a clear and easily accessible format on the website of the ,state4 ,such report shall contain any information required by the ,secretary and include1 at a minimum-- 7#a7 data on the average teacher salary baselines for the previous fiscal year1 disaggregated by the statewide average and the average in each local educational agency in the ,state2 7#b7 updated data on the number of teachers employed by local educational agencies in the ,state who earn less than the minimum salary for teachers1 disaggregated by each period of service described in section #gjb7;a77#d71 across the ,state and employed by each local educational agency2 7#c7 a description of the actions the ,state educational agency will take in the next fiscal year to support local educational agencies described in paragraph 7#b7 in decreasing the number of teachers employed by such agencies who earn less than the minimum salary for teachers2 7#d7 a description of actions taken by the ,state to increase the ,state's per-pupil expenditures or the aggregate expenditures of the ,state with respect to the provision of free public education in the ,state1 in a manner that-- 7,a7 supports local educational agencies in increasing salaries or wages for teachers1 paraprofessionals1 specialized instructional support personnel1 classified school employees1 principals1 other school leaders1 school librarians1 school bus drivers1 and other staff across their careers1 including through providing increased resources to local educational agencies2 and 7,b7 does not-- 7i7 increase average class sizes or student to full-time equivalent teacher ratios at the ,state1 local educational agency1 or school level2 7ii7 reduce planning time2 or 7iii7 require teachers to teach additional classes2 and 7#e7 a description of how the ,state improved the equitable distribution of teachers in such fiscal year1 as required under section #aaaa7;g77#a77;,b7 of the ,elementary and ,secondary ,education ,act of #aife 7#bj ,u4,s4,c4 #fcaa7;g77#a77;,b774 #gjd4 ,collective bargaining and related rules 7a7 ,rule of construction for collective bargaining 7#a7 ,in general ,subject to paragraph 7#b71 nothing in section #gjc shall be construed to alter or otherwise affect the rights1 remedies1 and procedures afforded to school or local educational agency employees under ,federal1 ,state1 or local laws 7including applicable regulations or court orders7 or under the terms of collective bargaining agreements1 memoranda of understanding1 or other agreements between such employers and their employees4 7#b7 ,compliance ,paragraph 7#a7 shall not be construed to exempt a ,state1 local educational agency1 or school from complying with section #gjc or from negotiating in compliance with ,state labor laws to comply with section #gjc4 7b7 ,rule of construction for additional pay or other salary augmenting systems ,nothing in section #gjc shall be construed to prevent ,states or local educational agencies from supplementing the annual base salary of teachers or other staff employed by such agencies-- 7#a7 for additional skills1 knowledge1 duties1 and responsibilities2 7#b7 by salary systems that increase teachers' compensation through supplemental pay that is not part of an annual base salary2 or 7#c7 through the provision of bonuses1 stipends1 or awards4 ,,viii ,investments in ,home and ,community-,based ,services and ,long-,term ,care ,quality and ,workforce #hja4 ,,hcbs improvement planning grants 7a7 ,funding 7#a7 ,in general ,in addition to amounts otherwise available1 there is appropriated to the ,secretary for fiscal year #bjbg1 out of any money in the ,treasury not otherwise appropriated1 #acj1jjj1jjj1 to remain available until expended1 for carrying out this section4 7#b7 ,technical assistance and guidance ,in addition to amounts otherwise available1 there is appropriated to the ,secretary for fiscal year #bjbg1 out of any money in the ,treasury not otherwise appropriated1 #e1jjj1jjj1 to remain available until expended1 for purposes of issuing guidance and providing technical assistance to ,states intending to apply for1 or which are awarded1 a planning grant under this section1 and for other administrative expenses related to awarding planning grants under this section4 7b7 ,award and use of grants 7#a7 ,deadline for award of grants ,from the amount appropriated under subsection 7a77#a71 the ,secretary1 not later than #ab months after the date of enactment of this ,act1 shall solicit ,state requests for ,,hcbs improvement planning grants and award such grants to all ,states that meet such requirements as determined by the ,secretary4 7#b7 ,use of funds ,subject to paragraph 7#c71 a ,state awarded a planning grant under this section shall use the grant to carry out planning activities for purposes of developing and submitting to the ,secretary an ,,hcbs improvement plan for the ,state that meets the requirements of subsection 7c74 ,a ,state may use planning grant funds to support activities related to the implementation of the ,,hcbs improvement plan for the ,state4 7#c7 ,limitation on use of funds ,none of the funds awarded to a ,state under this section may be used by a ,state as the source of the non-,federal share of expenditures under the ,state ,medicaid program4 7c7 ,,hcbs improvement plan requirements 7#a7 ,content ,the ,secretary shall define the content requirements for an ,,hcbs improvement plan1 which1 at minimum1 shall include an assessment of access barriers to home and community-based services and the availability 7as defined by the ,secretary7 of such services in the ,state1 a description of ,medicaid payment rates for such services1 a description of the current workforce of direct care workers1 the percentage of expenditures made by the ,state for long-term services and supports that are for home and community-based services1 and a description of how the ,state will meet the requirements of the ,,hcbs ,improvement ,program4 7#b7 ,submission2 approval2 amendments ,not later than #bd months after the date on which a ,state is awarded a planning grant under this section1 the ,state shall submit an ,,hcbs improvement plan for approval by the ,secretary1 along with assurances by the ,state that the ,state will implement the plan in accordance with the requirements of the ,,hcbs ,improvement ,program4 ,the ,secretary shall approve the ,,hcbs improvement plan for a ,state after the plan and such assurances are submitted to the ,secretary for approval and the ,secretary determines the plan meets the requirements of this subsection4 ,a ,state may amend its ,,hcbs improvement plan1 subject to the approval of the ,secretary that the plan as so amended meets the requirements of this subsection4 7d7 ,definitions ,in this part3 7#a7 ,direct care worker ,the term direct care worker means1 with respect to a ,state1 any of the following individuals who are paid to provide directly to ,medicaid eligible individuals home and community-based services available under the ,state ,medicaid program3 7,a7 ,a registered nurse1 licensed practical nurse1 nurse practitioner1 or clinical nurse specialist1 or a licensed nursing assistant who provides such services under the supervision of a registered nurse1 licensed practical nurse1 nurse practitioner1 or clinical nurse specialist4 7,b7 ,a direct support professional4 7,c7 ,a personal care attendant4 7,d7 ,a home health aide4 7,e7 ,any other paid health care professional or worker determined to be appropriate by the ,state and approved by the ,secretary4 7#b7 ,,hcbs ,improvement ,program ,the term ,,hcbs ,improvement ,program means the program established under subsection 7ll7 of section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 7as added by section #hjb74 7#c7 ,,hcbs ,improvement ,program ,state ,the term ,,hcbs ,improvement ,program ,state means a ,state that is awarded a planning grant under subsection 7b7 and has an ,,hcbs improvement plan approved by the ,secretary under subsection 7c77#b74 7#d7 ,home and community-based services ,the term home and community-based services means any of the following 7whether provided on a fee-for-service1 risk1 or other basis73 7,a7 ,home health care services authorized under paragraph 7#g7 of section #aije7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a774 7,b7 ,private duty nursing services authorized under paragraph 7#h7 of such section1 when such services are provided in a ,medicaid eligible individual's home4 7,c7 ,personal care services authorized under paragraph 7#bd7 of such section4 7,d7 ,,pace services authorized under paragraph 7#bf7 of such section4 7,e7 ,home and community-based services authorized under subsections 7b71 7c71 7i71 7j71 and 7k7 of section #aiae of such ,act 7#db ,u4,s4,c4 #acifn71 authorized under a waiver under section #aaae of such ,act 7#db ,u4,s4,c4 #acae71 or provided through coverage authorized under section #aicg of such ,act 7#db ,u4,s4,c4 #acifu-#g74 7,f7 ,case management services authorized under section #aije7;a77#ai7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77#ai77 and section #aiae7;g7 of such ,act 7#db ,u4,s4,c4 #acifn7g774 7,g7 ,rehabilitative services1 including those related to behavioral health1 described in section #aije7;a77#ac7 of such ,act 7#db ,u4,s4,c4 #acif;d7a77#ac774 7,h7 ,such other services specified by the ,secretary4 7#e7 ,medicaid eligible individual ,the term ,medicaid eligible individual means an individual who is eligible for and receiving medical assistance under a ,state ,medicaid program4 ,such term includes an individual who is on a waiting list and who would become eligible for medical assistance and enrolled under a ,state ,medicaid program upon receipt of home and community-based services4 7#f7 ,state ,medicaid program ,the term ,state ,medicaid program means1 with respect to a ,state1 the ,state program under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif through #acifw-#f7 7including any waiver or demonstration under such title or under section #aaae of such ,act 7#db ,u4,s4,c4 #acae7 relating to such title74 7#g7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7#h7 ,state ,the term ,state means each of the #ej ,states1 the ,district of ,columbia1 ,puerto ,rico1 the ,virgin ,islands1 ,guam1 the ,northern ,mariana ,islands1 and ,american ,samoa4 #hjb4 ,,hcbs ,improvement ,program 7a7 ,increased ,,fmap for ,,hcbs ,improvement ,program ,states ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is amended-- 7#a7 in subsection 7b71 by striking and 7ii7 and inserting 7ii71 and 7ll72 and 7#b7 by adding at the end the following new subsection3 7ll7 ,additional support for ,,hcbs ,improvement ,program ,states 7#a7 ,in general 7,a7 ,additional support ,subject to paragraph 7#e71 in the case of a ,state that is an ,,hcbs ,improvement ,program ,state1 for each fiscal quarter that begins on or after the first date on which the ,state is an ,,hcbs ,improvement ,program ,state-- 7i7 and for which the ,state meets the requirements described in paragraphs 7#b7 and 7#d71 notwithstanding subsection 7b7 or 7ff71 subject to subparagraph 7,b71 with respect to amounts expended during the quarter by such ,state for medical assistance for home and community-based services1 the ,federal medical assistance percentage for such ,state and quarter 7as determined for the ,state under subsection 7b7 or 7ff7 and1 if applicable1 increased under subsection 7y71 7z71 7aa71 or 7ii71 or section #aiae7k77#b77 shall be increased by #h percentage points2 and 7ii7 with respect to the ,state meeting the requirements described in paragraphs 7#b7 and 7#d7 and with respect to amounts expended during the quarter and before ,october #a1 #bjcf1 administrative costs for expanding and enhancing home and community-based services1 including for enhancing ,medicaid data and technology infrastructure1 modifying rate setting processes1 adopting or improving training programs for direct care workers and family caregivers1 home and community-based services ombudsman office activities1 developing processes to identify direct care workers and assign such workers unique identifiers1 and adopting1 carrying out1 or enhancing programs that register direct care workers or connect beneficiaries to direct care workers1 shall be eligible for ,federal financial participation in the same manner as other administrative expenditures under section #aijc7;a71 except that1 for purposes of this clause1 the per centum applicable to such expenditures shall be the greater of #hj percent or the per centum that would otherwise apply4 ,in no case may the application of clause 7i7 result in the ,federal medical assistance percentage determined for a ,state being more than #ie percent with respect to such expenditures4 ,any increase pursuant to clause 7ii7 shall be available to a ,state before the ,state meets the requirements of paragraphs 7#b7 and 7#d74 7,b7 ,additional ,,hcbs improvement efforts ,subject to paragraph 7#e71 in addition to the increase to the ,federal medical assistance percentage under subparagraph 7,a77i7 for amounts expended during a quarter for medical assistance for home and community-based services by an ,,hcbs ,improvement ,program ,state that meets the requirements of paragraphs 7#b7 and 7#d7 for the quarter1 the ,federal medical assistance percentage for amounts expended by the ,state during the quarter for medical assistance for home and community-based services shall be further increased by #b percentage points 7but not to exceed #ie percent7 during the first #f fiscal quarters throughout which the ,state has implemented and has in effect a program that meets the requirements of paragraph 7#c74 7,c7 ,nonapplication to ,,chip ,,efmap ,any increase to the ,federal medical assistance percentage of a ,state under subparagraph 7,a77i7 or 7,b7 or an increase to an applicable ,federal matching percentage under subparagraph 7,a77ii7 shall not be taken into account in calculating the enhanced ,,fmap of a ,state under section #baje4 7#b7 ,requirements ,as conditions for receipt of the increase under paragraph 7#a77;,a77i7 to the ,federal medical assistance percentage determined for a ,state1 with respect to a fiscal year quarter1 the ,state shall meet each of the following requirements3 7,a7 ,nonsupplantation ,the ,state uses an amount in ,state funds equivalent to the additional ,federal funds received by the ,state that are attributable to the increase to the ,federal medical assistance percentage for amounts expended during a quarter for medical assistance for home and community-based services under paragraph 7#a77;,a7 and paragraph 7#a77;,b7 7if applicable7 to supplement1 and not supplant1 the level of ,state funds expended for home and community-based services for eligible individuals through programs in effect as of the date the ,state is awarded a planning grant under section #hja of the ,make ,billionaires ,pay ,their ,fair ,share ,act4 ,in applying this subparagraph1 the ,secretary shall provide that a ,state shall have a #c-year period1 as specified by the ,secretary1 to spend any accumulated unspent ,state funds attributable to such increase to the ,federal medical assistance percentage4 7,b7 ,maintenance of effort 7i7 ,in general ,the ,state does not-- 7,i7 reduce the amount1 duration1 or scope of home and community-based services available under the ,state plan 7or waiver of such plan7 relative to the home and community-based services available under the plan or a waiver of such plan as of the date on which the ,state was awarded a planning grant under section #hja of the ,make ,billionaires ,pay ,their ,fair ,share ,act2 7,,ii7 reduce payment rates for home and community-based services lower than such rates that were in place as of the date described in subclause 7,i71 including1 to the extent applicable1 assumed payment rates for such services that are included in managed care capitation rates as such rates are being prospectively built2 or 7,,iii7 except to the extent permitted under clause 7ii71 adopt more restrictive standards1 methodologies1 or procedures for determining eligibility for1 or the scope of1 medical assistance for home and community-based services1 including with respect to cost-sharing1 than the standards1 methodologies1 or procedures applicable as of the date described in subclause 7,i74 7ii7 ,conditions for flexibility ,a ,state may make modifications that would otherwise violate the maintenance of effort described in clause 7i7 if the ,state demonstrates to the satisfaction of the ,secretary that such modifications shall not result in-- 7,i7 home and community-based services that are less comprehensive or lower in amount1 duration1 or scope2 7,,ii7 fewer individuals 7overall and within particular eligibility groups7 receiving home and community-based services1 adjusted for demographic changes since the date described in clause 7i77,i72 or 7,,iii7 increased cost-sharing 7other than resulting from the rate of inflation7 for home and community-based services4 7,c7 ,access to services ,the ,state undertakes efforts to improve access to home and community-based services by doing all of the following not later than an implementation date specified by the ,secretary 7which may vary for each of the following clauses7 after the first day of the first fiscal quarter for which a ,state receives an increase to the ,federal medical assistance percentage or other applicable ,federal matching percentage under paragraph 7#a73 7i7 ,reduces access barriers and disparities in access or utilization of home and community-based services4 7ii7 ,provides coverage of personal care services authorized under subsection 7a77#bd7 for all individuals eligible for and enrolled in medical assistance in the ,state4 7iii7 ,provides for navigation of home and community-based services through no wrong door programs1 provides expedited eligibility for home and community-based services1 and improves home and community-based services counseling and education programs4 7iv7 ,expands access to behavioral health services furnished in home and community-based settings4 7v7 ,improves coordination of home and community-based services with employment1 housing1 and transportation supports4 7vi7 ,provides supports to family caregivers4 7vii7 ,newly provides coverage under1 or expands existing eligibility criteria for1 #a or more of the eligibility categories authorized under subclause 7,,xiii71 7,,xv71 or 7,,xvi7 of section #aijb7;a77#aj77;,a77ii74 7,d7 ,workforce ,the ,state strengthens and expands the workforce of direct care workers that provides home and community-based services by-- 7i7 adopting processes to ensure that payment rates for home and community-based services are sufficient 7as defined by the ,secretary7 to ensure that services are available1 including by1 not later than #b years after approval of the ,,hcbs improvement plan and1 at least every #c years thereafter1 updating and1 as appropriate1 increasing payment rates for home and community-based services to support recruitment and retention of direct care workers using1 through existing or other processes to determine provider payments1 a transparent process involving input from nongovernmental stakeholders2 7ii7 ensuring that increases in the payment rates for home and community-based services result in at least a proportionate increase to payments for direct care workers2 and 7iii7 updating qualification standards as appropriate1 and developing and adopting training opportunities1 for direct care workers and family caregivers1 at such times as the ,secretary shall prescribe4 7#c7 ,self-directed models for the delivery of services ,as conditions for receipt of the increase under paragraph 7#a77;,b7 to the ,federal medical assistance percentage determined for a ,state1 with respect to a fiscal year quarter1 the ,state shall establish directly1 or by contract with #a or more entities1 including an agency with choice or a similar service delivery model1 a program for the performance of all of the following functions1 consistent with guidance issued by the ,secretary1 to facilitate beneficiary use of self-directed care in the case the ,state covers home and community-based services under authorities that permit self-direction3 7,a7 ,recruiting and registering qualified direct care workers and assisting beneficiaries in finding qualified direct care workers4 7,b7 ,supporting beneficiary hiring1 if selected by the beneficiary1 of independent providers of home and community-based services1 including through the provision of financial management services4 7,c7 ,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 services1 providing support to beneficiaries who wish to hire a caregiver who is a family member or individual with whom they have an existing relationship4 7,d7 ,ensuring that the program under this paragraph does not promote or deter the ability of workers to form a labor organization or discriminate against workers who may join or decline to join such an organization4 7#d7 ,reporting and oversight ,as a condition for receipt of an increase under subparagraphs 7,a77i7 or 7,b7 of paragraph 7#a7 to the ,federal medical assistance percentage determined for a ,state1 with respect to a fiscal year quarter1 the ,state shall1 beginning with the last day of the #eth fiscal quarter for which the ,state is an ,,hcbs ,improvement ,program ,state1 and annually thereafter1 report to the ,secretary1 in a manner the ,secretary shall prescribe1 on-- 7,a7 the ,state's progress in implementing the activities described in subparagraphs 7,c7 and 7,d7 of paragraph 7#b7 and 7if applicable7 paragraph 7#c7 in accordance with the ,state ,,hcbs improvement plan2 and 7,b7 the use of the increased funding provided under this subsection4 7#e7 ,benchmarks for demonstrating improvements ,an ,,hcbs ,improvement ,program ,state shall cease to be eligible for an increase to the ,federal medical assistance percentage under paragraph 7#a77;,a77i7 or 7#a77;,b7 or an increase to an applicable ,federal matching percentage under paragraph 7#a77;,a77ii7 for each fiscal quarter after the #bith fiscal quarter that begins on or after the first date on which the ,state is an ,,hcbs ,improvement ,program ,state unless1 at the end of such #bith fiscal quarter1 the ,state demonstrates the following in the annual report required in paragraph 7#d7 for such quarter3 7,a7 ,increased availability 7above a marginal increase7 of home and community-based services in the ,state relative to such availability as reported in the ,state ,,hcbs improvement plan and adjusted for demographic changes in the ,state since the submission of such plan4 7,b7 ,with respect to the percentage of expenditures made by the ,state for long-term services and supports that are for home and community-based services1 in the case of an ,,hcbs ,improvement ,program ,state for which such percentage 7as reported in the ,state ,,hcbs improvement plan7 was-- 7i7 less than #ej percent1 the ,state demonstrates that the percentage of such expenditures has increased to at least #ej percent since the plan was approved2 and 7ii7 at least #ej percent1 the ,state demonstrates that such percentage has not decreased since the plan was approved4 7#f7 ,definitions ,in this subsection1 the terms direct care worker1 ,,hcbs ,improvement ,program ,state1 and home and community-based services have the meaning given those terms in section #hja7;d7 of the ,make ,billionaires ,pay ,their ,fair ,share ,act4 4 #hjc4 ,funding for ,federal activities related to ,medicaid ,,hcbs ,in addition to amounts otherwise available1 there is appropriated to the ,secretary for fiscal year #bjbg1 out of any money in the ,treasury not otherwise appropriated1 #dj1jjj1jjj1 to remain available until expended1 to carry out section #hjb 7including the amendments made by such section71 including by issuing necessary guidance and technical assistance to ,states and conducting program integrity and oversight efforts4 #hjd4 ,funding for ,,hcbs quality measurement and improvement ,in addition to amounts otherwise available1 there is appropriated to the ,secretary for fiscal year #bjbg1 out of any money in the ,treasury not otherwise appropriated1 #be1jjj1jjj1 to remain available until expended1 for purposes of developing1 in consultation with nongovernmental stakeholders with expertise in home and community-based services 7including recipients and providers of such services71 a recommended set of home and community-based services quality measures that reflect the full range of home and community-based services 7as defined in section #hja7;d77 and the recipients of such services4 #hje4 ,permanent extension of ,medicaid protections against spousal impoverishment for recipients of home and community-based services 7a7 ,in general ,section #aibd7;h77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#e7;h77#a77;,a77 is amended by striking 7at the option of the ,state7 is described in section #aijb7;a77#aj77;,a77ii77,,vi7 and inserting the following3 is eligible for medical assistance for home and community-based services provided under subsection 7c71 7d71 or 7i7 of section #aiae or under a waiver approved under section #aaae1 or who is eligible for such medical assistance by reason of being determined eligible under section #aijb7;a77#aj77;,c7 or by reason of section #aijb7;f7 or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care1 or who is eligible for medical assistance for home and community-based attendant services and supports under section #aiae7k74 7b7 ,conforming amendment ,section #bdjd of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acifr-#e note7 is amended by striking ,september #cj1 #bjbg and inserting the date of enactment of the ,make ,billionaires ,pay ,their ,fair ,share ,act4 #hjf4 ,permanent extension of ,money ,follows the ,person ,rebalancing demonstration ,subsection 7h7 of section #fjga of the ,deficit ,reduction ,act of #bjje 7#db ,u4,s4,c4 #acif;a note7 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,i71 by inserting and after the semicolon2 7,b7 in subparagraph 7,j71 by inserting and each fiscal year thereafter before the semicolon2 and 7,c7 by striking subparagraphs 7,k7 and 7,l72 and 7#b7 in paragraph 7#c71 by striking through fiscal year #bjbi4