March 2, 2026
Mr. Sanders introduced the following bill; which was read twice and referred to the Committee on Finance
To amend the Internal Revenue Code of 1986 to impose an annual tax on the net value of assets held by a taxpayer, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
Section 1. Short title, etc
(a) Short title
This Act may be cited as the Make Billionaires Pay Their Fair Share Act
.
(b) Table of contents
The table of contents of this Act is as follows:
Title I Wealth tax
Sec. 101. Imposition of tax on net value of assets
(a) In general
The Internal Revenue Code of 1986 is amended by inserting after subtitle B the following new subtitle:
B-1 Wealth tax
18 Determination of wealth tax
2901. Imposition of tax
(a) In general
In the case of an applicable taxpayer, there is hereby imposed a tax computed equal to 5 percent of the net value of assets held by the taxpayer for the calendar year.
(b) Applicable taxpayer
(1) In general
For purposes of this chapter, 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 $1,000,000,000.
(2) Inflation adjustment
(A) In general
In the case of any calendar year after 2026, the $1,000,000,000 amount under paragraph (1) shall be increased by an amount equal to—
(i)
such dollar amount, multiplied by
(ii)
the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined by substituting in subparagraph (A)(ii) thereof
calendar year 2025forcalendar year 2016.(B) Rounding
If any amount as adjusted under subparagraph (A) is not a multiple of $1,000,000, such dollar amount shall be rounded to the next lowest multiple of $1,000,000.
(c) Treatment of married individuals
For purposes of this section, individuals who are married (as defined in section 7703) shall be treated as one taxpayer.
2902. Net value of assets
(a) In general
The net value of assets held by an applicable taxpayer for any calendar year shall be the excess of—
(1)
the value of all property of the taxpayer, real or personal, tangible or intangible, wherever situated, on the last day of such calendar year (computed without regard to any debt owed by the taxpayer and secured by the property), over
(2)
the amount of any debt owed by the taxpayer on the last day of such calendar year.
(b) Inclusion of property of related children
For purposes of this subtitle, any property of an individual who is a child of the taxpayer (as defined in section 152(f)(1)) and has not attained the age of 18 shall be treated as property held by the taxpayer for any calendar year before the year in which such individual attains the age of 18.
(c) Establishment of valuation rules
(1) Authority of Secretary
The Secretary shall establish rules and methods for determining the value of any asset for purposes of this subtitle.
(2) General rules
Except as otherwise provided in this paragraph, the rules and methods established under paragraph (1) may be similar to the rules of part III of subchapter A of chapter 11 (other than the rules of sections 2031(c), 2032A, 2035, and 2044).
(3) Rules for assets the value of which is not readily ascertainable
(A) In general
In the case of any property the value of which is not readily ascertainable, 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 class.
(B) 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 year.
2903. Special rules
(a) Deceased individuals
In the case of any individual who dies during a calendar year—
(1)
section 2901 shall be applied as if the calendar year ended on the day of the individual's death, and
(2)
the amount of the tax imposed under such section shall be reduced by an amount which bears the same ratio to such amount (determined without regard to this subsection) as—
(A)
the number of days in the calendar year after the date of the individual's death, bears to
(B)
365.
(b) Trusts
(1) 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 1, then the grantor or such other person shall be treated as holding that portion of the assets of such trust, and any remaining portion shall be subject to tax as provided in section 2901.
(2) 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 11, 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 trust.
(3) Aggregation rules
The rules of section 643(f) shall apply for purposes of this subtitle.
(c) Application to nonresidents
(1) In general
In the case of any taxpayer who is a non resident and not a citizen of the United States, section 2901(a) shall be applied by substituting
net value of domestic assetsfornet value of all assets.(2) Net value of domestic assets
For purposes of this subtitle, the term net value of domestic assets means—
(A)
the value of all property of the taxpayer, real or personal, tangible or intangible, situated in the United States (determined under rules similar to the rules under subchapter B of chapter 11), on the last day of such calendar year (computed without regard to any debt owed by the taxpayer and secured by the property), over
(B)
the amount of any debt owed by the taxpayer and secured by assets described in subparagraph (A), determined as of the last day of such calendar year.
(3) Treatment of married individuals
In the case of married individuals, this subsection shall only apply if both individuals are non residents and not citizens of the United States.
(d) Application to covered expatriates
(1) In general
In the case of an applicable taxpayer who is a covered expatriate the expatriation date of which occurs during the calendar year—
(A)
section 2901 shall be applied as if the calendar year ended on the day before the expatriation, and
(B)
the rate of tax under 2901(a) for such calendar year shall be 60 percent.
(2) Covered expatriate; expatriation date
For purposes of this subsection—
(A) Covered expatriate
The term covered expatriate has the meaning given such term under section 877A, except that in the case of married individuals, 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 (within the meaning of section 7701(b)(6)).
(B) Expatriation date
The term expatriation date has the meaning given such term under section 877A(g)(3).
2904. Administrative provisions
(a) Wealth registry
The Secretary shall establish a registry of ownership for assets taken into account under section 2902(a)(1), including publicly traded securities, digital assets, shares of closely held businesses, and real estate within the United States. For purposes of establishing and maintaining the registry under the preceding sentence, the Secretary shall—
(1)
rely on existing sources of information, including central depositories for securities and State, local, and foreign real property records; and
(2)
require timely reporting of newly acquired assets in conjunction with information required under existing information reporting requirements.
(b) Information reporting
(1) In general
The Secretary shall by regulations require the reporting of information concerning the value of assets, including—
(A)
the value of any accounts which pay interest reportable under section 6049,
(B)
the value of publicly traded stock with respect to which dividends are reported under section 6042,
(C)
the value of any applicable privately held business,
(D)
the value of any assets held through mutual funds or brokerage accounts,
(E)
the value of any assets held in eligible retirement plans (as defined in section 402(c)(8)(B)), and
(F)
such other assets as the Secretary determines is appropriate.
(2) Method of reporting
The Secretary shall, where appropriate, require the reporting made under paragraph (1) to be made as a part of existing income reporting requirements.
(3) Applicable privately held business
For purposes of this subsection, the term applicable privately held business means any trade or businesses—
(A)
which does not meet the gross receipts test under section 448(c) for the taxable year ending with or within the calendar year,
(B)
in which an individual who was an applicable taxpayer (other than a covered expatriate, as defined in section 2903(d)(2)) for the preceding calendar year holds (directly or indirectly) 5 percent or more of the ownership interests (by value), and
(C)
to which paragraph (1)(B) does not apply.
(c) 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 31 and the taxpayer owed tax for such taxable year.
(b) No deduction from income taxes
Section 275 of the Internal Revenue Code of 1986 is amended by inserting after paragraph (6) the following new paragraph:
(7)
Taxes imposed by chapter 18.
(c) Information reporting penalties
Section 6724(d)(1) of the Internal Revenue Code of 1986 is amended by striking and
at the end of subparagraph (C), by striking the period at the end of subparagraph (D) and inserting , and
, and by inserting after subparagraph (D) the following new subparagraph:
(E)
any statement or return required to be filed under section 2904(b) which is not reported under any other provision of this paragraph.
(d) Clerical amendment
The table of subtitles of the Internal Revenue Code of 1986 is amended by inserting after the item relating to subtitle B the following new item:
(e) Effective date
The amendments made by this section shall apply to calendar years beginning after the date of the enactment of this Act.
Sec. 102. Enforcement
(a) Standard
The Secretary of the Treasury shall audit not less than 50 percent of taxpayers required to pay the tax imposed under section 2901 of the Internal Revenue Code of 1986 (as added by section 101) in each calendar year.
(b) Funding
There is hereby appropriated to each fiscal year ending after the date of the enactment of this Act, out of any moneys in the Treasury not otherwise appropriated, amounts equivalent to 1 percent of the revenues attributable to the tax imposed under section 2901 of the Internal Revenue Code of 1986 (as added by section 101) for necessary expenses for enforcement activities of the Internal Revenue Service to determine and collect taxes owed under such section.
Title II Affordability Rebates
Sec. 201. Affordability rebates
(a) In general
Section 6428B of the Internal Revenue Code of 1986 is amended—
(1)
in the heading, by striking 2021 recovery rebates to individuals
and inserting affordability rebates
,
(2)
in subsection (a), by striking 2021 an amount equal to the 2021 rebate amount
and inserting 2026 an amount equal to the affordability rebate amount
,
(3)
by striking subsection (b) and inserting the following:
(b) Affordability rebate amount
For purposes of this section, the term
affordability rebate amountmeans, with respect to any taxpayer for any taxable year, the sum of—(1)
$3,000 ($6,000 in the case of a joint return), plus
(2)
$3,000 multiplied by the number of dependents of the taxpayer for such taxable year.,
(4)
in subsection (e)(2)—
(A)
in subparagraph (A), by striking $1,400
and inserting $3,000
, and
(B)
in subparagraph (B)—
(i)
in the matter preceding clause (i), by striking $2,800
and inserting $6,000
, and
(ii)
in clause (i), by striking $1,400
and inserting $3,000
, and
(5)
in subsection (g)—
(A)
in paragraph (1), by striking 2019
and inserting 2024
,
(B)
in paragraph (2)(B), by striking January 1, 2021
each place it appears and inserting January 1, 2026
,
(C)
in paragraph (3), by striking December 31, 2021
and inserting December 31, 2026
,
(D)
in paragraph (5)—
(i)
in the heading, by striking 2020
and inserting 2025
,
(ii)
in subparagraph (A)—
(I)
in the heading, by striking 2020
and inserting 2025
, and
(II)
by striking beginning in 2020, paragraph (1) shall be applied with respect to such individual by substituting
and inserting 2020
for 2019
beginning in 2025, paragraph (1) shall be applied with respect to such individual by substituting
, and2025
for 2024
(iii)
in subparagraph (B)—
(I)
in clause (i), by striking 2020
and inserting 2025
,
(II)
in clause (ii)—
(aa)
in subclause (I), by striking 2020
and inserting 2025
, and
(bb)
in subclause (II), by striking 2021
and inserting 2026
, and
(III)
in clause (iii)—
(aa)
in the heading, by striking 2020
and inserting 2025
, and
(bb)
by striking 2020
each place it appears and inserting 2025
, and
(E)
in the heading of paragraph (6), by striking 2019 or 2020
and inserting 2024 or 2025
.
(b) Conforming amendment
The table of sections for subchapter B of chapter 65 of the Internal Revenue Code of 1986 is amended by striking the item relating to section 6428B and inserting the following new item:
Title III Health care provisions
Sec. 301. Repeal of reconciliation health provisions
(a) In general
Except as provided in subsection (b), subtitle B of title VII of An Act to provide for reconciliation pursuant to title II of H. Con. Res. 14 (Public Law 119–21) 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 enacted.
(b) Exceptions
(1) In general
Subsection (a) shall not apply to the provisions of and amendments made by sections 71202, 71306, and 71401 of such Act.
(2) Availability of funds allocated under the rural health transformation program
Section 2105(h) of the Social Security Act (42 U.S.C. 1397ee(h)), as added by Public Law 119–21, is amended—
(A)
in paragraph (1)(B)—
(i)
in the subparagraph heading by striking Unexpended or unobligated
and inserting Availability of
;
(ii)
by striking clauses (i) through (iii) and inserting the following:
(i) In general
Subject to clause (ii), funds allocated to a State from amounts appropriated under subparagraph (A) shall remain available until expended.; and
(iii)
by redesignating clause (iv) as clause (ii); and
(B)
in paragraph (2)(C), by striking paragraph (1)(B)(iv)
and inserting paragraph (1)(B)(ii)
.
Sec. 302. Increase in eligibility for premium tax credit
(a) In general
Subparagraph (A) of section 36B(c)(1) of the Internal Revenue Code of 1986 is amended by striking but does not exceed 400 percent
.
(b) Applicable percentages
(1) In general
Subparagraph (A) of section 36B(b)(3) of the Internal Revenue Code of 1986 is amended to read as follows:
(A) 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 increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier:
In the case of household income
(expressed as a percent of poverty line)
within the following income tier:The initial premium percentage is— The final premium percentage is— Up to 150 percent 0 0 150 percent up to 200 percent 0 2.0 200 percent up to 250 percent 2.0 4.0 250 percent up to 300 percent 4.0 6.0 300 percent up to 400 percent 6.0 8.5 400 percent and higher 8.5 8.5.
(2) Conforming amendments relating to affordability of coverage
(A)
Paragraph (1) of section 36B(c) of such Code is amended by striking subparagraph (E).
(B)
Subparagraph (C) of section 36B(c)(2) of such Code is amended by striking clause (iv).
(C)
Paragraph (4) of section 36B(c) of such Code is amended by striking subparagraph (F).
(c) Effective date
The amendments made by this section shall apply to taxable years beginning after December 31, 2025.
Title IV Medicare Dental, Hearing, and Vision Expansion
Sec. 401. Short title
This title may be cited as the Medicare Dental, Hearing, and Vision Expansion Act of 2026
.
Sec. 402. Coverage of dental and oral health care
(a) Coverage
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—
(1)
in subparagraph (JJ), by striking and
at the end;
(2)
in subparagraph (KK), by inserting and
after the semicolon; and
(3)
by adding at the end the following new subparagraph:
(LL)
dental and oral health services (as defined in subsection (ooo));
(b) Dental and oral health services defined
Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:
(ooo) Dental and oral health services
(1) In general
Except as provided in paragraph (2), the term
dental and oral health servicesmeans the following items and services that are furnished by a doctor of dental surgery or of dental medicine (as described in subsection (r)(2)) or an oral health professional (as defined in paragraph (3)) on or after January 1, 2028 (or January 1, 2027, in the case of dentures):(A) Preventive and screening services
Preventive and screening services, including oral exams, dental cleanings, dental x-rays, and fluoride treatments.
(B) Procedures and treatment services
Services to address oral disease, including services such as restorative services, prosthodontic and endodontic services, including fillings, bridges, crowns, and root canals, periodontal maintenance, periodontal scaling and root planing, tooth extractions, therapeutic pulpotomy, and other related items and services.
(C) Dentures and dental prosthetics
Complete dentures, partial dentures, and implants, including related items and services.
(2) Exclusions
Such term does not include items and services for which, as of the date of the enactment of this subsection, coverage was permissible under section 1862(a)(12) and cosmetic services not otherwise covered under section 1862(a)(10).
(3) Oral health professional
The term oral health professional means, with respect to dental and oral health services, a health professional (other than a doctor of dental surgery or of dental medicine (as described in subsection (r)(2))) who is licensed to furnish such services, acting within the scope of such license, by the State in which such services are furnished.
(c) Payment; coinsurance; and limitations
(1) In general
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—
(A)
in subparagraph (N), by inserting and dental and oral health services (as defined in section 1861(ooo))
after section 1861(hhh)(1))
;
(B)
by striking and
before (HH)
; and
(C)
by inserting before the semicolon at the end the following: and (II) with respect to dental and oral health services (as defined in section 1861(ooo)), the amount paid shall be the payment amount specified under section 1834(bb)
.
(2) Payment and limits specified
Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:
(bb) Payment and limits for dental and oral health services
(1) Payment
The payment amount under this part for dental and oral health services (as defined in section 1861(ooo)) shall be, subject to paragraphs (3) and (4), 80 percent (or 100 percent, in the case of preventive and screening services described in section 1861(ooo)(1)(A)) of the lesser of—
(A)
the actual charge for the service; or
(B)
(i)
in the case of such services furnished by a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)), the amount determined under the fee schedule established under paragraph (2); or
(ii)
in the case of such services furnished by an oral health professional (as defined in section 1861(ooo)(3)), 85 percent of the amount determined under the fee schedule established under paragraph (2).
(2) Establishment of fee schedule for dental and oral health services
(A) Establishment
(i) In general
The Secretary shall establish a fee schedule for dental and oral health services furnished in 2028 (or 2027, in the case of dentures) and subsequent years. The fee schedule amount for a dental or oral health service shall be equal to 70 percent of the national median fee (as determined under subparagraph (B)) for the service or a similar service for the year (or, in the case of dentures, at the bundled payment amount under clause (iv) of such subparagraph), adjusted by the geographic adjustment factor established under section 1848(e)(2) for the area for the year.
(ii) Consultation
In carrying out this paragraph, 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 paragraph.
(B) Determination of national median fee
(i) In general
For purposes of subparagraph (A), the Secretary shall apply the national median fee for a dental or oral health service for 2028 (or 2027, in the case of dentures) and subsequent years in accordance with this subparagraph.
(ii) Use of 2020 dental fee survey
(I) In general
Except as provided in clause (iii) and clause (iv), the national median fee for a dental or oral health service shall be equal to—
(aa)
for 2028 (or 2027, in the case of dentures), the median fee for the service in the table titled
General Practitioners–Nationalof the2020 Survey of Dental Feespublished by the American Dental Association, increased by the applicable percent increase for the year determined under subclause (II), as reduced by the productivity adjustment under subclause (III); and(bb)
for 2029 (or 2028, in the case of dentures) and subsequent years, the amount determined under this subclause for the preceding year, updated pursuant to subparagraph (C)(i).
(II) Applicable percent increase
The applicable percent increase determined under this subclause for a year is an amount equal to the percentage increase between—
(aa)
the consumer price index for all urban consumers (United States city average) ending with June of the previous year; and
(bb)
the consumer price index for all urban consumers (United States city average) ending with June of 2027 (or 2026, in the case of dentures).
(III) Productivity adjustment
After determining the applicable percentage increase under subclause (II) for a year, the Secretary shall reduce such percentage increase by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II).
(iii) Determination if insufficient survey data
If the Secretary determines there is insufficient data under the Survey described in clause (ii) with respect to a dental or oral health service, the national median fee for the service for a year shall be equal to an amount established for the service using 1 or more of the following methods, as determined appropriate by the Secretary:
(I)
The payment basis determined under section 1848.
(II)
Fee schedules for dental and oral health services which shall include, as practicable, fee schedules—
(aa)
under Medicare Advantage plans under part C;
(bb)
under State plans (or waivers of such plans) under title XIX; and
(cc)
established by other health care payers.
(iv) Special rule for dentures
(I) In general
The Secretary shall make payment for dentures and associated professional services as a bundled payment as determined by the Secretary.
(II) Payment considerations
In establishing such bundled payment, the Secretary shall consider the national median fee for the service for the year determined under clause (ii) or (iii) and the rate determined for such dentures under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year determined under clause (ii)(II), as reduced by the productivity adjustment under clause (ii)(III), 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 Schedule, as so published and updated to the year involved.
(C) Annual update and adjustments
(i) Annual update
The Secretary shall update payment amounts determined under the fee schedule from year to year beginning in 2029 (or 2028, in the case of dentures) by increasing such amounts from the prior year by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II).
(ii) Adjustments
(I) In general
The Secretary shall, to the extent the Secretary determines to be necessary and subject to subclause (II), adjust the amounts determined under the fee schedule established under this paragraph for 2029 (or 2028, in the case of dentures) and subsequent years to take into account changes in dental practice, coding changes, new data on work, practice, or malpractice expenses, or the addition of new procedures.
(II) Limitation on annual adjustments
The adjustments under subclause (I) for a year shall not cause the amount of expenditures under this part for the year to differ by more than $20,000,000 from the amount of expenditures under this part that would have been made if such adjustments had not been made.
(3) Limitations
With respect to dental and oral health services that are preventive and screening services described in paragraph (1)(A) of section 1861(ooo)—
(A)
payment shall be made under this part for—
(i)
not more than 2 oral exams in a year;
(ii)
not more than 2 dental cleanings in a year;
(iii)
not more than 1 fluoride treatment in a year; and
(iv)
not more than 1 full-mouth series of x-rays as part of a preventive and screening oral exam every 3 years; and
(B)
in the case of preventive and screening services not described in subparagraph (A), payment shall be made under this part only at such frequencies determined appropriate by the Secretary.
(4) Incentives for rural providers
In the case of dental and oral health services furnished by a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) or an oral health professional (as defined in section 1861(ooo)(3)) who predominantly furnishes such services under this part in an area that is designated by the Secretary (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area, in addition to the amount of payment that would otherwise be made for such services under this subsection, there also shall be paid an amount equal to 10 percent of the payment amount for the service under this subsection for such doctor or professional.
(5) Limitation on beneficiary liability
The provisions of section 1848(g) shall apply to a nonparticipating doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) 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 service.
(6) Establishment of dental administrator
The Secretary shall designate 1 or more (not to exceed 4) medicare administrative contractors under section 1874A to establish coverage policies and establish such policies and process claims for payment for dental and oral health services, as determined appropriate by the Secretary.
(d) Inclusion of oral health professionals as certain practitioners
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clause:
(ix)
With respect to 2029 and each subsequent year, an oral health professional (as defined in section 1861(ooo)(3)).
(e) Exclusion modifications
Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended—
(1)
in paragraph (1)—
(A)
in subparagraph (O), by striking and
at the end;
(B)
in subparagraph (P), by striking the semicolon at the end and inserting , and
; and
(C)
by adding at the end the following new subparagraph:
(Q)
in the case of dental and oral health services (as defined in section 1861(ooo)) for which a limitation is applicable under section 1834(bb)(3), which are furnished more frequently than is provided under such section;; and
(2)
in paragraph (12), by inserting before the semicolon at the end the following: and except that payment shall be made under part B for dental and oral health services that are covered under section 1861(s)(2)(LL)
.
(f) Inclusion as excepted medical treatment
Section 1821(b)(5)(A) of the Social Security Act (42 U.S.C. 1395i–5(b)(5)(A)) is amended—
(1)
in clause (ii), by striking or
at the end;
(2)
in clause (iii), by striking the period and inserting , or
; and
(3)
by adding at the end the following new clause:
(iv)
consisting of dental and oral health services (as defined in subsection (ooo) of section 1861) that are payable under part B as a result of the amendments made by the Medicare Dental, Hearing, and Vision Expansion Act of 2026.
(g) Rural health clinics and federally qualified health centers
(1) Coverage of dental and oral health services
Section 1861(aa) of the Social Security Act (42 U.S.C. 1395x(aa)), is amended—
(A)
in paragraph (1)—
(i)
in subparagraph (C), by striking and
at the end;
(ii)
in subparagraph (D), by inserting and
after the comma at the end; and
(iii)
by inserting after subparagraph (D) the following new subparagraph:
(E)
dental and oral health services (as defined in subsection (ooo)) furnished by a doctor of dental surgery or of dental medicine (as described in subsection (r)(2)) or an oral health professional (as defined in subsection (ooo)(3)) who is employed by or working under contract with a rural health clinic if such rural health clinic furnishes such services,; and
(B)
in paragraph (3)(A), by striking (D)
and inserting (E)
.
(2) Temporary payment rates for certain services under the RHC AIR and FQHC PPS
(A) AIR
Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended—
(i)
in subsection (a)(3)(A), by inserting (which shall, in the case of dental and oral health services (as defined in section 1861(ooo))), in lieu of any limits on reasonable costs otherwise applicable, be based on the rates payable for such services under the payment basis determined under section 1848 until such time as the Secretary determines sufficient data has been collected to otherwise apply such limits (or January 1, 2031, if no such determination has been made as of such date))
after may prescribe in regulations
; and
(ii)
by adding at the end the following new subsection:
(ee) 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 (as defined in section 1861(ooo)) under the methodology for all-inclusive rates (established by the Secretary) under subsection (a)(3) 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 1848.
(B) PPS
Section 1834(o) of the Social Security Act (42 U.S.C. 1395m(o)) is amended by adding at the end the following new paragraph:
(6) Temporary payment rates based on pfs for certain services
The Secretary shall, in establishing payment rates for dental and oral health services (as defined in section 1861(ooo)) that are federally qualified health center services under the prospective payment system established under this subsection, in lieu of the rates otherwise applicable under such system, base such rates on rates payable for such services under the payment basis established under section 1848 until such time as the Secretary determines sufficient data has been collected to otherwise establish rates for such services under such system (or January 1, 2031, if no such determination has been made as of such date). 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 1848.
(h) Implementation
In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2026, out of any money in the Treasury not otherwise appropriated, $900,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2026, and ending on September 30, 2035.
Sec. 403. Providing coverage for hearing care under the Medicare program
(a) Provision of audiology services by qualified audiologists and hearing aid examination services by qualified hearing aid professionals
(1) In general
Section 1861(ll) of the Social Security Act (42 U.S.C. 1395x(ll)) is amended—
(A)
in paragraph (3)—
(i)
by inserting (A)
after (3)
;
(ii)
in subparagraph (A), as added by clause (i) of this subparagraph—
(I)
by striking means such hearing and balance assessment services
and inserting “means—
(i)
such hearing and balance assessment services and, beginning January 1, 2028, such hearing aid examination services and treatment services (including aural rehabilitation, vestibular rehabilitation, and cerumen management);
(II)
in clause (i), as added by subclause (I) of this clause, by striking the period at the end and inserting ; and
; and
(III)
by adding at the end the following new clause:
(ii)
beginning January 1, 2028, such hearing aid examination services furnished by a qualified hearing aid professional (as defined in paragraph (4)(C)) as the professional is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician.; and
(iii)
by adding at the end the following new subparagraph:
(B)
Beginning January 1, 2028, audiology services described in subparagraph (A)(i) shall be furnished without a requirement for an order from a physician or practitioner.; and
(B)
in paragraph (4), by adding at the end the following new subparagraph:
(C)
The term qualified hearing aid professional means an individual who—
(i)
is licensed or registered as a hearing aid dispenser, hearing aid specialist, hearing instrument dispenser, or related professional by the State in which the individual furnishes such services; and
(ii)
is accredited by the National Board for Certification in Hearing Instrument Sciences or meets such other requirements as the Secretary determines appropriate (including requirements relating to educational certifications or accreditations) taking into account any additional relevant requirements for hearing aid specialists, hearing aid dispensers, and hearing instrument dispensers established by Medicare Advantage organizations under part C, State plans (or waivers of such plans) under title XIX, and group health plans and health insurance issuers (as such terms are defined in section 2791 of the Public Health Service Act).
(2) Payment for qualified hearing aid professionals
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 402(c)(1), is amended—
(A)
by striking and
before (II)
; and
(B)
by inserting before the semicolon at the end the following: and (JJ) with respect to hearing aid examination services (as described in paragraph (3)(A)(ii) of section 1861(ll)) furnished by a qualified hearing aid professional (as defined in paragraph (4)(C) of such section), the amounts paid shall be equal to 80 percent of the lesser of the actual charge for such services or 85 percent of the amount for such services determined under the payment basis determined under section 1848
.
(3) Inclusion of qualified audiologists and qualified hearing aid professionals as certain practitioners to receive payment on an assignment-related basis
(A) Qualified audiologists
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by section 402(d), is amended by adding at the end the following new clause:
(x)
Beginning on January 1, 2028, a qualified audiologist (as defined in section 1861(ll)(4)(B)).
(B) Qualified hearing aid professionals
Section 1842(b)(18) of the Social Security Act (42 U.S.C. 1395u(b)(18)) is amended—
(i)
in each of subparagraphs (A) and (B), by striking subparagraph (C)
and inserting subparagraph (C) or, beginning on January 1, 2028, subparagraph (E)
; and
(ii)
by adding at the end the following new subparagraph:
(E)
A practitioner described in this subparagraph is a qualified hearing aid professional (as defined in section 1861(ll)(4)(C)).
(b) Coverage of hearing aids
(1) Inclusion of hearing aids as prosthetic devices
Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended by inserting , and including hearing aids (as described in section 1834(h)(7)) furnished on or after January 1, 2028, to individuals with moderately severe, severe, or profound hearing loss
before the semicolon at the end.
(2) Payment limitations for hearing aids
Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraphs:
(6) 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 basis. The provisions of subparagraphs (A) and (B) of section 1842(b)(18) shall apply to hearing aids in the same manner as they apply to services furnished by a practitioner described in subparagraph (C) of such section.
(7) Limitations for hearing aids
(A) In general
Payment may be made under this part with respect to an individual, with respect to hearing aids furnished by a qualified hearing aid supplier (as defined in subparagraph (C)) on or after January 1, 2028—
(i)
not more than once per ear during a 5-year period;
(ii)
only for types of such hearing aids that are determined appropriate by the Secretary; and
(iii)
only if furnished pursuant to a written order of a physician, qualified audiologist (as defined in section 1861(ll)(4)), qualified hearing aid professional (as defined in subparagraph (C) of such section), physician assistant, nurse practitioner, or clinical nurse specialist.
(B) Special rule
The payment basis determined under this subsection (including after application of paragraph (1)(H), relating to application of competitive acquisition) for hearing aids furnished by a qualified hearing aid supplier on or after January 1, 2028, shall not exceed the rate determined for such hearing aids under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year.
(C) Definitions
In this subsection:
(i) Hearing aid
The term hearing aid means the item and related services including selection, fitting, adjustment, and patient education and training.
(ii) Qualified hearing aid supplier
The term qualified hearing aid supplier means—
(I)
a qualified audiologist;
(II)
a physician (as defined in section 1861(r)(1));
(III)
a physician assistant, nurse practitioner, or clinical nurse specialist;
(IV)
a qualified hearing aid professional (as defined in section 1861(ll)(4)(C)); and
(V)
other suppliers as determined by the Secretary.
(3) Application of competitive acquisition
(A) In general
Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)) is amended—
(i)
in the header, by inserting and hearing aids
after orthotics
;
(ii)
in the matter preceding clause (i), by inserting or of hearing aids described in paragraph (2)(E) of such section,
after 2011,
; and
(iii)
in clause (i), by inserting or such hearing aids
after such orthotics
.
(B) Conforming amendments
(i) In general
Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)) is amended by adding at the end the following new subparagraph:
(E) Hearing aids
Hearing aids described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).
(ii) Exemption of certain items from competitive acquisition
Section 1847(a)(7) of the Social Security Act (42 U.S.C. 1395w–3(a)(7)) is amended by adding at the end the following new subparagraph:
(C) Certain hearing aids
Those items and services described in paragraph (2)(E) if furnished by a physician or other practitioner (as defined by the Secretary) to the physician's or practitioner's own patients as part of the physician's or practitioner's professional service.
(iii) Implementation
Section 1847(a) of the Social Security Act (42 U.S.C. 1395w–3(a)) is amended by adding at the end the following new paragraph:
(8) Competition with respect to hearing aids
Not later than January 1, 2031, the Secretary shall begin the competition with respect to the items and services described in paragraph (2)(E).
(4) Physician self-referral law
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)) is amended by adding at the end the following new paragraph:
(6) Hearing aids and services
In the case of hearing aid examination services and hearing aids—
(A)
furnished on or after January 1, 2028, and before January 1, 2030; and
(B)
furnished on or after January 1, 2030, if the financial relationship specified in subsection (a)(2) meets such requirements the Secretary imposes by regulation to protect against program or patient abuse.
(c) Exclusion modification
Section 1862(a)(7) of the Social Security Act (42 U.S.C. 1395y(a)(7)) is amended by inserting (except such hearing aids or examinations therefor as described in and otherwise allowed under section 1861(s)(8))
after hearing aids or examinations therefor
.
(d) Inclusion as excepted medical treatment
Section 1821(b)(5)(A)(iv) of the Social Security Act (42 U.S.C. 1395i–5(b)(5)(A)(iv)), as added by section 402(f), is amended by inserting , audiology services described in subsection (ll)(3) of such section, or hearing aids described in subsection (s)(8) of such section
after section 1861)
.
(e) Rural health clinics and federally qualified health centers
(1) Clarifying coverage of audiology services as physicians' services
Section 1861(aa)(1)(A) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(A)) is amended by inserting (including audiology services (as defined in subsection (ll)(3)))
after physicians' services
.
(2) Inclusion of qualified audiologists and qualified hearing aid professionals as RHC and FQHC practitioners
Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by inserting or by a qualified audiologist or a qualified hearing aid professional (as such terms are defined in subsection (ll)),
after (as defined in subsection (hh)(1)),
.
(3) Temporary payment rates for certain services under the RHC AIR and FQHC PPS
(A) AIR
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section 402(g)(2)(A), is amended—
(i)
in subsection (a)(3)(A), by inserting or audiology services (as defined in section 1861(ll)(3))
after (as defined in section 1861(ooo))
; and
(ii)
in subsection (ee), by inserting or audiology services (as defined in section 1861(ll)(3))
after (as defined in section 1861(ooo))
.
(B) PPS
Section 1834(o)(6) of the Social Security Act (42 U.S.C. 1395m(o)(6)), as added by section 402(g)(2)(B), is amended—
(i)
in the first sentence, by inserting or audiology services (as defined in section 1861(ll)(3))
after (as defined in section 1861(ooo))
; and
(ii)
in the second sentence, by inserting or such audiology services
after such dental and oral health services
.
(f) Expediting implementation
The Secretary of Health and Human Services shall implement this section for 2028 and 2029 through program instruction or other forms of program guidance.
(g) Funding
In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2026, out of any money in the Treasury not otherwise appropriated, $370,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2027, and ending on September 30, 2036.
Sec. 404. Providing coverage for vision care under the Medicare program
(a) Coverage
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 402(a), is amended—
(1)
in subparagraph (KK), by striking and
at the end;
(2)
in subparagraph (LL), by inserting and
after the semicolon; and
(3)
by adding at the end the following new subparagraph:
(MM)
vision services (as defined in subsection (ppp));
(b) Vision services defined
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 402(b), is amended by adding at the end the following new subsection:
(ppp) Vision services
The term vision services means routine eye examinations to determine the refractive state of the eyes, including procedures performed during the course of such examination, furnished on or after January 1, 2028, by or under the direct supervision of an ophthalmologist or optometrist who is legally authorized to furnish such examinations or procedures (as applicable) under State law (or the State regulatory mechanism provided by State law) of the State in which the examinations or procedures are furnished.
(c) Payment limitations
Section 1834 of the Social Security Act (42 U.S.C. 1395m), as amended by section 402(c)(2), is amended by adding at the end the following new subsection:
(cc) Limitation for vision services
With respect to vision services (as defined in section 1861(ppp)) and an individual, payment shall be made under this part for only 1 routine eye examination described in such subsection during a 2-year period.
(d) Payment under physician fee schedule
Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(MM),
before (3)
.
(e) Coverage of conventional eyeglasses
Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)), as amended by section 403(b)(1), is amended by striking , and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens
and inserting , including 1 pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens, if furnished before January 1, 2028, and including conventional eyeglasses (as described in section 1834(h)(8)), whether or not furnished subsequent to such a surgery, if furnished on or after January 1, 2028
.
(f) Special payment rules for eyeglasses
(1) Limitations
Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)), as amended by section 403(b)(2), is amended by adding at the end the following new paragraph:
(8) Payment limitations for eyeglasses
(A) In general
With respect to conventional eyeglasses furnished to an individual on or after January 1, 2028, subject to subparagraph (B), payment shall be made under this part only during a 2-year period, for 1 pair of eyeglasses (including lenses and the frame).
(B) Exception
With respect to a 2-year period described in subparagraph (A), in the case of an individual who receives cataract surgery with insertion of an intraocular lens, payment shall be made under this part for 1 pair of conventional eyeglasses furnished subsequent to such cataract surgery during such period.
(C) Special rule
The payment basis determined under this subsection (including after application of paragraph (1)(H), relating to application of competitive acquisition) for conventional eyeglasses furnished to an individual on or after January 1, 2028, shall not exceed the rate determined for such eyeglasses under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year.
(D) No coverage of certain items
Payment shall not be made under this part for deluxe eyeglasses or conventional reading glasses.
(2) Application of competitive acquisition
(A) In general
Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)), as amended by section 403(b)(3)(A), is amended—
(i)
in the heading, by striking and hearing aids
and inserting hearing aids, and eyeglasses
;
(ii)
in the matter preceding clause (i)—
(I)
by striking or of hearing aids
and inserting of hearing aids
; and
(II)
by inserting or of eyeglasses described in paragraph (2)(F) of such section,
after paragraph (2)(E) of such section,
; and
(iii)
in clause (i), by striking or such hearing aids
and inserting , such hearing aids, or such eyeglasses
.
(B) Conforming amendment
Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)), as amended by section 403(b)(3)(B)(i), is amended by adding at the end the following new subparagraph:
(F) Eyeglasses
Eyeglasses described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).
(C) Implementation
Section 1847(a) of the Social Security Act (42 U.S.C. 1395w–3(a)), as amended by section 403(b)(3)(B)(iii), is amended by adding at the end the following new paragraph:
(9) Competition with respect to eyeglasses
Not later than January 1, 2030, the Secretary shall begin the competition with respect to the items and services described in paragraph (2)(F).
(g) Exclusion modifications
Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)), as amended by section 402(e), is amended—
(1)
in paragraph (1)—
(A)
in subparagraph (P), by striking and
at the end;
(B)
in subparagraph (Q), by striking the semicolon at the end and inserting , and
; and
(C)
by adding at the end the following new subparagraph:
(R)
in the case of vision services (as defined in section 1861(ppp)) that are routine eye examinations as described in such section, which are furnished more frequently than once during a 2-year period;; and
(2)
in paragraph (7)—
(A)
by inserting (other than such an examination that is a vision service that is covered under section 1861(s)(2)(MM))
after eye examinations
; and
(B)
by inserting (other than such a procedure that is a vision service that is covered under section 1861(s)(2)(MM))
after refractive state of the eyes
.
(h) Inclusion as excepted medical treatment
Section 1821(b)(5)(A)(iv) of the Social Security Act (42 U.S.C. 1395i–5(b)(5)(A)(iv)), as added by section 402(f) and amended by section 403(d), is amended—
(1)
by striking or hearing aids
and inserting hearing aids
; and
(2)
by inserting , or vision services (as defined in subsection (ppp) of such section)
after subsection (s)(8) of such section
.
(i) Rural Health Clinics and Federally Qualified Health Centers
(1) Clarifying coverage of vision services as physicians' services
Section 1861(aa)(1)(A) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(A)), as amended by section 403(e)(1), is amended by inserting and vision services (as defined in subsection (ppp))
after (as defined in subsection (ll)(3))
.
(2) Temporary payment rates for certain services under the RHC AIR and FQHC PPS
(A) AIR
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by sections 402(g)(2)(A) and 403(e)(3)(A), is amended—
(i)
in subsection (a)(3)(A)—
(I)
by striking or audiology
and inserting , audiology
; and
(II)
by inserting , or vision services (as defined in section 1861(ppp))
after (as defined in section 1861(ll)(3))
; and
(ii)
in subsection (ee)—
(I)
by striking or audiology
and inserting , audiology
; and
(II)
by inserting , or vision services (as defined in section 1861(ppp))
after (as defined in section 1861(ll)(3))
.
(B) PPS
Section 1834(o)(6) of the Social Security Act (42 U.S.C. 1395m(o)(6)), as added by section 402(g)(2)(B) and amended by section 403(e)(3)(B), is amended—
(i)
in the first sentence—
(I)
by striking or audiology
and inserting , audiology
; and
(II)
by inserting , or vision services (as defined in section 1861(ppp))
after (as defined in section 1861(ll)(3))
; and
(ii)
in the second sentence, by striking or such audiology services
and inserting , such audiology services, or such vision services
.
(j) Expediting implementation
The Secretary of Health and Human Services shall implement this section for 2028 and 2029 through program instruction or other forms of program guidance.
(k) Funding
In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2026, out of any money in the Treasury not otherwise appropriated, $500,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2027, and ending on September 30, 2035.
Sec. 405. Phase-in of impact of dental and oral health coverage on part B premiums
Section 1839(a) of the Social Security Act (42 U.S.C. 1395r(a)) is amended—
(1)
in the second sentence of paragraph (1), by striking and (7)
and inserting (7), and (8)
;
(2)
in paragraph (3), by striking The Secretary
and inserting Subject to paragraph (8)(C), the Secretary
; and
(3)
by adding at the end the following:
(8) Special rule for 2027 through 2031
(A) Determination of alternative monthly actuarial rate for each of 2027 through 2031
For each of 2027 through 2031, the Secretary shall, at the same time as and in addition to the determination of the monthly actuarial rate for enrollees age 65 and over determined in each of 2026 through 2030 for the succeeding calendar year according to paragraph (1), determine an alternative monthly actuarial rate for enrollees age 65 and over for the year as described in subparagraph (B).
(B) Alternative monthly actuarial rate described
(i) In general
The alternative monthly actuarial rate described in this subparagraph is—
(I)
for 2027 and 2028, the monthly actuarial rate for enrollees age 65 and over for the year, determined as if the amendments made by section 402 of the Medicare Dental, Hearing, and Vision Expansion Act of 2026 did not apply; and
(II)
for 2029, 2030, and 2031, the monthly actuarial rate for enrollees age 65 and over for the year, determined as if the amendments made by such section 402 did not apply, plus the applicable percent of the amount by which—
(aa)
the monthly actuarial rate for enrollees age 65 and over for the year determined according to paragraph (1); exceeds
(bb)
the monthly actuarial rate for enrollees age 65 and over for the year, determined as if the amendments made by such section 402 did not apply.
(ii) Definition of applicable percent
For purposes of this subparagraph, the term applicable percent means—
(I)
for 2029, 25 percent;
(II)
for 2030, 50 percent; and
(III)
for 2031, 75 percent.
(C) Application to part b premium and other provisions of this part
For each of 2027 through 2031, the Secretary shall use the alternative monthly actuarial rate for enrollees age 65 and over for the year determined under subparagraph (A), in lieu of the monthly actuarial rate for such enrollees for the year determined according to paragraph (1), when determining the monthly premium rate for the year under paragraph (3) and subsection (j), the part B deductible under section 1833(b), and the premium subsidy and monthly adjustment amount under subsection (i).
Title V Housing Trust Fund
Sec. 501. Authorization of appropriations
Section 1338(a) of the Federal Housing Enterprises Financial Safety and Soundness Act of 1992 (12 U.S.C. 4568(a)) is amended by adding at the end the following:
(3) Authorization of appropriations
There is authorized to be appropriated to the Housing Trust Fund $85,647,000,000 for each of fiscal years 2026 through 2035.
Title VI Affordable Child Care for Working Families
Sec. 601. Birth through five child care and early learning entitlement
(a) Child care definitions
The definitions in section 658P of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858n) shall apply to this section, except as provided in subsection (b) and as otherwise specified.
(b) Additional definitions
In this section:
(1) Child care certificate
(A) In general
The term child care certificate means a certificate (that may be a check or other disbursement) that is issued by a State, tribal, territorial, 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 provider.
(B) Rule
Nothing in this section shall preclude the use of such certificates for sectarian child care services if freely chosen by the parent. For the purposes of this section, child care certificates shall be considered indirect Federal financial assistance to the provider.
(2) Child experiencing homelessness
The term child experiencing homelessness means an individual who is a homeless child or youth under section 725 of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a).
(3) Eligible activity
The term eligible activity, with respect to a parent, shall include, at minimum, activities consisting of—
(A)
full-time or part-time employment;
(B)
self-employment;
(C)
job search activities;
(D)
job training;
(E)
secondary, postsecondary, or adult education, including education through a program of high school classes, a course of study at an institution of higher education, classes towards an equivalent of a high school diploma recognized by State law, or English as a second language classes;
(F)
health treatment (including mental health and substance use treatment) for a condition that prevents the parent from participating in other eligible activities;
(G)
activities to prevent child abuse and neglect, or family violence prevention or intervention activities;
(H)
employment and training activities under the supplemental nutrition assistance program established under section 6(d)(4) the Food and Nutrition Act of 2008 (7 U.S.C. 2015(d)(4));
(I)
employment and training activities under the Workforce Innovation and Opportunity Act (29 U.S.C. 3101 et seq.);
(J)
a work activity described in subsection (d) of section 407 of the Social Security Act (42 U.S.C. 607) for which, consistent with clauses (ii) and (iii) of section 402(a)(1)(A) of such Act (42 U.S.C. 602(a)(1)(A)), 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 (42 U.S.C. 601 et seq.); and
(K)
taking leave under the Family and Medical Leave Act of 1993 (29 U.S.C. 2601 et seq.) (or equivalent provisions for Federal employees), a State or local paid or unpaid leave law, or a program of employer-provided leave.
(4) Eligible child
(A) In general
The term eligible child means an individual—
(i)
who is less than 6 years of age;
(ii)
who is not yet in kindergarten;
(iii)
whose family income does not exceed 250 percent of the State median income for a family of the same size for the fiscal year involved, for each fiscal year beginning with fiscal year 2026; and
(iv)
who—
(I)
resides with a parent or parents who are participating in an eligible activity;
(II)
is included in a population of vulnerable children identified by the lead agency involved, which at a minimum shall include children with disabilities, infants and toddlers with disabilities, children experiencing homelessness, children in foster care, children in kinship care, and children who are receiving, or need to receive, child protective services; or
(III)
resides with a parent who is more than 65 years of age.
(B) Longer-term period eligibility
For purposes of determining eligibility under this paragraph, 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—
(i)
that begins on the date of the determination; and
(ii)
that ends on the earlier of the date the individual becomes 6 years of age or the date the individual enters kindergarten.
(5) Eligible child care provider
(A) In general
The term eligible child care provider means a center-based child care provider, a family child care provider, or other provider of child care services for compensation that—
(i)
is licensed to provide child care services under State law applicable to the child care services it provides or, in the case of an Indian Tribe or tribal organization, meets the rules set by the Secretary;
(ii)
participates in the State’s tiered system for measuring and supporting the quality of eligible child care providers described in subsection (f)(3)(B), or, in the case of an Indian Tribe or tribal organization, meets the rules set by the Secretary—
(I)
not later than 3 years after the State first receives funds under this section; and
(II)
for the remainder of the period for which the provider receives funds under this section; and
(iii)
satisfies the State and local requirements, including those requirements described in section 658E(c)(2)(I) of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858c(c)(2)(I)), applicable to the child care services it provides.
(B) 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 1990 (42 U.S.C. 9857 et seq.) on the date the State submits an application for funds under this section, and remains in compliance with any licensing or registration standards, or regulations, of the State, shall be deemed to be an eligible child care provider under this section for 3 years after the State first receives funds under this section.
(6) FMAP
The term FMAP has the meaning given the term Federal medical assistance percentage in the first sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)).
(7) Family child care provider
The term family child care provider means one or more individuals who provide child care services, in a private residence other than the residences of the children involved, for less than 24 hours per day per child, or for 24 hours per day per child due to the nature of the work of the parent involved.
(8) Inclusive care
The term inclusive, with respect to care (including child care), means care provided by an eligible child care provider—
(A)
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 (whichever the provider serves) among children within the State involved; and
(B)
that provides care and full participation for children with disabilities and infants and toddlers with disabilities (whichever the provider serves) alongside children who are—
(i)
not children with disabilities; and
(ii)
not infants and toddlers with disabilities.
(9) Infant or toddler
The term infant or toddler means an individual who is less than 3 years of age.
(10) Infant or toddler with a disability
The term infant or toddler with a disability has the meaning given the term in section 632 of the Individuals with Disabilities Education Act (20 U.S.C. 1432).
(11) Lead agency
The term lead agency means the agency designated under subsection (e).
(12) Provider type
The term provider type means a type that is—
(A)
a center-based child care provider;
(B)
a family child care provider; or
(C)
another non-center-based child care provider.
(13) Staffed family child care network
The term staffed family child care network means a nonprofit organization or nonprofit cooperative—
(A)
that may be a component of a child care resource and referral organization;
(B)
that has at least one paid staff member; and
(C)
that offers evidence-based professional development, quality improvement support, business support, and technical assistance, including on achieving licensure as a child care provider, to family child care providers.
(14) State
The term State means any of the 50 States and the District of Columbia.
(15) Territory
The term territory means the Commonwealth of Puerto Rico, the Virgin Islands of the United States, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.
(c) Appropriations
(1) States, Indian Tribes and tribal organizations, and territories entitlement
In addition to amounts otherwise available, there is appropriated to the Department of Health and Human Services for fiscal year 2026 and each subsequent fiscal year, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary for payments to States, territories, and Indian Tribes and tribal organizations for carrying out the child care program described in this section (other than carrying out activities described in paragraph (2) or (3)).
(2) Grants to localities; awards to Head Start agencies
In addition to amounts otherwise available, there is appropriated to the Department of Health and Human Services for fiscal year 2026, out of any money in the Treasury not otherwise appropriated $20,000,000,000, to carry out the program of grants to localities, and the program of awards to Head Start agencies, described in subsection (i).
(3) Federal administration
Notwithstanding paragraph (1) or (2), of the funds appropriated under this section for a fiscal year, the Secretary of Health and Human Services may reserve an amount equal to not more than 0.5 percent of the funds appropriated under this section for the prior fiscal year, for purposes of Federal administration of this section.
(d) Establishment of birth through five child care and early learning entitlement program
(1) In general
The Secretary is authorized to administer a child care and early learning entitlement program under which an eligible child, in a State, territory, or Indian Tribe, or served by a tribal organization, with an approved application under subsection (f) or (g), shall be provided an opportunity to obtain high-quality child care services, subject to the requirements of this section.
(2) Assistance for every eligible child
Beginning on October 1, 2026, every child who applies for assistance under this section, who is in a State with an approved application under subsection (f), or in a territory or Indian Tribe or served by a tribal organization with an approved application under subsection (g), and who is determined, by a lead agency (or other entity designated by a lead agency) for the State, territory, Indian Tribe, or tribal organization involved, following standards and procedures established by the Secretary by rule, to be an eligible child, 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 section.
(e) Lead agency
The Governor of a State or the head of a territory or Indian Tribe, desiring for the State, territory, or Indian tribe or a related tribal organization to receive a payment under this section, shall designate a lead agency (such as a State agency or joint interagency office) to administer the child care program carried out under this section.
(f) Applications and State plans
(1) Application
To be eligible to receive assistance under this section, a State shall prepare and submit to the Secretary for approval an application containing a State plan that meets the requirements under paragraph (3) and contains such information as the Secretary may require.
(2) Period covered by plan
A State plan contained in the application shall be designed to be implemented during a period of not more than 3 years.
(3) Requirements for State plans
The Secretary shall award funds under this section to States with an approved application that contains a State plan, submitted under paragraph (1), at such time, in such manner, and containing such information as the Secretary shall by rule require, including, at a minimum, the following:
(A) Payment rates and cost estimation
(i) 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 plan, within 3 years after the State first receives funds under this section—
(I)
will be sufficient to meet the cost of child care (including fixed costs such as rent or mortgage, and salaries), and set (with pay being paid) in accordance with a cost estimation model or cost study described in clause (ii) that is approved by the Secretary; and
(II)
will correspond to differences in quality (including improved quality) based on the State’s tiered system for measuring and supporting the quality of eligible child care providers described in subparagraph (B).
(ii) Cost estimation
Such State plan shall—
(I)
demonstrate that the State has, after consulting with relevant entities and stakeholders, 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 (B), and variations in the cost of direct child care services by geographic area, provider type, and age of child, and the additional costs associated with providing inclusive care;
(II)
certify that the entities and stakeholders consulted included the State Advisory Council on Early Childhood Education and Care designated or established in section 642B(b)(1)(A)(i) of the Head Start Act (42 U.S.C. 9837b(b)(1)(A)(i)) (including State Directors of Head Start Collaboration), administrators of local child care programs and Head Start agencies, organizations representing child care directors, teachers, and other staff, local child care resource and referral organizations, organizations representing parents of children with disabilities and parents of infants and toddlers with disabilities, the State interagency coordinating council established under section 641 of the Individuals with Disabilities Education Act (20 U.S.C. 1441), the State advisory panel established under section 612(a)(21) of the Individuals with Disabilities Education Act (20 U.S.C. 1412(a)(21)), organizations and labor organizations representing child care providers, and other appropriate entities;
(III)
certify that the State—
(aa)
not later than 30 days after finalizing the cost estimation model or cost study, published a detailed report containing the child care costs estimated with the cost estimation model or cost study, and including an explanation detailing how the wage requirements described in subclause (IV)(cc) were applied in the estimation of such costs; and
(bb)
not later than 60 days after publishing the report described in item (aa), established a system to receive public comment on the report on the subject of making changes to the cost estimation model or cost study, provided an opportunity for the public to comment on the report through that system, and submitted the report to the Secretary;
(IV)
certify that the State’s payment rates for direct child care services for which assistance is provided in accordance with this section—
(aa)
are set (with pay being paid) in accordance with the most recent estimates from the most recent cost estimation model or cost study under subclause (I), so that providers at each tier of the tiered system for measuring and supporting the quality of eligible child care providers described in subparagraph (B) receive a payment that is sufficient to fully meet the requirements of such tier;
(bb)
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 tier;
(cc)
ensure adequate wages for staff of child care providers providing such direct child care services that—
(AA)
at a minimum, provide a living wage for all staff of such child care providers; and
(BB)
are equivalent to wages for elementary educators with similar credentials and experience in the State; and
(dd)
are adjusted on an annual basis for cost of living increases to ensure those payment rates remain sufficient to meet the requirements of this section;
(V)
certify that the State will update, not less often than once every 3 years, the cost estimation model or cost study described in subclause (I); and
(VI)
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 study.
(iii) 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 services.
(B) Tiered system for measuring and supporting the quality of eligible child care providers
Such State plan shall certify that the State has implemented, or assure that the State will implement within 3 years after first receiving funds under this section, with input (from early childhood education and development experts, from a diverse group of child care providers of a variety of provider types, from families, and from organizations representing child care directors, teachers, and other staff), 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 section. Such tiered system shall—
(i)
include a set of standards, for determining the tier of quality of a child care provider, that—
(I)
uses standards for a highest tier that at a minimum are equivalent to Head Start program performance standards described in section 641A(a)(1)(B) of the Head Start Act (42 U.S.C. 9836a(a)(1)(B)) or other equivalent evidence-based standards approved by the Secretary; and
(II)
includes quality indicators and thresholds that are appropriate for child development from child care providers of a variety of provider types, including child care centers and the settings of family child care providers, and are appropriate for providers serving different age groups (including mixed age groups) of children;
(ii)
include a different set of standards that includes indicators, when appropriate, for care during nontraditional hours of operation; and
(iii)
provide for sufficient resources and supports for child care providers at tiers lower than the highest tier to facilitate progression toward meeting higher quality standards.
(C) Achieving high quality for all children
Such State plan shall certify the State has implemented, or will implement within 3 years after first receiving funds under this section, policies and financing practices that will ensure all eligible children can choose to attend child care, with services provided by eligible child care providers from any of a variety of provider types including family child care providers, at the highest quality tier within 6 years after the date of enactment of this Act.
(D) Compensation
Such plan shall provide a certification that the State has or will have within 3 years after first receiving funds under this section, a wage ladder for staff of eligible child care providers receiving assistance under this section, including a certification that wages for such staff, at a minimum, will meet the requirements of subparagraph (A)(ii)(IV)(cc).
(E) Sliding fee scale for copayments
(i) In general
Except as provided in clause (ii)(I), 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 (ii) to determine a copayment for a family receiving assistance under this section (or, for a family receiving part-time care, a reduced copayment that is the proportionate amount of the full copayment).
(ii) Sliding fee scale
A full copayment described in clause (i) shall use a sliding fee scale that provides that, for a family with a family income—
(I)
of not more than 85 percent of State median income for a family of the same size, the family shall not pay a copayment, toward the cost of the child care involved for all eligible children in the family;
(II)
of more than 85 percent but not more than 100 percent of State median income for a family of the same size, the copayment shall be more than 0 but not more than 2 percent of that family income, toward such cost for all such children;
(III)
of more than 100 percent but not more than 125 percent of State median income for a family of the same size, the copayment shall be more than 2 but not more than 4 percent of that family income, toward such cost for all such children;
(IV)
of more than 125 percent but not more than 150 percent of State median income for a family of the same size, the copayment shall be more than 4 but not more than 7 percent of that family income, toward such cost for all such children; and
(V)
of more than 150 percent but not more than 250 percent of the State median income for a family of the same size, the copayment shall be 7 percent of that family income, toward such cost for all such children.
(F) Prohibition on charging more than copayment
The State plan shall certify that, after the State develops and begins using the cost estimation model or cost study described in subparagraph (A)(ii), the State will not permit a child care provider receiving financial assistance under this section to charge, for direct child care services for an eligible child, more than the total of—
(i)
the financial assistance provided for the child under this section; and
(ii)
any applicable copayment pursuant to subparagraph (E).
(G) 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 assistance, and will receive such assistance, for not less than 12 months unless the child has aged out of the program, and the child’s eligibility determination and redetermination, including any determination based on the State’s definition of eligible activities, shall be implemented in a manner that supports child well-being and reduces barriers to enrollment, including continuity of services.
(H) Policies to support access to child care for underserved populations
The State plan shall demonstrate that the State will prioritize increasing access to, and the quality and the supply of, child care in the State for underserved populations, including at a minimum, low-income children, children in underserved areas, infants and toddlers, children with disabilities and infants and toddlers with disabilities, children who are dual language learners, children experiencing homelessness, children in foster or kinship care, children who receive care during nontraditional hours, and vulnerable children as defined by the lead agency pursuant to subsection (b)(4)(A)(iv)(II).
(I) Policies
The State plan shall include a certification that the State will apply, under this section, the policies and procedures described in subparagraphs (A), (B), (I), (J), (K)(i), (R), and (U) of section 658E(c)(2) of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858c(c)(2)), and the policies and procedures described in section 658H of such Act (42 U.S.C. 9858f), to child care services provided under this section.
(J) Licensing
The State plan shall demonstrate that the State has consulted or will consult with organizations (including labor organizations and child care and early learning organizations) representing eligible child care providers (including family child care providers), child care associations, child care directors, teachers, and other staff (including child care directors, teachers, and other staff serving higher proportions of underserved populations as identified under subparagraph (H)), early childhood education and development experts, maternal and child health experts, and families to develop, within 2.5 years after first receiving funds under this section, 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 settings, that will offer providers eligible under the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9857 et seq.) a reasonable pathway to become eligible providers under this section, and that will assure an adequate supply of child care. Such plan shall describe the timeline the State will use to ensure sufficient time for providers described in subsection (b)(5)(B) to comply with such licensing standards in order to remain eligible providers after 3.5 years after the State first receives funding under this section.
(K) Financial support for providers
Such plan shall describe how the State will use funds reserved under subsection (h)(1)(C) to enable eligible child care providers from a variety of provider types to achieve licensure, including paying for the costs of required background checks, health screening, and initial and ongoing training, and other costs associated with achieving licensure.
(L) Prohibition on suspensions, expulsions, and aversive behavioral interventions
The State plan shall provide an assurance that the State will—
(i)
provide assistance to carry out this section only to eligible child care providers that prohibit—
(I)
the use of suspension and expulsion of children; and
(II)
the use of aversive behavioral interventions; and
(ii)
provide training resources to eligible child care providers and information to families to support the prohibition of practices described in subclauses (I) and (II) of clause (i).
(g) Payments
(1) In general
For each fiscal year:
(A) Child care assistance for eligible children
(i) In general
The Secretary shall pay to each State with an approved application under subsection (f), and that State shall be entitled to, an amount for each quarter equal to 90 percent of expenditures (which shall be the Federal share of such expenditures) in the quarter for direct child care services described under subsection (h)(1)(B) for eligible children.
(ii) Exception
Funds reserved from the total under subsection (h)(1)(C) shall be subject to subparagraph (B).
(iii) Prohibition
Activities described in subparagraph (B) and subparagraph (C) may not be included in the cost of direct child care services described in this subparagraph.
(B) Activities to improve the quality and supply of child care services
The Secretary shall pay to each State with such an approved application, and that State shall be entitled to, an amount equal to the FMAP of expenditures (which shall be the Federal share of such expenditures) to carry out activities to improve the quality and supply of child care services under subsection (h)(1)(C) subject to the limit specified in clause (i) of such subsection.
(C) Administration
The Secretary shall pay to each State with such an approved application, and that State shall be entitled to, an amount equal to 50 percent of expenditures (which shall be the Federal share of such expenditures) for the costs of administration incurred by the State—
(i)
which shall include costs incurred by the State in carrying out the child care program established in this section; and
(ii)
which may include, at the option of the State, costs associated with carrying out requirements, policies, and procedures described in section 658H of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858f).
(2) Advance payment; retrospective adjustment
For each fiscal year, 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 necessary, and shall reduce or increase the payments as necessary to adjust for any overpayment or underpayment for previous periods. No interest shall be charged or paid on any amount due because of an overpayment or underpayment for previous periods.
(3) Territories and tribes
(A) In general
For each fiscal year, from amounts appropriated under subsection (c)(1), the Secretary shall make payments to territories, and Indian Tribes and tribal organizations, as the case may be, with applications submitted as described in subparagraph (B), and approved by the Secretary for the purpose of carrying out the child care program described in this section, consistent, to the extent practicable as determined by the Secretary (subject to subsection (d)(2)), with the requirements applicable to States.
(B) Applications
(i) Territories
A territory seeking a payment under this paragraph shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may specify.
(ii) 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 time, in such manner, and containing such information as the Secretary may specify.
(C) Costs
The Secretary shall make the payments to such territories, Indian Tribes, and tribal organizations on the basis of their relative need. Each entity that is such a territory, Indian Tribe, or tribal organization shall be entitled to such a payment as may be necessary to pay for 100 percent of the expenses of carrying out the activities described in subsection (h)(1), and to pay for 100 percent of the costs of administration incurred by the entity, which shall include costs incurred by the entity in carrying out the child care program, and which may include, at the option of the entity, costs associated with carrying out requirements, policies, and procedures described in section 658H of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858f).
(h) Use of funds
(1) Use of funds
(A) In general
Starting on October 1, 2026, a State shall use amounts provided to the State under subsection (g)(1) for direct child care services (provided on a sliding fee scale basis), activities to improve the quality and supply of child care services consistent with subparagraph (C), and State administration consistent with subsection (g)(1)(C).
(B) Child care assistance for eligible children
(i) In general
For fiscal year 2026 and each subsequent fiscal year, from payments made to the State under subsection (g)(1) for that particular fiscal year, 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 (ii) or a certificate as described in clause (iii).
(ii) Grants and contracts
The State shall award grants or contracts to eligible child care providers, consistent with the requirements under this section, for the provision of child care services for eligible children under this section that, at a minimum—
(I)
support providers’ operating expenses to meet and sustain health, safety, quality, licensing, and wage standards required under this section; and
(II)
address underserved populations described in subsection (f)(3)(H).
(iii) 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 provider, consistent with the requirements under this section.
(C) Activities to improve the quality and supply of child care services
(i) Quality child care activities
(I) Amount
For fiscal year 2026 and each subsequent fiscal year, from the total of the payments made to the State for a particular fiscal year, the State shall reserve and use a quality child care amount equal to not less than 5 percent and not more than 10 percent of the amount made available to the State through such payments for the previous fiscal year.
(II) Use of quality child care amount
Each State shall use the quality child care amount described in subclause (I) to implement activities described in this subparagraph to improve the quality and supply of child care services by eligible child care providers, and increase the number of available slots in the State for child care services funded under this section, prioritizing assistance for child care providers who are in underserved communities and who are providing, or are seeking to provide, child care services for underserved populations identified in subsection (f)(3)(H).
(III) Administration
Activities funded under this subparagraph may be administered—
(aa)
directly by the lead agency; or
(bb)
through other State government agencies, local or regional child care resource and referral organizations, community development financial institutions, other intermediaries with experience supporting child care providers, or other appropriate entities that enter into a contract with the State to provide such assistance.
(ii) Quality and supply activities
Activities funded under the quality child care amount described in clause (i) shall include each of the following:
(I) Startup grants and supply expansion grants
(aa) In general
From a portion of the quality child care amount, a State shall make startup and supply expansion grants to support child care providers who are providing, or seeking to provide, child care services to children receiving assistance under this section, with priority for providers providing or seeking to provide child care in underserved communities and for underserved populations identified in subsection (f)(3)(H), to—
(AA)
support startup and expansion costs; and
(BB)
assist such providers in meeting health and safety requirements, achieving licensure, conducting background checks, and meeting requirements in the State’s tiered system for measuring and supporting the quality of eligible child care providers.
(bb) Requirement
As a condition of receiving a startup or supply expansion grant under this subclause, a child care provider shall commit to meeting the requirements of an eligible provider under this section, and providing child care services to children receiving assistance under this section on an ongoing basis.
(II) Quality grants
From a portion of the quality child care amount, 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 providers, including—
(aa)
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 (f)(3)(B); and
(bb)
supporting such providers in sustaining child care quality, including supporting increased wages for staff and supporting payment of fixed costs.
(III) Facilities grants
(aa) In general
From a portion of the quality child care amount, a State shall provide support, including through awarding facilities grants, for remodeling, renovation, or repair of a building or facility to the extent permitted under section 658F(b) of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858d(b)).
(bb) Additional uses
For fiscal year 2026 and subsequent fiscal years, a State may award such facilities grants for construction, permanent improvement, or major renovation of a building or facility primarily used for providing direct child care services, in accordance with the following:
(AA)
Federal interest provisions will not apply to the renovation or rebuilding of privately owned family child care homes under this subclause.
(BB)
Eligible child care providers may not use funds for buildings or facilities that are used primarily for sectarian instruction or religious worship.
(CC)
The Secretary shall develop parameters on the use of funds under this subclause for family child care homes.
(DD)
The Secretary shall not retain Federal interest after a period of 10 years in any facility built, renovated, or repaired with funds awarded under this subclause.
(IV) 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 program, which shall include—
(aa)
supporting the training and professional development of the early childhood workforce, including supporting degree attainment, continued education, and credentialing for early childhood educators;
(bb)
developing, implementing, or enhancing the State’s tiered system for measuring and supporting the quality of eligible child care providers under subsection (f)(3)(B);
(cc)
improving the supply and quality of developmentally appropriate and inclusive child care programs and services for underserved populations described in subsection (f)(3)(H);
(dd)
improving access to child care services for vulnerable children as defined by the lead agency pursuant to subsection (b)(4)(A)(iv)(II);
(ee)
providing outreach and enrollment support for families of eligible children;
(ff)
supporting eligible child care providers to eliminate use of suspensions, expulsions, and aversive behavioral interventions, including through adaptations and interventions by special educators, mental health consultants, and other community resource personnel, such as behavior coaches, psychologists, and other appropriate specialists, and through the provision of mental health services for the providers;
(gg)
improving coordination between States and local government with respect to licensing and other regulatory requirements for eligible child care providers; and
(hh)
establishing or supporting a system of local or regional child care resource and referral organizations that is coordinated, to the extent determined appropriate by the State, by a statewide public or private nonprofit, community-based or regionally based, lead child care resource and referral organization, as described in section 658E(c)(3)(B)(iii) of the Child Care and Development Block Grant Act of 1990 (42 U.S.C. 9858c(c)(3)(B)(iii)).
(V) Technical assistance
From a portion of the quality child care amount, the State, in coordination with local governments and staffed family child care networks as appropriate, shall provide technical assistance to increase the supply and quality of eligible child care providers who are providing, or seeking to provide, child care services to children receiving assistance under this section, including providing support to enable providers to achieve licensure.
(i) Grants to localities and awards to Head Start programs
(1) Eligible locality defined
In this subsection, the term eligible locality means a city, county, or other unit of general local government.
(2) Grants to localities
(A) In general
After reserving a portion of the funds appropriated under subsection (c)(2), the Secretary shall use the portion to award local Birth Through Five Child Care and Early Learning Grants, as determined by the Secretary, to eligible localities located in States that have not received payments under subsection (g). The Secretary shall award the grants to eligible localities in such a State from the allotment made for that State under subparagraph (B).
(B) Allotments
(i) Poverty line defined
In this subparagraph, the term poverty line means the poverty line defined and revised as described in section 673 of the Community Services Block Grant Act (42 U.S.C. 9902).
(ii) General authority
For each State described in subparagraph (A), the Secretary shall allot for the State for a fiscal year an amount that bears the same relationship to the portion described in subparagraph (A) for the fiscal year as the number of children from families with family incomes that are at or below 200 percent of the poverty line, and who are under the age of 6, in the State bears to the total number of all such children in all States described in subparagraph (A).
(C) Application
To receive a grant from the corresponding State allotment under subparagraph (B), an eligible locality shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. The requirements for the application shall, to the greatest extent practicable, be consistent with the State plan requirements applicable to States under subsection (f).
(D) Requirements
The Secretary shall specify the requirements for an eligible locality to provide access to child care, which child care requirements shall, to the greatest extent practicable, be consistent with the requirements applicable to States under this section.
(E) Recoupment of unused funds
Notwithstanding any other provision of this section, for each of fiscal years 2026 through 2030, the Secretary shall have the authority to recoup any unused funds allotted under subparagraph (B) for awards under paragraph (3)(A) to Head Start agencies in accordance with paragraph (3).
(3) Head Start expansion in nonparticipating States
(A) In general
The Secretary shall use funds appropriated under subsection (c)(2) and not reserved under paragraph (2)(A) and funds recouped under paragraph (2) to make awards to Head Start agencies in a State described in paragraph (2)(A) to carry out the purposes of the Head Start Act (42 U.S.C. 9831 et seq.) in such State.
(B) Rule
For purposes of carrying out the Head Start Act in circumstances not involving awards under this paragraph, funds awarded under subparagraph (A) shall not be included in the calculation of a base grant
as such term is defined in section 640(a)(7)(A) of the Head Start Act (42 U.S.C. 9835(a)(7)(A)).
(C) Definition
In this paragraph, the term Head Start agency means an entity designated or eligible to be designated as a Head Start agency under section 641(a)(1) of the Head Start Act (42 U.S.C. 9836(a)(1)) or as an Early Head Start agency (by receiving a grant) under section 645A(a) of such Act (42 U.S.C. 9840a(a)(1)).
(4) Priority for serving underserved populations
In making determinations to award a grant or make an award under this subsection, the Secretary shall give priority to entities serving a high percentage of individuals from underserved populations described in subsection (f)(3)(H).
(j) Program requirements
(1) Prohibition on additional eligibility requirements
No individual shall be determined, by the Secretary, a State, or another recipient of funds under this section, to be ineligible for child care services provided under this section, except on the basis of eligibility requirements specified in or under this section.
(2) Maintenance of effort
(A) In general
A State that receives payments under this section for a fiscal year, in using the funds made available through the payments, shall maintain the expenditures of the State for child care services at the average level of such expenditures by the State for the 3 preceding fiscal years.
(B) Counting rule
State expenditures counted for purposes of meeting the requirement in subparagraph (A) may also be counted for purposes of meeting the requirement to provide a non-Federal share under subparagraph (A), (B), or (C), as appropriate, of subsection (g)(1).
(3) Supplement not supplant
Funds received under this section shall be used to supplement and not supplant other Federal, State, and local public funds expended to provide child care services in the State on the date of enactment of this Act, calculated as the average amount of such Federal, State, and local public funds expended for fiscal year 2026 and each subsequent fiscal year that ended before the date on which the average is calculated.
(4) Allowable sources of non-Federal share
For purposes of providing the non-Federal share required under subsection (g)(1), a State’s non-Federal share—
(A)
for direct child care services described in subsection (g)(1)(A)—
(i)
shall not include contributions being used as a non-Federal share or match for another Federal award; and
(ii)
shall be provided from State or local sources, contributions from philanthropy or other private organizations, or a combination of such sources and contributions; and
(B)
for activities to improve the quality and supply of child care services described in subsection (g)(1)(B), and administration described in subsection (g)(1)(C)—
(i)
shall not include contributions being used as a non-Federal share or match for another Federal award;
(ii)
shall be provided from State or local sources, contributions from philanthropy or other private organizations, or a combination of such sources and contributions; and
(iii)
may be in cash or in-kind, fairly evaluated, including facilities or property, equipment, or services.
(5) Reports
A State, Indian Tribe, tribal organization, or territory receiving funds under this section shall provide to the Secretary such periodic reports, providing a detailed accounting of the uses of the funds received under this section, as the Secretary may require for the administration of this section. The State, Indian Tribe, tribal organization, or territory shall begin to provide the reports beginning not later than 60 days after its initial receipt of a payment under subsection (g).
(k) Monitoring and enforcement
(1) Review of compliance with requirements and State plan
The Secretary shall review and monitor compliance of States, territories, tribal entities, and local entities with this section and State compliance with the State plan described in subsection (f)(3).
(2) Issuance of rule
The Secretary shall establish by rule procedures for—
(A)
receiving, processing, 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 section;
(B)
notifying a State when the Secretary has determined there has been a failure by the State to comply with a requirement of this section; and
(C)
imposing sanctions under this subsection for such a failure.
(l) Federal administration
Using funds reserved under subsection (c)(3), the Secretary shall carry out administration of this section, shall provide (including through the use of grants or cooperative agreements) technical assistance to States, territories, Indian Tribes, and tribal organizations, and shall carry out research, and evaluations related to this section.
(m) Nonpostsecondary education program
For purposes of section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1611), the program carried out under this section shall be considered to be a program of nonpostsecondary education.
Title VII Establishing a $60,000 a year minimum salary for every public school teacher in the United States
Sec. 701. Purposes
The purposes of this title are to—
(1)
ensure public elementary and secondary school teachers earn a livable and competitive salary that—
(A)
includes a starting annual base salary of not less than $60,000; and
(B)
increases regularly throughout a teacher’s career;
(2)
increase Federal investments in public schools; and
(3)
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 teacher.
Sec. 702. Definitions
(a) Definitions
In this title:
(1) ESEA Terms
The terms elementary school, outlying area, and secondary school have the meanings given those terms in section 8101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801).
(2) Annual adjustment percentage
The term annual adjustment percentage, with respect to a fiscal year, means a percentage equal to the estimated percentage change in the Consumer Price Index, as determined by the Secretary, for the most recent calendar year ending prior to the beginning of such fiscal year.
(3) Annual base salary
The term annual base salary—
(A)
means the base salary, calculated as an annual rate of pay, of a full-time teacher; and
(B)
excludes—
(i)
any additional compensation earned by the teacher for taking on additional responsibilities (such as coaching or teaching during the summer or after school); and
(ii)
bonuses, stipends, and awards.
(4) Average teacher salary baselines
The term average teacher salary baselines means, for each of the following years of service as teachers, the average annual base salaries of all full-time teachers employed by local educational agencies in the State:
(A)
0 years, or starting teacher salaries.
(B)
3 years.
(C)
5 years.
(D)
10 years.
(E)
15 years.
(F)
20 years.
(G)
25 years.
(5) Consumer price index
The term Consumer Price Index has the meaning given the term in section 478(f) of the Higher Education Act of 1965 (20 U.S.C. 1087rr(f)).
(6) Minimum salary for teachers
The term minimum salary for teachers means an amount, determined by the State, that all full-time teachers employed by a local educational agency are, at a minimum, required by the State to be compensated by such agency as their annual base salary, and which—
(A)
for teachers in their first year of teaching, shall be an annual rate of pay that is not less than the amount described in subsection (b); and
(B)
for teachers with more than 2 years of experience, shall be an annual rate of pay that—
(i)
is greater than the amount described in subsection (b); and
(ii)
increases as the experience of a teacher increases.
(7) Secretary
The term Secretary means the Secretary of Education.
(8) Teacher
The term teacher means—
(A)
an employee of a local educational agency—
(i)
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 teacher;
(ii)
who fully meets all applicable public elementary school or secondary school teacher certification and licensure requirements of the State in which the school is located; and
(iii)
if the teacher is a special education teacher, who meets the qualifications described in section 612(a)(14)(C) of the Individuals with Disabilities Education Act; and
(B)
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 teacher.
(b) Special rules
(1) In general
For each fiscal year, the amount described in subsection (a)(6)(A) shall be determined under this subsection.
(2) Fiscal years 2027 through 2031
For each of fiscal years 2027 through 2031, the amount described in subsection (a)(6)(A) is $60,000.
(3) Fiscal years 2032 and after
(A) In general
For the fiscal year period 2032 through 2036 and for each subsequent 5 fiscal year period, the amount described in subsection (a)(6)(A) shall be adjusted for inflation as described in subparagraph (B).
(B) Determination
The amount shall be equal to the amount applicable for the previous 5 fiscal year period, increased by the greater of—
(i)
the aggregate annual adjustment percentage over the previous 5 fiscal years; or
(ii)
2 percent of the amount applicable under this subsection for the previous 5 fiscal year period.
Sec. 703. Ensuring teachers are paid a livable and competitive wage
(a) Authorization and appropriations for states
(1) In general
There are authorized to be appropriated to carry out this section such sums as may be necessary for fiscal year 2027 and each succeeding fiscal year.
(2) Appropriations for states
In addition to amounts otherwise available to carry out this section, there are appropriated, out of any money in the Treasury not otherwise appropriated, to the Secretary to carry out this section—
(A)
for fiscal year 2027, $14,500,000,000; and
(B)
for each succeeding fiscal year, the amount appropriated under this section for the preceding fiscal year, increased by the annual adjustment percentage.
(b) Program authorized
(1) In general
From amounts made available to carry out this section, and after making the reservations described in paragraph (2), the Secretary shall award grants, through allotments described in paragraph (3), 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 salary, which shall be an amount that—
(A)
is at least the minimum salary for teachers;
(B)
increases throughout each teacher’s career; and
(C)
is, to the greatest extent practicable, commensurate with annual salaries for college-educated and similarly experienced professionals in the region in which such agencies are located, as determined in accordance with procedures and requirements established by the Secretary.
(2) Reservations
(A) In General
From the amount appropriated under subsection (a) for a fiscal year, the Secretary shall reserve—
(i)
one-half of 1 percent for allotments for payments to the outlying areas, to be distributed among those outlying areas on the basis of their relative need, as determined by the Secretary, to ensure that teachers are paid a livable and competitive salary, in accordance with the purposes of this title;
(ii)
one-half of 1 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 (as defined in section 1141 of the Education Amendments of 1978 (25 U.S.C. 2021)) to ensure teachers are paid a livable and competitive salary, in accordance with the purposes of this title; and
(iii)
1 percent for program administration, technical assistance, and data collection for the program under this section.
(B) Special rule
Notwithstanding any other provision of this title, the requirements of this section and section 702 shall not apply to recipients described in clause (i) and (ii) of subparagraph (A), except that such recipients shall use funds described in this paragraph to ensure that teachers are paid a livable and competitive salary.
(3) Allotments
(A) In general
After making the reservations under paragraph (2), the Secretary shall allot 50 percent of the remaining amount appropriated under subsection (a) in accordance with subparagraph (B) and allot the other 50 percent of such remaining amount in accordance with subparagraph (C).
(B) Targeted formula
From an amount equal to 50 percent of the amounts appropriated under subsection (a) and remaining after the reservations of funds under paragraph (2) (referred to in this section as the targeted formula amounts
), the Secretary shall allot to each State having a plan approved by the Secretary under subsection (d) 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 1125 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 6335) for the preceding fiscal year bears to the amount all local educational agencies in all States received under such section for the preceding fiscal year.
(C) EFIG formula
From an amount equal to 50 percent of the amounts appropriated under subsection (a) and remaining after the reservations of funds under paragraph (2) (referred to in this section as the EFIG formula amounts
), the Secretary shall allot to each State having a plan approved by the Secretary under subsection (d) an amount that bears the same relationship to such EFIG formula amounts as the amount the State received under section 1125A of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 20 U.S.C. 6337) for the preceding fiscal year bears to the amount all States received under such section for the preceding fiscal year.
(D) Final allotments
For the purposes of this section, a State’s allotment shall be the sum of a State’s allotments calculated under subparagraph (B) and subparagraph (C).
(c) Improving teacher salaries
(1) In general
Subject to paragraph (3), 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—
(A)
is at least the minimum salary for teachers;
(B)
increases throughout each teacher’s career; and
(C)
is, to the greatest extent practicable, commensurate with annual salaries for college-educated and similarly experienced professionals in the region in which such agencies are located, as determined in accordance with procedures and requirements established by the Secretary.
(2) Compliance
To comply with paragraph (1), 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 teachers:
(A)
A statewide salary schedule that ensures that the salary of every full-time teacher employed by a local educational agency in the State is—
(i)
an amount not less than the minimum salary for teachers established by the State under subsection (d)(1)(A); and
(ii)
increases as the experience of a teacher increases.
(B)
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 (d)(1)(A).
(C)
A State law to increase salaries for teachers.
(3) Timing
The Secretary shall ensure that, not later than 3 years after a State receives an allotment under this section, each such State meets the teacher salary requirements described in paragraph (1).
(d) State plan
(1) In general
In order to receive an allotment under subsection (b)(3), a State shall submit a State plan to the Secretary at such time, in such manner, and containing such information as the Secretary may reasonably require. Such State plan shall include, at a minimum each of the following:
(A)
A description of the State’s minimum salary for teachers, including the State’s plan to ensure that the State will meet the requirements of subsection (c)(1) not later than 3 years after the State receives an allotment under this section.
(B)
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 State, in a manner that—
(i)
supports local educational agencies in increasing salaries or wages for teachers, paraprofessionals, specialized instructional support personnel, classified school employees, principals, other school leaders, school librarians, school bus drivers, and other staff across their careers, including through providing increased resources to local educational agencies; and
(ii)
does not—
(I)
increase average class sizes or student to full-time equivalent teacher ratios at the State, local educational agency, or school level;
(II)
reduce planning time; or
(III)
require teachers to teach additional classes.
(C)
An identification, with respect to the average teacher salary baselines in the most recent fiscal year, of the statewide average and the average in each local educational agency in the State.
(D)
An identification of the number and percentage of teachers employed by local educational agencies in the State who earn a salary of less than $60,000 annually, disaggregated by each period of service specified in the average teacher salary baselines, across the State and in each such local educational agency.
(E)
A description of the State’s plan to comply with the equitable distribution of teachers requirement under section 1111(g)(1)(B) of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 6311(g)(1)(B)).
(2) Public comment
Each State shall make the State plan publicly available for public comment for a period of not less than 30 days, by electronic means and in an easily accessible format, prior to submission to the Secretary for approval under this subsection. Upon submission, the State plan shall include a summary of the comments submitted to the Secretary, with a description of how the State addressed the comments, and make such summary with description publicly available on the website of the State educational agency.
(e) State use of funds
Each State that receives an allotment under subsection (b) shall—
(1)
reserve not more than 1 percent of the amounts allotted to the State under subsection (b)(3)(D) to provide technical assistance and conduct monitoring to ensure that all local educational agencies meet the requirements described in subsection (c);
(2)
reserve not more than 4 percent of the amounts allotted to the State under subsection (b)(3)(D) to conduct statewide efforts to—
(A)
increase teacher compensation across the State in accordance with in subsection (c);
(B)
identify and reform policies and practices at the State, local educational agency, and school-level to promote excellent teaching for all students, particularly subgroups of students; and
(C)
address structural and organizational challenges in the teaching profession, in order to—
(i)
raise the standards, status, and salaries of the teaching profession; and
(ii)
attract and retain promising and talented young people to teaching; and
(3)
from the amounts allotted to the State under subsection (b)(3)(D) that are remaining after reserving amounts under paragraphs (1) and (2), allocate—
(A)
50 percent of such remaining amounts to local educational agencies in the State in accordance with the targeted formula described in section 1125(b) of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 6335(b)); and
(B)
50 percent of such remaining amounts to local educational agencies in the State in accordance with the formula described in section 1125A(d) of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 6337(d)).
(f) Reporting requirements
Not later than 1 year after receiving an allotment under this section and annually thereafter, 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 State. Such report shall contain any information required by the Secretary and include, at a minimum—
(1)
data on the average teacher salary baselines for the previous fiscal year, disaggregated by the statewide average and the average in each local educational agency in the State;
(2)
updated data on the number of teachers employed by local educational agencies in the State who earn less than the minimum salary for teachers, disaggregated by each period of service described in section 702(a)(4), across the State and employed by each local educational agency;
(3)
a description of the actions the State educational agency will take in the next fiscal year to support local educational agencies described in paragraph (2) in decreasing the number of teachers employed by such agencies who earn less than the minimum salary for teachers;
(4)
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 State, in a manner that—
(A)
supports local educational agencies in increasing salaries or wages for teachers, paraprofessionals, specialized instructional support personnel, classified school employees, principals, other school leaders, school librarians, school bus drivers, and other staff across their careers, including through providing increased resources to local educational agencies; and
(B)
does not—
(i)
increase average class sizes or student to full-time equivalent teacher ratios at the State, local educational agency, or school level;
(ii)
reduce planning time; or
(iii)
require teachers to teach additional classes; and
(5)
a description of how the State improved the equitable distribution of teachers in such fiscal year, as required under section 1111(g)(1)(B) of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 6311(g)(1)(B)).
Sec. 704. Collective bargaining and related rules
(a) Rule of construction for collective bargaining
(1) In general
Subject to paragraph (2), nothing in section 703 shall be construed to alter or otherwise affect the rights, remedies, and procedures afforded to school or local educational agency employees under Federal, State, or local laws (including applicable regulations or court orders) or under the terms of collective bargaining agreements, memoranda of understanding, or other agreements between such employers and their employees.
(2) Compliance
Paragraph (1) shall not be construed to exempt a State, local educational agency, or school from complying with section 703 or from negotiating in compliance with State labor laws to comply with section 703.
(b) Rule of construction for additional pay or other salary augmenting systems
Nothing in section 703 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—
(1)
for additional skills, knowledge, duties, and responsibilities;
(2)
by salary systems that increase teachers’ compensation through supplemental pay that is not part of an annual base salary; or
(3)
through the provision of bonuses, stipends, or awards.
Title VIII Investments in Home and Community-Based Services and Long-Term Care Quality and Workforce
Sec. 801. HCBS improvement planning grants
(a) Funding
(1) In general
In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2027, out of any money in the Treasury not otherwise appropriated, $130,000,000, to remain available until expended, for carrying out this section.
(2) Technical assistance and guidance
In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2027, out of any money in the Treasury not otherwise appropriated, $5,000,000, to remain available until expended, for purposes of issuing guidance and providing technical assistance to States intending to apply for, or which are awarded, a planning grant under this section, and for other administrative expenses related to awarding planning grants under this section.
(b) Award and use of grants
(1) Deadline for award of grants
From the amount appropriated under subsection (a)(1), the Secretary, not later than 12 months after the date of enactment of this Act, shall solicit State requests for HCBS improvement planning grants and award such grants to all States that meet such requirements as determined by the Secretary.
(2) Use of funds
Subject to paragraph (3), 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 (c). A State may use planning grant funds to support activities related to the implementation of the HCBS improvement plan for the State.
(3) 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 program.
(c) HCBS improvement plan requirements
(1) Content
The Secretary shall define the content requirements for an HCBS improvement plan, which, at minimum, shall include an assessment of access barriers to home and community-based services and the availability (as defined by the Secretary) of such services in the State, a description of Medicaid payment rates for such services, a description of the current workforce of direct care workers, the percentage of expenditures made by the State for long-term services and supports that are for home and community-based services, and a description of how the State will meet the requirements of the HCBS Improvement Program.
(2) Submission; approval; amendments
Not later than 24 months after the date on which a State is awarded a planning grant under this section, the State shall submit an HCBS improvement plan for approval by the Secretary, along with assurances by the State that the State will implement the plan in accordance with the requirements of the HCBS Improvement Program. 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 subsection. A State may amend its HCBS improvement plan, subject to the approval of the Secretary that the plan as so amended meets the requirements of this subsection.
(d) Definitions
In this part:
(1) Direct care worker
The term direct care worker means, with respect to a State, 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 program:
(A)
A registered nurse, licensed practical nurse, nurse practitioner, or clinical nurse specialist, or a licensed nursing assistant who provides such services under the supervision of a registered nurse, licensed practical nurse, nurse practitioner, or clinical nurse specialist.
(B)
A direct support professional.
(C)
A personal care attendant.
(D)
A home health aide.
(E)
Any other paid health care professional or worker determined to be appropriate by the State and approved by the Secretary.
(2) HCBS Improvement Program
The term HCBS Improvement Program means the program established under subsection (ll) of section 1905 of the Social Security Act (42 U.S.C. 1396d) (as added by section 802).
(3) HCBS Improvement Program State
The term HCBS Improvement Program State means a State that is awarded a planning grant under subsection (b) and has an HCBS improvement plan approved by the Secretary under subsection (c)(2).
(4) Home and community-based services
The term home and community-based services means any of the following (whether provided on a fee-for-service, risk, or other basis):
(A)
Home health care services authorized under paragraph (7) of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)).
(B)
Private duty nursing services authorized under paragraph (8) of such section, when such services are provided in a Medicaid eligible individual’s home.
(C)
Personal care services authorized under paragraph (24) of such section.
(D)
PACE services authorized under paragraph (26) of such section.
(E)
Home and community-based services authorized under subsections (b), (c), (i), (j), and (k) of section 1915 of such Act (42 U.S.C. 1396n), authorized under a waiver under section 1115 of such Act (42 U.S.C. 1315), or provided through coverage authorized under section 1937 of such Act (42 U.S.C. 1396u–7).
(F)
Case management services authorized under section 1905(a)(19) of the Social Security Act (42 U.S.C. 1396d(a)(19)) and section 1915(g) of such Act (42 U.S.C. 1396n(g)).
(G)
Rehabilitative services, including those related to behavioral health, described in section 1905(a)(13) of such Act (42 U.S.C. 1396d(a)(13)).
(H)
Such other services specified by the Secretary.
(5) Medicaid eligible individual
The term Medicaid eligible individual means an individual who is eligible for and receiving medical assistance under a State Medicaid program. 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 services.
(6) State Medicaid program
The term State Medicaid program means, with respect to a State, the State program under title XIX of the Social Security Act (42 U.S.C. 1396 through 1396w–6) (including any waiver or demonstration under such title or under section 1115 of such Act (42 U.S.C. 1315) relating to such title).
(7) Secretary
The term Secretary means the Secretary of Health and Human Services.
(8) State
The term State means each of the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
Sec. 802. HCBS Improvement Program
(a) Increased FMAP for HCBS Improvement Program States
Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—
(1)
in subsection (b), by striking and (ii)
and inserting (ii), and (ll)
; and
(2)
by adding at the end the following new subsection:
(ll) Additional support for HCBS Improvement Program States
(1) In general
(A) Additional support
Subject to paragraph (5), in the case of a State that is an HCBS Improvement Program State, for each fiscal quarter that begins on or after the first date on which the State is an HCBS Improvement Program State—
(i)
and for which the State meets the requirements described in paragraphs (2) and (4), notwithstanding subsection (b) or (ff), subject to subparagraph (B), with respect to amounts expended during the quarter by such State for medical assistance for home and community-based services, the Federal medical assistance percentage for such State and quarter (as determined for the State under subsection (b) or (ff) and, if applicable, increased under subsection (y), (z), (aa), or (ii), or section 1915(k)(2)) shall be increased by 8 percentage points; and
(ii)
with respect to the State meeting the requirements described in paragraphs (2) and (4) and with respect to amounts expended during the quarter and before October 1, 2036, administrative costs for expanding and enhancing home and community-based services, including for enhancing Medicaid data and technology infrastructure, modifying rate setting processes, adopting or improving training programs for direct care workers and family caregivers, home and community-based services ombudsman office activities, developing processes to identify direct care workers and assign such workers unique identifiers, and adopting, carrying out, or enhancing programs that register direct care workers or connect beneficiaries to direct care workers, shall be eligible for Federal financial participation in the same manner as other administrative expenditures under section 1903(a), except that, for purposes of this clause, the per centum applicable to such expenditures shall be the greater of 80 percent or the per centum that would otherwise apply.
In no case may the application of clause (i) result in the Federal medical assistance percentage determined for a State being more than 95 percent with respect to such expenditures. Any increase pursuant to clause (ii) shall be available to a State before the State meets the requirements of paragraphs (2) and (4).
(B) Additional HCBS improvement efforts
Subject to paragraph (5), in addition to the increase to the Federal medical assistance percentage under subparagraph (A)(i) 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 (2) and (4) for the quarter, 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 2 percentage points (but not to exceed 95 percent) during the first 6 fiscal quarters throughout which the State has implemented and has in effect a program that meets the requirements of paragraph (3).
(C) Nonapplication to CHIP EFMAP
Any increase to the Federal medical assistance percentage of a State under subparagraph (A)(i) or (B) or an increase to an applicable Federal matching percentage under subparagraph (A)(ii) shall not be taken into account in calculating the enhanced FMAP of a State under section 2105.
(2) Requirements
As conditions for receipt of the increase under paragraph (1)(A)(i) to the Federal medical assistance percentage determined for a State, with respect to a fiscal year quarter, the State shall meet each of the following requirements:
(A) 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 (1)(A) and paragraph (1)(B) (if applicable) to supplement, and not supplant, 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 801 of the Make Billionaires Pay Their Fair Share Act. In applying this subparagraph, the Secretary shall provide that a State shall have a 3-year period, as specified by the Secretary, to spend any accumulated unspent State funds attributable to such increase to the Federal medical assistance percentage.
(B) Maintenance of effort
(i) In general
The State does not—
(I)
reduce the amount, duration, or scope of home and community-based services available under the State plan (or waiver of such plan) 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 801 of the Make Billionaires Pay Their Fair Share Act;
(II)
reduce payment rates for home and community-based services lower than such rates that were in place as of the date described in subclause (I), including, to the extent applicable, assumed payment rates for such services that are included in managed care capitation rates as such rates are being prospectively built; or
(III)
except to the extent permitted under clause (ii), adopt more restrictive standards, methodologies, or procedures for determining eligibility for, or the scope of, medical assistance for home and community-based services, including with respect to cost-sharing, than the standards, methodologies, or procedures applicable as of the date described in subclause (I).
(ii) Conditions for flexibility
A State may make modifications that would otherwise violate the maintenance of effort described in clause (i) if the State demonstrates to the satisfaction of the Secretary that such modifications shall not result in—
(I)
home and community-based services that are less comprehensive or lower in amount, duration, or scope;
(II)
fewer individuals (overall and within particular eligibility groups) receiving home and community-based services, adjusted for demographic changes since the date described in clause (i)(I); or
(III)
increased cost-sharing (other than resulting from the rate of inflation) for home and community-based services.
(C) 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 (which may vary for each of the following clauses) 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 (1):
(i)
Reduces access barriers and disparities in access or utilization of home and community-based services.
(ii)
Provides coverage of personal care services authorized under subsection (a)(24) for all individuals eligible for and enrolled in medical assistance in the State.
(iii)
Provides for navigation of home and community-based services through
no wrong doorprograms, provides expedited eligibility for home and community-based services, and improves home and community-based services counseling and education programs.(iv)
Expands access to behavioral health services furnished in home and community-based settings.
(v)
Improves coordination of home and community-based services with employment, housing, and transportation supports.
(vi)
Provides supports to family caregivers.
(vii)
Newly provides coverage under, or expands existing eligibility criteria for, 1 or more of the eligibility categories authorized under subclause (XIII), (XV), or (XVI) of section 1902(a)(10)(A)(ii).
(D) Workforce
The State strengthens and expands the workforce of direct care workers that provides home and community-based services by—
(i)
adopting processes to ensure that payment rates for home and community-based services are sufficient (as defined by the Secretary) to ensure that services are available, including by, not later than 2 years after approval of the HCBS improvement plan and, at least every 3 years thereafter, updating and, as appropriate, increasing payment rates for home and community-based services to support recruitment and retention of direct care workers using, through existing or other processes to determine provider payments, a transparent process involving input from nongovernmental stakeholders;
(ii)
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 workers; and
(iii)
updating qualification standards as appropriate, and developing and adopting training opportunities, for direct care workers and family caregivers, at such times as the Secretary shall prescribe.
(3) Self-directed models for the delivery of services
As conditions for receipt of the increase under paragraph (1)(B) to the Federal medical assistance percentage determined for a State, with respect to a fiscal year quarter, the State shall establish directly, or by contract with 1 or more entities, including an agency with choice or a similar service delivery model, a program for the performance of all of the following functions, consistent with guidance issued by the Secretary, to facilitate beneficiary use of self-directed care in the case the State covers home and community-based services under authorities that permit self-direction:
(A)
Recruiting and registering qualified direct care workers and assisting beneficiaries in finding qualified direct care workers.
(B)
Supporting beneficiary hiring, if selected by the beneficiary, of independent providers of home and community-based services, including through the provision of financial management services.
(C)
To the extent a State permits beneficiaries to hire a family member or individual with whom they have an existing relationship to provide home and community-based services, providing support to beneficiaries who wish to hire a caregiver who is a family member or individual with whom they have an existing relationship.
(D)
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 organization.
(4) Reporting and oversight
As a condition for receipt of an increase under subparagraphs (A)(i) or (B) of paragraph (1) to the Federal medical assistance percentage determined for a State, with respect to a fiscal year quarter, the State shall, beginning with the last day of the 5th fiscal quarter for which the State is an HCBS Improvement Program State, and annually thereafter, report to the Secretary, in a manner the Secretary shall prescribe, on—
(A)
the State's progress in implementing the activities described in subparagraphs (C) and (D) of paragraph (2) and (if applicable) paragraph (3) in accordance with the State HCBS improvement plan; and
(B)
the use of the increased funding provided under this subsection.
(5) 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 (1)(A)(i) or (1)(B) or an increase to an applicable Federal matching percentage under paragraph (1)(A)(ii) for each fiscal quarter after the 29th fiscal quarter that begins on or after the first date on which the State is an HCBS Improvement Program State unless, at the end of such 29th fiscal quarter, the State demonstrates the following in the annual report required in paragraph (4) for such quarter:
(A)
Increased availability (above a marginal increase) 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 plan.
(B)
With respect to the percentage of expenditures made by the State for long-term services and supports that are for home and community-based services, in the case of an HCBS Improvement Program State for which such percentage (as reported in the State HCBS improvement plan) was—
(i)
less than 50 percent, the State demonstrates that the percentage of such expenditures has increased to at least 50 percent since the plan was approved; and
(ii)
at least 50 percent, the State demonstrates that such percentage has not decreased since the plan was approved.
(6) Definitions
In this subsection, the terms direct care worker, HCBS Improvement Program State, and home and community-based services have the meaning given those terms in section 801(d) of the Make Billionaires Pay Their Fair Share Act.
Sec. 803. Funding for Federal activities related to Medicaid HCBS
In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2027, out of any money in the Treasury not otherwise appropriated, $40,000,000, to remain available until expended, to carry out section 802 (including the amendments made by such section), including by issuing necessary guidance and technical assistance to States and conducting program integrity and oversight efforts.
Sec. 804. Funding for HCBS quality measurement and improvement
In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2027, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until expended, for purposes of developing, in consultation with nongovernmental stakeholders with expertise in home and community-based services (including recipients and providers of such services), a recommended set of home and community-based services quality measures that reflect the full range of home and community-based services (as defined in section 801(d)) and the recipients of such services.
Sec. 805. Permanent extension of Medicaid protections against spousal impoverishment for recipients of home and community-based services
(a) In general
Section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amended by striking (at the option of the State) is described in section 1902(a)(10)(A)(ii)(VI)
and inserting the following: is eligible for medical assistance for home and community-based services provided under subsection (c), (d), or (i) of section 1915 or under a waiver approved under section 1115, or who is eligible for such medical assistance by reason of being determined eligible under section 1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care, or who is eligible for medical assistance for home and community-based attendant services and supports under section 1915(k)
.
(b) Conforming amendment
Section 2404 of the Patient Protection and Affordable Care Act (42 U.S.C. 1396r–5 note) is amended by striking September 30, 2027
and inserting the date of enactment of the Make Billionaires Pay Their Fair Share Act
.
Sec. 806. Permanent extension of Money Follows the Person Rebalancing demonstration
Subsection (h) of section 6071 of the Deficit Reduction Act of 2005 (42 U.S.C. 1396a note) is amended—
(1)
in paragraph (1)—
(A)
in subparagraph (I), by inserting and
after the semicolon;
(B)
in subparagraph (J), by inserting and each fiscal year thereafter
before the semicolon; and
(C)
by striking subparagraphs (K) and (L); and
(2)
in paragraph (3), by striking through fiscal year 2029
.