January 14, 2000  
Dear State Medicaid Director:  
The recent Supreme Court decision in Olmstead v. L. C., 119 S.Ct. 2176 (1999), provides an 
important legal framework for our mutual efforts to enable individuals with disabilities to live in 
the most integrated setting appropriate to their needs. The Court's decision clearly challenges us to 
develop more opportunities for individuals with disabilities through more accessible systems of 
cost-effective community-based services.  
This decision confirms what this Administration already believes: that no one should have to live 
in an institution or a nursing home if they can live in the community with the right support. Our 
goal is to integrate people with disabilities into the social mainstream, promote equality of 
opportunity and maximize individual choice.  
The Department of Health and Human Services (DHHS) is committed to working with all affected 
parties to craft comprehensive, fiscally responsible solutions that comply with the Americans with 
Disabilities Act of 1990 (ADA). Although the ADA applies to all State programs, Medicaid 
programs play a critical role in making community services available. As a consequence, State 
Medicaid Directors play an important role in helping their States comply with the ADA. This letter 
conveys our initial approach to Olmstead and outlines a framework for us to respond to the 
challenge.  
The Olmstead Decision  
The Olmstead case was brought by two Georgia women whose disabilities include mental retardation and mental 
illness. At the time the suit was filed, both plaintiffs lived in State-run institutions, despite the fact that their 
treatment professionals had determined that they could be appropriately served in a community setting. The 
plaintiffs asserted that continued institutionalization was a violation of their right under the ADA to live in the most 
integrated setting appropriate. The Olmstead decision interpreted Title II of the ADA and its implementing 
regulation, which oblige States to administer their services, programs, and activities "in the most integrated setting 
appropriate to the needs of qualified individuals with disabilities." (28 CFR 35.130(d)). In doing so, the Supreme 
Court answered the fundamental question of whether it is discrimination to deny people with disabilities services in 
the most integrated setting appropriate. The Court stated directly that "Unjustified isolation . . . is properly regarded 
as discrimination based on disability." It observed that (a) "institutional placement of persons  
  
who can handle and benefit from community settings perpetuates unwarranted assumptions that 
persons so isolated are incapable or unworthy of participating in community life," and (b) 
"confinement in an institution severely diminishes the everyday life activities of individuals, 
including family relations, social contacts, work options, economic independence, educational 
advancement, and cultural enrichment."  
Under the Court's decision, States are required to provide community-based services for persons 
with disabilities who would otherwise be entitled to institutional services when: (a) the State's 
treatment professionals reasonably determine that such placement is appropriate; (b) the affected  persons do not oppose such treatment; and (c) the placement can be reasonably accommodated, 
taking into account the resources available to the State and the needs of others who are receiving 
State-supported disability services. The Court cautioned however, that nothing in the ADA 
condones termination of institutional settings for persons unable to handle or benefit from 
community settings. Moreover, the State's responsibility, once it provides community-based 
treatment to qualified persons with disabilities, is not unlimited.  
Under the ADA, States are obliged to "make reasonable modifications in policies, practices, or 
procedures when the modifications are necessary to avoid discrimination on the basis of disability, 
unless the public entity can demonstrate that making the modifications would fundamentally alter 
the nature of the service, program or activity." (28 CFR 35.130(b)(7)). The Supreme Court 
indicated that the test as to whether a modification entails "fundamental alteration" of a program 
takes into account three factors: the cost of providing services to the individual in the most 
integrated setting appropriate; the resources available to the State; and how the provision of 
services affects the ability of the State to meet the needs of others with disabilities. Significantly, 
the Court suggests that a State could establish compliance with title II of the ADA if it 
demonstrates that it has:  
a comprehensive, effectively working plan for placing qualified persons with disabilities in 
less restrictive settings, and  
a waiting list that moves at a reasonable pace not controlled by the State's endeavors to keep 
its institutions fully populated.  
Olmstead and the Medicaid Program 
Olmstead challenges States to prevent and correct inappropriate institutionalization and to review 
intake and admissions processes to assure that persons with disabilities are served in the most 
integrated setting appropriate. Medicaid can be an important resource to assist States in meeting 
these goals. We want to work closely with States to make effective use of Medicaid support in your 
planning and implementation of Olmstead. As an example of the interface between Olmstead's 
explanation of the State's ADA obligation and your Medicaid program we would point to the State's 
responsibility, under Medicaid, to periodically review the services of all residents in Medicaid-
funded institutional settings. Those reviews may provide a useful component of the State's planning 
for a comprehensive response to Olmstead.  
  
States must also be responsive to institutionalized individuals who request that their situation be 
reviewed to determine if a community setting is appropriate. In such a case the State has a duty 
to redress the situation, subject to the limits outlined by the Court and the ADA. As another 
example, States may choose to utilize their Medicaid funds to provide appropriate services in a 
range of settings from institutions to fully integrated community support.  
Comprehensive, Effectively Working Plans  As we have noted, the Supreme Court in Olmstead indicated that a State may be able to meet its 
obligation under the ADA by demonstrating that it has a comprehensive, effectively working 
plan for placing qualified persons with disabilities in the most integrated setting appropriate, and 
a waiting list that moves at a reasonable pace not controlled by a State's objective of keeping its 
institutions fully populated. The Department believes that comprehensive, effectively working 
plans are best achieved with the active involvement of individuals with disabilities and their 
representatives in design, development and implementation.  
The Court's Olmstead decision regarding the integration requirement applies to all individuals 
with disabilities protected from discrimination by title II of the ADA. Although Olmstead 
involved two individuals with mental disabilities, the scope of the ADA is not limited only to such 
individuals, nor is the scope of Olmstead limited to Medicaid beneficiaries or to services financed 
by the Medicaid program. In addition, the requirement to provide services in the most integrated 
setting appropriate applies not only to persons already in institutional settings but to those being 
assessed for possible institutionalization.  
The enclosure to this letter offers some recommendations about key principles and practices for 
States to consider as they develop plans. We recognize that there is no single plan that is best suited 
for all States, and accordingly that there are many ways to meet the requirements of the ADA. We 
certainly hope States and people with disabilities will expand and improve on these ideas. Although 
these plans encompass more than just the Medicaid program, we realize the important role played 
by State Medicaid Directors in this area. As just one example, Federal financial participation will 
be available at the administrative rate to design and administer methods to meet these requirements, 
subject to the normal condition that the changes must be necessary for the proper and efficient 
administration of the State's Medicaid program. Because of your significant role, we have taken 
this opportunity to raise these issues with you.  
The principles and practices contained in the accompanying technical assistance enclosure also 
serve as an important foundation for the DHHS Office for Civil Rights' (OCR) activities in this 
area. As you know, OCR has responsibility for investigating discrimination complaints involving 
the most integrated setting issue. OCR also has authority to conduct compliance reviews of State 
programs and has already contacted a number of States to discuss complaints. OCR strongly 
desires to resolve these complaints through collaboration and cooperation with all interested 
parties.  
Next Steps for the Department of Health and Human Services  
Consultation: We have begun consultation with States (including State Medicaid Directors and 
members of the long term care technical advisory group, who share responsibility for Medicaid) 
and with people with disabilities. We look forward to building on this start. Many States have 
made great strides toward enabling individuals with disabilities to live in their communities. 
There is much that we can learn from these States. We are interested in your ideas regarding the  methods by which we might accomplish such continuing consultation effectively and 
economically.  
Addressing Issues and Questions Regarding Olmstead and Medicaid: As we move forward, 
we recognize that States may have specific issues and questions about the interaction between the 
ADA and the Medicaid program. In response to the issues and questions we receive, we will 
review relevant federal Medicaid regulations, policies and previous guidance to assure that they (a) 
are compatible with the requirements of the ADA and the Olmstead decision, and (b) facilitate 
States' efforts to comply with the law.  
Technical Assistance: In response to any issues raised by the States, the DHHS working group 
will develop a plan to provide technical assistance and information sharing among States and 
stakeholders. Responses to questions and technical assistance materials will be published on a 
special website. We are also funding projects in a number of States to assist with nursing home 
transition. Finally, we seek your ideas on the additional forms of technical assistance you would 
find most helpful for home and community-based services and conferences for State policy makers. 
We will use your suggestions to facilitate the implementation of the integration requirement. We 
invite all States and stakeholders to submit questions and recommendations to our departmental 
workgroup co-chaired by the Director of HCFA's Center for Medicaid and State Operations and the 
Director of the DHHS Office for Civil Rights. Please send such written correspondence to:  
DHHS Working Group for ADA/Olmstead  
c/o Center for Medicaid and State Operations  
HCFA, Room S2-14-26, DEHPG  
7500 Security Blvd.  
Baltimore MD 21244-1850 
Conclusion 
The Administration and DHHS have a commitment to expanding home and community-based 
services and offering consumers choices in how services are organized and delivered. Over the 
past few years, DHHS has focused on expanding and promoting home and community-based 
services, offering support and technical assistance to States, and using the flexibility of the 
Medicaid program. The Olmstead decision affirms that we are moving in the right direction and 
we intend to continue these efforts.  
We recognize that this interim guidance leaves many questions unanswered; with your input, we 
expect  
  
to develop further guidance and technical assistance. We recommend that States do the following:  
Develop a comprehensive, effectively working plan (or plans) to strengthen community  service systems and serve people with disabilities in the most integrated setting appropriate to their 
needs;  
Actively involve people with disabilities, and where appropriate, their family members or 
representatives, in design, development and implementation;  
Use the attached technical assistance material as one of the guides in the planning process;  
Inform us of questions that need resolution and of ideas regarding technical assistance that 
would be helpful.  
We look forward to working with you to improve the nation's community services system.  
Sincerely,  
/s/ Timothy M. Westmoreland Director Center for Medicaid and State Operations Health Care 
Financing Administration  
/s/ Thomas Perez Director Office for Civil Rights  
Enclosure  
cc: All HCFA Regional Administrators All HCFA Associate Regional Administrators, Division of 
Medicaid and State Operations American Public Human Services Association National Association 
of State Alcohol and Drug Abuse Directors, Inc. National Association of State Directors of 
Developmental Disabilities Services National Association for State Mental Health Program 
Directors National Association of State Units on Aging National Conference of State Legislatures 
National Governors' Association  
Enclosure 
Developing Comprehensive, Effectively Working Plans 
Initial Technical Assistance Recommendations 
In ruling on the case of Olmstead v L.C., the Supreme Court affirmed the right of individuals with 
disabilities to receive public benefits and services in the most integrated setting appropriate to their 
needs. The Supreme Court indicated that a State can demonstrate compliance with its ADA 
obligations by showing that it has a comprehensive, effectively working plan for placing qualified  persons with disabilities in less restrictive settings, and a waiting list that moves at a reasonable 
pace not controlled by the State's endeavors to keep its institutions fully populated.  
We strongly urge States to increase access to community-based services for individuals with 
disabilities by developing comprehensive, effectively working plans for ensuring compliance with 
the ADA. There is no single model plan appropriate for all States and situations. In developing 
their plans, States must take into account their particular circumstances. However, we believe 
there are some factors that are critically important for States that seek to develop comprehensive, 
effectively working plans. Our intent in this enclosure is to identify some of the key principles, 
including the involvement of people with disabilities throughout the planning and implementation 
process. These principles also will be used by the Office for Civil Rights as it investigates 
complaints and conducts compliance reviews involving "most integrated setting" issues. We 
strongly recommend that States factor in these principles and practices as they develop plans 
tailored to their needs.  
Comprehensive, Effectively Working Plans 
Principle: Develop and implement a comprehensive, effectively working plan (or plans) for 
providing services to eligible individuals with disabilities in more integrated, community-based 
settings. When effectively carrying out this principle:  
The State develops a plan or plans to ensure that people with disabilities are served in the 
most integrated setting appropriate. It considers the extent to which there are programs that can 
serve as a framework for the development of an effectively working plan. It also considers the level 
of awareness and agreement among stakeholders and decision-makers regarding the elements 
needed to create an effective system, and how this foundation can be strengthened.  
The plan ensures the transition of qualified individuals into community-based settings at a 
reasonable pace. The State identifies improvements that could be made.  
The plan ensures that individuals with disabilities benefit from assessments to determine how 
community living might be possible (without limiting consideration to what is currently available  
in the community). In this process, individuals are provided the opportunity for informed choice.  
The plan evaluates the adequacy with which the State is conducting thorough, objective and 
periodic reviews of all individuals with disabilities in institutional settings (such as State 
institutions, ICFs/MR, nursing facilities, psychiatric hospitals, and residential service facilities for 
children) to determine the extent to which they can and should receive services in a more integrated 
setting.  
The plan establishes similar procedures to avoid unjustifiable institutionalization in the first 
place.  
Plan Development and Implementation Process 
Principle: Provide an opportunity for interested persons, including individuals with disabilities and 
their representatives, to be integral participants in plan development and follow-up. When 
effectively carrying out this principle:   The State involves people with disabilities (and their representatives, where appropriate) in 
the plan development and implementation process. It considers what methods could be employed to 
ensure constructive, on-going involvement and dialogue.  
The State assesses what partnerships are needed to ensure that any plan is comprehensive 
and works effectively.  
Assessments on Behalf of Potentially Eligible Populations 
Principle: Take steps to prevent or correct current and future unjustified 
institutionalization of individuals with disabilities. When effectively carrying out this 
principle:  
 The State has a reliable sense of how many individuals with disabilities are currently
institutionalized and are eligible for services in community-based settings. The plan
considers what information and data collection systems exist to enable the State to make this
determination. Where appropriate, the State considers improvements to data collection
systems to enable it to plan adequately to meet needs.
1  The State evaluates whether existing assessment procedures are adequate to identify 
institutionalized individuals with disabilities who could benefit from services in a more integrated 
setting.  
2  The State also evaluates whether existing assessment procedures are adequate to identify 
individuals in the community who are at risk of placement in an unnecessarily restrictive setting.  
3  The plan ensures that the State can act in a timely and effective manner in response to the 
findings of any assessment process.  
Availability of Community-Integrated Services 
Principle: Ensure the Availability of Community-Integrated Services. When effectively carrying 
out  
this principle:  
(cid:31)  The plan identifies what community-based services are available in the State. It assesses the 
extent to which these programs are able to serve people in the most integrated setting appropriate 
(as described in the ADA). The State identifies what improvements could be accomplished, 
including in information systems, to make this an even better system, and how the system might be 
made comprehensive.  
(cid:31)  The plan evaluates whether the identified supports and services meet the needs of persons 
who are likely to require assistance in order to live in community. It identifies what changes could 
be made to improve the availability, quality and adequacy of the supports.  
(cid:31)  The State evaluates whether its system adequately plans for making supports and services 
available to assist individuals who reside in their own homes with the presence of other family 
members. It also considers whether its plan is adequate to address the needs of those without family 
members or other informal caregivers.  
(cid:31)  The State examines how the identified supports and services integrate the individual into the 
community.   (cid:31)  The State reviews what funding sources are available (both Medicaid and other funding 
sources) to increase the availability of community-based services. It also considers what efforts are 
under way to coordinate access to these services. Planners assess the extent to which these funding 
sources can be organized into a coherent system of long term care which affords people with 
reasonable, timely access to community-based services.  
(cid:31)  Planners also assess how well the current service system works for different groups (e.g. 
elderly people with disabilities, people with physical disabilities, developmental disabilities, mental 
illness, HIV-AIDS, etc.). The assessment includes a review of changes that might be desirable to 
make services a reality in the most integrated setting appropriate for all populations.  
(cid:31)  The plan examines the operation of waiting lists, if any. It examines what might be done to 
ensure that people are able to come off waiting lists and receive needed community services at a 
reasonable pace.  
Informed Choice 
Principle: Afford individuals with disabilities and their families the opportunity to make 
informed choices regarding how their needs can best be met in community or institutional 
settings. When effectively carrying out this principle:  
(cid:31)  The plan ensures that individuals who may be eligible to receive services in more integrated 
community-based settings (and their representatives, where appropriate) are given the opportunity 
to make informed choices regarding whether -and how- their needs can best be met.  
(cid:31)  Planners address what information, education, and referral systems would be useful to ensure 
that people with disabilities receive the information necessary to make informed choices.  
Implications for State and Community Infrastructure 
  
Principle: Take steps to ensure that quality assurance, quality improvement and sound 
management support implementation of the plan. When effectively carrying out this principle:  
(cid:31)  Planners evaluate how quality assurance and quality improvement can be conducted 
effectively as more people with disabilities live in community settings.  
(cid:31)  The State also examines how it can best manage the overall system of health and long term 
care so that placement in the most integrated setting appropriate becomes the norm. It considers 
what planning, contracting and management infrastructure might be necessary to achieve this result 
at the State and the community level.  
FACT SHEET Assuring Access to Community Living for the Disabled 
Overview:  On June 22, 1999, the U.S. Supreme Court affirmed that policy by ruling in Olmstead v. L.C. that 
under the Americans With Disabilities Act (ADA) unjustifiable institutionalization of a person with 
a disability who, with proper support, can live in the community is discrimination. In its ruling, the 
Court said that institutionalization severely limits the person's ability to interact with family and 
friends, to work and to make a life for him or herself.  
The Olmstead case was brought by two Georgia women whose disabilities include mental 
retardation and mental illness. At the time the suit was filed, both plaintiffs were receiving mental 
health services in state-run institutions, despite the fact that their treatment professionals believed 
they could be appropriately served in a community-based setting.  
In accordance with that Court ruling, the U.S. Department of Health and Human Services (HHS) 
today issued guidance to state Medicaid directors on how to make state programs responsive to 
the desires of disabled persons to live in appropriate community-based settings. The 
Administration's goal is to integrate people with disabilities into the social mainstream with equal 
opportunities and the chance to make choices.  
In addition, HHS Secretary Donna E. Shalala wrote to the governor of each state, 
underlining the Department's commitment to community services for those with disabilities 
and noting that the Olmstead decision applied to all relevant state programs, not just 
Medicaid.  
The Olmstead Decision  
The Court based its ruling in Olmstead on sections of the ADA and federal regulations that require 
states to administer their services, programs and activities Ain the most integrated setting 
appropriate to the needs of qualified individuals with disabilities.  
Under the Court's ruling, certain principles have emerged:  
(cid:31)  unjustified institutionalization of people with disabilities is discrimination and violates the 
ADA;  
(cid:31)  states are required to provide community-based services for persons with disabilities 
otherwise entitled to institutional services when the state's treatment professionals reasonably 
determine that community placement is appropriate; the person does not oppose such placement; 
and the placement can reasonably be accommodated, taking into account resources available to the 
state and the needs of others receiving state-supported disability services;  
(cid:31)  a person cannot be denied community services just to keep an institution at its full capacity; 
and,  
(cid:31)  there is no requirement under the ADA that community-based services be imposed on people 
with disabilities who do not desire it.  
The Court also said that states are obliged to "make reasonable modifications in policies, 
practices, or procedures when the modifications are necessary to avoid discrimination on the 
basis of disability, unless the public entity can demonstrate that making the modifications would  fundamentally alter the nature of the service, program or activity." Meeting the fundamental 
alteration test takes into account three factors: the cost of providing services in the most 
integrated setting; the resources available to the state; and how the provision of services affects 
the ability of the state to meet the needs of others with disabilities.  
Olmstead and the Medicaid Program 
The Medicaid program can be an important resource to assist states in meeting the principles set 
out in Olmstead. In its letter/guidance to State Medicaid Directors, the Health Care Financing 
Administration, which oversees the Medicaid and Medicare programs, reminds states they have an 
obligation under Medicaid to periodically review the services of all residents in Medicaid-funded 
institutions.  
The letter also reminds states they may chose to utilize their Medicaid funds to provide 
appropriate services in a range of settings from institutions to fully integrated community 
support.  
HCFA urges states to develop comprehensive working plans to strengthen community service 
systems and to actively involve people with disabilities and their families in the design, 
development and implementation of such plans. HCFA also encourages states to take steps to 
prevent future inappropriate institutionalization of persons with disabilities and to assure the 
availability of community-based services.  
Next Steps  
Over the past few years, HHS has focused on expanding and promoting home and community-
based services, offering support and technical assistance to states and using the flexibility of the 
Medicaid program. The Olmstead decision affirms that we are moving in the right direction.  
To help states comply with the Court ruling, HCFA and the HHS Office for Civil Rights have 
begun working with states and the disability community toward the goals of promoting home and 
community-based services; honoring individual choice in service provision; and acknowledging 
that resources available to a state are limited by the need to serve both community-based and 
institutionalized persons.  
In addition to continued technical assistance to states, HHS will review relevant federal Medicaid 
regulations, policies and previous guidance to assure that they are compatible with requirements 
of the ADA and Olmstead decision and that they facilitate states' efforts to comply with the law.  
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