I 

116TH CONGRESS 

1ST SESSION H. R. 555 

To prohibit discrimination against individuals with disabilities who need longterm services and supports, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 15, 2019 

Mr. SENSENBRENNER (for himself, Mr. DOGGETT, Ms. NORTON, Mr. WELCH, 

Mr. FITZPATRICK, Mr. CONNOLLY, Ms. TITUS, Mr. SERRANO, Mr. 

MORELLE, Mr. ESPAILLAT, Ms. DEAN, Mr. SUOZZI, Mr. CARBAJAL, Mr. 

BRENDAN F. BOYLE of Pennsylvania, Mr. MCGOVERN, Mr. KATKO, Mr. 

PERLMUTTER, Mr. DELGADO, Mr. HIGGINS of New York, Ms. MATSUI, 

Ms. WASSERMAN SCHULTZ, Ms. OCASIO-CORTEZ, Ms. DELAURO, Ms. 

DEGETTE, Mr. RASKIN, Ms. BARRAGA ́N, Mr. CUMMINGS, Mr. LANGEVIN, 

Ms. SCHAKOWSKY, Miss RICE of New York, Mr. RUPPERSBERGER, Ms. 

STEFANIK, Ms. BONAMICI, Mr. CROW, Mr. ENGEL, Mr. TIPTON, Mr. 

PETERSON, Mr. CASTRO of Texas, Mrs. LAWRENCE, Mr. NEGUSE, and 

Mr. BRINDISI) introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committee 

on the Judiciary, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To prohibit discrimination against individuals with disabilities who need long-term services and supports, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Disability Integration 

3 Act of 2019’’. 

4 SEC. 2. FINDINGS AND PURPOSES. 

5 (a) FINDINGS.—Congress finds the following: 

6 (1) In enacting the Americans with Disabilities 

7 Act of 1990 (referred to in this Act as the ‘‘ADA’’), 

8 Congress— 

9 (A) recognized that ‘‘historically, society 

10 has tended to isolate and segregate individuals 

11 with disabilities, and, despite some improve12 ments, such forms of discrimination against in13 dividuals with disabilities continue to be a seri14 ous and pervasive social problem’’; and 

15 (B) intended that the ADA assure ‘‘full 

16 participation’’ and ‘‘independent living’’ for in17 dividuals with disabilities by addressing ‘‘dis18 crimination against individuals with disabilities 

19 [that] persists in critical areas’’, including insti20 tutionalization. 

21 (2) While Congress expected that the ADA’s in22 tegration mandate would be interpreted in a manner 

23 that ensures that individuals who are eligible for in24 stitutional placement are able to exercise a right to 

25 community-based long-term services and supports, 

26 that expectation has not been fulfilled. 


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1 (3) The holdings of the Supreme Court in 

2 Olmstead v. L.C., 527 U.S. 581 (1999), and com3 panion cases, have clearly articulated that individ4 uals with disabilities have a civil right under the 

5 ADA to participate in society as equal citizens. How6 ever, many States still do not provide sufficient com7 munity-based long-term services and supports to in8 dividuals with disabilities to end segregation in insti9 tutions. 

10 (4) The right to live in the community is nec11 essary for the exercise of the civil rights that the 

12 ADA was intended to secure for all individuals with 

13 disabilities. The lack of adequate community-based 

14 services and supports has imperiled the civil rights 

15 of all individuals with disabilities, and has under16 mined the very promise of the ADA. It is, therefore, 

17 necessary to recognize in statute a robust and fully 

18 articulated right to community living. 

19 (5) States, with a few exceptions, continue to 

20 approach decisions regarding long-term services and 

21 supports from social welfare and budgetary perspec22 tives, but for the promise of the ADA to be fully re23 alized, States must approach these decisions from a 

24 civil rights perspective. 


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1 (6) States have not consistently planned to en2 sure sufficient services and supports for individuals 

3 with disabilities, including those with the most sig4 nificant disabilities, to enable individuals with dis5 abilities to live in the most integrated setting. As a 

6 result, many individuals with disabilities who reside 

7 in institutions are prevented from residing in the 

8 community and individuals with disabilities who are 

9 not in institutions find themselves at risk of institu10 tional placement. 

11 (7) The continuing existence of unfair and un12 necessary institutionalization denies individuals with 

13 disabilities the opportunity to live and participate on 

14 an equal basis in the community and costs the 

15 United States billions of dollars in unnecessary 

16 spending related to perpetuating dependency and 

17 unnecessary confinement. 

18 (b) PURPOSES.—The purposes of this Act are— 

19 (1) to clarify and strengthen the ADA’s inte20 gration mandate in a manner that accelerates State 

21 compliance; 

22 (2) to clarify that every individual who is eligi23 ble for long-term services and supports has a feder24 ally protected right to be meaningfully integrated 


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1 into that individual’s community and receive commu2 nity-based long-term services and supports; 

3 (3) to ensure that States provide long-term 

4 services and supports to individuals with disabilities 

5 in a manner that allows individuals with disabilities 

6 to live in the most integrated setting, including the 

7 individual’s own home, have maximum control over 

8 their services and supports, and ensure that long9 term services and supports are provided in a manner 

10 that allows individuals with disabilities to lead an 

11 independent life; 

12 (4) to establish a comprehensive State planning 

13 requirement that includes enforceable, measurable 

14 objectives that are designed to transition individuals 

15 with all types of disabilities at all ages out of institu16 tions and into the most integrated setting; and 

17 (5) to establish a requirement for clear and uni18 form annual public reporting by States that includes 

19 reporting about— 

20 (A) the number of individuals with disabil21 ities who are served in the community and the 

22 number who are served in institutions; and 

23 (B) the number of individuals with disabil24 ities who have transitioned from an institution 

25 to a community-based living situation, and the 


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1 type of community-based living situation into 

2 which those individuals have transitioned. 

3 SEC. 3. DEFINITIONS AND RULE. 

4 (a) DEFINITIONS.—In this Act: 

5 (1) ACTIVITIES OF DAILY LIVING.—The term 

6 ‘‘activities of daily living’’ has the meaning given the 

7 term in section 441.505 of title 42, Code of Federal 

8 Regulations (or a successor regulation). 

9 (2) ADMINISTRATOR.—The term ‘‘Adminis10 trator’’ means— 

11 (A) the Administrator of the Administra12 tion for Community Living; or 

13 (B) another designee of the Secretary of 

14 Health and Human Services. 

15 (3) COMMUNITY-BASED.—The term ‘‘commu16 nity-based’’, when used in reference to services or 

17 supports, means services or supports that are pro18 vided to an individual with an LTSS disability to en19 able that individual to live in the community and 

20 lead an independent life, and that are delivered in 

21 whichever setting the individual with an LTSS dis22 ability has chosen out of the following settings with 

23 the following qualities: 

24 (A) In the case of a dwelling or a nonresi25 dential setting (such as a setting in which an 


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1 individual with an LTSS disability receives day 

2 services and supported employment), a dwelling 

3 or setting— 

4 (i) that, as a matter of infrastructure, 

5 environment, amenities, location, services, 

6 and features, is integrated into the greater 

7 community and supports, for each indi8 vidual with an LTSS disability who re9 ceives services or supports at the setting— 

10 (I) full access to the greater com11 munity (including access to opportuni12 ties to seek employment and work in 

13 competitive integrated settings, en14 gage in community life, control per15 sonal resources, and receive services 

16 in the community); and 

17 (II) access to the greater commu18 nity to the same extent as access to 

19 the community is enjoyed by an indi20 vidual who is not receiving long-term 

21 services or supports; 

22 (ii) that the individual has selected as 

23 a meaningful choice from among nonresi24 dential setting options, including nondis25 ability-specific settings; 


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1 (iii) in which an individual has rights 

2 to privacy, dignity, and respect, and free3 dom from coercion and restraint; 

4 (iv) that, as a matter of infrastruc5 ture, environment, amenities, location, 

6 services, and features, optimizes, but does 

7 not regiment, individual initiative, auton8 omy, and independence in making life 

9 choices, including choices about daily ac10 tivities, physical environment, and persons 

11 with whom the individual interacts; and 

12 (v) that, as a matter of infrastructure, 

13 environment, amenities, location, services, 

14 and features, facilitates individual choice 

15 regarding the provision of services and 

16 supports, and who provides those services 

17 and supports. 

18 (B) In the case of a dwelling, a dwelling— 

19 (i) that is owned by an individual with 

20 an LTSS disability or the individual’s fam21 ily member; 

22 (ii) that is leased to the individual 

23 with an LTSS disability under an indi24 vidual lease, that has lockable access and 

25 egress, and that includes living, sleeping, 


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1 bathing, and cooking areas over which an 

2 individual with an LTSS disability or the 

3 individual’s family member has domain 

4 and control; or 

5 (iii) that is a group or shared resi6 dence— 

7 (I) in which no more than 4 un8 related individuals with an LTSS dis9 ability reside; 

10 (II) for which each individual 

11 with an LTSS disability living at the 

12 residence owns, rents, or occupies the 

13 residence under a legally enforceable 

14 agreement under which the individual 

15 has, at a minimum, the same respon16 sibilities and protections as tenants 

17 have under applicable landlord-tenant 

18 law; 

19 (III) in which each individual 

20 with an LTSS disability living at the 

21 residence— 

22 (aa) has privacy in the indi23 vidual’s sleeping unit, including a 

24 lockable entrance door controlled 

25 by the individual; 


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1 (bb) shares a sleeping unit 

2 only if such individual and the 

3 individual sharing the unit choose 

4 to do so, and if individuals in the 

5 residence so choose, they also 

6 have a choice of roommates with7 in the residence; 

8 (cc) has the freedom to fur9 nish and decorate the individual’s 

10 sleeping or living unit as per11 mitted under the lease or other 

12 agreement; 

13 (dd) has the freedom and 

14 support to control the individ15 ual’s own schedules and activi16 ties; and 

17 (ee) is able to have visitors 

18 of the individual’s choosing at 

19 any time; and 

20 (IV) that is physically accessible 

21 to the individual with an LTSS dis22 ability living at the residence. 

23 (4) DWELLING.—The term ‘‘dwelling’’ has the 

24 meaning given the term in section 802 of the Fair 

25 Housing Act (42 U.S.C. 3602). 


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1 (5) HEALTH-RELATED TASKS.—The term 

2 ‘‘health-related tasks’’ means specific nonacute 

3 tasks, typically regulated by States as medical or 

4 nursing tasks that an individual with a disability 

5 may require to live in the community, including— 

6 (A) administration of medication; 

7 (B) assistance with use, operation, and 

8 maintenance of a ventilator; and 

9 (C) maintenance and use of a gastrostomy 

10 tube, a catheter, or a stable ostomy. 

11 (6) INDIVIDUAL WITH A DISABILITY.—The term 

12 ‘‘individual with a disability’’ means an individual 

13 who is a person with a disability, as defined in sec14 tion 3 of the Americans with Disabilities Act of 

15 1990 (42 U.S.C. 12102). 

16 (7) INDIVIDUAL WITH AN LTSS DISABILITY.— 

17 The term ‘‘individual with an LTSS disability’’ 

18 means an individual with a disability who— 

19 (A) in order to live in the community and 

20 lead an independent life requires assistance in 

21 accomplishing— 

22 (i) activities of daily living; 

23 (ii) instrumental activities of daily liv24 ing; 

25 (iii) health-related tasks; or 


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1 (iv) other functions, tasks, or activi2 ties related to an activity or task described 

3 in clause (i), (ii), or (iii); and 

4 (B)(i) is currently in an institutional place5 ment; or 

6 (ii) is at risk of institutionalization if the 

7 individual does not receive community-based 

8 long-term services and supports. 

9 (8) INSTRUMENTAL ACTIVITIES OF DAILY LIV10 ING.— 

11 (A) IN GENERAL.—The term ‘‘instru12 mental activities of daily living’’ means one or 

13 more activities related to living independently in 

14 the community, including activities related to— 

15 (i) nutrition, such as preparing meals 

16 or special diets, monitoring to prevent 

17 choking or aspiration, or assisting with 

18 special utensils; 

19 (ii) household chores and environ20 mental maintenance tasks; 

21 (iii) communication and interpersonal 

22 skills, such as— 

23 (I) using the telephone or other 

24 communications devices; 


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1 (II) forming and maintaining 

2 interpersonal relationships; or 

3 (III) securing opportunities to 

4 participate in group support or peer5 to-peer support arrangements; 

6 (iv) travel and community participa7 tion, such as shopping, arranging appoint8 ments, or moving around the community; 

9 (v) care of others, such as raising 

10 children, taking care of pets, or selecting 

11 caregivers; or 

12 (vi) management of personal property 

13 and personal safety, such as— 

14 (I) taking medication; 

15 (II) handling or managing 

16 money; or 

17 (III) responding to emergent 

18 situations or unscheduled needs re19 quiring an immediate response. 

20 (B) ASSISTANCE.—The term ‘‘assistance’’ 

21 used with respect to instrumental activities of 

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1 tellectual, mental, or emotional disabilities, in2 cluding support to— 

3 (i) help the individual identify and set 

4 goals, overcome fears, and manage transi5 tions; 

6 (ii) help the individual with executive 

7 functioning, decisionmaking, and problem 

8 solving; 

9 (iii) provide reassurance to the indi10 vidual; and 

11 (iv) help the individual with orienta12 tion, memory, and other activities related 

13 to independent living. 

14 (9) LONG-TERM SERVICE OR SUPPORT.—The 

15 terms ‘‘long-term service or support’’ and ‘‘LTSS’’ 

16 mean the assistance provided to an individual with 

17 a disability in accomplishing, acquiring the means or 

18 ability to accomplish, maintaining, or enhancing— 

19 (A) activities of daily living; 

20 (B) instrumental activities of daily living; 

21 (C) health-related tasks; or 

22 (D) other functions, tasks, or activities re23 lated to an activity or task described in sub24 paragraph (A), (B), or (C). 


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1 (10) LTSS INSURANCE PROVIDER.—The term 

2 ‘‘LTSS insurance provider’’ means a public or pri3 vate entity that— 

4 (A) provides funds for long-term services 

5 and supports; and 

6 (B) is engaged in commerce or in an in7 dustry or activity affecting commerce. 

8 (11) PUBLIC ENTITY.— 

9 (A) IN GENERAL.—The term ‘‘public enti10 ty’’ means an entity that— 

11 (i) provides or funds institutional 

12 placements for individuals with LTSS dis13 abilities; and 

14 (ii) is— 

15 (I) a State or local government; 

16 or 

17 (II) any department, agency, en18 tity administering a special purpose 

19 district, or other instrumentality, of a 

20 State or local government. 

21 (B) INTERSTATE COMMERCE.—For pur22 poses of subparagraph (A), a public entity shall 

23 be considered to be a person engaged in com24 merce or in an industry or activity affecting 

25 commerce. 


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1 (b) RULE OF CONSTRUCTION.—Nothing in sub2 section (a)(2) or any other provision of this section shall 

3 be construed to preclude an individual with a disability 

4 from receiving community-based services and supports in 

5 an integrated community setting such as a grocery store, 

6 retail establishment, restaurant, bank, park, concert 

7 venue, theater, or workplace. 

8 SEC. 4. DISCRIMINATION. 

9 (a) IN GENERAL.—No public entity or LTSS insur10 ance provider shall deny an individual with an LTSS dis11 ability who is eligible for institutional placement, or other12 wise discriminate against that individual in the provision 

13 of, community-based long-term services and supports that 

14 enable the individual to live in the community and lead 

15 an independent life. 

16 (b) SPECIFIC PROHIBITIONS.—For purposes of this 

17 Act, discrimination by a public entity or LTSS insurance 

18 provider includes— 

19 (1) the imposition or application of eligibility 

20 criteria or another policy that prevents or tends to 

21 prevent an individual with an LTSS disability, or 

22 any class of individuals with LTSS disabilities, from 

23 receiving a community-based long-term service or 

24 support; 


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1 (2) the imposition or application of a policy or 

2 other mechanism, such as a service or cost cap, that 

3 prevent or tends to prevent an individual with an 

4 LTSS disability, or any class of individuals with 

5 LTSS disabilities, from receiving a community-based 

6 long-term service or support; 

7 (3) a failure to provide a specific community8 based long-term service or support or a type of com9 munity-based long-term service or support needed 

10 for an individual with an LTSS disability, or any 

11 class of individuals with LTSS disabilities; 

12 (4) the imposition or application of a policy, 

13 rule, regulation, or restriction that interferes with 

14 the opportunity for an individual with an LTSS dis15 ability, or any class of individuals with LTSS dis16 abilities, to live in the community and lead an inde17 pendent life, which may include a requirement that 

18 an individual with an LTSS disability receive a serv19 ice or support (such as day services or employment 

20 services) in a congregate or disability-specific set21 ting; 

22 (5) the imposition or application of a waiting 

23 list or other mechanism that delays or restricts ac24 cess of an individual with an LTSS disability to a 

25 community-based long-term service or support; 


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1 (6) a failure to establish an adequate rate or 

2 other payment structure that is necessary to ensure 

3 the availability of a workforce sufficient to support 

4 an individual with an LTSS disability in living in 

5 the community and leading an independent life; 

6 (7) a failure to provide community-based serv7 ices and supports, on an intermittent, short-term, or 

8 emergent basis, that assist an individual with an 

9 LTSS disability to live in the community and lead 

10 an independent life; 

11 (8) the imposition or application of a policy, 

12 such as a requirement that an individual utilize in13 formal support, that restricts, limits, or delays the 

14 ability of an individual with an LTSS disability to 

15 secure a community-based long-term service or sup16 port to live in the community or lead an independent 

17 life; 

18 (9) a failure to implement a formal procedure 

19 and a mechanism to ensure that— 

20 (A) individuals with LTSS disabilities are 

21 offered the alternative of community-based 

22 long-term services and supports prior to institu23 tionalization; and 

24 (B) if selected by an individual with an 

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1 term services and supports described in sub2 paragraph (A) are provided; 

3 (10) a failure to ensure that each institutional4 ized individual with an LTSS disability is regularly 

5 notified of the alternative of community-based long6 term services and supports and that those commu7 nity-based long-term services and supports are pro8 vided if the individual with an LTSS disability se9 lects such services and supports; and 

10 (11) a failure to make a reasonable modifica11 tion in a policy, practice, or procedure, when such 

12 modification is necessary to allow an individual with 

13 an LTSS disability to receive a community-based 

14 long-term service or support. 

15 (c) ADDITIONAL PROHIBITION.—For purposes of this 

16 Act, discrimination by a public entity also includes a fail17 ure to ensure that there is sufficient availability of afford18 able, accessible, and integrated housing to allow an indi19 vidual with an LTSS disability to choose to live in the 

20 community and lead an independent life, including the 

21 availability of an option to live in housing where the re22 ceipt of LTSS is not tied to tenancy. 

23 (d) CONSTRUCTION.—Nothing in this section— 

24 (1) shall be construed— 


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1 (A) to prevent a public entity or LTSS in2 surance provider from providing community3 based long-term services and supports at a level 

4 that is greater than the level that is required by 

5 this section; or 

6 (B) to limit the rights of an individual with 

7 a disability under any provision of law other 

8 than this section; 

9 (2) shall be construed to affect the scope of ob10 ligations imposed by any other provision of law; or 

11 (3) shall be construed to prohibit a public entity 

12 or LTSS insurance provider from using managed 

13 care techniques, as long as the use of such tech14 niques does not have the effect of discriminating 

15 against an individual in the provision of community16 based long-term services and supports, as prohibited 

17 by this Act. 

18 SEC. 5. ADMINISTRATION. 

19 (a) AUTHORITY AND RESPONSIBILITY.— 

20 (1) DEPARTMENT OF JUSTICE.—The Attorney 

21 General shall— 

22 (A) investigate and take enforcement ac23 tion for violations of this Act; and 

24 (B) enforce section 6(c). 


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1 (2) DEPARTMENT OF HEALTH AND HUMAN

2 SERVICES.—The Secretary of Health and Human 

3 Services, through the Administrator, shall— 

4 (A) conduct studies regarding the nature 

5 and extent of institutionalization of individuals 

6 with LTSS disabilities in representative com7 munities, including urban, suburban, and rural 

8 communities, throughout the United States; 

9 (B) publish and disseminate reports, rec10 ommendations, and information derived from 

11 such studies, including an annual report to 

12 Congress, specifying— 

13 (i) the nature and extent of progress 

14 in the United States in eliminating institu15 tionalization for individuals with LTSS 

16 disabilities in violation of this Act and fur17 thering the purposes of this Act; 

18 (ii) obstacles that remain in the effort 

19 to achieve the provision of community20 based long-term services and supports for 

21 all individuals with LTSS disabilities; and 

22 (iii) recommendations for further leg23 islative or executive action; 

24 (C) cooperate with, and provide grants for 

25 technical assistance to, Federal, State, and local 


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1 public or private agencies and organizations 

2 that are formulating or carrying out programs 

3 to prevent or eliminate institutionalization of 

4 individuals with LTSS disabilities or to promote 

5 the provision of community-based long-term 

6 services and supports; 

7 (D) implement educational and conciliatory 

8 activities to further the purposes of this Act; 

9 and 

10 (E) refer information on violations of this 

11 Act to the Attorney General for investigation 

12 and enforcement action under this Act. 

13 (b) COOPERATION OF EXECUTIVE DEPARTMENTS

14 AND AGENCIES.—Each Federal agency and, in particular, 

15 each Federal agency covered by Executive Order 13217 

16 (66 Fed. Reg. 33155; relating to community-based alter17 natives for individuals with disabilities), shall carry out 

18 programs and activities relating to the institutionalization 

19 of individuals with LTSS disabilities and the provision of 

20 community-based long-term services and supports for indi21 viduals with LTSS disabilities in accordance with this Act 

22 and shall cooperate with the Attorney General and the Ad23 ministrator to further the purposes of this Act. 


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1 SEC. 6. REGULATIONS. 

2 (a) ISSUANCE OF REGULATIONS.—Not later than 24 

3 months after the date of enactment of this Act, the Attor4 ney General and the Secretary of Health and Human 

5 Services shall issue, in accordance with section 553 of title 

6 5, United States Code, final regulations to carry out this 

7 Act, which shall include the regulations described in sub8 section (b). 

9 (b) REQUIRED CONTENTS OF REGULATIONS.— 

10 (1) ELIGIBLE RECIPIENTS OF SERVICE.—The 

11 regulations shall require each public entity and 

12 LTSS insurance provider to offer, and, if accepted, 

13 provide community-based long-term services and 

14 supports as required under this Act to any indi15 vidual with an LTSS disability who would otherwise 

16 qualify for institutional placement provided or fund17 ed by the public entity or LTSS insurance provider. 

18 (2) SERVICES TO BE PROVIDED.—The regula19 tions issued under this section shall require each 

20 public entity and LTSS insurance provider to pro21 vide the Attorney General and the Administrator 

22 with an assurance that the public entity or LTSS in23 surance provider— 

24 (A) ensures that individuals with LTSS 

25 disabilities receive assistance through hands-on 

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1 toring, including access to backup systems, 

2 with— 

3 (i) activities of daily living; 

4 (ii) instrumental activities of daily liv5 ing; 

6 (iii) health-related tasks; or 

7 (iv) other functions, tasks, or activi8 ties related to an activity or task described 

9 in clause (i), (ii), or (iii); 

10 (B) coordinates, conducts, performs, pro11 vides, or funds discharge planning from acute, 

12 rehabilitation, and long-term facilities to pro13 mote individuals with LTSS disabilities living in 

14 the most integrated setting chosen by the indi15 viduals; 

16 (C) issues, conducts, performs, provides, or 

17 funds policies and programs to promote self-di18 rection and the provision of consumer-directed 

19 services and supports for all populations of indi20 viduals with LTSS disabilities served; 

21 (D) issues, conducts, performs, provides, 

22 or funds policies and programs to support infor23 mal caregivers who provide services for individ24 uals with LTSS disabilities; and 


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1 (E) ensures that individuals with all types 

2 of LTSS disabilities are able to live in the com3 munity and lead an independent life, including 

4 ensuring that the individuals have maximum 

5 control over the services and supports that the 

6 individuals receive, choose the setting in which 

7 the individuals receive those services and sup8 ports, and exercise control and direction over 

9 their own lives. 

10 (3) PUBLIC PARTICIPATION.— 

11 (A) PUBLIC ENTITY.—The regulations 

12 issued under this section shall require each pub13 lic entity to carry out an extensive public par14 ticipation process in preparing the public enti15 ty’s self-evaluation under paragraph (5) and 

16 transition plan under paragraph (10). 

17 (B) LTSS INSURANCE PROVIDER.—The 

18 regulations issued under this section shall re19 quire each LTSS insurance provider to carry 

20 out a public participation process that involves 

21 holding a public hearing, providing an oppor22 tunity for public comment, and consulting with 

23 individuals with LTSS disabilities, in preparing 

24 the LTSS insurance provider’s self-evaluation 

25 under paragraph (5). 


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1 (C) PROCESS.—In carrying out a public 

2 participation process under subparagraph (A) 

3 or (B), a public entity or LTSS insurance pro4 vider shall ensure that the process meets the re5 quirements of subparagraphs (A) and (C) of 

6 section 1115(d)(2) of the Social Security Act 

7 (42 U.S.C. 1315(d)(2)), except that— 

8 (i) the reference to ‘‘at the State 

9 level’’ shall be disregarded; and 

10 (ii) the reference to an application 

11 shall be considered to be a reference to the 

12 self-evaluation or plan involved. 

13 (4) ADDITIONAL SERVICES AND SUPPORTS.— 

14 The regulations issued under this section shall es15 tablish circumstances under which a public entity 

16 shall provide community-based long-term services 

17 and supports under this section beyond the level of 

18 community-based long-term services and supports 

19 which would otherwise be required under this sub20 section. 

21 (5) SELF-EVALUATION.— 

22 (A) IN GENERAL.—The regulations issued 

23 under this section shall require each public enti24 ty and each LTSS insurance provider, not later 

25 than 30 months after the date of enactment of 


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1 this Act, to evaluate current services, policies, 

2 and practices, and the effects thereof, that do 

3 not or may not meet the requirements of this 

4 Act and, to the extent modification of any such 

5 services, policies, and practices is required to 

6 meet the requirements of this Act, make the 

7 necessary modifications. The self-evaluation 

8 shall include— 

9 (i) collection of baseline information, 

10 including the numbers of individuals with 

11 LTSS disabilities in various institutional 

12 and community-based settings served by 

13 the public entity or LTSS insurance pro14 vider; 

15 (ii) a review of community capacity, in 

16 communities served by the entity or pro17 vider, in providing community-based long18 term services and supports; 

19 (iii) identification of improvements 

20 needed to ensure that all community-based 

21 long-term services and supports provided 

22 by the public entity or LTSS insurance 

23 provider to individuals with LTSS disabil24 ities are comprehensive, are accessible, are 

25 not duplicative of existing (as of the date 


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1 of the identification) services and supports, 

2 meet the needs of persons who are likely to 

3 require assistance in order to live, or lead 

4 a life, as described in section 4(a), and are 

5 high-quality services and supports, which 

6 may include identifying system improve7 ments that create an option to self-direct 

8 receipt of such services and supports for 

9 all populations of such individuals served; 

10 and 

11 (iv) a review of funding sources for 

12 community-based long-term services and 

13 supports and an analysis of how those 

14 funding sources could be organized into a 

15 fair, coherent system that affords individ16 uals reasonable and timely access to com17 munity-based long-term services and sup18 ports. 

19 (B) PUBLIC ENTITY.—A public entity, in20 cluding an LTSS insurance provider that is a 

21 public entity, shall— 

22 (i) include in the self-evaluation de23 scribed in subparagraph (A)— 

24 (I) an assessment of the avail25 ability of accessible, affordable transVerDate Sep 11 2014 21:01 Feb 04, 2019 Jkt 089200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\H555.IH H555

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1 portation across the State involved 

2 and whether transportation barriers 

3 prevent individuals from receiving 

4 long-term services and supports in the 

5 most integrated setting; and 

6 (II) an assessment of the avail7 ability of integrated employment op8 portunities in the jurisdiction served 

9 by the public entity for individuals 

10 with LTSS disabilities; and 

11 (ii) provide the self-evaluation de12 scribed in subparagraph (A) to the Attor13 ney General and the Administrator. 

14 (C) LTSS INSURANCE PROVIDER.—An 

15 LTSS insurance provider shall keep the self16 evaluation described in subparagraph (A) on 

17 file, and may be required to produce such self18 evaluation in the event of a review, investiga19 tion, or action described in section 8. 

20 (6) ADDITIONAL REQUIREMENT FOR PUBLIC

21 ENTITIES.—The regulations issued under this sec22 tion shall require a public entity, in conjunction with 

23 the housing agencies serving the jurisdiction served 

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1 tirety of that jurisdiction, in providing affordable, 

2 accessible, and integrated housing, including an eval3 uation of available units, unmet need, and other 

4 identifiable barriers to the provision of that housing. 

5 In carrying out that improvement, the public entity, 

6 in conjunction with such housing agencies, shall— 

7 (A) ensure, and assure the Administrator 

8 and the Attorney General that there is, suffi9 cient availability of affordable, accessible, and 

10 integrated housing in a setting that is not a dis11 ability-specific residential setting or a setting 

12 where services are tied to tenancy, in order to 

13 provide individuals with LTSS disabilities a 

14 meaningful choice in their housing; 

15 (B) in order to address the need for af16 fordable, accessible, and integrated housing— 

17 (i) in the case of such a housing agen18 cy, establish relationships with State and 

19 local housing authorities; and 

20 (ii) in the case of the public entity, es21 tablish relationships with State and local 

22 housing agencies, including housing au23 thorities; 

24 (C) establish, where needed, necessary 

25 preferences and set-asides in housing programs 


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1 for individuals with LTSS disabilities who are 

2 transitioning from or avoiding institutional 

3 placement; 

4 (D) establish a process to fund necessary 

5 home modifications so that individuals with 

6 LTSS disabilities can live independently; and 

7 (E) ensure, and assure the Administrator 

8 and the Attorney General, that funds and pro9 grams implemented or overseen by the public 

10 entity or in the public entity’s jurisdiction are 

11 targeted toward affordable, accessible, inte12 grated housing for individuals with an LTSS 

13 disability who have the lowest income levels in 

14 the jurisdiction as a priority over any other de15 velopment until capacity barriers for such hous16 ing are removed or unmet needs for such hous17 ing have been met. 

18 (7) DESIGNATION OF RESPONSIBLE EM19 PLOYEE.—The regulations issued under this section 

20 shall require each public entity and LTSS insurance 

21 provider to designate at least one employee to co22 ordinate the entity’s or provider’s efforts to comply 

23 with and carry out the entity or provider’s respon24 sibilities under this Act, including the investigation 

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1 vider that alleges a violation of this Act. Each public 

2 entity and LTSS insurance provider shall make 

3 available to all interested individuals the name, of4 fice address, and telephone number of the employee 

5 designated pursuant to this paragraph. 

6 (8) GRIEVANCE PROCEDURES.—The regulations 

7 issued under this section shall require public entities 

8 and LTSS insurance providers to adopt and publish 

9 grievance procedures providing for prompt and equi10 table resolution of complaints alleging a violation of 

11 this Act. 

12 (9) PROVISION OF SERVICE BY OTHERS.—The 

13 regulations issued under this section shall require 

14 each public entity submitting a self-evaluation under 

15 paragraph (5) to identify, as part of the transition 

16 plan described in paragraph (10), any other entity 

17 that is, or acts as, an agent, subcontractor, or other 

18 instrumentality of the public entity with regards to 

19 a service, support, policy, or practice described in 

20 such plan or self-evaluation. 

21 (10) TRANSITION PLANS.—The regulations 

22 issued under this section shall require each public 

23 entity, not later than 42 months after the date of 

24 enactment of this Act, to submit to the Adminis25 trator, and begin implementing, a transition plan for 


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1 carrying out this Act that establishes the achieve2 ment of the requirements of this Act, as soon as 

3 practicable, but in no event later than 12 years after 

4 the date of enactment of this Act. The transition 

5 plan shall— 

6 (A) establish measurable objectives to ad7 dress the barriers to community living identified 

8 in the self-evaluation under paragraph (5); 

9 (B) establish specific annual targets for 

10 the transition of individuals with LTSS disabil11 ities, and shifts in funding, from institutional 

12 settings to integrated community-based services 

13 and supports, and related programs; 

14 (C) describe specific efforts to support in15 dividuals with LTSS disabilities to avoid un16 wanted institutionalization through the provi17 sion of LTSS; and 

18 (D) describe the manner in which the pub19 lic entity has obtained or plans to obtain nec20 essary funding and resources needed for imple21 mentation of the plan (regardless of whether 

22 the entity began carrying out the objectives of 

23 this Act prior to the date of enactment of this 

24 Act). 

25 (11) ANNUAL REPORTING.— 


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1 (A) IN GENERAL.—The regulations issued 

2 under this section shall establish annual report3 ing requirements for each public entity covered 

4 by this section. 

5 (B) PROGRESS ON OBJECTIVES, TARGETS, 

6 AND EFFORTS.—The regulations issued under 

7 this section shall require each public entity that 

8 has submitted a transition plan to submit to the 

9 Administrator an annual report on the progress 

10 the public entity has made during the previous 

11 year in meeting the measurable objectives, spe12 cific annual targets, and specific efforts de13 scribed in paragraph (10). 

14 (12) OTHER PROVISIONS.—The regulations 

15 issued under this section shall include such other 

16 provisions and requirements as the Attorney General 

17 and the Secretary of Health and Human Services 

18 determine are necessary to carry out the objectives 

19 of this Act. 

20 (c) REVIEW OF TRANSITION PLANS.— 

21 (1) GENERAL RULE.—The Administrator shall 

22 review a transition plan submitted in accordance 

23 with subsection (b)(10) for the purpose of deter24 mining whether such plan meets the requirements of 


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1 this Act, including the regulations issued under this 

2 section. 

3 (2) DISAPPROVAL.—If the Administrator deter4 mines that a transition plan reviewed under this 

5 subsection fails to meet the requirements of this Act, 

6 the Administrator shall disapprove the transition 

7 plan and notify the public entity that submitted the 

8 transition plan of, and the reasons for, such dis9 approval. 

10 (3) MODIFICATION OF DISAPPROVED PLAN.— 

11 Not later than 90 days after the date of disapproval 

12 of a transition plan under this subsection, the public 

13 entity that submitted the transition plan shall mod14 ify the transition plan to meet the requirements of 

15 this section and shall submit to the Administrator, 

16 and commence implementation of, such modified 

17 transition plan. 

18 (4) INCENTIVES.— 

19 (A) DETERMINATION.—For 10 years after 

20 the issuance of the regulations described in sub21 section (a), the Secretary of Health and Human 

22 Services shall annually determine whether each 

23 State, or each other public entity in the State, 

24 is complying with the transition plan or modi25 fied transition plan the State or other public 


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1 entity submitted, and obtained approval for, 

2 under this section. Notwithstanding any other 

3 provision of law, if the Secretary of Health and 

4 Human Services determines under this subpara5 graph that the State or other public entity is 

6 complying with the corresponding transition 

7 plan, the Secretary shall make the increase de8 scribed in subparagraph (B). 

9 (B) INCREASE IN FMAP.—On making the 

10 determination described in subparagraph (A) 

11 for a public entity (including a State), the Sec12 retary of Health and Human Services shall, as 

13 described in subparagraph (C), increase by 5 

14 percentage points the FMAP (but shall in no 

15 event increase the FMAP above 100 percent) 

16 for the State in which the public entity is lo17 cated for amounts expended by the State for 

18 medical assistance consisting of home and com19 munity-based services furnished under the State 

20 Medicaid plan under title XIX of the Social Se21 curity Act (42 U.S.C. 1396 et seq.) or a waiver 

22 of such plan— 

23 (i) that— 


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1 (I) are identified by a public enti2 ty or LTSS insurance provider under 

3 subsection (b)(5)(A)(iii); 

4 (II) resulted from shifts in fund5 ing identified by a public entity under 

6 subsection (b)(10)(B); or 

7 (III) are environmental modifica8 tions to achieve the affordable, acces9 sible, integrated housing identified by 

10 a public entity under subsection 

11 (b)(6)(E); and 

12 (ii) are described by the State in a re13 quest to the Secretary of Health and 

14 Human Services for the increase. 

15 (C) PERIOD OF INCREASE.—The Secretary 

16 of Health and Human Services shall increase 

17 the FMAP described in subparagraph (B)— 

18 (i) beginning with the first quarter 

19 that begins after the date of the deter20 mination; and 

21 (ii) ending with the quarter in which 

22 the next annual determination under sub23 paragraph (A) occurs. 

24 (D) ADDITIONAL CONDITION FOR PAY25 MENT.— 


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1 (i) STATE REPORT.—As a condition 

2 for the receipt of a payment based on an 

3 increase described in subparagraph (B) 

4 with respect to amounts to be expended by 

5 the State for medical assistance consisting 

6 of home and community-based services de7 scribed in subparagraph (B), the State 

8 shall report to the Secretary, for the re9 porting year, the amount of funds ex10 pended by the State for home and commu11 nity-based services (as defined in subpara12 graph (E)(ii)) in that year. The State shall 

13 make the report in a format developed or 

14 approved by the Secretary. 

15 (ii) REDUCTION IN PAYMENT IF FAIL16 URE TO MAINTAIN EFFORT.—If the 

17 amount reported under clause (i) by a 

18 State with respect to a reporting year is 

19 less than the amount reported under clause 

20 (i) with respect to the previous fiscal year 

21 or fiscal year 2019, whichever was the 

22 greater reported amount, the Secretary 

23 shall provide for a reduction in the pay24 ment to the State based on the increase. 

25 (E) DEFINITIONS.—In this paragraph: 


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1 (i) FMAP.—The term ‘‘FMAP’’ 

2 means the Federal medical assistance per3 centage for a State determined under sec4 tion 1905(b) of the Social Security Act (42 

5 U.S.C. 1396d(b)) without regard to any in6 creases in that percentage applicable under 

7 other subsections of that section or any 

8 other provision of law, including this sec9 tion. 

10 (ii) HOME AND COMMUNITY-BASED

11 SERVICES DEFINED.—The term ‘‘home and 

12 community-based services’’ means any of 

13 the following services provided under a 

14 State Medicaid plan under title XIX of the 

15 Social Security Act (42 U.S.C. 1396 et 

16 seq.) or a waiver of such plan: 

17 (I) Home and community-based 

18 services provided under subsection (c), 

19 (d), or (i) of section 1915 of the So20 cial Security Act (42 U.S.C. 1396n). 

21 (II) Home health care services. 

22 (III) Personal care services. 

23 (IV) Services described in section 

24 1905(a)(26) of the Social Security Act 


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1 (42 U.S.C. 1396d(a)(26)) (relating to 

2 PACE program services). 

3 (V) Self-directed personal assist4 ance services provided in accordance 

5 with section 1915(j) of the Social Se6 curity Act (42 U.S.C. 1396n(j)). 

7 (VI) Community-based attendant 

8 services and supports provided in ac9 cordance with section 1915(k) of the 

10 Social Security Act (42 U.S.C. 

11 1396n(k)). 

12 (VII) Rehabilitative services, 

13 within the meaning of section 

14 1905(a)(13) of the Social Security Act 

15 (42 U.S.C. 1396d(a)(13)). 

16 (iii) REPORTING YEAR.—The term 

17 ‘‘reporting year’’ means the most recent 

18 fiscal year preceding the date of a report 

19 under subparagraph (D)(i). 

20 (d) RULE OF CONSTRUCTION.—Nothing in sub21 section (b)(10) or (c) or any other provision of this Act 

22 shall be construed to limit the rights, protections, or re23 quirements of any other Federal law, relating to integra24 tion of individuals with disabilities into the community and 


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1 enabling those individuals to live in the most integrated 

2 setting. 

3 SEC. 7. EXEMPTIONS FOR RELIGIOUS ORGANIZATIONS. 

4 This Act shall not prohibit a religious organization, 

5 association, or society from giving preference in providing 

6 community-based long-term services and supports to indi7 viduals of a particular religion connected with the beliefs 

8 of such organization, association, or society. 

9 SEC. 8. ENFORCEMENT. 

10 (a) CIVIL ACTION.— 

11 (1) IN GENERAL.—A civil action for preventive 

12 relief, including an application for a permanent or 

13 temporary injunction, restraining order, or other 

14 order, may be instituted by an individual described 

15 in paragraph (2) in an appropriate Federal district 

16 court. 

17 (2) AGGRIEVED INDIVIDUAL.— 

18 (A) IN GENERAL.—The remedies and pro19 cedures set forth in this section are the rem20 edies and procedures this Act provides to any 

21 individual who is being subjected to a violation 

22 of this Act, or who has reasonable grounds for 

23 believing that such individual is about to be 

24 subjected to such a violation. 


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1 (B) STANDING.—An individual with a dis2 ability shall have standing to institute a civil ac3 tion under this subsection if the individual 

4 makes a prima facie showing that the indi5 vidual— 

6 (i) is an individual with an LTSS dis7 ability; and 

8 (ii) is being subjected to, or about to 

9 be subjected to, such a violation (including 

10 a violation of section 4(b)(11)). 

11 (3) APPOINTMENT OF ATTORNEY; NO FEES, 

12 COSTS, OR SECURITY.—Upon application by the 

13 complainant described in paragraph (2) and in such 

14 circumstances as the court may determine to be just, 

15 the court may appoint an attorney for the complain16 ant and may authorize the commencement of such 

17 civil action without the payment of fees, costs, or se18 curity. 

19 (4) FUTILE GESTURE NOT REQUIRED.—Noth20 ing in this section shall require an individual with an 

21 LTSS disability to engage in a futile gesture if such 

22 person has actual notice that a public entity or 

23 LTSS insurance provider does not intend to comply 

24 with the provisions of this Act. 


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1 (b) DAMAGES AND INJUNCTIVE RELIEF.—If the 

2 court finds that a violation of this Act has occurred or 

3 is about to occur, the court may award to the complain4 ant— 

5 (1) actual and punitive damages; 

6 (2) immediate injunctive relief to prevent insti7 tutionalization; 

8 (3) as the court determines to be appropriate, 

9 any permanent or temporary injunction (including 

10 an order to immediately provide or maintain commu11 nity-based long-term services or supports for an in12 dividual to prevent institutionalization or further in13 stitutionalization), temporary restraining order, or 

14 other order (including an order enjoining the defend15 ant from engaging in a practice that violates this 

16 Act or ordering such affirmative action as may be 

17 appropriate); and 

18 (4) in an appropriate case, injunctive relief to 

19 require the modification of a policy, practice, or pro20 cedure, or the provision of an alternative method of 

21 providing LTSS, to the extent required by this Act. 

22 (c) ATTORNEY’S FEES; LIABILITY OF UNITED

23 STATES FOR COSTS.—In any action commenced pursuant 

24 to this Act, the court, in its discretion, may allow the party 

25 bringing a claim or counterclaim under this Act, other 


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1 than the United States, a reasonable attorney’s fee as part 

2 of the costs, and the United States shall be liable for costs 

3 to the same extent as a private person. 

4 (d) ENFORCEMENT BY ATTORNEY GENERAL.— 

5 (1) DENIAL OF RIGHTS.— 

6 (A) DUTY TO INVESTIGATE.—The Attor7 ney General shall investigate alleged violations 

8 of this Act, and shall undertake periodic reviews 

9 of the compliance of public entities and LTSS 

10 insurance providers under this Act. 

11 (B) POTENTIAL VIOLATION.—The Attor12 ney General may commence a civil action in any 

13 appropriate Federal district court if the Attor14 ney General has reasonable cause to believe 

15 that— 

16 (i) any public entity or LTSS insur17 ance provider, including a group of public 

18 entities or LTSS insurance providers, is 

19 engaged in a pattern or practice of viola20 tions of this Act; or 

21 (ii) any individual, including a group, 

22 has been subjected to a violation of this 

23 Act and the violation raises an issue of 

24 general public importance. 


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1 (2) AUTHORITY OF COURT.—In a civil action 

2 under paragraph (1)(B), the court— 

3 (A) may grant any equitable relief that 

4 such court considers to be appropriate, includ5 ing, to the extent required by this Act— 

6 (i) granting temporary, preliminary, 

7 or permanent relief; and 

8 (ii) requiring the modification of a 

9 policy, practice, or procedure, or the provi10 sion of an alternative method of providing 

11 LTSS; 

12 (B) may award such other relief as the 

13 court considers to be appropriate, including 

14 damages to individuals described in subsection 

15 (a)(2), when requested by the Attorney General; 

16 and 

17 (C) may, to vindicate the public interest, 

18 assess a civil penalty against the public entity 

19 or LTSS insurance provider in an amount— 

20 (i) not exceeding $100,000 for a first 

21 violation; and 

22 (ii) not exceeding $200,000 for any 

23 subsequent violation. 

24 (3) SINGLE VIOLATION.—For purposes of para25 graph (2)(C), in determining whether a first or subVerDate Sep 11 2014 21:01 Feb 04, 2019 Jkt 089200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\H555.IH H555

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1 sequent violation has occurred, a determination in a 

2 single action, by judgment or settlement, that the 

3 public entity or LTSS insurance provider has en4 gaged in more than one violation of this Act shall be 

5 counted as a single violation. 

6 SEC. 9. CONSTRUCTION. 

7 For purposes of construing this Act— 

8 (1) section 4(b)(11) shall be construed in a 

9 manner that takes into account its similarities with 

10 section 302(b)(2)(A)(ii) of the Americans with Dis11 abilities Act of 1990 (42 U.S.C. 12182(b)(2)(A)(ii)); 

12 (2) the first sentence of section 6(b)(5)(A) shall 

13 be construed in a manner that takes into account its 

14 similarities with section 35.105(a) of title 28, Code 

15 of Federal Regulations (as in effect on the day be16 fore the date of enactment of this Act); 

17 (3) section 7 shall be construed in a manner 

18 that takes into account its similarities with section 

19 807(a) of the Civil Rights Act of 1968 (42 U.S.C. 

20 3607(a)); 

21 (4) section 8(a)(2) shall be construed in a man22 ner that takes into account its similarities with sec23 tion 308(a)(1) of the Americans with Disabilities 

24 Act of 1990 (42 U.S.C. 12188(a)(1)); and 


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1 (5) section 8(d)(1)(B) shall be construed in a 

2 manner that takes into account its similarities with 

3 section 308(b)(1)(B) of the Americans with Disabil4 ities Act of 1990 (42 U.S.C. 12188(b)(1)(B)). 

Æ 


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