I 

108TH CONGRESS 

1ST SESSION H. R. 2032

To amend title XIX of the Social Security Act to provide individuals with 

disabilities and older Americans with equal access to community-based 

attendant services and supports, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 8, 2003

Mr. DAVIS of Illinois (for himself, Mr. SHIMKUS, Mr. DOGGETT, Mr. UDALL

of Colorado, Mr. MOORE, Mr. MCNULTY, Mr. ENGEL, Mr. RYUN of Kansas, Mr. HINOJOSA, Mr. MCHUGH, Mr. HOLDEN, Ms. LEE, Mr. DOYLE, 

Mr. HOYER, Ms. SCHAKOWSKY, Mr. TOWNS, Mr. HINCHEY, Mr. 

SERRANO, Mr. PAYNE, Mr. GRIJALVA, Mr. KILDEE, Mr. BRADY of Pennsylvania, Mr. PALLONE, and Mrs. CHRISTENSEN) introduced the following bill; which was referred to the Committee on Energy and Commerce 

A BILL

To amend title XIX of the Social Security Act to provide 

individuals with disabilities and older Americans with 

equal access to community-based attendant 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; TABLE OF CONTENTS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Medicaid Community-Based Attendant Services and 

4 Supports Act of 2003’’. 

5 (b) TABLE OF CONTENTS.—The table of contents for 

6 this Act is as follows:

Sec. 1. Short title; table of contents. 

Sec. 2. Findings and purposes. 

TITLE I—ESTABLISHMENT OF MEDICAID PLAN BENEFIT 

Sec. 101. Coverage of community-based attendant services and supports under 

the medicaid program. 

Sec. 102. Enhanced FMAP for ongoing activities of early coverage States that 

enhance and promote the use of community-based attendant 

services and supports. 

Sec. 103. Increased Federal financial participation for certain expenditures. 

TITLE II—PROMOTION OF SYSTEMS CHANGE AND CAPACITY 

BUILDING 

Sec. 201. Grants to promote systems change and capacity building. 

Sec. 202. Demonstration project to enhance coordination of care under the 

medicare and medicaid programs for non-elderly dual eligible 

individuals.

7 SEC. 2. FINDINGS AND PURPOSES. 

8 (a) FINDINGS.—Congress makes the following find9 ings: 

10 (1) Long-term services and supports provided 

11 under the medicaid program established under title 

12 XIX of the Social Security Act (42 U.S.C. 1396 et 

13 seq.) must meet the ability and life choices of indi14 viduals with disabilities and older Americans, includ15 ing the choice to live in one’s own home or with 

16 one’s own family and to become a productive mem17 ber of the community. 
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1 (2) Research on the provision of long-term serv2 ices and supports under the medicaid program (con3 ducted by and on behalf of the Department of 

4 Health and Human Services) has revealed a signifi5 cant funding bias toward institutional care. Only 

6 about 27 percent of long term care funds expended 

7 under the medicaid program, and only about 9 per8 cent of all funds expended under that program, pay 

9 for services and supports in home and community10 based settings. 

11 (3) In the case of medicaid beneficiaries who 

12 need long term care, the only long-term care service 

13 currently guaranteed by Federal law in every State 

14 is nursing home care. Only 27 States have adopted 

15 the benefit option of providing personal care services 

16 under the medicaid program. Although every State 

17 has chosen to provide certain services under home 

18 and community-based waivers, these services are un19 evenly available within and across States, and reach 

20 a small percentage of eligible individuals. In fiscal 

21 year 2000, only 3 States spent 50 percent or more 

22 of their medicaid long term care funds under the 

23 medicaid program on home and community-based 

24 care. 
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1 (4) Despite the funding bias and the uneven 

2 distribution of home and community-based services, 

21 3 ⁄2 times more people are served in home and com4 munity-based settings than in institutional settings. 

5 (5) The goals of the Nation properly include 

6 providing families of children with disabilities, work7 ing-age adults with disabilities, and older Americans 

8 with—

9 (A) a meaningful choice of receiving long10 term services and supports in the most inte11 grated setting appropriate to their needs; 

12 (B) the greatest possible control over the 

13 services received and, therefore, their own lives 

14 and futures; and 

15 (C) quality services that maximize inde16 pendence in the home and community, including 

17 in the workplace. 

18 (b) PURPOSES.—The purposes of this Act are the fol19 lowing: 

20 (1) To reform the medicaid program established 

21 under title XIX of the Social Security Act (42 

22 U.S.C. 1396 et seq.) to provide equal access to com23 munity-based attendant services and supports. 

24 (2) To provide financial assistance to States as 

25 they reform their long-term care systems to provide
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1 comprehensive statewide long-term services and sup2 ports, including community-based attendant services 

3 and supports that provide consumer choice and di4 rection, in the most integrated setting appropriate.

5 TITLE I—ESTABLISHMENT OF 

6 MEDICAID PLAN BENEFIT 

7 SEC. 101. COVERAGE OF COMMUNITY-BASED ATTENDANT 

8 SERVICES AND SUPPORTS UNDER THE MED9 ICAID PROGRAM. 

10 (a) MANDATORY COVERAGE.—Section 

11 1902(a)(10)(D) of the Social Security Act (42 U.S.C. 

12 1396a(a)(10)(D)) is amended—

13 (1) by inserting ‘‘(i)’’ after ‘‘(D)’’; 

14 (2) by adding ‘‘and’’ after the semicolon; and

15 (3) by adding at the end the following new 

16 clause: 

17 ‘‘(ii) subject to section 1935, for the inclu18 sion of community-based attendant services and 

19 supports for any individual who—

20 ‘‘(I) is eligible for medical assistance 

21 under the State plan; 

22 ‘‘(II) with respect to whom there has 

23 been a determination that the individual 

24 requires the level of care provided in a 

25 nursing facility or an intermediate care fa-
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1 cility for the mentally retarded (whether or 

2 not coverage of such intermediate care fa3 cility is provided under the State plan); 

4 and

5 ‘‘(III) who chooses to receive such 

6 services and supports;’’. 

7 (b) COMMUNITY-BASED ATTENDANT SERVICES AND

8 SUPPORTS.—

9 (1) IN GENERAL.—Title XIX of the Social Se10 curity Act (42 U.S.C. 1396 et seq.) is amended—

11 (A) by redesignating section 1935 as sec12 tion 1936; and 

13 (B) by inserting after section 1934 the fol14 lowing:

15 ‘‘COMMUNITY-BASED ATTENDANT SERVICES AND

16 SUPPORTS

17 ‘‘SEC. 1935. (a) REQUIRED COVERAGE.—

18 ‘‘(1) IN GENERAL.—Not later than October 1, 

19 2007, a State shall provide through a plan amend20 ment for the inclusion of community-based attendant 

21 services and supports (as defined in subsection 

22 (g)(1)) for individuals described in section 

23 1902(a)(10)(D)(ii) in accordance with this section. 

24 ‘‘(2) ENHANCED FMAP AND ADDITIONAL FED25 ERAL FINANCIAL SUPPORT FOR EARLIER COV26 ERAGE.—Notwithstanding section 1905(b), during 
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1 the period that begins on or after October 1, 2003, 

2 and ends on September 30, 2007, in the case of a 

3 State with an approved plan amendment under this 

4 section during that period that also satisfies the re5 quirements of subsection (c) the Federal medical as6 sistance percentage shall be equal to the enhanced 

7 FMAP described in section 2105(b) with respect to 

8 medical assistance in the form of community-based 

9 attendant services and supports provided to individ10 uals described in section 1902(a)(10)(D)(ii) in ac11 cordance with this section. 

12 ‘‘(b) DEVELOPMENT AND IMPLEMENTATION OF BEN13 EFIT.—In order for a State plan amendment to be ap14 proved under this section, a State shall provide the Sec15 retary with the following assurances: 

16 ‘‘(1) ASSURANCE OF DEVELOPMENT AND IM17 PLEMENTATION COLLABORATION.—That the State 

18 has developed and shall implement the provision of 

19 community-based attendant services and supports 

20 under the State plan through active collaboration 

21 with—

22 ‘‘(A) individuals with disabilities; 

23 ‘‘(B) elderly individuals; 

24 ‘‘(C) representatives of such individuals; 

25 and 
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1 ‘‘(D) providers of, and advocates for, serv2 ices and supports for such individuals. 

3 ‘‘(2) ASSURANCE OF PROVISION ON A STATE4 WIDE BASIS AND IN MOST INTEGRATED SETTING.—

5 That community-based attendant services and sup6 ports will be provided under the State plan to indi7 viduals described in section 1902(a)(10)(D)(ii) on a 

8 statewide basis and in a manner that provides such 

9 services and supports in the most integrated setting 

10 appropriate for each individual eligible for such serv11 ices and supports. 

12 ‘‘(3) ASSURANCE OF NONDISCRIMINATION.—

13 That the State will provide community-based attend14 ant services and supports to an individual described 

15 in section 1902(a)(10)(D)(ii) without regard to the 

16 individual’s age, type of disability, or the form of 

17 community-based attendant services and supports 

18 that the individual requires in order to lead an inde19 pendent life. 

20 ‘‘(4) ASSURANCE OF MAINTENANCE OF EF21 FORT.—That the level of State expenditures for op22 tional medical assistance that—

23 ‘‘(A) is described in a paragraph other 

24 than paragraphs (1) through (5), (17) and (21) 

25 of section 1905(a) or that is provided under a 
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1 waiver under section 1915, section 1115, or 

2 otherwise; and 

3 ‘‘(B) is provided to individuals with disabil4 ities or elderly individuals for a fiscal year,

5 shall not be less than the level of such expenditures 

6 for the fiscal year preceding the fiscal year in which 

7 the State plan amendment to provide community8 based attendant services and supports in accordance 

9 with this section is approved. 

10 ‘‘(c) REQUIREMENTS FOR ENHANCED FMAP FOR

11 EARLY COVERAGE.—In addition to satisfying the other re12 quirements for an approved plan amendment under this 

13 section, in order for a State to be eligible under subsection 

14 (a)(2) during the period described in that subsection for 

15 the enhanced FMAP for early coverage under subsection 

16 (a)(2), the State shall satisfy the following requirements: 

17 ‘‘(1) SPECIFICATIONS.—With respect to a fiscal 

18 year, the State shall provide the Secretary with the 

19 following specifications regarding the provision of 

20 community-based attendant services and supports 

21 under the plan for that fiscal year: 

22 ‘‘(A)(i) The number of individuals who are 

23 estimated to receive community-based attendant 

24 services and supports under the plan during the 

25 fiscal year.
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1 ‘‘(ii) The number of individuals that re2 ceived such services and supports during the 

3 preceding fiscal year. 

4 ‘‘(B) The maximum number of individuals 

5 who will receive such services and supports 

6 under the plan during that fiscal year. 

7 ‘‘(C) The procedures the State will imple8 ment to ensure that the models for delivery of 

9 such services and supports are consumer con10 trolled (as defined in subsection (g)(2)(B)). 

11 ‘‘(D) The procedures the State will imple12 ment to inform all potentially eligible individ13 uals and relevant other individuals of the avail14 ability of such services and supports under this 

15 title, and of other items and services that may 

16 be provided to the individual under this title or 

17 title XVIII. 

18 ‘‘(E) The procedures the State will imple19 ment to ensure that such services and supports 

20 are provided in accordance with the require21 ments of subsection (b)(1). 

22 ‘‘(F) The procedures the State will imple23 ment to actively involve individuals with disabil24 ities, elderly individuals, and representatives of 

25 such individuals in the design, delivery, admin-
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1 istration, and evaluation of the provision of 

2 such services and supports under this title.

3 ‘‘(2) PARTICIPATION IN EVALUATIONS.—The 

4 State shall provide the Secretary with such sub5 stantive input into, and participation in, the design 

6 and conduct of data collection, analyses, and other 

7 qualitative or quantitative evaluations of the provi8 sion of community-based attendant services and sup9 ports under this section as the Secretary deems nec10 essary in order to determine the effectiveness of the 

11 provision of such services and supports in allowing 

12 the individuals receiving such services and supports 

13 to lead an independent life to the maximum extent 

14 possible. 

15 ‘‘(d) QUALITY ASSURANCE PROGRAM.—

16 ‘‘(1) STATE RESPONSIBILITIES.—In order for a 

17 State plan amendment to be approved under this 

18 section, a State shall establish and maintain a qual19 ity assurance program with respect to community20 based attendant services and supports that provides 

21 for the following: 

22 ‘‘(A) The State shall establish require23 ments, as appropriate, for agency-based and 

24 other delivery models that include—
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1 ‘‘(i) minimum qualifications and train2 ing requirements for agency-based and 

3 other models; 

4 ‘‘(ii) financial operating standards; 

5 and 

6 ‘‘(iii) an appeals procedure for eligi7 bility denials and a procedure for resolving 

8 disagreements over the terms of an individ9 ualized plan. 

10 ‘‘(B) The State shall modify the quality as11 surance program, as appropriate, to maximize 

12 consumer independence and consumer control 

13 in both agency-provided and other delivery mod14 els. 

15 ‘‘(C) The State shall provide a system that 

16 allows for the external monitoring of the quality 

17 of services and supports by entities consisting 

18 of consumers and their representatives, dis19 ability organizations, providers, families of dis20 abled or elderly individuals, members of the 

21 community, and others. 

22 ‘‘(D) The State shall provide for ongoing 

23 monitoring of the health and well-being of each 

24 individual who receives community-based at25 tendant services and supports. 
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1 ‘‘(E) The State shall require that quality 

2 assurance mechanisms appropriate for the indi3 vidual be included in the individual’s written 

4 plan. 

5 ‘‘(F) The State shall establish a process 

6 for the mandatory reporting, investigation, and 

7 resolution of allegations of neglect, abuse, or ex8 ploitation in connection with the provision of 

9 such services and supports. 

10 ‘‘(G) The State shall obtain meaningful 

11 consumer input, including consumer surveys, 

12 that measure the extent to which an individual 

13 receives the services and supports described in 

14 the individual’s plan and the individual’s satis15 faction with such services and supports. 

16 ‘‘(H) The State shall make available to the 

17 public the findings of the quality assurance pro18 gram. 

19 ‘‘(I) The State shall establish an ongoing 

20 public process for the development, implementa21 tion, and review of the State’s quality assurance 

22 program. 

23 ‘‘(J) The State shall develop and imple24 ment a program of sanctions for providers of 

25 community-based services and supports that 
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1 violate the terms or conditions for the provision 

2 of such services and supports.

3 ‘‘(2) FEDERAL RESPONSIBILITIES.—

4 ‘‘(A) PERIODIC EVALUATIONS.—The Sec5 retary shall conduct a periodic sample review of 

6 outcomes for individuals who receive commu7 nity-based attendant services and supports 

8 under this title. 

9 ‘‘(B) INVESTIGATIONS.—The Secretary 

10 may conduct targeted reviews and investiga11 tions upon receipt of an allegation of neglect, 

12 abuse, or exploitation of an individual receiving 

13 community-based attendant services and sup14 ports under this section. 

15 ‘‘(C) DEVELOPMENT OF PROVIDER SANC16 TION GUIDELINES.—The Secretary shall de17 velop guidelines for States to use in developing 

18 the sanctions required under paragraph (1)(J). 

19 ‘‘(e) REPORTS.—The Secretary shall submit to Con20 gress periodic reports on the provision of community-based 

21 attendant services and supports under this section, par22 ticularly with respect to the impact of the provision of 

23 such services and supports on—

24 ‘‘(1) individuals eligible for medical assistance 

25 under this title;
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1 ‘‘(2) States; and 

2 ‘‘(3) the Federal Government. 

3 ‘‘(f) NO EFFECT ON ABILITY TO PROVIDE COV4 ERAGE UNDER A WAIVER.—

5 ‘‘(1) IN GENERAL.—Nothing in this section 

6 shall be construed as affecting the ability of a State 

7 to provide coverage under the State plan for commu8 nity-based attendant services and supports (or simi9 lar coverage) under a waiver approved under section 

10 1915, section 1115, or otherwise. 

11 ‘‘(2) ELIGIBILITY FOR ENHANCED MATCH.—In 

12 the case of a State that provides coverage for such 

13 services and supports under a waiver, the State shall 

14 not be eligible under subsection (a)(2) for the en15 hanced FMAP for the early provision of such cov16 erage unless the State submits a plan amendment to 

17 the Secretary that meets the requirements of this 

18 section. 

19 ‘‘(g) DEFINITIONS.—In this title: 

20 ‘‘(1) COMMUNITY-BASED ATTENDANT SERVICES

21 AND SUPPORTS.—

22 ‘‘(A) IN GENERAL.—The term ‘community23 based attendant services and supports’ means 

24 attendant services and supports furnished to an 

25 individual, as needed, to assist in accomplishing 
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1 activities of daily living, instrumental activities 

2 of daily living, and health-related functions 

3 through hands-on assistance, supervision, or 

4 cueing—

5 ‘‘(i) under a plan of services and sup6 ports that is based on an assessment of 

7 functional need and that is agreed to by 

8 the individual or, as appropriate, the indi9 vidual’s representative; 

10 ‘‘(ii) in a home or community setting, 

11 which may include a school, workplace, or 

12 recreation or religious facility, but does not 

13 include a nursing facility or an inter14 mediate care facility for the mentally re15 tarded; 

16 ‘‘(iii) under an agency-provider model 

17 or other model (as defined in paragraph 

18 (2)(C)); and 

19 ‘‘(iv) the furnishing of which is se20 lected, managed, and dismissed by the in21 dividual, or, as appropriate, with assistance 

22 from the individual’s representative. 

23 ‘‘(B) INCLUDED SERVICES AND SUP24 PORTS.—Such term includes—
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1 ‘‘(i) tasks necessary to assist an indi2 vidual in accomplishing activities of daily 

3 living, instrumental activities of daily liv4 ing, and health-related functions; 

5 ‘‘(ii) the acquisition, maintenance, and 

6 enhancement of skills necessary for the in7 dividual to accomplish activities of daily 

8 living, instrumental activities of daily liv9 ing, and health-related functions; 

10 ‘‘(iii) backup systems or mechanisms 

11 (such as the use of beepers) to ensure con12 tinuity of services and supports; and 

13 ‘‘(iv) voluntary training on how to se14 lect, manage, and dismiss attendants. 

15 ‘‘(C) EXCLUDED SERVICES AND SUP16 PORTS.—Subject to subparagraph (D), such 

17 term does not include—

18 ‘‘(i) the provision of room and board 

19 for the individual; 

20 ‘‘(ii) special education and related 

21 services provided under the Individuals 

22 with Disabilities Education Act and voca23 tional rehabilitation services provided 

24 under the Rehabilitation Act of 1973; 
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1 ‘‘(iii) assistive technology devices and 

2 assistive technology services; 

3 ‘‘(iv) durable medical equipment; or

4 ‘‘(v) home modifications. 

5 ‘‘(D) FLEXIBILITY IN TRANSITION TO

6 COMMUNITY-BASED HOME SETTING.—Such 

7 term may include expenditures for transitional 

8 costs, such as rent and utility deposits, first 

9 month’s rent and utilities, bedding, basic kitch10 en supplies, and other necessities required for 

11 an individual to make the transition from a 

12 nursing facility or intermediate care facility for 

13 the mentally retarded to a community-based 

14 home setting where the individual resides. 

15 ‘‘(2) ADDITIONAL DEFINITIONS.—

16 ‘‘(A) ACTIVITIES OF DAILY LIVING.—The 

17 term ‘activities of daily living’ includes eating, 

18 toileting, grooming, dressing, bathing, and 

19 transferring. 

20 ‘‘(B) CONSUMER CONTROLLED.—The term 

21 ‘consumer controlled’ means a method of pro22 viding services and supports that allow the indi23 vidual, or where appropriate, the individual’s 

24 representative, maximum control of the commu-
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1 nity-based attendant services and supports, re2 gardless of who acts as the employer of record. 

3 ‘‘(C) DELIVERY MODELS.—

4 ‘‘(i) AGENCY-PROVIDER MODEL.—The 

5 term ‘agency-provider model’ means, with 

6 respect to the provision of community7 based attendant services and supports for 

8 an individual, a method of providing con9 sumer controlled services and supports 

10 under which entities contract for the provi11 sion of such services and supports. 

12 ‘‘(ii) OTHER MODELS.—The term 

13 ‘other models’ means methods, other than 

14 an agency-provider model, for the provision 

15 of consumer controlled services and sup16 ports. Such models may include the provi17 sion of vouchers, direct cash payments, or 

18 use of a fiscal agent to assist in obtaining 

19 services. 

20 ‘‘(D) HEALTH-RELATED FUNCTIONS.—The 

21 term ‘health-related functions’ means functions 

22 that can be delegated or assigned by licensed 

23 health-care professionals under State law to be 

24 performed by an attendant.
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1 ‘‘(E) INSTRUMENTAL ACTIVITIES OF DAILY

2 LIVING.—The term ‘instrumental activities of 

3 daily living’ includes meal planning and prepa4 ration, managing finances, shopping for food, 

5 clothing, and other essential items, performing 

6 essential household chores, communicating by 

7 phone and other media, and traveling around 

8 and participating in the community. 

9 ‘‘(F) INDIVIDUAL’S REPRESENTATIVE.—

10 The term ‘individual’s representative’ means a 

11 parent, a family member, a guardian, an advo12 cate, or an authorized representative of an indi13 vidual.’’. 

14 (c) CONFORMING AMENDMENTS.—

15 (1) MANDATORY BENEFIT.—Section 

16 1902(a)(10)(A) of the Social Security Act (42 

17 U.S.C. 1396a(a)(10)(A)) is amended, in the matter 

18 preceding clause (i), by striking ‘‘(17) and (21)’’ and 

19 inserting ‘‘(17), (21), and (27)’’. 

20 (2) DEFINITION OF MEDICAL ASSISTANCE.—

21 Section 1905(a) of the Social Security Act (42 

22 U.S.C. 1396d) is amended—

23 (A) by striking ‘‘and’’ at the end of para24 graph (26); 
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1 (B) by redesignating paragraph (27) as 

2 paragraph (28); and 

3 (C) by inserting after paragraph (26) the 

4 following:

5 ‘‘(27) community-based attendant services and 

6 supports (to the extent allowed and as defined in 

7 section 1935); and’’. 

8 (3) IMD/ICFMR REQUIREMENTS.—Section 

9 1902(a)(10)(C)(iv) of the Social Security Act (42 

10 U.S.C. 1396a(a)(10)(C)(iv)) is amended by inserting 

11 ‘‘and (27)’’ after ‘‘(24)’’. 

12 (d) EFFECTIVE DATES.—

13 (1) IN GENERAL.—Except as provided in para14 graph (2), the amendments made by this section 

15 (other than the amendment made by subsection 

16 (c)(1)) take effect on October 1, 2003, and apply to 

17 medical assistance provided for community-based at18 tendant services and supports described in section 

19 1935 of the Social Security Act furnished on or 

20 after that date. 

21 (2) MANDATORY BENEFIT.—The amendment 

22 made by subsection (c)(1) takes effect on October 1, 

23 2007.
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1 SEC. 102. ENHANCED FMAP FOR ONGOING ACTIVITIES OF 

2 EARLY COVERAGE STATES THAT ENHANCE 

3 AND PROMOTE THE USE OF COMMUNITY4 BASED ATTENDANT SERVICES AND SUP5 PORTS. 

6 (a) IN GENERAL.—Section 1935 of the Social Secu7 rity Act, as added by section 101(b), is amended—

8 (1) by redesignating subsections (d) through (g) 

9 as subsections (f) through (i), respectively; 

10 (2) in subsection (a)(1), by striking ‘‘subsection 

11 (g)(1)’’ and inserting ‘‘subsection (i)(1)’’; 

12 (3) in subsection (a)(2), by inserting ‘‘, and 

13 with respect to expenditures described in subsection 

14 (d), the Secretary shall pay the State the amount 

15 described in subsection (d)(1)’’ before the period; 

16 (4) in subsection (c)(1)(C), by striking ‘‘sub17 section (g)(2)(B)’’ and inserting ‘‘subsection 

18 (i)(2)(B)’’; and 

19 (5) by inserting after subsection (c), the fol20 lowing: 

21 ‘‘(d) INCREASED FEDERAL FINANCIAL PARTICIPA22 TION FOR EARLY COVERAGE STATES THAT MEET CER23 TAIN BENCHMARKS.—

24 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

25 for purposes of subsection (a)(2), the amount and 

26 expenditures described in this subsection are an 
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1 amount equal to the Federal medical assistance per2 centage, increased by 10 percentage points, of the 

3 expenditures incurred by the State for the provision 

4 or conduct of the services or activities described in 

5 paragraph (3). 

6 ‘‘(2) EXPENDITURE CRITERIA.—A State shall—

7 ‘‘(A) develop criteria for determining the 

8 expenditures described in paragraph (1) in col9 laboration with the individuals and representa10 tives described in subsection (b)(1); and 

11 ‘‘(B) submit such criteria for approval by 

12 the Secretary. 

13 ‘‘(3) SERVICES AND ACTIVITIES DESCRIBED.—

14 For purposes of paragraph (1), the services and ac15 tivities described in this subparagraph are the fol16 lowing: 

17 ‘‘(A) One-stop intake, referral, and institu18 tional diversion services. 

19 ‘‘(B) Identifying and remedying gaps and 

20 inequities in the State’s current provision of 

21 long-term services, particularly those services 

22 that are provided based on such factors as age, 

23 disability type, ethnicity, income, institutional 

24 bias, or other similar factors. 
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1 ‘‘(C) Establishment of consumer participa2 tion and consumer governance mechanisms, 

3 such as cooperatives and regional service au4 thorities, that are managed and controlled by 

5 individuals with significant disabilities who use 

6 community-based services and supports or their 

7 representatives. 

8 ‘‘(D) Activities designed to enhance the 

9 skills, earnings, benefits, supply, career, and fu10 ture prospects of workers who provide commu11 nity-based attendant services and supports. 

12 ‘‘(E) Continuous improvement activities 

13 that are designed to ensure and enhance the 

14 health and well-being of individuals who rely on 

15 community-based attendant services and sup16 ports, particularly activities involving or initi17 ated by consumers of such services and sup18 ports or their representatives. 

19 ‘‘(F) Family support services to augment 

20 the efforts of families and friends to enable in21 dividuals with disabilities of all ages to live in 

22 their own homes and communities. 

23 ‘‘(G) Health promotion and wellness serv24 ices and activities.
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1 ‘‘(H) Provider recruitment and enhance2 ment activities, particularly such activities that 

3 encourage the development and maintenance of 

4 consumer controlled cooperatives or other small 

5 businesses or microenterprises that provide 

6 community-based attendant services and sup7 ports or related services. 

8 ‘‘(I) Activities designed to ensure service 

9 and systems coordination. 

10 ‘‘(J) Any other services or activities that 

11 the Secretary deems appropriate.’’. 

12 (b) EFFECTIVE DATE.—The amendments made by 

13 subsection (a) take effect on October 1, 2003. 

14 SEC. 103. INCREASED FEDERAL FINANCIAL PARTICIPATION 

15 FOR CERTAIN EXPENDITURES. 

16 (a) IN GENERAL.—Section 1935 of the Social Secu17 rity Act, as added by section 101(b) and amended by sec18 tion 102, is amended by inserting after subsection (d) the 

19 following: 

20 ‘‘(e) INCREASED FEDERAL FINANCIAL PARTICIPA21 TION FOR CERTAIN EXPENDITURES.—

22 ‘‘(1) ELIGIBILITY FOR PAYMENT.—

23 ‘‘(A) IN GENERAL.—In the case of a State 

24 that the Secretary determines satisfies the re25 quirements of subparagraph (B), the Secretary
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1 shall pay the State the amounts described in 

2 paragraph (2) in addition to any other pay3 ments provided for under section 1903 or this 

4 section for the provision of community-based at5 tendant services and supports. 

6 ‘‘(B) REQUIREMENTS.—The requirements 

7 of this subparagraph are the following: 

8 ‘‘(i) The State has an approved plan 

9 amendment under this section. 

10 ‘‘(ii) The State has incurred expendi11 tures described in paragraph (2). 

12 ‘‘(iii) The State develops and submits 

13 to the Secretary criteria to identify and se14 lect such expenditures in accordance with 

15 the requirements of paragraph (3). 

16 ‘‘(iv) The Secretary determines that 

17 payment of the applicable percentage of 

18 such expenditures (as determined under 

19 paragraph (2)(B)) would enable the State 

20 to provide a meaningful choice of receiving 

21 community-based services and supports to 

22 individuals with disabilities and elderly in23 dividuals who would otherwise only have 

24 the option of receiving institutional care. 
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1 ‘‘(2) AMOUNTS AND EXPENDITURES DE2 SCRIBED.—

3 ‘‘(A) EXPENDITURES IN EXCESS OF 150

4 PERCENT OF BASELINE AMOUNT.—The 

5 amounts and expenditures described in this 

6 paragraph are an amount equal to the applica7 ble percentage, as determined by the Secretary 

8 in accordance with subparagraph (B), of the ex9 penditures incurred by the State for the provi10 sion of community-based attendant services and 

11 supports to an individual that exceed 150 per12 cent of the average cost of providing nursing fa13 cility services to an individual who resides in 

14 the State and is eligible for such services under 

15 this title, as determined in accordance with cri16 teria established by the Secretary. 

17 ‘‘(B) APPLICABLE PERCENTAGE.—The 

18 Secretary shall establish a payment scale for 

19 the expenditures described in subparagraph (A) 

20 so that the Federal financial participation for 

21 such expenditures gradually increases from 70 

22 percent to 90 percent as such expenditures in23 crease. 
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1 ‘‘(3) SPECIFICATION OF ORDER OF SELECTION

2 FOR EXPENDITURES.—In order to receive the 

3 amounts described in paragraph (2), a State shall—

4 ‘‘(A) develop, in collaboration with the in5 dividuals and representatives described in sub6 section (b)(1) and pursuant to guidelines estab7 lished by the Secretary, criteria to identify and 

8 select the expenditures submitted under that 

9 paragraph; and 

10 ‘‘(B) submit such criteria to the Sec11 retary.’’. 

12 (b) EFFECTIVE DATE.—The amendment made by 

13 subsection (a) takes effect on October 1, 2003. 

14 TITLE II—PROMOTION OF SYS15 TEMS CHANGE AND CAPACITY 

16 BUILDING 

17 SEC. 201. GRANTS TO PROMOTE SYSTEMS CHANGE AND CA18 PACITY BUILDING. 

19 (a) AUTHORITY TO AWARD GRANTS.—

20 (1) IN GENERAL.—The Secretary of Health and 

21 Human Services (in this section referred to as the 

22 ‘‘Secretary’’) shall award grants to eligible States to 

23 carry out the activities described in subsection (b). 

24 (2) APPLICATION.—In order to be eligible for a 

25 grant under this section, a State shall submit to the
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1 Secretary an application in such form and manner, 

2 and that contains such information, as the Secretary 

3 may require. 

4 (b) PERMISSIBLE ACTIVITIES.—A State that receives 

5 a grant under this section may use funds provided under 

6 the grant for any of the following activities, focusing on 

7 areas of need identified by the State and the Consumer 

8 Task Force established under subsection (c): 

9 (1) The development and implementation of the 

10 provision of community-based attendant services and 

11 supports under section 1935 of the Social Security 

12 Act (as added by section 101(b) and amended by 

13 sections 102 and 103) through active collaboration 

14 with—

15 (A) individuals with disabilities; 

16 (B) elderly individuals; 

17 (C) representatives of such individuals; and 

18 (D) providers of, and advocates for, serv19 ices and supports for such individuals. 

20 (2) Substantially involving individuals with sig21 nificant disabilities and representatives of such indi22 viduals in jointly developing, implementing, and con23 tinually improving a mutually acceptable comprehen24 sive, effectively working statewide plan for pre-
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1 venting and alleviating unnecessary institutionaliza2 tion of such individuals. 

3 (3) Engaging in system change and other ac4 tivities deemed necessary to achieve any or all of the 

5 goals of such statewide plan. 

6 (4) Identifying and remedying disparities and 

7 gaps in services to classes of individuals with disabil8 ities and elderly individuals who are currently expe9 riencing or who face substantial risk of unnecessary 

10 institutionalization. 

11 (5) Building and expanding system capacity to 

12 offer quality consumer controlled community-based 

13 services and supports to individuals with disabilities 

14 and elderly individuals, including by—

15 (A) seeding the development and effective 

16 use of community-based attendant services and 

17 supports cooperatives, independent living cen18 ters, small businesses, microenterprises and 

19 similar joint ventures owned and controlled by 

20 individuals with disabilities or representatives of 

21 such individuals and community-based attend22 ant services and supports workers; 

23 (B) enhancing the choice and control indi24 viduals with disabilities and elderly individuals 

25 exercise, including through their representa-
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1 tives, with respect to the personal assistance 

2 and supports they rely upon to lead inde3 pendent, self-directed lives; 

4 (C) enhancing the skills, earnings, benefits, 

5 supply, career, and future prospects of workers 

6 who provide community-based attendant serv7 ices and supports; 

8 (D) engaging in a variety of needs assess9 ment and data gathering; 

10 (E) developing strategies for modifying 

11 policies, practices, and procedures that result in 

12 unnecessary institutional bias or the 

13 overmedicalization of long-term services and 

14 supports; 

15 (F) engaging in interagency coordination 

16 and single point of entry activities; 

17 (G) providing training and technical assist18 ance with respect to the provision of commu19 nity-based attendant services and supports; 

20 (H) engaging in—

21 (i) public awareness campaigns; 

22 (ii) facility-to-community transitional 

23 activities; and 

24 (iii) demonstrations of new ap25 proaches; and 
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1 (I) engaging in other systems change ac2 tivities necessary for developing, implementing, 

3 or evaluating a comprehensive statewide system 

4 of community-based attendant services and sup5 ports. 

6 (6) Ensuring that the activities funded by the 

7 grant are coordinated with other efforts to increase 

8 personal attendant services and supports, includ9 ing—

10 (A) programs funded under or amended by 

11 the Ticket to Work and Work Incentives Im12 provement Act of 1999 (Public Law 106–170; 

13 113 Stat. 1860); 

14 (B) grants funded under the Families of 

15 Children With Disabilities Support Act of 2000 

16 (42 U.S.C. 15091 et seq.); and 

17 (C) other initiatives designed to enhance 

18 the delivery of community-based services and 

19 supports to individuals with disabilities and el20 derly individuals. 

21 (7) Engaging in transition partnership activities 

22 with nursing facilities and intermediate care facili23 ties for the mentally retarded that utilize and build 

24 upon items and services provided to individuals with 

25 disabilities or elderly individuals under the medicaid
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1 program under title XIX of the Social Security Act, 

2 or by Federal, State, or local housing agencies, inde3 pendent living centers, and other organizations con4 trolled by consumers or their representatives. 

5 (c) CONSUMER TASK FORCE.—

6 (1) ESTABLISHMENT AND DUTIES.—To be eli7 gible to receive a grant under this section, each 

8 State shall establish a Consumer Task Force (re9 ferred to in this subsection as the ‘‘Task Force’’) to 

10 assist the State in the development, implementation, 

11 and evaluation of real choice systems change initia12 tives. 

13 (2) APPOINTMENT.—Members of the Task 

14 Force shall be appointed by the Chief Executive Of15 ficer of the State in accordance with the require16 ments of paragraph (3), after the solicitation of rec17 ommendations from representatives of organizations 

18 representing a broad range of individuals with dis19 abilities, elderly individuals, representatives of such 

20 individuals, and organizations interested in individ21 uals with disabilities and elderly individuals. 

22 (3) COMPOSITION.—

23 (A) IN GENERAL.—The Task Force shall 

24 represent a broad range of individuals with dis25 abilities from diverse backgrounds and shall in-
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1 clude representatives from Developmental Dis2 abilities Councils, Mental Health Councils, 

3 State Independent Living Centers and Councils, 

4 Commissions on Aging, organizations that pro5 vide services to individuals with disabilities and 

6 consumers of long-term services and supports. 

7 (B) INDIVIDUALS WITH DISABILITIES.—A 

8 majority of the members of the Task Force 

9 shall be individuals with disabilities or rep10 resentatives of such individuals. 

11 (C) LIMITATION.—The Task Force shall 

12 not include employees of any State agency pro13 viding services to individuals with disabilities 

14 other than employees of entities described in 

15 the Developmental Disabilities Assistance and 

16 Bill of Rights Act of 2000 (42 U.S.C. 15001 et 

17 seq.). 

18 (d) ANNUAL REPORT.—

19 (1) STATES.—A State that receives a grant 

20 under this section shall submit an annual report to 

21 the Secretary on the use of funds provided under the 

22 grant in such form and manner as the Secretary 

23 may require. 
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1 (2) SECRETARY.—The Secretary shall submit 

2 to Congress an annual report on the grants made 

3 under this section. 

4 (e) AUTHORIZATION OF APPROPRIATIONS.—

5 (1) IN GENERAL.—There is authorized to be 

6 appropriated to carry out this section, $50,000,000 

7 for each of fiscal years 2004 through 2006. 

8 (2) AVAILABILITY.—Amounts appropriated to 

9 carry out this section shall remain available without 

10 fiscal year limitation. 

11 SEC. 202. DEMONSTRATION PROJECT TO ENHANCE CO12 ORDINATION OF CARE UNDER THE MEDI13 CARE AND MEDICAID PROGRAMS FOR NON14 ELDERLY DUAL ELIGIBLE INDIVIDUALS. 

15 (a) DEFINITIONS.—In this section: 

16 (1) NON-ELDERLY DUALLY ELIGIBLE INDI17 VIDUAL.—The term ‘‘non-elderly dually eligible indi18 vidual’’ means an individual who—

19 (A) has not attained age 65; and 

20 (B) is enrolled in the medicare and med21 icaid programs established under titles XVIII 

22 and XIX, respectively, of the Social Security 

23 Act (42 U.S.C. 1395 et seq., 1396 et seq.). 
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1 (2) PROJECT.—The term ‘‘project’’ means the 

2 demonstration project authorized to be conducted 

3 under this section. 

4 (3) SECRETARY.—The term ‘‘Secretary’’ means 

5 the Secretary of Health and Human Services. 

6 (b) AUTHORITY TO CONDUCT PROJECT.—The Sec7 retary shall conduct a project under this section for the 

8 purpose of evaluating service coordination and cost-shar9 ing approaches with respect to the provision of commu10 nity-based services and supports to non-elderly dually eli11 gible individuals. 

12 (c) REQUIREMENTS.—

13 (1) NUMBER OF PARTICIPANTS.—Not more 

14 than 5 States may participate in the project. 

15 (2) APPLICATION.—A State that desires to par16 ticipate in the project shall submit an application to 

17 the Secretary, at such time and in such form and 

18 manner as the Secretary shall specify. 

19 (3) DURATION.—The project shall be conducted 

20 for at least 5, but not more than 10 years. 

21 (d) EVALUATION AND REPORT.—

22 (1) EVALUATION.—Not later than 1 year prior 

23 to the termination date of the project, the Secretary, 

24 in consultation with States participating in the 

25 project, representatives of non-elderly dually eligible 
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1 individuals, and others, shall evaluate the impact 

2 and effectiveness of the project. 

3 (2) REPORT.—The Secretary shall submit a re4 port to Congress that contains the findings of the 

5 evaluation conducted under paragraph (1) along 

6 with recommendations regarding whether the project 

7 should be extended or expanded, and any other legis8 lative or administrative actions that the Secretary 

9 considers appropriate as a result of the project. 

10 (e) AUTHORIZATION OF APPROPRIATIONS.—There 

11 are authorized to be appropriated such sums as are nec12 essary to carry out this section.

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