I 

111TH CONGRESS 

1ST SESSION H. R. 1670 

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 

MARCH 23, 2009 

Mr. DAVIS of Illinois (for himself, Mr. PAYNE, Mrs. CHRISTENSEN, Mr. 

BRADY of Pennsylvania, Ms. LEE of California, Mr. MEEKS of New York, 

Mr. CARNEY, Mr. DOYLE, Mr. LARSON of Connecticut, Mr. MOORE of 

Kansas, Mr. HINCHEY, Mr. KUCINICH, Mr. LEWIS of Georgia, Ms. BALDWIN, Mr. COHEN, Mr. FATTAH, Ms. DELAURO, Mr. ISRAEL, Ms. KAPTUR, Mr. KIND, Mr. LANGEVIN, Mr. OLVER, Ms. LORETTA SANCHEZ of 

California, Ms. SCHWARTZ, Mr. SESTAK, and Ms. VELA ́ZQUEZ) 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, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Community Choice Act of 2009’’. 


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

2 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 dual eligible individuals. 

3 SEC. 2. FINDINGS AND PURPOSES. 

4 (a) FINDINGS.—Congress makes the following find5 ings: 

6 (1) Long-term services and supports provided 

7 under the Medicaid program established under title 

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

9 seq.) must meet the abilities and life choices of indi10 viduals with disabilities and older Americans, includ11 ing the choice to live in one’s own home or with 

12 one’s own family and to become a productive mem13 ber of the community. 

14 (2) Similarly, under the United States Supreme 

15 Court’s decision in Olmstead v. L.C., 527 U.S. 581 

16 (1999), individuals with disabilities have the right to 

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1 ports in the community, rather than in an institu2 tional setting. 

3 (3) Nevertheless, research on the provision of 

4 long-term services and supports under the Medicaid 

5 program (conducted by and on behalf of the Depart6 ment of Health and Human Services) continues to 

7 show a significant funding and programmatic bias 

8 toward institutional care. In 2007, only 42 percent 

9 of long-term care funds expended under the Med10 icaid program, and only about 13.6 percent of all 

11 funds expended under that program, pay for services 

12 and supports in home and community-based set13 tings. 

14 (4) While much effort has been dedicated to 

15 ‘‘rebalancing’’ the current system, overall about 60 

16 percent of Medicaid long-term care dollars are still 

17 spent on institutional services, with about 40 percent 

18 going to home and community-based services. In 

19 2007, only 11 States spent 50 percent or more of 

20 their Medicaid long-term care funds on home and 

21 community-based care. 

22 (5) The statistics are even more dispropor23 tionate for adults with physical disabilities. In 2007, 

24 69 percent of Medicaid long-term care spending for 

25 older people and adults with physical disabilities 


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1 paid for institutional services. Only 6 States spent 

2 50 percent or more of their Medicaid long-term care 

3 dollars on home and community-based services for 

4 older people and adults with physical disabilities 

while 1 5 ⁄2 of the States spent less than 25 percent. 

6 This disparity continues even though, on average, it 

7 is estimated that Medicaid dollars can support near8 ly 3 older people and adults with physical disabilities 

9 in home and community-based services for every per10 son in a nursing home. 

11 (6) For Medicaid beneficiaries who need long12 term care, services provided in an institutional set13 ting represent the only guaranteed benefit. Only 30 

14 States have adopted the benefit option of providing 

15 personal care, or attendant, services under their 

16 Medicaid programs. 

17 (7) Although every State has chosen to provide 

18 certain services under home and community-based 

19 waivers, these services are unevenly available within 

20 and across States, and reach a small percentage of 

21 eligible individuals. Individuals with the most signifi22 cant disabilities are usually afforded the least 

23 amount of choice, despite advances in medical and 

24 assistive technologies and related areas. 


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1 (8) Despite the more limited funding for home 

2 and community-based services, the majority of indi3 viduals who use Medicaid long-term services and 

4 supports prefer to live in the community, rather 

5 than in institutional settings. 

6 (9) The goals of the Nation properly include 

7 providing families of children with disabilities, work8 ing-age adults with disabilities, and older Americans 

9 with— 

10 (A) a meaningful choice of receiving long11 term services and supports in the most inte12 grated setting appropriate to the individual’s 

13 needs; 

14 (B) the greatest possible control over the 

15 services received and, therefore, their own lives 

16 and futures; and 

17 (C) quality services that maximize inde18 pendence in the home and community. 

19 (b) PURPOSES.—The purposes of this Act are the fol20 lowing: 

21 (1) To reform the Medicaid program estab22 lished under title XIX of the Social Security Act (42 

23 U.S.C. 1396 et seq.) to provide services in the most 

24 integrated setting appropriate to the individual’s 

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1 based attendant services and supports in order to 

2 assist individuals in achieving equal opportunity, full 

3 participation, independent living, and economic self4 sufficiency. 

5 (2) To provide financial assistance to States as 

6 they reform their long-term care systems to provide 

7 comprehensive statewide long-term services and sup8 ports, including community-based attendant services 

9 and supports that provide consumer choice and di10 rection, in the most integrated setting appropriate. 

11 (3) To assist States in meeting the growing de12 mand for community-based attendant services and 

13 supports, as the Nation’s population ages and indi14 viduals with disabilities live longer. 

15 (4) To assist States in complying with the U.S. 

16 Supreme Court decision in Olmstead v. L.C., 527 

17 U.S. 581 (1999), and implementing the integration 

18 mandate of the Americans with Disabilities Act. 


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1 TITLE I—ESTABLISHMENT OF 

2 MEDICAID PLAN BENEFIT 

3 SEC. 101. COVERAGE OF COMMUNITY-BASED ATTENDANT 

4 SERVICES AND SUPPORTS UNDER THE MED5 ICAID PROGRAM. 

6 (a) MANDATORY COVERAGE.—Section 

7 1902(a)(10)(D) of the Social Security Act (42 U.S.C. 

8 1396a(a)(10)(D)) is amended— 

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

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

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

12 clause: 

13 ‘‘(ii) subject to section 1943, for the 

14 inclusion of community-based attendant 

15 services and supports for any individual 

16 who— 

17 ‘‘(I) is eligible for medical assist18 ance under the State plan; 

19 ‘‘(II) with respect to whom there 

20 has been a determination that the in21 dividual requires the level of care pro22 vided in a nursing facility, institution 

23 for mental diseases, or an inter24 mediate care facility for the mentally 

25 retarded (whether or not coverage of 


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1 such institution or intermediate care 

2 facility is provided under the State 

3 plan); and 

4 ‘‘(III) chooses to receive such 

5 services and supports;’’. 

6 (b) COMMUNITY-BASED ATTENDANT SERVICES AND

7 SUPPORTS.— 

8 (1) IN GENERAL.—Title XIX of the Social Se9 curity Act (42 U.S.C. 1396 et seq.) is amended by 

10 adding at the end the following new section: 

11 ‘‘COMMUNITY-BASED ATTENDANT SERVICES AND

12 SUPPORTS

13 ‘‘SEC. 1943. (a) REQUIRED COVERAGE.— 

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

15 2014, a State shall provide through a plan amend16 ment for the inclusion of community-based attendant 

17 services and supports (as defined in subsection 

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

19 1902(a)(10)(D)(ii) in accordance with this section. 

20 ‘‘(2) ENHANCED FMAP AND ADDITIONAL FED21 ERAL FINANCIAL SUPPORT FOR EARLIER COV22 ERAGE.—Notwithstanding section 1905(b), during 

23 the period that begins on October 1, 2009, and ends 

24 on September 30, 2014, in the case of a State with 

25 an approved plan amendment under this section dur26 ing that period that also satisfies the requirements 


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1 of subsection (c) the Federal medical assistance per2 centage shall be equal to the enhanced FMAP de3 scribed in section 2105(b) with respect to medical 

4 assistance in the form of community-based attendant 

5 services and supports provided to individuals de6 scribed in section 1902(a)(10)(D)(ii) in accordance 

7 with this section on or after the date of the approval 

8 of such plan amendment. 

9 ‘‘(b) DEVELOPMENT AND IMPLEMENTATION OF BEN10 EFIT.—In order for a State plan amendment to be ap11 proved under this section, a State shall provide the Sec12 retary with the following assurances: 

13 ‘‘(1) ASSURANCE OF DEVELOPMENT AND IM14 PLEMENTATION COLLABORATION.— 

15 ‘‘(A) IN GENERAL.—That State plan 

16 amendment— 

17 ‘‘(i) has been developed in collabora18 tion with, and with the approval of, a De19 velopment and Implementation Council es20 tablished by the State that satisfies the re21 quirements of subparagraph (B); and 

22 ‘‘(ii) will be implemented in collabora23 tion with such Council and on the basis of 

24 public input solicited by the State and the 

25 Council. 


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1 ‘‘(B) DEVELOPMENT AND IMPLEMENTA2 TION COUNCIL REQUIREMENTS.—For purposes 

3 of subparagraph (A), the requirements of this 

4 subparagraph are that— 

5 ‘‘(i) the majority of the members of 

6 the Development and Implementation 

7 Council are individuals with disabilities, el8 derly individuals, and their representatives; 

9 and 

10 ‘‘(ii) in carrying out its responsibil11 ities, the Council actively collaborates 

12 with— 

13 ‘‘(I) individuals with disabilities; 

14 ‘‘(II) elderly individuals; 

15 ‘‘(III) representatives of such in16 dividuals; and 

17 ‘‘(IV) providers of, and advocates 

18 for, services and supports for such in19 dividuals. 

20 ‘‘(2) ASSURANCE OF PROVISION ON A STATE21 WIDE BASIS AND IN MOST INTEGRATED SETTING.— 

22 That consumer controlled community-based attend23 ant services and supports will be provided under the 

24 State plan to individuals described in section 

25 1902(a)(10)(D)(ii) on a statewide basis and in a 


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1 manner that provides such services and supports in 

2 the most integrated setting appropriate to the indi3 vidual’s needs. 

4 ‘‘(3) ASSURANCE OF NONDISCRIMINATION.— 

5 That the State will provide community-based attend6 ant services and supports to an individual described 

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

8 individual’s age, type or nature of disability, severity 

9 of disability, or the form of community-based attend10 ant services and supports that the individual re11 quires in order to lead an independent life. 

12 ‘‘(4) ASSURANCE OF MAINTENANCE OF EF13 FORT.—That the level of State expenditures for 

14 medical assistance that is provided under section 

15 1905(a), section 1915, section 1115, or otherwise to 

16 individuals with disabilities or elderly individuals for 

17 a fiscal year shall not be less than the level of such 

18 expenditures for the fiscal year preceding the first 

19 full fiscal year in which the State plan amendment 

20 to provide community-based attendant services and 

21 supports in accordance with this section is imple22 mented. 

23 ‘‘(c) REQUIREMENTS FOR ENHANCED FMAP FOR

24 EARLY COVERAGE.—In addition to satisfying the other re25 quirements for an approved plan amendment under this 


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

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

3 the enhanced FMAP for early coverage under subsection 

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

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

6 year, the State shall provide the Secretary with the 

7 following specifications regarding the provision of 

8 community-based attendant services and supports 

9 under the plan for that fiscal year: 

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

11 estimated to receive community-based attendant 

12 services and supports under the plan during the 

13 fiscal year. 

14 ‘‘(ii) The number of individuals that re15 ceived such services and supports during the 

16 preceding fiscal year. 

17 ‘‘(B) The maximum number of individuals 

18 who will receive such services and supports 

19 under the plan during that fiscal year. 

20 ‘‘(C) The procedures the State will imple21 ment to ensure that the models for delivery of 

22 such services and supports are consumer con23 trolled (as defined in subsection (g)(2)(B)). 

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1 uals and relevant other individuals of the avail2 ability of such services and supports under this 

3 title, and of other items and services that may 

4 be provided to the individual under this title or 

5 title XVIII and other Federal or State long6 term service and support programs. 

7 ‘‘(E) The procedures the State will imple8 ment to ensure that such services and supports 

9 are provided in accordance with the require10 ments of subsection (b)(1). 

11 ‘‘(F) The procedures the State will imple12 ment to actively involve in a systematic, com13 prehensive, and ongoing basis, the Development 

14 and Implementation Council established in ac15 cordance with subsection (b)(1)(A)(ii), individ16 uals with disabilities, elderly individuals, and 

17 representatives of such individuals in the de18 sign, delivery, administration, implementation, 

19 and evaluation of the provision of such services 

20 and supports under this title. 

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

22 State shall provide the Secretary with such sub23 stantive input into, and participation in, the design 

24 and conduct of data collection, analyses, and other 

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1 sion of community-based attendant services and sup2 ports under this section as the Secretary deems nec3 essary in order to determine the effectiveness of the 

4 provision of such services and supports in allowing 

5 the individuals receiving such services and supports 

6 to lead an independent life to the maximum extent 

7 possible. 

8 ‘‘(d) QUALITY ASSURANCE.— 

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

10 State plan amendment to be approved under this 

11 section, a State shall establish and maintain a com12 prehensive, continuous quality assurance system 

13 with respect to community-based attendant services 

14 and supports that provides for the following: 

15 ‘‘(A) The State shall establish require16 ments, as appropriate, for agency-based and 

17 other delivery models that include— 

18 ‘‘(i) minimum qualifications and train19 ing requirements for agency-based and 

20 other models; 

21 ‘‘(ii) financial operating standards; 

22 and 

23 ‘‘(iii) an appeals procedure for eligi24 bility denials and a procedure for resolving 


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1 disagreements over the terms of an individ2 ualized plan. 

3 ‘‘(B) The State shall modify the quality as4 surance system, as appropriate, to maximize 

5 consumer independence and consumer control 

6 in both agency-provided and other delivery mod7 els. 

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

9 allows for the external monitoring of the quality 

10 of services and supports by entities consisting 

11 of consumers and their representatives, dis12 ability organizations, providers, families of dis13 abled or elderly individuals, members of the 

14 community, and others. 

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

16 monitoring of the health and well-being of each 

17 individual who receives community-based at18 tendant services and supports. 

19 ‘‘(E) The State shall require that quality 

20 assurance mechanisms pertaining to the indi21 vidual be included in the individual’s written 

22 plan. 

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

24 for the mandatory reporting, investigation, and 

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1 ploitation in connection with the provision of 

2 such services and supports. 

3 ‘‘(G) The State shall obtain meaningful 

4 consumer input, including consumer surveys, 

5 that measure the extent to which an individual 

6 receives the services and supports described in 

7 the individual’s plan and the individual’s satis8 faction with such services and supports. 

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

10 public the findings of the quality assurance sys11 tem. 

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

13 public process for the development, implementa14 tion, and review of the State’s quality assurance 

15 system. 

16 ‘‘(J) The State shall develop and imple17 ment a program of sanctions for providers of 

18 community-based services and supports that 

19 violate the terms or conditions for the provision 

20 of such services and supports. 

21 ‘‘(2) FEDERAL RESPONSIBILITIES.— 

22 ‘‘(A) PERIODIC EVALUATIONS.—The Sec23 retary shall conduct a periodic sample review of 

24 outcomes for individuals who receive commuVerDate Nov 24 2008 04:49 Mar 24, 2009 Jkt 079200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\H1670.IH H1670

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1 nity-based attendant services and supports 

2 under this title. 

3 ‘‘(B) INVESTIGATIONS.—The Secretary 

4 may conduct targeted reviews and investiga5 tions upon receipt of an allegation of neglect, 

6 abuse, or exploitation of an individual receiving 

7 community-based attendant services and sup8 ports under this section. 

9 ‘‘(C) DEVELOPMENT OF PROVIDER SANC10 TION GUIDELINES.—The Secretary shall de11 velop guidelines for States to use in developing 

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

13 ‘‘(e) REPORTS.—The Secretary shall submit to Con14 gress periodic reports on the provision of community-based 

15 attendant services and supports under this section, par16 ticularly with respect to the impact of the provision of 

17 such services and supports on— 

18 ‘‘(1) individuals eligible for medical assistance 

19 under this title; 

20 ‘‘(2) States; and 

21 ‘‘(3) the Federal Government. 

22 ‘‘(f) NO EFFECT ON ABILITY TO PROVIDE COV23 ERAGE.— 

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

25 shall be construed as affecting the ability of a State 


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1 to provide coverage under the State plan for commu2 nity-based attendant services and supports (or simi3 lar coverage) under section 1905(a), section 1915, 

4 section 1115, or otherwise. 

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

6 the case of a State that provides coverage for such 

7 services and supports under a waiver, the State shall 

8 not be eligible under subsection (a)(2) for the en9 hanced FMAP for the early provision of such cov10 erage unless the State submits a plan amendment to 

11 the Secretary that meets the requirements of this 

12 section and demonstrates that the State is able to 

13 fully comply with and implement the requirements of 

14 this section. 

15 ‘‘(g) DEFINITIONS.—In this title: 

16 ‘‘(1) COMMUNITY-BASED ATTENDANT SERVICES

17 AND SUPPORTS.— 

18 ‘‘(A) IN GENERAL.—The term ‘community19 based attendant services and supports’ means 

20 attendant services and supports furnished to an 

21 individual, as needed, to assist in accomplishing 

22 activities of daily living, instrumental activities 

23 of daily living, and health-related tasks through 

24 hands-on assistance, supervision, or cueing— 


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1 ‘‘(i) under a plan of services and sup2 ports that is based on an assessment of 

3 functional need and that is agreed to in 

4 writing by the individual or, as appro5 priate, the individual’s representative; 

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

7 which shall include but not be limited to a 

8 school, workplace, or recreation or religious 

9 facility, but does not include a nursing fa10 cility, institution for mental diseases, or an 

11 intermediate care facility for the mentally 

12 retarded; 

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

14 or other model (as defined in paragraph 

15 (2)(C)); 

16 ‘‘(iv) the furnishing of which— 

17 ‘‘(I) is selected, managed, and 

18 dismissed by the individual, or, as ap19 propriate, with assistance from the in20 dividual’s representative; and 

21 ‘‘(II) provided by an individual 

22 who is qualified to provide such serv23 ices, including family members (as de24 fined by the Secretary). 


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1 ‘‘(B) INCLUDED SERVICES AND SUP2 PORTS.—Such term includes— 

3 ‘‘(i) tasks necessary to assist an indi4 vidual in accomplishing activities of daily 

5 living, instrumental activities of daily liv6 ing, and health-related tasks; 

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

8 enhancement of skills necessary for the in9 dividual to accomplish activities of daily 

10 living, instrumental activities of daily liv11 ing, and health-related tasks; 

12 ‘‘(iii) backup systems or mechanisms 

13 (such as the use of beepers) to ensure con14 tinuity of services and supports; and 

15 ‘‘(iv) voluntary training on how to se16 lect, manage, and dismiss attendants. 

17 ‘‘(C) EXCLUDED SERVICES AND SUP18 PORTS.—Subject to subparagraph (D), such 

19 term does not include— 

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

21 for the individual; 

22 ‘‘(ii) special education and related 

23 services provided under the Individuals 

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1 tional rehabilitation services provided 

2 under the Rehabilitation Act of 1973; 

3 ‘‘(iii) assistive technology devices and 

4 assistive technology services; 

5 ‘‘(iv) durable medical equipment; or 

6 ‘‘(v) home modifications. 

7 ‘‘(D) FLEXIBILITY IN TRANSITION TO

8 COMMUNITY-BASED HOME SETTING.—Such 

9 term may include expenditures for transitional 

10 costs, such as rent and utility deposits, first 

11 month’s rent and utilities, bedding, basic kitch12 en supplies, and other necessities required for 

13 an individual to make the transition from a 

14 nursing facility, institution for mental diseases, 

15 or intermediate care facility for the mentally re16 tarded to a community-based home setting 

17 where the individual resides. 

18 ‘‘(2) ADDITIONAL DEFINITIONS.— 

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

20 term ‘activities of daily living’ includes eating, 

21 toileting, grooming, dressing, bathing, and 

22 transferring. 

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

24 ‘consumer controlled’ means a method of select25 ing and providing services and supports that 


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1 allow the individual, or where appropriate, the 

2 individual’s representative, maximum control of 

3 the community-based attendant services and 

4 supports, regardless of who acts as the em5 ployer of record. 

6 ‘‘(C) DELIVERY MODELS.— 

7 ‘‘(i) AGENCY-PROVIDER MODEL.—The 

8 term ‘agency-provider model’ means, with 

9 respect to the provision of community10 based attendant services and supports for 

11 an individual, subject to clause (iii), a 

12 method of providing consumer controlled 

13 services and supports under which entities 

14 contract for the provision of such services 

15 and supports. 

16 ‘‘(ii) OTHER MODELS.—The term 

17 ‘other models’ means, subject to clause 

18 (iii), methods, other than an agency-pro19 vider model, for the provision of consumer 

20 controlled services and supports. Such 

21 models may include the provision of vouch22 ers, direct cash payments, or use of a fiscal 

23 agent to assist in obtaining services. 

24 ‘‘(iii) COMPLIANCE WITH CERTAIN

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1 less of whether the State uses an agency2 provider model or other models to provide 

3 services and supports under a State plan 

4 amendment under this section, such serv5 ices and supports are provided in accord6 ance with the requirements of the Fair 

7 Labor Standards Act of 1938 and applica8 ble Federal and State laws regarding— 

9 ‘‘(I) withholding and payment of 

10 Federal and State income and payroll 

11 taxes; 

12 ‘‘(II) the provision of unemploy13 ment and workers compensation in14 surance; 

15 ‘‘(III) maintenance of general li16 ability insurance; and 

17 ‘‘(IV) occupational health and 

18 safety. 

19 ‘‘(D) HEALTH-RELATED TASKS.—The 

20 term ‘health-related tasks’ means specific tasks 

21 that can be delegated or assigned by licensed 

22 health-care professionals under State law to be 

23 performed by an attendant. 

24 ‘‘(E) INSTRUMENTAL ACTIVITIES OF DAILY

25 LIVING.—The term ‘instrumental activities of 


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1 daily living’ includes, but is not limited to, meal 

2 planning and preparation, managing finances, 

3 shopping for food, clothing, and other essential 

4 items, performing essential household chores, 

5 communicating by phone and other media, and 

6 traveling around and participating in the com7 munity. 

8 ‘‘(F) INDIVIDUALS REPRESENTATIVE.— 

9 The term ‘individual’s representative’ means a 

10 parent, a family member, a guardian, an advo11 cate, or other authorized representative of an 

12 individual.’’. 

13 (c) CONFORMING AMENDMENTS.— 

14 (1) MANDATORY BENEFIT.—Section 

15 1902(a)(10)(A) of the Social Security Act (42 

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

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

18 inserting ‘‘(17), (21), and (28)’’. 

19 (2) DEFINITION OF MEDICAL ASSISTANCE.— 

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

21 U.S.C. 1396d) is amended— 

22 (A) by striking ‘‘and’’ at the end of para23 graph (27); 

24 (B) by redesignating paragraph (28) as 

25 paragraph (29); and 


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1 (C) by inserting after paragraph (27) the 

2 following: 

3 ‘‘(28) community-based attendant services and 

4 supports (to the extent allowed and as defined in 

5 section 1943); and’’. 

6 (3) IMD/ICFMR REQUIREMENTS.—Section 

7 1902(a)(10)(C)(iv) of the Social Security Act (42 

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

9 ‘‘and (28)’’ after ‘‘(24)’’. 

10 (d) EFFECTIVE DATES.— 

11 (1) IN GENERAL.—Except as provided in para12 graph (2), the amendments made by this section 

13 (other than the amendment made by subsection 

14 (c)(1)) take effect on October 1, 2009, and apply to 

15 medical assistance provided for community-based at16 tendant services and supports described in section 

17 1943 of the Social Security Act furnished on or 

18 after that date. 

19 (2) MANDATORY BENEFIT.—The amendment 

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

21 2014. 


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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 1943 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, SUPPORTS AND ACTIVITIES DE14 SCRIBED.—For purposes of paragraph (1), the serv15 ices, supports and activities described in this sub16 paragraph are the following: 

17 ‘‘(A) 1-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 and supports, particularly 

22 those services and supports that are provided 

23 based on such factors as age, severity of dis24 ability, type of disability, ethnicity, income, in25 stitutional 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, comprehensive quality 

13 improvement activities that are designed to en14 sure and enhance the health and well-being of 

15 individuals who rely on community-based at16 tendant services and supports, particularly ac17 tivities involving or initiated by consumers of 

18 such services and supports or their representa19 tives. 

20 ‘‘(F) Family support services to augment 

21 the efforts of families and friends to enable in22 dividuals with disabilities of all ages to live in 

23 their own homes and communities. 

24 ‘‘(G) Health promotion and wellness serv25 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 micro-enterprises 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, 2009. 

14 SEC. 103. INCREASED FEDERAL FINANCIAL PARTICIPATION 

15 FOR CERTAIN EXPENDITURES. 

16 (a) IN GENERAL.—Section 1943 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, 2009. 

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 1943 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 preVerDate Nov 24 2008 04:49 Mar 24, 2009 Jkt 079200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\H1670.IH H1670

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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, micro-enterprises, micro19 boards, and similar joint ventures owned and 

20 controlled by individuals with disabilities or rep21 resentatives of such individuals and community22 based attendant services and supports workers; 

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

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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 over13 medicalization of long-term services and sup14 ports; 

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 

4 controlled 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 

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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 2010 through 2012. 

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 DUAL 

14 ELIGIBLE INDIVIDUALS. 

15 (a) DEFINITIONS.—In this section: 

16 (1) DUALLY ELIGIBLE INDIVIDUAL.—The term 

17 ‘‘dually eligible individual’’ means an individual who 

18 is enrolled in the Medicare and Medicaid programs 

19 established under Titles XVIII and XIX, respec20 tively, of the Social Security Act (42 U.S.C. 1395 et 

21 seq., 1396 et seq.). 

22 (2) PROJECT.—The term ‘‘project’’ means the 

23 demonstration project authorized to be conducted 

24 under this section. 


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

2 the Secretary of Health and Human Services. 

3 (b) AUTHORITY TO CONDUCT PROJECT.—The Sec4 retary shall conduct a project under this section for the 

5 purpose of evaluating service coordination and cost-shar6 ing approaches with respect to the provision of commu7 nity-based services and supports to dually eligible individ8 uals. 

9 (c) REQUIREMENTS.— 

10 (1) NUMBER OF PARTICIPANTS.—Not more 

11 than 5 States may participate in the project. 

12 (2) APPLICATION.—A State that desires to par13 ticipate in the project shall submit an application to 

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

15 manner as the Secretary shall specify. 

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

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

18 (d) EVALUATION AND REPORT.— 

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

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

21 in consultation with States participating in the 

22 project, representatives of dually eligible individuals, 

23 and others, shall evaluate the impact and effective24 ness of the project. 


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1 (2) REPORT.—The Secretary shall submit a re2 port to Congress that contains the findings of the 

3 evaluation conducted under paragraph (1) along 

4 with recommendations regarding whether the project 

5 should be extended or expanded, and any other legis6 lative or administrative actions that the Secretary 

7 considers appropriate as a result of the project. 

8 (e) AUTHORIZATION OF APPROPRIATIONS.—There 

9 are authorized to be appropriated such sums as are nec10 essary to carry out this section. 

Æ 


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