II 

111TH CONGRESS 

1ST SESSION S. 1256 

To amend title XIX of the Social Security Act to establish financial incentives 

for States to expand the provision of long-term services and supports 

to Medicaid beneficiaries who do not reside in an institution, and for 

other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 11, 2009 

Ms. CANTWELL (for herself and Mr. KOHL) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XIX of the Social Security Act to establish 

financial incentives for States to expand the provision 

of long-term services and supports to Medicaid beneficiaries who do not reside in an institution, 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 ‘‘Home and Community Balanced Incentives Act of 

6 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. 

TITLE I—BALANCING INCENTIVES 

Sec. 101. Enhanced FMAP for expanding the provision of non-institutionallybased long-term services and supports. 

TITLE II—STRENGTHENING THE MEDICAID HOME AND 

COMMUNITY-BASED STATE PLAN AMENDMENT OPTION 

Sec. 201. Removal of barriers to providing home and community-based services 

under State plan amendment option for individuals in need. 

Sec. 202. Mandatory application of spousal impoverishment protections to recipients of home and community-based services. 

Sec. 203. State authority to elect to exclude up to 6 months of average cost 

of nursing facility services from assets or resources for purposes of eligibility for home and community-based services. 

TITLE III—COORDINATION OF HOME AND COMMUNITY-BASED 

WAIVERS 

Sec. 301. Streamlined process for combined waivers under subsections (b) and 

(c) of section 1915. 

3 TITLE I—BALANCING 

4 INCENTIVES 

5 SEC. 101. ENHANCED FMAP FOR EXPANDING THE PROVI6 SION OF NON-INSTITUTIONALLY-BASED 

7 LONG-TERM SERVICES AND SUPPORTS. 

8 (a) ENHANCED FMAP TO ENCOURAGE EXPAN9 SION.—Section 1905 of the Social Security Act (42 U.S.C. 

10 1396d) is amended— 

11 (1) in the first sentence of subsection (b)— 

12 (A) by striking ‘‘, and (4)’’ and inserting 

13 ‘‘, (4)’’; and 

14 (B) by inserting before the period the fol15 lowing: ‘‘, and (5) in the case of a balancing inVerDate Nov 24 2008 06:55 Jun 12, 2009 Jkt 079200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1256.IS S1256

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1 centive payment State, as defined in subsection 

2 (y)(1), that meets the conditions described in 

3 subsection (y)(2), the Federal medical assist4 ance percentage shall be increased by the appli5 cable number of percentage points determined 

6 under subsection (y)(3) for the State with re7 spect to medical assistance described in sub8 section (y)(4)’’; and 

9 (2) by adding at the end the following new sub10 section: 

11 ‘‘(y) STATE BALANCING INCENTIVE PAYMENTS PRO12 GRAM.—For purposes of clause (5) of the first sentence 

13 of subsection (b): 

14 ‘‘(1) BALANCING INCENTIVE PAYMENT

15 STATE.—A balancing incentive payment State is a 

16 State— 

17 ‘‘(A) in which less than 50 percent of the 

18 total expenditures for medical assistance for fis19 cal year 2009 for long-term services and sup20 ports (as defined by the Secretary, subject to 

21 paragraph (5)) are for non-institutionally-based 

22 long-term services and supports described in 

23 paragraph (5)(B); 


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1 ‘‘(B) that submits an application and 

2 meets the conditions described in paragraph 

3 (2); and 

4 ‘‘(C) that is selected by the Secretary to 

5 participate in the State balancing incentive pay6 ment program established under this sub7 section. 

8 ‘‘(2) CONDITIONS.—The conditions described in 

9 this paragraph are the following: 

10 ‘‘(A) APPLICATION.—The State submits an 

11 application to the Secretary that includes the 

12 following: 

13 ‘‘(i) A description of the availability of 

14 non-institutionally-based long-term services 

15 and supports described in paragraph 

16 (5)(B) available (for fiscal years beginning 

17 with fiscal year 2009). 

18 ‘‘(ii) A description of eligibility re19 quirements for receipt of such services. 

20 ‘‘(iii) A projection of the number of 

21 additional individuals that the State ex22 pects to provide with such services to dur23 ing the 5-fiscal-year period that begins 

24 with fiscal year 2011. 


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1 ‘‘(iv) An assurance of the State’s com2 mitment to a consumer-directed long-term 

3 services and supports system that values 

4 quality of life in addition to quality of care 

5 and in which beneficiaries are empowered 

6 to choose providers and direct their own 

7 care as much as possible. 

8 ‘‘(v) A proposed budget that details 

9 the State’s plan to expand and diversify 

10 medical assistance for non-institutionally11 based long-term services and supports de12 scribed in paragraph (5)(B) during such 5- 

13 fiscal-year period, and that includes— 

14 ‘‘(I) a description of the new or 

15 expanded offerings of such services 

16 that the State will provide; and 

17 ‘‘(II) the projected costs of the 

18 services identified in subclause (I). 

19 ‘‘(vi) A description of how the State 

20 intends to achieve the target spending per21 centage applicable to the State under sub22 paragraph (B). 

23 ‘‘(vii) An assurance that the State will 

24 not use Federal funds, revenues described 

25 in section 1903(w)(1), or revenues obVerDate Nov 24 2008 06:55 Jun 12, 2009 Jkt 079200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1256.IS S1256

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1 tained through the imposition of bene2 ficiary cost-sharing for medical assistance 

3 for non-institutionally-based long-term 

4 services and supports described in para5 graph (5)(B) for the non-Federal share of 

6 expenditures for medical assistance de7 scribed in paragraph (4). 

8 ‘‘(B) TARGET SPENDING PERCENTAGES.— 

9 ‘‘(i) In the case of a balancing incen10 tive payment State in which less than 25 

11 percent of the total expenditures for home 

12 and community-based services under the 

13 State plan and the various waiver authori14 ties for fiscal year 2009 are for such serv15 ices, the target spending percentage for the 

16 State to achieve by not later than October 

17 1, 2015, is that 25 percent of the total ex18 penditures for home and community-based 

19 services under the State plan and the var20 ious waiver authorities are for such serv21 ices. 

22 ‘‘(ii) In the case of any other bal23 ancing incentive payment State, the target 

24 spending percentage for the State to 

25 achieve by not later than October 1, 2015, 


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1 is that 50 percent of the total expenditures 

2 for home and community-based services 

3 under the State plan and the various waiv4 er authorities are for such services. 

5 ‘‘(C) MAINTENANCE OF ELIGIBILITY RE6 QUIREMENTS.—The State does not apply eligi7 bility standards, methodologies, or procedures 

8 for determining eligibility for medical assistance 

9 for non-institutionally-based long-term services 

10 and supports described in paragraph (5)(B)) 

11 that are more restrictive than the eligibility 

12 standards, methodologies, or procedures in ef13 fect for such purposes on December 31, 2010. 

14 ‘‘(D) USE OF ADDITIONAL FUNDS.—The 

15 State agrees to use the additional Federal funds 

16 paid to the State as a result of this subsection 

17 only for purposes of providing new or expanded 

18 offerings of non-institutionally-based long-term 

19 services and supports described in paragraph 

20 (5)(B) (including expansion through offering 

21 such services to increased numbers of bene22 ficiaries of medical assistance under this title). 

23 ‘‘(E) STRUCTURAL CHANGES.—The State 

24 agrees to make, not later than the end of the 

25 6-month period that begins on the date the 


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1 State submits and application under this para2 graph, such changes to the administration of 

3 the State plan (and, if applicable, to waivers ap4 proved for the State that involve the provision 

5 of long-term care services and supports) as the 

6 Secretary determines, by regulation or other7 wise, are essential to achieving an improved bal8 ance between the provision of non-institution9 ally-based long-term services and supports de10 scribed in paragraph (5)(B) and other long11 term services and supports, and which shall in12 clude the following: 

13 ‘‘(i) ‘NO WRONG DOOR’—SINGLE

14 ENTRY POINT SYSTEM.—Development of a 

15 statewide system to enable consumers to 

16 access all long-term services and supports 

17 through an agency, organization, coordi18 nated network, or portal, in accordance 

19 with such standards as the State shall es20 tablish and that— 

21 ‘‘(I) shall require such agency, 

22 organization, network, or portal to 

23 provide— 

24 ‘‘(aa) consumers with infor25 mation regarding the availability 


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1 of such services, how to apply for 

2 such services, and other referral 

3 services; and 

4 ‘‘(bb) information regarding, 

5 and make recommendations for, 

6 providers of such services; and 

7 ‘‘(II) may, at State option, per8 mit such agency, organization, net9 work, or portal to— 

10 ‘‘(aa) determine financial 

11 and functional eligibility for such 

12 services and supports; and 

13 ‘‘(bb) provide or refer eligi14 ble individuals to services and 

15 supports otherwise available in 

16 the community (under programs 

17 other than the State program 

18 under this title), such as housing, 

19 job training, and transportation. 

20 ‘‘(ii) PRESUMPTIVE ELIGIBILITY.—At 

21 the option of the State, provision of a 60- 

22 day period of presumptive eligibility for 

23 medical assistance for non-institutionally24 based long-term services and supports de25 scribed in paragraph (5)(B) for any indiVerDate Nov 24 2008 06:55 Jun 12, 2009 Jkt 079200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1256.IS S1256

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1 vidual whom the State has reason to be2 lieve will qualify for such medical assist3 ance (provided that any expenditures for 

4 such medical assistance during such period 

5 are disregarded for purposes of deter6 mining the rate of erroneous excess pay7 ments for medical assistance under section 

8 1903(u)(1)(D)). 

9 ‘‘(iii) CASE MANAGEMENT.—Develop10 ment, in accordance with guidance from 

11 the Secretary, of conflict-free case manage12 ment services to— 

13 ‘‘(I) address transitioning from 

14 receipt of institutionally-based long15 term services and supports described 

16 in paragraph (5)(A) to receipt of non17 institutionally-based long-term serv18 ices and supports described in para19 graph (5)(B); and 

20 ‘‘(II) in conjunction with the ben21 eficiary, assess the beneficiary’s needs 

22 and, if appropriate, the needs of fam23 ily caregivers for the beneficiary, and 

24 develop a service plan, arrange for 

25 services and supports, support the 


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1 beneficiary (and, if appropriate, the 

2 caregivers) in directing the provision 

3 of services and supports, for the bene4 ficiary, and conduct ongoing moni5 toring to assure that services and sup6 ports are delivered to meet the bene7 ficiary’s needs and achieve intended 

8 outcomes. 

9 ‘‘(iv) CORE STANDARDIZED ASSESS10 MENT INSTRUMENTS.—Development of 

11 core standardized assessment instruments 

12 for determining eligibility for non-institu13 tionally-based long-term services and sup14 ports described in paragraph (5)(B), which 

15 shall be used in a uniform manner 

16 throughout the State, to— 

17 ‘‘(I) assess a beneficiary’s eligi18 bility and functional level in terms of 

19 relevant areas that may include med20 ical, cognitive, and behavioral status, 

21 as well as daily living skills, and voca22 tional and communication skills; 

23 ‘‘(II) based on the assessment 

24 conducted under subclause (I), deter25 mine a beneficiary’s needs for trainVerDate Nov 24 2008 06:55 Jun 12, 2009 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1256.IS S1256

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1 ing, support services, medical care, 

2 transportation, and other services, 

3 and develop an individual service plan 

4 to address such needs; 

5 ‘‘(III) conduct ongoing moni6 toring based on the service plan; and 

7 ‘‘(IV) require reporting of collect 

8 data for purposes of comparison 

9 among different service models. 

10 ‘‘(F) DATA COLLECTION.—Collecting from 

11 providers of services and through such other 

12 means as the State determines appropriate the 

13 following data: 

14 ‘‘(i) SERVICES DATA.—Services data 

15 from providers of non-institutionally-based 

16 long-term services and supports described 

17 in paragraph (5)(B) on a per-beneficiary 

18 basis and in accordance with such stand19 ardized coding procedures as the State 

20 shall establish in consultation with the Sec21 retary. 

22 ‘‘(ii) QUALITY DATA.—Quality data 

23 on a selected set of core quality measures 

24 agreed upon by the Secretary and the 

25 State that are linked to population-specific 


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1 outcomes measures and accessible to pro2 viders. 

3 ‘‘(iii) OUTCOMES MEASURES.—Out4 comes measures data on a selected set of 

5 core population-specific outcomes measures 

6 agreed upon by the Secretary and the 

7 State that are accessible to providers and 

8 include— 

9 ‘‘(I) measures of beneficiary and 

10 family caregiver experience with pro11 viders; 

12 ‘‘(II) measures of beneficiary and 

13 family caregiver satisfaction with serv14 ices; and 

15 ‘‘(III) measures for achieving de16 sired outcomes appropriate to a spe17 cific beneficiary, including employ18 ment, participation in community life, 

19 health stability, and prevention of loss 

20 in function. 

21 ‘‘(3) APPLICABLE NUMBER OF PERCENTAGE

22 POINTS INCREASE IN FMAP.—The applicable number 

23 of percentage points are— 

24 ‘‘(A) in the case of a balancing incentive 

25 payment State subject to the target spending 


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1 percentage described in paragraph (2)(B)(i), 5 

2 percentage points; and 

3 ‘‘(B) in the case of any other balancing in4 centive payment State, 2 percentage points. 

5 ‘‘(4) ELIGIBLE MEDICAL ASSISTANCE EXPENDI6 TURES.— 

7 ‘‘(A) IN GENERAL.—Subject to subpara8 graph (B), medical assistance described in this 

9 paragraph is medical assistance for non-institu10 tionally-based long-term services and supports 

11 described in paragraph (5)(B) that is provided 

12 during the period that begins on October 1, 

13 2011, and ends on September 30, 2015. 

14 ‘‘(B) LIMITATION ON PAYMENTS.—In no 

15 case may the aggregate amount of payments 

16 made by the Secretary to balancing incentive 

17 payment States under this subsection during 

18 the period described in subparagraph (A), or to 

19 a State to which paragraph (6) of the first sen20 tence of subsection (b) applies, exceed 

21 $3,000,000,000. 

22 ‘‘(5) LONG-TERM SERVICES AND SUPPORTS DE23 FINED.—In this subsection, the term ‘long-term 

24 services and supports’ has the meaning given that 

25 term by Secretary and shall include the following: 


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1 ‘‘(A) INSTITUTIONALLY-BASED LONG-TERM

2 SERVICES AND SUPPORTS.—Services provided 

3 in an institution, including the following: 

4 ‘‘(i) Nursing facility services. 

5 ‘‘(ii) Services in an intermediate care 

6 facility for the mentally retarded described 

7 in subsection (a)(15). 

8 ‘‘(B) NON-INSTITUTIONALLY-BASED LONG9 TERM SERVICES AND SUPPORTS.—Services not 

10 provided in an institution, including the fol11 lowing: 

12 ‘‘(i) Home and community-based serv13 ices provided under subsection (c), (d), or 

14 (i), of section 1915 or under a waiver 

15 under section 1115. 

16 ‘‘(ii) Home health care services. 

17 ‘‘(iii) Personal care services. 

18 ‘‘(iv) Services described in subsection 

19 (a)(26) (relating to PACE program serv20 ices). 

21 ‘‘(v) Self-directed personal assistance 

22 services described in section 1915(j)’’. 

23 (b) ENHANCED FMAP FOR CERTAIN STATES TO

24 MAINTAIN THE PROVISION OF HOME AND COMMUNITY25 BASED SERVICES.—The first sentence of section 1905(b) 


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1 of such Act (42 U.S.C. 1396d (b)), as amended by sub2 section (a), is amended 

3 (1) by striking ‘‘, and (5)’’ and inserting ‘‘, 

4 (5)’’; and 

5 (2) by inserting before the period the following: 

6 ‘‘, and (6) in the case of a State in which at least 

7 50 percent of the total expenditures for medical as8 sistance for fiscal year 2009 for long-term services 

9 and supports (as defined by the Secretary for pur10 poses of subsection (y)) are for non-institutionally11 based long-term services and supports described in 

12 subsection (y)(5)(B), and which satisfies the require13 ments of subparagraphs (A) (other than clauses (iii), 

14 (v), and (vi)), (C), and (F) of subsection (y)(2), and 

15 has implemented the structural changes described in 

16 each clause of subparagraph (E) of that subsection, 

17 the Federal medical assistance percentage shall be 

18 increased by 1 percentage point with respect to med19 ical assistance described in subparagraph (A) of sub20 section (y)(4) (but subject to the limitation described 

21 in subparagraph (B) of that subsection)’’. 

22 (c) GRANTS TO SUPPORT STRUCTURAL CHANGES.— 

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

24 Human Services shall award grants to States for the 

25 following purposes: 


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1 (A) To support the development of com2 mon national set of coding methodologies and 

3 databases related to the provision of non-insti4 tutionally-based long-term services and supports 

5 described in paragraph (5)(B) of section 

6 1905(y) of the Social Security Act (as added by 

7 subsection (a)). 

8 (B) To make structural changes described 

9 in paragraph (2)(E) of section 1905(y) to the 

10 State Medicaid program. 

11 (2) PRIORITY.—In awarding grants for the pur12 pose described in paragraph (1)(A), the Secretary of 

13 Health and Human Services shall give priority to 

14 States in which at least 50 percent of the total ex15 penditures for medical assistance under the State 

16 Medicaid program for fiscal year 2009 for long-term 

17 services and supports, as defined by the Secretary 

18 for purposes of section 1905(y) of the Social Secu19 rity Act, are for non-institutionally-based long-term 

20 services and supports described in paragraph (5)(B) 

21 of such section. 

22 (3) COLLABORATION.—States awarded a grant 

23 for the purpose described in paragraph (1)(A) shall 

24 collaborate with other States, the National Gov25 ernor’s Association, the National Conference of 


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1 State Legislatures, the National Association of State 

2 Medicaid Directors, the National Association of 

3 State Directors of Developmental Disabilities, and 

4 other appropriate organizations in developing speci5 fications for a common national set of coding meth6 odologies and databases. 

7 (4) AUTHORIZATION OF APPROPRIATIONS.— 

8 There are authorized to be appropriated to carry out 

9 this subsection, such sums as may be necessary for 

10 each of fiscal years 2010 through 2012. 

11 (d) AUTHORITY FOR INDIVIDUALIZED BUDGETS

12 UNDER WAIVERS TO PROVIDE HOME AND COMMUNITY13 BASED SERVICES.—In the case of any waiver to provide 

14 home and community-based services under subsection (c) 

15 or (d) of section 1915 of the Social Security Act (42 

16 U.S.C. 1396n) or section 1115 of such Act (42 U.S.C. 

17 1315), that is approved or renewed after the date of enact18 ment of this Act, the Secretary of Health and Human 

19 Services shall permit a State to establish individualized 

20 budgets that identify the dollar value of the services and 

21 supports to be provided to an individual under the waiver. 

22 (e) OVERSIGHT AND ASSESSMENT.— 

23 (1) DEVELOPMENT OF STANDARDIZED REPORT24 ING REQUIREMENTS.— 


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1 (A) STANDARDIZATION OF DATA AND OUT2 COME MEASURES.—The Secretary of Health 

3 and Human Services shall consult with States 

4 and the National Governor’s Association, the 

5 National Conference of State Legislatures, the 

6 National Association of State Medicaid Direc7 tors, the National Association of State Direc8 tors of Developmental Disabilities, and other 

9 appropriate organizations to develop specifica10 tions for standardization of— 

11 (i) reporting of assessment data for 

12 long-term services and supports (as defined 

13 by the Secretary for purposes of section 

14 1905(y)(5) of the Social Security Act) for 

15 each population served, including informa16 tion standardized for purposes of certified 

17 EHR technology (as defined in section 

18 1903(t)(3)(A) of the Social Security Act 

19 (42 U.S.C. 1396b(t)(3)(A)) and under 

20 other electronic medical records initiatives; 

21 and 

22 (ii) outcomes measures that track as23 sessment processes for long-term services 

24 and supports (as so defined) for each such 

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1 vidual function, independence, and sta2 bility. 

3 (2) ADMINISTRATION OF HOME AND COMMU4 NITY SERVICES.—The Secretary of Health and 

5 Human Services shall promulgate regulations to en6 sure that all States develop service systems that are 

7 designed to— 

8 (A) allocate resources for services in a 

9 manner that is responsive to the changing 

10 needs and choices of beneficiaries receiving non11 institutionally-based long-term services and sup12 ports described in paragraph (5)(B) of section 

13 1905(y) of the Social Security Act (as added by 

14 subsection (a)) (including such services and 

15 supports that are provided under programs 

16 other the State Medicaid program), and that 

17 provides strategies for beneficiaries receiving 

18 such services to maximize their independence; 

19 (B) provide the support and coordination 

20 needed for a beneficiary in need of such services 

21 (and their family caregivers or representative, if 

22 applicable) to design an individualized, self-di23 rected, community-supported life; and 


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1 (C) improve coordination among all pro2 viders of such services under federally and 

3 State-funded programs in order to— 

4 (i) achieve a more consistent adminis5 tration of policies and procedures across 

6 programs in relation to the provision of 

7 such services; and 

8 (ii) oversee and monitor all service 

9 system functions to assure— 

10 (I) coordination of, and effective11 ness of, eligibility determinations and 

12 individual assessments; and 

13 (II) development and service 

14 monitoring of a complaint system, a 

15 management system, a system to 

16 qualify and monitor providers, and 

17 systems for role-setting and individual 

18 budget determinations. 

19 (3) MONITORING.—The Secretary of Health 

20 and Human Services shall assess on an ongoing 

21 basis and based on measures specified by the Agency 

22 for Healthcare Research and Quality, the safety and 

23 quality of non-institutionally-based long-term serv24 ices and supports described in paragraph (5)(B) of 

25 section 1905(y) of that Act provided to beneficiaries 


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1 of such services and supports and the outcomes with 

2 regard to such beneficiaries’ experiences with such 

3 services. Such oversight shall include examination 

4 of— 

5 (A) the consistency, or lack thereof, of 

6 such services in care plans as compared to 

7 those services that were actually delivered; and 

8 (B) the length of time between when a 

9 beneficiary was assessed for such services, when 

10 the care plan was completed, and when the ben11 eficiary started receiving such services. 

12 (4) GAO STUDY AND REPORT.—The Comp13 troller General of the United States shall study the 

14 longitudinal costs of Medicaid beneficiaries receiving 

15 long-term services and supports (as defined by the 

16 Secretary for purposes of section 1905(y)(5) of the 

17 Social Security Act) over 5-year periods across var18 ious programs, including the non-institutionally19 based long-term services and supports described in 

20 paragraph (5)(B) of such section, PACE program 

21 services under section 1894 of the Social Security 

22 Act (42 U.S.C. 1395eee, 1396u–4), and services pro23 vided under specialized MA plans for special needs 

24 individuals under part C of title XVIII of the Social 

25 Security Act. 


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1 TITLE II—STRENGTHENING THE 

2 MEDICAID HOME AND COM3 MUNITY-BASED STATE PLAN 

4 AMENDMENT OPTION 

5 SEC. 201. REMOVAL OF BARRIERS TO PROVIDING HOME 

6 AND COMMUNITY-BASED SERVICES UNDER 

7 STATE PLAN AMENDMENT OPTION FOR INDI8 VIDUALS IN NEED. 

9 (a) PARITY WITH INCOME ELIGIBILITY STANDARD

10 FOR INSTITUTIONALIZED INDIVIDUALS.—Paragraph (1) 

11 of section 1915(i) of the Social Security Act (42 U.S.C. 

12 1396n(i)) is amended by striking ‘‘150 percent of the pov13 erty line (as defined in section 2110(c)(5))’’ and inserting 

14 ‘‘300 percent of the supplemental security income benefit 

15 rate established by section 1611(b)(1)’’. 

16 (b) ADDITIONAL STATE OPTIONS.—Section 1915(i) 

17 of the Social Security Act (42 U.S.C. 1396n(i)) is amend18 ed by adding at the end the following new paragraphs: 

19 ‘‘(6) STATE OPTION TO PROVIDE HOME AND

20 COMMUNITY-BASED SERVICES TO INDIVIDUALS ELI21 GIBLE FOR SERVICES UNDER A WAIVER.— 

22 ‘‘(A) IN GENERAL.—A State that provides 

23 home and community-based services in accord24 ance with this subsection to individuals who 

25 satisfy the needs-based criteria for the receipt 


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1 of such services established under paragraph 

2 (1)(A) may, in addition to continuing to provide 

3 such services to such individuals, elect to pro4 vide home and community-based services in ac5 cordance with the requirements of this para6 graph to individuals who are eligible for home 

7 and community-based services under a waiver 

8 approved for the State under subsection (c), 

9 (d), or (e) or under section 1115 to provide 

10 such services, but only for those individuals 

11 whose income does not exceed 300 percent of 

12 the supplemental security income benefit rate 

13 established by section 1611(b)(1). 

14 ‘‘(B) APPLICATION OF SAME REQUIRE15 MENTS FOR INDIVIDUALS SATISFYING NEEDS16 BASED CRITERIA.—Subject to subparagraph 

17 (C), a State shall provide home and community18 based services to individuals under this para19 graph in the same manner and subject to the 

20 same requirements as apply under the other 

21 paragraphs of this subsection to the provision 

22 of home and community-based services to indi23 viduals who satisfy the needs-based criteria es24 tablished under paragraph (1)(A). 


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1 ‘‘(C) AUTHORITY TO OFFER DIFFERENT

2 TYPE, AMOUNT, DURATION, OR SCOPE OF HOME

3 AND COMMUNITY-BASED SERVICES.—A State 

4 may offer home and community-based services 

5 to individuals under this paragraph that differ 

6 in type, amount, duration, or scope from the 

7 home and community-based services offered for 

8 individuals who satisfy the needs-based criteria 

9 established under paragraph (1)(A), so long as 

10 such services are within the scope of services 

11 described in paragraph (4)(B) of subsection (c) 

12 for which the Secretary has the authority to ap13 prove a waiver and do not include room or 

14 board. 

15 ‘‘(7) STATE OPTION TO OFFER HOME AND COM16 MUNITY-BASED SERVICES TO SPECIFIC, TARGETED

17 POPULATIONS.— 

18 ‘‘(A) IN GENERAL.—A State may elect in 

19 a State plan amendment under this subsection 

20 to target the provision of home and community21 based services under this subsection to specific 

22 populations and to differ the type, amount, du23 ration, or scope of such services to such specific 

24 populations. 

25 ‘‘(B) 5-YEAR TERM.— 


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1 ‘‘(i) IN GENERAL.—An election by a 

2 State under this paragraph shall be for a 

3 period of 5 years. 

4 ‘‘(ii) PHASE-IN OF SERVICES AND ELI5 GIBILITY PERMITTED DURING INITIAL 5- 

6 YEAR PERIOD.—A State making an elec7 tion under this paragraph may, during the 

8 first 5-year period for which the election is 

9 made, phase-in the enrollment of eligible 

10 individuals, or the provision of services to 

11 such individuals, or both, so long as all eli12 gible individuals in the State for such serv13 ices are enrolled, and all such services are 

14 provided, before the end of the initial 5- 

15 year period. 

16 ‘‘(C) RENEWAL.—An election by a State 

17 under this paragraph may be renewed for addi18 tional 5-year terms if the Secretary determines, 

19 prior to beginning of each such renewal period, 

20 that the State has— 

21 ‘‘(i) adhered to the requirements of 

22 this subsection and paragraph in providing 

23 services under such an election; and 


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1 ‘‘(ii) met the State’s objectives with 

2 respect to quality improvement and bene3 ficiary outcomes.’’. 

4 (c) REMOVAL OF LIMITATION ON SCOPE OF SERV5 ICES.—Paragraph (1) of section 1915(i) of the Social Se6 curity Act (42 U.S.C. 1396n(i)), as amended by sub7 section (a), is amended by striking ‘‘or such other services 

8 requested by the State as the Secretary may approve’’. 

9 (d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE

10 FULL MEDICAID BENEFITS TO INDIVIDUALS RECEIVING

11 HOME AND COMMUNITY-BASED SERVICES UNDER A

12 STATE PLAN AMENDMENT.— 

13 (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) 

14 of the Social Security Act (42 U.S.C. 

15 1396a(a)(10)(A)(ii)) is amended— 

16 (A) in subclause (XVIII), by striking ‘‘or’’ 

17 at the end; 

18 (B) in subclause (XIX), by adding ‘‘or’’ at 

19 the end; and 

20 (C) by inserting after subclause (XIX), the 

21 following new subclause: 

22 ‘‘(XX) who are eligible for home 

23 and community-based services under 

24 needs-based criteria established under 

25 paragraph (1)(A) of section 1915(i), 


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1 or who are eligible for home and com2 munity-based services under para3 graph (6) of such section, and who 

4 will receive home and community5 based services pursuant to a State 

6 plan amendment under such sub7 section;’’. 

8 (2) CONFORMING AMENDMENTS.— 

9 (A) Section 1903(f)(4) of the Social Secu10 rity Act (42 U.S.C. 1396b(f)(4)) is amended in 

11 the matter preceding subparagraph (A), by in12 serting ‘‘1902(a)(10)(A)(ii)(XX),’’ after 

13 ‘‘1902(a)(10)(A)(ii)(XIX),’’. 

14 (B) Section 1905(a) of the Social Security 

15 Act (42 U.S.C. 1396d(a)) is amended in the 

16 matter preceding paragraph (1)— 

17 (i) in clause (xii), by striking ‘‘or’’ at 

18 the end; 

19 (ii) in clause (xiii), by adding ‘‘or’’ at 

20 the end; and 

21 (iii) by inserting after clause (xiii) the 

22 following new clause: 

23 ‘‘(xiv) individuals who are eligible for home and 

24 community-based services under needs-based criteria 

25 established under paragraph (1)(A) of section 


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1 1915(i), or who are eligible for home and commu2 nity-based services under paragraph (6) of such sec3 tion, and who will receive home and community4 based services pursuant to a State plan amendment 

5 under such subsection,’’. 

6 (e) ELIMINATION OF OPTION TO LIMIT NUMBER OF

7 ELIGIBLE INDIVIDUALS OR LENGTH OF PERIOD FOR

8 GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA

9 IS MODIFIED.—Paragraph (1) of section 1915(i) of such 

10 Act (42 U.S.C. 1396n(i)) is amended— 

11 (1) by striking subparagraph (C) and inserting 

12 the following: 

13 ‘‘(C) PROJECTION OF NUMBER OF INDI14 VIDUALS TO BE PROVIDED HOME AND COMMU15 NITY-BASED SERVICES.—The State submits to 

16 the Secretary, in such form and manner, and 

17 upon such frequency as the Secretary shall 

18 specify, the projected number of individuals to 

19 be provided home and community-based serv20 ices.’’; and 

21 (2) in subclause (II) of subparagraph (D)(ii), 

22 by striking ‘‘to be eligible for such services for a pe23 riod of at least 12 months beginning on the date the 

24 individual first received medical assistance for such 

25 services’’ and inserting ‘‘to continue to be eligible for 


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1 such services after the effective date of the modifica2 tion and until such time as the individual no longer 

3 meets the standard for receipt of such services under 

4 such pre-modified criteria’’. 

5 (f) ELIMINATION OF OPTION TO WAIVE

6 STATEWIDENESS; ADDITION OF OPTION TO WAIVE COM7 PARABILITY.—Paragraph (3) of section 1915(i) of such 

8 Act (42 U.S.C. 1396n(3)) is amended by striking 

9 ‘‘1902(a)(1) (relating to statewideness)’’ and inserting 

10 ‘‘1902(a)(10)(B) (relating to comparability)’’. 

11 (g) EFFECTIVE DATE.—The amendments made by 

12 this section take effect on the first day of the first fiscal 

13 year quarter that begins after the date of enactment of 

14 this Act. 

15 SEC. 202. MANDATORY APPLICATION OF SPOUSAL IMPOV16 ERISHMENT PROTECTIONS TO RECIPIENTS 

17 OF HOME AND COMMUNITY-BASED SERVICES. 

18 (a) IN GENERAL.—Section 1924(h)(1)(A) of the So19 cial Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amend20 ed by striking ‘‘(at the option of the State) is described 

21 in section 1902(a)(10)(A)(ii)(VI)’’ and inserting ‘‘is eligi22 ble for medical assistance for home and community-based 

23 services under subsection (c), (d), (e), or (i) of section 

24 1915’’. 


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

2 subsection (a) takes effect on October 1, 2009. 

3 SEC. 203. STATE AUTHORITY TO ELECT TO EXCLUDE UP TO 

4 6 MONTHS OF AVERAGE COST OF NURSING 

5 FACILITY SERVICES FROM ASSETS OR RE6 SOURCES FOR PURPOSES OF ELIGIBILITY 

7 FOR HOME AND COMMUNITY-BASED SERV8 ICES. 

9 (a) IN GENERAL.—Section 1917 of the Social Secu10 rity Act (42 U.S.C. 1396p) is amended by adding at the 

11 end the following new subsection: 

12 ‘‘(i) STATE AUTHORITY TO EXCLUDE UP TO 6 

13 MONTHS OF AVERAGE COST OF NURSING FACILITY

14 SERVICES FROM HOME AND COMMUNITY-BASED SERV15 ICES ELIGIBILITY DETERMINATIONS.—Nothing in this 

16 section or any other provision of this title, shall be con17 strued as prohibiting a State from excluding from any de18 termination of an individual’s assets or resources for pur19 poses of determining the eligibility of the individual for 

20 medical assistance for home and community-based services 

21 under subsection (c), (d), (e), or (i) of section 1915 (if 

22 a State imposes an limitation on assets or resources for 

23 purposes of eligibility for such services), an amount equal 

24 to the product of the amount applicable under subsection 

25 (c)(1)(E)(ii)(II) (at the time such determination is made) 


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1 and such number, not to exceed 6, as the State may 

2 elect.’’. 

3 (b) RULE OF CONSTRUCTION.—Nothing in the 

4 amendment made by subsection (a) shall be construed as 

5 affecting a State’s option to apply less restrictive meth6 odologies under section 1902(r)(2) for purposes of deter7 mining income and resource eligibility for individuals spec8 ified in that section. 

9 TITLE III—COORDINATION OF 

10 HOME AND COMMUNITY11 BASED WAIVERS 

12 SEC. 301. STREAMLINED PROCESS FOR COMBINED WAIV13 ERS UNDER SUBSECTIONS (B) AND (C) OF 

14 SECTION 1915. 

15 Not later than 90 days after the date of enactment 

16 of this Act, the Secretary of Health and Human Services 

17 shall create a template to streamline the process of ap18 proving, monitoring, evaluating, and renewing State pro19 posals to conduct a program that combines the waiver au20 thority provided under subsections (b) and (c) of section 

21 1915 of the Social Security Act (42 U.S.C. 1396n) into 

22 a single program under which the State provides home and 

23 community-based services to individuals based on individ24 ualized assessments and care plans (in this section re25 ferred to as the ‘‘combined waivers program’’). The temVerDate Nov 24 2008 06:55 Jun 12, 2009 Jkt 079200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S1256.IS S1256

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1 plate required under this section shall provide for the fol2 lowing: 

3 (1) A standard 5-year term for conducting a 

4 combined waivers program. 

5 (2) Harmonization of any requirements under 

6 subsections (b) and (c) of such section that overlap. 

7 (3) An option for States to elect, during the 

8 first 5-year term for which the combined waivers 

9 program is approved to phase-in the enrollment of 

10 eligible individuals, or the provision of services to 

11 such individuals, or both, so long as all eligible indi12 viduals in the State for such services are enrolled, 

13 and all such services are provided, before the end of 

14 the initial 5-year period. 

15 (4) Examination by the Secretary, prior to each 

16 renewal of a combined waivers program, of how well 

17 the State has— 

18 (A) adhered to the combined waivers pro19 gram requirements; and 

20 (B) performed in meeting the State’s ob21 jectives for the combined waivers program, in22 cluding with respect to quality improvement 

23 and beneficiary outcomes. 

Æ 


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