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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1256 Introduced in Senate (IS)]

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.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Home and Community 
Balanced Incentives Act of 2009''.
    (b) Table of Contents.--The table of contents for 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-
                            institutionally-based 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.

                     TITLE I--BALANCING INCENTIVES

SEC. 101. ENHANCED FMAP FOR EXPANDING THE PROVISION OF NON-
              INSTITUTIONALLY-BASED LONG-TERM SERVICES AND SUPPORTS.

    (a) Enhanced FMAP To Encourage Expansion.--Section 1905 of the 
Social Security Act (42 U.S.C. 1396d) is amended--
            (1) in the first sentence of subsection (b)--
                    (A) by striking ``, and (4)'' and inserting ``, 
                (4)''; and
                    (B) by inserting before the period the following: 
                ``, and (5) in the case of a balancing incentive 
                payment State, as defined in subsection (y)(1), that 
                meets the conditions described in subsection (y)(2), 
                the Federal medical assistance percentage shall be 
                increased by the applicable number of percentage points 
                determined under subsection (y)(3) for the State with 
                respect to medical assistance described in subsection 
                (y)(4)''; and
            (2) by adding at the end the following new subsection:
    ``(y) State Balancing Incentive Payments Program.--For purposes of 
clause (5) of the first sentence of subsection (b):
            ``(1) Balancing incentive payment state.--A balancing 
        incentive payment State is a State--
                    ``(A) in which less than 50 percent of the total 
                expenditures for medical assistance for fiscal year 
                2009 for long-term services and supports (as defined by 
                the Secretary, subject to paragraph (5)) are for non-
                institutionally-based long-term services and supports 
                described in paragraph (5)(B);
                    ``(B) that submits an application and meets the 
                conditions described in paragraph (2); and
                    ``(C) that is selected by the Secretary to 
                participate in the State balancing incentive payment 
                program established under this subsection.
            ``(2) Conditions.--The conditions described in this 
        paragraph are the following:
                    ``(A) Application.--The State submits an 
                application to the Secretary that includes the 
                following:
                            ``(i) A description of the availability of 
                        non-institutionally-based long-term services 
                        and supports described in paragraph (5)(B) 
                        available (for fiscal years beginning with 
                        fiscal year 2009).
                            ``(ii) A description of eligibility 
                        requirements for receipt of such services.
                            ``(iii) A projection of the number of 
                        additional individuals that the State expects 
                        to provide with such services to during the 5-
                        fiscal-year period that begins with fiscal year 
                        2011.
                            ``(iv) An assurance of the State's 
                        commitment to a consumer-directed long-term 
                        services and supports system that values 
                        quality of life in addition to quality of care 
                        and in which beneficiaries are empowered to 
                        choose providers and direct their own care as 
                        much as possible.
                            ``(v) A proposed budget that details the 
                        State's plan to expand and diversify medical 
                        assistance for non-institutionally-based long-
                        term services and supports described in 
                        paragraph (5)(B) during such 5-fiscal-year 
                        period, and that includes--
                                    ``(I) a description of the new or 
                                expanded offerings of such services 
                                that the State will provide; and
                                    ``(II) the projected costs of the 
                                services identified in subclause (I).
                            ``(vi) A description of how the State 
                        intends to achieve the target spending 
                        percentage applicable to the State under 
                        subparagraph (B).
                            ``(vii) An assurance that the State will 
                        not use Federal funds, revenues described in 
                        section 1903(w)(1), or revenues obtained 
                        through the imposition of beneficiary cost-
                        sharing for medical assistance for non-
                        institutionally-based long-term services and 
                        supports described in paragraph (5)(B) for the 
                        non-Federal share of expenditures for medical 
                        assistance described in paragraph (4).
                    ``(B) Target spending percentages.--
                            ``(i) In the case of a balancing incentive 
                        payment State in which less than 25 percent of 
                        the total expenditures for home and community-
                        based services under the State plan and the 
                        various waiver authorities for fiscal year 2009 
                        are for such services, the target spending 
                        percentage for the State to achieve by not 
                        later than October 1, 2015, is that 25 percent 
                        of the total expenditures for home and 
                        community-based services under the State plan 
                        and the various waiver authorities are for such 
                        services.
                            ``(ii) In the case of any other balancing 
                        incentive payment State, the target spending 
                        percentage for the State to achieve by not 
                        later than October 1, 2015, is that 50 percent 
                        of the total expenditures for home and 
                        community-based services under the State plan 
                        and the various waiver authorities are for such 
                        services.
                    ``(C) Maintenance of eligibility requirements.--The 
                State does not apply eligibility standards, 
                methodologies, or procedures for determining 
                eligibility for medical assistance for non-
                institutionally-based long-term services and supports 
                described in paragraph (5)(B)) that are more 
                restrictive than the eligibility standards, 
                methodologies, or procedures in effect for such 
                purposes on December 31, 2010.
                    ``(D) Use of additional funds.--The State agrees to 
                use the additional Federal funds paid to the State as a 
                result of this subsection only for purposes of 
                providing new or expanded offerings of non-
                institutionally-based long-term services and supports 
                described in paragraph (5)(B) (including expansion 
                through offering such services to increased numbers of 
                beneficiaries of medical assistance under this title).
                    ``(E) Structural changes.--The State agrees to 
                make, not later than the end of the 6-month period that 
                begins on the date the State submits and application 
                under this paragraph, such changes to the 
                administration of the State plan (and, if applicable, 
                to waivers approved for the State that involve the 
                provision of long-term care services and supports) as 
                the Secretary determines, by regulation or otherwise, 
                are essential to achieving an improved balance between 
                the provision of non-institutionally-based long-term 
                services and supports described in paragraph (5)(B) and 
                other long-term services and supports, and which shall 
                include the following:
                            ``(i) `No wrong door'--single entry point 
                        system.--Development of a statewide system to 
                        enable consumers to access all long-term 
                        services and supports through an agency, 
                        organization, coordinated network, or portal, 
                        in accordance with such standards as the State 
                        shall establish and that--
                                    ``(I) shall require such agency, 
                                organization, network, or portal to 
                                provide--
                                            ``(aa) consumers with 
                                        information regarding the 
                                        availability of such services, 
                                        how to apply for such services, 
                                        and other referral services; 
                                        and
                                            ``(bb) information 
                                        regarding, and make 
                                        recommendations for, providers 
                                        of such services; and
                                    ``(II) may, at State option, permit 
                                such agency, organization, network, or 
                                portal to--
                                            ``(aa) determine financial 
                                        and functional eligibility for 
                                        such services and supports; and
                                            ``(bb) provide or refer 
                                        eligible individuals to 
                                        services and supports otherwise 
                                        available in the community 
                                        (under programs other than the 
                                        State program under this 
                                        title), such as housing, job 
                                        training, and transportation.
                            ``(ii) Presumptive eligibility.--At the 
                        option of the State, provision of a 60-day 
                        period of presumptive eligibility for medical 
                        assistance for non-institutionally-based long-
                        term services and supports described in 
                        paragraph (5)(B) for any individual whom the 
                        State has reason to believe will qualify for 
                        such medical assistance (provided that any 
                        expenditures for such medical assistance during 
                        such period are disregarded for purposes of 
                        determining the rate of erroneous excess 
                        payments for medical assistance under section 
                        1903(u)(1)(D)).
                            ``(iii) Case management.--Development, in 
                        accordance with guidance from the Secretary, of 
                        conflict-free case management services to--
                                    ``(I) address transitioning from 
                                receipt of institutionally-based long-
                                term services and supports described in 
                                paragraph (5)(A) to receipt of non-
                                institutionally-based long-term 
                                services and supports described in 
                                paragraph (5)(B); and
                                    ``(II) in conjunction with the 
                                beneficiary, assess the beneficiary's 
                                needs and, if appropriate, the needs of 
                                family caregivers for the beneficiary, 
                                and develop a service plan, arrange for 
                                services and supports, support the 
                                beneficiary (and, if appropriate, the 
                                caregivers) in directing the provision 
                                of services and supports, for the 
                                beneficiary, and conduct ongoing 
                                monitoring to assure that services and 
                                supports are delivered to meet the 
                                beneficiary's needs and achieve 
                                intended outcomes.
                            ``(iv) Core standardized assessment 
                        instruments.--Development of core standardized 
                        assessment instruments for determining 
                        eligibility for non-institutionally-based long-
                        term services and supports described in 
                        paragraph (5)(B), which shall be used in a 
                        uniform manner throughout the State, to--
                                    ``(I) assess a beneficiary's 
                                eligibility and functional level in 
                                terms of relevant areas that may 
                                include medical, cognitive, and 
                                behavioral status, as well as daily 
                                living skills, and vocational and 
                                communication skills;
                                    ``(II) based on the assessment 
                                conducted under subclause (I), 
                                determine a beneficiary's needs for 
                                training, support services, medical 
                                care, transportation, and other 
                                services, and develop an individual 
                                service plan to address such needs;
                                    ``(III) conduct ongoing monitoring 
                                based on the service plan; and
                                    ``(IV) require reporting of collect 
                                data for purposes of comparison among 
                                different service models.
                    ``(F) Data collection.--Collecting from providers 
                of services and through such other means as the State 
                determines appropriate the following data:
                            ``(i) Services data.--Services data from 
                        providers of non-institutionally-based long-
                        term services and supports described in 
                        paragraph (5)(B) on a per-beneficiary basis and 
                        in accordance with such standardized coding 
                        procedures as the State shall establish in 
                        consultation with the Secretary.
                            ``(ii) Quality data.--Quality data on a 
                        selected set of core quality measures agreed 
                        upon by the Secretary and the State that are 
                        linked to population-specific outcomes measures 
                        and accessible to providers.
                            ``(iii) Outcomes measures.--Outcomes 
                        measures data on a selected set of core 
                        population-specific outcomes measures agreed 
                        upon by the Secretary and the State that are 
                        accessible to providers and include--
                                    ``(I) measures of beneficiary and 
                                family caregiver experience with 
                                providers;
                                    ``(II) measures of beneficiary and 
                                family caregiver satisfaction with 
                                services; and
                                    ``(III) measures for achieving 
                                desired outcomes appropriate to a 
                                specific beneficiary, including 
                                employment, participation in community 
                                life, health stability, and prevention 
                                of loss in function.
            ``(3) Applicable number of percentage points increase in 
        fmap.--The applicable number of percentage points are--
                    ``(A) in the case of a balancing incentive payment 
                State subject to the target spending percentage 
                described in paragraph (2)(B)(i), 5 percentage points; 
                and
                    ``(B) in the case of any other balancing incentive 
                payment State, 2 percentage points.
            ``(4) Eligible medical assistance expenditures.--
                    ``(A) In general.--Subject to subparagraph (B), 
                medical assistance described in this paragraph is 
                medical assistance for non-institutionally-based long-
                term services and supports described in paragraph 
                (5)(B) that is provided during the period that begins 
                on October 1, 2011, and ends on September 30, 2015.
                    ``(B) Limitation on payments.--In no case may the 
                aggregate amount of payments made by the Secretary to 
                balancing incentive payment States under this 
                subsection during the period described in subparagraph 
                (A), or to a State to which paragraph (6) of the first 
                sentence of subsection (b) applies, exceed 
                $3,000,000,000.
            ``(5) Long-term services and supports defined.--In this 
        subsection, the term `long-term services and supports' has the 
        meaning given that term by Secretary and shall include the 
        following:
                    ``(A) Institutionally-based long-term services and 
                supports.--Services provided in an institution, 
                including the following:
                            ``(i) Nursing facility services.
                            ``(ii) Services in an intermediate care 
                        facility for the mentally retarded described in 
                        subsection (a)(15).
                    ``(B) Non-institutionally-based long-term services 
                and supports.--Services not provided in an institution, 
                including the following:
                            ``(i) Home and community-based services 
                        provided under subsection (c), (d), or (i), of 
                        section 1915 or under a waiver under section 
                        1115.
                            ``(ii) Home health care services.
                            ``(iii) Personal care services.
                            ``(iv) Services described in subsection 
                        (a)(26) (relating to PACE program services).
                            ``(v) Self-directed personal assistance 
                        services described in section 1915(j)''.
    (b) Enhanced FMAP for Certain States To Maintain the Provision of 
Home and Community-Based Services.--The first sentence of section 
1905(b) of such Act (42 U.S.C. 1396d (b)), as amended by subsection 
(a), is amended
            (1) by striking ``, and (5)'' and inserting ``, (5)''; and
            (2) by inserting before the period the following: ``, and 
        (6) in the case of a State in which at least 50 percent of the 
        total expenditures for medical assistance for fiscal year 2009 
        for long-term services and supports (as defined by the 
        Secretary for purposes of subsection (y)) are for non-
        institutionally-based long-term services and supports described 
        in subsection (y)(5)(B), and which satisfies the requirements 
        of subparagraphs (A) (other than clauses (iii), (v), and (vi)), 
        (C), and (F) of subsection (y)(2), and has implemented the 
        structural changes described in each clause of subparagraph (E) 
        of that subsection, the Federal medical assistance percentage 
        shall be increased by 1 percentage point with respect to 
        medical assistance described in subparagraph (A) of subsection 
        (y)(4) (but subject to the limitation described in subparagraph 
        (B) of that subsection)''.
    (c) Grants To Support Structural Changes.--
            (1) In general.--The Secretary of Health and Human Services 
        shall award grants to States for the following purposes:
                    (A) To support the development of common national 
                set of coding methodologies and databases related to 
                the provision of non-institutionally-based long-term 
                services and supports described in paragraph (5)(B) of 
                section 1905(y) of the Social Security Act (as added by 
                subsection (a)).
                    (B) To make structural changes described in 
                paragraph (2)(E) of section 1905(y) to the State 
                Medicaid program.
            (2) Priority.--In awarding grants for the purpose described 
        in paragraph (1)(A), the Secretary of Health and Human Services 
        shall give priority to States in which at least 50 percent of 
        the total expenditures for medical assistance under the State 
        Medicaid program for fiscal year 2009 for long-term services 
        and supports, as defined by the Secretary for purposes of 
        section 1905(y) of the Social Security Act, are for non-
        institutionally-based long-term services and supports described 
        in paragraph (5)(B) of such section.
            (3) Collaboration.--States awarded a grant for the purpose 
        described in paragraph (1)(A) shall collaborate with other 
        States, the National Governor's Association, the National 
        Conference of State Legislatures, the National Association of 
        State Medicaid Directors, the National Association of State 
        Directors of Developmental Disabilities, and other appropriate 
        organizations in developing specifications for a common 
        national set of coding methodologies and databases.
            (4) Authorization of appropriations.--There are authorized 
        to be appropriated to carry out this subsection, such sums as 
        may be necessary for each of fiscal years 2010 through 2012.
    (d) Authority for Individualized Budgets Under Waivers To Provide 
Home and Community-Based Services.--In the case of any waiver to 
provide home and community-based services under subsection (c) or (d) 
of section 1915 of the Social Security Act (42 U.S.C. 1396n) or section 
1115 of such Act (42 U.S.C. 1315), that is approved or renewed after 
the date of enactment of this Act, the Secretary of Health and Human 
Services shall permit a State to establish individualized budgets that 
identify the dollar value of the services and supports to be provided 
to an individual under the waiver.
    (e) Oversight and Assessment.--
            (1) Development of standardized reporting requirements.--
                    (A) Standardization of data and outcome measures.--
                The Secretary of Health and Human Services shall 
                consult with States and the National Governor's 
                Association, the National Conference of State 
                Legislatures, the National Association of State 
                Medicaid Directors, the National Association of State 
                Directors of Developmental Disabilities, and other 
                appropriate organizations to develop specifications for 
                standardization of--
                            (i) reporting of assessment data for long-
                        term services and supports (as defined by the 
                        Secretary for purposes of section 1905(y)(5) of 
                        the Social Security Act) for each population 
                        served, including information standardized for 
                        purposes of certified EHR technology (as 
                        defined in section 1903(t)(3)(A) of the Social 
                        Security Act (42 U.S.C. 1396b(t)(3)(A)) and 
                        under other electronic medical records 
                        initiatives; and
                            (ii) outcomes measures that track 
                        assessment processes for long-term services and 
                        supports (as so defined) for each such 
                        population that maintain and enhance individual 
                        function, independence, and stability.
            (2) Administration of home and community services.--The 
        Secretary of Health and Human Services shall promulgate 
        regulations to ensure that all States develop service systems 
        that are designed to--
                    (A) allocate resources for services in a manner 
                that is responsive to the changing needs and choices of 
                beneficiaries receiving non-institutionally-based long-
                term services and supports described in paragraph 
                (5)(B) of section 1905(y) of the Social Security Act 
                (as added by subsection (a)) (including such services 
                and supports that are provided under programs other the 
                State Medicaid program), and that provides strategies 
                for beneficiaries receiving such services to maximize 
                their independence;
                    (B) provide the support and coordination needed for 
                a beneficiary in need of such services (and their 
                family caregivers or representative, if applicable) to 
                design an individualized, self-directed, community-
                supported life; and
                    (C) improve coordination among all providers of 
                such services under federally and State-funded programs 
                in order to--
                            (i) achieve a more consistent 
                        administration of policies and procedures 
                        across programs in relation to the provision of 
                        such services; and
                            (ii) oversee and monitor all service system 
                        functions to assure--
                                    (I) coordination of, and 
                                effectiveness of, eligibility 
                                determinations and individual 
                                assessments; and
                                    (II) development and service 
                                monitoring of a complaint system, a 
                                management system, a system to qualify 
                                and monitor providers, and systems for 
                                role-setting and individual budget 
                                determinations.
            (3) Monitoring.--The Secretary of Health and Human Services 
        shall assess on an ongoing basis and based on measures 
        specified by the Agency for Healthcare Research and Quality, 
        the safety and quality of non-institutionally-based long-term 
        services and supports described in paragraph (5)(B) of section 
        1905(y) of that Act provided to beneficiaries of such services 
        and supports and the outcomes with regard to such 
        beneficiaries' experiences with such services. Such oversight 
        shall include examination of--
                    (A) the consistency, or lack thereof, of such 
                services in care plans as compared to those services 
                that were actually delivered; and
                    (B) the length of time between when a beneficiary 
                was assessed for such services, when the care plan was 
                completed, and when the beneficiary started receiving 
                such services.
            (4) GAO study and report.--The Comptroller General of the 
        United States shall study the longitudinal costs of Medicaid 
        beneficiaries receiving long-term services and supports (as 
        defined by the Secretary for purposes of section 1905(y)(5) of 
        the Social Security Act) over 5-year periods across various 
        programs, including the non-institutionally-based long-term 
        services and supports described in paragraph (5)(B) of such 
        section, PACE program services under section 1894 of the Social 
        Security Act (42 U.S.C. 1395eee, 1396u-4), and services 
        provided under specialized MA plans for special needs 
        individuals under part C of title XVIII of the Social Security 
        Act.

  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.

    (a) Parity With Income Eligibility Standard for Institutionalized 
Individuals.--Paragraph (1) of section 1915(i) of the Social Security 
Act (42 U.S.C. 1396n(i)) is amended by striking ``150 percent of the 
poverty line (as defined in section 2110(c)(5))'' and inserting ``300 
percent of the supplemental security income benefit rate established by 
section 1611(b)(1)''.
    (b) Additional State Options.--Section 1915(i) of the Social 
Security Act (42 U.S.C. 1396n(i)) is amended by adding at the end the 
following new paragraphs:
            ``(6) State option to provide home and community-based 
        services to individuals eligible for services under a waiver.--
                    ``(A) In general.--A State that provides home and 
                community-based services in accordance with this 
                subsection to individuals who satisfy the needs-based 
                criteria for the receipt of such services established 
                under paragraph (1)(A) may, in addition to continuing 
                to provide such services to such individuals, elect to 
                provide home and community-based services in accordance 
                with the requirements of this paragraph to individuals 
                who are eligible for home and community-based services 
                under a waiver approved for the State under subsection 
                (c), (d), or (e) or under section 1115 to provide such 
                services, but only for those individuals whose income 
                does not exceed 300 percent of the supplemental 
                security income benefit rate established by section 
                1611(b)(1).
                    ``(B) Application of same requirements for 
                individuals satisfying needs-based criteria.--Subject 
                to subparagraph (C), a State shall provide home and 
                community-based services to individuals under this 
                paragraph in the same manner and subject to the same 
                requirements as apply under the other paragraphs of 
                this subsection to the provision of home and community-
                based services to individuals who satisfy the needs-
                based criteria established under paragraph (1)(A).
                    ``(C) Authority to offer different type, amount, 
                duration, or scope of home and community-based 
                services.--A State may offer home and community-based 
                services to individuals under this paragraph that 
                differ in type, amount, duration, or scope from the 
                home and community-based services offered for 
                individuals who satisfy the needs-based criteria 
                established under paragraph (1)(A), so long as such 
                services are within the scope of services described in 
                paragraph (4)(B) of subsection (c) for which the 
                Secretary has the authority to approve a waiver and do 
                not include room or board.
            ``(7) State option to offer home and community-based 
        services to specific, targeted populations.--
                    ``(A) In general.--A State may elect in a State 
                plan amendment under this subsection to target the 
                provision of home and community-based services under 
                this subsection to specific populations and to differ 
                the type, amount, duration, or scope of such services 
                to such specific populations.
                    ``(B) 5-year term.--
                            ``(i) In general.--An election by a State 
                        under this paragraph shall be for a period of 5 
                        years.
                            ``(ii) Phase-in of services and eligibility 
                        permitted during initial 5-year period.--A 
                        State making an election under this paragraph 
                        may, during the first 5-year period for which 
                        the election is made, phase-in the enrollment 
                        of eligible individuals, or the provision of 
                        services to such individuals, or both, so long 
                        as all eligible individuals in the State for 
                        such services are enrolled, and all such 
                        services are provided, before the end of the 
                        initial 5-year period.
                    ``(C) Renewal.--An election by a State under this 
                paragraph may be renewed for additional 5-year terms if 
                the Secretary determines, prior to beginning of each 
                such renewal period, that the State has--
                            ``(i) adhered to the requirements of this 
                        subsection and paragraph in providing services 
                        under such an election; and
                            ``(ii) met the State's objectives with 
                        respect to quality improvement and beneficiary 
                        outcomes.''.
    (c) Removal of Limitation on Scope of Services.--Paragraph (1) of 
section 1915(i) of the Social Security Act (42 U.S.C. 1396n(i)), as 
amended by subsection (a), is amended by striking ``or such other 
services requested by the State as the Secretary may approve''.
    (d) Optional Eligibility Category To Provide Full Medicaid Benefits 
to Individuals Receiving Home and Community-Based Services Under a 
State Plan Amendment.--
            (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
        Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
                    (A) in subclause (XVIII), by striking ``or'' at the 
                end;
                    (B) in subclause (XIX), by adding ``or'' at the 
                end; and
                    (C) by inserting after subclause (XIX), the 
                following new subclause:
                                    ``(XX) who are eligible for home 
                                and community-based services under 
                                needs-based criteria established under 
                                paragraph (1)(A) of section 1915(i), or 
                                who are eligible for home and 
                                community-based services under 
                                paragraph (6) of such section, and who 
                                will receive home and community-based 
                                services pursuant to a State plan 
                                amendment under such subsection;''.
            (2) Conforming amendments.--
                    (A) Section 1903(f)(4) of the Social Security Act 
                (42 U.S.C. 1396b(f)(4)) is amended in the matter 
                preceding subparagraph (A), by inserting 
                ``1902(a)(10)(A)(ii)(XX),'' after 
                ``1902(a)(10)(A)(ii)(XIX),''.
                    (B) Section 1905(a) of the Social Security Act (42 
                U.S.C. 1396d(a)) is amended in the matter preceding 
                paragraph (1)--
                            (i) in clause (xii), by striking ``or'' at 
                        the end;
                            (ii) in clause (xiii), by adding ``or'' at 
                        the end; and
                            (iii) by inserting after clause (xiii) the 
                        following new clause:
            ``(xiv) individuals who are eligible for home and 
        community-based services under needs-based criteria established 
        under paragraph (1)(A) of section 1915(i), or who are eligible 
        for home and community-based services under paragraph (6) of 
        such section, and who will receive home and community-based 
        services pursuant to a State plan amendment under such 
        subsection,''.
    (e) Elimination of Option To Limit Number of Eligible Individuals 
or Length of Period for Grandfathered Individuals if Eligibility 
Criteria Is Modified.--Paragraph (1) of section 1915(i) of such Act (42 
U.S.C. 1396n(i)) is amended--
            (1) by striking subparagraph (C) and inserting the 
        following:
                    ``(C) Projection of number of individuals to be 
                provided home and community-based services.--The State 
                submits to the Secretary, in such form and manner, and 
                upon such frequency as the Secretary shall specify, the 
                projected number of individuals to be provided home and 
                community-based services.''; and
            (2) in subclause (II) of subparagraph (D)(ii), by striking 
        ``to be eligible for such services for a period of at least 12 
        months beginning on the date the individual first received 
        medical assistance for such services'' and inserting ``to 
        continue to be eligible for such services after the effective 
        date of the modification and until such time as the individual 
        no longer meets the standard for receipt of such services under 
        such pre-modified criteria''.
    (f) Elimination of Option To Waive Statewideness; Addition of 
Option To Waive Comparability.--Paragraph (3) of section 1915(i) of 
such Act (42 U.S.C. 1396n(3)) is amended by striking ``1902(a)(1) 
(relating to statewideness)'' and inserting ``1902(a)(10)(B) (relating 
to comparability)''.
    (g) Effective Date.--The amendments made by this section take 
effect on the first day of the first fiscal year quarter that begins 
after the date of enactment of this Act.

SEC. 202. MANDATORY APPLICATION OF SPOUSAL IMPOVERISHMENT PROTECTIONS 
              TO RECIPIENTS OF HOME AND COMMUNITY-BASED SERVICES.

    (a) In General.--Section 1924(h)(1)(A) of the Social Security Act 
(42 U.S.C. 1396r-5(h)(1)(A)) is amended by striking ``(at the option of 
the State) is described in section 1902(a)(10)(A)(ii)(VI)'' and 
inserting ``is eligible for medical assistance for home and community-
based services under subsection (c), (d), (e), or (i) of section 
1915''.
    (b) Effective Date.--The amendment made by subsection (a) takes 
effect on October 1, 2009.

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.

    (a) In General.--Section 1917 of the Social Security Act (42 U.S.C. 
1396p) is amended by adding at the end the following new subsection:
    ``(i) State Authority To Exclude up to 6 Months of Average Cost of 
Nursing Facility Services From Home and Community-Based Services 
Eligibility Determinations.--Nothing in this section or any other 
provision of this title, shall be construed as prohibiting a State from 
excluding from any determination of an individual's assets or resources 
for purposes of determining the eligibility of the individual for 
medical assistance for home and community-based services under 
subsection (c), (d), (e), or (i) of section 1915 (if a State imposes an 
limitation on assets or resources for purposes of eligibility for such 
services), an amount equal to the product of the amount applicable 
under subsection (c)(1)(E)(ii)(II) (at the time such determination is 
made) and such number, not to exceed 6, as the State may elect.''.
    (b) Rule of Construction.--Nothing in the amendment made by 
subsection (a) shall be construed as affecting a State's option to 
apply less restrictive methodologies under section 1902(r)(2) for 
purposes of determining income and resource eligibility for individuals 
specified in that section.

      TITLE III--COORDINATION OF HOME AND COMMUNITY-BASED WAIVERS

SEC. 301. STREAMLINED PROCESS FOR COMBINED WAIVERS UNDER SUBSECTIONS 
              (B) AND (C) OF SECTION 1915.

    Not later than 90 days after the date of enactment of this Act, the 
Secretary of Health and Human Services shall create a template to 
streamline the process of approving, monitoring, evaluating, and 
renewing State proposals to conduct a program that combines the waiver 
authority provided under subsections (b) and (c) of section 1915 of the 
Social Security Act (42 U.S.C. 1396n) into a single program under which 
the State provides home and community-based services to individuals 
based on individualized assessments and care plans (in this section 
referred to as the ``combined waivers program''). The template required 
under this section shall provide for the following:
            (1) A standard 5-year term for conducting a combined 
        waivers program.
            (2) Harmonization of any requirements under subsections (b) 
        and (c) of such section that overlap.
            (3) An option for States to elect, during the first 5-year 
        term for which the combined waivers program is approved to 
        phase-in the enrollment of eligible individuals, or the 
        provision of services to such individuals, or both, so long as 
        all eligible individuals in the State for such services are 
        enrolled, and all such services are provided, before the end of 
        the initial 5-year period.
            (4) Examination by the Secretary, prior to each renewal of 
        a combined waivers program, of how well the State has--
                    (A) adhered to the combined waivers program 
                requirements; and
                    (B) performed in meeting the State's objectives for 
                the combined waivers program, including with respect to 
                quality improvement and beneficiary outcomes.
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