I 

116TH CONGRESS 

2D SESSION H. R. 8934 

To ensure that Medicaid beneficiaries have the opportunity to receive care 

in a home and community-based setting. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 10, 2020 

Mr. CARTWRIGHT introduced the following bill; which was referred to the 

Committee on Energy and Commerce 

A BILL 

To ensure that Medicaid beneficiaries have the opportunity 

to receive care in a home and community-based setting. 

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. 

4 This Act may be cited as the ‘‘Community Integra5 tion Act of 2020’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 

8 (1) The Supreme Court’s 1999 decision in 

9 Olmstead v. L.C., 527 U.S. 581 (1999), held that 

10 the unnecessary segregation of individuals with disVerDate Sep 11 2014 06:38 Dec 24, 2020 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H8934.IH H8934

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1 abilities is a violation of the Americans with Disabil2 ities Act of 1990 (42 U.S.C. 12101 et seq.). 

3 (2) Under Olmstead, individuals generally have 

4 the right to receive their supports and services in 

5 home and community-based settings, rather than in 

6 institutional settings, if they so choose. 

7 (3) Olmstead envisioned that States would pro8 vide appropriate long-term services and supports to 

9 individuals with disabilities through home and com10 munity-based services and end forced segregation in 

11 nursing homes and other institutions. 

12 (4) While there has been progress in rebal13 ancing State spending on individuals with disabilities 

14 in institutions as compared to home and community15 based settings, more than 75 percent of States con16 tinue to spend the majority of their long-term care 

17 dollars on nursing homes and other institutional set18 tings, and the number of individuals with disabilities 

19 under age 65 in nursing homes increased between 

20 2008 and 2012. 

21 (5) As of June 2013, there were more than 

22 200,000 individuals younger than age 65 in nursing 

23 homes—almost 16 percent of the total nursing home 

24 population. 


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1 (6) Thirty-eight studies published from 2005 to 

2 2012 concluded that providing services in home and 

3 community-based settings is less costly than pro4 viding care in a nursing home or other institutional 

5 setting. 

6 (7) No clear or centralized reporting system ex7 ists to compare how effectively States are meeting 

8 the Olmstead mandate. 

9 SEC. 3. ENSURING MEDICAID BENEFICIARIES MAY ELECT 

10 TO RECEIVE CARE IN A HOME AND COMMU11 NITY-BASED SETTING. 

12 (a) IN GENERAL.—Section 1902(a) of the Social Se13 curity Act (42 U.S.C. 1396a(a)) is amended— 

14 (1) in paragraph (85), by striking ‘‘and’’ at the 

15 end; 

16 (2) in paragraph (86), by striking the period 

17 and inserting ‘‘; and’’; and 

18 (3) by inserting after paragraph (86) the fol19 lowing new paragraph: 

20 ‘‘(87) in the case of any individual with respect 

21 to whom there has been a determination that the in22 dividual requires the level of care provided in a nurs23 ing facility, an intermediate care facility for the 

24 mentally retarded, an institution for mental diseases, 


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1 or any other similarly restrictive or institutional set2 ting— 

3 ‘‘(A) provide the individual with the choice 

4 and opportunity to receive such care in a home 

5 and community-based setting, including reha6 bilitative services, assistance and support in ac7 complishing activities of daily living, instru8 mental activities of daily living, and health-re9 lated tasks, and assistance in acquiring, main10 taining, or enhancing skills necessary to accom11 plish such activities, tasks, or services; 

12 ‘‘(B) ensure that each such individual has 

13 an equal opportunity (when compared to the re14 ceipt and availability of nursing facility serv15 ices) to receive care in a home and community16 based setting, if the individual so chooses, by 

17 ensuring that the provision of such care in a 

18 home and community-based setting is widely 

19 available on a statewide basis for all such indi20 viduals within the State; and 

21 ‘‘(C) meet the requirements of section 

22 1904A (relating to the provision of care in a 

23 home and community-based setting).’’. 

24 (b) REQUIREMENTS FOR COMMUNITY CARE OP25 TIONS.—Title XIX of the Social Security Act is amended 


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1 by inserting after section 1904 (42 U.S.C. 1396c) the fol2 lowing new section: 

3 ‘‘PROVISIONS RELATED TO HOME AND COMMUNITY4 BASED CARE

5 ‘‘SEC. 1904A. (a) DEFINITIONS.—For purposes of 

6 this section, section 1902(a)(87), and section 

7 1905(a)(4)(A): 

8 ‘‘(1) ACTIVITIES OF DAILY LIVING.—The term 

9 ‘activities of daily living’ includes, but is not limited 

10 to, tasks such as eating, toileting, grooming, dress11 ing, bathing, and transferring. 

12 ‘‘(2) HEALTH-RELATED TASKS.—The term 

13 ‘health-related tasks’ means specific tasks related to 

14 the needs of an individual, including, but not limited 

15 to, bowel or bladder care, wound care, use and care 

16 of ventilators and feeding tubes, and the administra17 tion of medications and injections, which, in the 

18 opinion of the individual’s physician, can be dele19 gated to be performed by an attendant. 

20 ‘‘(3) HOME AND COMMUNITY-BASED SET21 TING.—The term ‘home and community-based set22 ting’ means, with respect to an individual who re23 quires a level of care provided in a nursing facility, 

24 an intermediate care facility for the mentally re25 tarded, an institution for mental diseases, or any 


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1 other similarly restrictive or institutional setting, a 

2 setting that— 

3 ‘‘(A) includes a house, an apartment, a 

4 townhouse, a condominium, or any similar pub5 lic or private housing where the individual re6 sides that— 

7 ‘‘(i) is owned or leased by the indi8 vidual or a member of the individual’s fam9 ily; 

10 ‘‘(ii) ensures the individual’s privacy, 

11 dignity, respect, and freedom from coer12 cion; and 

13 ‘‘(iii) maximizes the individual’s au14 tonomy and independence; 

15 ‘‘(B) is integrated in, and provides access 

16 to, the general community in which the setting 

17 is located so that the individual has access to 

18 the community and opportunities to seek em19 ployment and work in competitive integrated 

20 settings, participate in community life, control 

21 and utilize personal resources, benefit from 

22 community services, and participate in the com23 munity in an overall manner that is comparable 

24 to that available to individuals who are not indi25 viduals with disabilities; and 


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1 ‘‘(C) has the services and supports that the 

2 individual needs in order to live as independ3 ently as possible. 

4 ‘‘(4) INSTRUMENTAL ACTIVITIES OF DAILY LIV5 ING.—The term ‘instrumental activities of daily liv6 ing’ means activities related to living independently 

7 in the community and includes, but is not limited to, 

8 meal planning and preparation, managing finances, 

9 shopping for food, clothing, and other items, per10 forming household chores, communicating by phone 

11 or other media, and traveling around and partici12 pating in the community. 

13 ‘‘(5) PUBLIC ENTITY.—The term ‘public entity’ 

14 means a public entity as defined in subparagraphs 

15 (A) and (B) of section 201(1) of the Americans with 

16 Disabilities Act of 1990. 

17 ‘‘(b) REQUIREMENTS FOR PROVIDING SERVICES IN

18 HOME AND COMMUNITY-BASED SETTINGS.—With respect 

19 to the availability and provision of services under the State 

20 plan under this title, or under any waiver of State plan 

21 requirements (subject to section 3(d) of the Community 

22 Integration Act of 2020), in a home and community-based 

23 setting to any individual who requires a level of care pro24 vided in a nursing facility, an intermediate care facility 

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1 eases, or any other similarly restrictive or institutional set2 ting, any public entity that receives payment under the 

3 State plan or waiver for providing services to such an indi4 vidual shall not— 

5 ‘‘(1) impose or utilize policies, practices, or pro6 cedures, such as unnecessary requirements or arbi7 trary service or cost caps, that limit the availability 

8 of services in home and community-based settings to 

9 an individual with a disability (including individuals 

10 with the most significant disabilities) who need such 

11 services; 

12 ‘‘(2) impose or utilize policies, practices, or pro13 cedures that limit the availability of services in a 

14 home and community-based setting (including assist15 ance and support in accomplishing activities of daily 

16 living, instrumental activities of daily living, health17 related tasks, and rehabilitative services) based on 

18 the specific disability of an otherwise eligible indi19 vidual; 

20 ‘‘(3) impose or utilize policies, practices, or pro21 cedures that arbitrarily restrict an individual with a 

22 disability from full and meaningful participation in 

23 community life; 

24 ‘‘(4) impose or utilize policies, practices, or pro25 cedures that unnecessarily delay or restrict the proVerDate Sep 11 2014 06:38 Dec 24, 2020 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H8934.IH H8934

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1 vision of services in a home and community-based 

2 setting to any individual who requires such services; 

3 ‘‘(5) fail to establish and utilize adequate pay4 ment structures to maintain a sufficient workforce 

5 to provide services in home and community-based 

6 settings to any individual who requires such services; 

7 ‘‘(6) fail to provide information, on an ongoing 

8 basis, to help any individual who receives care in a 

9 nursing facility, an intermediate care facility for the 

10 mentally retarded, an institution for mental diseases, 

11 or any other similarly restrictive or institutional set12 ting, understand the individual’s right to choose to 

13 receive such care in a home and community-based 

14 setting; or 

15 ‘‘(7) fail to provide information to help any in16 dividual that requires the level of care provided in a 

17 nursing facility, an intermediate care facility for the 

18 mentally retarded, an institution for mental diseases, 

19 or any other similarly restrictive or institutional set20 ting, prior to the individual’s placement in such a fa21 cility or an institution, understand the individual’s 

22 right to choose to receive such care in a home and 

23 community-based setting. 

24 ‘‘(c) PLAN TO INCREASE AFFORDABLE AND ACCES25 SIBLE HOUSING.—Not later than 180 days after the enVerDate Sep 11 2014 06:38 Dec 24, 2020 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H8934.IH H8934

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1 actment of this section, each State shall develop a state2 wide plan to increase the availability of affordable and ac3 cessible private and public housing stock for individuals 

4 with disabilities (including accessible housing for individ5 uals with physical disabilities and those using mobility de6 vices). 

7 ‘‘(d) AVAILABILITY OF REMEDIES AND PROCE8 DURES.— 

9 ‘‘(1) IN GENERAL.—The remedies and proce10 dures set forth in sections 203 and 505 of the Amer11 icans with Disabilities Act of 1990 shall be available 

12 to any person aggrieved by the failure of— 

13 ‘‘(A) a State to comply with this section or 

14 section 1902(a)(87); or 

15 ‘‘(B) a public entity (including a State) to 

16 comply with the requirements of subsection (b). 

17 ‘‘(2) RULE OF CONSTRUCTION.—Nothing in 

18 paragraph (1) shall be construed to limit any rem19 edy or right of action that otherwise is available to 

20 an aggrieved person under this title. 

21 ‘‘(e) ENFORCEMENT BY THE SECRETARY.— 

22 ‘‘(1) IN GENERAL.—The Secretary may reduce 

23 the Federal medical assistance percentage applicable 

24 to the State (as determined under section 1905(b)) 


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1 if the Secretary determines that the State has vio2 lated the requirements of subsection (b). 

3 ‘‘(2) RULE OF CONSTRUCTION.—Nothing in 

4 paragraph (1) shall be construed to limit any rem5 edy or right of action that is otherwise available to 

6 the Secretary. 

7 ‘‘(f) REPORTING REQUIREMENTS.—With respect to 

8 fiscal year 2020, and for each fiscal year thereafter, each 

9 State shall submit to the Administrator of the Administra10 tion for Community Living of the Department of Health 

11 and Human Services, not later than April 1 of the suc12 ceeding fiscal year, a report, in such form and manner 

13 as the Secretary shall require, that includes— 

14 ‘‘(1) the total number of individuals enrolled in 

15 the State plan or under a waiver of the plan during 

16 such fiscal year that required the level of care pro17 vided in a nursing facility, an intermediate care fa18 cility for the mentally retarded, an institution for 

19 mental diseases, or any other similarly restrictive or 

20 institutional setting, disaggregated by the type of fa21 cility or setting; 

22 ‘‘(2) with respect to the total number described 

23 in paragraph (1), the total number of individuals de24 scribed in that paragraph who received care in a 

25 nursing facility, an intermediate care facility for the 


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1 mentally retarded, an institution for mental diseases, 

2 or any other similarly restrictive or institutional set3 ting, disaggregated by the type of facility or setting; 

4 and 

5 ‘‘(3) with respect to the total number described 

6 in paragraph (2), the total number of individuals de7 scribed in that paragraph who were transitioned 

8 from a nursing facility, an intermediate care facility 

9 for the mentally retarded, an institution for mental 

10 diseases, or any other similarly restrictive or institu11 tional setting to a home and community-based set12 ting, disaggregated by the type of home and commu13 nity-based setting.’’. 

14 (c) INCLUSION AS A MANDATORY SERVICE.—Section 

15 1905(a)(4)(A) of the Social Security Act (42 U.S.C. 

16 1396d(a)(4)(A)) is amended by striking ‘‘other than’’ and 

17 inserting ‘‘including similar services such as rehabilitative 

18 services and assistance and support in accomplishing ac19 tivities of daily living, instrumental activities of daily liv20 ing, and health-related tasks, that are provided, at the in21 dividual’s option, in a home and community-based setting 

22 (as defined in section 1904A(a)(3)), but not including’’. 

23 (d) APPLICATION TO WAIVERS.—Notwithstanding 

24 section 1904A of the Social Security Act (as added by sub25 section (b)), such section and sections 1902(a)(87) and 


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1 1905(a)(4)(A) of the Social Security Act (42 U.S.C. 1396 

2 et seq.), as amended by subsections (a) and (c), respec3 tively, shall not apply to any individuals who are eligible 

4 for medical assistance for home and community-based 

5 services under a waiver under section 1115 or 1915 of 

6 the Social Security Act (42 U.S.C. 1315, 1396n) and who 

7 are receiving such services, to the extent such sections (as 

8 so added or amended) are inconsistent with any such waiv9 er. 

10 (e) EFFECTIVE DATE.— 

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

13 shall take effect on October 1, 2021. 

14 (2) DELAY PERMITTED IF STATE LEGISLATION

15 REQUIRED.—In the case of a State plan under sec16 tion 1902 of the Social Security Act (42 U.S.C. 

17 1396a) which the Secretary of Health and Human 

18 Services determines requires State legislation (other 

19 than legislation appropriating funds) in order for the 

20 plan to meet the additional requirements imposed by 

21 the amendments made by this section, the State 

22 plan shall not be regarded as failing to comply with 

23 the requirements of such section 1902 solely on the 

24 basis of the failure of the plan to meet such addi25 tional requirements before the first day of the first 


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1 calendar quarter beginning after the close of the 

2 first regular session of the State legislature that be3 gins after the date of enactment of this Act. For 

4 purposes of the previous sentence, in the case of a 

5 State that has a 2-year legislative session, each year 

6 of such session shall be deemed to be a separate reg7 ular session of the State legislature. 

Æ 


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