II 

110TH CONGRESS 

1ST SESSION S. 799 

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

disabilities and older Americans with equal access to community-based 

attendant services and supports, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 7, 2007 

Mr. HARKIN (for himself, Mr. SPECTER, Mr. KENNEDY, Mr. INOUYE, Mr. 

SALAZAR, Mr. BIDEN, Mr. LIEBERMAN, Mrs. CLINTON, Mr. SCHUMER, 

and Mr. DODD) 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 provide 

individuals with disabilities and older Americans with 

equal access to community-based attendant services and 

supports, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Community Choice Act of 2007’’. 

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

7 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

Sec. 2. Findings and purposes. 

TITLE I—ESTABLISHMENT OF MEDICAID PLAN BENEFIT 

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

the Medicaid program. 

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

enhance and promote the use of community-based attendant 

services and supports. 

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

TITLE II—PROMOTION OF SYSTEMS CHANGE AND CAPACITY 

BUILDING 

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

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

Medicare and Medicaid programs for dual eligible individuals. 

1 SEC. 2. FINDINGS AND PURPOSES. 

2 (a) FINDINGS.—Congress makes the following find3 ings: 

4 (1) Long-term services and supports provided 

5 under the Medicaid program established under title 

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

7 seq.) must meet the ability and life choices of indi8 viduals with disabilities and older Americans, includ9 ing the choice to live in one’s own home or with 

10 one’s own family and to become a productive mem11 ber of the community. 

12 (2) Research on the provision of long-term serv13 ices and supports under the Medicaid program (con14 ducted by and on behalf of the Department of 

15 Health and Human Services) has revealed a signifi16 cant funding and programmatic bias toward institu17 tional care. Only about 37 percent of long-term care 


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1 funds expended under the Medicaid program, and 

2 only about 12.5 percent of all funds expended under 

3 that program, pay for services and supports in home 

4 and community-based settings. 

5 (3) In the case of Medicaid beneficiaries who 

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

7 currently guaranteed by Federal law in every State 

8 are services related to nursing home care. Only 30 

9 States have adopted the benefit option of providing 

10 personal care services under the Medicaid program. 

11 Although every State has chosen to provide certain 

12 services under home and community-based waivers, 

13 these services are unevenly available within and 

14 across States, and reach a small percentage of eligi15 ble individuals. In fiscal year 2003, only 7 States 

16 spent 50 percent or more of their Medicaid long17 term care funds under the Medicaid program on 

18 home and community-based care. Individuals with 

19 the most significant disabilities are usually afforded 

20 the least amount of choice, despite advances in med21 ical and assistive technologies and related areas. 

22 (4) Despite the more limited funding for com23 munity services, the majority of individuals who use 

24 Medicaid long-term services and supports are in the 


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1 community, indicating that community services is a 

2 more cost effective alternative to institutional care. 

3 (5) The goals of the Nation properly include 

4 providing families of children with disabilities, work5 ing-age adults with disabilities, and older Americans 

6 with— 

7 (A) a meaningful choice of receiving long8 term services and supports in the most inte9 grated setting appropriate to the individual’s 

10 needs; 

11 (B) the greatest possible control over the 

12 services received and, therefore, their own lives 

13 and futures; and 

14 (C) quality services that maximize inde15 pendence in the home and community, including 

16 in the workplace. 

17 (b) PURPOSES.—The purposes of this Act are the fol18 lowing: 

19 (1) To reform the Medicaid program estab20 lished under title XIX of the Social Security Act (42 

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

22 integrated setting appropriate to the individual’s 

23 needs, and to provide equal access to community24 based attendant services and supports in order to 

25 assist individuals in achieving equal opportunity, full 


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1 participation, independent living, and economic self2 sufficiency. 

3 (2) To provide financial assistance to States as 

4 they reform their long-term care systems to provide 

5 comprehensive statewide long-term services and sup6 ports, including community-based attendant services 

7 and supports that provide consumer choice and di8 rection, in the most integrated setting appropriate. 

9 (3) To assist States in meeting the growing de10 mand for community-based attendant services and 

11 supports, as the Nation’s population ages and indi12 viduals with disabilities live longer. 

13 (4) To assist States in addressing the decision 

14 of the Supreme Court in Olmstead v. L.C., (527 

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

16 mandate of the Americans with Disabilities Act. 

17 TITLE I—ESTABLISHMENT OF 

18 MEDICAID PLAN BENEFIT 

19 SEC. 101. COVERAGE OF COMMUNITY-BASED ATTENDANT 

20 SERVICES AND SUPPORTS UNDER THE MED21 ICAID PROGRAM. 

22 (a) MANDATORY COVERAGE.—Section 

23 1902(a)(10)(D) of the Social Security Act (42 U.S.C. 

24 1396a(a)(10)(D)) is amended— 

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


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

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

3 clause: 

4 ‘‘(ii) subject to section 1939, for the 

5 inclusion of community-based attendant 

6 services and supports for any individual 

7 who— 

8 ‘‘(I) is eligible for medical assist9 ance under the State plan; 

10 ‘‘(II) with respect to whom there 

11 has been a determination that the in12 dividual requires the level of care pro13 vided in a nursing facility, institution 

14 for mental diseases, or an inter15 mediate care facility for the mentally 

16 retarded (whether or not coverage of 

17 such institution or intermediate care 

18 facility is provided under the State 

19 plan); and 

20 ‘‘(III) chooses to receive such 

21 services and supports;’’. 

22 (b) COMMUNITY-BASED ATTENDANT SERVICES AND

23 SUPPORTS.— 

24 (1) IN GENERAL.—Title XIX of the Social Se25 curity Act (42 U.S.C. 1396 et seq.) is amended— 


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1 (A) by redesignating section 1939 as sec2 tion 1940; and 

3 (B) by inserting after section 1938 the fol4 lowing: 

5 ‘‘COMMUNITY-BASED ATTENDANT SERVICES AND

6 SUPPORTS

7 ‘‘SEC. 1939. (a) REQUIRED COVERAGE.— 

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

9 2012, a State shall provide through a plan amend10 ment for the inclusion of community-based attendant 

11 services and supports (as defined in subsection 

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

13 1902(a)(10)(D)(ii) in accordance with this section. 

14 ‘‘(2) ENHANCED FMAP AND ADDITIONAL FED15 ERAL FINANCIAL SUPPORT FOR EARLIER COV16 ERAGE.—Notwithstanding section 1905(b), during 

17 the period that begins on October 1, 2007, and ends 

18 on September 30, 2012, in the case of a State with 

19 an approved plan amendment under this section dur20 ing that period that also satisfies the requirements 

21 of subsection (c) the Federal medical assistance per22 centage shall be equal to the enhanced FMAP de23 scribed in section 2105(b) with respect to medical 

24 assistance in the form of community-based attendant 

25 services and supports provided to individuals de26 scribed in section 1902(a)(10)(D)(ii) in accordance 


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

2 of such plan amendment. 

3 ‘‘(b) DEVELOPMENT AND IMPLEMENTATION OF BEN4 EFIT.—In order for a State plan amendment to be ap5 proved under this section, a State shall provide the Sec6 retary with the following assurances: 

7 ‘‘(1) ASSURANCE OF DEVELOPMENT AND IM8 PLEMENTATION COLLABORATION.— 

9 ‘‘(A) IN GENERAL.—That State plan 

10 amendment— 

11 ‘‘(i) has been developed in collabora12 tion with, and with the approval of, a De13 velopment and Implementation Council es14 tablished by the State that satisfies the re15 quirements of subparagraph (B); and 

16 ‘‘(ii) will be implemented in collabora17 tion with such Council and on the basis of 

18 public input solicited by the State and the 

19 Council. 

20 ‘‘(B) DEVELOPMENT AND IMPLEMENTA21 TION COUNCIL REQUIREMENTS.—For purposes 

22 of subparagraph (A), the requirements of this 

23 subparagraph are that— 

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

25 the Development and Implementation 


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1 Council are individuals with disabilities, el2 derly individuals, and their representatives; 

3 and 

4 ‘‘(ii) in carrying out its responsibil5 ities, the Council actively collaborates 

6 with— 

7 ‘‘(I) individuals with disabilities; 

8 ‘‘(II) elderly individuals; 

9 ‘‘(III) representatives of such in10 dividuals; and 

11 ‘‘(IV) providers of, and advocates 

12 for, services and supports for such in13 dividuals. 

14 ‘‘(2) ASSURANCE OF PROVISION ON A STATE15 WIDE BASIS AND IN MOST INTEGRATED SETTING.— 

16 That consumer controlled community-based attend17 ant services and supports will be provided under the 

18 State plan to individuals described in section 

19 1902(a)(10)(D)(ii) on a statewide basis and in a 

20 manner that provides such services and supports in 

21 the most integrated setting appropriate to the indi22 vidual’s needs. 

23 ‘‘(3) ASSURANCE OF NONDISCRIMINATION.— 

24 That the State will provide community-based attend25 ant services and supports to an individual described 


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

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

3 of disability, or the form of community-based attend4 ant services and supports that the individual re5 quires in order to lead an independent life. 

6 ‘‘(4) ASSURANCE OF MAINTENANCE OF EF7 FORT.—That the level of State expenditures for 

8 medical assistance that is provided under section 

9 1905(a), section 1915, section 1115, or otherwise to 

10 individuals with disabilities or elderly individuals for 

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

12 expenditures for the fiscal year preceding the first 

13 full fiscal year in which the State plan amendment 

14 to provide community-based attendant services and 

15 supports in accordance with this section is imple16 mented. 

17 ‘‘(c) REQUIREMENTS FOR ENHANCED FMAP FOR

18 EARLY COVERAGE.—In addition to satisfying the other re19 quirements for an approved plan amendment under this 

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

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

22 the enhanced FMAP for early coverage under subsection 

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

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

25 year, the State shall provide the Secretary with the 


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1 following specifications regarding the provision of 

2 community-based attendant services and supports 

3 under the plan for that fiscal year: 

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

5 estimated to receive community-based attendant 

6 services and supports under the plan during the 

7 fiscal year. 

8 ‘‘(ii) The number of individuals that re9 ceived such services and supports during the 

10 preceding fiscal year. 

11 ‘‘(B) The maximum number of individuals 

12 who will receive such services and supports 

13 under the plan during that fiscal year. 

14 ‘‘(C) The procedures the State will imple15 ment to ensure that the models for delivery of 

16 such services and supports are consumer con17 trolled (as defined in subsection (g)(2)(B)). 

18 ‘‘(D) The procedures the State will imple19 ment to inform all potentially eligible individ20 uals and relevant other individuals of the avail21 ability of such services and supports under this 

22 title, and of other items and services that may 

23 be provided to the individual under this title or 

24 title XVIII and other Federal or State long25 term service and support programs. 


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1 ‘‘(E) The procedures the State will imple2 ment to ensure that such services and supports 

3 are provided in accordance with the require4 ments of subsection (b)(1). 

5 ‘‘(F) The procedures the State will imple6 ment to actively involve in a systematic, com7 prehensive, and ongoing basis, the Development 

8 and Implementation Council established in ac9 cordance with subsection (b)(1)(A)(ii), individ10 uals with disabilities, elderly individuals, and 

11 representatives of such individuals in the de12 sign, delivery, administration, implementation, 

13 and evaluation of the provision of such services 

14 and supports under this title. 

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

16 State shall provide the Secretary with such sub17 stantive input into, and participation in, the design 

18 and conduct of data collection, analyses, and other 

19 qualitative or quantitative evaluations of the provi20 sion of community-based attendant services and sup21 ports under this section as the Secretary deems nec22 essary in order to determine the effectiveness of the 

23 provision of such services and supports in allowing 

24 the individuals receiving such services and supports 


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1 to lead an independent life to the maximum extent 

2 possible. 

3 ‘‘(d) QUALITY ASSURANCE.— 

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

5 State plan amendment to be approved under this 

6 section, a State shall establish and maintain a com7 prehensive, continuous quality assurance system 

8 with respect to community-based attendant services 

9 and supports that provides for the following: 

10 ‘‘(A) The State shall establish require11 ments, as appropriate, for agency-based and 

12 other delivery models that include— 

13 ‘‘(i) minimum qualifications and train14 ing requirements for agency-based and 

15 other models; 

16 ‘‘(ii) financial operating standards; 

17 and 

18 ‘‘(iii) an appeals procedure for eligi19 bility denials and a procedure for resolving 

20 disagreements over the terms of an individ21 ualized plan. 

22 ‘‘(B) The State shall modify the quality as23 surance system, as appropriate, to maximize 

24 consumer independence and consumer control 


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1 in both agency-provided and other delivery mod2 els. 

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

4 allows for the external monitoring of the quality 

5 of services and supports by entities consisting 

6 of consumers and their representatives, dis7 ability organizations, providers, families of dis8 abled or elderly individuals, members of the 

9 community, and others. 

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

11 monitoring of the health and well-being of each 

12 individual who receives community-based at13 tendant services and supports. 

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

15 assurance mechanisms pertaining to the indi16 vidual be included in the individual’s written 

17 plan. 

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

19 for the mandatory reporting, investigation, and 

20 resolution of allegations of neglect, abuse, or ex21 ploitation in connection with the provision of 

22 such services and supports. 

23 ‘‘(G) The State shall obtain meaningful 

24 consumer input, including consumer surveys, 

25 that measure the extent to which an individual 


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1 receives the services and supports described in 

2 the individual’s plan and the individual’s satis3 faction with such services and supports. 

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

5 public the findings of the quality assurance sys6 tem. 

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

8 public process for the development, implementa9 tion, and review of the State’s quality assurance 

10 system. 

11 ‘‘(J) The State shall develop and imple12 ment a program of sanctions for providers of 

13 community-based services and supports that 

14 violate the terms or conditions for the provision 

15 of such services and supports. 

16 ‘‘(2) FEDERAL RESPONSIBILITIES.— 

17 ‘‘(A) PERIODIC EVALUATIONS.—The Sec18 retary shall conduct a periodic sample review of 

19 outcomes for individuals who receive commu20 nity-based attendant services and supports 

21 under this title. 

22 ‘‘(B) INVESTIGATIONS.—The Secretary 

23 may conduct targeted reviews and investiga24 tions upon receipt of an allegation of neglect, 

25 abuse, or exploitation of an individual receiving 


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1 community-based attendant services and sup2 ports under this section. 

3 ‘‘(C) DEVELOPMENT OF PROVIDER SANC4 TION GUIDELINES.—The Secretary shall de5 velop guidelines for States to use in developing 

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

7 ‘‘(e) REPORTS.—The Secretary shall submit to Con8 gress periodic reports on the provision of community-based 

9 attendant services and supports under this section, par10 ticularly with respect to the impact of the provision of 

11 such services and supports on— 

12 ‘‘(1) individuals eligible for medical assistance 

13 under this title; 

14 ‘‘(2) States; and 

15 ‘‘(3) the Federal Government. 

16 ‘‘(f) NO EFFECT ON ABILITY TO PROVIDE COV17 ERAGE.— 

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

19 shall be construed as affecting the ability of a State 

20 to provide coverage under the State plan for commu21 nity-based attendant services and supports (or simi22 lar coverage) under section 1905(a), section 1915, 

23 section 1115, or otherwise. 

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

25 the case of a State that provides coverage for such 


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1 services and supports under a waiver, the State shall 

2 not be eligible under subsection (a)(2) for the en3 hanced FMAP for the early provision of such cov4 erage unless the State submits a plan amendment to 

5 the Secretary that meets the requirements of this 

6 section and demonstrates that the State is able to 

7 fully comply with and implement the requirements of 

8 this section. 

9 ‘‘(g) DEFINITIONS.—In this title: 

10 ‘‘(1) COMMUNITY-BASED ATTENDANT SERVICES

11 AND SUPPORTS.— 

12 ‘‘(A) IN GENERAL.—The term ‘community13 based attendant services and supports’ means 

14 attendant services and supports furnished to an 

15 individual, as needed, to assist in accomplishing 

16 activities of daily living, instrumental activities 

17 of daily living, and health-related tasks through 

18 hands-on assistance, supervision, or cueing— 

19 ‘‘(i) under a plan of services and sup20 ports that is based on an assessment of 

21 functional need and that is agreed to in 

22 writing by the individual or, as appro23 priate, the individual’s representative; 

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

25 which shall include but not be limited to a 


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1 school, workplace, or recreation or religious 

2 facility, but does not include a nursing fa3 cility, institution for mental diseases, or an 

4 intermediate care facility for the mentally 

5 retarded; 

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

7 or other model (as defined in paragraph 

8 (2)(C)); 

9 ‘‘(iv) the furnishing of which— 

10 ‘‘(I) is selected, managed, and 

11 dismissed by the individual, or, as ap12 propriate, with assistance from the in13 dividual’s representative; and 

14 ‘‘(II) provided by an individual 

15 who is qualified to provide such serv16 ices, including family members (as de17 fined by the Secretary). 

18 ‘‘(B) INCLUDED SERVICES AND SUP19 PORTS.—Such term includes— 

20 ‘‘(i) tasks necessary to assist an indi21 vidual in accomplishing activities of daily 

22 living, instrumental activities of daily liv23 ing, and health-related tasks; 

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

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1 dividual to accomplish activities of daily 

2 living, instrumental activities of daily liv3 ing, and health-related tasks; 

4 ‘‘(iii) backup systems or mechanisms 

5 (such as the use of beepers) to ensure con6 tinuity of services and supports; and 

7 ‘‘(iv) voluntary training on how to se8 lect, manage, and dismiss attendants. 

9 ‘‘(C) EXCLUDED SERVICES AND SUP10 PORTS.—Subject to subparagraph (D), such 

11 term does not include— 

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

13 for the individual; 

14 ‘‘(ii) special education and related 

15 services provided under the Individuals 

16 with Disabilities Education Act and voca17 tional rehabilitation services provided 

18 under the Rehabilitation Act of 1973; 

19 ‘‘(iii) assistive technology devices and 

20 assistive technology services; 

21 ‘‘(iv) durable medical equipment; or 

22 ‘‘(v) home modifications. 

23 ‘‘(D) FLEXIBILITY IN TRANSITION TO

24 COMMUNITY-BASED HOME SETTING.—Such 

25 term may include expenditures for transitional 


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1 costs, such as rent and utility deposits, first 

2 month’s rent and utilities, bedding, basic kitch3 en supplies, and other necessities required for 

4 an individual to make the transition from a 

5 nursing facility, institution for mental diseases, 

6 or intermediate care facility for the mentally re7 tarded to a community-based home setting 

8 where the individual resides. 

9 ‘‘(2) ADDITIONAL DEFINITIONS.— 

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

11 term ‘activities of daily living’ includes eating, 

12 toileting, grooming, dressing, bathing, and 

13 transferring. 

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

15 ‘consumer controlled’ means a method of select16 ing and providing services and supports that 

17 allow the individual, or where appropriate, the 

18 individual’s representative, maximum control of 

19 the community-based attendant services and 

20 supports, regardless of who acts as the em21 ployer of record. 

22 ‘‘(C) DELIVERY MODELS.— 

23 ‘‘(i) AGENCY-PROVIDER MODEL.—The 

24 term ‘agency-provider model’ means, with 

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1 based attendant services and supports for 

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

3 method of providing consumer controlled 

4 services and supports under which entities 

5 contract for the provision of such services 

6 and supports. 

7 ‘‘(ii) OTHER MODELS.—The term 

8 ‘other models’ means, subject to clause 

9 (iii), methods, other than an agency-pro10 vider model, for the provision of consumer 

11 controlled services and supports. Such 

12 models may include the provision of vouch13 ers, direct cash payments, or use of a fiscal 

14 agent to assist in obtaining services. 

15 ‘‘(iii) COMPLIANCE WITH CERTAIN

16 LAWS.—A State shall ensure that, regard17 less of whether the State uses an agency18 provider model or other models to provide 

19 services and supports under a State plan 

20 amendment under this section, such serv21 ices and supports are provided in accord22 ance with the requirements of the Fair 

23 Labor Standards Act of 1938 and applica24 ble Federal and State laws regarding— 


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1 ‘‘(I) withholding and payment of 

2 Federal and State income and payroll 

3 taxes; 

4 ‘‘(II) the provision of unemploy5 ment and workers compensation in6 surance; 

7 ‘‘(III) maintenance of general li8 ability insurance; and 

9 ‘‘(IV) occupational health and 

10 safety. 

11 ‘‘(D) HEALTH-RELATED TASKS.—The 

12 term ‘health-related tasks’ means specific tasks 

13 that can be delegated or assigned by licensed 

14 health-care professionals under State law to be 

15 performed by an attendant. 

16 ‘‘(E) INSTRUMENTAL ACTIVITIES OF DAILY

17 LIVING.—The term ‘instrumental activities of 

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

19 planning and preparation, managing finances, 

20 shopping for food, clothing, and other essential 

21 items, performing essential household chores, 

22 communicating by phone and other media, and 

23 traveling around and participating in the com24 munity. 


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1 ‘‘(F) INDIVIDUALS REPRESENTATIVE.— 

2 The term ‘individual’s representative’ means a 

3 parent, a family member, a guardian, an advo4 cate, or other authorized representative of an 

5 individual.’’. 

6 (c) CONFORMING AMENDMENTS.— 

7 (1) MANDATORY BENEFIT.—Section 

8 1902(a)(10)(A) of the Social Security Act (42 

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

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

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

12 (2) DEFINITION OF MEDICAL ASSISTANCE.— 

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

14 U.S.C. 1396d) is amended— 

15 (A) by striking ‘‘and’’ at the end of para16 graph (27); 

17 (B) by redesignating paragraph (28) as 

18 paragraph (29); and 

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

20 following: 

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

22 supports (to the extent allowed and as defined in 

23 section 1939); and’’. 

24 (3) IMD/ICFMR REQUIREMENTS.—Section 

25 1902(a)(10)(C)(iv) of the Social Security Act (42 


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

2 ‘‘and (28)’’ after ‘‘(24)’’. 

3 (d) EFFECTIVE DATES.— 

4 (1) IN GENERAL.—Except as provided in para5 graph (2), the amendments made by this section 

6 (other than the amendment made by subsection 

7 (c)(1)) take effect on October 1, 2007, and apply to 

8 medical assistance provided for community-based at9 tendant services and supports described in section 

10 1939 of the Social Security Act furnished on or 

11 after that date. 

12 (2) MANDATORY BENEFIT.—The amendment 

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

14 2012. 

15 SEC. 102. ENHANCED FMAP FOR ONGOING ACTIVITIES OF 

16 EARLY COVERAGE STATES THAT ENHANCE 

17 AND PROMOTE THE USE OF COMMUNITY18 BASED ATTENDANT SERVICES AND SUP19 PORTS. 

20 (a) IN GENERAL.—Section 1939 of the Social Secu21 rity Act, as added by section 101(b), is amended— 

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

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

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

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


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

2 with respect to expenditures described in subsection 

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

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

5 (4) in subsection (c)(1)(C), by striking ‘‘sub6 section (g)(2)(B)’’ and inserting ‘‘subsection 

7 (i)(2)(B)’’; and 

8 (5) by inserting after subsection (c), the fol9 lowing: 

10 ‘‘(d) INCREASED FEDERAL FINANCIAL PARTICIPA11 TION FOR EARLY COVERAGE STATES THAT MEET CER12 TAIN BENCHMARKS.— 

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

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

15 expenditures described in this subsection are an 

16 amount equal to the Federal medical assistance per17 centage, increased by 10 percentage points, of the 

18 expenditures incurred by the State for the provision 

19 or conduct of the services or activities described in 

20 paragraph (3). 

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

22 ‘‘(A) develop criteria for determining the 

23 expenditures described in paragraph (1) in col24 laboration with the individuals and representa25 tives described in subsection (b)(1); and 


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

2 the Secretary. 

3 ‘‘(3) SERVICES, SUPPORTS AND ACTIVITIES DE4 SCRIBED.—For purposes of paragraph (1), the serv5 ices, supports and activities described in this sub6 paragraph are the following: 

7 ‘‘(A) 1-stop intake, referral, and institu8 tional diversion services. 

9 ‘‘(B) Identifying and remedying gaps and 

10 inequities in the State’s current provision of 

11 long-term services and supports, particularly 

12 those services and supports that are provided 

13 based on such factors as age, severity of dis14 ability, type of disability, ethnicity, income, in15 stitutional bias, or other similar factors. 

16 ‘‘(C) Establishment of consumer participa17 tion and consumer governance mechanisms, 

18 such as cooperatives and regional service au19 thorities, that are managed and controlled by 

20 individuals with significant disabilities who use 

21 community-based services and supports or their 

22 representatives. 

23 ‘‘(D) Activities designed to enhance the 

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1 ture prospects of workers who provide commu2 nity-based attendant services and supports. 

3 ‘‘(E) Continuous, comprehensive quality 

4 improvement activities that are designed to en5 sure and enhance the health and well-being of 

6 individuals who rely on community-based at7 tendant services and supports, particularly ac8 tivities involving or initiated by consumers of 

9 such services and supports or their representa10 tives. 

11 ‘‘(F) Family support services to augment 

12 the efforts of families and friends to enable in13 dividuals with disabilities of all ages to live in 

14 their own homes and communities. 

15 ‘‘(G) Health promotion and wellness serv16 ices and activities. 

17 ‘‘(H) Provider recruitment and enhance18 ment activities, particularly such activities that 

19 encourage the development and maintenance of 

20 consumer controlled cooperatives or other small 

21 businesses or micro-enterprises that provide 

22 community-based attendant services and sup23 ports or related services. 

24 ‘‘(I) Activities designed to ensure service 

25 and systems coordination. 


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

2 the Secretary deems appropriate.’’. 

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

4 subsection (a) take effect on October 1, 2007. 

5 SEC. 103. INCREASED FEDERAL FINANCIAL PARTICIPATION 

6 FOR CERTAIN EXPENDITURES. 

7 (a) IN GENERAL.—Section 1939 of the Social Secu8 rity Act, as added by section 101(b) and amended by sec9 tion 102, is amended by inserting after subsection (d) the 

10 following: 

11 ‘‘(e) INCREASED FEDERAL FINANCIAL PARTICIPA12 TION FOR CERTAIN EXPENDITURES.— 

13 ‘‘(1) ELIGIBILITY FOR PAYMENT.— 

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

15 that the Secretary determines satisfies the re16 quirements of subparagraph (B), the Secretary 

17 shall pay the State the amounts described in 

18 paragraph (2) in addition to any other pay19 ments provided for under section 1903 or this 

20 section for the provision of community-based at21 tendant services and supports. 

22 ‘‘(B) REQUIREMENTS.—The requirements 

23 of this subparagraph are the following: 

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

25 amendment under this section. 


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1 ‘‘(ii) The State has incurred expendi2 tures described in paragraph (2). 

3 ‘‘(iii) The State develops and submits 

4 to the Secretary criteria to identify and se5 lect such expenditures in accordance with 

6 the requirements of paragraph (3). 

7 ‘‘(iv) The Secretary determines that 

8 payment of the applicable percentage of 

9 such expenditures (as determined under 

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

11 to provide a meaningful choice of receiving 

12 community-based services and supports to 

13 individuals with disabilities and elderly in14 dividuals who would otherwise only have 

15 the option of receiving institutional care. 

16 ‘‘(2) AMOUNTS AND EXPENDITURES DE17 SCRIBED.— 

18 ‘‘(A) EXPENDITURES IN EXCESS OF 150

19 PERCENT OF BASELINE AMOUNT.—The 

20 amounts and expenditures described in this 

21 paragraph are an amount equal to the applica22 ble percentage, as determined by the Secretary 

23 in accordance with subparagraph (B), of the ex24 penditures incurred by the State for the provi25 sion of community-based attendant services and 


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1 supports to an individual that exceed 150 per2 cent of the average cost of providing nursing fa3 cility services to an individual who resides in 

4 the State and is eligible for such services under 

5 this title, as determined in accordance with cri6 teria established by the Secretary. 

7 ‘‘(B) APPLICABLE PERCENTAGE.—The 

8 Secretary shall establish a payment scale for 

9 the expenditures described in subparagraph (A) 

10 so that the Federal financial participation for 

11 such expenditures gradually increases from 70 

12 percent to 90 percent as such expenditures in13 crease. 

14 ‘‘(3) SPECIFICATION OF ORDER OF SELECTION

15 FOR EXPENDITURES.—In order to receive the 

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

17 ‘‘(A) develop, in collaboration with the in18 dividuals and representatives described in sub19 section (b)(1) and pursuant to guidelines estab20 lished by the Secretary, criteria to identify and 

21 select the expenditures submitted under that 

22 paragraph; and 

23 ‘‘(B) submit such criteria to the Sec24 retary.’’. 


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

2 subsection (a) takes effect on October 1, 2007. 

3 TITLE II—PROMOTION OF SYS4 TEMS CHANGE AND CAPACITY 

5 BUILDING 

6 SEC. 201. GRANTS TO PROMOTE SYSTEMS CHANGE AND CA7 PACITY BUILDING. 

8 (a) AUTHORITY TO AWARD GRANTS.— 

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

10 Human Services (in this section referred to as the 

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

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

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

14 grant under this section, a State shall submit to the 

15 Secretary an application in such form and manner, 

16 and that contains such information, as the Secretary 

17 may require. 

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

19 a grant under this section may use funds provided under 

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

21 areas of need identified by the State and the Consumer 

22 Task Force established under subsection (c): 

23 (1) The development and implementation of the 

24 provision of community-based attendant services and 

25 supports under section 1939 of the Social Security 


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

2 sections 102 and 103) through active collaboration 

3 with— 

4 (A) individuals with disabilities; 

5 (B) elderly individuals; 

6 (C) representatives of such individuals; and 

7 (D) providers of, and advocates for, serv8 ices and supports for such individuals. 

9 (2) Substantially involving individuals with sig10 nificant disabilities and representatives of such indi11 viduals in jointly developing, implementing, and con12 tinually improving a mutually acceptable comprehen13 sive, effectively working statewide plan for pre14 venting and alleviating unnecessary institutionaliza15 tion of such individuals. 

16 (3) Engaging in system change and other ac17 tivities deemed necessary to achieve any or all of the 

18 goals of such statewide plan. 

19 (4) Identifying and remedying disparities and 

20 gaps in services to classes of individuals with disabil21 ities and elderly individuals who are currently expe22 riencing or who face substantial risk of unnecessary 

23 institutionalization. 

24 (5) Building and expanding system capacity to 

25 offer quality consumer controlled community-based 


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1 services and supports to individuals with disabilities 

2 and elderly individuals, including by— 

3 (A) seeding the development and effective 

4 use of community-based attendant services and 

5 supports cooperatives, Independent Living Cen6 ters, small businesses, micro-enterprises, micro7 boards, and similar joint ventures owned and 

8 controlled by individuals with disabilities or rep9 resentatives of such individuals and community10 based attendant services and supports workers; 

11 (B) enhancing the choice and control indi12 viduals with disabilities and elderly individuals 

13 exercise, including through their representa14 tives, with respect to the personal assistance 

15 and supports they rely upon to lead inde16 pendent, self-directed lives; 

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

18 supply, career, and future prospects of workers 

19 who provide community-based attendant serv20 ices and supports; 

21 (D) engaging in a variety of needs assess22 ment and data gathering; 

23 (E) developing strategies for modifying 

24 policies, practices, and procedures that result in 

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1 medicalization of long-term services and sup2 ports; 

3 (F) engaging in interagency coordination 

4 and single point of entry activities; 

5 (G) providing training and technical assist6 ance with respect to the provision of commu7 nity-based attendant services and supports; 

8 (H) engaging in— 

9 (i) public awareness campaigns; 

10 (ii) facility-to-community transitional 

11 activities; and 

12 (iii) demonstrations of new ap13 proaches; and 

14 (I) engaging in other systems change ac15 tivities necessary for developing, implementing, 

16 or evaluating a comprehensive statewide system 

17 of community-based attendant services and sup18 ports. 

19 (6) Ensuring that the activities funded by the 

20 grant are coordinated with other efforts to increase 

21 personal attendant services and supports, includ22 ing— 

23 (A) programs funded under or amended by 

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1 provement Act of 1999 (Public Law 106–170; 

2 113 Stat. 1860); 

3 (B) grants funded under the Families of 

4 Children With Disabilities Support Act of 2000 

5 (42 U.S.C. 15091 et seq.); and 

6 (C) other initiatives designed to enhance 

7 the delivery of community-based services and 

8 supports to individuals with disabilities and el9 derly individuals. 

10 (7) Engaging in transition partnership activities 

11 with nursing facilities and intermediate care facili12 ties for the mentally retarded that utilize and build 

13 upon items and services provided to individuals with 

14 disabilities or elderly individuals under the Medicaid 

15 program under title XIX of the Social Security Act, 

16 or by Federal, State, or local housing agencies, Inde17 pendent Living Centers, and other organizations 

18 controlled by consumers or their representatives. 

19 (c) CONSUMER TASK FORCE.— 

20 (1) ESTABLISHMENT AND DUTIES.—To be eli21 gible to receive a grant under this section, each 

22 State shall establish a Consumer Task Force (re23 ferred to in this subsection as the ‘‘Task Force’’) to 

24 assist the State in the development, implementation, 


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1 and evaluation of real choice systems change initia2 tives. 

3 (2) APPOINTMENT.—Members of the Task 

4 Force shall be appointed by the Chief Executive Of5 ficer of the State in accordance with the require6 ments of paragraph (3), after the solicitation of rec7 ommendations from representatives of organizations 

8 representing a broad range of individuals with dis9 abilities, elderly individuals, representatives of such 

10 individuals, and organizations interested in individ11 uals with disabilities and elderly individuals. 

12 (3) COMPOSITION.— 

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

14 represent a broad range of individuals with dis15 abilities from diverse backgrounds and shall in16 clude representatives from Developmental Dis17 abilities Councils, Mental Health Councils, 

18 State Independent Living Centers and Councils, 

19 Commissions on Aging, organizations that pro20 vide services to individuals with disabilities and 

21 consumers of long-term services and supports. 

22 (B) INDIVIDUALS WITH DISABILITIES.—A 

23 majority of the members of the Task Force 

24 shall be individuals with disabilities or rep25 resentatives of such individuals. 


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1 (C) LIMITATION.—The Task Force shall 

2 not include employees of any State agency pro3 viding services to individuals with disabilities 

4 other than employees of entities described in 

5 the Developmental Disabilities Assistance and 

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

7 seq.). 

8 (d) ANNUAL REPORT.— 

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

10 under this section shall submit an annual report to 

11 the Secretary on the use of funds provided under the 

12 grant in such form and manner as the Secretary 

13 may require. 

14 (2) SECRETARY.—The Secretary shall submit 

15 to Congress an annual report on the grants made 

16 under this section. 

17 (e) AUTHORIZATION OF APPROPRIATIONS.— 

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

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

20 for each of fiscal years 2008 through 2010. 

21 (2) AVAILABILITY.—Amounts appropriated to 

22 carry out this section shall remain available without 

23 fiscal year limitation. 


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1 SEC. 202. DEMONSTRATION PROJECT TO ENHANCE CO2 ORDINATION OF CARE UNDER THE MEDI3 CARE AND MEDICAID PROGRAMS FOR DUAL 

4 ELIGIBLE INDIVIDUALS. 

5 (a) DEFINITIONS.—In this section: 

6 (1) DUALLY ELIGIBLE INDIVIDUAL.—The term 

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

8 is enrolled in the Medicare and Medicaid programs 

9 established under Titles XVIII and XIX, respec10 tively, of the Social Security Act (42 U.S.C. 1395 et 

11 seq., 1396 et seq.). 

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

13 demonstration project authorized to be conducted 

14 under this section. 

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

16 the Secretary of Health and Human Services. 

17 (b) AUTHORITY TO CONDUCT PROJECT.—The Sec18 retary shall conduct a project under this section for the 

19 purpose of evaluating service coordination and cost-shar20 ing approaches with respect to the provision of commu21 nity-based services and supports to dually eligible individ22 uals. 

23 (c) REQUIREMENTS.— 

24 (1) NUMBER OF PARTICIPANTS.—Not more 

25 than 5 States may participate in the project. 


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1 (2) APPLICATION.—A State that desires to par2 ticipate in the project shall submit an application to 

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

4 manner as the Secretary shall specify. 

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

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

7 (d) EVALUATION AND REPORT.— 

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

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

10 in consultation with States participating in the 

11 project, representatives of dually eligible individuals, 

12 and others, shall evaluate the impact and effective13 ness of the project. 

14 (2) REPORT.—The Secretary shall submit a re15 port to Congress that contains the findings of the 

16 evaluation conducted under paragraph (1) along 

17 with recommendations regarding whether the project 

18 should be extended or expanded, and any other legis19 lative or administrative actions that the Secretary 

20 considers appropriate as a result of the project. 

21 (e) AUTHORIZATION OF APPROPRIATIONS.—There 

22 are authorized to be appropriated such sums as are nec23 essary to carry out this section. 

Æ 


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