II 

113TH CONGRESS 

2D SESSION S. 2515 

To ensure that Medicaid beneficiaries have the opportunity to receive care 

in a home and community-based setting. 

IN THE SENATE OF THE UNITED STATES 

JUNE 24, 2014 

Mr. HARKIN introduced the following bill; which was read twice and referred 

to the Committee on Finance 

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 2014’’. 

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 Mar 15 2010 04:28 Jun 28, 2014 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S2515.IS S2515

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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 (80), by striking ‘‘and’’ at the 

15 end; 

16 (2) in paragraph (81), by striking the period 

17 and inserting ‘‘; and’’; and 

18 (3) by inserting after paragraph (81) the fol19 lowing new paragraph: 

20 ‘‘(82) 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, intermediate care facility for the men24 tally retarded, institution for mental disease, or 

25 other similarly restrictive or institutional setting— 


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

2 and opportunity to receive such care in a home 

3 and community-based setting, including reha4 bilitative services, assistance and support in ac5 complishing activities of daily living, instru6 mental activities of daily living, and health-re7 lated tasks, and assistance in acquiring, main8 taining, or enhancing skills necessary to accom9 plish such activities, tasks, or services; 

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

11 an equal opportunity (when compared to the re12 ceipt and availability of nursing facility serv13 ices) to receive care in a home and community14 based setting, if the individual so chooses, by 

15 ensuring that the provision of such care in a 

16 home and community-based setting is widely 

17 available on a statewide basis for all such indi18 viduals within the State; and 

19 ‘‘(C) meet the requirements of section 

20 1904A (relating to the provision of care in a 

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

22 (b) REQUIREMENTS FOR COMMUNITY CARE OP23 TIONS.—Title XIX of the Social Security Act (42 U.S.C. 

24 1396 et seq.) is amended by inserting after section 1904 

25 the following new section: 


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1 ‘‘PROVISIONS RELATED TO HOME AND COMMUNITY2 BASED CARE

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

4 this section, section 1902(a)(82), and section 

5 1905(a)(4)(A): 

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

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

8 to, tasks such as eating, toileting, grooming, dress9 ing, bathing, and transferring. 

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

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

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

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

14 of ventilators and feeding tubes, and the administra15 tion of medications and injections, which, in the 

16 opinion of the individual’s physician, can be dele17 gated to be performed by an attendant. 

18 ‘‘(3) HOME AND COMMUNITY-BASED SET19 TING.—The term ‘home and community-based set20 ting’ means, with respect to an individual who re21 quires a level of care provided in a nursing facility, 

22 intermediate care facility for the mentally retarded, 

23 institution for mental disease, or other similarly re24 strictive or institutional setting, a setting that— 


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1 ‘‘(A) includes a house, apartment, town2 house, condominium, or similar public or pri3 vate housing where the individual resides that— 

4 ‘‘(i) is owned or leased by the indi5 vidual or a member of the individual’s fam6 ily; 

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

8 dignity, respect, and freedom from coer9 cion; and 

10 ‘‘(iii) maximizes the individual’s au11 tonomy and independence; 

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

13 to, the general community in which the setting 

14 is located so that the individual has access to 

15 the community and opportunities to seek em16 ployment and work in competitive integrated 

17 settings, participate in community life, control 

18 and utilize personal resources, benefit from 

19 community services, and participate in the com20 munity in an overall manner that is comparable 

21 to that available to individuals who are not indi22 viduals with disabilities; and 

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

24 individual needs in order to live as independ25 ently as possible. 


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1 ‘‘(4) INSTRUMENTAL ACTIVITIES OF DAILY LIV2 ING.—The term ‘instrumental activities of daily liv3 ing’ means activities related to living independently 

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

5 meal planning and preparation, managing finances, 

6 shopping for food, clothing, and other items, per7 forming household chores, communicating by phone 

8 or other media, and traveling around and partici9 pating in the community. 

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

11 means a public entity as defined in subparagraphs 

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

13 Disabilities Act of 1990. 

14 ‘‘(b) REQUIREMENTS FOR PROVIDING SERVICES IN

15 HOME AND COMMUNITY-BASED SETTINGS.—With respect 

16 to the availability and provision of services under the State 

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

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

19 Integration Act of 2014), in a home and community-based 

20 setting to any individual who requires a level of care pro21 vided in a nursing facility, intermediate care facility for 

22 the mentally retarded, institution for mental disease, or 

23 other similarly restrictive or institutional setting, any pub24 lic entity that receives payment under the State plan or 


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1 waiver for providing services to such an individual shall 

2 not— 

3 ‘‘(1) impose or utilize policies, practices, or pro4 cedures, such as unnecessary requirements or arbi5 trary service or cost caps, that limit the availability 

6 of services in home and community-based settings to 

7 an individual with a disability (including individuals 

8 with the most significant disabilities) who need such 

9 services; 

10 ‘‘(2) impose or utilize policies, practices, or pro11 cedures that limit the availability of services in a 

12 home and community-based setting (including assist13 ance and support in accomplishing activities of daily 

14 living, instrumental activities of daily living, health15 related tasks, and rehabilitative services) based on 

16 the specific disability of an otherwise eligible indi17 vidual; 

18 ‘‘(3) impose or utilize policies, practices, or pro19 cedures that arbitrarily restrict an individual with a 

20 disability from full and meaningful participation in 

21 community life; 

22 ‘‘(4) impose or utilize policies, practices, or pro23 cedures that unnecessarily delay or restrict the pro24 vision of services in a home and community-based 

25 setting to any individual who requires such services; 


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1 ‘‘(5) fail to establish and utilize adequate pay2 ment structures to maintain a sufficient workforce 

3 to provide services in home and community-based 

4 settings to any individual who requires such services; 

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

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

7 nursing facility, intermediate care facility for the 

8 mentally retarded, institution for mental disease, or 

9 other similarly restrictive or institutional setting, un10 derstand the individual’s right to choose to receive 

11 such care in a home and community-based setting; 

12 or 

13 ‘‘(7) fail to provide information to help any in14 dividual that requires the level of care provided in a 

15 nursing facility, intermediate care facility for the 

16 mentally retarded, institution for mental disease, or 

17 other similarly restrictive or institutional setting, 

18 prior to the individual’s placement in such a facility 

19 or institution, understand the individual’s right to 

20 choose to receive such care in a home and commu21 nity-based setting. 

22 ‘‘(c) PLAN TO INCREASE AFFORDABLE AND ACCES23 SIBLE HOUSING.—Not later than 180 days after the en24 actment of this section, each State shall develop a state25 wide plan to increase the availability of affordable and acVerDate Mar 15 2010 04:28 Jun 28, 2014 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S2515.IS S2515

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1 cessible private and public housing stock for individuals 

2 with disabilities (including accessible housing for individ3 uals with physical disabilities and those using mobility de4 vices). 

5 ‘‘(d) AVAILABILITY OF REMEDIES AND PROCE6 DURES.— 

7 ‘‘(1) IN GENERAL.—The remedies and proce8 dures set forth in sections 203 and 505 of the Amer9 icans with Disabilities Act of 1990 shall be available 

10 to any person aggrieved by the failure of— 

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

12 section 1902(a)(82); or 

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

14 comply with the requirements of subsection (b). 

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

16 paragraph (1) shall be construed to limit any rem17 edy or right of action that otherwise is available to 

18 an aggrieved person under this title. 

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

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

21 the Federal matching assistance percentage applica22 ble to the State (as determined under section 

23 1905(b)) if the Secretary determines that the State 

24 has violated the requirements of subsection (b). 


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

2 paragraph (1) shall be construed to limit any rem3 edy or right of action that is otherwise available to 

4 the Secretary. 

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

6 fiscal year 2016, and for each fiscal year thereafter, each 

7 State shall submit to the Administrator of the Administra8 tion for Community Living of the Department of Health 

9 and Human Services, not later than April 1 of the suc10 ceeding fiscal year, a report, in such form and manner 

11 as the Secretary shall require, that includes— 

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

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

14 such fiscal year that required the level of care pro15 vided in a nursing facility, intermediate care facility 

16 for the mentally retarded, institution for mental dis17 ease, or other similarly restrictive or institutional 

18 setting, disaggregated by the type of facility or set19 ting; 

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

21 in paragraph (1), the total number of individuals de22 scribed in that paragraph who received care in a 

23 nursing facility, intermediate care facility for the 

24 mentally retarded, institution for mental disease, or 


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1 other similarly restrictive or institutional setting, 

2 disaggregated by the type of facility or setting; and 

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

4 in paragraph (2), the total number of individuals de5 scribed in that paragraph who were transitioned 

6 from a nursing facility, intermediate care facility for 

7 the mentally retarded, institution for mental disease, 

8 or other similarly restrictive or institutional setting 

9 to a home and community-based setting, disaggre10 gated by the type of home and community-based set11 ting.’’. 

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

13 1905(a)(4)(A) of the Social Security Act (42 U.S.C. 

14 1396d(a)(4)(A)) is amended by striking ‘‘other than’’ and 

15 inserting ‘‘including similar services such as rehabilitative 

16 services and assistance and support in accomplishing ac17 tivities of daily living, instrumental activities of daily liv18 ing, and health-related tasks, that are provided, at the in19 dividual’s option, in a home and community-based setting 

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

21 (d) APPLICATION TO WAIVERS.—Notwithstanding 

22 section 1904A of the Social Security Act (as added by sub23 section (b)), such section, and sections 1902(a)(82), and 

24 1905(a)(4)(A) of the Social Security Act (42 U.S.C. 1396 

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1 tively, shall not apply to any individuals who are eligible 

2 for medical assistance for home and community-based 

3 services under a waiver under section 1115 or 1915 of 

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

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

6 so added or amended) are inconsistent with any such waiv7 er. 

8 (e) EFFECTIVE DATE.— 

9 (1) IN GENERAL.—Except as provided in para10 graph (2), the amendments made by this section 

11 shall take effect on October 1, 2014. 

12 (2) DELAY PERMITTED IF STATE LEGISLATION

13 REQUIRED.—In the case of a State plan under sec14 tion 1902 of the Social Security Act (42 U.S.C. 

15 1396a) which the Secretary of Health and Human 

16 Services determines requires State legislation (other 

17 than legislation appropriating funds) in order for the 

18 plan to meet the additional requirements imposed by 

19 the amendments made by this section, the State 

20 plan shall not be regarded as failing to comply with 

21 the requirements of such section 1902 solely on the 

22 basis of the failure of the plan to meet such addi23 tional requirements before the 1st day of the 1st cal24 endar quarter beginning after the close of the 1st 

25 regular session of the State legislature that begins 


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1 after the date of enactment of this Act. For pur2 poses of the previous sentence, in the case of a State 

3 that has a 2-year legislative session, each year of 

4 such session shall be deemed to be a separate reg5 ular session of the State legislature. 

Æ 


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