II 

116TH CONGRESS 

1ST SESSION S. 117 

To prohibit discrimination against individuals with disabilities who need longterm services and supports, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JANUARY 15, 2019 

Mr. SCHUMER (for himself, Mr. GARDNER, Ms. BALDWIN, Mr. BENNET, Mr. 

BLUMENTHAL, Ms. CANTWELL, Mr. CASEY, Mr. COONS, Ms. 

DUCKWORTH, Mrs. GILLIBRAND, Ms. HARRIS, Ms. HASSAN, Mr. JONES, 

Mr. LEAHY, Mr. MARKEY, Mrs. MURRAY, Mr. VAN HOLLEN, Ms. WARREN, Mr. TESTER, Mr. SANDERS, Mr. DURBIN, Mr. BOOKER, Mr. 

MERKLEY, and Ms. SMITH) introduced the following bill; which was read 

twice and referred to the Committee on Health, Education, Labor, and 

Pensions 

A BILL 

To prohibit discrimination against individuals with disabilities who need long-term 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. 

4 This Act may be cited as the ‘‘Disability Integration 

5 Act of 2019’’. 

6 SEC. 2. FINDINGS AND PURPOSES. 

7 (a) FINDINGS.—Congress finds the following: 


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1 (1) In enacting the Americans with Disabilities 

2 Act of 1990 (referred to in this Act as the ‘‘ADA’’), 

3 Congress— 

4 (A) recognized that ‘‘historically, society 

5 has tended to isolate and segregate individuals 

6 with disabilities, and, despite some improve7 ments, such forms of discrimination against in8 dividuals with disabilities continue to be a seri9 ous and pervasive social problem’’; and 

10 (B) intended that the ADA assure ‘‘full 

11 participation’’ and ‘‘independent living’’ for in12 dividuals with disabilities by addressing ‘‘dis13 crimination against individuals with disabilities 

14 [that] persists in critical areas’’, including insti15 tutionalization. 

16 (2) While Congress expected that the ADA’s in17 tegration mandate would be interpreted in a manner 

18 that ensures that individuals who are eligible for in19 stitutional placement are able to exercise a right to 

20 community-based long-term services and supports, 

21 that expectation has not been fulfilled. 

22 (3) The holdings of the Supreme Court in 

23 Olmstead v. L.C., 527 U.S. 581 (1999), and com24 panion cases, have clearly articulated that individ25 uals with disabilities have a civil right under the 


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1 ADA to participate in society as equal citizens. How2 ever, many States still do not provide sufficient com3 munity-based long-term services and supports to in4 dividuals with disabilities to end segregation in insti5 tutions. 

6 (4) The right to live in the community is nec7 essary for the exercise of the civil rights that the 

8 ADA was intended to secure for all individuals with 

9 disabilities. The lack of adequate community-based 

10 services and supports has imperiled the civil rights 

11 of all individuals with disabilities, and has under12 mined the very promise of the ADA. It is, therefore, 

13 necessary to recognize in statute a robust and fully 

14 articulated right to community living. 

15 (5) States, with a few exceptions, continue to 

16 approach decisions regarding long-term services and 

17 supports from social welfare and budgetary perspec18 tives, but for the promise of the ADA to be fully re19 alized, States must approach these decisions from a 

20 civil rights perspective. 

21 (6) States have not consistently planned to en22 sure sufficient services and supports for individuals 

23 with disabilities, including those with the most sig24 nificant disabilities, to enable individuals with dis25 abilities to live in the most integrated setting. As a 


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1 result, many individuals with disabilities who reside 

2 in institutions are prevented from residing in the 

3 community and individuals with disabilities who are 

4 not in institutions find themselves at risk of institu5 tional placement. 

6 (7) The continuing existence of unfair and un7 necessary institutionalization denies individuals with 

8 disabilities the opportunity to live and participate on 

9 an equal basis in the community and costs the 

10 United States billions of dollars in unnecessary 

11 spending related to perpetuating dependency and 

12 unnecessary confinement. 

13 (b) PURPOSES.—The purposes of this Act are— 

14 (1) to clarify and strengthen the ADA’s inte15 gration mandate in a manner that accelerates State 

16 compliance; 

17 (2) to clarify that every individual who is eligi18 ble for long-term services and supports has a feder19 ally protected right to be meaningfully integrated 

20 into that individual’s community and receive commu21 nity-based long-term services and supports; 

22 (3) to ensure that States provide long-term 

23 services and supports to individuals with disabilities 

24 in a manner that allows individuals with disabilities 

25 to live in the most integrated setting, including the 


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1 individual’s own home, have maximum control over 

2 their services and supports, and ensure that long3 term services and supports are provided in a manner 

4 that allows individuals with disabilities to lead an 

5 independent life; 

6 (4) to establish a comprehensive State planning 

7 requirement that includes enforceable, measurable 

8 objectives that are designed to transition individuals 

9 with all types of disabilities at all ages out of institu10 tions and into the most integrated setting; and 

11 (5) to establish a requirement for clear and uni12 form annual public reporting by States that includes 

13 reporting about— 

14 (A) the number of individuals with disabil15 ities who are served in the community and the 

16 number who are served in institutions; and 

17 (B) the number of individuals with disabil18 ities who have transitioned from an institution 

19 to a community-based living situation, and the 

20 type of community-based living situation into 

21 which those individuals have transitioned. 

22 SEC. 3. DEFINITIONS AND RULE. 

23 (a) DEFINITIONS.—In this Act: 

24 (1) ACTIVITIES OF DAILY LIVING.—The term 

25 ‘‘activities of daily living’’ has the meaning given the 


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1 term in section 441.505 of title 42, Code of Federal 

2 Regulations (or a successor regulation). 

3 (2) ADMINISTRATOR.—The term ‘‘Adminis4 trator’’ means— 

5 (A) the Administrator of the Administra6 tion for Community Living; or 

7 (B) another designee of the Secretary of 

8 Health and Human Services. 

9 (3) COMMUNITY-BASED.—The term ‘‘commu10 nity-based’’, when used in reference to services or 

11 supports, means services or supports that are pro12 vided to an individual with an LTSS disability to en13 able that individual to live in the community and 

14 lead an independent life, and that are delivered in 

15 whichever setting the individual with an LTSS dis16 ability has chosen out of the following settings with 

17 the following qualities: 

18 (A) In the case of a dwelling or a nonresi19 dential setting (such as a setting in which an 

20 individual with an LTSS disability receives day 

21 services and supported employment), a dwelling 

22 or setting— 

23 (i) that, as a matter of infrastructure, 

24 environment, amenities, location, services, 

25 and features, is integrated into the greater 


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1 community and supports, for each indi2 vidual with an LTSS disability who re3 ceives services or supports at the setting— 

4 (I) full access to the greater com5 munity (including access to opportuni6 ties to seek employment and work in 

7 competitive integrated settings, en8 gage in community life, control per9 sonal resources, and receive services 

10 in the community); and 

11 (II) access to the greater commu12 nity to the same extent as access to 

13 the community is enjoyed by an indi14 vidual who is not receiving long-term 

15 services or supports; 

16 (ii) that the individual has selected as 

17 a meaningful choice from among nonresi18 dential setting options, including nondis19 ability-specific settings; 

20 (iii) in which an individual has rights 

21 to privacy, dignity, and respect, and free22 dom from coercion and restraint; 

23 (iv) that, as a matter of infrastruc24 ture, environment, amenities, location, 

25 services, and features, optimizes, but does 


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1 not regiment, individual initiative, auton2 omy, and independence in making life 

3 choices, including choices about daily ac4 tivities, physical environment, and persons 

5 with whom the individual interacts; and 

6 (v) that, as a matter of infrastructure, 

7 environment, amenities, location, services, 

8 and features, facilitates individual choice 

9 regarding the provision of services and 

10 supports, and who provides those services 

11 and supports. 

12 (B) In the case of a dwelling, a dwelling— 

13 (i) that is owned by an individual with 

14 an LTSS disability or the individual’s fam15 ily member; 

16 (ii) that is leased to the individual 

17 with an LTSS disability under an indi18 vidual lease, that has lockable access and 

19 egress, and that includes living, sleeping, 

20 bathing, and cooking areas over which an 

21 individual with an LTSS disability or the 

22 individual’s family member has domain 

23 and control; or 

24 (iii) that is a group or shared resi25 dence— 


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1 (I) in which no more than 4 un2 related individuals with an LTSS dis3 ability reside; 

4 (II) for which each individual 

5 with an LTSS disability living at the 

6 residence owns, rents, or occupies the 

7 residence under a legally enforceable 

8 agreement under which the individual 

9 has, at a minimum, the same respon10 sibilities and protections as tenants 

11 have under applicable landlord-tenant 

12 law; 

13 (III) in which each individual 

14 with an LTSS disability living at the 

15 residence— 

16 (aa) has privacy in the indi17 vidual’s sleeping unit, including a 

18 lockable entrance door controlled 

19 by the individual; 

20 (bb) shares a sleeping unit 

21 only if such individual and the 

22 individual sharing the unit choose 

23 to do so, and if individuals in the 

24 residence so choose, they also 


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1 have a choice of roommates with2 in the residence; 

3 (cc) has the freedom to fur4 nish and decorate the individual’s 

5 sleeping or living unit as per6 mitted under the lease or other 

7 agreement; 

8 (dd) has the freedom and 

9 support to control the individ10 ual’s own schedules and activi11 ties; and 

12 (ee) is able to have visitors 

13 of the individual’s choosing at 

14 any time; and 

15 (IV) that is physically accessible 

16 to the individual with an LTSS dis17 ability living at the residence. 

18 (4) DWELLING.—The term ‘‘dwelling’’ has the 

19 meaning given the term in section 802 of the Fair 

20 Housing Act (42 U.S.C. 3602). 

21 (5) HEALTH-RELATED TASKS.—The term 

22 ‘‘health-related tasks’’ means specific nonacute 

23 tasks, typically regulated by States as medical or 

24 nursing tasks that an individual with a disability 

25 may require to live in the community, including— 


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1 (A) administration of medication; 

2 (B) assistance with use, operation, and 

3 maintenance of a ventilator; and 

4 (C) maintenance and use of a gastrostomy 

5 tube, a catheter, or a stable ostomy. 

6 (6) INDIVIDUAL WITH A DISABILITY.—The term 

7 ‘‘individual with a disability’’ means an individual 

8 who is a person with a disability, as defined in sec9 tion 3 of the Americans with Disabilities Act of 

10 1990 (42 U.S.C. 12102). 

11 (7) INDIVIDUAL WITH AN LTSS DISABILITY.— 

12 The term ‘‘individual with an LTSS disability’’ 

13 means an individual with a disability who— 

14 (A) in order to live in the community and 

15 lead an independent life requires assistance in 

16 accomplishing— 

17 (i) activities of daily living; 

18 (ii) instrumental activities of daily liv19 ing; 

20 (iii) health-related tasks; or 

21 (iv) other functions, tasks, or activi22 ties related to an activity or task described 

23 in clause (i), (ii), or (iii); and 

24 (B)(i) is currently in an institutional place25 ment; or 


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1 (ii) is at risk of institutionalization if the 

2 individual does not receive community-based 

3 long-term services and supports. 

4 (8) INSTRUMENTAL ACTIVITIES OF DAILY LIV5 ING.— 

6 (A) IN GENERAL.—The term ‘‘instru7 mental activities of daily living’’ means one or 

8 more activities related to living independently in 

9 the community, including activities related to— 

10 (i) nutrition, such as preparing meals 

11 or special diets, monitoring to prevent 

12 choking or aspiration, or assisting with 

13 special utensils; 

14 (ii) household chores and environ15 mental maintenance tasks; 

16 (iii) communication and interpersonal 

17 skills, such as— 

18 (I) using the telephone or other 

19 communications devices; 

20 (II) forming and maintaining 

21 interpersonal relationships; or 

22 (III) securing opportunities to 

23 participate in group support or peer24 to-peer support arrangements; 


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1 (iv) travel and community participa2 tion, such as shopping, arranging appoint3 ments, or moving around the community; 

4 (v) care of others, such as raising 

5 children, taking care of pets, or selecting 

6 caregivers; or 

7 (vi) management of personal property 

8 and personal safety, such as— 

9 (I) taking medication; 

10 (II) handling or managing 

11 money; or 

12 (III) responding to emergent sit13 uations or unscheduled needs requir14 ing an immediate response. 

15 (B) ASSISTANCE.—The term ‘‘assistance’’ 

16 used with respect to instrumental activities of 

17 daily living, includes support provided to an in18 dividual by another person due to confusion, de19 mentia, behavioral symptoms, or cognitive, in20 tellectual, mental, or emotional disabilities, in21 cluding support to— 

22 (i) help the individual identify and set 

23 goals, overcome fears, and manage transi24 tions; 


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1 (ii) help the individual with executive 

2 functioning, decisionmaking, and problem 

3 solving; 

4 (iii) provide reassurance to the indi5 vidual; and 

6 (iv) help the individual with orienta7 tion, memory, and other activities related 

8 to independent living. 

9 (9) LONG-TERM SERVICE OR SUPPORT.—The 

10 terms ‘‘long-term service or support’’ and ‘‘LTSS’’ 

11 mean the assistance provided to an individual with 

12 a disability in accomplishing, acquiring the means or 

13 ability to accomplish, maintaining, or enhancing— 

14 (A) activities of daily living; 

15 (B) instrumental activities of daily living; 

16 (C) health-related tasks; or 

17 (D) other functions, tasks, or activities re18 lated to an activity or task described in sub19 paragraph (A), (B), or (C). 

20 (10) LTSS INSURANCE PROVIDER.—The term 

21 ‘‘LTSS insurance provider’’ means a public or pri22 vate entity that— 

23 (A) provides funds for long-term services 

24 and supports; and 


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1 (B) is engaged in commerce or in an in2 dustry or activity affecting commerce. 

3 (11) PUBLIC ENTITY.— 

4 (A) IN GENERAL.—The term ‘‘public enti5 ty’’ means an entity that— 

6 (i) provides or funds institutional 

7 placements for individuals with LTSS dis8 abilities; and 

9 (ii) is— 

10 (I) a State or local government; 

11 or 

12 (II) any department, agency, en13 tity administering a special purpose 

14 district, or other instrumentality, of a 

15 State or local government. 

16 (B) INTERSTATE COMMERCE.—For pur17 poses of subparagraph (A), a public entity shall 

18 be considered to be a person engaged in com19 merce or in an industry or activity affecting 

20 commerce. 

21 (b) RULE OF CONSTRUCTION.—Nothing in sub22 section (a)(2) or any other provision of this section shall 

23 be construed to preclude an individual with a disability 

24 from receiving community-based services and supports in 

25 an integrated community setting such as a grocery store, 


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1 retail establishment, restaurant, bank, park, concert 

2 venue, theater, or workplace. 

3 SEC. 4. DISCRIMINATION. 

4 (a) IN GENERAL.—No public entity or LTSS insur5 ance provider shall deny an individual with an LTSS dis6 ability who is eligible for institutional placement, or other7 wise discriminate against that individual in the provision 

8 of, community-based long-term services and supports that 

9 enable the individual to live in the community and lead 

10 an independent life. 

11 (b) SPECIFIC PROHIBITIONS.—For purposes of this 

12 Act, discrimination by a public entity or LTSS insurance 

13 provider includes— 

14 (1) the imposition or application of eligibility 

15 criteria or another policy that prevents or tends to 

16 prevent an individual with an LTSS disability, or 

17 any class of individuals with LTSS disabilities, from 

18 receiving a community-based long-term service or 

19 support; 

20 (2) the imposition or application of a policy or 

21 other mechanism, such as a service or cost cap, that 

22 prevent or tends to prevent an individual with an 

23 LTSS disability, or any class of individuals with 

24 LTSS disabilities, from receiving a community-based 

25 long-term service or support; 


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1 (3) a failure to provide a specific community2 based long-term service or support or a type of com3 munity-based long-term service or support needed 

4 for an individual with an LTSS disability, or any 

5 class of individuals with LTSS disabilities; 

6 (4) the imposition or application of a policy, 

7 rule, regulation, or restriction that interferes with 

8 the opportunity for an individual with an LTSS dis9 ability, or any class of individuals with LTSS dis10 abilities, to live in the community and lead an inde11 pendent life, which may include a requirement that 

12 an individual with an LTSS disability receive a serv13 ice or support (such as day services or employment 

14 services) in a congregate or disability-specific set15 ting; 

16 (5) the imposition or application of a waiting 

17 list or other mechanism that delays or restricts ac18 cess of an individual with an LTSS disability to a 

19 community-based long-term service or support; 

20 (6) a failure to establish an adequate rate or 

21 other payment structure that is necessary to ensure 

22 the availability of a workforce sufficient to support 

23 an individual with an LTSS disability in living in 

24 the community and leading an independent life; 


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1 (7) a failure to provide community-based serv2 ices and supports, on an intermittent, short-term, or 

3 emergent basis, that assist an individual with an 

4 LTSS disability to live in the community and lead 

5 an independent life; 

6 (8) the imposition or application of a policy, 

7 such as a requirement that an individual utilize in8 formal support, that restricts, limits, or delays the 

9 ability of an individual with an LTSS disability to 

10 secure a community-based long-term service or sup11 port to live in the community or lead an independent 

12 life; 

13 (9) a failure to implement a formal procedure 

14 and a mechanism to ensure that— 

15 (A) individuals with LTSS disabilities are 

16 offered the alternative of community-based 

17 long-term services and supports prior to institu18 tionalization; and 

19 (B) if selected by an individual with an 

20 LTSS disability, the community-based long21 term services and supports described in sub22 paragraph (A) are provided; 

23 (10) a failure to ensure that each institutional24 ized individual with an LTSS disability is regularly 

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1 term services and supports and that those commu2 nity-based long-term services and supports are pro3 vided if the individual with an LTSS disability se4 lects such services and supports; and 

5 (11) a failure to make a reasonable modifica6 tion in a policy, practice, or procedure, when such 

7 modification is necessary to allow an individual with 

8 an LTSS disability to receive a community-based 

9 long-term service or support. 

10 (c) ADDITIONAL PROHIBITION.—For purposes of this 

11 Act, discrimination by a public entity also includes a fail12 ure to ensure that there is sufficient availability of afford13 able, accessible, and integrated housing to allow an indi14 vidual with an LTSS disability to choose to live in the 

15 community and lead an independent life, including the 

16 availability of an option to live in housing where the re17 ceipt of LTSS is not tied to tenancy. 

18 (d) CONSTRUCTION.—Nothing in this section— 

19 (1) shall be construed— 

20 (A) to prevent a public entity or LTSS in21 surance provider from providing community22 based long-term services and supports at a level 

23 that is greater than the level that is required by 

24 this section; or 


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1 (B) to limit the rights of an individual with 

2 a disability under any provision of law other 

3 than this section; 

4 (2) shall be construed to affect the scope of ob5 ligations imposed by any other provision of law; or 

6 (3) shall be construed to prohibit a public entity 

7 or LTSS insurance provider from using managed 

8 care techniques, as long as the use of such tech9 niques does not have the effect of discriminating 

10 against an individual in the provision of community11 based long-term services and supports, as prohibited 

12 by this Act. 

13 SEC. 5. ADMINISTRATION. 

14 (a) AUTHORITY AND RESPONSIBILITY.— 

15 (1) DEPARTMENT OF JUSTICE.—The Attorney 

16 General shall— 

17 (A) investigate and take enforcement ac18 tion for violations of this Act; and 

19 (B) enforce section 6(c). 

20 (2) DEPARTMENT OF HEALTH AND HUMAN

21 SERVICES.—The Secretary of Health and Human 

22 Services, through the Administrator, shall— 

23 (A) conduct studies regarding the nature 

24 and extent of institutionalization of individuals 

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1 munities, including urban, suburban, and rural 

2 communities, throughout the United States; 

3 (B) publish and disseminate reports, rec4 ommendations, and information derived from 

5 such studies, including an annual report to 

6 Congress, specifying— 

7 (i) the nature and extent of progress 

8 in the United States in eliminating institu9 tionalization for individuals with LTSS 

10 disabilities in violation of this Act and fur11 thering the purposes of this Act; 

12 (ii) obstacles that remain in the effort 

13 to achieve the provision of community14 based long-term services and supports for 

15 all individuals with LTSS disabilities; and 

16 (iii) recommendations for further leg17 islative or executive action; 

18 (C) cooperate with, and provide grants for 

19 technical assistance to, Federal, State, and local 

20 public or private agencies and organizations 

21 that are formulating or carrying out programs 

22 to prevent or eliminate institutionalization of 

23 individuals with LTSS disabilities or to promote 

24 the provision of community-based long-term 

25 services and supports; 


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1 (D) implement educational and conciliatory 

2 activities to further the purposes of this Act; 

3 and 

4 (E) refer information on violations of this 

5 Act to the Attorney General for investigation 

6 and enforcement action under this Act. 

7 (b) COOPERATION OF EXECUTIVE DEPARTMENTS

8 AND AGENCIES.—Each Federal agency and, in particular, 

9 each Federal agency covered by Executive Order 13217 

10 (66 Fed. Reg. 33155; relating to community-based alter11 natives for individuals with disabilities), shall carry out 

12 programs and activities relating to the institutionalization 

13 of individuals with LTSS disabilities and the provision of 

14 community-based long-term services and supports for indi15 viduals with LTSS disabilities in accordance with this Act 

16 and shall cooperate with the Attorney General and the Ad17 ministrator to further the purposes of this Act. 

18 SEC. 6. REGULATIONS. 

19 (a) ISSUANCE OF REGULATIONS.—Not later than 24 

20 months after the date of enactment of this Act, the Attor21 ney General and the Secretary of Health and Human 

22 Services shall issue, in accordance with section 553 of title 

23 5, United States Code, final regulations to carry out this 

24 Act, which shall include the regulations described in sub25 section (b). 


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1 (b) REQUIRED CONTENTS OF REGULATIONS.— 

2 (1) ELIGIBLE RECIPIENTS OF SERVICE.—The 

3 regulations shall require each public entity and 

4 LTSS insurance provider to offer, and, if accepted, 

5 provide community-based long-term services and 

6 supports as required under this Act to any indi7 vidual with an LTSS disability who would otherwise 

8 qualify for institutional placement provided or fund9 ed by the public entity or LTSS insurance provider. 

10 (2) SERVICES TO BE PROVIDED.—The regula11 tions issued under this section shall require each 

12 public entity and LTSS insurance provider to pro13 vide the Attorney General and the Administrator 

14 with an assurance that the public entity or LTSS in15 surance provider— 

16 (A) ensures that individuals with LTSS 

17 disabilities receive assistance through hands-on 

18 assistance, training, cueing, and safety moni19 toring, including access to backup systems, 

20 with— 

21 (i) activities of daily living; 

22 (ii) instrumental activities of daily liv23 ing; 

24 (iii) health-related tasks; or 


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1 (iv) other functions, tasks, or activi2 ties related to an activity or task described 

3 in clause (i), (ii), or (iii); 

4 (B) coordinates, conducts, performs, pro5 vides, or funds discharge planning from acute, 

6 rehabilitation, and long-term facilities to pro7 mote individuals with LTSS disabilities living in 

8 the most integrated setting chosen by the indi9 viduals; 

10 (C) issues, conducts, performs, provides, or 

11 funds policies and programs to promote self-di12 rection and the provision of consumer-directed 

13 services and supports for all populations of indi14 viduals with LTSS disabilities served; 

15 (D) issues, conducts, performs, provides, 

16 or funds policies and programs to support infor17 mal caregivers who provide services for individ18 uals with LTSS disabilities; and 

19 (E) ensures that individuals with all types 

20 of LTSS disabilities are able to live in the com21 munity and lead an independent life, including 

22 ensuring that the individuals have maximum 

23 control over the services and supports that the 

24 individuals receive, choose the setting in which 

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1 ports, and exercise control and direction over 

2 their own lives. 

3 (3) PUBLIC PARTICIPATION.— 

4 (A) PUBLIC ENTITY.—The regulations 

5 issued under this section shall require each pub6 lic entity to carry out an extensive public par7 ticipation process in preparing the public enti8 ty’s self-evaluation under paragraph (5) and 

9 transition plan under paragraph (10). 

10 (B) LTSS INSURANCE PROVIDER.—The 

11 regulations issued under this section shall re12 quire each LTSS insurance provider to carry 

13 out a public participation process that involves 

14 holding a public hearing, providing an oppor15 tunity for public comment, and consulting with 

16 individuals with LTSS disabilities, in preparing 

17 the LTSS insurance provider’s self-evaluation 

18 under paragraph (5). 

19 (C) PROCESS.—In carrying out a public 

20 participation process under subparagraph (A) 

21 or (B), a public entity or LTSS insurance pro22 vider shall ensure that the process meets the re23 quirements of subparagraphs (A) and (C) of 

24 section 1115(d)(2) of the Social Security Act 

25 (42 U.S.C. 1315(d)(2)), except that— 


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1 (i) the reference to ‘‘at the State 

2 level’’ shall be disregarded; and 

3 (ii) the reference to an application 

4 shall be considered to be a reference to the 

5 self-evaluation or plan involved. 

6 (4) ADDITIONAL SERVICES AND SUPPORTS.— 

7 The regulations issued under this section shall es8 tablish circumstances under which a public entity 

9 shall provide community-based long-term services 

10 and supports under this section beyond the level of 

11 community-based long-term services and supports 

12 which would otherwise be required under this sub13 section. 

14 (5) SELF-EVALUATION.— 

15 (A) IN GENERAL.—The regulations issued 

16 under this section shall require each public enti17 ty and each LTSS insurance provider, not later 

18 than 30 months after the date of enactment of 

19 this Act, to evaluate current services, policies, 

20 and practices, and the effects thereof, that do 

21 not or may not meet the requirements of this 

22 Act and, to the extent modification of any such 

23 services, policies, and practices is required to 

24 meet the requirements of this Act, make the 


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1 necessary modifications. The self-evaluation 

2 shall include— 

3 (i) collection of baseline information, 

4 including the numbers of individuals with 

5 LTSS disabilities in various institutional 

6 and community-based settings served by 

7 the public entity or LTSS insurance pro8 vider; 

9 (ii) a review of community capacity, in 

10 communities served by the entity or pro11 vider, in providing community-based long12 term services and supports; 

13 (iii) identification of improvements 

14 needed to ensure that all community-based 

15 long-term services and supports provided 

16 by the public entity or LTSS insurance 

17 provider to individuals with LTSS disabil18 ities are comprehensive, are accessible, are 

19 not duplicative of existing (as of the date 

20 of the identification) services and supports, 

21 meet the needs of persons who are likely to 

22 require assistance in order to live, or lead 

23 a life, as described in section 4(a), and are 

24 high-quality services and supports, which 

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1 ments that create an option to self-direct 

2 receipt of such services and supports for 

3 all populations of such individuals served; 

4 and 

5 (iv) a review of funding sources for 

6 community-based long-term services and 

7 supports and an analysis of how those 

8 funding sources could be organized into a 

9 fair, coherent system that affords individ10 uals reasonable and timely access to com11 munity-based long-term services and sup12 ports. 

13 (B) PUBLIC ENTITY.—A public entity, in14 cluding an LTSS insurance provider that is a 

15 public entity, shall— 

16 (i) include in the self-evaluation de17 scribed in subparagraph (A)— 

18 (I) an assessment of the avail19 ability of accessible, affordable trans20 portation across the State involved 

21 and whether transportation barriers 

22 prevent individuals from receiving 

23 long-term services and supports in the 

24 most integrated setting; and 


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1 (II) an assessment of the avail2 ability of integrated employment op3 portunities in the jurisdiction served 

4 by the public entity for individuals 

5 with LTSS disabilities; and 

6 (ii) provide the self-evaluation de7 scribed in subparagraph (A) to the Attor8 ney General and the Administrator. 

9 (C) LTSS INSURANCE PROVIDER.—An 

10 LTSS insurance provider shall keep the self11 evaluation described in subparagraph (A) on 

12 file, and may be required to produce such self13 evaluation in the event of a review, investiga14 tion, or action described in section 8. 

15 (6) ADDITIONAL REQUIREMENT FOR PUBLIC

16 ENTITIES.—The regulations issued under this sec17 tion shall require a public entity, in conjunction with 

18 the housing agencies serving the jurisdiction served 

19 by the public entity, to review and improve commu20 nity capacity, in all communities throughout the en21 tirety of that jurisdiction, in providing affordable, 

22 accessible, and integrated housing, including an eval23 uation of available units, unmet need, and other 

24 identifiable barriers to the provision of that housing. 


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1 In carrying out that improvement, the public entity, 

2 in conjunction with such housing agencies, shall— 

3 (A) ensure, and assure the Administrator 

4 and the Attorney General that there is, suffi5 cient availability of affordable, accessible, and 

6 integrated housing in a setting that is not a dis7 ability-specific residential setting or a setting 

8 where services are tied to tenancy, in order to 

9 provide individuals with LTSS disabilities a 

10 meaningful choice in their housing; 

11 (B) in order to address the need for af12 fordable, accessible, and integrated housing— 

13 (i) in the case of such a housing agen14 cy, establish relationships with State and 

15 local housing authorities; and 

16 (ii) in the case of the public entity, es17 tablish relationships with State and local 

18 housing agencies, including housing au19 thorities; 

20 (C) establish, where needed, necessary 

21 preferences and set-asides in housing programs 

22 for individuals with LTSS disabilities who are 

23 transitioning from or avoiding institutional 

24 placement; 


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1 (D) establish a process to fund necessary 

2 home modifications so that individuals with 

3 LTSS disabilities can live independently; and 

4 (E) ensure, and assure the Administrator 

5 and the Attorney General, that funds and pro6 grams implemented or overseen by the public 

7 entity or in the public entity’s jurisdiction are 

8 targeted toward affordable, accessible, inte9 grated housing for individuals with an LTSS 

10 disability who have the lowest income levels in 

11 the jurisdiction as a priority over any other de12 velopment until capacity barriers for such hous13 ing are removed or unmet needs for such hous14 ing have been met. 

15 (7) DESIGNATION OF RESPONSIBLE EM16 PLOYEE.—The regulations issued under this section 

17 shall require each public entity and LTSS insurance 

18 provider to designate at least one employee to co19 ordinate the entity’s or provider’s efforts to comply 

20 with and carry out the entity or provider’s respon21 sibilities under this Act, including the investigation 

22 of any complaint communicated to the entity or pro23 vider that alleges a violation of this Act. Each public 

24 entity and LTSS insurance provider shall make 

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1 fice address, and telephone number of the employee 

2 designated pursuant to this paragraph. 

3 (8) GRIEVANCE PROCEDURES.—The regulations 

4 issued under this section shall require public entities 

5 and LTSS insurance providers to adopt and publish 

6 grievance procedures providing for prompt and equi7 table resolution of complaints alleging a violation of 

8 this Act. 

9 (9) PROVISION OF SERVICE BY OTHERS.—The 

10 regulations issued under this section shall require 

11 each public entity submitting a self-evaluation under 

12 paragraph (5) to identify, as part of the transition 

13 plan described in paragraph (10), any other entity 

14 that is, or acts as, an agent, subcontractor, or other 

15 instrumentality of the public entity with regards to 

16 a service, support, policy, or practice described in 

17 such plan or self-evaluation. 

18 (10) TRANSITION PLANS.—The regulations 

19 issued under this section shall require each public 

20 entity, not later than 42 months after the date of 

21 enactment of this Act, to submit to the Adminis22 trator, and begin implementing, a transition plan for 

23 carrying out this Act that establishes the achieve24 ment of the requirements of this Act, as soon as 

25 practicable, but in no event later than 12 years after 


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1 the date of enactment of this Act. The transition 

2 plan shall— 

3 (A) establish measurable objectives to ad4 dress the barriers to community living identified 

5 in the self-evaluation under paragraph (5); 

6 (B) establish specific annual targets for 

7 the transition of individuals with LTSS disabil8 ities, and shifts in funding, from institutional 

9 settings to integrated community-based services 

10 and supports, and related programs; 

11 (C) describe specific efforts to support in12 dividuals with LTSS disabilities to avoid un13 wanted institutionalization through the provi14 sion of LTSS; and 

15 (D) describe the manner in which the pub16 lic entity has obtained or plans to obtain nec17 essary funding and resources needed for imple18 mentation of the plan (regardless of whether 

19 the entity began carrying out the objectives of 

20 this Act prior to the date of enactment of this 

21 Act). 

22 (11) ANNUAL REPORTING.— 

23 (A) IN GENERAL.—The regulations issued 

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1 ing requirements for each public entity covered 

2 by this section. 

3 (B) PROGRESS ON OBJECTIVES, TARGETS, 

4 AND EFFORTS.—The regulations issued under 

5 this section shall require each public entity that 

6 has submitted a transition plan to submit to the 

7 Administrator an annual report on the progress 

8 the public entity has made during the previous 

9 year in meeting the measurable objectives, spe10 cific annual targets, and specific efforts de11 scribed in paragraph (10). 

12 (12) OTHER PROVISIONS.—The regulations 

13 issued under this section shall include such other 

14 provisions and requirements as the Attorney General 

15 and the Secretary of Health and Human Services 

16 determine are necessary to carry out the objectives 

17 of this Act. 

18 (c) REVIEW OF TRANSITION PLANS.— 

19 (1) GENERAL RULE.—The Administrator shall 

20 review a transition plan submitted in accordance 

21 with subsection (b)(10) for the purpose of deter22 mining whether such plan meets the requirements of 

23 this Act, including the regulations issued under this 

24 section. 


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1 (2) DISAPPROVAL.—If the Administrator deter2 mines that a transition plan reviewed under this 

3 subsection fails to meet the requirements of this Act, 

4 the Administrator shall disapprove the transition 

5 plan and notify the public entity that submitted the 

6 transition plan of, and the reasons for, such dis7 approval. 

8 (3) MODIFICATION OF DISAPPROVED PLAN.— 

9 Not later than 90 days after the date of disapproval 

10 of a transition plan under this subsection, the public 

11 entity that submitted the transition plan shall mod12 ify the transition plan to meet the requirements of 

13 this section and shall submit to the Administrator, 

14 and commence implementation of, such modified 

15 transition plan. 

16 (4) INCENTIVES.— 

17 (A) DETERMINATION.—For 10 years after 

18 the issuance of the regulations described in sub19 section (a), the Secretary of Health and Human 

20 Services shall annually determine whether each 

21 State, or each other public entity in the State, 

22 is complying with the transition plan or modi23 fied transition plan the State or other public 

24 entity submitted, and obtained approval for, 

25 under this section. Notwithstanding any other 


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1 provision of law, if the Secretary of Health and 

2 Human Services determines under this subpara3 graph that the State or other public entity is 

4 complying with the corresponding transition 

5 plan, the Secretary shall make the increase de6 scribed in subparagraph (B). 

7 (B) INCREASE IN FMAP.—On making the 

8 determination described in subparagraph (A) 

9 for a public entity (including a State), the Sec10 retary of Health and Human Services shall, as 

11 described in subparagraph (C), increase by 5 

12 percentage points the FMAP (but shall in no 

13 event increase the FMAP above 100 percent) 

14 for the State in which the public entity is lo15 cated for amounts expended by the State for 

16 medical assistance consisting of home and com17 munity-based services furnished under the State 

18 Medicaid plan under title XIX of the Social Se19 curity Act (42 U.S.C. 1396 et seq.) or a waiver 

20 of such plan— 

21 (i) that— 

22 (I) are identified by a public enti23 ty or LTSS insurance provider under 

24 subsection (b)(5)(A)(iii); 


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1 (II) resulted from shifts in fund2 ing identified by a public entity under 

3 subsection (b)(10)(B); or 

4 (III) are environmental modifica5 tions to achieve the affordable, acces6 sible, integrated housing identified by 

7 a public entity under subsection 

8 (b)(6)(E); and 

9 (ii) are described by the State in a re10 quest to the Secretary of Health and 

11 Human Services for the increase. 

12 (C) PERIOD OF INCREASE.—The Secretary 

13 of Health and Human Services shall increase 

14 the FMAP described in subparagraph (B)— 

15 (i) beginning with the first quarter 

16 that begins after the date of the deter17 mination; and 

18 (ii) ending with the quarter in which 

19 the next annual determination under sub20 paragraph (A) occurs. 

21 (D) ADDITIONAL CONDITION FOR PAY22 MENT.— 

23 (i) STATE REPORT.—As a condition 

24 for the receipt of a payment based on an 

25 increase described in subparagraph (B) 


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1 with respect to amounts to be expended by 

2 the State for medical assistance consisting 

3 of home and community-based services de4 scribed in subparagraph (B), the State 

5 shall report to the Secretary, for the re6 porting year, the amount of funds ex7 pended by the State for home and commu8 nity-based services (as defined in subpara9 graph (E)(ii)) in that year. The State shall 

10 make the report in a format developed or 

11 approved by the Secretary. 

12 (ii) REDUCTION IN PAYMENT IF FAIL13 URE TO MAINTAIN EFFORT.—If the 

14 amount reported under clause (i) by a 

15 State with respect to a reporting year is 

16 less than the amount reported under clause 

17 (i) with respect to the previous fiscal year 

18 or fiscal year 2019, whichever was the 

19 greater reported amount, the Secretary 

20 shall provide for a reduction in the pay21 ment to the State based on the increase. 

22 (E) DEFINITIONS.—In this paragraph: 

23 (i) FMAP.—The term ‘‘FMAP’’ 

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1 tion 1905(b) of the Social Security Act (42 

2 U.S.C. 1396d(b)) without regard to any in3 creases in that percentage applicable under 

4 other subsections of that section or any 

5 other provision of law, including this sec6 tion. 

7 (ii) HOME AND COMMUNITY-BASED

8 SERVICES DEFINED.—The term ‘‘home and 

9 community-based services’’ means any of 

10 the following services provided under a 

11 State Medicaid plan under title XIX of the 

12 Social Security Act (42 U.S.C. 1396 et 

13 seq.) or a waiver of such plan: 

14 (I) Home and community-based 

15 services provided under subsection (c), 

16 (d), or (i) of section 1915 of the So17 cial Security Act (42 U.S.C. 1396n). 

18 (II) Home health care services. 

19 (III) Personal care services. 

20 (IV) Services described in section 

21 1905(a)(26) of the Social Security Act 

22 (42 U.S.C. 1396d(a)(26)) (relating to 

23 PACE program services). 

24 (V) Self-directed personal assist25 ance services provided in accordance 


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1 with section 1915(j) of the Social Se2 curity Act (42 U.S.C. 1396n(j)). 

3 (VI) Community-based attendant 

4 services and supports provided in ac5 cordance with section 1915(k) of the 

6 Social Security Act (42 U.S.C. 

7 1396n(k)). 

8 (VII) Rehabilitative services, 

9 within the meaning of section 

10 1905(a)(13) of the Social Security Act 

11 (42 U.S.C. 1396d(a)(13)). 

12 (iii) REPORTING YEAR.—The term 

13 ‘‘reporting year’’ means the most recent 

14 fiscal year preceding the date of a report 

15 under subparagraph (D)(i). 

16 (d) RULE OF CONSTRUCTION.—Nothing in sub17 section (b)(10) or (c) or any other provision of this Act 

18 shall be construed to limit the rights, protections, or re19 quirements of any other Federal law, relating to integra20 tion of individuals with disabilities into the community and 

21 enabling those individuals to live in the most integrated 

22 setting. 

23 SEC. 7. EXEMPTIONS FOR RELIGIOUS ORGANIZATIONS. 

24 This Act shall not prohibit a religious organization, 

25 association, or society from giving preference in providing 


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1 community-based long-term services and supports to indi2 viduals of a particular religion connected with the beliefs 

3 of such organization, association, or society. 

4 SEC. 8. ENFORCEMENT. 

5 (a) CIVIL ACTION.— 

6 (1) IN GENERAL.—A civil action for preventive 

7 relief, including an application for a permanent or 

8 temporary injunction, restraining order, or other 

9 order, may be instituted by an individual described 

10 in paragraph (2) in an appropriate Federal district 

11 court. 

12 (2) AGGRIEVED INDIVIDUAL.— 

13 (A) IN GENERAL.—The remedies and pro14 cedures set forth in this section are the rem15 edies and procedures this Act provides to any 

16 individual who is being subjected to a violation 

17 of this Act, or who has reasonable grounds for 

18 believing that such individual is about to be 

19 subjected to such a violation. 

20 (B) STANDING.—An individual with a dis21 ability shall have standing to institute a civil ac22 tion under this subsection if the individual 

23 makes a prima facie showing that the indi24 vidual— 


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1 (i) is an individual with an LTSS dis2 ability; and 

3 (ii) is being subjected to, or about to 

4 be subjected to, such a violation (including 

5 a violation of section 4(b)(11)). 

6 (3) APPOINTMENT OF ATTORNEY; NO FEES, 

7 COSTS, OR SECURITY.—Upon application by the 

8 complainant described in paragraph (2) and in such 

9 circumstances as the court may determine to be just, 

10 the court may appoint an attorney for the complain11 ant and may authorize the commencement of such 

12 civil action without the payment of fees, costs, or se13 curity. 

14 (4) FUTILE GESTURE NOT REQUIRED.—Noth15 ing in this section shall require an individual with an 

16 LTSS disability to engage in a futile gesture if such 

17 person has actual notice that a public entity or 

18 LTSS insurance provider does not intend to comply 

19 with the provisions of this Act. 

20 (b) DAMAGES AND INJUNCTIVE RELIEF.—If the 

21 court finds that a violation of this Act has occurred or 

22 is about to occur, the court may award to the complain23 ant— 

24 (1) actual and punitive damages; 


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1 (2) immediate injunctive relief to prevent insti2 tutionalization; 

3 (3) as the court determines to be appropriate, 

4 any permanent or temporary injunction (including 

5 an order to immediately provide or maintain commu6 nity-based long-term services or supports for an in7 dividual to prevent institutionalization or further in8 stitutionalization), temporary restraining order, or 

9 other order (including an order enjoining the defend10 ant from engaging in a practice that violates this 

11 Act or ordering such affirmative action as may be 

12 appropriate); and 

13 (4) in an appropriate case, injunctive relief to 

14 require the modification of a policy, practice, or pro15 cedure, or the provision of an alternative method of 

16 providing LTSS, to the extent required by this Act. 

17 (c) ATTORNEY’S FEES; LIABILITY OF UNITED

18 STATES FOR COSTS.—In any action commenced pursuant 

19 to this Act, the court, in its discretion, may allow the party 

20 bringing a claim or counterclaim under this Act, other 

21 than the United States, a reasonable attorney’s fee as part 

22 of the costs, and the United States shall be liable for costs 

23 to the same extent as a private person. 

24 (d) ENFORCEMENT BY ATTORNEY GENERAL.— 

25 (1) DENIAL OF RIGHTS.— 


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1 (A) DUTY TO INVESTIGATE.—The Attor2 ney General shall investigate alleged violations 

3 of this Act, and shall undertake periodic reviews 

4 of the compliance of public entities and LTSS 

5 insurance providers under this Act. 

6 (B) POTENTIAL VIOLATION.—The Attor7 ney General may commence a civil action in any 

8 appropriate Federal district court if the Attor9 ney General has reasonable cause to believe 

10 that— 

11 (i) any public entity or LTSS insur12 ance provider, including a group of public 

13 entities or LTSS insurance providers, is 

14 engaged in a pattern or practice of viola15 tions of this Act; or 

16 (ii) any individual, including a group, 

17 has been subjected to a violation of this 

18 Act and the violation raises an issue of 

19 general public importance. 

20 (2) AUTHORITY OF COURT.—In a civil action 

21 under paragraph (1)(B), the court— 

22 (A) may grant any equitable relief that 

23 such court considers to be appropriate, includ24 ing, to the extent required by this Act— 


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1 (i) granting temporary, preliminary, 

2 or permanent relief; and 

3 (ii) requiring the modification of a 

4 policy, practice, or procedure, or the provi5 sion of an alternative method of providing 

6 LTSS; 

7 (B) may award such other relief as the 

8 court considers to be appropriate, including 

9 damages to individuals described in subsection 

10 (a)(2), when requested by the Attorney General; 

11 and 

12 (C) may, to vindicate the public interest, 

13 assess a civil penalty against the public entity 

14 or LTSS insurance provider in an amount— 

15 (i) not exceeding $100,000 for a first 

16 violation; and 

17 (ii) not exceeding $200,000 for any 

18 subsequent violation. 

19 (3) SINGLE VIOLATION.—For purposes of para20 graph (2)(C), in determining whether a first or sub21 sequent violation has occurred, a determination in a 

22 single action, by judgment or settlement, that the 

23 public entity or LTSS insurance provider has en24 gaged in more than one violation of this Act shall be 

25 counted as a single violation. 


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1 SEC. 9. CONSTRUCTION. 

2 For purposes of construing this Act— 

3 (1) section 4(b)(11) shall be construed in a 

4 manner that takes into account its similarities with 

5 section 302(b)(2)(A)(ii) of the Americans with Dis6 abilities Act of 1990 (42 U.S.C. 12182(b)(2)(A)(ii)); 

7 (2) the first sentence of section 6(b)(5)(A) shall 

8 be construed in a manner that takes into account its 

9 similarities with section 35.105(a) of title 28, Code 

10 of Federal Regulations (as in effect on the day be11 fore the date of enactment of this Act); 

12 (3) section 7 shall be construed in a manner 

13 that takes into account its similarities with section 

14 807(a) of the Civil Rights Act of 1968 (42 U.S.C. 

15 3607(a)); 

16 (4) section 8(a)(2) shall be construed in a man17 ner that takes into account its similarities with sec18 tion 308(a)(1) of the Americans with Disabilities 

19 Act of 1990 (42 U.S.C. 12188(a)(1)); and 

20 (5) section 8(d)(1)(B) shall be construed in a 

21 manner that takes into account its similarities with 

22 section 308(b)(1)(B) of the Americans with Disabil23 ities Act of 1990 (42 U.S.C. 12188(b)(1)(B)). 

Æ 


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