based attendant services and supports in order to 
assist individuals in achieving equal opportunity, full 
participation, independent living, and economic self- 
sufficiency. 
(2) To provide financial assistance to States as 
they reform their long-term care systems to provide 
comprehensive statewide long-term services and sup-
ports, including community-based attendant services 
and supports that provide consumer choice and di-
rection, in the most integrated setting appropriate. 
(3) To assist States in meeting the growing de-
mand for community-based attendant services and 
supports, as the Nation’s population ages and indi-
viduals with disabilities live longer. 
(4) To assist States in complying with the U.S. 
Supreme Court decision in Olmstead v. L.C., 527 
U.S. 581 (1999), and implementing the integration 
mandate of the Americans with Disabilities Act. 
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TITLE I—ESTABLISHMENT OF 
MEDICAID PLAN BENEFIT 
SEC. 101. COVERAGE OF COMMUNITY-BASED ATTENDANT 
SERVICES AND SUPPORTS UNDER THE MED-
ICAID PROGRAM. 
(a) 
MANDATORY
COVERAGE.—Section 
1902(a)(10)(D) of the Social Security Act (42 U.S.C. 
1396a(a)(10)(D)) is amended— 
(1) by inserting ‘‘(i)’’ after ‘‘(D)’’; 
(2) by adding ‘‘and’’ after the semicolon; and 
(3) by adding at the end the following new 
clause: 
‘‘(ii) subject to section 1943, for the 
inclusion of community-based attendant 
services and supports for any individual 
who— 
‘‘(I) is eligible for medical assist-
ance under the State plan; 
‘‘(II) with respect to whom there 
has been a determination that the in-
dividual requires the level of care pro-
vided in a nursing facility, institution 
for mental diseases, or an inter-
mediate care facility for the mentally 
retarded (whether or not coverage of 
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such institution or intermediate care 
facility is provided under the State 
plan); and 
‘‘(III) chooses to receive such 
services and supports;’’. 
(b) COMMUNITY-BASED ATTENDANT SERVICES AND 
SUPPORTS.— 
(1) IN GENERAL.—Title XIX of the Social Se-
curity Act (42 U.S.C. 1396 et seq.) is amended by 
adding at the end the following new section: 
‘‘COMMUNITY-BASED ATTENDANT SERVICES AND 
SUPPORTS 
‘‘SEC. 1943. (a) REQUIRED COVERAGE.— 
‘‘(1) IN GENERAL.—Not later than October 1, 
2014, a State shall provide through a plan amend-
ment for the inclusion of community-based attendant 
services and supports (as defined in subsection 
(g)(1)) 
for 
individuals 
described 
in 
section 
1902(a)(10)(D)(ii) in accordance with this section. 
‘‘(2) ENHANCED FMAP AND ADDITIONAL FED-
ERAL
FINANCIAL
SUPPORT
FOR
EARLIER
COV-
ERAGE.—Notwithstanding section 1905(b), during 
the period that begins on October 1, 2009, and ends 
on September 30, 2014, in the case of a State with 
an approved plan amendment under this section dur-
ing that period that also satisfies the requirements 
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of subsection (c) the Federal medical assistance per-
centage shall be equal to the enhanced FMAP de-
scribed in section 2105(b) with respect to medical 
assistance in the form of community-based attendant 
services and supports provided to individuals de-
scribed in section 1902(a)(10)(D)(ii) in accordance 
with this section on or after the date of the approval 
of such plan amendment. 
‘‘(b) DEVELOPMENT AND IMPLEMENTATION OF BEN-
EFIT.—In order for a State plan amendment to be ap-
proved under this section, a State shall provide the Sec-
retary with the following assurances: 
‘‘(1) ASSURANCE OF DEVELOPMENT AND IM-
PLEMENTATION COLLABORATION.— 
‘‘(A) IN
GENERAL.—That State plan 
amendment— 
‘‘(i) has been developed in collabora-
tion with, and with the approval of, a De-
velopment and Implementation Council es-
tablished by the State that satisfies the re-
quirements of subparagraph (B); and 
‘‘(ii) will be implemented in collabora-
tion with such Council and on the basis of 
public input solicited by the State and the 
Council. 
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‘‘(B) DEVELOPMENT
AND
IMPLEMENTA-
TION COUNCIL REQUIREMENTS.—For purposes 
of subparagraph (A), the requirements of this 
subparagraph are that— 
‘‘(i) the majority of the members of 
the 
Development 
and 
Implementation 
Council are individuals with disabilities, el-
derly individuals, and their representatives; 
and 
‘‘(ii) in carrying out its responsibil-
ities, the Council actively collaborates 
with— 
‘‘(I) individuals with disabilities; 
‘‘(II) elderly individuals; 
‘‘(III) representatives of such in-
dividuals; and 
‘‘(IV) providers of, and advocates 
for, services and supports for such in-
dividuals. 
‘‘(2) ASSURANCE OF PROVISION ON A STATE-
WIDE BASIS AND IN MOST INTEGRATED SETTING.— 
That consumer controlled community-based attend-
ant services and supports will be provided under the 
State plan to individuals described in section 
1902(a)(10)(D)(ii) on a statewide basis and in a 
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manner that provides such services and supports in 
the most integrated setting appropriate to the indi-
vidual’s needs. 
‘‘(3) ASSURANCE
OF
NONDISCRIMINATION.— 
That the State will provide community-based attend-
ant services and supports to an individual described 
in section 1902(a)(10)(D)(ii) without regard to the 
individual’s age, type or nature of disability, severity 
of disability, or the form of community-based attend-
ant services and supports that the individual re-
quires in order to lead an independent life. 
‘‘(4) ASSURANCE
OF
MAINTENANCE
OF
EF-
FORT.—That the level of State expenditures for 
medical assistance that is provided under section 
1905(a), section 1915, section 1115, or otherwise to 
individuals with disabilities or elderly individuals for 
a fiscal year shall not be less than the level of such 
expenditures for the fiscal year preceding the first 
full fiscal year in which the State plan amendment 
to provide community-based attendant services and 
supports in accordance with this section is imple-
mented. 
‘‘(c) REQUIREMENTS FOR ENHANCED FMAP FOR 
EARLY COVERAGE.—In addition to satisfying the other re-
quirements for an approved plan amendment under this 
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section, in order for a State to be eligible under subsection 
(a)(2) during the period described in that subsection for 
the enhanced FMAP for early coverage under subsection 
(a)(2), the State shall satisfy the following requirements: 
‘‘(1) SPECIFICATIONS.—With respect to a fiscal 
year, the State shall provide the Secretary with the 
following specifications regarding the provision of 
community-based attendant services and supports 
under the plan for that fiscal year: 
‘‘(A)(i) The number of individuals who are 
estimated to receive community-based attendant 
services and supports under the plan during the 
fiscal year. 
‘‘(ii) The number of individuals that re-
ceived such services and supports during the 
preceding fiscal year. 
‘‘(B) The maximum number of individuals 
who will receive such services and supports 
under the plan during that fiscal year. 
‘‘(C) The procedures the State will imple-
ment to ensure that the models for delivery of 
such services and supports are consumer con-
trolled (as defined in subsection (g)(2)(B)). 
‘‘(D) The procedures the State will imple-
ment to inform all potentially eligible individ-
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uals and relevant other individuals of the avail-
ability of such services and supports under this 
title, and of other items and services that may 
be provided to the individual under this title or 
title XVIII and other Federal or State long- 
term service and support programs. 
‘‘(E) The procedures the State will imple-
ment to ensure that such services and supports 
are provided in accordance with the require-
ments of subsection (b)(1). 
‘‘(F) The procedures the State will imple-
ment to actively involve in a systematic, com-
prehensive, and ongoing basis, the Development 
and Implementation Council established in ac-
cordance with subsection (b)(1)(A)(ii), individ-
uals with disabilities, elderly individuals, and 
representatives of such individuals in the de-
sign, delivery, administration, implementation, 
and evaluation of the provision of such services 
and supports under this title. 
‘‘(2) PARTICIPATION
IN
EVALUATIONS.—The 
State shall provide the Secretary with such sub-
stantive input into, and participation in, the design 
and conduct of data collection, analyses, and other 
qualitative or quantitative evaluations of the provi-
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sion of community-based attendant services and sup-
ports under this section as the Secretary deems nec-
essary in order to determine the effectiveness of the 
provision of such services and supports in allowing 
the individuals receiving such services and supports 
to lead an independent life to the maximum extent 
possible. 
‘‘(d) QUALITY ASSURANCE.— 
‘‘(1) STATE RESPONSIBILITIES.—In order for a 
State plan amendment to be approved under this 
section, a State shall establish and maintain a com-
prehensive, continuous quality assurance system 
with respect to community-based attendant services 
and supports that provides for the following: 
‘‘(A) The State shall establish require-
ments, as appropriate, for agency-based and 
other delivery models that include— 
‘‘(i) minimum qualifications and train-
ing requirements for agency-based and 
other models; 
‘‘(ii) financial operating standards; 
and 
‘‘(iii) an appeals procedure for eligi-
bility denials and a procedure for resolving 
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disagreements over the terms of an individ-
ualized plan. 
‘‘(B) The State shall modify the quality as-
surance system, as appropriate, to maximize 
consumer independence and consumer control 
in both agency-provided and other delivery mod-
els. 
‘‘(C) The State shall provide a system that 
allows for the external monitoring of the quality 
of services and supports by entities consisting 
of consumers and their representatives, dis-
ability organizations, providers, families of dis-
abled or elderly individuals, members of the 
community, and others. 
‘‘(D) The State shall provide for ongoing 
monitoring of the health and well-being of each 
individual who receives community-based at-
tendant services and supports. 
‘‘(E) The State shall require that quality 
assurance mechanisms pertaining to the indi-
vidual be included in the individual’s written 
plan. 
‘‘(F) The State shall establish a process 
for the mandatory reporting, investigation, and 
resolution of allegations of neglect, abuse, or ex-
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ploitation in connection with the provision of 
such services and supports. 
‘‘(G) The State shall obtain meaningful 
consumer input, including consumer surveys, 
that measure the extent to which an individual 
receives the services and supports described in 
the individual’s plan and the individual’s satis-
faction with such services and supports. 
‘‘(H) The State shall make available to the 
public the findings of the quality assurance sys-
tem. 
‘‘(I) The State shall establish an ongoing 
public process for the development, implementa-
tion, and review of the State’s quality assurance 
system. 
‘‘(J) The State shall develop and imple-
ment a program of sanctions for providers of 
community-based services and supports that 
violate the terms or conditions for the provision 
of such services and supports. 
‘‘(2) FEDERAL RESPONSIBILITIES.— 
‘‘(A) PERIODIC EVALUATIONS.—The Sec-
retary shall conduct a periodic sample review of 
outcomes for individuals who receive commu-
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nity-based attendant services and supports 
under this title. 
‘‘(B) 
INVESTIGATIONS.—The 
Secretary 
may conduct targeted reviews and investiga-
tions upon receipt of an allegation of neglect, 
abuse, or exploitation of an individual receiving 
community-based attendant services and sup-
ports under this section. 
‘‘(C) DEVELOPMENT OF PROVIDER SANC-
TION
GUIDELINES.—The Secretary shall de-
velop guidelines for States to use in developing 
the sanctions required under paragraph (1)(J). 
‘‘(e) REPORTS.—The Secretary shall submit to Con-
gress periodic reports on the provision of community-based 
attendant services and supports under this section, par-
ticularly with respect to the impact of the provision of 
such services and supports on— 
‘‘(1) individuals eligible for medical assistance 
under this title; 
‘‘(2) States; and 
‘‘(3) the Federal Government. 
‘‘(f) NO EFFECT ON ABILITY TO PROVIDE COV-
ERAGE.— 
‘‘(1) IN
GENERAL.—Nothing in this section 
shall be construed as affecting the ability of a State 
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