(A) to prevent a public entity or LTSS in-
surance provider from providing community- 
based long-term services and supports at a level 
that is greater than the level that is required by 
this section; or 
(B) to limit the rights of an individual with 
a disability under any provision of law other 
than this section; 
(2) shall be construed to affect the scope of ob-
ligations imposed by any other provision of law; or 
(3) shall be construed to prohibit a public entity 
or LTSS insurance provider from using managed 
care techniques, as long as the use of such tech-
niques does not have the effect of discriminating 
against an individual in the provision of community- 
based long-term services and supports, as prohibited 
by this Act. 
SEC. 5. ADMINISTRATION. 
(a) AUTHORITY AND RESPONSIBILITY.— 
(1) DEPARTMENT OF JUSTICE.—The Attorney 
General shall— 
(A) investigate and take enforcement ac-
tion for violations of this Act; and 
(B) enforce section 6(c). 
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(2) DEPARTMENT
OF
HEALTH
AND
HUMAN 
SERVICES.—The Secretary of Health and Human 
Services, through the Administrator, shall— 
(A) conduct studies regarding the nature 
and extent of institutionalization of individuals 
with LTSS disabilities in representative com-
munities, including urban, suburban, and rural 
communities, throughout the United States; 
(B) publish and disseminate reports, rec-
ommendations, and information derived from 
such studies, including an annual report to 
Congress, specifying— 
(i) the nature and extent of progress 
in the United States in eliminating institu-
tionalization for individuals with LTSS 
disabilities in violation of this Act and fur-
thering the purposes of this Act; 
(ii) obstacles that remain in the effort 
to achieve the provision of community- 
based long-term services and supports for 
all individuals with LTSS disabilities; and 
(iii) recommendations for further leg-
islative or executive action; 
(C) cooperate with, and provide grants for 
technical assistance to, Federal, State, and local 
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public or private agencies and organizations 
that are formulating or carrying out programs 
to prevent or eliminate institutionalization of 
individuals with LTSS disabilities or to promote 
the provision of community-based long-term 
services and supports; 
(D) implement educational and conciliatory 
activities to further the purposes of this Act; 
and 
(E) refer information on violations of this 
Act to the Attorney General for investigation 
and enforcement action under this Act. 
(b) COOPERATION
OF EXECUTIVE DEPARTMENTS 
AND AGENCIES.—Each Federal agency and, in particular, 
each Federal agency covered by Executive Order 13217 
(66 Fed. Reg. 33155; relating to community-based alter-
natives for individuals with disabilities), shall carry out 
programs and activities relating to the institutionalization 
of individuals with LTSS disabilities and the provision of 
community-based long-term services and supports for indi-
viduals with LTSS disabilities in accordance with this Act 
and shall cooperate with the Attorney General and the Ad-
ministrator to further the purposes of this Act. 
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SEC. 6. REGULATIONS. 
(a) ISSUANCE OF REGULATIONS.—Not later than 24 
months after the date of enactment of this Act, the Attor-
ney General and the Secretary of Health and Human 
Services shall issue, in accordance with section 553 of title 
5, United States Code, final regulations to carry out this 
Act, which shall include the regulations described in sub-
section (b). 
(b) REQUIRED CONTENTS OF REGULATIONS.— 
(1) ELIGIBLE RECIPIENTS OF SERVICE.—The 
regulations shall require each public entity and 
LTSS insurance provider to offer, and, if accepted, 
provide community-based long-term services and 
supports as required under this Act to any indi-
vidual with an LTSS disability who would otherwise 
qualify for institutional placement provided or fund-
ed by the public entity or LTSS insurance provider. 
(2) SERVICES TO BE PROVIDED.—The regula-
tions issued under this section shall require each 
public entity and LTSS insurance provider to pro-
vide the Attorney General and the Administrator 
with an assurance that the public entity or LTSS in-
surance provider— 
(A) ensures that individuals with LTSS 
disabilities receive assistance through hands-on 
assistance, training, cueing, and safety moni-
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toring, including access to backup systems, 
with— 
(i) activities of daily living; 
(ii) instrumental activities of daily liv-
ing; 
(iii) health-related tasks; or 
(iv) other functions, tasks, or activi-
ties related to an activity or task described 
in clause (i), (ii), or (iii); 
(B) coordinates, conducts, performs, pro-
vides, or funds discharge planning from acute, 
rehabilitation, and long-term facilities to pro-
mote individuals with LTSS disabilities living in 
the most integrated setting chosen by the indi-
viduals; 
(C) issues, conducts, performs, provides, or 
funds policies and programs to promote self-di-
rection and the provision of consumer-directed 
services and supports for all populations of indi-
viduals with LTSS disabilities served; 
(D) issues, conducts, performs, provides, 
or funds policies and programs to support infor-
mal caregivers who provide services for individ-
uals with LTSS disabilities; and 
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(E) ensures that individuals with all types 
of LTSS disabilities are able to live in the com-
munity and lead an independent life, including 
ensuring that the individuals have maximum 
control over the services and supports that the 
individuals receive, choose the setting in which 
the individuals receive those services and sup-
ports, and exercise control and direction over 
their own lives. 
(3) PUBLIC PARTICIPATION.— 
(A) PUBLIC
ENTITY.—The regulations 
issued under this section shall require each pub-
lic entity to carry out an extensive public par-
ticipation process in preparing the public enti-
ty’s self-evaluation under paragraph (5) and 
transition plan under paragraph (10). 
(B) LTSS INSURANCE
PROVIDER.—The 
regulations issued under this section shall re-
quire each LTSS insurance provider to carry 
out a public participation process that involves 
holding a public hearing, providing an oppor-
tunity for public comment, and consulting with 
individuals with LTSS disabilities, in preparing 
the LTSS insurance provider’s self-evaluation 
under paragraph (5). 
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(C) PROCESS.—In carrying out a public 
participation process under subparagraph (A) 
or (B), a public entity or LTSS insurance pro-
vider shall ensure that the process meets the re-
quirements of subparagraphs (A) and (C) of 
section 1115(d)(2) of the Social Security Act 
(42 U.S.C. 1315(d)(2)), except that— 
(i) the reference to ‘‘at the State 
level’’ shall be disregarded; and 
(ii) the reference to an application 
shall be considered to be a reference to the 
self-evaluation or plan involved. 
(4) ADDITIONAL SERVICES AND SUPPORTS.— 
The regulations issued under this section shall es-
tablish circumstances under which a public entity 
shall provide community-based long-term services 
and supports under this section beyond the level of 
community-based long-term services and supports 
which would otherwise be required under this sub-
section. 
(5) SELF-EVALUATION.— 
(A) IN GENERAL.—The regulations issued 
under this section shall require each public enti-
ty and each LTSS insurance provider, not later 
than 30 months after the date of enactment of 
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this Act, to evaluate current services, policies, 
and practices, and the effects thereof, that do 
not or may not meet the requirements of this 
Act and, to the extent modification of any such 
services, policies, and practices is required to 
meet the requirements of this Act, make the 
necessary modifications. The self-evaluation 
shall include— 
(i) collection of baseline information, 
including the numbers of individuals with 
LTSS disabilities in various institutional 
and community-based settings served by 
the public entity or LTSS insurance pro-
vider; 
(ii) a review of community capacity, in 
communities served by the entity or pro-
vider, in providing community-based long- 
term services and supports; 
(iii) identification of improvements 
needed to ensure that all community-based 
long-term services and supports provided 
by the public entity or LTSS insurance 
provider to individuals with LTSS disabil-
ities are comprehensive, are accessible, are 
not duplicative of existing (as of the date 
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of the identification) services and supports, 
meet the needs of persons who are likely to 
require assistance in order to live, or lead 
a life, as described in section 4(a), and are 
high-quality services and supports, which 
may include identifying system improve-
ments that create an option to self-direct 
receipt of such services and supports for 
all populations of such individuals served; 
and 
(iv) a review of funding sources for 
community-based long-term services and 
supports and an analysis of how those 
funding sources could be organized into a 
fair, coherent system that affords individ-
uals reasonable and timely access to com-
munity-based long-term services and sup-
ports. 
(B) PUBLIC ENTITY.—A public entity, in-
cluding an LTSS insurance provider that is a 
public entity, shall— 
(i) include in the self-evaluation de-
scribed in subparagraph (A)— 
(I) an assessment of the avail-
ability of accessible, affordable trans-
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portation across the State involved 
and whether transportation barriers 
prevent individuals from receiving 
long-term services and supports in the 
most integrated setting; and 
(II) an assessment of the avail-
ability of integrated employment op-
portunities in the jurisdiction served 
by the public entity for individuals 
with LTSS disabilities; and 
(ii) provide the self-evaluation de-
scribed in subparagraph (A) to the Attor-
ney General and the Administrator. 
(C) LTSS 
INSURANCE
PROVIDER.—An 
LTSS insurance provider shall keep the self- 
evaluation described in subparagraph (A) on 
file, and may be required to produce such self- 
evaluation in the event of a review, investiga-
tion, or action described in section 8. 
(6) ADDITIONAL
REQUIREMENT
FOR
PUBLIC 
ENTITIES.—The regulations issued under this sec-
tion shall require a public entity, in conjunction with 
the housing agencies serving the jurisdiction served 
by the public entity, to review and improve commu-
nity capacity, in all communities throughout the en-
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tirety of that jurisdiction, in providing affordable, 
accessible, and integrated housing, including an eval-
uation of available units, unmet need, and other 
identifiable barriers to the provision of that housing. 
In carrying out that improvement, the public entity, 
in conjunction with such housing agencies, shall— 
(A) ensure, and assure the Administrator 
and the Attorney General that there is, suffi-
cient availability of affordable, accessible, and 
integrated housing in a setting that is not a dis-
ability-specific residential setting or a setting 
where services are tied to tenancy, in order to 
provide individuals with LTSS disabilities a 
meaningful choice in their housing; 
(B) in order to address the need for af-
fordable, accessible, and integrated housing— 
(i) in the case of such a housing agen-
cy, establish relationships with State and 
local housing authorities; and 
(ii) in the case of the public entity, es-
tablish relationships with State and local 
housing agencies, including housing au-
thorities; 
(C) establish, where needed, necessary 
preferences and set-asides in housing programs 
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for individuals with LTSS disabilities who are 
transitioning from or avoiding institutional 
placement; 
(D) establish a process to fund necessary 
home modifications so that individuals with 
LTSS disabilities can live independently; and 
(E) ensure, and assure the Administrator 
and the Attorney General, that funds and pro-
grams implemented or overseen by the public 
entity or in the public entity’s jurisdiction are 
targeted toward affordable, accessible, inte-
grated housing for individuals with an LTSS 
disability who have the lowest income levels in 
the jurisdiction as a priority over any other de-
velopment until capacity barriers for such hous-
ing are removed or unmet needs for such hous-
ing have been met. 
(7) 
DESIGNATION
OF
RESPONSIBLE
EM-
PLOYEE.—The regulations issued under this section 
shall require each public entity and LTSS insurance 
provider to designate at least one employee to co-
ordinate the entity’s or provider’s efforts to comply 
with and carry out the entity or provider’s respon-
sibilities under this Act, including the investigation 
of any complaint communicated to the entity or pro-
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vider that alleges a violation of this Act. Each public 
entity and LTSS insurance provider shall make 
available to all interested individuals the name, of-
fice address, and telephone number of the employee 
designated pursuant to this paragraph. 
(8) GRIEVANCE PROCEDURES.—The regulations 
issued under this section shall require public entities 
and LTSS insurance providers to adopt and publish 
grievance procedures providing for prompt and equi-
table resolution of complaints alleging a violation of 
this Act. 
(9) PROVISION OF SERVICE BY OTHERS.—The 
regulations issued under this section shall require 
each public entity submitting a self-evaluation under 
paragraph (5) to identify, as part of the transition 
plan described in paragraph (10), any other entity 
that is, or acts as, an agent, subcontractor, or other 
instrumentality of the public entity with regards to 
a service, support, policy, or practice described in 
such plan or self-evaluation. 
(10) TRANSITION
PLANS.—The regulations 
issued under this section shall require each public 
entity, not later than 42 months after the date of 
enactment of this Act, to submit to the Adminis-
trator, and begin implementing, a transition plan for 
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carrying out this Act that establishes the achieve-
ment of the requirements of this Act, as soon as 
practicable, but in no event later than 12 years after 
the date of enactment of this Act. The transition 
plan shall— 
(A) establish measurable objectives to ad-
dress the barriers to community living identified 
in the self-evaluation under paragraph (5); 
(B) establish specific annual targets for 
the transition of individuals with LTSS disabil-
ities, and shifts in funding, from institutional 
settings to integrated community-based services 
and supports, and related programs; 
(C) describe specific efforts to support in-
dividuals with LTSS disabilities to avoid un-
wanted institutionalization through the provi-
sion of LTSS; and 
(D) describe the manner in which the pub-
lic entity has obtained or plans to obtain nec-
essary funding and resources needed for imple-
mentation of the plan (regardless of whether 
the entity began carrying out the objectives of 
this Act prior to the date of enactment of this 
Act). 
(11) ANNUAL REPORTING.— 
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(A) IN GENERAL.—The regulations issued 
under this section shall establish annual report-
ing requirements for each public entity covered 
by this section. 
(B) PROGRESS ON OBJECTIVES, TARGETS, 
AND EFFORTS.—The regulations issued under 
this section shall require each public entity that 
has submitted a transition plan to submit to the 
Administrator an annual report on the progress 
the public entity has made during the previous 
year in meeting the measurable objectives, spe-
cific annual targets, and specific efforts de-
scribed in paragraph (10). 
(12) OTHER
PROVISIONS.—The regulations 
issued under this section shall include such other 
provisions and requirements as the Attorney General 
and the Secretary of Health and Human Services 
determine are necessary to carry out the objectives 
of this Act. 
(c) REVIEW OF TRANSITION PLANS.— 
(1) GENERAL RULE.—The Administrator shall 
review a transition plan submitted in accordance 
with subsection (b)(10) for the purpose of deter-
mining whether such plan meets the requirements of 
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this Act, including the regulations issued under this 
section. 
(2) DISAPPROVAL.—If the Administrator deter-
mines that a transition plan reviewed under this 
subsection fails to meet the requirements of this Act, 
the Administrator shall disapprove the transition 
plan and notify the public entity that submitted the 
transition plan of, and the reasons for, such dis-
approval. 
(3) MODIFICATION OF DISAPPROVED PLAN.— 
Not later than 90 days after the date of disapproval 
of a transition plan under this subsection, the public 
entity that submitted the transition plan shall mod-
ify the transition plan to meet the requirements of 
this section and shall submit to the Administrator, 
and commence implementation of, such modified 
transition plan. 
(4) INCENTIVES.— 
(A) DETERMINATION.—For 10 years after 
the issuance of the regulations described in sub-
section (a), the Secretary of Health and Human 
Services shall annually determine whether each 
State, or each other public entity in the State, 
is complying with the transition plan or modi-
fied transition plan the State or other public 
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entity submitted, and obtained approval for, 
under this section. Notwithstanding any other 
provision of law, if the Secretary of Health and 
Human Services determines under this subpara-
graph that the State or other public entity is 
complying with the corresponding transition 
plan, the Secretary shall make the increase de-
scribed in subparagraph (B). 
(B) INCREASE IN FMAP.—On making the 
determination described in subparagraph (A) 
for a public entity (including a State), the Sec-
retary of Health and Human Services shall, as 
described in subparagraph (C), increase by 5 
percentage points the FMAP (but shall in no 
event increase the FMAP above 100 percent) 
for the State in which the public entity is lo-
cated for amounts expended by the State for 
medical assistance consisting of home and com-
munity-based services furnished under the State 
Medicaid plan under title XIX of the Social Se-
curity Act (42 U.S.C. 1396 et seq.) or a waiver 
of such plan— 
(i) that— 
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(I) are identified by a public enti-
ty or LTSS insurance provider under 
subsection (b)(5)(A)(iii); 
(II) resulted from shifts in fund-
ing identified by a public entity under 
subsection (b)(10)(B); or 
(III) are environmental modifica-
tions to achieve the affordable, acces-
sible, integrated housing identified by 
a public entity under subsection 
(b)(6)(E); and 
(ii) are described by the State in a re-
quest to the Secretary of Health and 
Human Services for the increase. 
(C) PERIOD OF INCREASE.—The Secretary 
of Health and Human Services shall increase 
the FMAP described in subparagraph (B)— 
(i) beginning with the first quarter 
that begins after the date of the deter-
mination; and 
(ii) ending with the quarter in which 
the next annual determination under sub-
paragraph (A) occurs. 
(D) ADDITIONAL
CONDITION
FOR
PAY-
MENT.— 
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(i) 
FMAP.—The 
term 
‘‘FMAP’’ 
means the Federal medical assistance per-
centage for a State determined under sec-
tion 1905(b) of the Social Security Act (42 
U.S.C. 1396d(b)) without regard to any in-
creases in that percentage applicable under 
other subsections of that section or any 
other provision of law, including this sec-
tion. 
(ii) HOME
AND
COMMUNITY-BASED 
SERVICES DEFINED.—The term ‘‘home and 
community-based services’’ means any of 
the following services provided under a 
State Medicaid plan under title XIX of the 
Social Security Act (42 U.S.C. 1396 et 
seq.) or a waiver of such plan: 
(I) Home and community-based 
services provided under subsection (c), 
(d), or (i) of section 1915 of the So-
cial Security Act (42 U.S.C. 1396n). 
(II) Home health care services. 
(III) Personal care services. 
(IV) Services described in section 
1905(a)(26) of the Social Security Act 
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(42 U.S.C. 1396d(a)(26)) (relating to 
PACE program services). 
(V) Self-directed personal assist-
ance services provided in accordance 
with section 1915(j) of the Social Se-
curity Act (42 U.S.C. 1396n(j)). 
(VI) Community-based attendant 
services and supports provided in ac-
cordance with section 1915(k) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1396n(k)). 
(VII) 
Rehabilitative 
services, 
within 
the 
meaning 
of 
section 
1905(a)(13) of the Social Security Act 
(42 U.S.C. 1396d(a)(13)). 
(iii) REPORTING
YEAR.—The term 
‘‘reporting year’’ means the most recent 
fiscal year preceding the date of a report 
under subparagraph (D)(i). 
(d) RULE
OF CONSTRUCTION.—Nothing in sub-
section (b)(10) or (c) or any other provision of this Act 
shall be construed to limit the rights, protections, or re-
quirements of any other Federal law, relating to integra-
tion of individuals with disabilities into the community and 
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enabling those individuals to live in the most integrated 
setting. 
SEC. 7. EXEMPTIONS FOR RELIGIOUS ORGANIZATIONS. 
This Act shall not prohibit a religious organization, 
association, or society from giving preference in providing 
community-based long-term services and supports to indi-
viduals of a particular religion connected with the beliefs 
of such organization, association, or society. 
SEC. 8. ENFORCEMENT. 
(a) CIVIL ACTION.— 
(1) IN GENERAL.—A civil action for preventive 
relief, including an application for a permanent or 
temporary injunction, restraining order, or other 
order, may be instituted by an individual described 
in paragraph (2) in an appropriate Federal district 
court. 
(2) AGGRIEVED INDIVIDUAL.— 
(A) IN GENERAL.—The remedies and pro-
cedures set forth in this section are the rem-
edies and procedures this Act provides to any 
individual who is being subjected to a violation 
of this Act, or who has reasonable grounds for 
believing that such individual is about to be 
subjected to such a violation. 
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(B) STANDING.—An individual with a dis-
ability shall have standing to institute a civil ac-
tion under this subsection if the individual 
makes a prima facie showing that the indi-
vidual— 
(i) is an individual with an LTSS dis-
ability; and 
(ii) is being subjected to, or about to 
be subjected to, such a violation (including 
a violation of section 4(b)(11)). 
(3) APPOINTMENT
OF
ATTORNEY; NO
FEES, 
COSTS, OR
SECURITY.—Upon application by the 
complainant described in paragraph (2) and in such 
circumstances as the court may determine to be just, 
the court may appoint an attorney for the complain-
ant and may authorize the commencement of such 
civil action without the payment of fees, costs, or se-
curity. 
(4) FUTILE GESTURE NOT REQUIRED.—Noth-
ing in this section shall require an individual with an 
LTSS disability to engage in a futile gesture if such 
person has actual notice that a public entity or 
LTSS insurance provider does not intend to comply 
with the provisions of this Act. 
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(b) DAMAGES
AND INJUNCTIVE RELIEF.—If the 
court finds that a violation of this Act has occurred or 
is about to occur, the court may award to the complain-
ant— 
(1) actual and punitive damages; 
(2) immediate injunctive relief to prevent insti-
tutionalization; 
(3) as the court determines to be appropriate, 
any permanent or temporary injunction (including 
an order to immediately provide or maintain commu-
nity-based long-term services or supports for an in-
dividual to prevent institutionalization or further in-
stitutionalization), temporary restraining order, or 
other order (including an order enjoining the defend-
ant from engaging in a practice that violates this 
Act or ordering such affirmative action as may be 
appropriate); and 
(4) in an appropriate case, injunctive relief to 
require the modification of a policy, practice, or pro-
cedure, or the provision of an alternative method of 
providing LTSS, to the extent required by this Act. 
(c) ATTORNEY’S
FEES; LIABILITY
OF
UNITED 
STATES FOR COSTS.—In any action commenced pursuant 
to this Act, the court, in its discretion, may allow the party 
bringing a claim or counterclaim under this Act, other 
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than the United States, a reasonable attorney’s fee as part 
of the costs, and the United States shall be liable for costs 
to the same extent as a private person. 
(d) ENFORCEMENT BY ATTORNEY GENERAL.— 
(1) DENIAL OF RIGHTS.— 
(A) DUTY TO INVESTIGATE.—The Attor-
ney General shall investigate alleged violations 
of this Act, and shall undertake periodic reviews 
of the compliance of public entities and LTSS 
insurance providers under this Act. 
(B) POTENTIAL
VIOLATION.—The Attor-
ney General may commence a civil action in any 
appropriate Federal district court if the Attor-
ney General has reasonable cause to believe 
that— 
(i) any public entity or LTSS insur-
ance provider, including a group of public 
entities or LTSS insurance providers, is 
engaged in a pattern or practice of viola-
tions of this Act; or 
(ii) any individual, including a group, 
has been subjected to a violation of this 
Act and the violation raises an issue of 
general public importance. 
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(2) AUTHORITY OF COURT.—In a civil action 
under paragraph (1)(B), the court— 
(A) may grant any equitable relief that 
such court considers to be appropriate, includ-
ing, to the extent required by this Act— 
(i) granting temporary, preliminary, 
or permanent relief; and 
(ii) requiring the modification of a 
policy, practice, or procedure, or the provi-
sion of an alternative method of providing 
LTSS; 
(B) may award such other relief as the 
court considers to be appropriate, including 
damages to individuals described in subsection 
(a)(2), when requested by the Attorney General; 
and 
(C) may, to vindicate the public interest, 
assess a civil penalty against the public entity 
or LTSS insurance provider in an amount— 
(i) not exceeding $100,000 for a first 
violation; and 
(ii) not exceeding $200,000 for any 
subsequent violation. 
(3) SINGLE VIOLATION.—For purposes of para-
graph (2)(C), in determining whether a first or sub-
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sequent violation has occurred, a determination in a 
single action, by judgment or settlement, that the 
public entity or LTSS insurance provider has en-
gaged in more than one violation of this Act shall be 
counted as a single violation. 
SEC. 9. CONSTRUCTION. 
For purposes of construing this Act— 
(1) section 4(b)(11) shall be construed in a 
manner that takes into account its similarities with 
section 302(b)(2)(A)(ii) of the Americans with Dis-
abilities Act of 1990 (42 U.S.C. 12182(b)(2)(A)(ii)); 
(2) the first sentence of section 6(b)(5)(A) shall 
be construed in a manner that takes into account its 
similarities with section 35.105(a) of title 28, Code 
of Federal Regulations (as in effect on the day be-
fore the date of enactment of this Act); 
(3) section 7 shall be construed in a manner 
that takes into account its similarities with section 
807(a) of the Civil Rights Act of 1968 (42 U.S.C. 
3607(a)); 
(4) section 8(a)(2) shall be construed in a man-
ner that takes into account its similarities with sec-
tion 308(a)(1) of the Americans with Disabilities 
Act of 1990 (42 U.S.C. 12188(a)(1)); and 
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(5) section 8(d)(1)(B) shall be construed in a 
manner that takes into account its similarities with 
section 308(b)(1)(B) of the Americans with Disabil-
ities Act of 1990 (42 U.S.C. 12188(b)(1)(B)). 
Æ 
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