I
106TH CONGRESS
2D SESSION
H. R. 4416
To amend title XIX of the Social Security Act to provide for coverage
of community-based attendant services and supports under the Medicaid
Program.
IN THE HOUSE OF REPRESENTATIVES
MAY 10, 2000
Mr. DAVIS of Illinois introduced the following bill; which was referred to the
Committee on Commerce
A BILL
To amend title XIX of the Social Security Act to provide
for coverage of community-based attendant services and
supports under the Medicaid Program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Medicaid Community
Attendant Services and Supports Act of 2000’’.
SEC. 2. STATEMENT OF FINDINGS, PURPOSES, AND POLICY.
(a) FINDINGS.—The Congress finds the following:
(1) Many studies have found that an over-
whelming majority of individuals with disabilities
needing long-term services and supports would pre-
fer to receive them in home and community-based
settings rather than in institutions. However, re-
search on the provision of long-term services and
supports under the Medicaid program (conducted by
and on behalf of the Department of Health and
Human Services) has revealed a significant bias to-
ward funding these services in institutional rather
than home and community-based settings. The ex-
tent of this bias is indicated by the fact that sev-
enty-five percent of Medicaid funds for long-term
services and supports are expended in nursing homes
and intermediate care facilities for the mentally re-
tarded while approximately twenty-five percent pays
for services in home and community-based settings.
(2) Because of this bias, significant numbers of
individuals with disabilities of all ages who would
prefer to live in the community and could do so with
community attendant services and supports, are
forced to live in unnecessarily segregated institu-
tional settings if they want to receive needed services
and supports. Benefit packages provided in these
settings are medically-oriented and constitute bar-
riers to the receipt of the types of services individ-
uals need and want. Decisions regarding the provi-
sion of services and supports are too often influ-
enced by what is reimbursable rather than what in-
dividuals need and want.
(3) There is a growing recognition that dis-
ability is a natural part of the human experience
that in no way diminishes a person’s right to—
(A) live independently;
(B) enjoy self-determination;
(C) make choices;
(D) contribute to society; and
(E) enjoy full inclusion and integration in
the mainstream of American society.
(4) Long-term services and supports provided
under the Medicaid program must meet the evolving
and changing needs and preferences of individuals
with disabilities, including the preference of living
within one’s own home or living with one’s own fam-
ily and becoming productive members of the commu-
nity.
(5) The goals of the Nation properly include
providing individuals with disabilities with—
(A) meaningful choice of receiving long-
term services and supports in the most inte-
grated setting appropriate;
(B) the greatest possible control over the
services received; and
(C) quality services that maximize social
functioning in the home and community.
(b) PURPOSES.—The purposes of this Act are as fol-
lows:
(1) to provide that States shall offer community
attendant services and supports for eligible individ-
uals with disabilities, and
(2) to provide financial assistance to the States
to support systems change initiatives designed to as-
sist each State to develop and enhance a comprehen-
sive consumer-responsive statewide system of long-
term services and supports that provides real con-
sumer choice and direction consistent with the prin-
ciple that services and supports are provided in the
most integrated setting appropriate to meeting the
unique needs of the individual.
(c) POLICY.—It is the policy of the United States
that all programs, projects, and activities receiving assist-
ance under this Act shall be carried out in a manner con-
sistent with the following principles:
(1) Individuals with disabilities, or, as appro-
priate, their representatives, must be empowered to
exercise real choice in selecting long-term services
and supports that are of high quality, are cost-effec-
tive and meet the unique needs of the individual in
the most integrated setting appropriate;
(2) No person should be forced into an institu-
tion to receive services that can be effectively and ef-
ficiently delivered in the home or community;
(3) Federal and State policies, practices, and
procedures should facilitate and be responsive to, not
impede, an individual’s choice; and
(4) Individuals and their families receiving
long-term services and supports must be involved in
decision-making about their own care and be pro-
vided with sufficient information to make informed
choices.
SEC. 3. COVERAGE OF COMMUNITY ATTENDANT SERVICES
AND SUPPORTS UNDER THE MEDICAID PRO-
GRAM.
(a) REQUIRING COVERAGE FOR INDIVIDUALS ENTI-
TLED TO NURSING FACILITY SERVICES OR ELIGIBLE FOR
INTERMEDIATE CARE FACILITY SERVICES FOR THE MEN-
TALLY RETARDED.—
(1) Section 1902(a)(10)(D) of the Social Secu-
rity Act (42 U.S.C. 1396a(a)(10)(D)) is amended—
(A) by inserting ‘‘(i)’’ after ‘‘(D)’’, and
(B) by adding at the end the following:
‘‘(ii) subject to section 1935(b), for
the inclusion of community attendant serv-
ices and supports for any individual who,
under the State plan, has a level of sever-
ity of physical or mental impairment that
entitles such individual to nursing facility
services or qualifies an individual to inter-
mediate care facility services for the men-
tally retarded and who requires such com-
munity attendant services and supports
based on functional need and without re-
gard to age or disability;’’.
(2) Section 1902(a)(10)(A) of the Social Secu-
rity Act (42 U.S.C. 1396a(a)(10)(A)) is amended by
striking ‘‘(17) and (21)’’ and inserting ‘‘(17), (21),
and (27)’’.
(b) MEDICAID COVERAGE OF COMMUNITY ATTEND-
ANT SERVICES AND SUPPORTS.—
(1) IN GENERAL.—Title XIX of the Social Se-
curity Act is amended—
(A) by redesignating section 1935 as sec-
tion 1936, and
(B) by inserting after section 1934 the fol-
lowing new section:
‘‘COVERAGE OF COMMUNITY ATTENDANT SERVICES AND
SUPPORTS
‘‘SEC. 1935. (a) COMMUNITY ATTENDANT SERVICES
AND SUPPORTS DEFINED.—
‘‘(1) IN GENERAL.—In this title, the term ‘com-
munity attendant services and supports’ means at-
tendant services and supports furnished to an indi-
vidual, as needed, to assist in accomplishing activi-
ties of daily living, instrumental activities of daily
living, and health-related functions through any (or
all) 
of 
hands-on 
assistance, 
supervision, 
and
cueing—
‘‘(A) under a plan of services and supports
that is based on an assessment of functional
need and that is agreed to by the individual or,
as appropriate, the individual’s representative;
‘‘(B) in a home or community setting,
which may include a school, workplace, or recre-
ation or religious facility, but does not include
a nursing facility, an intermediate care facility
for the mentally retarded, or other large con-
gregate setting;
‘‘(C) under an agency-provider model and
other models (as defined in paragraph (5)); and
‘‘(D) the furnishing of which is selected,
managed, and dismissed by the individual or, as
appropriate, with assistance from the individ-
ual’s representative.
‘‘(2) ATTENDANT SERVICES AND SUPPORTS IN-
CLUDED.—Such term includes—
‘‘(A) tasks necessary to assist an individual
in accomplishing activities of daily living, in-
strumental activities of daily living, and health-
related functions;
‘‘(B) acquisition, maintenance, and en-
hancement of skills necessary for the individual
to accomplish activities of daily living, instru-
mental activities of daily living, and health-re-
lated functions;
‘‘(C) back-up systems or mechanisms (such
as the use of beepers) to ensure continuity of
services and supports; and
‘‘(D) voluntary training for the individual
on how to select, manage, and dismiss attend-
ants.
‘‘(3) EXCLUDED
SERVICES
AND
SUPPORTS.—
Subject to paragraph (4), such term does not
include—
‘‘(A) provision of room and board for the
individual;
‘‘(B) special education and related services
provided under the Individuals with Disabilities
Education Act and vocational rehabilitation
services provided under the Rehabilitation Act
of 1973;
‘‘(C) assistive technology devices and as-
sistive technology services;
‘‘(D) durable medical equipment; and
‘‘(E) home modifications.
‘‘(4) FLEXIBILITY IN TRANSITION TO COMMU-
NITY-BASED HOME SETTING.—Such term may in-
clude expenditures for transitional costs, such as
rent and utility deposits, first month’s rent and utili-
ties, bedding, basic kitchen supplies, accessibility
modifications, and other necessities required for an
individual to make the transition from a nursing fa-
cility or intermediate care facility for the mentally
retarded to a community-based home setting where
the person resides.
‘‘(5) DEFINITIONS.—In this section:
‘‘(A) The term ‘activities of daily living’ in-
cludes eating, toileting, grooming, dressing,
bathing, and transferring.
‘‘(B) The term ‘instrumental activities of
daily living’ includes meal planning and prepa-
ration, managing finances, shopping for food,
clothing, and other essential items, performing
essential household chores, communicating by
phone and other media, and getting around and
participating in the community.
‘‘(C) The term ‘health-related functions’
means functions that can be delegated or as-
signed by licensed health-care professional
under State law to be performed by an attend-
ant.
‘‘(D) The term ‘individual’s representative’
means a parent, a family member, a guardian,
an advocate, or an authorized representative of
an individual.
‘‘(E) The term ‘consumer-directed’ means
methods of providing services and supports that
allow the individual, or where appropriate the
individual’s representative, maximum control of
the community attendant services and supports,
regardless of who acts as the employer of
record.
‘‘(b) LIMITATION ON AMOUNTS OF EXPENDITURES
UNDER
THIS
TITLE.—In 
carrying 
out 
section
1902(a)(10)(D)(ii), a State shall permit an individual who
has a level of severity of physical or mental impairment
that entitles such individual to medical assistance with re-
spect to nursing facility services or qualifies an individual
for intermediate care facility services for the mentally re-
tarded to choose to receive medical assistance for commu-
nity-based attendant services and supports (rather than
medical assistance for such institutional services and sup-
ports), in the most integrated setting appropriate to the
needs of the individual, so long as the aggregate amount
of the Federal expenditures for such individuals in a fiscal
year does not exceed the total that would have been ex-
pended for such individuals to receive such institutional
services and supports in the year.
‘‘(c) MAINTENANCE OF EFFORT REQUIREMENT.—
With respect to a fiscal year quarter, no Federal funds
may be paid to a State for medical assistance provided
to individuals described in section 1902(a)(10)(D)(ii) for
such fiscal year quarter if the Secretary determines that
the total of the State expenditures for programs to enable
such individuals with disabilities to receive community-
based attendant services and supports under other provi-
sions of this title for the preceding fiscal year quarter is
less than the total of such expenditures for the same fiscal
year quarter of the preceding fiscal year.