I 
109TH CONGRESS 
1ST SESSION H. R. 4153 
To amend title XIX of the Social Security Act to permit Medicaid beneficiaries 
the choice of self-directed personal assistance services through a cash 
and counseling program under the Medicaid Program. 
IN THE HOUSE OF REPRESENTATIVES 
OCTOBER 26, 2005 
Mr. STEARNS introduced the following bill; which was referred to the 
Committee on Energy and Commerce 
A BILL 
To amend title XIX of the Social Security Act to permit 
Medicaid beneficiaries the choice of self-directed personal 
assistance services through a cash and counseling pro-
gram 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 Cash and 
Counseling Program Act of 2005’’.
SEC. 2. OPTIONAL CHOICE OF SELF-DIRECTED PERSONAL 
ASSISTANCE SERVICES (CASH AND COUN-
SELING). 
(a) EXEMPTION FROM CERTAIN REQUIREMENTS.— 
Section 1915 of the Social Security Act (42 U.S.C. 1396n) 
is amended by adding at the end the following new sub-
section: 
‘‘(i)(1) A State may provide, as ‘medical assistance’, 
payment for part or all of the cost of self-directed personal 
assistance services (other than room and board) under the 
plan which are provided pursuant to a written plan of care 
to individuals with respect to whom there has been a de-
termination that, but for the provision of such services, 
the individuals would require and receive personal care 
services under the plan, or home and community-based 
services provided pursuant to a waiver under sub-section 
(c). Self-directed personal assistance services may not be 
provided under this subsection to individuals who reside 
in a home or property that is owned, operated, or con-
trolled by a provider of services, not related by blood or 
marriage. 
‘‘(2) The Secretary shall not grant approval for a 
State self-directed personal assistance services program 
under this section unless the State provides assurances 
satisfactory to the Secretary of the following:
‘‘(A) Necessary safeguards have been taken to 
protect the health and welfare of individuals pro-
vided services under the program, and to assure fi-
nancial accountability for funds expended with re-
spect to such services. 
‘‘(B) The State will provide, with respect to in-
dividuals who— 
‘‘(i) are entitled to medical assistance for 
personal care services under the plan, or receive 
home and community-based services under a 
waiver granted under subsection (c); 
‘‘(ii) may require self-directed personal as-
sistance services; and 
‘‘(iii) may be eligible for self-directed per-
sonal assistance services, 
an evaluation of the need for personal care under 
the plan, or personal services under a waiver granted 
under subsection (c). 
‘‘(C) Such individuals who are determined to be 
likely to require personal care under the plan, or 
home and community-based services under a waiver 
granted under subsection (c) are informed of the 
feasible alternatives, if available under the State’s 
self-directed personal assistance services program, at 
the choice of such individuals, to the provision of
personal care services under the plan, or personal 
assistance services under a waiver granted under 
subsection (c). 
‘‘(D) The State will provide for a support sys-
tem that ensures participants in the self-directed 
personal assistance services program are appro-
priately assessed and counseled prior to enrollment 
and are able to manage their budgets. Additional 
counseling and management support may be pro-
vided at the request of the participant. 
‘‘(E) The State will provide to the Secretary an 
annual report on the number of individuals served 
and total expenditures on their behalf in the aggre-
gate. The State shall also provide an evaluation of 
overall impact on the health and welfare of partici-
pating individuals compared to non-participants 
every three years. 
‘‘(3) A State may provide self-directed personal as-
sistance services under the State plan without regard to 
the requirements of section 1902(a)(1) and may limit the 
population eligible to receive these services and limit the 
number of persons served without regard to section 
1902(a)(10)(B). 
‘‘(4)(A) For purposes of this subsection, the term 
‘self-directed personal assistance services’ means personal
care and related services, or home and community-based 
services otherwise available under the plan under this title 
or subsection (c), that are provided to an eligible partici-
pant under a self-directed personal assistance services pro-
gram under this section, under which individuals, within 
an approved self-directed services plan and budget, pur-
chase personal assistance and related services, and per-
mits participants to hire, fire, supervise, and manage the 
individuals providing such services. 
‘‘(B) At the election of the State— 
‘‘(i) a participant may choose to use any indi-
vidual capable of providing the assigned tasks in-
cluding legally liable relatives as paid providers of 
the services; and 
‘‘(ii) the individual may use the individual’s 
budget to acquire items that increase independence 
or substitute (such as a microwave oven or an acces-
sibility ramp) for human assistance, to the extent 
that expenditures would otherwise be made for the 
human assistance. 
‘‘(5) For purpose of this section, the term ‘approved 
self-directed services plan and budget’ means, with respect 
to a participant, the establishment of a plan and budget 
for the provision of self-directed personal assistance serv-
ices, consistent with the following requirements:
‘‘(A) SELF-DIRECTION.—The participant (or in 
the case of a participant who is a minor child, the 
participant’s parent or guardian, or in the case of an 
incapacitated adult, another individual recognized by 
state law to act on behalf of the participant) exer-
cises choice and control over the budget, planning, 
and purchase of self-directed personal assistance 
services, including the amount, duration, scope, pro-
vider and location of service provision. 
‘‘(B) ASSESSMENT OF NEEDS.—There is an as-
sessment of the needs, strengths, and preferences of 
the participants for such services. 
‘‘(C) SERVICE PLAN.—A plan for such services 
(and supports for such services) for the participant 
has been developed and approved by the State based 
on such assessment through a person-centered proc-
ess that— 
‘‘(i) builds upon the participant’s capacity 
to engage in activities that promote community 
life and that respects the participant’s pref-
erences, choices and abilities; and 
‘‘(ii) involves families, friends, and profes-
sionals in the planning or delivery of services or 
supports as desired or required by the partici-
pant.