I 
108TH CONGRESS 
1ST SESSION H. R. 2032
To amend title XIX of the Social Security Act to provide individuals with 
disabilities and older Americans with equal access to community-based 
attendant services and supports, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 8, 2003
Mr. DAVIS of Illinois (for himself, Mr. SHIMKUS, Mr. DOGGETT, Mr. UDALL 
of Colorado, Mr. MOORE, Mr. MCNULTY, Mr. ENGEL, Mr. RYUN of Kan-
sas, Mr. HINOJOSA, Mr. MCHUGH, Mr. HOLDEN, Ms. LEE, Mr. DOYLE, 
Mr. HOYER, Ms. SCHAKOWSKY, Mr. TOWNS, Mr. HINCHEY, Mr. 
SERRANO, Mr. PAYNE, Mr. GRIJALVA, Mr. KILDEE, Mr. BRADY of Penn-
sylvania, Mr. PALLONE, and Mrs. CHRISTENSEN) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce 
A BILL 
To amend title XIX of the Social Security Act to provide 
individuals with disabilities and older Americans with 
equal access to community-based attendant services and 
supports, and for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Medicaid Community-Based Attendant Services and 
Supports Act of 2003’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows:
Sec. 1. Short title; table of contents. 
Sec. 2. Findings and purposes. 
TITLE I—ESTABLISHMENT OF MEDICAID PLAN BENEFIT 
Sec. 101. Coverage of community-based attendant services and supports under 
the medicaid program. 
Sec. 102. Enhanced FMAP for ongoing activities of early coverage States that 
enhance and promote the use of community-based attendant 
services and supports. 
Sec. 103. Increased Federal financial participation for certain expenditures. 
TITLE II—PROMOTION OF SYSTEMS CHANGE AND CAPACITY 
BUILDING 
Sec. 201. Grants to promote systems change and capacity building. 
Sec. 202. Demonstration project to enhance coordination of care under the 
medicare and medicaid programs for non-elderly dual eligible 
individuals.
SEC. 2. FINDINGS AND PURPOSES. 
(a) FINDINGS.—Congress makes the following find-
ings: 
(1) Long-term services and supports provided 
under the medicaid program established under title 
XIX of the Social Security Act (42 U.S.C. 1396 et 
seq.) must meet the ability and life choices of indi-
viduals with disabilities and older Americans, includ-
ing the choice to live in one’s own home or with 
one’s own family and to become a productive mem-
ber of the community.
(2) Research on the provision of long-term serv-
ices and supports under the medicaid program (con-
ducted by and on behalf of the Department of 
Health and Human Services) has revealed a signifi-
cant funding bias toward institutional care. Only 
about 27 percent of long term care funds expended 
under the medicaid program, and only about 9 per-
cent of all funds expended under that program, pay 
for services and supports in home and community-
based settings. 
(3) In the case of medicaid beneficiaries who 
need long term care, the only long-term care service 
currently guaranteed by Federal law in every State 
is nursing home care. Only 27 States have adopted 
the benefit option of providing personal care services 
under the medicaid program. Although every State 
has chosen to provide certain services under home 
and community-based waivers, these services are un-
evenly available within and across States, and reach 
a small percentage of eligible individuals. In fiscal 
year 2000, only 3 States spent 50 percent or more 
of their medicaid long term care funds under the 
medicaid program on home and community-based 
care.
(4) Despite the funding bias and the uneven 
distribution of home and community-based services, 
21⁄2 times more people are served in home and com-
munity-based settings than in institutional settings. 
(5) The goals of the Nation properly include 
providing families of children with disabilities, work-
ing-age adults with disabilities, and older Americans 
with—
(A) a meaningful choice of receiving long-
term services and supports in the most inte-
grated setting appropriate to their needs; 
(B) the greatest possible control over the 
services received and, therefore, their own lives 
and futures; and 
(C) quality services that maximize inde-
pendence in the home and community, including 
in the workplace. 
(b) PURPOSES.—The purposes of this Act are the fol-
lowing: 
(1) To reform the medicaid program established 
under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) to provide equal access to com-
munity-based attendant services and supports. 
(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.
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 1935, for the inclu-
sion of community-based attendant services and 
supports for any individual who—
‘‘(I) is eligible for medical assistance 
under the State plan; 
‘‘(II) with respect to whom there has 
been a determination that the individual 
requires the level of care provided in a 
nursing facility or an intermediate care fa-
cility for the mentally retarded (whether or 
not coverage of such intermediate care fa-
cility is provided under the State plan); 
and
‘‘(III) who 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—
(A) by redesignating section 1935 as sec-
tion 1936; and 
(B) by inserting after section 1934 the fol-
lowing:
‘‘COMMUNITY-BASED ATTENDANT SERVICES AND 
SUPPORTS 
‘‘SEC. 1935. (a) REQUIRED COVERAGE.—
‘‘(1) IN GENERAL.—Not later than October 1, 
2007, 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 or after October 1, 2003, 
and ends on September 30, 2007, in the case of a 
State with an approved plan amendment under this 
section during that period that also satisfies the re-
quirements of subsection (c) the Federal medical as-
sistance percentage shall be equal to the enhanced 
FMAP described in section 2105(b) with respect to 
medical assistance in the form of community-based 
attendant services and supports provided to individ-
uals described in section 1902(a)(10)(D)(ii) in ac-
cordance with this section. 
‘‘(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.—That the State 
has developed and shall implement the provision of 
community-based attendant services and supports 
under the State plan through active collaboration 
with—
‘‘(A) individuals with disabilities; 
‘‘(B) elderly individuals; 
‘‘(C) representatives of such individuals; 
and
‘‘(D) providers of, and advocates for, serv-
ices and supports for such individuals. 
‘‘(2) ASSURANCE OF PROVISION ON A STATE-
WIDE BASIS AND IN MOST INTEGRATED SETTING.—
That community-based attendant services and sup-
ports will be provided under the State plan to indi-
viduals described in section 1902(a)(10)(D)(ii) on a 
statewide basis and in a manner that provides such 
services and supports in the most integrated setting 
appropriate for each individual eligible for such serv-
ices and supports. 
‘‘(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 of disability, or the form of 
community-based attendant services and supports 
that the individual requires in order to lead an inde-
pendent life. 
‘‘(4) ASSURANCE
OF
MAINTENANCE
OF
EF-
FORT.—That the level of State expenditures for op-
tional medical assistance that—
‘‘(A) is described in a paragraph other 
than paragraphs (1) through (5), (17) and (21) 
of section 1905(a) or that is provided under a
‘‘(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-
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. 
‘‘(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 individuals with disabil-
ities, elderly individuals, and representatives of 
such individuals in the design, delivery, admin-
istration, 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-
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 PROGRAM.—
‘‘(1) STATE RESPONSIBILITIES.—In order for a 
State plan amendment to be approved under this 
section, a State shall establish and maintain a qual-
ity assurance program 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 
disagreements over the terms of an individ-
ualized plan. 
‘‘(B) The State shall modify the quality as-
surance program, 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 appropriate for 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-
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 pro-
gram. 
‘‘(I) The State shall establish an ongoing 
public process for the development, implementa-
tion, and review of the State’s quality assurance 
program. 
‘‘(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-
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 UNDER A WAIVER.—
‘‘(1) IN
GENERAL.—Nothing in this section 
shall be construed as affecting the ability of a State 
to provide coverage under the State plan for commu-
nity-based attendant services and supports (or simi-
lar coverage) under a waiver approved under section 
1915, section 1115, or otherwise. 
‘‘(2) ELIGIBILITY FOR ENHANCED MATCH.—In 
the case of a State that provides coverage for such 
services and supports under a waiver, the State shall 
not be eligible under subsection (a)(2) for the en-
hanced FMAP for the early provision of such cov-
erage unless the State submits a plan amendment to 
the Secretary that meets the requirements of this 
section. 
‘‘(g) DEFINITIONS.—In this title: 
‘‘(1) COMMUNITY-BASED ATTENDANT SERVICES 
AND SUPPORTS.—
‘‘(A) IN GENERAL.—The term ‘community-
based attendant services and supports’ means 
attendant services and supports furnished to an 
individual, as needed, to assist in accomplishing
activities of daily living, instrumental activities 
of daily living, and health-related functions 
through hands-on assistance, supervision, or 
cueing—
‘‘(i) under a plan of services and sup-
ports that is based on an assessment of 
functional need and that is agreed to by 
the individual or, as appropriate, the indi-
vidual’s representative; 
‘‘(ii) in a home or community setting, 
which may include a school, workplace, or 
recreation or religious facility, but does not 
include a nursing facility or an inter-
mediate care facility for the mentally re-
tarded; 
‘‘(iii) under an agency-provider model 
or other model (as defined in paragraph 
(2)(C)); and 
‘‘(iv) the furnishing of which is se-
lected, managed, and dismissed by the in-
dividual, or, as appropriate, with assistance 
from the individual’s representative. 
‘‘(B) INCLUDED
SERVICES
AND
SUP-
PORTS.—Such term includes—
‘‘(i) tasks necessary to assist an indi-
vidual in accomplishing activities of daily 
living, instrumental activities of daily liv-
ing, and health-related functions; 
‘‘(ii) the acquisition, maintenance, and 
enhancement of skills necessary for the in-
dividual to accomplish activities of daily 
living, instrumental activities of daily liv-
ing, and health-related functions; 
‘‘(iii) backup systems or mechanisms 
(such as the use of beepers) to ensure con-
tinuity of services and supports; and 
‘‘(iv) voluntary training on how to se-
lect, manage, and dismiss attendants. 
‘‘(C) EXCLUDED
SERVICES
AND
SUP-
PORTS.—Subject to subparagraph (D), such 
term does not include—
‘‘(i) the provision of room and board 
for the individual; 
‘‘(ii) special education and related 
services provided under the Individuals 
with Disabilities Education Act and voca-
tional 
rehabilitation 
services 
provided 
under the Rehabilitation Act of 1973;
‘‘(iii) assistive technology devices and 
assistive technology services; 
‘‘(iv) durable medical equipment; or
‘‘(v) home modifications. 
‘‘(D) FLEXIBILITY
IN
TRANSITION
TO 
COMMUNITY-BASED
HOME
SETTING.—Such 
term may include expenditures for transitional 
costs, such as rent and utility deposits, first 
month’s rent and utilities, bedding, basic kitch-
en supplies, and other necessities required for 
an individual to make the transition from a 
nursing facility or intermediate care facility for 
the mentally retarded to a community-based 
home setting where the individual resides. 
‘‘(2) ADDITIONAL DEFINITIONS.—
‘‘(A) ACTIVITIES OF DAILY LIVING.—The 
term ‘activities of daily living’ includes eating, 
toileting, grooming, dressing, bathing, and 
transferring. 
‘‘(B) CONSUMER CONTROLLED.—The term 
‘consumer controlled’ means a method of pro-
viding services and supports that allow the indi-
vidual, or where appropriate, the individual’s 
representative, maximum control of the commu-
nity-based attendant services and supports, re-
gardless of who acts as the employer of record. 
‘‘(C) DELIVERY MODELS.—
‘‘(i) AGENCY-PROVIDER MODEL.—The 
term ‘agency-provider model’ means, with 
respect to the provision of community-
based attendant services and supports for 
an individual, a method of providing con-
sumer controlled services and supports 
under which entities contract for the provi-
sion of such services and supports. 
‘‘(ii) OTHER
MODELS.—The term 
‘other models’ means methods, other than 
an agency-provider model, for the provision 
of consumer controlled services and sup-
ports. Such models may include the provi-
sion of vouchers, direct cash payments, or 
use of a fiscal agent to assist in obtaining 
services. 
‘‘(D) HEALTH-RELATED FUNCTIONS.—The 
term ‘health-related functions’ means functions 
that can be delegated or assigned by licensed 
health-care professionals under State law to be 
performed by an attendant.
‘‘(E) INSTRUMENTAL ACTIVITIES OF DAILY 
LIVING.—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 traveling around 
and participating in the community. 
‘‘(F) INDIVIDUAL’S
REPRESENTATIVE.—
The term ‘individual’s representative’ means a 
parent, a family member, a guardian, an advo-
cate, or an authorized representative of an indi-
vidual.’’. 
(c) CONFORMING AMENDMENTS.—
(1) 
MANDATORY
BENEFIT.—Section 
1902(a)(10)(A) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(A)) is amended, in the matter 
preceding clause (i), by striking ‘‘(17) and (21)’’ and 
inserting ‘‘(17), (21), and (27)’’. 
(2) DEFINITION
OF
MEDICAL
ASSISTANCE.—
Section 1905(a) of the Social Security Act (42 
U.S.C. 1396d) is amended—
(A) by striking ‘‘and’’ at the end of para-
graph (26);
(B) by redesignating paragraph (27) as 
paragraph (28); and 
(C) by inserting after paragraph (26) the 
following:
‘‘(27) community-based attendant services and 
supports (to the extent allowed and as defined in 
section 1935); and’’. 
(3) 
IMD/ICFMR 
REQUIREMENTS.—Section 
1902(a)(10)(C)(iv) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(C)(iv)) is amended by inserting 
‘‘and (27)’’ after ‘‘(24)’’. 
(d) EFFECTIVE DATES.—
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
(other than the amendment made by subsection 
(c)(1)) take effect on October 1, 2003, and apply to 
medical assistance provided for community-based at-
tendant services and supports described in section 
1935 of the Social Security Act furnished on or 
after that date. 
(2) MANDATORY
BENEFIT.—The amendment 
made by subsection (c)(1) takes effect on October 1, 
2007.
SEC. 102. ENHANCED FMAP FOR ONGOING ACTIVITIES OF 
EARLY COVERAGE STATES THAT ENHANCE 
AND PROMOTE THE USE OF COMMUNITY-
BASED 
ATTENDANT 
SERVICES 
AND 
SUP-
PORTS. 
(a) IN GENERAL.—Section 1935 of the Social Secu-
rity Act, as added by section 101(b), is amended—
(1) by redesignating subsections (d) through (g) 
as subsections (f) through (i), respectively; 
(2) in subsection (a)(1), by striking ‘‘subsection 
(g)(1)’’ and inserting ‘‘subsection (i)(1)’’; 
(3) in subsection (a)(2), by inserting ‘‘, and 
with respect to expenditures described in subsection 
(d), the Secretary shall pay the State the amount 
described in subsection (d)(1)’’ before the period; 
(4) in subsection (c)(1)(C), by striking ‘‘sub-
section 
(g)(2)(B)’’ 
and 
inserting 
‘‘subsection 
(i)(2)(B)’’; and 
(5) by inserting after subsection (c), the fol-
lowing: 
‘‘(d) INCREASED FEDERAL FINANCIAL PARTICIPA-
TION FOR EARLY COVERAGE STATES THAT MEET CER-
TAIN BENCHMARKS.—
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
for purposes of subsection (a)(2), the amount and 
expenditures described in this subsection are an
venting and alleviating unnecessary institutionaliza-
tion of such individuals. 
(3) Engaging in system change and other ac-
tivities deemed necessary to achieve any or all of the 
goals of such statewide plan. 
(4) Identifying and remedying disparities and 
gaps in services to classes of individuals with disabil-
ities and elderly individuals who are currently expe-
riencing or who face substantial risk of unnecessary 
institutionalization. 
(5) Building and expanding system capacity to 
offer quality consumer controlled community-based 
services and supports to individuals with disabilities 
and elderly individuals, including by—
(A) seeding the development and effective 
use of community-based attendant services and 
supports cooperatives, independent living cen-
ters, small businesses, microenterprises and 
similar joint ventures owned and controlled by 
individuals with disabilities or representatives of 
such individuals and community-based attend-
ant services and supports workers; 
(B) enhancing the choice and control indi-
viduals with disabilities and elderly individuals 
exercise, including through their representa-