I 
110TH CONGRESS 
2D SESSION 
H. R. 7212 
To amend title XIX of the Social Security Act to improve the State plan 
amendment option for providing home and community-based services 
under the Medicaid Program, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 28, 2008 
Mr. PALLONE (for himself and Ms. DEGETTE) 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 improve 
the State plan amendment option for providing home 
and community-based services under the Medicaid Pro-
gram, 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 
‘‘Empowered at Home Act of 2008’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
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TITLE I—STRENGTHENING THE MEDICAID HOME AND 
COMMUNITY-BASED STATE PLAN AMENDMENT OPTION 
Sec. 101. Removal of barriers to providing home and community-based services 
under State plan amendment option for individuals in need. 
Sec. 102. Increase in Federal medical assistance percentage (FMAP) for the 
provision of home and community-based services under Med-
icaid through the State plan amendment option. 
Sec. 103. Annual report on use of Medicaid State plan amendment option for 
home and community-based services. 
TITLE II—STATE GRANTS TO FACILITATE HOME AND 
COMMUNITY-BASED SERVICES AND PROMOTE HEALTH 
Sec. 201. Reauthorization of Medicaid investment grants and expansion of per-
missible uses in order to facilitate the provision of home and 
community-based and other long-term care services. 
Sec. 202. Health promotion grants. 
TITLE III—PROMOTING AND PROTECTING COMMUNITY LIVING 
Sec. 301. Mandatory application of spousal impoverishment protections to re-
cipients of home and community-based services. 
Sec. 302. Exclusion of 6 months of average cost of nursing facility services 
from assets or resources for purposes of eligibility for home 
and community-based services. 
TITLE IV—MISCELLANEOUS 
Sec. 401. Improved data collection. 
Sec. 402. GAO report on Medicaid home health services and the extent of con-
sumer self-direction of such services. 
TITLE I—STRENGTHENING THE 
MEDICAID HOME AND COM-
MUNITY-BASED STATE PLAN 
AMENDMENT OPTION 
SEC. 101. REMOVAL OF BARRIERS TO PROVIDING HOME 
AND COMMUNITY-BASED SERVICES UNDER 
STATE PLAN AMENDMENT OPTION FOR INDI-
VIDUALS IN NEED. 
(a) PARITY WITH INCOME ELIGIBILITY STANDARD 
FOR INSTITUTIONALIZED INDIVIDUALS.—Paragraph (1) 
of section 1915(i) of the Social Security Act (42 U.S.C. 
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1396n(i)) is amended by striking ‘‘150 percent of the pov-
erty line (as defined in section 2110(c)(5))’’ and inserting 
‘‘300 percent of the supplemental security income benefit 
rate established by section 1611(b)(1)’’. 
(b) AUTHORITY
TO
OFFER
DIFFERENT
TYPE, 
AMOUNT, DURATION, OR SCOPE OF HOME AND COMMU-
NITY-BASED SERVICES.—Section 1915(i) of the Social Se-
curity Act (42 U.S.C. 1396n(i)) is amended by adding at 
the end the following new paragraph: 
‘‘(6) AUTHORITY TO OFFER DIFFERENT TYPE, 
AMOUNT, DURATION, OR SCOPE OF HOME AND COM-
MUNITY-BASED SERVICES.—A State may offer home 
and community-based services to individuals under 
this paragraph that differ in type, amount, duration, 
or scope from the home and community-based serv-
ices offered to other such individuals, taking into ac-
count the needs-based criteria established under 
paragraph (1)(A), so long as such services are with-
in the scope of services described in paragraph 
(4)(B) of subsection (c) for which the Secretary has 
the authority to approve a waiver and do not include 
room or board.’’. 
(c) REMOVAL OF LIMITATION ON SCOPE OF SERV-
ICES.—Paragraph (1) of section 1915(i) of the Social Se-
curity Act (42 U.S.C. 1396n(i)), as amended by sub-
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section (a), is amended by striking ‘‘or such other services 
requested by the State as the Secretary may approve’’ 
(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE 
FULL MEDICAID BENEFITS TO INDIVIDUALS RECEIVING 
HOME
AND COMMUNITY-BASED SERVICES UNDER
A 
STATE PLAN AMENDMENT.— 
(1) IN
GENERAL.—Section 1902(a)(10)(A)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396a(a)(10)(A)(ii)) is amended— 
(A) in subclause (XVIII), by striking ‘‘or’’ 
at the end; 
(B) in subclause (XIX), by adding ‘‘or’’ at 
the end; and 
(C) by inserting after subclause (XIX), the 
following new subclause: 
‘‘(XX) who are eligible for home 
and community-based services under 
needs-based criteria established under 
paragraph (1)(A) of section 1915(i) 
and who will receive home and com-
munity-based services pursuant to a 
State plan amendment under section 
1915(i);’’. 
(2) CONFORMING AMENDMENTS.— 
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(A) Section 1903(f)(4) of the Social Secu-
rity Act (42 U.S.C. 1396b(f)(4)) is amended in 
the matter preceding subparagraph (A), by in-
serting 
‘‘1902(a)(10)(A)(ii)(XX),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XIX),’’. 
(B) Section 1905(a) of the Social Security 
Act (42 U.S.C. 1396d(a)) is amended in the 
matter preceding paragraph (1)— 
(i) in clause (xii), by striking ‘‘or’’ at 
the end; 
(ii) in clause (xiii), by adding ‘‘or’’ at 
the end; and 
(iii) by inserting after clause (xiii) the 
following new clause: 
‘‘(xiv) individuals who are eligible for home and 
community-based services under needs-based criteria 
established under paragraph (1)(A) of section 
1915(i) and who will receive home and community- 
based services pursuant to a State plan amendment 
under such subsection,’’. 
(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF 
ELIGIBLE INDIVIDUALS
OR LENGTH
OF PERIOD
FOR 
GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA 
IS MODIFIED.—Paragraph (1) of section 1915(i) of such 
Act (42 U.S.C. 1396n(i)) is amended— 
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(1) by striking subparagraph (C) and inserting 
the following: 
‘‘(C) PROJECTION OF NUMBER OF INDI-
VIDUALS TO BE PROVIDED HOME AND COMMU-
NITY-BASED SERVICES.—The State submits to 
the Secretary, in such form and manner, and 
upon such frequency as the Secretary shall 
specify, the projected number of individuals to 
be provided home and community-based serv-
ices.’’; and 
(2) in subclause (II) of subparagraph (D)(ii), 
by striking ‘‘to be eligible for such services for a pe-
riod of at least 12 months beginning on the date the 
individual first received medical assistance for such 
services’’ and inserting ‘‘to continue to be eligible for 
such services after the effective date of the modifica-
tion and until such time as the individual no longer 
meets the standard for receipt of such services under 
such pre-modified criteria’’. 
(f) 
ELIMINATION
OF
OPTION
TO
WAIVE 
STATEWIDENESS.—Paragraph (3) of section 1915(i) of 
such Act (42 U.S.C. 1396n(3)) is amended by striking 
‘‘section 1902(a)(1) (relating to statewideness) and’’. 
(g) EFFECTIVE DATE.—The amendments made by 
this section take effect on the first day of the first fiscal 
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year quarter that begins after the date of enactment of 
this Act. 
SEC. 102. INCREASE IN FEDERAL MEDICAL ASSISTANCE 
PERCENTAGE (FMAP) FOR THE PROVISION 
OF HOME AND COMMUNITY-BASED SERVICES 
UNDER 
MEDICAID 
THROUGH 
THE 
STATE 
PLAN AMENDMENT OPTION. 
(a) IN GENERAL.—Section 1905(b) of the Social Se-
curity Act (42 U.S.C. 1396d(b)) is amended by adding 
at the end the following: ‘‘Notwithstanding the first sen-
tence of this subsection, the Federal medical assistance 
percentage shall be increased by 5 percentage points with 
respect to amounts expended as medical assistance for 
home and community-based services provided through a 
State plan amendment that satisfies the requirements of 
section 1915(i).’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to home and community-based 
services furnished on or after October 1, 2008. 
SEC. 103. ANNUAL REPORT ON USE OF MEDICAID STATE 
PLAN AMENDMENT OPTION FOR HOME AND 
COMMUNITY-BASED SERVICES. 
The Secretary of Health and Human Services shall 
submit to Congress an annual report on the extent to 
which State Medicaid plans have adopted a State plan 
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amendment under section 1915(i) of the Social Security 
Act (42 U.S.C. 1396n(i)), as amended by this title, for 
medical assistance for home and community-based services 
for elderly and disabled individuals. Each such report shall 
include the number of beneficiaries who are provided serv-
ices under such an amendment and on changes made in 
the use of waiver authority under section 1915(c) of such 
Act (42 U.S.C. 1396n(c)) as a result of implementation 
of such a State plan amendment. 
TITLE II—STATE GRANTS TO FA-
CILITATE HOME AND COMMU-
NITY-BASED 
SERVICES 
AND 
PROMOTE HEALTH 
SEC. 201. REAUTHORIZATION OF MEDICAID INVESTMENT 
GRANTS AND EXPANSION OF PERMISSIBLE 
USES IN ORDER TO FACILITATE THE PROVI-
SION OF HOME AND COMMUNITY-BASED AND 
OTHER LONG-TERM CARE SERVICES. 
(a) 2-YEAR REAUTHORIZATION; INCREASED FUND-
ING.—Section 1903(z)(4)(A) of the Social Security Act 
(42 U.S.C. 1396b(z)(4)(A)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii), by striking the period at the 
end and inserting ‘‘; and’’; and 
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(3) by inserting after clause (ii), the following 
new clauses: 
‘‘(iii) $150,000,000 for fiscal year 
2009; and 
‘‘(iv) $150,000,000 for fiscal year 
2010.’’. 
(b) EXPANSION
OF PERMISSIBLE USES.—Section 
1903(z)(2) of the Social Security Act (42 U.S.C. 
1396b(z)(2)) is amended by adding at the end the fol-
lowing new subparagraphs: 
‘‘(G)(i) Methods for ensuring the avail-
ability and accessibility of home and commu-
nity-based services in the State, recognizing 
multiple delivery options that take into account 
differing needs of individuals, through the cre-
ation or designation (in consultation with orga-
nizations representing elderly individuals and 
individuals of all ages with physical, mental, 
cognitive, or intellectual impairments, and orga-
nizations representing the long-term care work-
force, including organized labor, and health 
care and direct service providers) of one or 
more statewide or regional public entities or 
non-profit organizations (such as fiscal inter-
mediaries, agencies with choice, home care com-
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missions, public authorities, worker associa-
tions, consumer-owned and controlled organiza-
tions (including representatives of individuals 
with severe intellectual or cognitive impair-
ment), area agencies on aging, independent liv-
ing centers, aging and disability resource cen-
ters, or other disability organizations) which 
may— 
‘‘(I) develop programs where qualified 
individuals provide home- and community- 
based services while solely or jointly em-
ployed by recipients of such services; 
‘‘(II) facilitate the training and re-
cruitment of qualified health and direct 
service professionals and consumers who 
use services; 
‘‘(III) recommend or develop a system 
to set wages and benefits, and recommend 
commensurate reimbursement rates; 
‘‘(IV) with meaningful ongoing in-
volvement from consumers and workers (or 
their respective representatives), develop 
procedures for the appropriate screening of 
workers, create a registry or registries of 
available workers, including policies and 
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procedures to ensure no interruption of 
care for eligible individuals; 
‘‘(V) assist consumers in identifying 
workers; 
‘‘(VI) act as a fiscal intermediary; 
‘‘(VII) assist workers in finding em-
ployment, including consumer-directed em-
ployment; 
‘‘(VIII) provide funding for disability 
organizations, 
aging 
organizations, 
or 
other organizations, to assume roles that 
promote consumers’ ability to acquire the 
necessary skills for directing their own 
services and financial resources; or 
‘‘(IX) create workforce development 
plans on a regional or statewide basis (or 
both), to ensure a sufficient supply of 
qualified home and community-based serv-
ices workers, including reviews and anal-
yses of actual and potential worker short-
ages, training and retention programs for 
home and community-based services work-
ers (which may include, as determined ap-
propriate by the State, allowing participa-
tion in such training to count as an allow-
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able work activity under the State tem-
porary assistance for needy families pro-
gram funded under part A of title IV), and 
plans to assist consumers with finding and 
retaining qualified workers. 
‘‘(ii) Nothing in clause (i) shall be con-
strued as prohibiting the use of funds made 
available to carry out this subparagraph for 
start-up costs associated with any of the activi-
ties described in subclauses (I) through (IX), as 
requiring any consumer to hire workers who are 
listed in a worker registry developed with such 
funds, or to limit the ability of consumers to 
hire or fire their own workers. 
‘‘(H) Methods for providing an integrated 
and efficient system of long-term care through 
a review of the Federal, State, local, and pri-
vate long-term care resources, services, and 
supports available to elderly individuals and in-
dividuals of all ages with physical, mental, cog-
nitive, or intellectual impairments and the de-
velopment and implementation of a plan to fully 
integrate such resources, services, and supports 
by aggregating such resources, services, and 
supports to create a consumer-centered and 
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cost-effective resource and delivery system and 
expanding the availability of home and commu-
nity-based services, and that is designed to re-
sult in administrative savings, consolidation of 
common activities, and the elimination of re-
dundant processes.’’. 
(c) ALLOCATION OF FUNDS.— 
(1) ELIMINATION OF CURRENT LAW REQUIRE-
MENTS
FOR
ALLOCATION
OF
FUNDS.—Section 
1903(z)(4)(B) of the Social Security Act (42 U.S.C. 
1396b(z)(4)(B)) is amended by striking the second 
and third sentences. 
(2) ASSURANCE OF FUNDS TO FACILITATE THE 
PROVISION OF HOME AND COMMUNITY-BASED SERV-
ICES
AND
INTEGRATED
SYSTEMS
OF
LONG-TERM 
CARE.—Section 1903(z)(4)(B) of the Social Security 
Act (42 U.S.C. 1396b(z)(4)(B)), as amended by 
paragraph (1), is amended by inserting after the 
first sentence the following new sentence: ‘‘Such 
method shall provide that 50 percent of such funds 
shall be allocated among States that design pro-
grams to adopt the innovative methods described in 
subparagraph (G) or (H) (or both) of paragraph 
(2).’’. 
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(d) RENAMING PROGRAM.—The heading of section 
1903(z) of such Act is amended by striking ‘‘TRANS-
FORMATION’’ and inserting ‘‘INVESTMENT’’. 
(e) CLARIFICATION.—Such section is further amend-
ed by adding at the end the following new paragraph: 
‘‘(6) CLARIFICATION OF PROTECTION OF BENE-
FICIARIES.—Nothing in this section shall be con-
strued as authorizing States to use payments pro-
vided under this subsection for the purpose of lim-
iting eligibility or benefits under this title.’’. 
(f) EFFECTIVE DATE.—The amendments made by 
this section take effect on October 1, 2008. 
SEC. 202. HEALTH PROMOTION GRANTS. 
(a) DEFINITIONS.—In this section: 
(1) ELIGIBLE
MEDICAID
BENEFICIARY.—The 
term ‘‘eligible Medicaid beneficiary’’ means an indi-
vidual who is enrolled in the State Medicaid plan 
under title XIX of the Social Security Act and— 
(A) has attained the age of 60 and is not 
a resident of a nursing facility; or 
(B) is an adult with a physical, mental, 
cognitive, or intellectual impairment. 
(2) ELIGIBLE
STATE.—The term ‘‘eligible 
State’’ means a State that submits an application to 
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the Secretary for a grant under this section, in such 
form and manner as the Secretary shall require. 
(3) 
EVIDENCE- 
AND
COMMUNITY-BASED 
HEALTH
PROMOTION
PROGRAM.—The 
term 
‘‘evidence- and community-based health promotion 
program’’ means a community-based program (such 
as a program for chronic disease self-management, 
physical or mental activity, falls prevention, smoking 
cessation, or dietary modification) that has been ob-
jectively evaluated and found to improve health out-
comes or meet health promotion goals by preventing, 
delaying, or decreasing the severity of physical, men-
tal, cognitive, or intellectual impairment and that 
meets generally accepted standards for best profes-
sional practice. 
(4) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(b) AUTHORITY
TO
CONDUCT
DEMONSTRATION 
PROJECT.—The Secretary shall award grants on a com-
petitive basis to eligible States to conduct in accordance 
with this section an evidence- and community-based health 
promotion program that is designed to achieve the fol-
lowing objectives with respect to eligible Medicaid bene-
ficiaries: 
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