‘‘(3) ROUNDING.—Any increase determined 
under paragraph (2) shall be rounded to the nearest 
multiple of $50.’’. 
(b) USE OF ACCOUNT FOR INDIVIDUAL HIGH DE-
DUCTIBLE
HEALTH
PLAN
PREMIUMS.—Section 
223(d)(2)(C) (relating to exceptions) is amended by strik-
ing ‘‘or’’ at the end of clause (iii), by striking the period 
at the end of clause (iv) and inserting ‘‘, or’’, and by add-
ing at the end the following new clause: 
‘‘(v) a high deductible health plan, but 
only if— 
‘‘(I) the plan is not a group 
health plan (as defined in section 
5000(b)(1) without regard to section 
5000(d)), and 
‘‘(II) the expenses are for cov-
erage for a month with respect to 
which the account beneficiary is an el-
igible individual by reason of the cov-
erage under the plan. 
For purposes of clause (v), an arrangement 
which constitutes individual health insurance 
shall not be treated as a group health plan, not-
withstanding that an employer or employee or-
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ganization negotiates the cost of benefits of 
such arrangement.’’. 
(c) SAFE HARBOR FOR ABSENCE OF MAINTENANCE 
OF CHRONIC DISEASE.—Section 223(c)(2)(C) (safe har-
bor for absence of preventive care deductible) is amend-
ed— 
(1) by inserting ‘‘or maintenance of chronic dis-
ease, or both’’ after ‘‘the Secretary)’’, and 
(2) by inserting ‘‘OR MAINTENANCE OF CHRON-
IC
DISEASE’’ in the heading after ‘‘PREVENTIVE 
CARE’’. 
(d) CLARIFICATION OF TREATMENT OF CAPITATED 
PRIMARY CARE PAYMENTS AS AMOUNTS PAID FOR MED-
ICAL CARE.—Section 213(d) (relating to definitions) is 
amended by adding at the end the following new para-
graph: 
‘‘(12) TREATMENT
OF
CAPITATED
PRIMARY 
CARE PAYMENTS.—Capitated primary care payments 
shall be treated as amounts paid for medical care.’’. 
(e) SPECIAL RULE FOR INDIVIDUALS ELIGIBLE FOR 
VETERANS
OR
INDIAN
HEALTH
BENEFITS.—Section 
223(c)(1) (defining eligible individual) is amended by add-
ing at the end the following new subparagraph: 
‘‘(C) SPECIAL RULE FOR INDIVIDUALS ELI-
GIBLE FOR VETERANS OR INDIAN HEALTH BEN-
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EFITS.—For purposes of subparagraph (A)(ii), 
an individual shall not be treated as covered 
under a health plan described in such subpara-
graph merely because the individual receives 
periodic hospital care or medical services under 
any law administered by the Secretary of Vet-
erans Affairs or the Bureau of Indian Affairs.’’. 
(f) CERTAIN PHYSICIAN FEES TO BE TREATED AS 
MEDICAL CARE.— 
(1) IN GENERAL.—Section 213(d), is amended 
by adding at the end the following new paragraph: 
‘‘(12) PRE-PAID PHYSICIAN FEES.—The term 
‘medical care’ shall include amounts paid by patients 
to their primary physician in advance for the right 
to receive medical services on an as-needed basis.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by this section shall apply to taxable years beginning 
after the date of the enactment of this Act. 
(g) EFFECTIVE DATES.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall apply to taxable years beginning after Decem-
ber 31, 2009. 
(2) CAPITATED
PRIMARY
CARE
PAYMENTS.— 
The amendment made by subsection (d) shall apply 
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to amounts paid before, on, or after the date of the 
enactment of this Act. 
SEC. 312. EXCEPTION TO REQUIREMENT FOR EMPLOYERS 
TO MAKE COMPARABLE HEALTH SAVINGS AC-
COUNT CONTRIBUTIONS. 
(a) GREATER
EMPLOYER-PROVIDED
CONTRIBU-
TIONS
TO HSAS
FOR CHRONICALLY ILL EMPLOYEES 
TREATED
AS
MEETING
COMPARABILITY
REQUIRE-
MENTS.—Subsection (b) of section 4980G (relating to fail-
ure of employer to make comparable health savings ac-
count contributions) is amended to read as follows: 
‘‘(b) RULES AND REQUIREMENTS.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), rules and requirements similar to the 
rules and requirements of section 4980E shall apply 
for purposes of this section. 
‘‘(2) TREATMENT
OF
EMPLOYER-PROVIDED 
CONTRIBUTIONS
TO
HSAS
FOR
CHRONICALLY
ILL 
EMPLOYEES.—For purposes of this section— 
‘‘(A) IN GENERAL.—Any contribution by 
an employer to a health savings account of an 
employee who is (or the spouse or any depend-
ent of the employee who is) a chronically ill in-
dividual in an amount which is greater than a 
contribution to a health savings account of a 
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comparable participating employee who is not a 
chronically ill individual shall not fail to be con-
sidered a comparable contribution. 
‘‘(B) 
NONDISCRIMINATION
REQUIRE-
MENT.—Subparagraph (A) shall not apply un-
less the excess employer contributions described 
in subparagraph (A) are the same for all chron-
ically ill individuals who are similarly situated. 
‘‘(C) CHRONICALLY ILL INDIVIDUAL.—For 
purposes of this paragraph, the term ‘chron-
ically ill individual’ means any individual whose 
qualified medical expenses for any taxable year 
are more than 50 percent greater than the av-
erage qualified medical expenses of all employ-
ees of the employer for such year.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2009. 
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TITLE IV—FAIRNESS FOR EVERY 
AMERICAN PATIENT 
Subtitle A—Medicaid 
Modernization 
SEC. 401. MEDICAID MODERNIZATION. 
(a) IN GENERAL.—Effective January 1, 2011, title 
XIX of the Social Security Act (42 U.S.C. 1396 et seq.) 
is amended to read as follows: 
‘‘TITLE XIX—GRANTS TO STATES 
FOR 
MEDICAL 
ASSISTANCE 
PROGRAMS 
‘‘TABLE OF CONTENTS OF TITLE 
‘‘Sec. 1900. References to pre-modernized Medicaid provisions; continuity for 
commonwealths and territories. 
‘‘PART A—GRANTS TO STATES FOR ACUTE CARE FOR INDIVIDUALS WITH 
DISABILITIES AND CERTAIN LOW-INCOME INDIVIDUALS 
‘‘Sec. 1901. Purpose; Appropriation. 
‘‘Sec. 1902. Payments to States for acute care medical assistance. 
‘‘Sec. 1903. Definitions of eligible individuals and acute care medical assist-
ance. 
‘‘Sec. 1904. State plan requirements for acute care medical assistance. 
‘‘Sec. 1905. Definitions. 
‘‘Sec. 1906. Enrollment of individuals under group health plans and other ar-
rangements. 
‘‘Sec. 1907. Drug rebates. 
‘‘Sec. 1908. Managed care. 
‘‘Sec. 1909. Annual reports. 
‘‘PART B—GRANTS TO STATES FOR LONG-TERM CARE SERVICES AND 
SUPPORTS 
‘‘Sec. 1911. Purpose. 
‘‘Sec. 1912. State plan. 
‘‘Sec. 1913. State allotments. 
‘‘Sec. 1914. Use of grants. 
‘‘Sec. 1915. Administrative provisions. 
‘‘Sec. 1916. Definition of long-term care services and supports. 
‘‘Sec. 1917. Provision requirements for long-term care services and supports, 
including option for self-directed services and supports. 
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‘‘Sec. 1918. Treatment of income and resources for certain institutionalized 
spouses. 
‘‘Sec. 1919. Annual reports. 
‘‘PART C—GRANTS TO STATES FOR SURVEY AND CERTIFICATION OF 
MEDICAL FACILITIES AND OTHER REQUIREMENTS 
‘‘Sec. 1931. Authorization of appropriations. 
‘‘Sec. 1932. Application of certain requirements under pre-modernized Med-
icaid. 
‘‘PART D—GRANTS TO STATES FOR PROGRAM INTEGRITY 
‘‘Sec. 1941. Authorization of appropriations. 
‘‘Sec. 1942. Application of certain requirements under pre-modernized Med-
icaid. 
‘‘PART E—GRANTS TO STATES FOR ADMINISTRATION 
‘‘Sec. 1951. Authorization of appropriations; payments to states. 
‘‘Sec. 1952. Cost-sharing protections. 
‘‘Sec. 1953. Application of certain requirements under pre-modernized Med-
icaid. 
‘‘PART F—OTHER PROVISIONS 
‘‘Sec. 1961. Application of certain requirements under pre-modernized Med-
icaid. 
‘‘SEC. 1900. REFERENCES TO PRE-MODERNIZED MEDICAID 
PROVISIONS; 
CONTINUITY 
FOR 
COMMON-
WEALTHS AND TERRITORIES. 
‘‘(a) IN GENERAL.—In this title, if a reference to this 
title or to a provision of this title is prefaced by the term 
‘old’, such reference is to this title or a provision of this 
title as in effect on December 31, 2010. 
‘‘(b) REGULATIONS.—The Secretary shall promul-
gate regulations to bring requirements imposed under an 
old provision of this title that applies under this title after 
December 31, 2010, into conformity with the policies em-
bodied in this title as in effect on and after January 1, 
2011. 
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‘‘(c) CONTINUITY FOR COMMONWEALTHS AND TER-
RITORIES.—In the case of Puerto Rico, the United States 
Virgin Islands, Guam, the Northen Mariana Islands, and 
American Samoa, this title as in effect on and after Janu-
ary 1, 2011, shall not apply to such commonwealths and 
territories, and old title XIX shall apply to a Medicaid pro-
gram operated by such commonwealths or territories on 
and after that date. 
‘‘PART A—GRANTS TO STATES FOR ACUTE CARE 
FOR INDIVIDUALS WITH DISABILITIES AND 
CERTAIN LOW-INCOME INDIVIDUALS 
‘‘SEC. 1901. PURPOSE; APPROPRIATION. 
‘‘(a) PURPOSE.—It is the purpose of this part to en-
able each State, as far as practicable under the conditions 
in the State, to provide acute care medical assistance to 
eligible individuals described in section 1903 whose income 
and resources are insufficient to meet the costs of nec-
essary medical services, and (2) rehabilitation and other 
services to help such individuals attain or retain capability 
for independence or self-care. 
‘‘(b) APPROPRIATION.—For the purpose of making 
payments to States under this part, there is appropriated 
out of any money in the Treasury not otherwise appro-
priated, such sums as are necessary for fiscal year 2011 
and each fiscal year thereafter. 
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‘‘SEC. 1902. PAYMENTS TO STATES FOR ACUTE CARE MED-
ICAL ASSISTANCE. 
‘‘(a) IN GENERAL.—From the amounts appropriated 
under section 1901 for a fiscal year, the Secretary shall 
pay to each State which has a plan approved under this 
part, for each quarter, beginning with the quarter com-
mencing January 1, 2011, an amount equal to the Federal 
medical assistance percentage (as defined in section 
1905(b)) of the total amount expended during such quar-
ter as acute care medical assistance under the State plan 
under this part. 
‘‘(b) ADMINISTRATIVE EXPENSES.—Each State with 
a plan approved under this part shall receive a payment 
determined in accordance with part E for administrative 
expenses incurred in carrying out the plan under this part 
and part B (if the State has a plan approved under that 
part). 
‘‘SEC. 1903. DEFINITIONS OF ELIGIBLE INDIVIDUALS AND 
ACUTE CARE MEDICAL ASSISTANCE. 
‘‘(a) ELIGIBLE INDIVIDUALS.— 
‘‘(1) IN GENERAL.—In this part, the term ‘eli-
gible individual’ means an individual— 
‘‘(A) who is— 
‘‘(i) a blind or disabled individual; or 
‘‘(ii) an individual described in para-
graph (2); and 
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‘‘(B) who the State determines satisfies— 
‘‘(i) the income and resources eligi-
bility requirements established by the State 
under the State plan under this part; and 
‘‘(ii) such other requirements for as-
sistance as are imposed under this title, in-
cluding documentation of citizenship or 
status as a qualified alien under title IV of 
the Personal Responsibility and Work Op-
portunity Reconciliation Act of 1996. 
‘‘(2) INDIVIDUALS DESCRIBED.—For purposes 
of paragraph (1)(A)(ii), the following individuals are 
described in this paragraph: 
‘‘(A) A child in foster care under the re-
sponsibility of the State. 
‘‘(B) A low-income woman with breast or 
cervical 
cancer 
described 
in 
old 
section 
1902(aa). 
‘‘(C) Certain TB-infected individuals de-
scribed in old section 1902(z)(1). 
‘‘(3) GRANDFATHERED INDIVIDUALS.—An indi-
vidual shall be an eligible individual under the State 
plan under this part if— 
‘‘(A) the individual is described in para-
graph (1)(A); 
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‘‘(B) the individual satisfies the docu-
mentation requirements referred to in para-
graph (1)(B)(ii); and 
‘‘(C) the State would have provided med-
ical assistance under the State plan under old 
title XIX to the individual, but only so long as 
the individual continues to satisfy such old eligi-
bility requirements. 
‘‘(4) CONCURRENT ELIGIBILITY FOR PART B.— 
An eligible individual under this part may be eligible 
under part B, but only if the individual satisfies the 
eligibility requirements of part B in addition to sat-
isfying the requirements for eligibility under this 
part. 
‘‘(5) PRESUMPTIVE ELIGIBILITY FOR CERTAIN 
BREAST OR CERVICAL CANCER PATIENTS.—Old sec-
tion 1920B (relating to presumptive eligibility for 
certain breast or cervical cancer patients) shall apply 
under this part. 
‘‘(b) BENEFITS.—Subject to paragraph (3), in this 
part, the term ‘acute care medical assistance’ means the 
following: 
‘‘(1) MANDATORY
BENEFITS.—The care and 
services listed in paragraphs (1) through (5), (17), 
and (21) of old section 1905(a) (but, in the case of 
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paragraph (4)(A) of such section, without regard to 
any limitation based on age or services in an institu-
tion for mental diseases). 
‘‘(2) OPTIONAL BENEFITS.—Any care or serv-
ices listed in a paragraph of old section 1905(a) 
(other than paragraph (16)). 
‘‘(3) EXCEPTIONS.— 
‘‘(A) CERTAIN SERVICES LIMITED TO PART 
B.—Services described in paragraphs (15), 
(22), (23), (24), and (26) of old section 
1905(a) shall only be provided under the State 
plan under part B. 
‘‘(B) LIMIT ON PROVISION OF LONG-TERM 
CARE
SERVICES
AND
SUPPORTS.—A care or 
service that the Secretary determines is a long- 
term care service and support (including nurs-
ing facility services described in old section 
1905(a)(4)(A)) shall not be provided to an indi-
vidual under the State plan under this part for 
more than 30 days within any 12-month period. 
‘‘(C) EXCLUSIONS.—Such term shall not 
include any payments with respect to care or 
services for any individual who is an inmate of 
a public institution or a patient in an institu-
tion for mental diseases (regardless of age). 
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‘‘SEC. 1904. STATE PLAN REQUIREMENTS FOR ACUTE CARE 
MEDICAL ASSISTANCE. 
‘‘(a) IN GENERAL.—In order to receive payments 
under this part, a State shall have an approved State plan 
for acute care medical assistance. For purposes of this 
part, such assistance includes payments for preventive 
care, primary care, diagnosis and treatment of acute and 
chronic health conditions, emergency care, diagnosis and 
treatment of mental illnesses and related conditions, and 
rehabilitation and other services to help eligible individuals 
attain or retain capability for independence or self-care. 
A State medical assistance plan shall include a descrip-
tion, consistent with the requirements of this part of— 
‘‘(1) eligibility standards, including income and 
asset standards; 
‘‘(2) benefits, including the amount, duration, 
and scope of covered items and services; 
‘‘(3) strategies for improving access and quality 
of care; and 
‘‘(4) methods of service delivery. 
‘‘(b) PUBLIC AVAILABILITY OF STATE PLAN.—The 
State shall make available to the public the State plan 
under this part and any amendments submitted by the 
State to the plan. 
‘‘(c) AMOUNT, DURATION, AND SCOPE.—The State 
plan shall provide that the acute care medical assistance 
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made available to any eligible individual shall not be less 
in amount, duration, or scope than the acute care medical 
assistance made available to any other eligible individual. 
‘‘(d) APPLICATION OF CERTAIN PRE-MODERNIZED 
MEDICAID REQUIREMENTS.— 
‘‘(1) OLD STATE PLAN REQUIREMENTS.—The 
following provisions of old section 1902 shall apply 
to the State plans under this part: 
‘‘(A) Old section 1902(a)(10)(C) (relating 
to certain eligibility and other requirements). 
‘‘(B) Old section 1902(a)(10)(D) (relating 
to home health services). 
‘‘(C) Old section 1902(a)(10)(G) (relating 
to nonapplication of certain supplemental secu-
rity income eligibility criteria). 
‘‘(D) The subclauses in the flush matter 
following old section 1902(a)(10)(G) (relating 
to the provision of certain services) other than 
subclauses (V), (VII), (VIII), and (IX). 
‘‘(E) Old section 1902(a)(17) (relating to 
reasonable standards for determining eligi-
bility). 
‘‘(F) Old section 1902(a)(19) (relating to 
eligibility safeguards). 
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‘‘(G) Old section 1902(a)(34) (relating to 
eligibility beginning with the third month prior 
to the month of application). 
‘‘(H) Subparagraphs (A), (B), and (C) of 
old section 1902(a)(43) (relating to early and 
periodic screening, diagnostic, and treatment 
services). 
‘‘(I) Old section 1902(a)(46)(A) (relating 
to compliance with section 1137 requirements). 
‘‘(J) The fourth and sixth sentences of old 
section 1902(a) (relating to eligibility for cer-
tain individuals). 
‘‘(2) OTHER OLD TITLE XIX REQUIREMENTS.— 
‘‘(A) Old section 1902(e)(3) (relating to 
optional eligibility for certain disabled individ-
uals). 
‘‘(B) Old section 1902(e)(9) (relating to 
optional respiratory care services). 
‘‘(C) Old section 1902(f) (relating to eligi-
bility of certain aged, blind, or disabled individ-
uals). 
‘‘(D) Old section 1902(m) (relating to eli-
gibility of certain aged or disabled individuals), 
other than paragraph (4). 
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‘‘(E) Old section 1902(o) (relating to dis-
regard of certain supplemental security income 
benefits). 
‘‘(F) Old section 1902(v) (relating to eligi-
bility determinations of blind or disabled indi-
viduals). 
‘‘(e) OTHER REQUIREMENTS.—The State plan under 
this part shall— 
‘‘(1) comply with the requirements of the other 
parts of this title; and 
‘‘(2) provide that the State will make the con-
tributions specified under section 340A–1(e) of the 
Public Health Service Act . 
‘‘SEC. 1905. DEFINITIONS. 
‘‘(a) IN GENERAL.—The definitions specified in this 
section shall apply for purposes of this part and, to the 
extent applicable and consistent with the policy embodied 
in such part, parts B, C, D, E, and F. 
‘‘(b) FEDERAL MEDICAL ASSISTANCE PERCENT-
AGE.—The term ‘Federal medical assistance percentage’ 
for any State shall be 100 percent less the State percent-
age; and the State percentage shall be that percentage 
which bears the same ratio to 45 percent as the square 
of the per capita income of such State bears to the square 
of the per capita income of the continental United States 
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(including Alaska) and Hawaii, except that the Federal 
medical assistance percentage shall in no case be less than 
50 percent or more than 83 percent. The Federal medical 
assistance percentage for any State shall be determined 
and promulgated in accordance with the provisions of sec-
tion 1101(a)(8)(B). 
‘‘(c) APPLICATION OF CERTAIN PRE-MODERNIZED 
MEDICAID PROVISIONS.—The following old provisions 
shall apply under this part: 
‘‘(1) OLD SECTION 1905 PROVISIONS.—The fol-
lowing provisions of old section 1905: 
‘‘(A) Old section 1905(d) (relating to the 
definition of an intermediate care facility for 
the mentally retarded). 
‘‘(B) Old section 1905(e) (relating to the 
definition of physicians services). 
‘‘(C) Old section 1905(f) (relating to the 
definition of nursing facility services). 
‘‘(D) Old section 1905(g) (relating to the 
provision of chiropractors’ services). 
‘‘(E) Old section 1905(j) (relating to State 
supplementary payments). 
‘‘(F) Old section 1905(k) (relating to sup-
plemental security income benefits payable pur-
suant to section 211 of Public Law 93–66). 
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‘‘(2) OTHER OLD PROVISIONS.— 
‘‘(A) Old section 1903(m) (relating to the 
definition of a medicaid managed care organiza-
tion). 
‘‘SEC. 1906. ENROLLMENT OF INDIVIDUALS UNDER GROUP 
HEALTH PLANS AND OTHER ARRANGEMENTS. 
‘‘The following old provisions shall apply under this 
part: 
‘‘(1) Old section 1906 (relating to enrollment of 
individuals under group health plans). 
‘‘(2) Old section 1902(a)(70) (relating to State 
option to establish a non-emergency medical trans-
portation brokerage program). 
‘‘(3) Paragraphs (2) and (11) of old section 
1902(e) (relating to eligibility for individuals en-
rolled with a group health plan or under a managed 
care arrangement during a minimum enrollment pe-
riod). 
‘‘SEC. 1907. DRUG REBATES. 
‘‘Old sections 1902(a)(54) and 1927 (relating to pay-
ment for covered outpatient drugs and rebates) shall apply 
under this part. 
‘‘SEC. 1908. MANAGED CARE. 
‘‘The following old provisions shall apply under this 
part: 
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‘‘(1) Old section 1932 (relating to managed 
care), other than subsection (a)(2) of such section. 
‘‘(2) Old section 1903(k) (relating to technical 
and actuarial assistance for States). 
‘‘SEC. 1909. ANNUAL REPORTS. 
‘‘(a) IN GENERAL.—Each State that receives pay-
ments under this part shall submit an annual report to 
the Secretary, in such form and manner as the Secretary 
shall specify. 
‘‘(b) APPLICATION OF OLD EPSDT REPORTING RE-
QUIREMENTS.—Each annual report shall include the in-
formation required to be reported under old section 
1902(a)(43)(D)(iv). 
‘‘PART B—GRANTS TO STATES FOR LONG-TERM 
CARE SERVICES AND SUPPORTS 
‘‘SEC. 1911. PURPOSE. 
‘‘(a) IN GENERAL.—The purpose of this part is to 
increase the flexibility of States in operating a system of 
long-term care services and supports designed to— 
‘‘(1) provide assistance to needy families so that 
individuals with disabilities and low-income senior 
citizens may be served and supported in their own 
homes and communities; 
‘‘(2) emphasize the independence and dignity of 
the person served by public programs; 
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‘‘(3) end the institutional bias that existed 
under the Medicaid program prior to January 1, 
2011; 
‘‘(4) provide stable and predictable funding for 
States as they rebalance their long-term care sys-
tems from institutions to communities; 
‘‘(5) provide flexibility to States to adopt new 
and innovative service delivery methods; and 
‘‘(6) promote independence and support activi-
ties that will enable individuals to return or main-
tain ties to the community, including through em-
ployment. 
‘‘(b) NO INDIVIDUAL ENTITLEMENT.—No individual 
determined eligible for long-term care services and sup-
ports under this part shall be entitled to a specific service 
or type of delivery of service. 
‘‘SEC. 1912. STATE PLAN. 
‘‘(a) IN GENERAL.—In order to receive payments 
under this part, a State must have an approved State plan 
for long-term care services and supports. A State long 
term care services and supports plan shall include a de-
scription, consistent with the requirements of this part, 
of— 
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‘‘(1) income and assets eligibility standards and 
spousal impoverishment protections consistent with 
subsection (b); 
‘‘(2) the standardized assessments tools used to 
determine eligibility for specific long-term care serv-
ices and supports; 
‘‘(3) the person-centered plans used to provide 
such services and supports; 
‘‘(4) the proposed uses of funding, if applicable, 
to provide targeted methods to meet individual level 
of support needs including tiering (preventive, emer-
gency, low, medium, high); and 
‘‘(5) the long-term care services and supports to 
be available under the plan based on individual as-
sessment of need in accordance with sections 1916 
and 1917. 
‘‘(b) MINIMUM ELIGIBILITY STANDARDS.— 
‘‘(1) POPULATIONS COVERED.—The State plan 
shall specify the disabled and elderly populations 
who are eligible for long-term care services and sup-
ports. 
‘‘(2) NEEDS-BASED CRITERIA.—The plan shall 
include a description of the needs-based criteria the 
State will use to assess an individual’s need for spe-
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cific services and supports available under the State 
plan. 
‘‘(3) OTHER ELIGIBILITY REQUIREMENTS.— 
‘‘(A) INCOME AND ASSETS.—A State may 
use different income and asset standards and 
methodologies for determining eligibility than 
those used for determining eligibility for acute 
care medical assistance under part A. A State 
may not make eligibility standards related to 
income, asset, and spousal impoverishment pro-
tection more restrictive than the Federal min-
imum requirements of December 31, 2008. 
‘‘(B) APPLICATION OF SPOUSAL IMPOVER-
ISHMENT PROTECTIONS.—The State plan shall 
provide that the State shall comply with the re-
quirements of section 1918 (relating to spousal 
impoverishment protections). 
‘‘(C) STATEWIDENESS.—The State plan 
shall provide that, except with respect to meth-
ods used for determining homestead exemp-
tions, the income and asset standards and 
methodologies shall be in effect in all political 
subdivisions of the State. 
‘‘(4) TRANSITION ASSISTANCE.—The State plan 
shall specify how the State will provide transition as-
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sistance for individuals who, on December 31, 2010, 
are enrolled under the State plan under old title 
XIX (or under a waiver of that plan) and receiving 
long-term care services or supports on that date. 
The State shall provide such assistance to individ-
uals who are and are not likely to be determined eli-
gible for long-term care services and supports under 
the State plan under this part, as in effect on Janu-
ary 1, 2011 (or the first day on which the State plan 
is in effect under this part). 
‘‘(c) PAYMENT METHODOLOGIES TO PROVIDERS.— 
‘‘(1) IN GENERAL.—The State plan shall de-
scribe the methodologies used to determine payments 
to providers. Such methodologies— 
‘‘(A) 
may 
be 
varied 
to 
assist 
in 
transitioning from facilities-based to commu-
nity-based care; and 
‘‘(B) shall not be subject to Secretarial ap-
proval. 
‘‘(2) TRANSPARENCY.—The State plan shall 
provide that the State shall make publicly avail-
able— 
‘‘(A) the payment methodologies applicable 
under the plan; and 
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‘‘(B) the name of any provider that re-
ceives $1,000,000 or more in any 12-month pe-
riod and the actual amount paid to the provider 
during that period. 
‘‘(d) COORDINATION OF EFFORT WITH OTHER RE-
LATED PUBLIC AND PRIVATE PROGRAMS.—The plan shall 
include a description of the State’s efforts to coordinate 
the delivery of services and supports under the plan with 
other related public and private programs that serve indi-
viduals with disabilities or aged populations that need or 
may be at risk of needing long term care. 
‘‘(e) PUBLIC AVAILABILITY OF STATE PLAN.—The 
State shall make available to the public the State plan 
under this part and any amendments submitted by the 
State to the plan. 
‘‘(f) APPLICATION OF OLD TITLE XIX REQUIRE-
MENTS.—The following old title XIX provisions shall 
apply to a State plan under this part: 
‘‘(1) Subsections (a)(50) and (q) of old section 
1902 (relating to a monthly personal needs allow-
ance for certain institutionalized individuals and 
couples). 
‘‘(2) Old section 1902(a)(67) (relating to pay-
ment for certain services furnished to a PACE pro-
gram eligible individual). 
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‘‘(3) Paragraph (1) of old section 1902(r) (re-
lating to the post-eligibility treatment of income for 
certain individuals) and paragraph (2) of such sec-
tion (relating to methodologies for determining in-
come and resource eligibility for individuals, but only 
with respect to individuals who are eligible under 
this part on or after January 1, 2011). 
‘‘(4) Old section 1905(i) (relating to the defini-
tion of an institution for mental diseases). 
‘‘(g) OTHER REQUIREMENTS OF OTHER PARTS.— 
The State plan under this part shall— 
‘‘(1) comply with the requirements of the other 
parts of this title; and 
‘‘(2) provide that the State will make the con-
tributions specified under section 340A–1(e) of the 
Public Health Service Act. 
‘‘SEC. 1913. STATE ALLOTMENTS. 
‘‘(a) APPROPRIATION.—For the purpose of providing 
allotments to States under this section, there is appro-
priated out of any money in the Treasury not otherwise 
appropriated— 
‘‘(1) for fiscal year 2011, $65,274,560,000; 
‘‘(2) for fiscal year 2012, $67,885,540,000; 
‘‘(3) for fiscal year 2013, $70,600,964,100; 
‘‘(4) for fiscal year 2014, $73,425,000,000; 
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‘‘(5) for fiscal year 2015, $76,362,000,000; 
‘‘(6) for fiscal year 2016, $79,416,480,000; 
‘‘(7) for fiscal year 2017, $82,593,140,000; 
‘‘(8) for fiscal year 2018, $85,896,870,000; and 
‘‘(9) for fiscal year 2019, $89,332,743,000. 
‘‘(b) ALLOTMENTS TO 50 STATES AND THE DISTRICT 
OF COLUMBIA.— 
‘‘(1) FISCAL YEAR 2011 ALLOTMENTS.—Subject 
to subsection (e), the Secretary shall allot to each 
State with a long term care plan approved under 
this title an amount in fiscal year 2011 equal to the 
Federal expenditures made by the State for long- 
term care as defined in section 1916 in fiscal year 
2008, increased by 8 percent. 
‘‘(2) 
SUBSEQUENT
FISCAL
YEAR
ALLOT-
MENTS.—For fiscal year 2012 and each subsequent 
fiscal year through fiscal year 2019, the allotment 
for a State under this section is equal to the allot-
ment for the State determined for the preceding fis-
cal year, increased by 4 percent. 
‘‘(c) LIMITATION.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), no other Federal funds are available 
under this title for expenditures incurred for long- 
term care services and supports after December 31, 
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2010, except as provided under a State plan ap-
proved under this part. 
‘‘(2) EXCEPTION.— 
‘‘(A) IN GENERAL.—If a State does not 
have an approved State plan by October 1, 
2010, the Secretary may make payments equal 
to 85 percent of the State’s estimated quarterly 
allotment until June 30, 2011. 
‘‘(B) FULL FUNDING.—A State shall re-
ceive 100 percent of its allotment for fiscal year 
2011 if the State has a plan approved under 
this part by June 30, 2011. 
‘‘(d) MAINTENANCE OF EFFORT.—In order to qualify 
for the grant payable under this section, the State must 
demonstrate in each fiscal year that it made long-term 
care service and supports expenditures (including funding 
from local government sources) equal to the amount of 
not less than 95 percent of the nonfederal share amount 
spent in fiscal year 2009 under the State plan under old 
title XIX on long term care services and supports (as de-
fined in section 1916). Expenditures not made under this 
part shall not be recognized by the Secretary for purposes 
of this requirement. 
‘‘(e) GRANTS REDUCED IF INSUFFICIENT APPRO-
PRIATIONS.— 
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‘‘(1) IN GENERAL.—If the amount appropriated 
for fiscal year 2011 under subsection (a)(1) is less 
than the amount necessary to fund each State’s al-
lotment for that fiscal year, the Secretary shall re-
duce the allotment for each State for that fiscal year 
based on the applicable percentage determined for 
the State under paragraph (2) provide a reduced 
percentage basis as follows: Each state shall receive 
a percentage of its allotment based on the ratio of 
non-institutional spending to total long term care 
spending in FY 2009. 
‘‘(2) APPLICABLE PERCENTAGE.—For purposes 
of paragraph (1), the applicable percentage deter-
mined with respect to a State is as follows: 
‘‘If the ratio of the State’s non-institutional 
spending to total long-term care spending 
for fiscal year 2009 is: 
The applicable 
percentage is: 
50 percent or greater .............................................
100 
at least 46, but less than 50 percent .....................
at least 40, but less than 46 percent .....................
at least 36, but less than 40 ..................................
at least 30, but less than 36 ..................................
less than 30 percent ...............................................
95. 
‘‘(f) ADMINISTRATIVE EXPENSES.— 
‘‘(1) IN GENERAL.—Each State with a plan ap-
proved under this part shall receive a payment deter-
mined in accordance with amounts appropriated for 
part E for administrative expenses incurred in car-
rying out the plan under this part and part A. 
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‘‘(2) ASSESSMENT-RELATED COSTS.—Costs at-
tributable to providing an individualized needs-based 
assessment for purposes of identifying the long-term 
care services and supports to be provided under the 
State plan to an individual shall be considered a 
long-term care service and support and shall not be 
treated as an administrative expense. 
‘‘SEC. 1914. USE OF GRANTS. 
‘‘(a) IN GENERAL.—A State shall use funds for long- 
term care services and supports as defined in section 
1916. 
‘‘(b) SELF-DIRECTION.—A State shall offer individ-
uals the opportunity to self-direct their long-term care 
services and supports. 
‘‘SEC. 1915. ADMINISTRATIVE PROVISIONS. 
‘‘(a) FUNDING ON A QUARTERLY BASIS.—The Sec-
retary shall make payments to States in equal amounts 
of a State’s annual allotment on a quarterly basis. Each 
quarterly payment shall remain available for use by the 
State for twelve succeeding fiscal year quarters. 
‘‘(b) PUBLICATION.—The Secretary shall publish 
each State’s allotment— 
‘‘(1) for fiscal year 2011 not later than Decem-
ber 15, 2009; and 
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‘‘(2) for each subsequent fiscal year, not later 
than December 15 of the calendar year preceding 
the calendar year in which the fiscal year begins. 
‘‘SEC. 1916. DEFINITION OF LONG-TERM CARE SERVICES 
AND SUPPORTS. 
‘‘(a) DEFINITION.— 
‘‘(1) IN GENERAL.—Subject to subsection (e), 
in this part, the term ‘long-term care services and 
supports’ means any of the services or supports 
specified in paragraphs (2) or (3) that may be pro-
vided in a nursing facility, an institution, a home, or 
other setting. 
‘‘(2) SERVICES AND SUPPORTS DESCRIBED.— 
For purposes of paragraph (1), the services and sup-
ports described in this paragraph include assistive 
technology, adaptive equipment, remote monitoring 
equipment, case management for the aged, case 
management for individuals with disabilities, nursing 
home services, long-term rehabilitative services nec-
essary to restore functional abilities, services pro-
vided in intermediate care facilities for people with 
disabilities, habilitation services (including adult day 
care programs), community treatment teams for in-
dividuals with mental illness, home health services, 
services provided in an institution for mental dis-
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ease, a Program of All-Inclusive Care for the Elderly 
(PACE), personal care (including personal assist-
ance services), recovery support including peer coun-
seling, supportive employment, training skills nec-
essary to assist the individual in achieving or main-
taining independence, training of family members in-
cluding foster parents in supportive and behavioral 
modification skills, ongoing and periodic training to 
maintain life skills, transitional care including room 
and board not to exceed 60 days within a 12-month 
period. 
‘‘(3) INCLUSION OF CERTAIN BENEFITS UNDER 
OLD TITLE XIX.—Such services and supports may 
include any of the following services: 
‘‘(A) Old section 1905(a)(15) (relating to 
services in an intermediate care facility for the 
mentally retarded). 
‘‘(B) Services described in subsections 
(a)(16) and (h) of old section 1905, but without 
regard to any restriction on such services on 
the basis of age (relating to inpatient psy-
chiatric hospital services). 
‘‘(C) Old section 1905(a)(22) (relating to 
home and community care (to the extent al-
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lowed and as defined in old section 1929) for 
functionally disabled elderly individuals). 
‘‘(D) Old section 1905(a)(23) (relating to 
community supported living arrangements serv-
ices (to the extent allowed and as defined in old 
section 1930)). 
‘‘(E) Subject to subsection (e), old section 
1905(a)(24) but without regard to any restric-
tion on furnishing services to patients or resi-
dents of facilities or institutions (relating to 
personal care services). 
‘‘(F) Old sections 1905(a)(26) and 1934 
(relating to services furnished under a PACE 
program under old section 1934 to PACE pro-
gram eligible individuals enrolled under the pro-
gram under such old section). 
‘‘(G) Old section 1915(c)(5) (relating to 
the definition of habilitation services). 
‘‘(4) LIMITATION.—Long-term care services 
and supports cannot be used for services and admin-
istrative costs provided through the foster care (with 
the exception of training of foster care parents), 
child welfare, adult protective services, juvenile jus-
tice, public guardianship, or correctional systems. 
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‘‘(b) REHABILITATIVE CARE.—For purposes of reha-
bilitation due to acute care medical needs, a State may 
claim rehabilitative services provided in an institutional 
setting, nursing home, or as part of home health expendi-
tures as acute care benefits under the State plan under 
part A rather than under the State plan under this part 
for a cumulative period of 30 days within a 12-month pe-
riod if such care is directly related to the onset of an acute 
care need. A State shall demonstrate the services were 
provided as a direct result of an acute care need. 
‘‘(c) MANAGED CARE.—If a State provides long-term 
care services and supports through managed care, the 
State shall submit a methodology for determining the level 
of expenditures attributed to long term care for approval 
by the Secretary. 
‘‘(d) APPLICATION OF PART A DEFINITIONS.—A def-
inition specified in section 1905 shall apply to the same 
term used in this part, unless the Secretary determines 
that the application of such definition would be incon-
sistent with the purpose of this part. 
‘‘(e) EXCLUSION.—No payments shall be made under 
the State plan under this part with respect to long-term 
care supports and services provided for any individual who 
is an inmate of a public institution. Nothing in the pre-
ceding sentence shall be construed as precluding the provi-
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sion of long-term care services and supports under the 
State plan under this part to an individual who is a pa-
tient in an institution for mental diseases. 
‘‘SEC. 1917. PROVISION REQUIREMENTS FOR LONG-TERM 
CARE SERVICES AND SUPPORT, INCLUDING 
OPTION FOR SELF-DIRECTED SERVICES AND 
SUPPORTS. 
‘‘(a) REQUIREMENTS FOR THE PROVISION OF LONG- 
TERM CARE SERVICES AND SUPPORTS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding 
provisions of this subsection, a State may provide 
through a State plan amendment for the provision 
of long-term care services and supports for individ-
uals eligible under the State plan under this part, 
subject to the following requirements: 
‘‘(A) NEEDS-BASED CRITERIA FOR ELIGI-
BILITY
FOR, AND
RECEIPT
OF, LONG-TERM 
CARE SERVICES AND SUPPORTS.—The State es-
tablishes needs-based criteria for determining 
an individual’s eligibility under the State plan 
for medical assistance for such long-term care 
services and supports, and if the individual is 
eligible for such services and supports, the spe-
cific services and supports that will be available 
under the State plan to the individual. 
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‘‘(B) CRITERIA
FOR
INSTITUTIONALIZED 
VERSUS
NON-INSTITUTIONALIZED
SERVICES.— 
In establishing needs-based criteria, the State 
may establish criteria for determining eligibility 
for, and receipt of, services and supports pro-
vided in a facility or institution that are more 
stringent that the criteria established for eligi-
bility and receipt of services and supports in a 
non-facility or non-institutionalized setting. 
‘‘(C) AUTHORITY
TO
LIMIT
NUMBER
OF 
ELIGIBLE INDIVIDUALS.—A State may limit the 
number of individuals who are eligible for such 
services and supports and may establish waiting 
lists for the receipt of such services and sup-
ports. 
‘‘(D) CRITERIA BASED ON INDIVIDUAL AS-
SESSMENT.— 
‘‘(i) IN GENERAL.—The criteria estab-
lished by the State shall require an assess-
ment of an individual’s support needs and 
capabilities, and may take into account the 
inability of the individual to perform 2 or 
more activities of daily living (as defined in 
section 7702B(c)(2)(B) of the Internal 
Revenue Code of 1986) or the need for sig-
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nificant assistance to perform such activi-
ties, and such other risk factors as the 
State determines to be appropriate. 
‘‘(ii) ADJUSTMENT AUTHORITY.—The 
State plan amendment provides the State 
with the option to modify the criteria es-
tablished under subparagraph (A) (without 
having to obtain prior approval from the 
Secretary) in the event that the enrollment 
of individuals eligible for services exceeds 
the projected enrollment, but only if— 
‘‘(I) the State provides at least 
60 days notice to the Secretary and 
the public of the proposed modifica-
tion; 
‘‘(II) the State deems an indi-
vidual receiving long-term care serv-
ices and supports on the basis of the 
most recent version of the criteria in 
effect prior to the effective date of the 
modification to be eligible for such 
services and supports for a period of 
at least 12 months beginning on the 
date the individual first received med-
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ical assistance for such services and 
supports; and 
‘‘(III) after the effective date of 
such modification, the State, at a 
minimum, applies the criteria for de-
termining whether an individual re-
quires the level of care provided in a 
facility or institutionalized setting 
which applied under the State plan 
immediately prior to the application of 
the modified criteria. 
‘‘(E) INDEPENDENT EVALUATION AND AS-
SESSMENT.— 
‘‘(i) ELIGIBILITY DETERMINATION.— 
The State uses an independent evaluation 
for making the determinations described in 
subparagraph (A). 
‘‘(ii) ASSESSMENT.—In the case of an 
individual who is determined to be eligible 
for long-term care services and supports, 
the State uses an independent assessment, 
based on the needs of the individual to— 
‘‘(I) determine a necessary level 
of services and supports to be pro-
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vided, consistent with an individual’s 
physical and mental capacity; 
‘‘(II) prevent the provision of un-
necessary or inappropriate care; and 
‘‘(III) establish an individualized 
care plan for the individual in accord-
ance with subparagraph (G). 
‘‘(F) ASSESSMENT.—The independent as-
sessment required under subparagraph (E)(ii) 
shall include the following: 
‘‘(i) An objective evaluation of an in-
dividual’s inability to perform 2 or more 
activities of daily living (as defined in sec-
tion 7702B(c)(2)(B) of the Internal Rev-
enue Code of 1986) or the need for signifi-
cant assistance to perform such activities. 
‘‘(ii) A face-to-face evaluation of the 
individual by an individual trained in the 
assessment and evaluation of individuals 
whose physical or mental conditions trigger 
a potential need for long-term care services 
and supports. 
‘‘(iii) Where appropriate, consultation 
with the individual’s family, spouse, guard-
ian, or other responsible individual. 
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‘‘(iv) Consultation with appropriate 
treating and consulting health and support 
professionals caring for the individual. 
‘‘(v) An examination of the individ-
ual’s relevant history, medical records, and 
care and support needs, guided by best 
practices and research on effective strate-
gies that result in improved health and 
quality of life outcomes. 
‘‘(vi) An evaluation of the ability of 
the individual or the individual’s represent-
ative to self-direct the purchase of, or con-
trol the receipt of, such services and sup-
ports if the individual so elects. 
‘‘(G) INDIVIDUALIZED CARE PLAN.— 
‘‘(i) IN GENERAL.—In the case of an 
individual who is determined to be eligible 
for long-term care services and supports, 
the State uses the independent assessment 
required under subparagraph (E)(ii) to es-
tablish a written individualized care plan 
for the individual. 
‘‘(ii) 
PLAN
REQUIREMENTS.—The 
State ensures that the individualized care 
plan for an individual— 
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‘‘(I) is developed— 
‘‘(aa) in consultation with 
the individual, the individual’s 
treating physician, health care or 
support professional, or other ap-
propriate individuals, as defined 
by the State, and, where appro-
priate the individual’s family, 
caregiver, or representative; and 
‘‘(bb) taking into account 
the extent of, and need for, any 
family or other supports for the 
individual; 
‘‘(II) identifies the long-term care 
services and supports to be furnished 
to the individual (or, if the individual 
elects to self-direct the purchase of, or 
control the receipt of, such services 
and supports, funded for the indi-
vidual); and 
‘‘(III) is reviewed at least annu-
ally and as needed when there is a 
significant change in the individual’s 
circumstances. 
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‘‘(iii) STATE REQUIREMENT TO OFFER 
ELECTION FOR SELF-DIRECTED SERVICES 
AND SUPPORTS.— 
‘‘(I) INDIVIDUAL
CHOICE.—The 
State shall allow an individual or the 
individual’s representative the oppor-
tunity to elect to receive self-directed 
long-term care services and supports 
in a manner which gives them the 
most control over such services and 
supports consistent with the individ-
ual’s abilities and the requirements of 
subclauses (II) and (III). 
‘‘(II) 
SELF-DIRECTED.—The 
term ‘self-directed’ means, with re-
spect to the long-term care services 
and supports offered under the State 
plan amendment, such services and 
supports for the individual which are 
planned and purchased under the di-
rection and control of such individual 
or the individual’s authorized rep-
resentative, including the amount, du-
ration, scope, provider, and location of 
such services and supports, under the 
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State plan consistent with the fol-
lowing requirements: 
‘‘(aa) ASSESSMENT.—There 
is an assessment of the needs, ca-
pabilities, and preferences of the 
individual with respect to such 
services and supports. 
‘‘(bb) 
SERVICE
PLAN.— 
Based on such assessment, there 
is developed jointly with such in-
dividual or the individual’s au-
thorized representative a plan for 
such services and supports for 
such individual that is approved 
by the State and that satisfies 
the requirements of subclause 
(III). 
‘‘(III) PLAN
REQUIREMENTS.— 
For purposes of subclause (II)(bb), 
the requirements of this subclause are 
that the plan— 
‘‘(aa) specifies those services 
and supports which the individual 
or the individual’s authorized 
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representative would be respon-
sible for directing; 
‘‘(bb) identifies the methods 
by which the individual or the in-
dividual’s authorized representa-
tive will select, manage, and dis-
miss providers of such services 
and supports; 
‘‘(cc) specifies the role of 
family members and others whose 
participation is sought by the in-
dividual or the individual’s au-
thorized representative with re-
spect to such services and sup-
ports; 
‘‘(dd) is developed through a 
person-centered process that is 
directed by the individual or the 
individual’s authorized represent-
ative, builds upon the individual’s 
capacity to engage in activities 
that promote community life and 
that respects the individual’s 
preferences, choices, and abilities, 
and involves families, friends, 
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100 
and professionals as desired or 
required by the individual or the 
individual’s authorized represent-
ative; 
‘‘(ee) includes appropriate 
risk management techniques that 
recognize the roles and sharing of 
responsibilities in obtaining serv-
ices and supports in a self-di-
rected manner and assure the ap-
propriateness of such plan based 
upon the resources and capabili-
ties of the individual or the indi-
vidual’s authorized representa-
tive; and 
‘‘(ff) may include an individ-
ualized budget which identifies 
the dollar value of the services 
and supports under the control 
and direction of the individual or 
the individual’s authorized rep-
resentative. 
‘‘(IV) BUDGET
PROCESS.—With 
respect to individualized budgets de-
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101 
scribed in subclause (III)(ff), the 
State plan amendment— 
‘‘(aa) describes the method 
for calculating the dollar values 
in such budgets based on reliable 
costs and service utilization; 
‘‘(bb) defines a process for 
making adjustments in such dol-
lar values to reflect changes in 
individual assessments and serv-
ice plans; and 
‘‘(cc) provides a procedure 
to evaluate expenditures under 
such budgets. 
‘‘(H) QUALITY ASSURANCE; CONFLICT OF 
INTEREST STANDARDS.— 
‘‘(i) 
QUALITY
ASSURANCE.—The 
State ensures that the provision of long- 
term care services and supports meets 
Federal and State guidelines for quality 
assurance. 
‘‘(ii) CONFLICT OF INTEREST STAND-
ARDS.—The State establishes standards 
for the conduct of the independent evalua-
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102 
tion and the independent assessment to 
safeguard against conflicts of interest. 
‘‘(I) REDETERMINATIONS AND APPEALS.— 
The State allows for at least annual redeter-
minations of eligibility, and appeals in accord-
ance with the frequency of, and manner in 
which, redeterminations and appeals of eligi-
bility are made under the State plan. 
‘‘(J) PRESUMPTIVE ELIGIBILITY FOR AS-
SESSMENT.—The State, at its option, elects to 
provide for a period of presumptive eligibility 
(not to exceed a period of 60 days) only for 
those individuals that the State has reason to 
believe may be eligible for long-term care serv-
ices and supports. Such presumptive eligibility 
shall be limited to medical assistance for car-
rying out the independent evaluation and as-
sessment under subparagraph (E) to determine 
an individual’s eligibility for such services and 
if the individual is so eligible, the specific long- 
term care services and supports that the indi-
vidual will receive. 
‘‘(2) 
DEFINITION
OF
INDIVIDUAL’S
REP-
RESENTATIVE.—In this section, the term ‘individ-
ual’s representative’ means, with respect to an indi-
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103 
vidual, a parent, a family member, or a guardian of 
the individual, an advocate for the individual, or any 
other individual who is authorized to represent the 
individual. 
‘‘(b) SELF-DIRECTED PERSONAL ASSISTANCE SERV-
ICES.—If a State includes personal care or personal assist-
ance services in the long-term care services and supports 
available under the State plan, the State shall comply with 
the requirements of old section 1915(j) in the case of an 
individual who elects to self-direct the receipt of such care 
or services. 
‘‘SEC. 1918. TREATMENT OF INCOME AND RESOURCES FOR 
CERTAIN INSTITUTIONALIZED SPOUSES. 
‘‘Old section 1924 (relating to treatment of income 
and resources for certain institutionalized spouses), other 
than paragraphs (2) and (4)(A) of subsection (a) of such 
section, shall apply under this part. 
‘‘SEC. 1919. ANNUAL REPORTS. 
‘‘(a) IN GENERAL.—Each State that receives pay-
ments under this part shall submit an annual report to 
the Secretary, in such form and manner as the Secretary 
shall specify. 
‘‘(b) REQUIREMENTS.—The report shall include the 
following with respect to the most recent fiscal year ended: 
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104 
‘‘(1) The number of individuals served under 
the plan. 
‘‘(2) The number of individuals served by tier 
(preventive, emergency, low, medium, and high 
needs). 
‘‘(3) The number of individuals known to the 
State on waiting list for services (if any) and type 
of disability (physical, developmental, mental health) 
or aged. 
‘‘(4) Expenditures by service category. 
‘‘PART C—GRANTS TO STATES FOR SURVEY AND 
CERTIFICATION 
OF 
MEDICAL 
FACILITIES 
AND OTHER REQUIREMENTS 
‘‘SEC. 1931. AUTHORIZATION OF APPROPRIATIONS. 
‘‘For the purpose of carrying our Federal activities 
and providing grants to States for expenses necessary to 
carry out this part, there is authorized to be appro-
priated— 
‘‘(1) for fiscal year 2011, $300,000,000; and 
‘‘(2) for each succeeding fiscal year, the amount 
authorized under this section for the preceding fiscal 
year, increased by 5 percent. 
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106 
‘‘(9) Old section 1903(q)(4)(B) (relating to the 
definition of a board and care facility). 
‘‘(10) Old section 1910 (relating to certification 
and approval of rural health clinics and intermediate 
care facilities for the mentally retarded). 
‘‘(11) Old section 1911 (relating to Indian 
Health Service facilities). 
‘‘(12) Old section 1913 (relating to hospital 
providers of nursing facility services). 
‘‘(13) Old section 1919 (relating to require-
ments for nursing facilities). 
‘‘PART D—GRANTS TO STATES FOR PROGRAM 
INTEGRITY 
‘‘SEC. 1941. AUTHORIZATION OF APPROPRIATIONS. 
‘‘(a) IN GENERAL.—For the purpose of carrying out 
Federal activities under this part and providing grants to 
States for expenses necessary to carry out this part, there 
is authorized to be appropriated— 
‘‘(1) for fiscal year 2011, $100,000,000; and 
‘‘(2) for each succeeding fiscal year, the amount 
authorized under this section for the preceding fiscal 
year, increased by 5 percent. 
‘‘(b) AVAILABILITY; AUTHORITY
FOR
USE
OF 
FUNDS.— 
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107 
‘‘(1) 
AVAILABILITY.—Amounts 
appropriated 
pursuant to subsection (a) shall remain available 
until expended. 
‘‘(2) AUTHORITY
FOR
USE
OF
FUNDS
FOR 
TRANSPORTATION
AND
TRAVEL
EXPENSES
FOR 
ATTENDEES
AT
EDUCATION, TRAINING, OR
CON-
SULTATIVE ACTIVITIES.— 
‘‘(A) IN
GENERAL.—The Secretary may 
use amounts appropriated pursuant to sub-
section (a) to pay for transportation and the 
travel expenses, including per diem in lieu of 
subsistence, at rates authorized for employees 
of agencies under subchapter I of chapter 57 of 
title 5, United States Code, while away from 
their homes or regular places of business, of in-
dividuals described in subsection (b)(4) who at-
tend education, training, or consultative activi-
ties conducted under the authority of that sub-
section. 
‘‘(B) PUBLIC DISCLOSURE.—The Secretary 
shall make available on a website of the Centers 
for Medicare & Medicaid Services that is acces-
sible to the public— 
‘‘(i) the total amount of funds ex-
pended for each conference conducted 
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108 
under the authority of subsection (b)(4); 
and 
‘‘(ii) the amount of funds expended 
for each such conference that were for 
transportation and for travel expenses. 
‘‘(c) ANNUAL REPORT.—Not later than 180 days 
after the end of each fiscal year, the Secretary shall sub-
mit a report to Congress which identifies— 
‘‘(1) the use of funds appropriated pursuant to 
subsection (a); and 
‘‘(2) the effectiveness of the use of such funds. 
‘‘SEC. 1942. APPLICATION OF CERTAIN REQUIREMENTS 
UNDER PRE-MODERNIZED MEDICAID. 
‘‘The following old provisions shall apply under this 
part: 
‘‘(1) Old subsections (a)(25) (other than sub-
paragraph (E)) and (g) of section 1902 and section 
1903(o) (relating to third party liability). 
‘‘(2) Old section 1902(a)(30)(B) (relating to 
hospital, intermediate care facility for the mentally 
retarded, or hospital for mental diseases admission 
screening and review requirements). 
‘‘(3) Old section 1902(a)(32) (relating to cer-
tain payment requirements). 
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109 
‘‘(4) Old section 1902(a)(35) (relating to dis-
closing entities under section 1124). 
‘‘(5) Old section 1902(a)(37) and the fifth sen-
tence (relating to claims payment procedures). 
‘‘(6) Old section 1902(a)(44) (relating to pay-
ment for inpatient hospital services, services in an 
intermediate care facility for the mentally retarded, 
or inpatient mental hospital services). 
‘‘(7) Old sections 1902(a)(45) and 1912 (relat-
ing to assignment of rights of payment). 
‘‘(8) Old sections 1902(a)(49) and 1921 (relat-
ing to information and access to information con-
cerning sanctions taken by State licensing authori-
ties against health care practitioners and providers). 
‘‘(9) Old sections 1902(a)(61) and 1903(q) (re-
lating to requirements for a medicaid fraud and 
abuse control unit). 
‘‘(10) Old section 1902(a)(64) (relating to re-
ports from beneficiaries and others and data com-
pilation requirements concerning alleged instances of 
waste, fraud, and abuse). 
‘‘(11) Old section 1902(a)(65) (relating to pro-
vider number and surety bond requirement for sup-
pliers of durable medical equipment). 
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110 
‘‘(12) Old section 1902(a)(68) (relating to re-
quirements for certain entities). 
‘‘(13) Old sections 1902(a)(69) and 1936 (re-
lating to the Medicaid Integrity Program) other 
than paragraphs (1), (2)(A), and (3) of old section 
1936(e). 
‘‘(14) Old section 1902(a)(70)(B)(iv) (relating 
to prohibitions on referrals and conflict of interest 
for certain brokers of non-emergency medical trans-
portation). 
‘‘(15) Old sections 1902(a)(71) and 1940 (re-
lating to a required asset verification program). 
‘‘(16) Old section 1902(p) (relating to exclusion 
of certain individuals or entities). 
‘‘(17) Old section 1902(x) (relating to unique 
identifiers for physicians). 
‘‘(18) Old section 1903(p) (relating to inter-
state collection of rights of support). 
‘‘(19) Old section 1903(r)(2) (relating to re-
quirements for mechanized claims processing and in-
formation retrieval systems). 
‘‘(20) Old section 1903(u) (relating to erro-
neous excess payments), other than clause (v) of 
paragraph (1)(D). 
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111 
‘‘(21) Old section 1903(v) and the seventh sen-
tence of old section 1902(a) (relating to limitations 
on payments for services furnished to aliens), other 
than subparagraphs (A) and (B) of paragraph (4). 
‘‘(22) Old section 1903(x) (relating to citizen-
ship documentation). 
‘‘(23) Old section 1909 (relating to State false 
claims act requirements for increased State share of 
recoveries). 
‘‘(24) Old section 1914 (relating to withholding 
of Federal share of payments for certain Medicare 
providers). 
‘‘(25) Old section 1917 (relating to liens, ad-
justments and recoveries, and transfers of assets). 
‘‘(26) Old section 1922 (relating to correction 
and reduction plans for intermediate care facilities 
for the mentally retarded). 
‘‘PART E—GRANTS TO STATES FOR 
ADMINISTRATION 
‘‘SEC. 1951. AUTHORIZATION OF APPROPRIATIONS; PAY-
MENTS TO STATES. 
‘‘(a) IN GENERAL.—For the purpose of providing 
grants to States for administrative expenses necessary to 
carry out parts A and B, there is authorized to be appro-
priated— 
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‘‘(1) for fiscal year 2011, $7,000,000,000; and 
‘‘(2) for each succeeding fiscal year, the amount 
authorized under this subsection for the preceding 
fiscal year, increased by 3 percent. 
‘‘(b) PAYMENTS TO STATES.— 
‘‘(1) IN GENERAL.—From the amount appro-
priated pursuant to subsection (a) for a fiscal year, 
the Secretary shall pay each State with approved 
plans under parts A and B for the fiscal year an 
amount equal to the product of the amount appro-
priated for the fiscal year and the ratio of the total 
amount of payments made to the State under para-
graphs (2) through (7) of section 1903(a) for fiscal 
year 2008 (as such section was in effect for that fis-
cal year) to the total amount of such payments made 
to all States for such fiscal year. 
‘‘(2) PRO RATA ADJUSTMENT.—The Secretary 
shall make pro rata adjustments to the amounts de-
termined under paragraph (1) for a fiscal year as 
necessary so as to not exceed the amount appro-
priated pursuant to subsection (a) for the fiscal 
year. 
‘‘SEC. 1952. COST-SHARING PROTECTIONS. 
‘‘(a) IN GENERAL.—A State may impose cost-sharing 
for individuals provided acute care medical assistance 
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113 
under a State plan under part A or long-term care services 
and supports under a State plan under part B consistent 
with the following: 
‘‘(1) The State may (in a uniform manner) re-
quire payment of monthly premiums or other cost- 
sharing set on a sliding scale based on family in-
come. 
‘‘(2) A premium or other cost-sharing require-
ment imposed under paragraph (1) may only apply 
to the extent that, in the case of an individual whose 
family income— 
‘‘(A) exceeds 150 percent of the poverty 
line, the aggregate annual amount of such pre-
mium and other cost-sharing charges imposed 
under the plan does not exceed 5 percent of the 
individual’s annual income; and 
‘‘(B) exceeds 250 percent of the poverty 
line, the aggregate annual amount of such pre-
mium and other cost-sharing charges do not ex-
ceed 7.5 percent of the individual’s annual in-
come. 
‘‘(3) A State shall not require prepayment of 
any premium or cost-sharing imposed pursuant to 
paragraph (1) and shall not terminate eligibility of 
an individual under the State plan on the basis of 
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114 
failure to pay any such premium or cost-sharing 
until such failure continues for a period of at least 
60 days from the date on which the premium or 
cost-sharing became past due. The State may waive 
payment of any such premium or cost-sharing in any 
case where the State determines that requiring such 
payment would create an undue hardship. 
‘‘(b) APPLICATION TO INSTITUTIONALIZED INDIVID-
UALS.—A State may impose cost-sharing consistent with 
subsection (a) to individuals who are patients in, or resi-
dents of, a medical institution or nursing facility except 
that rules relating to the post-eligibility treatment of in-
come (including a minium monthly personal needs allow-
ance) applicable to institutionalized individuals under old 
title XIX shall apply in the same manner to individuals 
eligible for long-term care services and supports under a 
State plan under part B. 
‘‘(c) POVERTY LINE DEFINED.—In this section, the 
term ‘poverty line’ has the meaning given such term in 
section 673(2) of the Community Services Block Grant 
Act (42 U.S.C. 9902(2)), including any revision required 
by such section. 
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‘‘SEC. 1953. APPLICATION OF CERTAIN REQUIREMENTS 
UNDER PRE-MODERNIZED MEDICAID. 
‘‘The following old provisions shall apply to the State 
plans under this title: 
‘‘(1) OLD STATE PLAN REQUIREMENTS.— 
‘‘(A) Old section 1902(a)(1) (relating to 
the requirement for plans to be in effect in all 
political subdivisions of the State). 
‘‘(B) Old section 1902(a)(2) (relating to 
State financial participation). 
‘‘(C) Old section 1902(a)(3) (relating to 
opportunity for a fair hearing). 
‘‘(D) Old section 1902(a)(4) (relating to 
administration). 
‘‘(E) Old section 1902(a)(5) (relating to 
designation of a single State agency). 
‘‘(F) Old section 1902(a)(6) (relating to 
reporting requirements). 
‘‘(G) Old section 1902(a)(7) (relating to 
restrictions on the use or disclosure of informa-
tion). 
‘‘(H) Old section 1902(a)(8) (relating to 
applications for assistance). 
‘‘(I) Old section 1902(a)(11) (relating to 
cooperative agreements with other State agen-
cies). 
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‘‘(J) Old section 1902(a)(12) (relating to 
determinations of blindness). 
‘‘(K) Old section 1902(a)(13) (relating to 
determination of rates of payment for certain 
services), other than clause (iv) of subpara-
graph (A). 
‘‘(L) Subsections (a)(15) and (bb) of old 
section 1902(a) (relating to payment for serv-
ices provided by rural health clinics and feder-
ally qualified health centers). 
‘‘(M) Old section 1902(a)(16) (relating to 
furnishing services to individuals when absent 
from the State). 
‘‘(N) Old section 1902(a)(22) (relating to 
certain administrative provisions). 
‘‘(O) Paragraphs (23) and (25)(D) of old 
section 1902(a) (relating to any willing provider 
requirements). 
‘‘(P) Old section 1902(a)(24) (relating to 
consultative services by other agencies). 
‘‘(Q) Old section 1902(a)(26) (relating to 
review of need for inpatient mental hospital 
services and written plan of care requirements). 
‘‘(R) Old section 1902(a)(27) (relating to 
provider record keeping requirements). 
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‘‘(S) Old section 1902(a)(30)(A) (relating 
to utilization review). 
‘‘(T) Old section 1902(a)(31) (relating to 
written plan of care for services and review for 
intermediate care facility for the mentally re-
tarded services). 
‘‘(U) Old section 1902(a)(33)(A) (relating 
to quality review requirements). 
‘‘(V) Old section 1902(a)(36) (relating to 
public availability of facility surveys). 
‘‘(W) Old section 1902(a)(38) (relating to 
the provision of information described in section 
1128(b)(9) by certain entities). 
‘‘(X) Old section 1902(a)(39) (relating to 
the exclusion of certain entities). 
‘‘(Y) Old section 1902(a)(40) (relating to 
requirement for uniform reporting systems). 
‘‘(Z) Old section 1902(a)(41) (relating to 
notice to State medical licensing boards). 
‘‘(AA) Old section 1902(a)(42) (relating to 
certain audit requirements). 
‘‘(BB) Old section 1902(a)(48) (relating to 
eligibility cards). 
‘‘(CC) Old section 1902(a)(55) (relating to 
the receipt and initial processing of applica-
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118 
tions, but only to the extent such section is con-
sistent with the policy embodied in the State 
plans under parts A and B). 
‘‘(DD) Subsections (a)(56) and (s) of old 
section 1902 (relating to adjusted payments for 
certain inpatient hospital services). 
‘‘(EE) Old section 1902(a)(59) (relating to 
maintenance of list of participating physicians). 
‘‘(FF) The second sentence of old section 
1902 (relating to designation of certain State 
agencies). 
‘‘(GG) Old section 1902(b) (relating to 
limitations on approval of plans). 
‘‘(HH) Old section 1902(j) (relating to ap-
plication of requirements to American Samoa 
and the Northern Mariana Islands). 
‘‘(2) OTHER OLD TITLE XIX REQUIREMENTS.— 
‘‘(A) Old section 1903(b)(4) (relating to 
limitations on payments to enrollment brokers). 
‘‘(B) Old section 1903(c) (relating to fur-
nishing of services included in a program or 
plan under part B or C of the Individuals with 
Disabilities Education Act). 
‘‘(C) Old section 1903(d) (relating to pay-
ments). 
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