I
107TH CONGRESS
2D SESSION
H. R. 3612
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
JANUARY 23, 2002
Mr. DAVIS of Illinois (for himself and Mr. SHIMKUS) 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 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 2002’’.
(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 estab-
lished 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,
2006, 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, 2002,
and ends on September 30, 2006, in the case of a
State with an approved plan amendment under this
section during that period that also satisfies the re-
shall not be less than the level of such expenditures
for the fiscal year preceding the fiscal year in which
the State plan amendment to provide community-
based attendant services and supports in accordance
with this section is approved.
‘‘(c) REQUIREMENTS FOR ENHANCED FMAP FOR
EARLY COVERAGE.—In addition to satisfying the other re-
quirements for an approved plan amendment under this
section, in order for a State to be eligible under subsection
(a)(2) during the period described in that subsection for
the enhanced FMAP for early coverage under subsection
(a)(2), the State shall satisfy the following requirements:
‘‘(1) SPECIFICATIONS.—With respect to a fiscal
year, the State shall provide the Secretary with the
following specifications regarding the provision of
community-based attendant services and supports
under the plan for that fiscal year:
‘‘(A)(i) The number of individuals who are
estimated to receive community-based attendant
services and supports under the plan during the
fiscal year.
‘‘(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 the
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: