(b) 100 PERCENT MATCHING RATE FOR URBAN IN-
DIAN HEALTH SERVICES.—The third sentence of section 
1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) 
is amended—
(1) by inserting ‘‘or program’’ after ‘‘facility’’; 
(2) by striking ‘‘or by’’ and inserting ‘‘, by’’; 
and 
(3) by inserting ‘‘, or by an urban Indian orga-
nization pursuant to a grant or contract with the In-
dian Health Service under title V of the Indian 
Health Care Improvement Act’’ before the period. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on July 1, 2003. 
TITLE 
III—STRENGTHENING 
STATE AND FEDERAL COM-
MITMENT TO THE ELDERLY 
AND PERSONS WITH DISABIL-
ITIES; FAMILY OPPORTUNITY 
ACT 
Subtitle A—Elderly and Persons 
With Disabilities 
SEC. 301. FULL ACCOUNTING OF SAVINGS IN DETERMINING 
COST-EFFECTIVENESS. 
(a) IN GENERAL.—Section 1915(c)(2)(D) of the So-
cial Security Act (42 U.S.C. 1396n(c)(2)(D)) is amended
by inserting ‘‘(reduced by average per capita reductions 
in spending under other Federal mandatory spending pro-
grams resulting from operation of the waiver)’’ after ‘‘with 
respect to such individuals’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection shall take effect on the date of the enactment 
of this Act.
SEC. 302. EXTENSION OF MEDICAID COVERAGE UNDER THE 
TICKET 
TO 
WORK 
PROGRAM 
TO 
COVER 
SPOUSES. 
(a) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is 
amended—
(1) in clause (i)(II), by inserting before the 
comma at the end the following: ‘‘, and at the option 
of a State, any individual who is the spouse of such 
an individual’’; 
(2) in clause (ii)(XIII), by inserting before the 
semicolon at the end the following: ‘‘, and at the op-
tion of a State, any individual who is the spouse of 
such an individual’’; 
(3) in subclause (XV), by inserting before the 
semicolon at the end the following: ‘‘, and at the op-
tion of a State, any individual who is the spouse of 
such an individual’’; and
(4) in subclause (XVI), by inserting before the 
semicolon at the end the following: ‘‘, and at the op-
tion of a State, any individual who is the spouse of 
such an individual’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1905(a)(xii) of such Act (42 U.S.C. 1396d(a)(xii)) is 
amended by inserting ‘‘and spouses described in clauses 
(i)(II), (ii)(XIII), (ii)(XV), and (ii)(XVI) of section 
1902(a)(10)(A)’’ after ‘‘subsection (v))’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on October 1, 2003, whether or 
not regulations implementing such amendments have been 
issued. 
SEC. 303. ENCOURAGING TRANSITION TO HOME AND COM-
MUNITY CARE. 
(a) IN GENERAL.—Section 1905(b) of the Social Se-
curity Act (42 U.S.C. 1396d(b)), as amended by section 
101(a), is amended—
(1) by striking ‘‘and’’ before ‘‘(5)’’; and 
(2) by inserting before the period the following: 
‘‘, and (6) the Federal medical assistance percentage 
shall be equal to the enhanced FMAP described in 
section 2105(b) with respect to medical assistance 
provided under a waiver under section 1915(c)’’.
(b) CONFORMING AMENDMENT.—Section 1915(c) of 
such Act (42 U.S.C. 1396n(c)) is amended by adding at 
the end the following new paragraph: 
‘‘(11) For purposes of determining the amount of ex-
penditures under this section or a State plan for purposes 
of applying any test of cost-effectiveness or similar test 
in carrying out this subsection, the provisions of section 
1905(b)(6) shall not be taken into account.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to medical assistance for items and 
services furnished on or after July 1, 2003, regardless of 
whether the waiver under which such assistance is pro-
vided was approved before, on, or after the date of the 
enactment of this Act. 
SEC. 304. ENHANCED MATCHING RATE FOR DISABLED INDI-
VIDUALS AWAITING MEDICARE ELIGIBILITY. 
(a) IN GENERAL.—Section 1905(b) of the Social Se-
curity Act (42 U.S.C. 1396d(b)), as amended by sections 
101(a) and 303(a), is amended—
(1) by striking ‘‘and’’ before ‘‘(6)’’; and 
(2) by inserting before the period the following: 
‘‘, and (7) the Federal medical assistance percentage 
shall be equal to 100 percent with respect to medical 
assistance provided to individuals who are not enti-
tled to benefits under part A of title XVIII pursuant
to section 226(b) but who would be entitled to such 
benefits pursuant to such section but for the appli-
cation of a 24-month waiting period under such sec-
tion’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to medical assistance for items and 
services furnished on or after October 1, 2003. 
SEC. 305. PROVIDING INITIAL TERM OF 5 YEARS FOR SEC-
TION 1915 WAIVERS. 
(a) IN GENERAL.—Subsections (d)(3) and (e)(3) of 
section 1915 of the Social Security Act (42 U.S.C. 1396n) 
are each amended by striking ‘‘3 years’’ and inserting ‘‘5 
years’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to waivers granted on or after 
the date of the enactment of this Act. 
SEC. 306. OPTIONAL COVERAGE OF COMMUNITY-BASED AT-
TENDANT SERVICES AND SUPPORTS UNDER 
THE MEDICAID PROGRAM. 
(a) OPTIONAL 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) at the option of the State and subject 
to section 1935, for the inclusion 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; 
insofar as such services are appropriate for the 
individual’s condition according to the individ-
ual’s plan of care;’’. 
(b) COMMUNITY-BASED ATTENDANT SERVICES AND 
SUPPORTS OPTION.—
(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) COVERAGE.—
‘‘(1) IN
GENERAL.—A State may provide 
through a plan amendment for the inclusion of com-
munity-based attendant services and supports (as 
defined in subsection (g)(1)) for individuals de-
scribed in section 1902(a)(10)(D)(ii) in accordance 
with this section. 
‘‘(2) ENHANCED FMAP FOR COVERAGE.—Not-
withstanding section 1905(b), in the case of a State 
with an approved plan amendment under this section 
during that period that also satisfies the require-
ments of subsection (c) the Federal medical assist-
ance percentage shall be equal to the enhanced 
FMAP described in section 2105(b) with respect to 
medical assistance in the form of community-based 
attendant services and supports provided to individ-
uals described in section 1902(a)(10)(D)(ii) in ac-
cordance with this section. 
‘‘(b) DEVELOPMENT AND IMPLEMENTATION OF BEN-
EFIT.—In order for a State plan amendment to be ap-
proved under this section, a State shall develop and imple-
ment the proposal through a public process which includes 
individuals with disabilities, elderly individuals, their rep-
resentatives, and providers, and include in that proposed 
plan amendment—
‘‘(1) a State process to notify and inform indi-
viduals (including individuals who live in nursing fa-
cilities, individuals who live in intermediate care fa-
cilities for the mentally retarded, and individuals 
who live in the community and who have an unmet 
need for such services) of the availability 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; and 
‘‘(2) a quality assurance program that will 
maximize consumer independence and consumer con-
trol and will—
‘‘(A) train consumers to appropriately 
manage their own attendant; 
‘‘(B) provide a quality review process; and 
‘‘(C) provide for investigation and resolu-
tion of allegations of neglect, abuse, or exploi-
tation in connection with the provision of such 
services and supports.
‘‘(c) 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 section 1935 for the enhanced 
FMAP for the provision of such coverage under this 
unless the State submits a plan amendment to the 
Secretary that meets the requirements of this sec-
tion. 
‘‘(d) DEFINITIONS.—In this title: 
‘‘(1) COMMUNITY-BASED ATTENDANT SERVICES 
AND SUPPORTS.—
‘‘(A) IN GENERAL.—The term ‘community-
based attendant services and supports’ may in-
clude one or more of the following: attendant 
services and supports furnished to an indi-
vidual, as needed, to assist in accomplishing ac-
tivities 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 may include one or more of 
the following:
‘‘(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 individual to accomplish activities of 
daily living, instrumental activities of daily 
living, and health-related functions. 
‘‘(iii) Backup systems or mechanisms 
(such as the use of beepers), as defined by 
the State according to the client’s needs, to 
ensure continuity of services and supports. 
‘‘(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 required for an individual to make the 
transition from a nursing facility or inter-
mediate care facility for the mentally retarded 
to a community-based home setting where the 
individual resides. 
‘‘(E) CLARIFICATION OF PERMITTING PAY-
MENT OF RELATIVES FOR PROVIDING SERVICES 
AND SUPPORTS.—Nothing in this section shall 
be construed as preventing community-based at-
tendant services and supports from being fur-
nished to an individual by others who are re-
lated to that individual and for such others 
being paid for so furnishing such services and 
supports. 
‘‘(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 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 other activities 
needed to participate in the community, as ap-
propriate. 
‘‘(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) 
INVESTIGATION
BY
STATE.—Section 
1903(q)(4)(A)(i) 
of 
such 
Act 
(42 
U.S.C. 
1396b(q)(4)(A)(i)) is amended by inserting ‘‘and for in-
vestigation and resolution of allegations of neglect, abuse, 
or exploitation in connection with the provision of commu-
nity-based attendant services and supports under section 
1935(b)(2)(C)’’ before the semicolon. 
(d) EFFECTIVE DATE.—The amendments made by 
this section take effect on October 1, 2003, and apply to 
medical assistance provided for community-based attend-
ant services and supports described in section 1935 of the 
Social Security Act furnished on or after that date. 
Subtitle B—Family Opportunity 
Act 
SEC. 311. SHORT TITLE. 
This subtitle may be cited as the ‘‘Family Oppor-
tunity Act of 2003’’ or the ‘‘Dylan Lee James Act’’. 
SEC. 312. OPPORTUNITY FOR FAMILIES OF DISABLED CHIL-
DREN TO PURCHASE MEDICAID COVERAGE 
FOR SUCH CHILDREN. 
(a) STATE OPTION TO ALLOW FAMILIES OF DIS-
ABLED CHILDREN TO PURCHASE MEDICAID COVERAGE 
FOR SUCH CHILDREN.—
(1) IN
GENERAL.—Section 1902 (42 U.S.C. 
1396a) is amended—
(A) in subsection (a)(10)(A)(ii)—
(i) by striking ‘‘or’’ at the end of sub-
clause (XVII); 
(ii) by adding ‘‘or’’ at the end of sub-
clause (XVIII); and
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(XIX) who are disabled children 
described in subsection (cc)(1);’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(cc)(1) Individuals described in this paragraph are 
individuals—
‘‘(A) who have not attained 18 years of age; 
‘‘(B) who would be considered disabled under 
section 1614(a)(3)(C) (determined without regard to 
the reference to age in that section) but for having 
earnings or deemed income or resources (as deter-
mined under title XVI for children) that exceed the 
requirements for receipt of supplemental security in-
come benefits; and 
‘‘(C) whose family income does not exceed such 
income level as the State establishes and does not 
exceed—
‘‘(i) 300 percent of the income official pov-
erty line (as defined by the Office of Manage-
ment and Budget, and revised annually in ac-
cordance with section 673(2) of the Omnibus 
Budget Reconciliation Act of 1981) applicable 
to a family of the size involved; or
‘‘(ii) such higher percent of such poverty 
line as a State may establish, except that no 
Federal financial participation shall be provided 
under section 1903(a) for any medical assist-
ance provided to an individual who would not be 
described in this subsection but for this 
clause.’’. 
(2) INTERACTION WITH EMPLOYER-SPONSORED 
FAMILY
COVERAGE.—Section 1902(cc) (42 U.S.C. 
1396a(cc)), as added by paragraph (1), is amended 
by adding at the end the following new paragraph: 
‘‘(2)(A) If an employer of a parent of an individual 
described in paragraph (1) offers family coverage under 
a group health plan (as defined in section 2791(a) of the 
Public Health Service Act), the State may—
‘‘(i) require such parent to apply for, enroll in, 
and pay premiums for, such coverage as a condition 
of such parent’s child being or remaining eligible for 
medical 
assistance 
under 
subsection 
(a)(10)(A)(ii)(XIX) if the parent is determined eligi-
ble for such coverage and the employer contributes 
at least 50 percent of the total cost of annual pre-
miums for such coverage; and 
‘‘(ii) if such coverage is obtained—
‘‘(I) subject to paragraph (2) of section 
1916(h), reduce the premium imposed by the 
State under that section (if any) in an amount 
that reasonably reflects the premium contribu-
tion made by the parent for private coverage on 
behalf of a child with a disability; and 
‘‘(II) treat such coverage as a third party 
liability under subsection (a)(25). 
‘‘(B) In the case of a parent to which subparagraph 
(A) applies, if the family income of such parent does not 
exceed 300 percent of the income official poverty line (re-
ferred to in paragraph (1)(C)(i)), a State may provide for 
payment of any portion of the annual premium for such 
family coverage that the parent is required to pay. Any 
payments made by the State under this subparagraph 
shall be considered, for purposes of section 1903(a), to 
be payments for medical assistance.’’.
(b) STATE OPTION TO IMPOSE INCOME-RELATED 
PREMIUMS.—Section 1916 (42 U.S.C. 1396o) is amend-
ed—
(1) in subsection (a), by striking ‘‘subsection 
(g)’’ and inserting ‘‘subsections (g) and (h)’’; and 
(2) by adding at the end the following new sub-
section:
‘‘(h)(1) With respect to disabled children provided 
medical assistance under section 1902(a)(10)(A)(ii)(XIX), 
subject to paragraph (2), a State may (in a uniform man-
ner for such children) require the families of such children 
to pay monthly premiums set on a sliding scale based on 
family income. 
‘‘(2) A premium requirement imposed under para-
graph (1) may only apply to the extent that—
‘‘(A) the aggregate amount of such premium 
and any premium that the parent is required to pay 
for family coverage under section 1902(cc)(2)(A)(i) 
does not exceed 5 percent of the family’s income; 
and 
‘‘(B) the requirement is imposed consistent with 
section 1902(cc)(2)(A)(ii)(I). 
‘‘(3) A State shall not require prepayment of a pre-
mium imposed pursuant to paragraph (1) and shall not 
terminate 
eligibility 
of 
a 
child 
under 
section 
1902(a)(10)(A)(ii)(XIX) for medical assistance under this 
title on the basis of failure to pay any such premium until 
such failure continues for a period of not less than 60 days 
from the date on which the premium became past due. 
The State may waive payment of any such premium in 
any case where the State determines that requiring such 
payment would create an undue hardship.’’.