(ii) help the individual with executive 
functioning, decisionmaking, and problem 
solving; 
(iii) provide reassurance to the indi-
vidual; and 
(iv) help the individual with orienta-
tion, memory, and other activities related 
to independent living. 
(9) LONG-TERM
SERVICE
OR
SUPPORT.—The 
terms ‘‘long-term service or support’’ and ‘‘LTSS’’ 
mean the assistance provided to an individual with 
a disability in accomplishing, acquiring the means or 
ability to accomplish, maintaining, or enhancing— 
(A) activities of daily living; 
(B) instrumental activities of daily living; 
(C) health-related tasks; or 
(D) other functions, tasks, or activities re-
lated to an activity or task described in sub-
paragraph (A), (B), or (C). 
(10) LTSS INSURANCE PROVIDER.—The term 
‘‘LTSS insurance provider’’ means a public or pri-
vate entity that— 
(A) either directly provides funds for long- 
term services and supports; and 
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(B) is engaged in commerce or in an in-
dustry or activity affecting commerce. 
(11) PUBLIC ENTITY.— 
(A) IN GENERAL.—The term ‘‘public enti-
ty’’ means an entity that— 
(i) provides or funds institutional 
placements for individuals with LTSS dis-
abilities; and 
(ii) is— 
(I) a State or local government; 
or 
(II) any department, agency, en-
tity administering a special purpose 
district, or other instrumentality, of a 
State or local government. 
(B) INTERSTATE
COMMERCE.—For pur-
poses of subparagraph (A), a public entity shall 
be considered to be a person engaged in com-
merce or in an industry or activity affecting 
commerce. 
(b) RULE
OF CONSTRUCTION.—Nothing in sub-
section (a)(2) or any other provision of this section shall 
be construed to preclude an individual with a disability 
from receiving community-based services and supports in 
an integrated community setting such as a grocery store, 
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retail establishment, restaurant, bank, park, concert 
venue, theater, or workplace. 
SEC. 4. DISCRIMINATION. 
(a) IN GENERAL.—No public entity or LTSS insur-
ance provider shall deny an individual with an LTSS dis-
ability who is eligible for institutional placement, or other-
wise discriminate against that individual in the provision 
of, community-based long-term services and supports that 
enable the individual to live in the community and lead 
an independent life. 
(b) SPECIFIC PROHIBITIONS.—For purposes of this 
Act, discrimination by a public entity or LTSS insurance 
provider includes— 
(1) the imposition or application of eligibility 
criteria or another policy that prevents or tends to 
prevent an individual with an LTSS disability, or 
any class of individuals with LTSS disabilities, from 
receiving a community-based long-term service or 
support; 
(2) the imposition or application of a policy or 
other mechanism, such as a service or cost cap, that 
prevents or tends to prevent an individual with an 
LTSS disability, or any class of individuals with 
LTSS disabilities, from receiving a community-based 
long-term service or support; 
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(3) a failure to provide a specific community- 
based long-term service or support or a type of com-
munity-based long-term service or support needed 
for an individual with an LTSS disability, or any 
class of individuals with LTSS disabilities; 
(4) the imposition or application of a policy, 
rule, regulation, or restriction that interferes with 
the opportunity for an individual with an LTSS dis-
ability, or any class of individuals with LTSS dis-
abilities, to live in the community and lead an inde-
pendent life, which may include a requirement that 
an individual with an LTSS disability receive a serv-
ice or support (such as day services or employment 
services) in a congregate or disability-specific set-
ting; 
(5) the imposition or application of a waiting 
list or other mechanism that delays or restricts ac-
cess of an individual with an LTSS disability to a 
community-based long-term service or support; 
(6) a failure to establish an adequate rate or 
other payment structure that is necessary to ensure 
the availability of a workforce sufficient to support 
an individual with an LTSS disability in living in 
the community and leading an independent life; 
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(7) a failure to provide community-based serv-
ices and supports, on an intermittent, short-term, or 
emergent basis, that assist an individual with an 
LTSS disability to live in the community and lead 
an independent life; 
(8) the imposition or application of a policy, 
such as a requirement that an individual utilize in-
formal support, that restricts, limits, or delays the 
ability of an individual with an LTSS disability to 
secure a community-based long-term service or sup-
port to live in the community or lead an independent 
life; 
(9) a failure to implement a formal procedure 
and a mechanism to ensure that— 
(A) individuals with LTSS disabilities are 
offered the alternative of community-based 
long-term services and supports prior to institu-
tionalization; and 
(B) if selected by an individual with an 
LTSS disability, the community-based long- 
term services and supports described in sub-
paragraph (A) are provided; 
(10) a failure to ensure that each institutional-
ized individual with an LTSS disability is regularly 
notified of the alternative of community-based long- 
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term services and supports and that those commu-
nity-based long-term services and supports are pro-
vided if the individual with an LTSS disability se-
lects such services and supports; and 
(11) a failure to make a reasonable modifica-
tion in a policy, practice, or procedure, when such 
modification is necessary to allow an individual with 
an LTSS disability to receive a community-based 
long-term service or support. 
(c) ADDITIONAL PROHIBITION.—For purposes of this 
Act, discrimination by a public entity also includes a fail-
ure to ensure that there is sufficient availability of afford-
able, accessible, and integrated housing to allow an indi-
vidual with an LTSS disability to choose to live in the 
community and lead an independent life, including the 
availability of an option to live in housing where the re-
ceipt of LTSS is not tied to tenancy. 
(d) CONSTRUCTION.—Nothing in this section shall be 
construed so as to prevent a public entity or LTSS insur-
ance provider from providing community-based long-term 
services and supports at a level that is greater than the 
level that is required by this section. 
SEC. 5. ADMINISTRATION. 
(a) AUTHORITY AND RESPONSIBILITY.— 
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(1) DEPARTMENT OF JUSTICE.—The Attorney 
General shall— 
(A) investigate and take enforcement ac-
tion for violations of this Act; and 
(B) enforce section 6(c). 
(2) DEPARTMENT
OF
HEALTH
AND
HUMAN 
SERVICES.—The Secretary of Health and Human 
Services, through the Administrator, shall— 
(A) conduct studies regarding the nature 
and extent of institutionalization of individuals 
with LTSS disabilities in representative com-
munities, including urban, suburban, and rural 
communities, throughout the United States; 
(B) publish and disseminate reports, rec-
ommendations, and information derived from 
such studies, including an annual report to 
Congress, specifying— 
(i) the nature and extent of progress 
in the United States in eliminating institu-
tionalization for individuals with LTSS 
disabilities in violation of this Act and fur-
thering the purposes of this Act; 
(ii) obstacles that remain in the effort 
to achieve the provision of community- 
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based long-term services and supports for 
all individuals with LTSS disabilities; and 
(iii) recommendations for further leg-
islative or executive action; 
(C) cooperate with, and provide technical 
assistance to, Federal, State, and local public or 
private agencies and organizations that are for-
mulating or carrying out programs to prevent 
or eliminate institutionalization of individuals 
with LTSS disabilities or to promote the provi-
sion of community-based long-term services and 
supports; 
(D) implement educational and conciliatory 
activities to further the purposes of this Act; 
and 
(E) refer information on violations of this 
Act to the Attorney General for investigation 
and enforcement action under this Act. 
(b) COOPERATION
OF EXECUTIVE DEPARTMENTS 
AND AGENCIES.—Each Federal agency and, in particular, 
each Federal agency covered by Executive Order 13217 
(66 Fed. Reg. 33155; relating to community-based alter-
natives for individuals with disabilities), shall carry out 
programs and activities relating to the institutionalization 
of individuals with LTSS disabilities and the provision of 
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community-based long-term services and supports for indi-
viduals with LTSS disabilities in accordance with this Act 
and shall cooperate with the Attorney General and the Ad-
ministrator to further the purposes of this Act. 
SEC. 6. REGULATIONS. 
(a) ISSUANCE OF REGULATIONS.—Not later than 24 
months after the date of enactment of this Act, the Attor-
ney General and the Secretary of Health and Human 
Services shall issue, in accordance with section 553 of title 
5, United States Code, final regulations to carry out this 
Act, which shall include the regulations described in sub-
section (b). 
(b) REQUIRED CONTENTS OF REGULATIONS.— 
(1) ELIGIBLE RECIPIENTS OF SERVICE.—The 
regulations shall require each public entity and 
LTSS insurance provider to offer, and, if accepted, 
provide community-based long-term services and 
supports as required under this Act to any indi-
vidual with an LTSS disability who would otherwise 
qualify for institutional placement provided or fund-
ed by the public entity or LTSS insurance provider. 
(2) SERVICES TO BE PROVIDED.—The regula-
tions issued under this section shall require each 
public entity and LTSS insurance provider to pro-
vide the Attorney General and the Administrator 
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with an assurance that the public entity or LTSS in-
surance provider— 
(A) ensures that individuals with LTSS 
disabilities receive, as an alternative to institu-
tional placement, assistance through hands-on 
assistance, training, cueing, and safety moni-
toring, including access to backup systems, 
with— 
(i) activities of daily living; 
(ii) instrumental activities of daily liv-
ing; 
(iii) health-related tasks; or 
(iv) other functions, tasks, or activi-
ties related to an activity or task described 
in clause (i), (ii), or (iii); 
(B) coordinates, conducts, performs, pro-
vides, or funds discharge planning from acute, 
rehabilitation, and long-term facilities to pro-
mote individuals with LTSS disabilities living in 
the most integrated setting chosen by the indi-
viduals; 
(C) issues, conducts, performs, provides, or 
funds policies and programs to promote self-di-
rection and the provision of consumer-directed 
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services and supports for all populations of indi-
viduals with LTSS disabilities served; 
(D) issues, conducts, performs, provides, 
or funds policies and programs to support infor-
mal caregivers who provide services for individ-
uals with LTSS disabilities; and 
(E) ensures that individuals with all types 
of LTSS disabilities are able to live in the com-
munity and lead an independent life, including 
ensuring that the individuals have maximum 
control over the services and supports that the 
individuals receive, choose the setting in which 
the individuals receive those services and sup-
ports, and exercise control and direction over 
their own lives to the greatest extent possible. 
(3) PUBLIC PARTICIPATION.— 
(A) PUBLIC
ENTITY.—The regulations 
issued under this section shall require each pub-
lic entity to carry out an extensive public par-
ticipation process in preparing the public enti-
ty’s self-evaluation under paragraph (5) and 
transition plan under paragraph (10). 
(B) LTSS INSURANCE
PROVIDER.—The 
regulations issued under this section shall re-
quire each LTSS insurance provider to carry 
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out a public participation process that involves 
holding a public hearing, providing an oppor-
tunity for public comment, and consulting with 
individuals with LTSS disabilities, in preparing 
the LTSS insurance provider’s self-evaluation 
under paragraph (5). 
(C) PROCESS.—In carrying out a public 
participation process under subparagraph (A) 
or (B), a public entity or LTSS insurance pro-
vider shall ensure that the process meets the re-
quirements of subparagraphs (A) and (C) of 
section 1115(d)(2) of the Social Security Act 
(42 U.S.C. 1315(d)(2)), except that— 
(i) the reference to ‘‘at the State 
level’’ shall be disregarded; and 
(ii) the reference to an application 
shall be considered to be a reference to the 
self-evaluation or plan involved. 
(4) ADDITIONAL SERVICES AND SUPPORTS.— 
The regulations issued under this section shall es-
tablish circumstances under which a public entity 
shall provide community-based long-term services 
and supports under this section beyond the level of 
community-based long-term services and supports 
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which would otherwise be required under this sub-
section. 
(5) SELF-EVALUATION.— 
(A) IN GENERAL.—The regulations issued 
under this section shall require each public enti-
ty and each LTSS insurance provider, not later 
than 30 months after the date of enactment of 
this Act, to evaluate current services, policies, 
and practices, and the effects thereof, that do 
not or may not meet the requirements of this 
Act and, to the extent modification of any such 
services, policies, and practices is required to 
meet the requirements of this Act, make the 
necessary modifications. The self-evaluation 
shall include— 
(i) collection of baseline information, 
including the numbers of individuals with 
LTSS disabilities in various institutional 
and community-based settings served by 
the public entity or LTSS insurance pro-
vider; 
(ii) a review of community capacity, in 
communities served by the entity or pro-
vider, in providing community-based long- 
term services and supports; 
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(iii) identification of improvements 
needed to ensure that all community-based 
long-term services and supports provided 
by the public entity or LTSS insurance 
provider to individuals with LTSS disabil-
ities are comprehensive, are accessible, are 
not duplicative of existing (as of the date 
of the identification) services and supports, 
meet the needs of persons who are likely to 
require assistance in order to live, or lead 
a life, as described in section 4(a), and are 
high-quality services and supports, which 
may include identifying system improve-
ments that create an option to self-direct 
receipt of such services and supports for 
all populations of such individuals served; 
and 
(iv) a review of funding sources for 
community-based long-term services and 
supports and an analysis of how those 
funding sources could be organized into a 
fair, coherent system that affords individ-
uals reasonable and timely access to com-
munity-based long-term services and sup-
ports. 
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(B) PUBLIC ENTITY.—A public entity, in-
cluding a LTSS insurance provider that is a 
public entity, shall— 
(i) include in the self-evaluation de-
scribed in subparagraph (A)— 
(I) an assessment of the avail-
ability of accessible, affordable trans-
portation across the State involved 
and whether transportation barriers 
prevent individuals from receiving 
long-term services and supports in the 
most integrated setting; and 
(II) an assessment of the avail-
ability of integrated employment op-
portunities in the jurisdiction served 
by the public entity for individuals 
with LTSS disabilities; and 
(ii) provide the self-evaluation de-
scribed in subparagraph (A) to the Attor-
ney General and the Administrator. 
(C) 
LTSS 
INSURANCE
PROVIDER.—A 
LTSS insurance provider shall keep the self- 
evaluation described in subparagraph (A) on 
file, and may be required to produce such self- 
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evaluation in the event of a review, investiga-
tion, or action described in section 8. 
(6) ADDITIONAL
REQUIREMENT
FOR
PUBLIC 
ENTITIES.—The regulations issued under this sec-
tion shall require a public entity, in conjunction with 
the housing agencies serving the jurisdiction served 
by the public entity, to review and improve commu-
nity capacity, in all communities throughout the en-
tirety of that jurisdiction, in providing affordable, 
accessible, and integrated housing, including an eval-
uation of available units, unmet need, and other 
identifiable barriers to the provision of that housing. 
In carrying out that improvement, the public entity, 
in conjunction with such housing agencies, shall— 
(A) ensure, and assure the Attorney Gen-
eral that there is, sufficient availability of af-
fordable, accessible, and integrated housing in a 
setting that is not a disability-specific residen-
tial setting or a setting where services are tied 
to tenancy, in order to provide individuals with 
LTSS disabilities a meaningful choice in their 
housing; 
(B) in order to address the need for af-
fordable, accessible, and integrated housing— 
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(i) in the case of such a housing agen-
cy, establish relationships with State and 
local housing authorities; and 
(ii) in the case of the public entity, es-
tablish relationships with State and local 
housing agencies, including housing au-
thorities; 
(C) establish, where needed, necessary 
preferences and set-asides in housing programs 
for individuals with LTSS disabilities who are 
transitioning from or avoiding institutional 
placement; 
(D) establish a process to fund necessary 
home modifications so that individuals with 
LTSS disabilities can live independently; and 
(E) ensure, and assure the Attorney Gen-
eral, that funds and programs implemented or 
overseen by the public entity or in the public 
entity’s jurisdiction are targeted toward afford-
able, accessible, integrated housing for individ-
uals with an LTSS disability who have the low-
est income levels in the jurisdiction as a priority 
over any other development until capacity bar-
riers for such housing are removed or unmet 
needs for such housing have been met. 
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(7) 
DESIGNATION
OF
RESPONSIBLE
EM-
PLOYEE.—The regulations issued under this section 
shall require each public entity and LTSS insurance 
provider to designate at least one employee to co-
ordinate the entity’s or provider’s efforts to comply 
with and carry out the entity or provider’s respon-
sibilities under this Act, including the investigation 
of any complaint communicated to the entity or pro-
vider that alleges a violation of this Act. Each public 
entity and LTSS insurance provider shall make 
available to all interested individuals the name, of-
fice address, and telephone number of the employee 
designated pursuant to this paragraph. 
(8) GRIEVANCE PROCEDURES.—The regulations 
issued under this section shall require public entities 
and LTSS insurance providers to adopt and publish 
grievance procedures providing for prompt and equi-
table resolution of complaints alleging a violation of 
this Act. 
(9) PROVISION OF SERVICE BY OTHERS.—The 
regulations issued under this section shall require 
each public entity submitting a self-evaluation under 
paragraph (5) to identify, as part of the transition 
plan described in paragraph (10), any other entity 
that is, or acts as, an agent, subcontractor, or other 
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instrumentality of the public entity with regards to 
a service, support, policy, or practice described in 
such plan or self-evaluation. 
(10) TRANSITION
PLANS.—The regulations 
issued under this section shall require each public 
entity, not later than 42 months after the date of 
enactment of this Act, to submit to the Adminis-
trator, and begin implementing, a transition plan for 
carrying out this Act that establishes the achieve-
ment of the requirements of this Act, as soon as 
practicable, but in no event later than 12 years after 
the date of enactment of this Act. The transition 
plan shall— 
(A) establish measurable objectives to ad-
dress the barriers to community living identified 
in the self-evaluation under paragraph (5); 
(B) establish specific annual targets for 
the transition of individuals with LTSS disabil-
ities, and shifts in funding, from institutional 
settings to integrated community-based services 
and supports, and related programs; and 
(C) describe the manner in which the pub-
lic entity has obtained or plans to obtain nec-
essary funding and resources needed for imple-
mentation of the plan (regardless of whether 
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the entity began carrying out the objectives of 
this Act prior to the date of enactment of this 
Act). 
(11) ANNUAL REPORTING.— 
(A) IN GENERAL.—The regulations issued 
under this section shall establish annual report-
ing requirements for each public entity covered 
by this section. 
(B) PROGRESS ON OBJECTIVES AND TAR-
GETS.—The regulations issued under this sec-
tion shall require each public entity that has 
submitted a transition plan to submit to the 
Administrator an annual report on the progress 
the public entity has made during the previous 
year in meeting the measurable objectives and 
specific annual targets described in subpara-
graphs (A) and (B) of paragraph (10). 
(12) OTHER
PROVISIONS.—The regulations 
issued under this section shall include such other 
provisions and requirements as the Attorney General 
and the Secretary of Health and Human Services 
determine are necessary to carry out the objectives 
of this Act. 
(c) REVIEW OF TRANSITION PLANS.— 
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(1) GENERAL RULE.—The Administrator shall 
review a transition plan submitted in accordance 
with subsection (b)(10) for the purpose of deter-
mining whether such plan meets the requirements of 
this Act, including the regulations issued under this 
section. 
(2) DISAPPROVAL.—If the Administrator deter-
mines that a transition plan reviewed under this 
subsection fails to meet the requirements of this Act, 
the Administrator shall disapprove the transition 
plan and notify the public entity that submitted the 
transition plan of, and the reasons for, such dis-
approval. 
(3) MODIFICATION OF DISAPPROVED PLAN.— 
Not later than 90 days after the date of disapproval 
of a transition plan under this subsection, the public 
entity that submitted the transition plan shall mod-
ify the transition plan to meet the requirements of 
this section and shall submit to the Administrator, 
and commence implementation of, such modified 
transition plan. 
(4) INCENTIVES.— 
(A) DETERMINATION.—For 10 years after 
the issuance of the regulations described in sub-
section (a), the Secretary of Health and Human 
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Services shall annually determine whether each 
State, or each other public entity in the State, 
is complying with the transition plan or modi-
fied transition plan the State or other public 
entity submitted, and obtained approval for, 
under this section. Notwithstanding any other 
provision of law, if the Secretary of Health and 
Human Services determines under this subpara-
graph that the State or other public entity is 
complying with the corresponding transition 
plan, the Secretary shall make the increase de-
scribed in subparagraph (B). 
(B) INCREASE IN FMAP.—On making the 
determination described in subparagraph (A) 
for a public entity (including a State), the Sec-
retary of Health and Human Services shall, as 
described in subparagraph (C), increase by 5 
percentage points the FMAP for the State in 
which the public entity is located for amounts 
expended by the State for medical assistance 
consisting of home and community-based serv-
ices furnished under the State Medicaid plan 
under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) or a waiver of such plan— 
(i) that— 
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(I) are identified by a public enti-
ty or LTSS insurance provider under 
subsection(b)(5)(A)(iii); 
(II) resulted from shifts in fund-
ing identified by a public entity under 
subsection (b)(10)(B); or 
(III) are environmental modifica-
tions to achieve the affordable, acces-
sible, integrated housing identified by 
a public entity under subsection 
(b)(6)(E); and 
(ii) are described by the State in a re-
quest to the Secretary of Health and 
Human Services for the increase. 
(C) PERIOD OF INCREASE.—The Secretary 
of Health and Human Services shall increase 
the FMAP described in subparagraph (B)— 
(i) beginning with the first quarter 
that begins after the date of the deter-
mination; and 
(ii) ending with the quarter in which 
the next annual determination under sub-
paragraph (A) occurs. 
(D) DEFINITIONS.—In this paragraph: 
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(i) 
FMAP.—The 
term 
‘‘FMAP’’ 
means the Federal medical assistance per-
centage for a State determined under sec-
tion 1905(b) of the Social Security Act (42 
U.S.C. 1396d(b)) without regard to any in-
creases in that percentage applicable under 
other subsections of that section or any 
other provision of law, including this sec-
tion. 
(ii) HOME
AND
COMMUNITY-BASED 
SERVICES DEFINED.—The term ‘‘home and 
community-based services’’ means any of 
the following services provided under a 
State Medicaid plan under title XIX of the 
Social Security Act (42 U.S.C. 1396 et 
seq.) or a waiver of such plan: 
(I) Home and community-based 
services provided under subsection (c), 
(d), or (i) of section 1915 of the So-
cial Security Act (42 U.S.C. 1396n). 
(II) Home health care services. 
(III) Personal care services. 
(IV) Services described in section 
1905(a)(26) of the Social Security Act 
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(42 U.S.C. 1395d(a)(26)) (relating to 
PACE program services). 
(V) Self-directed personal assist-
ance services provided in accordance 
with section 1915(j) of the Social Se-
curity Act (42 U.S.C. 1396n(j)). 
(VI) Community-based attendant 
services and supports provided in ac-
cordance with section 1915(k) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1396n(k)). 
(d) RULE
OF CONSTRUCTION.—Nothing in sub-
section (b)(10) or (c) or any other provision of this Act 
shall be construed to modify the requirements of any other 
Federal law, relating to integration of individuals with dis-
abilities into the community and enabling those individuals 
to live in the most integrated setting. 
SEC. 7. EXEMPTIONS FOR RELIGIOUS ORGANIZATIONS. 
This Act shall not prohibit a religious organization, 
association, or society from giving preference in providing 
community-based long-term services and supports to indi-
viduals of a particular religion connected with the beliefs 
of such organization, association, or society. 
SEC. 8. ENFORCEMENT. 
(a) CIVIL ACTION.— 
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