I 
113TH CONGRESS 
2D SESSION 
H. R. 5547 
To ensure that Medicaid beneficiaries have the opportunity to receive care 
in a home and community-based setting. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 18, 2014 
Mr. CARTWRIGHT (for himself and Mr. MICHAUD) introduced the following 
bill; which was referred to the Committee on Energy and Commerce 
A BILL 
To ensure that Medicaid beneficiaries have the opportunity 
to receive care in a home and community-based setting. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Community Integra-
tion Act of 2014’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
(1) The Supreme Court’s 1999 decision in 
Olmstead v. L.C., 527 U.S. 581 (1999), held that 
the unnecessary segregation of individuals with dis-
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abilities is a violation of the Americans with Disabil-
ities Act of 1990 (42 U.S.C. 12101 et seq.). 
(2) Under Olmstead, individuals generally have 
the right to receive their supports and services in 
home and community-based settings, rather than in 
institutional settings, if they so choose. 
(3) Olmstead envisioned that States would pro-
vide appropriate long-term services and supports to 
individuals with disabilities through home and com-
munity-based services and end forced segregation in 
nursing homes and other institutions. 
(4) While there has been progress in rebal-
ancing State spending on individuals with disabilities 
in institutions as compared to home and community- 
based settings, more than 75 percent of States con-
tinue to spend the majority of their long-term care 
dollars on nursing homes and other institutional set-
tings, and the number of individuals with disabilities 
under age 65 in nursing homes increased between 
2008 and 2012. 
(5) As of June 2013, there were more than 
200,000 individuals younger than age 65 in nursing 
homes—almost 16 percent of the total nursing home 
population. 
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(6) Thirty-eight studies published from 2005 to 
2012 concluded that providing services in home and 
community-based settings is less costly than pro-
viding care in a nursing home or other institutional 
setting. 
(7) No clear or centralized reporting system ex-
ists to compare how effectively States are meeting 
the Olmstead mandate. 
SEC. 3. ENSURING MEDICAID BENEFICIARIES MAY ELECT 
TO RECEIVE CARE IN A HOME AND COMMU-
NITY-BASED SETTING. 
(a) IN GENERAL.—Section 1902(a) of the Social Se-
curity Act (42 U.S.C. 1396a(a)) is amended— 
(1) in paragraph (80), by striking ‘‘and’’ at the 
end; 
(2) in paragraph (81), by striking the period 
and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (81) the fol-
lowing new paragraph: 
‘‘(82) in the case of any individual with respect 
to whom there has been a determination that the in-
dividual requires the level of care provided in a nurs-
ing facility, intermediate care facility for the men-
tally retarded, institution for mental disease, or 
other similarly restrictive or institutional setting— 
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‘‘(A) provide the individual with the choice 
and opportunity to receive such care in a home 
and community-based setting, including reha-
bilitative services, assistance and support in ac-
complishing activities of daily living, instru-
mental activities of daily living, and health-re-
lated tasks, and assistance in acquiring, main-
taining, or enhancing skills necessary to accom-
plish such activities, tasks, or services; 
‘‘(B) ensure that each such individual has 
an equal opportunity (when compared to the re-
ceipt and availability of nursing facility serv-
ices) to receive care in a home and community- 
based setting, if the individual so chooses, by 
ensuring that the provision of such care in a 
home and community-based setting is widely 
available on a statewide basis for all such indi-
viduals within the State; and 
‘‘(C) meet the requirements of section 
1904A (relating to the provision of care in a 
home and community-based setting).’’. 
(b) REQUIREMENTS
FOR COMMUNITY CARE OP-
TIONS.—Title XIX of the Social Security Act (42 U.S.C. 
1396 et seq.) is amended by inserting after section 1904 
the following new section: 
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‘‘PROVISIONS RELATED TO HOME AND COMMUNITY- 
BASED CARE 
‘‘SEC. 1904A. (a) DEFINITIONS.—For purposes of 
this 
section, 
section 
1902(a)(82), 
and 
section 
1905(a)(4)(A): 
‘‘(1) ACTIVITIES OF DAILY LIVING.—The term 
‘activities of daily living’ includes, but is not limited 
to, tasks such as eating, toileting, grooming, dress-
ing, bathing, and transferring. 
‘‘(2) HEALTH-RELATED
TASKS.—The term 
‘health-related tasks’ means specific tasks related to 
the needs of an individual, including, but not limited 
to, bowel or bladder care, wound care, use and care 
of ventilators and feeding tubes, and the administra-
tion of medications and injections, which, in the 
opinion of the individual’s physician, can be dele-
gated to be performed by an attendant. 
‘‘(3) HOME
AND
COMMUNITY-BASED
SET-
TING.—The term ‘home and community-based set-
ting’ means, with respect to an individual who re-
quires a level of care provided in a nursing facility, 
intermediate care facility for the mentally retarded, 
institution for mental disease, or other similarly re-
strictive or institutional setting, a setting that— 
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‘‘(A) includes a house, apartment, town-
house, condominium, or similar public or pri-
vate housing where the individual resides that— 
‘‘(i) is owned or leased by the indi-
vidual or a member of the individual’s fam-
ily; 
‘‘(ii) ensures the individual’s privacy, 
dignity, respect, and freedom from coer-
cion; and 
‘‘(iii) maximizes the individual’s au-
tonomy and independence; 
‘‘(B) is integrated in, and provides access 
to, the general community in which the setting 
is located so that the individual has access to 
the community and opportunities to seek em-
ployment and work in competitive integrated 
settings, participate in community life, control 
and utilize personal resources, benefit from 
community services, and participate in the com-
munity in an overall manner that is comparable 
to that available to individuals who are not indi-
viduals with disabilities; and 
‘‘(C) has the services and supports that the 
individual needs in order to live as independ-
ently as possible. 
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‘‘(4) INSTRUMENTAL ACTIVITIES OF DAILY LIV-
ING.—The term ‘instrumental activities of daily liv-
ing’ means activities related to living independently 
in the community and includes, but is not limited to, 
meal planning and preparation, managing finances, 
shopping for food, clothing, and other items, per-
forming household chores, communicating by phone 
or other media, and traveling around and partici-
pating in the community. 
‘‘(5) PUBLIC ENTITY.—The term ‘public entity’ 
means a public entity as defined in subparagraphs 
(A) and (B) of section 201(1) of the Americans with 
Disabilities Act of 1990. 
‘‘(b) REQUIREMENTS FOR PROVIDING SERVICES IN 
HOME AND COMMUNITY-BASED SETTINGS.—With respect 
to the availability and provision of services under the State 
plan under this title, or under any waiver of State plan 
requirements (subject to section 3(d) of the Community 
Integration Act of 2014), in a home and community-based 
setting to any individual who requires a level of care pro-
vided in a nursing facility, intermediate care facility for 
the mentally retarded, institution for mental disease, or 
other similarly restrictive or institutional setting, any pub-
lic entity that receives payment under the State plan or 
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waiver for providing services to such an individual shall 
not— 
‘‘(1) impose or utilize policies, practices, or pro-
cedures, such as unnecessary requirements or arbi-
trary service or cost caps, that limit the availability 
of services in home and community-based settings to 
an individual with a disability (including individuals 
with the most significant disabilities) who need such 
services; 
‘‘(2) impose or utilize policies, practices, or pro-
cedures that limit the availability of services in a 
home and community-based setting (including assist-
ance and support in accomplishing activities of daily 
living, instrumental activities of daily living, health- 
related tasks, and rehabilitative services) based on 
the specific disability of an otherwise eligible indi-
vidual; 
‘‘(3) impose or utilize policies, practices, or pro-
cedures that arbitrarily restrict an individual with a 
disability from full and meaningful participation in 
community life; 
‘‘(4) impose or utilize policies, practices, or pro-
cedures that unnecessarily delay or restrict the pro-
vision of services in a home and community-based 
setting to any individual who requires such services; 
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‘‘(5) fail to establish and utilize adequate pay-
ment structures to maintain a sufficient workforce 
to provide services in home and community-based 
settings to any individual who requires such services; 
‘‘(6) fail to provide information, on an ongoing 
basis, to help any individual who receives care in a 
nursing facility, intermediate care facility for the 
mentally retarded, institution for mental disease, or 
other similarly restrictive or institutional setting, un-
derstand the individual’s right to choose to receive 
such care in a home and community-based setting; 
or 
‘‘(7) fail to provide information to help any in-
dividual that requires the level of care provided in a 
nursing facility, intermediate care facility for the 
mentally retarded, institution for mental disease, or 
other similarly restrictive or institutional setting, 
prior to the individual’s placement in such a facility 
or institution, understand the individual’s right to 
choose to receive such care in a home and commu-
nity-based setting. 
‘‘(c) PLAN TO INCREASE AFFORDABLE AND ACCES-
SIBLE HOUSING.—Not later than 180 days after the en-
actment of this section, each State shall develop a state-
wide plan to increase the availability of affordable and ac-
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cessible private and public housing stock for individuals 
with disabilities (including accessible housing for individ-
uals with physical disabilities and those using mobility de-
vices). 
‘‘(d) AVAILABILITY
OF
REMEDIES
AND
PROCE-
DURES.— 
‘‘(1) IN GENERAL.—The remedies and proce-
dures set forth in sections 203 and 505 of the Amer-
icans with Disabilities Act of 1990 shall be available 
to any person aggrieved by the failure of— 
‘‘(A) a State to comply with this section or 
section 1902(a)(82); or 
‘‘(B) a public entity (including a State) to 
comply with the requirements of subsection (b). 
‘‘(2) RULE
OF
CONSTRUCTION.—Nothing in 
paragraph (1) shall be construed to limit any rem-
edy or right of action that otherwise is available to 
an aggrieved person under this title. 
‘‘(e) ENFORCEMENT BY THE SECRETARY.— 
‘‘(1) IN GENERAL.—The Secretary may reduce 
the Federal matching assistance percentage applica-
ble to the State (as determined under section 
1905(b)) if the Secretary determines that the State 
has violated the requirements of subsection (b). 
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‘‘(2) RULE
OF
CONSTRUCTION.—Nothing in 
paragraph (1) shall be construed to limit any rem-
edy or right of action that is otherwise available to 
the Secretary. 
‘‘(f) REPORTING REQUIREMENTS.—With respect to 
fiscal year 2016, and for each fiscal year thereafter, each 
State shall submit to the Administrator of the Administra-
tion for Community Living of the Department of Health 
and Human Services, not later than April 1 of the suc-
ceeding fiscal year, a report, in such form and manner 
as the Secretary shall require, that includes— 
‘‘(1) the total number of individuals enrolled in 
the State plan or under a waiver of the plan during 
such fiscal year that required the level of care pro-
vided in a nursing facility, intermediate care facility 
for the mentally retarded, institution for mental dis-
ease, or other similarly restrictive or institutional 
setting, disaggregated by the type of facility or set-
ting; 
‘‘(2) with respect to the total number described 
in paragraph (1), the total number of individuals de-
scribed in that paragraph who received care in a 
nursing facility, intermediate care facility for the 
mentally retarded, institution for mental disease, or 
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other similarly restrictive or institutional setting, 
disaggregated by the type of facility or setting; and 
‘‘(3) with respect to the total number described 
in paragraph (2), the total number of individuals de-
scribed in that paragraph who were transitioned 
from a nursing facility, intermediate care facility for 
the mentally retarded, institution for mental disease, 
or other similarly restrictive or institutional setting 
to a home and community-based setting, disaggre-
gated by the type of home and community-based set-
ting.’’. 
(c) INCLUSION AS A MANDATORY SERVICE.—Section 
1905(a)(4)(A) of the Social Security Act (42 U.S.C. 
1396d(a)(4)(A)) is amended by striking ‘‘other than’’ and 
inserting ‘‘including similar services such as rehabilitative 
services and assistance and support in accomplishing ac-
tivities of daily living, instrumental activities of daily liv-
ing, and health-related tasks, that are provided, at the in-
dividual’s option, in a home and community-based setting 
(as defined in section 1904A(a)(3)), but not including’’. 
(d) APPLICATION
TO WAIVERS.—Notwithstanding 
section 1904A of the Social Security Act (as added by sub-
section (b)), such section, and sections 1902(a)(82), and 
1905(a)(4)(A) of the Social Security Act (42 U.S.C. 1396 
et seq.), as amended by subsections (a) and (c), respec-
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tively, shall not apply to any individuals who are eligible 
for medical assistance for home and community-based 
services under a waiver under section 1115 or 1915 of 
the Social Security Act (42 U.S.C. 1315, 1396n) and who 
are receiving such services, to the extent such sections (as 
so added or amended) are inconsistent with any such waiv-
er. 
(e) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall take effect on October 1, 2014. 
(2) DELAY PERMITTED IF STATE LEGISLATION 
REQUIRED.—In the case of a State plan under sec-
tion 1902 of the Social Security Act (42 U.S.C. 
1396a) which the Secretary of Health and Human 
Services determines requires State legislation (other 
than legislation appropriating funds) in order for the 
plan to meet the additional requirements imposed by 
the amendments made by this section, the State 
plan shall not be regarded as failing to comply with 
the requirements of such section 1902 solely on the 
basis of the failure of the plan to meet such addi-
tional requirements before the 1st day of the 1st cal-
endar quarter beginning after the close of the 1st 
regular session of the State legislature that begins 
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after the date of enactment of this Act. For pur-
poses of the previous sentence, in the case of a State 
that has a 2-year legislative session, each year of 
such session shall be deemed to be a separate reg-
ular session of the State legislature. 
Æ 
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