I 
111TH CONGRESS 
1ST SESSION H. R. 2688 
To amend title XIX of the Social Security Act to improve the State plan 
amendment option for providing home and community-based services 
under the Medicaid Program, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 3, 2009 
Mr. PALLONE (for himself and Ms. DEGETTE) 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 improve 
the State plan amendment option for providing home 
and community-based services under the Medicaid Pro-
gram, 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 
‘‘Empowered at Home Act of 2009’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
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TITLE I—STRENGTHENING THE MEDICAID HOME AND 
COMMUNITY-BASED STATE PLAN AMENDMENT OPTION 
Sec. 101. Removal of barriers to providing home and community-based services 
under State plan amendment option for individuals in need. 
Sec. 102. Increase in Federal medical assistance percentage (FMAP) for the 
provision of home and community-based services under Med-
icaid through the State plan amendment option. 
Sec. 103. Annual report on use of Medicaid State plan amendment option for 
home and community-based services. 
TITLE II—STATE GRANTS TO FACILITATE HOME AND 
COMMUNITY-BASED SERVICES AND PROMOTE HEALTH 
Sec. 201. Reauthorization of Medicaid investment grants and expansion of per-
missible uses in order to facilitate the provision of home and 
community-based and other long-term care services. 
Sec. 202. Health promotion grants. 
TITLE III—PROMOTING AND PROTECTING COMMUNITY LIVING 
Sec. 301. Mandatory application of spousal impoverishment protections to re-
cipients of home and community-based services. 
Sec. 302. Exclusion of 6 months of average cost of nursing facility services 
from assets or resources for purposes of eligibility for home 
and community-based services. 
TITLE IV—MISCELLANEOUS 
Sec. 401. Improved data collection. 
Sec. 402. GAO report on Medicaid home health services and the extent of con-
sumer self-direction of such services. 
TITLE I—STRENGTHENING THE 
MEDICAID HOME AND COM-
MUNITY-BASED STATE PLAN 
AMENDMENT OPTION 
SEC. 101. REMOVAL OF BARRIERS TO PROVIDING HOME 
AND COMMUNITY-BASED SERVICES UNDER 
STATE PLAN AMENDMENT OPTION FOR INDI-
VIDUALS IN NEED. 
(a) PARITY WITH INCOME ELIGIBILITY STANDARD 
FOR INSTITUTIONALIZED INDIVIDUALS.—Paragraph (1) 
of section 1915(i) of the Social Security Act (42 U.S.C. 
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1396n(i)) is amended by striking ‘‘150 percent of the pov-
erty line (as defined in section 2110(c)(5))’’ and inserting 
‘‘300 percent of the supplemental security income benefit 
rate established by section 1611(b)(1)’’. 
(b) AUTHORITY
TO
OFFER
DIFFERENT
TYPE, 
AMOUNT, DURATION, OR SCOPE OF HOME AND COMMU-
NITY-BASED SERVICES.—Section 1915(i) of the Social Se-
curity Act (42 U.S.C. 1396n(i)) is amended by adding at 
the end the following new paragraph: 
‘‘(6) AUTHORITY TO OFFER DIFFERENT TYPE, 
AMOUNT, DURATION, OR SCOPE OF HOME AND COM-
MUNITY-BASED SERVICES.—A State may offer home 
and community-based services to individuals under 
this paragraph that differ in type, amount, duration, 
or scope from the home and community-based serv-
ices offered to other such individuals, taking into ac-
count the needs-based criteria established under 
paragraph (1)(A), so long as such services are with-
in the scope of services described in paragraph 
(4)(B) of subsection (c) for which the Secretary has 
the authority to approve a waiver and do not include 
room or board.’’. 
(c) REMOVAL OF LIMITATION ON SCOPE OF SERV-
ICES.—Paragraph (1) of section 1915(i) of the Social Se-
curity Act (42 U.S.C. 1396n(i)), as amended by sub-
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section (a), is amended by striking ‘‘or such other services 
requested by the State as the Secretary may approve’’ 
(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE 
FULL MEDICAID BENEFITS TO INDIVIDUALS RECEIVING 
HOME
AND COMMUNITY-BASED SERVICES UNDER
A 
STATE PLAN AMENDMENT.— 
(1) IN
GENERAL.—Section 1902(a)(10)(A)(ii) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396a(a)(10)(A)(ii)) is amended— 
(A) in subclause (XVIII), by striking ‘‘or’’ 
at the end; 
(B) in subclause (XIX), by adding ‘‘or’’ at 
the end; and 
(C) by inserting after subclause (XIX), the 
following new subclause: 
‘‘(XX) who are eligible for home 
and community-based services under 
needs-based criteria established under 
paragraph (1)(A) of section 1915(i) 
and who will receive home and com-
munity-based services pursuant to a 
State plan amendment under section 
1915(i);’’. 
(2) CONFORMING AMENDMENTS.— 
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(A) Section 1903(f)(4) of the Social Secu-
rity Act (42 U.S.C. 1396b(f)(4)) is amended in 
the matter preceding subparagraph (A), by in-
serting 
‘‘1902(a)(10)(A)(ii)(XX),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XIX),’’. 
(B) Section 1905(a) of the Social Security 
Act (42 U.S.C. 1396d(a)) is amended in the 
matter preceding paragraph (1)— 
(i) in clause (xii), by striking ‘‘or’’ at 
the end; 
(ii) in clause (xiii), by adding ‘‘or’’ at 
the end; and 
(iii) by inserting after clause (xiii) the 
following new clause: 
‘‘(xiv) individuals who are eligible for home and 
community-based services under needs-based criteria 
established under paragraph (1)(A) of section 
1915(i) and who will receive home and community- 
based services pursuant to a State plan amendment 
under such subsection,’’. 
(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF 
ELIGIBLE INDIVIDUALS
OR LENGTH
OF PERIOD
FOR 
GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA 
IS MODIFIED.—Paragraph (1) of section 1915(i) of such 
Act (42 U.S.C. 1396n(i)) is amended— 
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(1) by striking subparagraph (C) and inserting 
the following: 
‘‘(C) PROJECTION OF NUMBER OF INDI-
VIDUALS TO BE PROVIDED HOME AND COMMU-
NITY-BASED SERVICES.—The State submits to 
the Secretary, in such form and manner, and 
upon such frequency as the Secretary shall 
specify, the projected number of individuals to 
be provided home and community-based serv-
ices.’’; and 
(2) in subclause (II) of subparagraph (D)(ii), 
by striking ‘‘to be eligible for such services for a pe-
riod of at least 12 months beginning on the date the 
individual first received medical assistance for such 
services’’ and inserting ‘‘to continue to be eligible for 
such services after the effective date of the modifica-
tion and until such time as the individual no longer 
meets the standard for receipt of such services under 
such pre-modified criteria’’. 
(f) 
ELIMINATION
OF
OPTION
TO
WAIVE 
STATEWIDENESS.—Paragraph (3) of section 1915(i) of 
such Act (42 U.S.C. 1396n(3)) is amended by striking 
‘‘section 1902(a)(1) (relating to statewideness) and’’. 
(g) EFFECTIVE DATE.—The amendments made by 
this section take effect on the first day of the first fiscal 
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year quarter that begins after the date of enactment of 
this Act. 
SEC. 102. INCREASE IN FEDERAL MEDICAL ASSISTANCE 
PERCENTAGE (FMAP) FOR THE PROVISION 
OF HOME AND COMMUNITY-BASED SERVICES 
UNDER 
MEDICAID 
THROUGH 
THE 
STATE 
PLAN AMENDMENT OPTION. 
(a) IN GENERAL.—Section 1905(b) of the Social Se-
curity Act (42 U.S.C. 1396d(b)) is amended by adding 
at the end the following: ‘‘Notwithstanding the previous 
provisions of this subsection, the Federal medical assist-
ance percentage with respect to amounts expended as 
medical assistance for home and community-based services 
provided through a State plan amendment that satisfies 
the requirements of section 1915(i) shall be the enhanced 
FMAP (as defined in section 2105(b)), but determined by 
substituting ‘10 percent’ for ‘30 percent’ in such section.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to home and community-based 
services furnished on or after October 1, 2009. 
SEC. 103. ANNUAL REPORT ON USE OF MEDICAID STATE 
PLAN AMENDMENT OPTION FOR HOME AND 
COMMUNITY-BASED SERVICES. 
The Secretary of Health and Human Services shall 
submit to Congress an annual report on the extent to 
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which State Medicaid plans have adopted a State plan 
amendment under section 1915(i) of the Social Security 
Act (42 U.S.C. 1396n(i)), as amended by this title, for 
medical assistance for home and community-based services 
for elderly and disabled individuals. Each such report shall 
include the number of beneficiaries who are provided serv-
ices under such an amendment and on changes made in 
the use of waiver authority under section 1915(c) of such 
Act (42 U.S.C. 1396n(c)) as a result of implementation 
of such a State plan amendment. 
TITLE II—STATE GRANTS TO FA-
CILITATE HOME AND COMMU-
NITY-BASED 
SERVICES 
AND 
PROMOTE HEALTH 
SEC. 201. REAUTHORIZATION OF MEDICAID INVESTMENT 
GRANTS AND EXPANSION OF PERMISSIBLE 
USES IN ORDER TO FACILITATE THE PROVI-
SION OF HOME AND COMMUNITY-BASED AND 
OTHER LONG-TERM CARE SERVICES. 
(a) 2-YEAR REAUTHORIZATION; INCREASED FUND-
ING.—Section 1903(z)(4)(A) of the Social Security Act 
(42 U.S.C. 1396b(z)(4)(A)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii), by striking the period at the 
end and inserting ‘‘; and’’; and 
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(3) by inserting after clause (ii), the following 
new clauses: 
‘‘(iii) $150,000,000 for fiscal year 
2010; and 
‘‘(iv) $150,000,000 for fiscal year 
2011.’’. 
(b) EXPANSION
OF PERMISSIBLE USES.—Section 
1903(z)(2) of the Social Security Act (42 U.S.C. 
1396b(z)(2)) is amended by adding at the end the fol-
lowing new subparagraphs: 
‘‘(G)(i) Methods for ensuring the avail-
ability and accessibility of home- and commu-
nity-based services in the State, recognizing 
multiple delivery options that take into account 
differing needs of individuals, through the cre-
ation or designation (in consultation with orga-
nizations representing elderly individuals and 
individuals of all ages with physical, mental, 
cognitive, or intellectual impairments, and orga-
nizations representing the long-term care work-
force, including organized labor, and health 
care and direct service providers) of one or 
more statewide or regional public entities or 
nonprofit organizations (such as fiscal inter-
mediaries, agencies with choice, home care com-
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missions, public authorities, worker associa-
tions, consumer-owned and controlled organiza-
tions (including representatives of individuals 
with severe intellectual or cognitive impair-
ment), area agencies on aging, independent liv-
ing centers, aging and disability resource cen-
ters, or other disability organizations) which 
may— 
‘‘(I) develop programs where qualified 
individuals provide home- and community- 
based services while solely or jointly em-
ployed by recipients of such services; 
‘‘(II) facilitate the training and re-
cruitment of qualified health and direct 
service professionals and consumers who 
use services; 
‘‘(III) recommend or develop a system 
to set wages and benefits, and recommend 
commensurate reimbursement rates; 
‘‘(IV) with meaningful ongoing in-
volvement from consumers and workers (or 
their respective representatives), develop 
procedures for the appropriate screening of 
workers, create a registry or registries of 
available workers, including policies and 
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procedures to ensure no interruption of 
care for eligible individuals; 
‘‘(V) assist consumers in identifying 
workers; 
‘‘(VI) act as a fiscal intermediary; 
‘‘(VII) assist workers in finding em-
ployment, including consumer-directed em-
ployment; 
‘‘(VIII) provide funding for disability 
organizations, 
aging 
organizations, 
or 
other organizations, to assume roles that 
promote consumers’ ability to acquire the 
necessary skills for directing their own 
services and financial resources; or 
‘‘(IX) create workforce development 
plans on a regional or statewide basis (or 
both), to ensure a sufficient supply of 
qualified home and community-based serv-
ices workers, including reviews and anal-
yses of actual and potential worker short-
ages, training and retention programs for 
home and community-based services work-
ers (which may include, as determined ap-
propriate by the State, allowing participa-
tion in such training to count as an allow-
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able work activity under the State tem-
porary assistance for needy families pro-
gram funded under part A of title IV), and 
plans to assist consumers with finding and 
retaining qualified workers. 
‘‘(ii) Nothing in clause (i) shall be con-
strued as prohibiting the use of funds made 
available to carry out this subparagraph for 
start-up costs associated with any of the activi-
ties described in subclauses (I) through (IX), as 
requiring any consumer to hire workers who are 
listed in a worker registry developed with such 
funds, or to limit the ability of consumers to 
hire or fire their own workers. 
‘‘(H) Methods for providing an integrated 
and efficient system of long-term care through 
a review of the Federal, State, local, and pri-
vate long-term care resources, services, and 
supports available to elderly individuals and in-
dividuals of all ages with physical, mental, cog-
nitive, or intellectual impairments and the de-
velopment and implementation of a plan to fully 
integrate such resources, services, and supports 
by aggregating such resources, services, and 
supports to create a consumer-centered and 
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and each State plan amendment option to provide 
such services elected by the State. 
(2) The total amount of expenditures incurred 
for such services under each such waiver and State 
plan amendment option, disaggregated by expendi-
tures for medical assistance and administrative or 
other expenditures. 
(3) The types of such services provided by the 
State under each such waiver and State plan amend-
ment option. 
(4) The number of individuals on a waiting list 
(if any) to be enrolled under each such waiver and 
State plan amendment option or to receive services 
under each such waiver and State plan amendment 
option. 
(5) With respect to home health services, pri-
vate duty nursing services, case management serv-
ices, and rehabilitative services provided under each 
such waiver and State plan amendment option, the 
total number of individuals provided each type of 
such services, the total amount of expenditures in-
curred for each type of services, and whether each 
such service was provided for long-term care or 
acute care purposes. 
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