Title: Transition to Independence Act of 2018
Policy area: Health

Summary:
Transition to Independence Act of 2018
This bill directs the Centers for Medicare & Medicaid Services to establish a demonstration program under which a state that has a Medicaid Buy-In program and meets other specified requirements may receive bonus payments for expanding employment opportunities for working-age individuals with disabilities who receive Medicaid-funded home- or community-based services.


[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4931 Introduced in House (IH)]

<DOC>






115th CONGRESS
  2d Session
                                H. R. 4931

   To establish the Transition to Independence demonstration program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            February 5, 2018

Mr. Langevin (for himself, Mr. Harper, Mr. Beyer, Mr. Sessions, and Mr. 
   Foster) introduced the following bill; which was referred to the 
                    Committee on Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
   To establish the Transition to Independence demonstration program.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Transition to Independence Act of 
2018''.

SEC. 2. TRANSITION TO INDEPENDENCE DEMONSTRATION PROGRAM.

    (a) Establishment.--The Secretary shall establish a demonstration 
program under which a State that is a Medicaid Buy-In State and meets 
certain criteria may receive bonus payments for meeting specific 
measurable benchmarks in expanding individual integrated employment and 
reducing subminimum wage work, congregate setting work, or facility-
based day habilitation placements for working-age individuals with a 
disability receiving Medicaid-funded home or community-based services 
and for taking other actions conducive to expanding employment 
opportunities for individuals with disabilities within the State.
    (b) Requirements for the Transition to Independence Demonstration 
Program.--
            (1) Minimum standards.--The Secretary shall establish 
        minimum standards for Medicaid Buy-In States participating in 
        the demonstration program to comply with in establishing 
        eligibility requirements for individual participants, benefits, 
        and administrative requirements for the Transition to 
        Independence Medicaid Buy-In Option offered under the 
        demonstration program.
            (2) Preference given to certain states for demonstration 
        participation.--The Secretary shall give preference in 
        selecting States to participate in the demonstration program to 
        States that have Medicaid Buy-In programs that--
                    (A) establish an assets or resources test for 
                participation by an individual in the Medicaid Buy-In 
                Option that is not less than $20,000;
                    (B) establish an income requirement for 
                participation by an individual in the Medicaid Buy-In 
                Option that is at least up to 400 percent of the 
                poverty line;
                    (C) offer home and community-based services, 
                including employment-based services and supports, in 
                the Medicaid Buy-In Option; and
                    (D) establish such other requirements for an 
                individual's participation in the Medicaid Buy-In 
                Option as the Secretary shall specify.
            (3) Work incentives coordinator.--The minimum standards 
        shall require a Medicaid Buy-In State participating in the 
        demonstration program to provide work incentives coordinators 
        who have been trained as work incentive specialists under a 
        community-based work incentives planning and assistance program 
        established under section 1149 of the Social Security Act (42 
        U.S.C. 1320b-20) to assist the individuals who elect to 
        participate in the Medicaid Buy-In Option in order to ensure 
        the individuals are provided with appropriate items and 
        services.
    (c) Application and Selection Requirements.--
            (1) In general.--Not later than June 30, 2019, the 
        Secretary shall solicit applications from Medicaid Buy-In 
        States and select 15 Medicaid Buy-In States to participate in 
        the demonstration program.
            (2) Application requirements.--An application to 
        participate in the demonstration program shall include the 
        following:
                    (A) Data and information regarding the numbers of 
                working-age individuals with disabilities who are 
                receiving Medicaid-funded home or community-based 
                services in the Medicaid Buy-In State who are in 
                individual integrated employment, subminimum wage work, 
                congregate setting work, or facility-based day 
                habilitation or day treatment, respectively.
                    (B) Data and information verifying that the 
                Medicaid Buy-In State is prepared to meet the minimum 
                standards established by the Secretary for the Medicaid 
                Buy-In Option.
                    (C) A plan for promoting the Medicaid Buy-In Option 
                to potentially eligible individuals that includes--
                            (i) clear and easy-to-understand, multi-
                        media information on how to enroll in the 
                        Medicaid Buy-In Option on the Web sites for the 
                        Medicaid Buy-In State's Medicaid and Disability 
                        Determination Services Agencies; and
                            (ii) a ``no-wrong door'' policy under which 
                        individuals who apply for a determination of 
                        eligibility for the Medicaid Buy-In Option are 
                        also determined if they are eligible for an 
                        applicable State health subsidy program in 
                        accordance with section 1413 of the Patient 
                        Protection and Affordable Care Act (42 U.S.C. 
                        18083) (including the State Medicaid program 
                        under another eligibility pathway), informed of 
                        the results of such determinations and, 
                        depending on their eligibility, provided with 
                        the option to voluntarily elect to participate 
                        in the Medicaid Buy-In Option or an applicable 
                        State health subsidy program.
                    (D)(i) An assurance that the State will establish 
                and build capacity for an eligibility process to make 
                eligibility determinations for the Medicaid Buy-In 
                program. Such process shall provide for a determination 
                of eligibility not later than 90 days after the date 
                that an application to participate in the program is 
                filed, including for individuals who are not receiving 
                disability insurance benefits under title II of the 
                Social Security Act (42 U.S.C. 401 et seq.) or 
                supplemental security income benefits under title XVI 
                of such Act (42 U.S.C. 1381 et seq.).
                    (ii) A description of the eligibility criteria the 
                State will use, the process it will use to determine 
                eligibility, for individuals who do not qualify for 
                such title II or SSI benefits and the staff who will be 
                responsible for making those determinations. This 
                eligibility process shall not use the disability 
                determination process used by the Social Security 
                Administration for such title II and SSI benefits.
                    (E) Verification that the Medicaid Buy-In State 
                shall establish a Stakeholder Advisory Committee that 
                meets the requirements of paragraph (3) and shall 
                consult with and consider recommendations of the 
                Committee while conducting the demonstration program.
                    (F) A description of the person-centered planning 
                process that the State intends to use for participants 
                in the demonstration program.
                    (G) Such other information as the Secretary may 
                require relating to the demonstration program.
            (3) Stakeholder advisory committee requirements.--
                    (A) Membership.--In establishing the Stakeholder 
                Advisory Committee required for the demonstration 
                program, the Medicaid Buy-In State shall ensure that--
                            (i) at least 50 percent of the members of 
                        the Stakeholder Advisory Committee are 
                        individuals with disabilities; and
                            (ii) at least 1 member of the Committee is 
                        a provider of services to individuals with 
                        disabilities.
                    (B) Duties.--The Stakeholder Advisory Committee 
                shall--
                            (i) analyze outcomes data and other 
                        information related to the conduct of the 
                        demonstration program; and
                            (ii) regularly submit recommendations, 
                        including for specific actions by the Medicaid 
                        Buy-In State participating in the demonstration 
                        program, that the Committee determines 
                        appropriate with respect to the conduct of the 
                        demonstration program by the State.
    (d) Requirement for Selecting States.--In selecting Medicaid Buy-In 
States to participate in the demonstration program, the Secretary shall 
ensure that the Medicaid Buy-In States selected include Medicaid Buy-In 
States with low, medium, and high numbers of working-age individuals 
with disabilities who are receiving Medicaid-funded home or community-
based services and are in individual integrated employment, subminimum 
wage work, congregate setting work, or facility-based day habilitation 
or day treatment, respectively.
    (e) Length of Demonstration Program.--The demonstration program 
shall be conducted for a period of 5 fiscal years, beginning with 
fiscal year 2020.
    (f) Performance Bonus Payments.--
            (1) In general.--For each fiscal year in which the 
        demonstration program is conducted, a Medicaid Buy-In State 
        participating in the demonstration program during that fiscal 
        year may qualify for a performance bonus payment.
            (2) State-specified criteria and performance plans.--In 
        order to participate in the demonstration program, a Medicaid 
        Buy-In State shall submit criteria and a plan for achieving 
        each of the mandatory benchmarks described in paragraph (3) and 
        a selection of the additional benchmarks described in paragraph 
        (4) as determined by the Secretary. The Secretary shall 
        establish a methodology for assessing State performance with 
        respect to the State-specified criteria for the mandatory and 
        additional benchmarks.
            (3) Mandatory benchmarks.--The mandatory benchmarks 
        described in this paragraph are the following:
                    (A) Reduced participation in segregated programs 
                and increased participation in individual integrated 
                employment.--
                            (i) Reduced population census of segregated 
                        programs.--
                                    (I) In general.--Achieving a 
                                reduction in the population in the 
                                State of working-age individuals with 
                                disabilities who are receiving 
                                Medicaid-funded home or community-based 
                                services or who are receiving services 
                                through an Intermediate Care Facility 
                                for Persons with Developmental 
                                Disabilities (ICF-DD), a nursing 
                                facility, an institution for 
                                individuals with mental illness, or 
                                other congregate facilities and are in 
                                subminimum wage work, congregate 
                                setting work, or facility-based day 
                                habilitation or day treatment.
                                    (II) Minimum percent reductions; 
                                bonus based on achievement of differing 
                                tiers.--In order to receive a bonus 
                                payment for a fiscal year under this 
                                clause, a Medicaid Buy-In State shall 
                                achieve a reduction of the population 
                                described in subclause (I) of at least 
                                10 percent below the State's most 
                                recent prior fiscal year's census of 
                                the eligible population in subminimum 
                                wage work, congregate setting work, or 
                                facility-based day habilitation or day 
                                treatment. Subject to paragraph (5)(B), 
                                the Secretary shall award an increased 
                                bonus payment for a fiscal year to a 
                                Medicaid Buy-In State that achieves a 
                                percentage reduction of 20, 30, 40 or 
                                more with respect to the prior fiscal 
                                year's census of such population.
                                    (III) Requirements for meeting 
                                benchmark.--A working-age individual 
                                with a disability shall be deemed as 
                                counting towards a percentage reduction 
                                for purposes of this clause if the 
                                individual is--
                                            (aa) employed in a 
                                        competitive, integrated 
                                        employment setting for at least 
                                        10 hours a week on average over 
                                        a 120-day period during the 
                                        year involved;
                                            (bb) receiving integrated 
                                        day services that reach the 
                                        level of care required in the 
                                        individual's person-centered 
                                        plan; or
                                            (cc) a combination of items 
                                        (aa) and (bb),
                                enabling the individual to achieve, if 
                                desired, a comparable level of benefit 
                                as before the change in placement. The 
                                State must report aggregate data to the 
                                Secretary on the outcome of all 
                                individuals transitioning out of 
                                congregate settings being counted 
                                towards fulfillment of this benchmark.
                            (ii) Increased population census of 
                        individual integrated employment.--
                                    (I) In general.--Achieving an 
                                increase in the population in the State 
                                of working-age individuals with 
                                disabilities who are receiving 
                                Medicaid-funded home or community-based 
                                services and are in individual 
                                integrated employment.
                                    (II) Minimum percent increases; 
                                bonus based on achievement of certain 
                                tiers.--In order to receive a bonus 
                                payment for a fiscal year under this 
                                clause, a Medicaid Buy-In State shall 
                                achieve an increase in the population 
                                described in subclause (I) of at least 
                                10 percent above the State's most 
                                recent prior fiscal year's census of 
                                the eligible population in individual 
                                integrated employment. Subject to 
                                paragraph (5)(B), the Secretary shall 
                                award an increased bonus payment for a 
                                fiscal year to a Medicaid Buy-In State 
                                that achieves a percentage increase of 
                                20, 30, 40 or more with respect to the 
                                prior fiscal year's census of such 
                                population.
                                    (III) Requirements for meeting 
                                benchmark.--A working-age individual 
                                with a disability shall be deemed as 
                                counting towards a percentage increase 
                                for purposes of this clause if the 
                                individual is employed in an integrated 
                                individual employment setting for at 
                                least 10 hours a week on average over a 
                                120-day period during the fiscal year 
                                involved.
                    (B) Meeting the medicaid buy-in standards.--Meeting 
                the minimum standards established by the Secretary for 
                the Medicaid Buy-In Option.
            (4) Additional benchmarks.--The additional benchmarks 
        described in this paragraph are the following:
                    (A) Elimination of new placement approvals.--
                Eliminating new approvals for placement in the State of 
                working-age individuals with disabilities who are 
                receiving Medicaid-funded home or community-based 
                services in subminimum wage work, congregate setting 
                work, or facility-based day habilitation or day 
                treatment, in accordance with criteria established by 
                the Secretary.
                    (B) Demonstration of inter-agency collaboration.--
                Demonstrating inter-agency collaboration between the 
                State agencies responsible for administering Medicaid, 
                vocational rehabilitation, and education (and, if the 
                State is participating the Promoting Readiness of 
                Minors in Supplemental Security Income initiative 
                (PROMISE), including coordination with that 
                initiative), in determining payer of last resort rules 
                and rules for providing individuals with a seamless 
                transition of services provided under such agencies, in 
                accordance with criteria established by the Secretary.
                    (C) Termination of vocational rehabilitation 
                funding.--Ending the use of vocational rehabilitation 
                funding for subminimum wage work, congregate setting 
                work, or facility-based day habilitation or day 
                treatment, in accordance with criteria established by 
                the Secretary.
                    (D) Workforce development.--Demonstrating in 
                accordance with criteria established by the Secretary 
                satisfaction of at least two of the following 
                strategies to promote workforce development:
                            (i) Increasing Medicaid payments for 
                        supported employment providers for individuals 
                        with disabilities by an amount necessary to 
                        ensure an adequately supported employment 
                        network, as determined by the Secretary.
                            (ii) Adopting employment strategies that 
                        result in working-age individuals with 
                        disabilities who are receiving Medicaid-funded 
                        home or community-based services being 
                        recruited, hired, and retained as full-time 
                        employees of State government or by contractors 
                        of State government.
                            (iii) Developing a State equivalent of 
                        section 503 of the Rehabilitation Act of 1973 
                        (29 U.S.C. 793) to recruit, hire, promote, and 
                        retain working-age individuals with 
                        disabilities who are receiving Medicaid-funded 
                        home or community-based services with a 
                        utilization goal of at least 7 percent of the 
                        State government workforce.
                            (iv) Developing a special hiring authority 
                        mechanism akin to the Schedule A appointing 
                        authority under section 213.3102(u) of title 5 
                        of the Code of Federal Regulations (commonly 
                        referred to as the ``Schedule A Hiring 
                        Authority'') to assist in easing the hiring of 
                        working-age individuals with disabilities who 
                        are receiving Medicaid-funded home or 
                        community-based services within the State 
                        government with an accompanying plan submitted 
                        to the Secretary outlining targeted 
                        implementation goals for the amount of 
                        individuals with disabilities within State 
                        government.
                            (v) Increasing the hiring of working-age 
                        individuals with disabilities who are receiving 
                        Medicaid-funded home or community-based 
                        services in employment for which the individual 
                        is compensated at or above the minimum wage, 
                        through collaboration with the State vocational 
                        rehabilitation and workforce development 
                        programs and Federal contractors.
                            (vi) Providing State tax credits to 
                        employers for hiring new workers who are 
                        working-age individuals with disabilities who 
                        are receiving Medicaid-funded home or 
                        community-based services.
            (5) Payment to states.--
                    (A) In general.--Subject to the succeeding 
                provisions of this paragraph, the Secretary shall make 
                a performance bonus payment to each Medicaid Buy-In 
                State participating in the demonstration program that 
                qualifies for such a payment with respect to a fiscal 
                year as a single payment not later than the last day of 
                the first calendar quarter of the fiscal year following 
                the fiscal year to which the performance bonus payments 
                applies. Payments to States made under this paragraph 
                shall be considered to have been made under, and are 
                subject to the requirements of, section 1903 of the 
                Social Security Act (42 U.S.C. 1396b).
                    (B) Determination of payment.--The performance 
                bonus payment for a Medicaid Buy-In State shall consist 
                of the additional amount that the State would have been 
                paid for providing medical assistance to individuals 
                enrolled in the State's Medicaid Buy-In Option during 
                the preceding fiscal year if the regular FMAP 
                applicable to such assistance were increased (subject 
                to subparagraph (C)) as follows:
                            (i) Two percentage points for achieving the 
                        minimum 10 percent reduction in the mandatory 
                        benchmark described in paragraph (3)(A) during 
                        the preceding fiscal year (or 2.4 percentage 
                        points for achieving a reduction of at least 20 
                        percent (but not more than 30 percent), 2.6 
                        percentage points for achieving a reduction of 
                        at least 30 percent (but not more than 40 
                        percent), and 2.8 percentage points for 
                        achieving a reduction of at least 40 percent).
                            (ii) Two percentage points for achieving 
                        the minimum 10 percent increase in the 
                        mandatory benchmark described in paragraph 
                        (3)(B) during the preceding fiscal year (or 2.4 
                        percentage points for achieving an increase of 
                        at least 20 percent (but not more than 30 
                        percent), 2.6 percentage points for achieving 
                        an increase of at least 30 percent (but not 
                        more than 40 percent), and 2.8 percentage 
                        points for achieving an increase of at least 40 
                        percent).
                            (iii) One-half percentage points for each 
                        additional benchmark described in paragraph (4) 
                        that the State achieves during the preceding 
                        fiscal year.
                    (C) Limitations.--In no case may--
                            (i) the increase in the regular FMAP 
                        resulting from the application of subparagraph 
                        (B) for any Medicaid Buy-In State exceed 100 
                        percent of the costs for providing medical 
                        assistance to individuals enrolled in the 
                        Medicaid Buy-In Option with respect to each 
                        fiscal year of the 5-fiscal-year period in 
                        which the demonstration project is conducted; 
                        or
                            (ii) payments be made to a Medicaid Buy-In 
                        State under this paragraph after December 31, 
                        2023.
                    (D) Use of payments.--A Medicaid Buy-In State 
                receiving a performance bonus payment under this 
                paragraph shall use the payment only to expand 
                individual integrated employment and community 
                integration for working-age individuals with 
                disabilities who are receiving Medicaid-funded home or 
                community-based services.
    (g) Reports; Recommendations.--
            (1) Annual state reports.--
                    (A) In general.--Each Medicaid Buy-In State 
                participating in the demonstration program annually 
                shall submit a detailed report to the Secretary 
                regarding the State's conduct of the demonstration 
                program.
                    (B) Information to be included.--Such annual 
                reports shall include, in addition to data and 
                information regarding State performance with respect 
                the mandatory and additional benchmarks described in 
                paragraphs (3) and (4) of subsection (f) and such other 
                information as the Secretary may require, data and 
                information regarding the extent to which, since the 
                start of the demonstration program--
                            (i) the State has reduced the State 
                        population of individuals with disabilities who 
                        have attained age 18 but have not attained age 
                        31, are receiving Medicaid-funded home or 
                        community-based services or services through an 
                        Intermediate Care Facility for Persons with 
                        Developmental Disabilities (ICF-DD), a nursing 
                        facility, an institution for individuals with 
                        mental illness, or other congregate facilities, 
                        and were in subminimum wage work, congregate 
                        setting work, or facility-based day 
                        habilitation or day treatment; and
                            (ii) the State has increased the State 
                        population of individuals with disabilities who 
                        have attained age 18 but have not attained age 
                        31, are receiving Medicaid-funded home or 
                        community-based services, and are engaged in 
                        individual integrated employment.
                    (C) Additional information on transitioning 
                individuals to integrated employment.--Each such annual 
                report shall include information regarding--
                            (i) the State's efforts to transition 
                        individuals with disabilities who are 
                        participating in the demonstration program to 
                        individual integrated employment during the 
                        preceding fiscal year;
                            (ii) the full spectrum of employment 
                        outcomes for such individuals;
                            (iii) best practices for successfully 
                        achieving such transitions; and
                            (iv) lessons learned.
                    (D) Promoting public participation.--To promote 
                transparency with respect to such annual reports, each 
                Medicaid Buy-In State shall--
                            (i) provide, before submission of each such 
                        report--
                                    (I) for posting of a draft of the 
                                report for review by the public on a 
                                publicly accessible Web site of the 
                                State;
                                    (II) for providing a period of not 
                                less than 30 days for the receipt of 
                                public comments on the draft report; 
                                and
                                    (III) for at least two public 
                                hearings regarding the draft report; 
                                and
                            (ii) include in the report so submitted a 
                        response to public comments received during 
                        such period (along with a description of 
                        whether changes have been made in the report in 
                        response to such comments).
                With respect to each such State report submitted, the 
                Secretary, at the Federal level, shall provide for 
                another 30-day public comment period to receive 
                comments on such report.
                    (E) Posting of reports on publicly accessible web 
                site.--The Secretary shall post each of the annual 
                reports submitted under this paragraph, with a summary 
                of the comments received under subparagraph (D), on a 
                publicly accessible Web site.
            (2) Reports and recommendations to congress.--
                    (A) In general.--Not later than January 1, 2020, 
                and January 1 of each of the 6 years thereafter, the 
                Secretary shall submit to Congress a report on the 
                demonstration program. Each such report shall include 
                data and information regarding State performance with 
                respect to each of the mandatory and additional 
                benchmarks described in paragraphs (3) and (4) of 
                subsection (f) and other data and information reported 
                by States under paragraph (1) and an assessment of the 
                extent to which the demonstration program is successful 
                in transitioning working-age individuals with 
                disabilities to independent living and work in their 
                communities.
                    (B) Recommendations.--Not later than December 31, 
                2021, the Secretary shall submit to Congress 
                recommendations regarding whether the demonstration 
                program should be continued, expanded, modified, or 
                terminated.
            (3) Research and evaluation.--
                    (A) In general.--The Secretary, acting through the 
                Administration on Community Living, directly or through 
                grant or contract, shall provide for research on, and a 
                national evaluation of, the demonstration program, 
                including assistance to the Secretary in preparing the 
                final report required under subparagraph (C).
                    (B) Contents of evaluation.--Such national 
                evaluation shall include an analysis of the 
                characteristics and outcomes of the individuals 
                participating in the demonstration program and the best 
                practices developed to achieve the goals of the 
                demonstration program.
                    (C) Final report.--Not later than June 30, 2022, 
                the Secretary shall submit to the President and 
                Congress a final report that reflects the evaluation 
                under subparagraph (A), that provides findings and 
                conclusions on the conduct and effectiveness of 
                demonstration program, and that includes a summary of 
                the public comments received under paragraph (1)(D).
    (h) Definitions.--In this section:
            (1) Congregate setting work.--The term ``congregate setting 
        work'' means a nonprofit, for-profit, or State agency entity 
        that employs a majority of individuals with disabilities and 
        receives Medicaid or other State funds for the purpose of 
        providing employment services, or a facility or sub-unit of any 
        such agency that meets such criteria.
            (2) Demonstration program.--The term ``demonstration 
        program'' means the Transition to Independence Demonstration 
        Program established under this section.
            (3) Facility-based day habilitation or day treatment.--The 
        term ``facility-based day habilitation or day treatment'' has 
        the meaning established by the Secretary for that term for 
        purposes of the demonstration program and shall include non-
        residential day services which take place predominantly or in 
        large part at a single site, fixed site, or center-based 
        program for individuals with disabilities. In establishing the 
        meaning of such term, the Secretary shall provide clear 
        instructions distinguishing facility-based day habilitation or 
        day treatment from integrated day habilitation or day treatment 
        programs taking place in settings within the broader community 
        and which do not isolate individuals participating in such 
        integrated day habilitation or day treatment programs from 
        mainstream life.
            (4) Individual integrated employment.--
                    (A) In general.--The term ``individual integrated 
                employment'' means the ongoing supports to an 
                individual who, because of the individual's 
                disabilities, needs intensive on-going supports to 
                obtain and maintain an individual job in competitive or 
                customized employment, self-employment, or in an 
                integrated working setting in the general workforce for 
                which the individual is compensated at or above the 
                minimum wage, but not less than the customary wage and 
                level of benefits paid by the employer for the same or 
                similar work performed by an individual without a 
                disability.
                    (B) Customized employment services included.--Such 
                term includes customized employment services in which 
                an individual receives support to craft a job 
                description around their strengths and challenges.
                    (C) Exclusions.--Such term does not include 
                segregated enclaves, segregated mobile work crews, or 
                other employment scenarios where an individual is 
                placed solely based on the individual's disability. In 
                this subparagraph, the term ``segregated'' means, with 
                respect to a setting or work crew, a setting or work 
                crew in which individuals with disabilities are 
                separated (in place or in rates of pay) from 
                individuals without disabilities.
            (5) Integrated day habilitation services.--The term 
        ``integrated day habilitation services'' means services that 
        are provided outside of disability specific programs or 
        facilities, in a setting that supports the full access of 
        individuals with disabilities to the greater community to the 
        same degree as individuals not receiving services, and 
        consistent with the following:
                    (A) Each individual receiving such services has an 
                individually tailored schedule that is directly related 
                to and reflects the individual's specific interests and 
                goals.
                    (B) Activities take place on an individual basis or 
                in small groups of individuals who choose to be served 
                together.
                    (C) The majority of time spent receiving such 
                services takes place within the broader community 
                rather than within a single-site, fixed site, or 
                center-based program for individuals with disabilities, 
                regardless of the program size.
                    (D) The services are provided consistent with the 
                requirements of section 441.710 of title 42, Code of 
                Federal Regulations.
            (6) Medicaid.--The term ``Medicaid'' means the program for 
        medical assistance established under title XIX of the Social 
        Security Act (42 U.S.C. 1396 et seq.).
            (7) Medicaid buy-in state.--The term ``Medicaid Buy-In 
        State'' means a State that, under subclause (XIII), (XV), or 
        (XVI) of section 1902(a)(10)(A)(ii) of the Social Security Act 
        (42 U.S.C. 1396a(a)(10)(A)(ii)), a waiver approved under 
        section 1115 or 1915 of such Act (42 U.S.C. 1315, 1396n), or 
        other authority, has a program under which individuals with 
        disabilities with earnings and assets that would otherwise make 
        them ineligible for medical assistance under the State's 
        Medicaid program are able to maintain their eligibility for 
        such assistance.
            (8) Nursing facility.--The term ``nursing facility'' has 
        the meaning given that term in section 1919(a) of the Social 
        Security Act (42 U.S.C. 1396r(a)).
            (9) Poverty line.--The term ``poverty line'' has the 
        meaning given that term in section 2110(c)(5) of the Social 
        Security Act (42 U.S.C. 1397jj(c)(5)).
            (10) Regular fmap.--The term ``regular FMAP'' means the 
        Federal medical assistance percentage applicable to the State 
        (as determined under section 1905(b) of the Social Security Act 
        (42 U.S.C. 1396d(b))) without regard to any increases in that 
        percentage applicable under subsection (y), (z), (aa), or (dd) 
        of section 1905 of such Act or under any other provision of 
        law.
            (11) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (12) Subminimum wage work.--The term ``subminimum wage 
        work'' means any setting in which individuals with disabilities 
        are paid less than minimum wage under a certificate issued in 
        accordance with section 14(c) of the Fair Labor Standards Act 
        of 1938 (29 U.S.C. 214(c)).
            (13) Supported employment.--The term ``supported 
        employment'' has the meaning given that term in section 7 of 
        the Rehabilitation Act of 1973 (29 U.S.C. 705).
            (14) State.--The term ``State'' has the meaning given such 
        term for purposes of title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.).
            (15) Title ii disability beneficiary.--The term ``title II 
        disability beneficiary'' means an individual entitled to 
        disability insurance benefits under section 223 of the Social 
        Security Act (42 U.S.C. 423) or to monthly insurance benefits 
        under section 202 of such Act (42 U.S.C. 402) based on such 
        individual's disability (as defined in section 223(d) of such 
        Act (42 U.S.C. 423(d))).
            (16) Title xvi disability beneficiary.--The term ``title 
        XVI disability beneficiary'' means an individual eligible for 
        supplemental security income benefits under title XVI of the 
        Social Security Act (42 U.S.C. 1381 et seq.) on the basis of 
        blindness (within the meaning of section 1614(a)(2) of such Act 
        (42 U.S.C. 1382c(a)(2))) or disability (within the meaning of 
        section 1614(a)(3) of such Act (42 U.S.C. 1382c(a)(3))).
            (17) Working-age individual with a disability receiving 
        medicaid-funded home or community-based services.--The term 
        ``working-age individual with a disability receiving Medicaid-
        funded home or community-based services'' means a title II 
        disability beneficiary or a title XVI disability beneficiary 
        who has attained age 18, but has not attained age 65, and is 
        receiving home or community-based services--
                    (A) under a waiver approved under subsection (c) or 
                (d) of section 1915 the Social Security Act (42 U.S.C. 
                1396n);
                    (B) under the State Medicaid plan in accordance 
                with subsection (i), (j), or (k) of such section; or
                    (C) under a Medicaid waiver approved under section 
                1115 of the Social Security Act (42 U.S.C. 1315).
                                 <all>