[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4416 Introduced in House (IH)]







106th CONGRESS
  2d Session
                                H. R. 4416

 To amend title XIX of the Social Security Act to provide for coverage 
 of community-based attendant services and supports under the Medicaid 
                                Program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 10, 2000

Mr. Davis of Illinois introduced the following bill; which was referred 
                      to the Committee on Commerce

_______________________________________________________________________

                                 A BILL


 
 To amend title XIX of the Social Security Act to provide for coverage 
 of community-based attendant services and supports under the Medicaid 
                                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 ``Medicaid Community Attendant 
Services and Supports Act of 2000''.

SEC. 2. STATEMENT OF FINDINGS, PURPOSES, AND POLICY.

    (a) Findings.--The Congress finds the following:
            (1) Many studies have found that an overwhelming majority 
        of individuals with disabilities needing long-term services and 
        supports would prefer to receive them in home and community-
        based settings rather than in institutions. However, research 
        on the provision of long-term services and supports under the 
        Medicaid program (conducted by and on behalf of the Department 
        of Health and Human Services) has revealed a significant bias 
        toward funding these services in institutional rather than home 
        and community-based settings. The extent of this bias is 
        indicated by the fact that seventy-five percent of Medicaid 
        funds for long-term services and supports are expended in 
        nursing homes and intermediate care facilities for the mentally 
        retarded while approximately twenty-five percent pays for 
        services in home and community-based settings.
            (2) Because of this bias, significant numbers of 
        individuals with disabilities of all ages who would prefer to 
        live in the community and could do so with community attendant 
        services and supports, are forced to live in unnecessarily 
        segregated institutional settings if they want to receive 
        needed services and supports. Benefit packages provided in 
        these settings are medically-oriented and constitute barriers 
        to the receipt of the types of services individuals need and 
        want. Decisions regarding the provision of services and 
        supports are too often influenced by what is reimbursable 
        rather than what individuals need and want.
            (3) There is a growing recognition that disability is a 
        natural part of the human experience that in no way diminishes 
        a person's right to--
                    (A) live independently;
                    (B) enjoy self-determination;
                    (C) make choices;
                    (D) contribute to society; and
                    (E) enjoy full inclusion and integration in the 
                mainstream of American society.
            (4) Long-term services and supports provided under the 
        Medicaid program must meet the evolving and changing needs and 
        preferences of individuals with disabilities, including the 
        preference of living within one's own home or living with one's 
        own family and becoming productive members of the community.
            (5) The goals of the Nation properly include providing 
        individuals with disabilities with--
                    (A) meaningful choice of receiving long-term 
                services and supports in the most integrated setting 
                appropriate;
                    (B) the greatest possible control over the services 
                received; and
                    (C) quality services that maximize social 
                functioning in the home and community.
    (b) Purposes.--The purposes of this Act are as follows:
            (1) to provide that States shall offer community attendant 
        services and supports for eligible individuals with 
        disabilities, and
            (2) to provide financial assistance to the States to 
        support systems change initiatives designed to assist each 
        State to develop and enhance a comprehensive consumer-
        responsive statewide system of long-term services and supports 
        that provides real consumer choice and direction consistent 
        with the principle that services and supports are provided in 
        the most integrated setting appropriate to meeting the unique 
        needs of the individual.
    (c) Policy.--It is the policy of the United States that all 
programs, projects, and activities receiving assistance under this Act 
shall be carried out in a manner consistent with the following 
principles:
            (1) Individuals with disabilities, or, as appropriate, 
        their representatives, must be empowered to exercise real 
        choice in selecting long-term services and supports that are of 
        high quality, are cost-effective and meet the unique needs of 
        the individual in the most integrated setting appropriate;
            (2) No person should be forced into an institution to 
        receive services that can be effectively and efficiently 
        delivered in the home or community;
            (3) Federal and State policies, practices, and procedures 
        should facilitate and be responsive to, not impede, an 
        individual's choice; and
            (4) Individuals and their families receiving long-term 
        services and supports must be involved in decision-making about 
        their own care and be provided with sufficient information to 
        make informed choices.

SEC. 3. COVERAGE OF COMMUNITY ATTENDANT SERVICES AND SUPPORTS UNDER THE 
              MEDICAID PROGRAM.

    (a) Requiring Coverage for Individuals Entitled to Nursing Facility 
Services or Eligible for Intermediate Care Facility Services for the 
Mentally Retarded.--
            (1) Section 1902(a)(10)(D) of the Social Security Act (42 
        U.S.C. 1396a(a)(10)(D)) is amended--
                    (A) by inserting ``(i)'' after ``(D)'', and
                    (B) by adding at the end the following:
                            ``(ii) subject to section 1935(b), for the 
                        inclusion of community attendant services and 
                        supports for any individual who, under the 
                        State plan, has a level of severity of physical 
                        or mental impairment that entitles such 
                        individual to nursing facility services or 
                        qualifies an individual to intermediate care 
                        facility services for the mentally retarded and 
                        who requires such community attendant services 
                        and supports based on functional need and 
                        without regard to age or disability;''.
            (2) Section 1902(a)(10)(A) of the Social Security Act (42 
        U.S.C. 1396a(a)(10)(A)) is amended by striking ``(17) and 
        (21)'' and inserting ``(17), (21), and (27)''.
    (b) Medicaid Coverage of Community Attendant Services and 
Supports.--
            (1) In general.--Title XIX of the Social Security Act is 
        amended--
                    (A) by redesignating section 1935 as section 1936, 
                and
                    (B) by inserting after section 1934 the following 
                new section:

        ``coverage of community attendant services and supports

    ``Sec. 1935. (a) Community Attendant Services and Supports 
Defined.--
            ``(1) In general.--In this title, the term `community 
        attendant services and supports' means attendant services and 
        supports furnished to an individual, as needed, to assist in 
        accomplishing activities of daily living, instrumental 
        activities of daily living, and health-related functions 
        through any (or all) of hands-on assistance, supervision, and 
        cueing--
                    ``(A) under a plan of services and supports that is 
                based on an assessment of functional need and that is 
                agreed to by the individual or, as appropriate, the 
                individual's representative;
                    ``(B) in a home or community setting, which may 
                include a school, workplace, or recreation or religious 
                facility, but does not include a nursing facility, an 
                intermediate care facility for the mentally retarded, 
                or other large congregate setting;
                    ``(C) under an agency-provider model and other 
                models (as defined in paragraph (5)); and
                    ``(D) the furnishing of which is selected, managed, 
                and dismissed by the individual or, as appropriate, 
                with assistance from the individual's representative.
            ``(2) Attendant services and supports included.--Such term 
        includes--
                    ``(A) tasks necessary to assist an individual in 
                accomplishing activities of daily living, instrumental 
                activities of daily living, and health-related 
                functions;
                    ``(B) acquisition, maintenance, and enhancement of 
                skills necessary for the individual to accomplish 
                activities of daily living, instrumental activities of 
                daily living, and health-related functions;
                    ``(C) back-up systems or mechanisms (such as the 
                use of beepers) to ensure continuity of services and 
                supports; and
                    ``(D) voluntary training for the individual on how 
                to select, manage, and dismiss attendants.
            ``(3) Excluded services and supports.--Subject to paragraph 
        (4), such term does not include--
                    ``(A) provision of room and board for the 
                individual;
                    ``(B) special education and related services 
                provided under the Individuals with Disabilities 
                Education Act and vocational rehabilitation services 
                provided under the Rehabilitation Act of 1973;
                    ``(C) assistive technology devices and assistive 
                technology services;
                    ``(D) durable medical equipment; and
                    ``(E) home modifications.
            ``(4) Flexibility in transition to community-based home 
        setting.--Such term may include expenditures for transitional 
        costs, such as rent and utility deposits, first month's rent 
        and utilities, bedding, basic kitchen supplies, accessibility 
        modifications, and other necessities required for an individual 
        to make the transition from a nursing facility or intermediate 
        care facility for the mentally retarded to a community-based 
        home setting where the person resides.
            ``(5) Definitions.--In this section:
                    ``(A) The term `activities of daily living' 
                includes eating, toileting, grooming, dressing, 
                bathing, and transferring.
                    ``(B) The term `instrumental activities of daily 
                living' includes meal planning and preparation, 
                managing finances, shopping for food, clothing, and 
                other essential items, performing essential household 
                chores, communicating by phone and other media, and 
                getting around and participating in the community.
                    ``(C) The term `health-related functions' means 
                functions that can be delegated or assigned by licensed 
                health-care professional under State law to be 
                performed by an attendant.
                    ``(D) The term `individual's representative' means 
                a parent, a family member, a guardian, an advocate, or 
                an authorized representative of an individual.
                    ``(E) The term `consumer-directed' means methods of 
                providing services and supports that allow the 
                individual, or where appropriate the individual's 
                representative, maximum control of the community 
                attendant services and supports, regardless of who acts 
as the employer of record.
    ``(b) Limitation on Amounts of Expenditures Under This Title.--In 
carrying out section 1902(a)(10)(D)(ii), a State shall permit an 
individual who has a level of severity of physical or mental impairment 
that entitles such individual to medical assistance with respect to 
nursing facility services or qualifies an individual for intermediate 
care facility services for the mentally retarded to choose to receive 
medical assistance for community-based attendant services and supports 
(rather than medical assistance for such institutional services and 
supports), in the most integrated setting appropriate to the needs of 
the individual, so long as the aggregate amount of the Federal 
expenditures for such individuals in a fiscal year does not exceed the 
total that would have been expended for such individuals to receive 
such institutional services and supports in the year.
    ``(c) Maintenance of Effort Requirement.--With respect to a fiscal 
year quarter, no Federal funds may be paid to a State for medical 
assistance provided to individuals described in section 
1902(a)(10)(D)(ii) for such fiscal year quarter if the Secretary 
determines that the total of the State expenditures for programs to 
enable such individuals with disabilities to receive community-based 
attendant services and supports under other provisions of this title 
for the preceding fiscal year quarter is less than the total of such 
expenditures for the same fiscal year quarter of the preceding fiscal 
year.
    ``(d) Delivery Models.--For purposes of this section:
            ``(1) Agency-provider model.--The term `agency-provider 
        model' means, with respect to the provision of community 
        attendant services and supports for an individual, a method of 
        providing consumer-directed services and supports under which 
        entities contract for the provision of such services and 
        supports.
            ``(2) Other models.--The term `other models' means methods, 
        other than an agency-provider model, for provision of consumer-
        directed services and supports. Such models may include the 
        provision of vouchers, direct cash payments, or use of a fiscal 
        agent to assist in obtaining services.
    ``(e) State Quality Assurance Program.--A State shall, in order to 
continue to receive Federal financial participation for providing 
services and supports under this section, be required to, at a minimum, 
establish and maintain a quality assurance program that provides the 
following:
            ``(1) The State shall establish requirements, as 
        appropriate for agency-based and other models, including--
                    ``(A) minimum qualifications and training 
                requirements, as appropriate for agency-based and other 
                models;
                    ``(B) financial operating standards; and
                    ``(C) an appeals procedure for eligibility denials 
                and a procedure for resolving disagreements over the 
                terms of an individualized plan.
            ``(2) The State shall modify its quality assurance program, 
        where appropriate, to maximize consumer independence and 
        consumer direction in both agency-provided and other models.
            ``(3) The State shall provide a system that provides for 
        the external monitoring of the quality of services by entities 
        consisting of consumers and their representatives, disability 
        organizations, providers, family, members of the community, and 
        others.
            ``(4) The State shall provide ongoing monitoring of the 
        health and well-being of each recipient.
            ``(5) The State shall require that quality assurance 
        mechanisms appropriate for the individual should be included in 
        the individual's written plan.
            ``(6) The State shall establish a process for reporting, 
        investigation, and resolution of allegations of neglect, abuse, 
        or exploitation.
            ``(7) The State shall obtain meaningful consumer input, 
        including consumer surveys, that measure the extent to which 
        participants receive the services and supports described in the 
        individual plan and participant satisfaction with such services 
        and supports.
            ``(8) The State shall make available to the public the 
        findings of the quality assurance program.
            ``(9) The State shall establish an on-going public process 
        for development, implementation, and review of the State's 
        quality assurance program as described in this subparagraph.
            ``(10) The State shall develop sanctions.
    ``(f) Federal Role in Quality Assurance.--The Secretary shall 
conduct a periodic sample review of outcomes for individuals based upon 
the individual's plan of support and based upon the quality assurance 
program of the state plan. The Secretary may conduct targeted reviews 
upon receipt of allegations of neglect, abuse, or exploitation. The 
Secretary shall develop guidelines for states to use in developing 
sanctions.
    ``(g) Eligibility.--Effective January 1, 2001, a State may not 
exercise the option of coverage of individuals under section 
1902(a)(10)(A)(ii)(V) without providing coverage under section 
1902(a)(10)(A)(ii)(VI).
    ``(h) Report on Impact of Section.--The Secretary shall submit to 
Congress periodic reports on the impact of this section on 
beneficiaries, States, and the Federal Government.''.
    (c) Coverage as Medical Assistance.--
            (1) In general.--Section 1905(a) of such Act (42 U.S.C. 
        1396d) is amended--
                    (A) by striking ``and'' at the end of paragraph 
                (26),
                    (B) by redesignating paragraph (27) as paragraph 
                (28), and
                    (C) by inserting after paragraph (26) the following 
                new paragraph:
            ``(27) community attendant services and supports (to the 
        extent allowed and as defined in section 1935); and''.
            (2) Eligibility classifications.--Section 
        1902(a)(10)(A)(ii)(VI) of such Act (42 U.S.C. 
        1396a(a)(10)(A)(ii)(VI)) is amended by inserting ``or community 
        attendant services and supports'' after ``section 1915'' each 
        place it appears.
            (3) Conforming amendment.--Section 1902(a)(10)(C)(iv) of 
        such Act (42 U.S.C. 1396a(a)(10)(C)(iv)) is amended by striking 
        ``(24)'' and inserting ``(27)''.

SEC. 4. GRANTS TO DEVELOP AND ESTABLISH REAL CHOICE SYSTEMS CHANGE 
              INITIATIVES.

    (a) Establishment.--
            (1) In general.--The Secretary of Health and Human Services 
        (in this section referred to as the ``Secretary'') shall award 
        grants described in subsection (b) to States to support real 
        choice systems change initiatives that establish specific 
        actions steps and specific timetables to provide consumer-
        responsive long term services and supports to eligible 
        individuals in the most integrated setting appropriate based on 
        the unique strengths and needs of the individual and the 
        priorities and concerns of the individual (or, as appropriate, 
        the individual's representative). A State may submit an 
        application for a grant authorized under this section at such 
        time, in such manner, and containing such information as the 
        Secretary may determine. The application shall be jointly 
        developed and signed by the designated state official and the 
        chairperson of the task force described in subsection (d), 
        acting on behalf of and at the direction of the task force.
            (2) Definition of state.--In this section, the term 
        ``State'' means each of the 50 States, the District of 
        Columbia, Puerto Rico, Guam, the United States Virgin Islands, 
        American Samoa, and the Commonwealth of the Northern Mariana 
        Islands.
    (b) Grants for Real Choice Systems Change Initiatives.--
            (1) In general.--Out of the funds appropriated under 
        subsection (f), the Secretary shall award grants to States to--
                    (A) support the establishment, implementation, and 
                operation of the State real choice systems change 
                initiatives described in subsection (a); and
                    (B) conduct outreach campaigns regarding the 
                existence of such initiatives.
            (2) Determination of awards; state allotments.--The 
        Secretary shall provide a formula for the distribution of the 
        total amount of the allotments provided in each fiscal year 
        under subparagraph (A) among States. Such formula shall give 
        preference to States that have a relatively higher proportion 
        of long-term services and supports furnished to individuals in 
        an institutional setting but who have a plan described in an 
        application submitted under subsection (a).
    (c) Authorized Activities.--Any State that receives a grant under 
this section shall use the funds made available through the grant to 
accomplish the purposes described in subsection (a) and, in 
accomplishing such purposes, may carry out any of the following systems 
change activities:
            (1) Needs assessment and data gathering.--The State may use 
        funds to conduct a statewide needs assessment that may be based 
        on data in existence on the date on which the assessment is 
        initiated and may include information about the number of 
        persons within the State who are receiving long term services 
        and supports in unnecessarily segregated settings, the nature 
        and extent to which current programs respond to the preferences 
        of individuals with disabilities to receive services in home 
        and community-based settings as well as in institutional 
        settings, and the expected change in demand for services 
        provided in home and community settings as well as 
        institutional settings.
            (2) Institutional bias.--The State may use funds to 
        identify, develop and implement strategies for modifying 
        policies, practices, and procedures that unnecessarily bias the 
        provision of long-term services and supports toward 
        institutional settings and away from home and community based 
        setting, including policies, practices and procedures governing 
        statewideness, comparability in amount, scope and duration of 
        services, financial eligibility, individualized functional 
        assessments and screenings (including individual and family 
        involvement), and knowledge about service options.
            (3) Over medicalization of services.--The State may use 
        funds to identify, develop, and implement strategies for 
        modifying policies, practices, and procedures that 
        unnecessarily bias the provision of long term services and 
        supports by health care professionals to the extent that 
        quality services and supports can be provided by other 
        qualified individuals, including policies, practices, and 
        procedures governing service authorization, case management and 
        service coordination, service delivery options, quality 
        controls, and supervision and training.
            (4) Interagency coordination; single point of entry.--The 
        State may support activities to identify and coordinate Federal 
        and State policies, resources, and services, relating to the 
        provision of long term services and supports, including the 
        convening of interagency work groups and the entering into of 
        interagency agreements that provide for a single point of entry 
        and the design and implementation of coordinated screening and 
        assessment system for all persons eligible for long term 
        services and supports.
            (5) Training and technical assistance.--The State may carry 
        out directly, or may provide support to a public or private 
        entity to carry out training and technical assistance 
        activities that are provided for individuals with disabilities, 
        as appropriate, their representatives, attendants and personnel 
        (including professionals, paraprofessionals, volunteers, and 
        other members of the community).
            (6) Public awareness.--The State may support a public 
        awareness program design to provide information relating to the 
        availability of choices individuals with disabilities may 
        select for receiving long term services and support in the most 
        integrated setting appropriate.
            (7) Downsizing of large institutions.--The State may use 
        funds to support the per capita increased fixed costs in 
institutional settings directly related to the movement of individuals 
with disabilities out of a specific facility into community-based 
settings.
            (8) Transitional costs.--The State may use funds to provide 
        transitional costs described in section 1935(a)(4) of the 
        Social Security Act, as added by section 3(b) of this Act.
            (9) Task force.--The State may use these funds to support 
        the operation of the task force described in subsection (d).
            (10) Demonstrations of new approaches.--The State may use 
        funds to conduct, on a time-limited basis, the demonstration of 
        new approaches to accomplishing the purposes described in 
        subsection (a).
            (11) Other activities.--The State may utilize amounts made 
        available through grants made under subsection (b) for any 
        systems change activities other than the activities described 
        in another paragraph of this subsection, that are necessary for 
        developing, implementing, or evaluating the comprehensive 
        statewide system of long term services and supports.
    (d) Consumer Task Force.--
            (1) Establishment and duties.--To be eligible to receive 
        financial assistance under this section, each State shall 
        establish a task force to assist the State in the development, 
        implementation, and evaluation of real choice systems change 
        initiative.
            (2) Appointment.--Members of the task force shall be 
        appointed by the Governor. The Governor shall select members 
        after soliciting recommendations from representatives of 
        organizations representing a broad range of individuals with 
        disabilities and organizations interested in individuals with 
        disabilities.
            (3) Composition.--
                    (A) The task force shall represent a broad range of 
                individuals with disabilities from diverse backgrounds 
                and shall include representatives from Developmental 
                Disabilities Councils, State Independent Living 
                Councils, Commissions on Aging, organizations that 
                provide services to individuals with disabilities and 
                consumers of long-term services and supports.
                    (B) A majority of task force members shall be 
                individuals with disabilities or their representatives.
                    (C) The task force shall not include employees of 
                any State agency providing services to individuals with 
                disabilities other than employees of agencies described 
                in the Developmental Disabilities Assistance and Bill 
                of Rights Act.
    (e) Availability of Funds.--
            (1) Funds allocated to states.--Funds allocated to a State 
        under a grant made under this section for a fiscal year shall 
        remain available until expended.
            (2) Funds not allocated to states.--Funds not allocated to 
        States in the fiscal year for which they are appropriated shall 
        remain available in succeeding fiscal years for allocation by 
        the Secretary using the allocation formula established by the 
        Secretary under subsection (b)(2).
    (f) Annual Report.--A State that receives a grant under this 
section shall submit an annual report to the Secretary on the use of 
funds provided under the grant. Each report shall include the 
percentage increase in the number of eligible individuals in the State 
who receive long term services and supports in the most integrated 
setting appropriate, including through community attendant services and 
supports and other community-based settings.
    (g) Appropriation.--Out of any funds in the Treasury not otherwise 
appropriated, there is authorized to be appropriated and there is 
appropriated to make grants under this section--
            (1) for fiscal year 2001, $25,000,000; and
            (2) for each of fiscal years 2002 through 2010, such 
        amounts as may be appropriate.

SEC. 5. STATE OPTION FOR ELIGIBILITY FOR INDIVIDUALS.

    (a) In General.--Section 1903(f) of the Social Security Act (42 
U.S.C. 1396b(f)) is amended--
            (1) in paragraph (4)(C), by inserting ``, subject to 
        paragraph (5),'' after ``does not exceed''; and
            (2) by adding at the end the following:
    ``(5)(A) A State may waive the income, resources, and deeming 
limitations described in paragraph (4)(C) in such cases as the State 
finds the potential for employment opportunities would be enhanced 
through the provision of such services.
    ``(B) In the case of an individual who is made eligible for medical 
assistance because of subparagraph (A), notwithstanding section 
1916(b), the State may impose a premium based on a sliding scale 
relating to income.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to medical assistance provided for items and services furnished 
on or after January 1, 2001.

SEC. 6. REVIEW OF, AND REPORT ON, REGULATIONS.

    The National Council on Disability established under title IV of 
the Rehabilitation Act of 1973 shall review existing regulations under 
title XIX of the Social Security Act insofar as they regulate the 
provision of home health services, personal care services, and other 
services in home and community-based settings. The Secretary of Health 
and Human Services shall submit to Congress a report on how excessive 
utilization of medical services can be reduced under such title by 
using community attendant services and supports.

SEC. 7. TASK FORCE ON FINANCING OF LONG-TERM CARE SERVICES.

    The Secretary of Health and Human Services shall establish a task 
force to examine appropriate methods for financing long-term services 
and supports. Such task force shall include significant representation 
of individuals (and representatives of individuals) who receive such 
services and supports.
                                 <all>