Money follows the person rebalancing demonstration

(a)

Program purpose and authority

The Secretary of Health and Human Services (in this section referred to as the Secretary) is authorized to award, on a competitive basis, grants to States in accordance with this section for demonstration projects (each in this section referred to as an MFP demonstration project) designed to achieve the following objectives with respect to institutional and home and community-based long-term care services under State medicaid programs: (1)

Rebalancing

Increase the use of home and community-based, rather than institutional, long-term care services. (2)

Money follows the person

Eliminate barriers or mechanisms, whether in the State law, the State medicaid plan, the State budget, or otherwise, that prevent or restrict the flexible use of medicaid funds to enable medicaid-eligible individuals to receive support for appropriate and necessary long-term services in the settings of their choice. (3)

Continuity of service

Increase the ability of the State medicaid program to assure continued provision of home and community-based long-term care services to eligible individuals who choose to transition from an institutional to a community setting. (4)

Quality assurance and quality improvement

Ensure that procedures are in place (at least comparable to those required under the qualified HCB program) to provide quality assurance for eligible individuals receiving medicaid home and community-based long-term care services and to provide for continuous quality improvement in such services. (b)

Definitions

For purposes of this section: (1)

Home and community-based long-term care services

The term home and community-based long-term care services means, with respect to a State medicaid program, home and community-based services (including home health and personal care services) that are provided under the State’s qualified HCB program or that could be provided under such a program but are otherwise provided under the medicaid program. (2)

Eligible individual

The term eligible individual means, with respect to an MFP demonstration project of a State, an individual in the State— (A)who, immediately before beginning participation in the MFP demonstration project— (i)resides (and has resided, for a period of not less than six months or for such longer minimum period, not to exceed 2 years, as may be specified by the State) in an inpatient facility; (ii)is receiving medicaid benefits for inpatient services furnished by such inpatient facility; and (iii)with respect to whom a determination has been made that, but for the provision of home and community-based long-term care services, the individual would continue to require the level of care provided in an inpatient facility; and (B)who resides in a qualified residence beginning on the initial date of participation in the demonstration project. (3)

Inpatient facility

The term inpatient facility means a hospital, nursing facility, or intermediate care facility for the mentally retarded. Such term includes an institution for mental diseases, but only, with respect to a State, to the extent medical assistance is available under the State medicaid plan for services provided by such institution. (4)

Individual’s authorized representative

The term individual’s authorized representative means, with respect to an eligible individual, the individual’s parent, family member, guardian, advocate, or other authorized representative of the individual. (5)

Medicaid

The term medicaid means, with respect to a State, the State program under title XIX of the Social Security Act (including any waiver or demonstration under such title or under section 1115 of such Act relating to such title). (6)

Qualified HCB program

The term qualified HCB program means a program providing home and community-based long-term care services operating under medicaid, whether or not operating under waiver authority. (7)

Qualified residence

The term qualified residence means, with respect to an eligible individual— (A)a home owned or leased by the individual or the individual’s family member; (B)an apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual’s family has domain and control; and (C)a residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside. (8)

Qualified expenditures

The term qualified expenditures means expenditures by the State under its MFP demonstration project for home and community-based long-term care services for an eligible individual participating in the MFP demonstration project, but only with respect to services furnished during the 12-month period beginning on the date the individual is discharged from an inpatient facility referred to in paragraph (2)(A)(i). (9)

Self-directed services

The term self-directed means, with respect to, home and community-based long-term care services for an eligible individual, such services for the individual which are planned and purchased under the direction and control of such individual or the individual’s authorized representative, including the amount, duration, scope, provider, and location of such services, under the State medicaid program consistent with the following requirements: (A)

Assessment

There is an assessment of the needs, capabilities, and preferences of the individual with respect to such services. (B)

Service plan

Based on such assessment, there is developed jointly with such individual or the individual’s authorized representative a plan for such services for such individual that is approved by the State and that— (i)specifies those services which the individual or the individual’s authorized representative would be responsible for directing; (ii)identifies the methods by which the individual or the individual’s authorized representative will select, manage, and dismiss providers of such services; (iii)specifies the role of family members and others whose participation is sought by the individual or the individual’s authorized representative with respect to such services; (iv)is developed through a person-centered process that— (I)is directed by the individual or the individual’s authorized representative; (II)builds upon the individual’s capacity to engage in activities that promote community life and that respects the individual’s preferences, choices, and abilities; and (III)involves families, friends, and professionals as desired or required by the individual or the individual’s authorized representative; (v)includes appropriate risk management techniques that recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assure the appropriateness of such plan based upon the resources and capabilities of the individual or the individual’s authorized representative; and (vi)may include an individualized budget which identifies the dollar value of the services and supports under the control and direction of the individual or the individual’s authorized representative. (C)

Budget process

With respect to individualized budgets described in subparagraph (B)(vi), the State application under subsection (c)— (i)describes the method for calculating the dollar values in such budgets based on reliable costs and service utilization; (ii)defines a process for making adjustments in such dollar values to reflect changes in individual assessments and service plans; and (iii)provides a procedure to evaluate expenditures under such budgets. (10)

State

The term State has the meaning given such term for purposes of title XIX of the Social Security Act. (c)

State application

A State seeking approval of an MFP demonstration project shall submit to the Secretary, at such time and in such format as the Secretary requires, an application meeting the following requirements and containing such additional information, provisions, and assurances, as the Secretary may require: (1)

Assurance of a public development process

The application contains an assurance that the State has engaged, and will continue to engage, in a public process for the design, development, and evaluation of the MFP demonstration project that allows for input from eligible individuals, the families of such individuals, authorized representatives of such individuals, providers, and other interested parties. (2)

Operation in connection with qualified HCB program to assure continuity of services

The State will conduct the MFP demonstration project for eligible individuals in conjunction with the operation of a qualified HCB program that is in operation (or approved) in the State for such individuals in a manner that assures continuity of medicaid coverage for such individuals so long as such individuals continue to be eligible for medical assistance. (3)

Demonstration project period

The application shall specify the period of the MFP demonstration project, which shall include at least two consecutive fiscal years in the 5-fiscal-year period beginning with fiscal year 2006. (4)

Service area

The application shall specify the service area or areas of the MFP demonstration project, which may be a Statewide area or one or more geographic areas of the State. (5)

Targeted groups and numbers of individuals served

The application shall specify— (A)the target groups of eligible individuals to be assisted to transition from an inpatient facility to a qualified residence during each fiscal year of the MFP demonstration project; (B)the projected numbers of eligible individuals in each targeted group of eligible individuals to be so assisted during each such year; and (C)the estimated total annual qualified expenditures for each fiscal year of the MFP demonstration project. (6)

Individual choice, continuity of care

The application shall contain assurances that— (A)each eligible individual or the individual’s authorized representative will be provided the opportunity to make an informed choice regarding whether to participate in the MFP demonstration project; (B)each eligible individual or the individual’s authorized representative will choose the qualified residence in which the individual will reside and the setting in which the individual will receive home and community-based long-term care services; (C)the State will continue to make available, so long as the State operates its qualified HCB program consistent with applicable requirements, home and community-based long-term care services to each individual who completes participation in the MFP demonstration project for as long as the individual remains eligible for medical assistance for such services under such qualified HCB program (including meeting a requirement relating to requiring a level of care provided in an inpatient facility and continuing to require such services). (7)

Rebalancing

The application shall— (A)provide such information as the Secretary may require concerning the dollar amounts of State medicaid expenditures for the fiscal year, immediately preceding the first fiscal year of the State’s MFP demonstration project, for long-term care services and the percentage of such expenditures that were for institutional long-term care services or were for home and community-based long-term care services; (B) (i)specify the methods to be used by the State to increase, for each fiscal year during the MFP demonstration project, the dollar amount of such total expenditures for home and community-based long-term care services and the percentage of such total expenditures for long-term care services that are for home and community-based long-term care services; and (ii)describe the extent to which the MFP demonstration project will contribute to accomplishment of objectives described in subsection (a). (8)

Money follows the person

The application shall describe the methods to be used by the State to eliminate any legal, budgetary, or other barriers to flexibility in the availability of medicaid funds to pay for long-term care services for eligible individuals participating in the project in the appropriate settings of their choice, including costs to transition from an institutional setting to a qualified residence. (9)

Maintenance of effort and cost-effectiveness

The application shall contain or be accompanied by such information and assurances as may be required to satisfy the Secretary that— (A)total expenditures under the State medicaid program for home and community-based long-term care services will not be less for any fiscal year during the MFP demonstration project than for the greater of such expenditures for— (i)fiscal year 2004; or (ii)any succeeding fiscal year before the first year of the MFP demonstration project; and (B)in the case of a qualified HCB program operating under a waiver under subsection (c) or (d) of section 1915 of the Social Security Act (42 U.S.C. 1396n), but for the amount awarded under a grant under this section, the State program would continue to meet the cost-effectiveness requirements of subsection (c)(2)(D) of such section or comparable requirements under subsection (d)(5) of such section, respectively. (10)

Waiver requests

The application shall contain or be accompanied by requests for any modification or adjustment of waivers of medicaid requirements described in subsection (d)(3), including adjustments to maximum numbers of individuals included and package of benefits, including one-time transitional services, provided. (11)

Quality assurance and quality improvement

The application shall include— (A)a plan satisfactory to the Secretary for quality assurance and quality improvement for home and community-based long-term care services under the State medicaid program, including a plan to assure the health and welfare of individuals participating in the MFP demonstration project; and (B)an assurance that the State will cooperate in carrying out activities under subsection (f) to develop and implement continuous quality assurance and quality improvement systems for home and community-based long-term care services. (12)

Optional program for self-directed services

If the State elects to provide for any home and community-based long-term care services as self-directed services (as defined in subsection (b)(9)) under the MFP demonstration project, the application shall provide the following: (A)

Meeting requirements

A description of how the project will meet the applicable requirements of such subsection for the provision of self-directed services. (B)

Voluntary election

A description of how eligible individuals will be provided with the opportunity to make an informed election to receive self-directed services under the project and after the end of the project. (C)

State support in service plan development

Satisfactory assurances that the State will provide support to eligible individuals who self-direct in developing and implementing their service plans. (D)

Oversight of receipt of services

Satisfactory assurances that the State will provide oversight of eligible individuals’ receipt of such self-directed services, including steps to assure the quality of services provided and that the provision of such services are consistent with the service plan under such subsection.

Nothing in this section shall be construed as requiring a State to make an election under the project to provide for home and community-based long-term care services as self-directed services, or as requiring an individual to elect to receive self-directed services under the project.

(13)

Reports and evaluation

The application shall provide that— (A)the State will furnish to the Secretary such reports concerning the MFP demonstration project, on such timetable, in such uniform format, and containing such information as the Secretary may require, as will allow for reliable comparisons of MFP demonstration projects across States; and (B)the State will participate in and cooperate with the evaluation of the MFP demonstration project. (d)

Secretary’s award of competitive grants

(1)

In general

The Secretary shall award grants under this section on a competitive basis to States selected from among those with applications meeting the requirements of subsection (c), in accordance with the provisions of this subsection. (2)

Selection and modification of State applications

In selecting State applications for the awarding of such a grant, the Secretary— (A)shall take into consideration the manner in which and extent to which the State proposes to achieve the objectives specified in subsection (a); (B)shall seek to achieve an appropriate national balance in the numbers of eligible individuals, within different target groups of eligible individuals, who are assisted to transition to qualified residences under MFP demonstration projects, and in the geographic distribution of States operating MFP demonstration projects; (C)shall give preference to State applications proposing— (i)to provide transition assistance to eligible individuals within multiple target groups; and (ii)to provide eligible individuals with the opportunity to receive home and community-based long-term care services as self-directed services, as defined in subsection (b)(9); and (D)shall take such objectives into consideration in setting the annual amounts of State grant awards under this section. (3)

Waiver authority

The Secretary is authorized to waive the following provisions of title XIX of the Social Security Act, to the extent necessary to enable a State initiative to meet the requirements and accomplish the purposes of this section: (A)

Statewideness

Section 1902(a)(1), in order to permit implementation of a State initiative in a selected area or areas of the State. (B)

Comparability

Section 1902(a)(10)(B), in order to permit a State initiative to assist a selected category or categories of individuals described in subsection (b)(2)(A). (C)

Income and resources eligibility

Section 1902(a)(10)(C)(i)(III), in order to permit a State to apply institutional eligibility rules to individuals transitioning to community-based care. (D)

Provider agreements

Section 1902(a)(27), in order to permit a State to implement self-directed services in a cost-effective manner. (4)

Conditional approval of outyear grant

In awarding grants under this section, the Secretary shall condition the grant for the second and any subsequent fiscal years of the grant period on the following: (A)

Numerical benchmarks

The State must demonstrate to the satisfaction of the Secretary that it is meeting numerical benchmarks specified in the grant agreement for— (i)increasing State medicaid support for home and community-based long-term care services under subsection (c)(5); and (ii)numbers of eligible individuals assisted to transition to qualified residences. (B)

Quality of care

The State must demonstrate to the satisfaction of the Secretary that it is meeting the requirements under subsection (c)(9) to assure the health and welfare of MFP demonstration project participants. (e)

Payments to States; carryover of unused grant amounts

(1)

Payments

For each calendar quarter in a fiscal year during the period a State is awarded a grant under subsection (d), the Secretary shall pay to the State from its grant award for such fiscal year an amount equal to the lesser of— (A)100 percent of the amount of qualified expenditures made during such quarter; or (B)the total amount remaining in such grant award for such fiscal year (taking into account the application of paragraph (2)). (2)

Carryover of unused amounts

Any portion of a State grant award for a fiscal year under this section remaining at the end of such fiscal year shall remain available to the State for the next four fiscal years, subject to paragraph (3). (3)

Re-awarding of certain unused amounts

In the case of a State that the Secretary determines pursuant to subsection (d)(4) has failed to meet the conditions for continuation of a MFP demonstration project under this section in a succeeding year or years, the Secretary shall rescind the grant awards for such succeeding year or years, together with any unspent portion of an award for prior years, and shall add such amounts to the appropriation for the immediately succeeding fiscal year for grants under this section. (4)

Preventing duplication of payment

The payment under an MFP demonstration project with respect to qualified expenditures shall be in lieu of any payment with respect to such expenditures that could otherwise be paid under medicaid, including under section 1903(a) of the Social Security Act. Nothing in the previous sentence shall be construed as preventing the payment under medicaid for such expenditures in a grant year after amounts available to pay for such expenditures under the MFP demonstration project have been exhausted. (f)

Quality assurance and improvement; technical assistance; oversight

(1)

In general

The Secretary, either directly or by grant or contract, shall provide for technical assistance to and oversight of States for purposes of upgrading quality assurance and quality improvement systems under medicaid home and community-based waivers, including— (A)dissemination of information on promising practices; (B)guidance on system design elements addressing the unique needs of participating beneficiaries; (C)ongoing consultation on quality, including assistance in developing necessary tools, resources, and monitoring systems; and (D)guidance on remedying programmatic and systemic problems. (2)

Funding

From the amounts appropriated under subsection (h) for each of fiscal years 2006 through 2010, not more than $2,400,000 shall be available to the Secretary to carry out this subsection. (g)

Research and evaluation

(1)

In general

The Secretary, directly or through grant or contract, shall provide for research on and a national evaluation of the program under this section, including assistance to the Secretary in preparing the final report required under paragraph (2). The evaluation shall include an analysis of projected and actual savings related to the transition of individuals to qualified residences in each State conducting an MFP demonstration project. (2)

Final report

The Secretary shall make a final report to the President and the Congress, not later than September 30, 2011, reflecting the evaluation described in paragraph (1) and providing findings and conclusions on the conduct and effectiveness of MFP demonstration projects. (3)

Funding

From the amounts appropriated under subsection (h) for each of fiscal years 2006 through 2010, not more than $1,100,000 per year shall be available to the Secretary to carry out this subsection. (h)

Appropriations

(1)

In general

There are appropriated, from any funds in the Treasury not otherwise appropriated, for grants to carry out this section— (A)$250,000,000 for fiscal year 2006; (B)$300,000,000 for fiscal year 2007; (C)$350,000,000 for fiscal year 2008; (D)$400,000,000 for fiscal year 2009; and (E)$450,000,000 for fiscal year 2010. (2)

Availability

Amounts made available under paragraph (1) for a fiscal year shall remain available for the awarding of grants to States by not later than September 30, 2010. (i)

Rule of construction

Nothing in this Act shall be construed as requiring a State to agree to a capped allotment for expenditures for long-term care services under medicaid.