1.Short
title; table of contents
(a)This Act may be cited
as the Home and Community Balanced
Incentives Act of 2009
.
(b)The table of contents for this Act is as follows:
Sec. 1. Short title; table of
contents.
TITLE I—Balancing Incentives
Sec. 101. Enhanced FMAP for expanding the provision of
non-institutionally-based long-term services and supports.
TITLE II—Strengthening the Medicaid Home and Community-Based
State Plan Amendment Option
Sec. 201. Removal of barriers to providing home and
community-based services under State plan amendment option for individuals in
need.
Sec. 202. Mandatory application of spousal impoverishment
protections to recipients of home and community-based services.
Sec. 203. State authority to elect to exclude up to 6 months of
average cost of nursing facility services from assets or resources for purposes
of eligibility for home and community-based services.
TITLE III—Coordination of Home and Community-Based
Waivers
Sec. 301. Streamlined process for combined waivers under
subsections (b) and (c) of section 1915.
<enum>I</enum><header>Balancing
Incentives</header>
<section id="id89A38088E9A6492CAE87B0CD24078870" section-type="subsequent-section"><enum>101.</enum><header>Enhanced FMAP for
expanding the provision of non-institutionally-based long-term services and
supports</header>
<subsection id="id008E250BD8A34D2B8C494AC2333C7A4A"><enum>(a)</enum><header>Enhanced FMAP
To encourage expansion</header><text>Section 1905 of the Social Security Act
(42 U.S.C. 1396d) is amended—</text>
<paragraph id="id0B8F12CDE86B4CA4B9EC4D4EE513B046"><enum>(1)</enum><text>in the first
sentence of subsection (b)—</text>
<subparagraph id="idA2FD745A6AF84115A7CDA921D3AD2764"><enum>(A)</enum><text>by striking
<quote>, and (4)</quote> and inserting <quote>, (4)</quote>; and</text>
</subparagraph><subparagraph id="id905DF1DE249A4C21AD03769C5A02BCA0"><enum>(B)</enum><text>by inserting
before the period the following: <quote>, and (5) in the case of a balancing
incentive payment State, as defined in subsection (y)(1), that meets the
conditions described in subsection (y)(2), the Federal medical assistance
percentage shall be increased by the applicable number of percentage points
determined under subsection (y)(3) for the State with respect to medical
assistance described in subsection (y)(4)</quote>; and</text>
</subparagraph></paragraph><paragraph id="id087A2040BE4548C88C02B5C5D48E660C"><enum>(2)</enum><text>by adding at the
end the following new subsection:</text>
<quoted-block display-inline="no-display-inline" id="id9F2DF9EFC431445AB7B91A8C088414CB" style="OLC">
<subsection id="id9436AA94D6504083AF3D38807B45F017"><enum>(y)</enum><header>State balancing
incentive payments program</header><text>For purposes of clause (5) of the
first sentence of subsection (b):</text>
<paragraph id="id801ED45923D842A38B5D4433C1942C92"><enum>(1)</enum><header>Balancing
incentive payment state</header><text>A balancing incentive payment State is a
State—</text>
<subparagraph id="id8D0846516106406C9FA800F7A381FC67"><enum>(A)</enum><text>in which less
than 50 percent of the total expenditures for medical assistance for fiscal
year 2009 for long-term services and supports (as defined by the Secretary,
subject to paragraph (5)) are for non-institutionally-based long-term services
and supports described in paragraph (5)(B);</text>
</subparagraph><subparagraph id="id96E12B92FA9140EF973AD5ED9B4E406B"><enum>(B)</enum><text>that submits an
application and meets the conditions described in paragraph (2); and</text>
</subparagraph><subparagraph id="idA0AD257104704A46BDDC44A4673220B3"><enum>(C)</enum><text>that is selected
by the Secretary to participate in the State balancing incentive payment
program established under this subsection.</text>
</subparagraph></paragraph><paragraph id="id85B4DA210CE048AEA9866AE821701DC1"><enum>(2)</enum><header>Conditions</header><text>The
conditions described in this paragraph are the following:</text>
<subparagraph id="id408128C9CBF24F938F611218F4174A26"><enum>(A)</enum><header>Application</header><text>The
State submits an application to the Secretary that includes the
following:</text>
<clause id="idF191CC4C9C1E493B932F42E937C2810F"><enum>(i)</enum><text>A
description of the availability of non-institutionally-based long-term services
and supports described in paragraph (5)(B) available (for fiscal years
beginning with fiscal year 2009).</text>
</clause><clause id="id89C22661D8A14327B46E64466A69382D"><enum>(ii)</enum><text>A description of
eligibility requirements for receipt of such services.</text>
</clause><clause id="id3D3A1025914A44D38148143E7744CAE8"><enum>(iii)</enum><text>A projection of
the number of additional individuals that the State expects to provide with
such services to during the 5-fiscal-year period that begins with fiscal year
2011.</text>
</clause><clause id="id467D3C294F6A4B3E90A6F905C5785323"><enum>(iv)</enum><text>An assurance of
the State's commitment to a consumer-directed long-term services and supports
system that values quality of life in addition to quality of care and in which
beneficiaries are empowered to choose providers and direct their own care as
much as possible.</text>
</clause><clause id="idA2B34ADEE23C4394AD0C256EE034E77C"><enum>(v)</enum><text>A
proposed budget that details the State's plan to expand and diversify medical
assistance for non-institutionally-based long-term services and supports
described in paragraph (5)(B) during such 5-fiscal-year period, and that
includes—</text>
<subclause id="id10062D5184074008A501245554EB3529"><enum>(I)</enum><text>a description of
the new or expanded offerings of such services that the State will provide;
and</text>
</subclause><subclause id="id43D93D8CC3A54D8FBDCA0582B9FB24AF"><enum>(II)</enum><text>the projected
costs of the services identified in subclause (I).</text>
</subclause></clause><clause id="id80878483DE874DE6947A9A55471EA30F"><enum>(vi)</enum><text>A description of
how the State intends to achieve the target spending percentage applicable to
the State under subparagraph (B).</text>
</clause><clause id="idB03BE4D7C87B44ABB722B23C94860D52"><enum>(vii)</enum><text>An assurance
that the State will not use Federal funds, revenues described in section
1903(w)(1), or revenues obtained through the imposition of beneficiary
cost-sharing for medical assistance for non-institutionally-based long-term
services and supports described in paragraph (5)(B) for the non-Federal share
of expenditures for medical assistance described in paragraph (4).</text>
</clause></subparagraph><subparagraph id="id9E4CFC3FA08946839ED97F76DA09847E"><enum>(B)</enum><header>Target spending
percentages</header>
<clause id="idE13EB4AAF7BE44E2ADEF26B5F6DA7FF9"><enum>(i)</enum><text>In the case of a
balancing incentive payment State in which less than 25 percent of the total
expenditures for home and community-based services under the State plan and the
various waiver authorities for fiscal year 2009 are for such services, the
target spending percentage for the State to achieve by not later than October
1, 2015, is that 25 percent of the total expenditures for home and
community-based services under the State plan and the various waiver
authorities are for such services.</text>
</clause><clause id="id0ED7E70AF2FC442A9B2730B550F72411"><enum>(ii)</enum><text>In the case of
any other balancing incentive payment State, the target spending percentage for
the State to achieve by not later than October 1, 2015, is that 50 percent of
the total expenditures for home and community-based services under the State
plan and the various waiver authorities are for such services.</text>
</clause></subparagraph><subparagraph id="id23D5ADF1A0ED4851A750CF77EB2631DD"><enum>(C)</enum><header>Maintenance of
eligibility requirements</header><text>The State does not apply eligibility
standards, methodologies, or procedures for determining eligibility for medical
assistance for non-institutionally-based long-term services and supports
described in paragraph (5)(B)) that are more restrictive than the eligibility
standards, methodologies, or procedures in effect for such purposes on December
31, 2010.</text>
</subparagraph><subparagraph id="id4EC4B3D1801E48178FB7C67A4C1C14A1"><enum>(D)</enum><header>Use of
additional funds</header><text>The State agrees to use the additional Federal
funds paid to the State as a result of this subsection only for purposes of
providing new or expanded offerings of non-institutionally-based long-term
services and supports described in paragraph (5)(B) (including expansion
through offering such services to increased numbers of beneficiaries of medical
assistance under this title).</text>
</subparagraph><subparagraph id="id66F953D9B8634E55930A9ACF5EFF36E1"><enum>(E)</enum><header>Structural
changes</header><text>The State agrees to make, not later than the end of the
6-month period that begins on the date the State submits and application under
this paragraph, such changes to the administration of the State plan (and, if
applicable, to waivers approved for the State that involve the provision of
long-term care services and supports) as the Secretary determines, by
regulation or otherwise, are essential to achieving an improved balance between
the provision of non-institutionally-based long-term services and supports
described in paragraph (5)(B) and other long-term services and supports, and
which shall include the following:</text>
<clause id="idC014A1F952F94AA585D150BB7611CC0E"><enum>(i)</enum><header><quote>No wrong
door</quote>—single entry point system</header><text>Development of a statewide
system to enable consumers to access all long-term services and supports
through an agency, organization, coordinated network, or portal, in accordance
with such standards as the State shall establish and that—</text>
<subclause id="id2BFB9DF0F04D4E9ABADBBB4FCCE53908"><enum>(I)</enum><text>shall require
such agency, organization, network, or portal to provide—</text>
<item id="id06B4036646894097B17BE55A6B585B2F"><enum>(aa)</enum><text>consumers with
information regarding the availability of such services, how to apply for such
services, and other referral services; and</text>
</item><item id="id6E8FF6A52DFB4F06A34EC8D08318DD18"><enum>(bb)</enum><text>information
regarding, and make recommendations for, providers of such services; and</text>
</item></subclause><subclause id="id3F483DDCBD324FA6BE3E8088B2D64064"><enum>(II)</enum><text>may, at State
option, permit such agency, organization, network, or portal to—</text>
<item id="idCF6CF592A0594DDE919A73B28033B5F7"><enum>(aa)</enum><text>determine
financial and functional eligibility for such services and supports; and</text>
</item><item id="id2AE0305816E74920A46267107B8972C0"><enum>(bb)</enum><text>provide or refer
eligible individuals to services and supports otherwise available in the
community (under programs other than the State program under this title), such
as housing, job training, and transportation.</text>
</item></subclause></clause><clause id="id962B4C950E4A4CA5969E3E0188CADA57"><enum>(ii)</enum><header>Presumptive
Eligibility</header><text>At the option of the State, provision of a 60-day
period of presumptive eligibility for medical assistance for
non-institutionally-based long-term services and supports described in
paragraph (5)(B) for any individual whom the State has reason to believe will
qualify for such medical assistance (provided that any expenditures for such
medical assistance during such period are disregarded for purposes of
determining the rate of erroneous excess payments for medical assistance under
section 1903(u)(1)(D)).</text>
</clause><clause id="idEC3BCFEBE157460CA6D046A10F0FFA18"><enum>(iii)</enum><header>Case
Management</header><text>Development, in accordance with guidance from the
Secretary, of conflict-free case management services to—</text>
<subclause id="idC6B6F126EAAD475D8E2B5E8647F3C6EF"><enum>(I)</enum><text>address
transitioning from receipt of institutionally-based long-term services and
supports described in paragraph (5)(A) to receipt of non-institutionally-based
long-term services and supports described in paragraph (5)(B); and</text>
</subclause><subclause id="id65BF030376D44FC49D6464CAFB7EEC8E"><enum>(II)</enum><text>in conjunction
with the beneficiary, assess the beneficiary's needs and, if appropriate, the
needs of family caregivers for the beneficiary, and develop a service plan,
arrange for services and supports, support the beneficiary (and, if
appropriate, the caregivers) in directing the provision of services and
supports, for the beneficiary, and conduct ongoing monitoring to assure that
services and supports are delivered to meet the beneficiary's needs and achieve
intended outcomes.</text>
</subclause></clause><clause id="id0C13C3CF42254D98ADF769CBD2155C14"><enum>(iv)</enum><header>Core
standardized assessment instruments</header><text>Development of core
standardized assessment instruments for determining eligibility for
non-institutionally-based long-term services and supports described in
paragraph (5)(B), which shall be used in a uniform manner throughout the State,
to—</text>
<subclause id="idBBC93C7675AD4803BA26013EB9E8B484"><enum>(I)</enum><text>assess a
beneficiary's eligibility and functional level in terms of relevant areas that
may include medical, cognitive, and behavioral status, as well as daily living
skills, and vocational and communication skills;</text>
</subclause><subclause id="id011214A118094796A09789E822BA0AF8"><enum>(II)</enum><text>based on the
assessment conducted under subclause (I), determine a beneficiary's needs for
training, support services, medical care, transportation, and other services,
and develop an individual service plan to address such needs;</text>
</subclause><subclause id="id0A80695E064A4AC685D96E2B3C6CA63C"><enum>(III)</enum><text>conduct ongoing
monitoring based on the service plan; and</text>
</subclause><subclause id="id6CCAA100C762499583AE7BA72DCEDE83"><enum>(IV)</enum><text>require
reporting of collect data for purposes of comparison among different service
models.</text>
</subclause></clause></subparagraph><subparagraph id="idD94D53EEBB1744D2872AE585B6D2CC30"><enum>(F)</enum><header>Data
Collection</header><text>Collecting from providers of services and through such
other means as the State determines appropriate the following data:</text>
<clause id="id2E98CD84BBA04E579316D9F9FCD8009C"><enum>(i)</enum><header>Services
data</header><text>Services data from providers of non-institutionally-based
long-term services and supports described in paragraph (5)(B) on a
per-beneficiary basis and in accordance with such standardized coding
procedures as the State shall establish in consultation with the
Secretary.</text>
</clause><clause id="idE2957BA9A42C4ED386141462F253AFBD"><enum>(ii)</enum><header>Quality
data</header><text>Quality data on a selected set of core quality measures
agreed upon by the Secretary and the State that are linked to
population-specific outcomes measures and accessible to providers.</text>
</clause><clause id="id85D39E4D03D341C581DA425B1435BD4E"><enum>(iii)</enum><header>Outcomes
measures</header><text>Outcomes measures data on a selected set of core
population-specific outcomes measures agreed upon by the Secretary and the
State that are accessible to providers and include—</text>
<subclause id="id9D4E1979D8D2438E8E366E638C7F17BA"><enum>(I)</enum><text>measures of
beneficiary and family caregiver experience with providers;</text>
</subclause><subclause id="idCEAF49A99FAE46259980FD8CC3F1932B"><enum>(II)</enum><text>measures of
beneficiary and family caregiver satisfaction with services; and</text>
</subclause><subclause id="id33CAABB3A5E94542AA6E0806784E8F7F"><enum>(III)</enum><text>measures for
achieving desired outcomes appropriate to a specific beneficiary, including
employment, participation in community life, health stability, and prevention
of loss in function.</text>
</subclause></clause></subparagraph></paragraph><paragraph id="idA66BC8EDE85E4ED2A26D1D1530D924C0"><enum>(3)</enum><header>Applicable
number of percentage points increase in fmap</header><text>The applicable
number of percentage points are—</text>
<subparagraph id="id0027A96690F04CB6ABF25BC95B70C95B"><enum>(A)</enum><text>in the case of a
balancing incentive payment State subject to the target spending percentage
described in paragraph (2)(B)(i), 5 percentage points; and</text>
</subparagraph><subparagraph id="id1FF96A514D224B6880657450DE8B0A5C"><enum>(B)</enum><text>in the case of
any other balancing incentive payment State, 2 percentage points.</text>
</subparagraph></paragraph><paragraph id="id20AC3A5E6C9845F49605F3F7C6A2FA69"><enum>(4)</enum><header>Eligible
medical assistance expenditures</header>
<subparagraph id="idA124FF46C7F24AE9BA0641FE2BEB724C"><enum>(A)</enum><header>In
general</header><text>Subject to subparagraph (B), medical assistance described
in this paragraph is medical assistance for non-institutionally-based long-term
services and supports described in paragraph (5)(B) that is provided during the
period that begins on October 1, 2011, and ends on September 30, 2015.</text>
</subparagraph><subparagraph id="idC9FBB4B815D048FE902ABC0BCB1C7552"><enum>(B)</enum><header>Limitation on
payments</header><text>In no case may the aggregate amount of payments made by
the Secretary to balancing incentive payment States under this subsection
during the period described in subparagraph (A), or to a State to which
paragraph (6) of the first sentence of subsection (b) applies, exceed
$3,000,000,000.</text>
</subparagraph></paragraph><paragraph id="id253DF56DFF1440BBA5BFC400D23A5B0C"><enum>(5)</enum><header>Long-term
services and supports defined</header><text>In this subsection, the term
<term>long-term services and supports</term> has the meaning given that term by
Secretary and shall include the following:</text>
<subparagraph id="id3D2707E0BC074A6A933388603E6DB486"><enum>(A)</enum><header>Institutionally-based
long-term services and supports</header><text>Services provided in an
institution, including the following:</text>
<clause id="id60A6D9ACEBEA4F05A7889BAFD7603CCB"><enum>(i)</enum><text>Nursing facility
services.</text>
</clause><clause id="idEEBA91B0C93745F5A1DD70CD2425C227"><enum>(ii)</enum><text>Services in an
intermediate care facility for the mentally retarded described in subsection
(a)(15).</text>
</clause></subparagraph><subparagraph id="id805FAED6C8B348F884CA5AF374A72069"><enum>(B)</enum><header>Non-institutionally-based
long-term services and supports</header><text>Services not provided in an
institution, including the following:</text>
<clause id="id7286E956805543CBAC97E05A72E3188D"><enum>(i)</enum><text>Home and
community-based services provided under subsection (c), (d), or (i), of section
1915 or under a waiver under section 1115.</text>
</clause><clause id="idB7D7A302678441FF840F173B15CF0BBD"><enum>(ii)</enum><text>Home health care
services.</text>
</clause><clause id="idF150F6C55F1F492B867A58D0F871BE02"><enum>(iii)</enum><text>Personal care
services.</text>
</clause><clause commented="no" id="id9E74278FEAEA49DC83A8BF0284C0507C"><enum>(iv)</enum><text>Services
described in subsection (a)(26) (relating to PACE program services).</text>
</clause><clause commented="no" id="id825487B6E12E47D4880ED3B172135D8B"><enum>(v)</enum><text>Self-directed
personal assistance services described in section
1915(j)</text>
</clause></subparagraph></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection><subsection id="idE88D4AD5F48942AD927A1E16BB20AB4C"><enum>(b)</enum><header>Enhanced FMAP
for certain states To maintain the provision of home and community-based
services</header><text>The first sentence of section 1905(b) of such Act (42
U.S.C. 1396d (b)), as amended by subsection (a), is amended</text>
<paragraph id="idD019B588D8344525AD845A66027FFB71"><enum>(1)</enum><text>by striking
<quote>, and (5)</quote> and inserting <quote>, (5)</quote>; and</text>
</paragraph><paragraph commented="no" display-inline="no-display-inline" id="id016832A46F5647A88012BC91E4E85C26"><enum>(2)</enum><text>by inserting
before the period the following: <quote>, and (6) in the case of a State in
which at least 50 percent of the total expenditures for medical assistance for
fiscal year 2009 for long-term services and supports (as defined by the
Secretary for purposes of subsection (y)) are for non-institutionally-based
long-term services and supports described in subsection (y)(5)(B), and which
satisfies the requirements of subparagraphs (A) (other than clauses (iii), (v),
and (vi)), (C), and (F) of subsection (y)(2), and has implemented the
structural changes described in each clause of subparagraph (E) of that
subsection, the Federal medical assistance percentage shall be increased by 1
percentage point with respect to medical assistance described in subparagraph
(A) of subsection (y)(4) (but subject to the limitation described in
subparagraph (B) of that subsection)</quote>.</text>
</paragraph></subsection><subsection id="id28993214923C4831B35B44CD2B8D333E"><enum>(c)</enum><header>Grants To
support structural changes</header>
<paragraph id="idDA32364E08F348BFBD024D4235321202"><enum>(1)</enum><header>In
General</header><text>The Secretary of Health and Human Services shall award
grants to States for the following purposes:</text>
<subparagraph id="idA6CF95D7ACD948BEA059F8F7668895EB"><enum>(A)</enum><text>To support the
development of common national set of coding methodologies and databases
related to the provision of non-institutionally-based long-term services and
supports described in paragraph (5)(B) of section 1905(y) of the Social
Security Act (as added by subsection (a)).</text>
</subparagraph><subparagraph id="idD320465505AA4371896E8AB5EB60A95C"><enum>(B)</enum><text>To make
structural changes described in paragraph (2)(E) of section 1905(y) to the
State Medicaid program.</text>
</subparagraph></paragraph><paragraph id="idBBC3F13A38EF4D6C985592725BA0746B"><enum>(2)</enum><header>Priority</header><text>In
awarding grants for the purpose described in paragraph (1)(A), the Secretary of
Health and Human Services shall give priority to States in which at least 50
percent of the total expenditures for medical assistance under the State
Medicaid program for fiscal year 2009 for long-term services and supports, as
defined by the Secretary for purposes of section 1905(y) of the Social Security
Act, are for non-institutionally-based long-term services and supports
described in paragraph (5)(B) of such section.</text>
</paragraph><paragraph id="id7AD21EF9D2914AAE8CD40D63BEFB5AE5"><enum>(3)</enum><header>Collaboration</header><text>States
awarded a grant for the purpose described in paragraph (1)(A) shall collaborate
with other States, the National Governor's Association, the National Conference
of State Legislatures, the National Association of State Medicaid Directors,
the National Association of State Directors of Developmental Disabilities, and
other appropriate organizations in developing specifications for a common
national set of coding methodologies and databases.</text>
</paragraph><paragraph id="id7D4D7E7285F54C42BD5693A181221E48"><enum>(4)</enum><header>Authorization
of appropriations</header><text>There are authorized to be appropriated to
carry out this subsection, such sums as may be necessary for each of fiscal
years 2010 through 2012.</text>
</paragraph></subsection><subsection id="idD2BAB91B8B4E483682BA05AFD853C187"><enum>(d)</enum><header>Authority for
individualized budgets under waivers To provide home and community-based
services</header><text>In the case of any waiver to provide home and
community-based services under subsection (c) or (d) of section 1915 of the
Social Security Act (42 U.S.C. 1396n) or section 1115 of such Act (42 U.S.C.
1315), that is approved or renewed after the date of enactment of this Act, the
Secretary of Health and Human Services shall permit a State to establish
individualized budgets that identify the dollar value of the services and
supports to be provided to an individual under the waiver.</text>
</subsection><subsection id="id76D413B01B8B465D91E6A1E16B81F731"><enum>(e)</enum><header>Oversight and
assessment</header>
<paragraph id="idF39808AC30F54E1390FE2E5F02C8F2BE"><enum>(1)</enum><header>Development of
standardized reporting requirements</header>
<subparagraph id="idBEA932F82742438E9BA1CFCDB3194084"><enum>(A)</enum><header>Standardization
of data and outcome measures</header><text>The Secretary of Health and Human
Services shall consult with States and the National Governor's Association, the
National Conference of State Legislatures, the National Association of State
Medicaid Directors, the National Association of State Directors of
Developmental Disabilities, and other appropriate organizations to develop
specifications for standardization of—</text>
<clause id="id4F05437D78BE4B1DBF4B6914ACA6D770"><enum>(i)</enum><text>reporting of
assessment data for long-term services and supports (as defined by the
Secretary for purposes of section 1905(y)(5) of the Social Security Act) for
each population served, including information standardized for purposes of
certified EHR technology (as defined in section 1903(t)(3)(A) of the Social
Security Act (42 U.S.C. 1396b(t)(3)(A)) and under other electronic medical
records initiatives; and</text>
</clause><clause id="id7C0E9BC136AA4BA294B68DF42EA97680"><enum>(ii)</enum><text>outcomes
measures that track assessment processes for long-term services and supports
(as so defined) for each such population that maintain and enhance individual
function, independence, and stability.</text>
</clause></subparagraph></paragraph><paragraph id="id31AD2BCE5EAA43E087AA630BC026AB1A"><enum>(2)</enum><header>Administration
of home and community services</header><text>The Secretary of Health and Human
Services shall promulgate regulations to ensure that all States develop service
systems that are designed to—</text>
<subparagraph id="id6D60FCE9A09B4B13AFD0D1A1666F509A"><enum>(A)</enum><text>allocate
resources for services in a manner that is responsive to the changing needs and
choices of beneficiaries receiving non-institutionally-based long-term services
and supports described in paragraph (5)(B) of section 1905(y) of the Social
Security Act (as added by subsection (a)) (including such services and supports
that are provided under programs other the State Medicaid program), and that
provides strategies for beneficiaries receiving such services to maximize their
independence;</text>
</subparagraph><subparagraph id="IDfe6699f96239409f97a4f909a01ceb78"><enum>(B)</enum><text>provide the
support and coordination needed for a beneficiary in need of such services (and
their family caregivers or representative, if applicable) to design an
individualized, self-directed, community-supported life; and</text>
</subparagraph><subparagraph id="idC288D6981EDE48A69428B24036518077"><enum>(C)</enum><text>improve
coordination among all providers of such services under federally and
State-funded programs in order to—</text>
<clause id="id23BD32D868A74978AAF97CA9615818D5"><enum>(i)</enum><text>achieve a more
consistent administration of policies and procedures across programs in
relation to the provision of such services; and</text>
</clause><clause id="id0BA2FF49130C4964B877534523CF3B23"><enum>(ii)</enum><text>oversee and
monitor all service system functions to assure—</text>
<subclause id="idF283FC1C6BF042C69E6357248D0A2A2C"><enum>(I)</enum><text>coordination of,
and effectiveness of, eligibility determinations and individual assessments;
and</text>
</subclause><subclause id="id25A2C951A62A4685BD7CA8993C4E628F"><enum>(II)</enum><text>development and
service monitoring of a complaint system, a management system, a system to
qualify and monitor providers, and systems for role-setting and individual
budget determinations.</text>
</subclause></clause></subparagraph></paragraph><paragraph id="id70CCC8CC9A954523A6FF92199FDE002D"><enum>(3)</enum><header>Monitoring</header><text>The
Secretary of Health and Human Services shall assess on an ongoing basis and
based on measures specified by the Agency for Healthcare Research and Quality,
the safety and quality of non-institutionally-based long-term services and
supports described in paragraph (5)(B) of section 1905(y) of that Act provided
to beneficiaries of such services and supports and the outcomes with regard to
such beneficiaries’ experiences with such services. Such oversight shall
include examination of—</text>
<subparagraph id="id566D360517FD4D01BCC6D314497F8D0B"><enum>(A)</enum><text>the consistency,
or lack thereof, of such services in care plans as compared to those services
that were actually delivered; and</text>
</subparagraph><subparagraph id="idEE64EF827FD04D3A8BF597DFCDBFC0D8"><enum>(B)</enum><text>the length of
time between when a beneficiary was assessed for such services, when the care
plan was completed, and when the beneficiary started receiving such
services.</text>
</subparagraph></paragraph><paragraph id="idF1DDCEF9B3394FF2B7F7299F753E9685"><enum>(4)</enum><header>GAO study and
report</header><text>The Comptroller General of the United States shall study
the longitudinal costs of Medicaid beneficiaries receiving long-term services
and supports (as defined by the Secretary for purposes of section 1905(y)(5) of
the Social Security Act) over 5-year periods across various programs, including
the non-institutionally-based long-term services and supports described in
paragraph (5)(B) of such section, PACE program services under section 1894 of
the Social Security Act (42 U.S.C. 1395eee, 1396u–4), and services provided
under specialized MA plans for special needs individuals under part C of title
XVIII of the Social Security Act.</text>
</paragraph></subsection></section><enum>II</enum><header>Strengthening
the Medicaid Home and Community-Based State Plan Amendment Option</header>
<section id="id0700AC5B6F664697BD9D927AA3E0C3B9"><enum>201.</enum><header>Removal of
barriers to providing home and community-based services under State plan
amendment option for individuals in need</header>
<subsection id="idAD62ECC2ADB34822B6C388E862E47158"><enum>(a)</enum><header>Parity with
income eligibility standard for institutionalized individuals</header><text display-inline="yes-display-inline">Paragraph (1) of section 1915(i) of the
Social Security Act (42 U.S.C. 1396n(i)) is amended by striking <quote>150
percent of the poverty line (as defined in section 2110(c)(5))</quote> and
inserting <quote>300 percent of the supplemental security income benefit rate
established by section 1611(b)(1)</quote>.</text>
</subsection><subsection id="id5F1B2B99DC7F45518587CC39B61EEA83"><enum>(b)</enum><header>Additional
state options</header><text>Section 1915(i) of the Social Security Act (42
U.S.C. 1396n(i)) is amended by adding at the end the following new
paragraphs:</text>
<quoted-block display-inline="no-display-inline" id="id5F81AF4CDFA8435F865124490AD67848" style="OLC">
<paragraph id="idA8E1F695281A4CE5ADC15D8ED0E2D79B"><enum>(6)</enum><header>State option to
provide home and community-based services to individuals eligible for services
under a waiver</header>
<subparagraph id="id25DBE7DBD81E44319CC7C5BE15B5B8D1"><enum>(A)</enum><header>In
general</header><text>A State that provides home and community-based services
in accordance with this subsection to individuals who satisfy the needs-based
criteria for the receipt of such services established under paragraph (1)(A)
may, in addition to continuing to provide such services to such individuals,
elect to provide home and community-based services in accordance with the
requirements of this paragraph to individuals who are eligible for home and
community-based services under a waiver approved for the State under subsection
(c), (d), or (e) or under section 1115 to provide such services, but only for
those individuals whose income does not exceed 300 percent of the supplemental
security income benefit rate established by section 1611(b)(1).</text>
</subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id55A018A10ED4431192563EF503AE13A8"><enum>(B)</enum><header display-inline="yes-display-inline">Application of same requirements for
individuals satisfying needs-based criteria</header><text display-inline="yes-display-inline">Subject to subparagraph (C), a State shall
provide home and community-based services to individuals under this paragraph
in the same manner and subject to the same requirements as apply under the
other paragraphs of this subsection to the provision of home and
community-based services to individuals who satisfy the needs-based criteria
established under paragraph (1)(A).</text>
</subparagraph><subparagraph id="idB2467B9F6241412A8D2E6EA5098A3CBE"><enum>(C)</enum><header>Authority to
offer different type, amount, duration, or scope of home and community-based
services</header><text>A State may offer home and community-based services to
individuals under this paragraph that differ in type, amount, duration, or
scope from the home and community-based services offered for individuals who
satisfy the needs-based criteria established under paragraph (1)(A), so long as
such services are within the scope of services described in paragraph (4)(B) of
subsection (c) for which the Secretary has the authority to approve a waiver
and do not include room or board.</text>
</subparagraph></paragraph><paragraph id="id5D8CE67C3E0742E693CBA33DE5192641"><enum>(7)</enum><header>State option to
offer home and community-based services to specific, targeted
populations</header>
<subparagraph id="id485A769D761A4168A41010E7047C1381"><enum>(A)</enum><header>In
general</header><text>A State may elect in a State plan amendment under this
subsection to target the provision of home and community-based services under
this subsection to specific populations and to differ the type, amount,
duration, or scope of such services to such specific populations.</text>
</subparagraph><subparagraph id="id65E886D0EE5C49D7B507FBA647254A0F"><enum>(B)</enum><header>5-year
term</header>
<clause id="id5AEC44F1AAE24F8F8457187FB0361C51"><enum>(i)</enum><header>In
general</header><text>An election by a State under this paragraph shall be for
a period of 5 years.</text>
</clause><clause id="id4030CC1F0B9546A5884B7677543887CB"><enum>(ii)</enum><header>Phase-in of
services and eligibility permitted during initial 5-year period</header><text>A
State making an election under this paragraph may, during the first 5-year
period for which the election is made, phase-in the enrollment of eligible
individuals, or the provision of services to such individuals, or both, so long
as all eligible individuals in the State for such services are enrolled, and
all such services are provided, before the end of the initial 5-year
period.</text>
</clause></subparagraph><subparagraph id="id6654C69D1C26451B940B962B6E75116F"><enum>(C)</enum><header>Renewal</header><text>An
election by a State under this paragraph may be renewed for additional 5-year
terms if the Secretary determines, prior to beginning of each such renewal
period, that the State has—</text>
<clause id="id5DA4A76C000E4259A705A4B6FB491DBE"><enum>(i)</enum><text>adhered to the
requirements of this subsection and paragraph in providing services under such
an election; and</text>
</clause><clause id="idF45BD9B7B0094CB5BF92D9E1A57AA2E0"><enum>(ii)</enum><text>met the State's
objectives with respect to quality improvement and beneficiary
outcomes.</text>
</clause></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="idA3939D7392B742769F2972B757CC2B9F"><enum>(c)</enum><header>Removal of
limitation on scope of services</header><text display-inline="yes-display-inline">Paragraph (1) of section 1915(i) of the
Social Security Act (42 U.S.C. 1396n(i)), as amended by subsection (a), is
amended by striking <quote>or such other services requested by the State as the
Secretary may approve</quote>.</text>
</subsection><subsection id="idAFF56FF588974B87A013A9F671AC573C"><enum>(d)</enum><header>Optional
eligibility category To provide full medicaid benefits to individuals receiving
home and community-based services under a State plan amendment</header>
<paragraph id="id1B06FDA9BE8045FF86BE67AC4A80253F"><enum>(1)</enum><header>In
general</header><text>Section 1902(a)(10)(A)(ii) of the Social Security Act (42
U.S.C. 1396a(a)(10)(A)(ii)) is amended—</text>
<subparagraph id="idBC0EAF0C6C8C4BFAA0F3EF3E2D7595B7"><enum>(A)</enum><text>in subclause
(XVIII), by striking <quote>or</quote> at the end;</text>
</subparagraph><subparagraph id="id8BA6592A6F0E4D1BA30D2872CDE2DDF6"><enum>(B)</enum><text>in subclause
(XIX), by adding <quote>or</quote> at the end; and</text>
</subparagraph><subparagraph id="id6CE2AC48899F43BD8FAC15070230B346"><enum>(C)</enum><text>by inserting
after subclause (XIX), the following new subclause:</text>
<quoted-block display-inline="no-display-inline" id="id967E86257D5342B2A7B20CB881C0FBAA" style="OLC">
<subclause id="id8AD8296B6C49443F8077CB2BD2DC6E3E"><enum>(XX)</enum><text>who are eligible
for home and community-based services under needs-based criteria established
under paragraph (1)(A) of section 1915(i), or who are eligible for home and
community-based services under paragraph (6) of such section, and who will
receive home and community-based services pursuant to a State plan amendment
under such
subsection;</text>
</subclause><after-quoted-block>.</after-quoted-block></quoted-block>
</subparagraph></paragraph><paragraph id="idC2114BC2077F40ECAA6BBE7FBB28DB9A"><enum>(2)</enum><header>Conforming
amendments</header>
<subparagraph id="idF96D2AA40D2A4EA2B4B09EFCB1869B03"><enum>(A)</enum><text>Section
1903(f)(4) of the Social Security Act (42 U.S.C. 1396b(f)(4)) is amended in the
matter preceding subparagraph (A), by inserting
<quote>1902(a)(10)(A)(ii)(XX),</quote> after
<quote>1902(a)(10)(A)(ii)(XIX),</quote>.</text>
</subparagraph><subparagraph id="idD22455EA991C4EDAB79900400E5213D6"><enum>(B)</enum><text>Section 1905(a)
of the Social Security Act (42 U.S.C. 1396d(a)) is amended in the matter
preceding paragraph (1)—</text>
<clause id="id35086E95AA1F49ECB6C4BB8860B9A290"><enum>(i)</enum><text>in
clause (xii), by striking <quote>or</quote> at the end;</text>
</clause><clause id="id49077152B6CE4D50830363B6894C679C"><enum>(ii)</enum><text>in
clause (xiii), by adding <quote>or</quote> at the end; and</text>
</clause><clause id="id63723A9E68E5477F92C26704DC00F182"><enum>(iii)</enum><text>by inserting
after clause (xiii) the following new clause:</text>
<quoted-block display-inline="no-display-inline" id="idD1E4EF3B930846FE81CB502ADC16A13D" style="OLC">
<clause id="id31D269F133874BA386D85644092ABC6A" indent="up2"><enum>(xiv)</enum><text>individuals who are eligible for
home and community-based services under needs-based criteria established under
paragraph (1)(A) of section 1915(i), or who are eligible for home and
community-based services under paragraph (6) of such section, and who will
receive home and community-based services pursuant to a State plan amendment
under such
subsection,</text>
</clause><after-quoted-block>.</after-quoted-block></quoted-block>
</clause></subparagraph></paragraph></subsection><subsection id="id4C547D34BB554DA2B8386D2212090167"><enum>(e)</enum><header>Elimination of
option To limit number of eligible individuals or length of period for
grandfathered individuals if eligibility criteria is modified</header><text display-inline="yes-display-inline">Paragraph (1) of section 1915(i) of such
Act (42 U.S.C. 1396n(i)) is amended—</text>
<paragraph id="id38110720C6FB4379850162CF2E825AD2"><enum>(1)</enum><text display-inline="yes-display-inline">by striking subparagraph (C) and inserting
the following:</text>
<quoted-block display-inline="no-display-inline" id="id9E94DCCF06074B4F912C3B11C00CA6F8" style="OLC">
<subparagraph commented="no" display-inline="no-display-inline" id="ID33E13429CA62499DB4572002F982FCA1"><enum>(C)</enum><header display-inline="yes-display-inline">Projection of number of individuals to be
provided home and community-based services</header><text>The State submits to
the Secretary, in such form and manner, and upon such frequency as the
Secretary shall specify, the projected number of individuals to be provided
home and community-based services.</text>
</subparagraph><after-quoted-block>;
and</after-quoted-block></quoted-block>
</paragraph><paragraph id="id32C2F3EA143F4331853CF415F03D21F7"><enum>(2)</enum><text>in subclause (II)
of subparagraph (D)(ii), by striking <quote>to be eligible for such services
for a period of at least 12 months beginning on the date the individual first
received medical assistance for such services</quote> and inserting <quote>to
continue to be eligible for such services after the effective date of the
modification and until such time as the individual no longer meets the standard
for receipt of such services under such pre-modified criteria</quote>.</text>
</paragraph></subsection><subsection id="id3C848183CA474F4194F900C5F88F92ED"><enum>(f)</enum><header>Elimination of
option To waive statewideness; addition of option To waive
comparability</header><text display-inline="yes-display-inline">Paragraph (3)
of section 1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by striking
<quote>1902(a)(1) (relating to statewideness)</quote> and inserting
<quote>1902(a)(10)(B) (relating to comparability)</quote>.</text>
</subsection><subsection commented="no" display-inline="no-display-inline" id="idF863593FE7DA48D285EEA656D45CE311"><enum>(g)</enum><header>Effective
date</header><text>The amendments made by this section take effect on the first
day of the first fiscal year quarter that begins after the date of enactment of
this Act.</text>
</subsection></section><section id="idB3C759BEF27D438298E5E35B125BEC07"><enum>202.</enum><header>Mandatory
application of spousal impoverishment protections to recipients of home and
community-based services</header>
<subsection id="id269D58A9FD4E4D1394AA91E81D005DAC"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">Section 1924(h)(1)(A)
of the Social Security Act (42 U.S.C. 1396r–5(h)(1)(A)) is amended by striking
<quote>(at the option of the State) is described in section
1902(a)(10)(A)(ii)(VI)</quote> and inserting <quote>is eligible for medical
assistance for home and community-based services under subsection (c), (d),
(e), or (i) of section 1915</quote>.</text>
</subsection><subsection id="idED2B051D77564BE0A2B2DC069DC82C51"><enum>(b)</enum><header>Effective
date</header><text>The amendment made by subsection (a) takes effect on October
1, 2009.</text>
</subsection></section><section id="id72F54816BBA64A1A92A60AE813FB375E"><enum>203.</enum><header>State
authority to elect to exclude up to 6 months of average cost of nursing
facility services from assets or resources for purposes of eligibility for home
and community-based services</header>
<subsection id="idFF2D076FBC9D496399D11A0CDAC579D8"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">Section 1917 of the
Social Security Act (42 U.S.C. 1396p) is amended by adding at the end the
following new subsection:</text>
<quoted-block display-inline="no-display-inline" id="idC417D7AA89FC42A2A5D68E05982FF51D" style="OLC">
<subsection id="id32210DD99EC244D3B6E3A3712E3FDC04"><enum>(i)</enum><header>State authority
To exclude up to 6 months of average cost of nursing facility services from
home and community-based services eligibility
determinations</header><text>Nothing in this section or any other provision of
this title, shall be construed as prohibiting a State from excluding from any
determination of an individual's assets or resources for purposes of
determining the eligibility of the individual for medical assistance for home
and community-based services under subsection (c), (d), (e), or (i) of section
1915 (if a State imposes an limitation on assets or resources for purposes of
eligibility for such services), an amount equal to the product of the amount
applicable under subsection (c)(1)(E)(ii)(II) (at the time such determination
is made) and such number, not to exceed 6, as the State may
elect.</text>
</subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection commented="no" display-inline="no-display-inline" id="id9121387CCAAE421E83D5657B1EF74D11"><enum>(b)</enum><header>Rule of
construction</header><text>Nothing in the amendment made by subsection (a)
shall be construed as affecting a State's option to apply less restrictive
methodologies under section 1902(r)(2) for purposes of determining income and
resource eligibility for individuals specified in that section.</text>
</subsection></section><enum>III</enum><header>Coordination of
Home and Community-Based Waivers</header>
<section id="id88DB65B59A634C3F82A6137AFC98556F"><enum>301.</enum><header>Streamlined
process for combined waivers under subsections (b) and (c) of section
1915</header><text display-inline="no-display-inline">Not later than 90 days
after the date of enactment of this Act, the Secretary of Health and Human
Services shall create a template to streamline the process of approving,
monitoring, evaluating, and renewing State proposals to conduct a program that
combines the waiver authority provided under subsections (b) and (c) of section
1915 of the Social Security Act (42 U.S.C. 1396n) into a single program under
which the State provides home and community-based services to individuals based
on individualized assessments and care plans (in this section referred to as
the <quote>combined waivers program</quote>). The template required under this
section shall provide for the following:</text>
<paragraph id="idD9EF3A2FB117482F876A6E9CD0B90052"><enum>(1)</enum><text>A standard 5-year
term for conducting a combined waivers program.</text>
</paragraph><paragraph id="id0AFAF5C3D9A44D009B2C73B554A6AF72"><enum>(2)</enum><text>Harmonization of
any requirements under subsections (b) and (c) of such section that
overlap.</text>
</paragraph><paragraph id="id6175B05217A64A30A83EA75D95FB4B56"><enum>(3)</enum><text>An option for
States to elect, during the first 5-year term for which the combined waivers
program is approved to phase-in the enrollment of eligible individuals, or the
provision of services to such individuals, or both, so long as all eligible
individuals in the State for such services are enrolled, and all such services
are provided, before the end of the initial 5-year period.</text>
</paragraph><paragraph id="id58CCD7934E7040F9A9ACE41A283FEC09"><enum>(4)</enum><text>Examination by
the Secretary, prior to each renewal of a combined waivers program, of how well
the State has—</text>
<subparagraph id="idF87C115CDE9A43B1AD58203180D11A9A"><enum>(A)</enum><text>adhered to the
combined waivers program requirements; and</text>
</subparagraph><subparagraph id="idD575A293642E434C97FC33B76FA0E9D0"><enum>(B)</enum><text>performed in
meeting the State's objectives for the combined waivers program, including with
respect to quality improvement and beneficiary outcomes.</text>
</subparagraph></paragraph></section>