[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 683 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                 S. 683

 To amend title XIX of the Social Security Act to provide individuals 
 with disabilities and older Americans with equal access to community-
     based attendant services and supports, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 24, 2009

  Mr. Harkin (for himself, Mr. Specter, Mr. Kennedy, Mr. Durbin, Mr. 
Kerry, Mr. Schumer, Ms. Stabenow, Mr. Dodd, Mr. Brown, Mr. Sanders, Mr. 
  Casey, Mr. Tester, Mrs. Gillibrand, and Mr. Bennet) introduced the 
 following bill; which was read twice and referred to the Committee on 
                                Finance

_______________________________________________________________________

                                 A BILL


 
 To amend title XIX of the Social Security Act to provide individuals 
 with disabilities and older Americans with equal access to community-
     based attendant services and supports, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Community Choice 
Act of 2009''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings and purposes.
            TITLE I--ESTABLISHMENT OF MEDICAID PLAN BENEFIT

Sec. 101. Coverage of community-based attendant services and supports 
                            under the Medicaid program.
Sec. 102. Enhanced FMAP for ongoing activities of early coverage States 
                            that enhance and promote the use of 
                            community-based attendant services and 
                            supports.
Sec. 103. Increased Federal financial participation for certain 
                            expenditures.
      TITLE II--PROMOTION OF SYSTEMS CHANGE AND CAPACITY BUILDING

Sec. 201. Grants to promote systems change and capacity building.
Sec. 202. Demonstration project to enhance coordination of care under 
                            the Medicare and Medicaid programs for dual 
                            eligible individuals.

SEC. 2. FINDINGS AND PURPOSES.

    (a) Findings.--Congress makes the following findings:
            (1) Long-term services and supports provided under the 
        Medicaid program established under title XIX of the Social 
        Security Act (42 U.S.C. 1396 et seq.) must meet the abilities 
        and life choices of individuals with disabilities and older 
        Americans, including the choice to live in one's own home or 
        with one's own family and to become a productive member of the 
        community.
            (2) Similarly, under the United States Supreme Court's 
        decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals 
        with disabilities have the right to choose to receive their 
        long-term services and supports in the community, rather than 
        in an institutional setting.
            (3) Nevertheless, 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) 
        continues to show a significant funding and programmatic bias 
        toward institutional care. In 2007, only 42 percent of long-
        term care funds expended under the Medicaid program, and only 
        about 13.6 percent of all funds expended under that program, 
        pay for services and supports in home and community-based 
        settings.
            (4) While much effort has been dedicated to ``rebalancing'' 
        the current system, overall about 60 percent of Medicaid long-
        term care dollars are still spent on institutional services, 
        with about 40 percent going to home and community-based 
        services. In 2007, only 11 States spent 50 percent or more of 
        their Medicaid long-term care funds on home and community-based 
        care.
            (5) The statistics are even more disproportionate for 
        adults with physical disabilities. In 2007, 69 percent of 
        Medicaid long-term care spending for older people and adults 
        with physical disabilities paid for institutional services. 
        Only 6 states spent 50 percent or more of their Medicaid long-
        term care dollars on home and community-based services for 
        older people and adults with physical disabilities while \1/2\ 
        of the States spent less than 25 percent. This disparity 
        continues even though, on average, it is estimated that 
        Medicaid dollars can support nearly 3 older people and adults 
        with physical disabilities in home and community-based services 
        for every person in a nursing home.
            (6) For Medicaid beneficiaries who need long-term care, 
        services provided in an institutional setting represent the 
        only guaranteed benefit. Only 30 States have adopted the 
        benefit option of providing personal care, or attendant, 
        services under their Medicaid programs.
            (7) Although every State has chosen to provide certain 
        services under home and community-based waivers, these services 
        are unevenly available within and across States, and reach a 
        small percentage of eligible individuals. Individuals with the 
        most significant disabilities are usually afforded the least 
        amount of choice, despite advances in medical and assistive 
        technologies and related areas.
            (8) Despite the more limited funding for home and 
        community-based services, the majority of individuals who use 
        Medicaid long-term services and supports prefer to live in the 
        community, rather than in institutional settings.
            (9) The goals of the Nation properly include providing 
        families of children with disabilities, working-age adults with 
        disabilities, and older Americans with--
                    (A) a meaningful choice of receiving long-term 
                services and supports in the most integrated setting 
                appropriate to the individual's needs;
                    (B) the greatest possible control over the services 
                received and, therefore, their own lives and futures; 
                and
                    (C) quality services that maximize independence in 
                the home and community.
    (b) Purposes.--The purposes of this Act are the following:
            (1) To reform the Medicaid program established under title 
        XIX of the Social Security Act (42 U.S.C. 1396 et seq.) to 
        provide services in the most integrated setting appropriate to 
        the individual's needs, and to provide equal access to 
        community-based attendant services and supports in order to 
        assist individuals in achieving equal opportunity, full 
        participation, independent living, and economic self-
        sufficiency.
            (2) To provide financial assistance to States as they 
        reform their long-term care systems to provide comprehensive 
        statewide long-term services and supports, including community-
        based attendant services and supports that provide consumer 
        choice and direction, in the most integrated setting 
        appropriate.
            (3) To assist States in meeting the growing demand for 
        community-based attendant services and supports, as the 
        Nation's population ages and individuals with disabilities live 
        longer.
            (4) To assist States in complying with the U.S. Supreme 
        Court decision in Olmstead v. L.C., 527 U.S. 581 (1999), and 
        implementing the integration mandate of the Americans with 
        Disabilities Act.

            TITLE I--ESTABLISHMENT OF MEDICAID PLAN BENEFIT

SEC. 101. COVERAGE OF COMMUNITY-BASED ATTENDANT SERVICES AND SUPPORTS 
              UNDER THE MEDICAID PROGRAM.

    (a) Mandatory Coverage.--Section 1902(a)(10)(D) of the Social 
Security Act (42 U.S.C. 1396a(a)(10)(D)) is amended--
            (1) by inserting ``(i)'' after ``(D)'';
            (2) by adding ``and'' after the semicolon; and
            (3) by adding at the end the following new clause:
                            ``(ii) subject to section 1943, for the 
                        inclusion of community-based attendant services 
                        and supports for any individual who--
                                    ``(I) is eligible for medical 
                                assistance under the State plan;
                                    ``(II) with respect to whom there 
                                has been a determination that the 
                                individual requires the level of care 
                                provided in a nursing facility, 
                                institution for mental diseases, or an 
                                intermediate care facility for the 
                                mentally retarded (whether or not 
                                coverage of such institution or 
                                intermediate care facility is provided 
                                under the State plan); and
                                    ``(III) chooses to receive such 
                                services and supports;''.
    (b) Community-Based Attendant Services and Supports.--
            (1) In general.--Title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.) is amended by adding at the end the 
        following new section:

           ``community-based attendant services and supports

    ``Sec. 1943.  (a) Required Coverage.--
            ``(1) In general.--Not later than October 1, 2014, a State 
        shall provide through a plan amendment for the inclusion of 
        community-based attendant services and supports (as defined in 
        subsection (g)(1)) for individuals described in section 
        1902(a)(10)(D)(ii) in accordance with this section.
            ``(2) Enhanced fmap and additional federal financial 
        support for earlier coverage.--Notwithstanding section 1905(b), 
        during the period that begins on October 1, 2009, and ends on 
        September 30, 2014, in the case of a State with an approved 
        plan amendment under this section during that period that also 
        satisfies the requirements of subsection (c) the Federal 
        medical assistance percentage shall be equal to the enhanced 
        FMAP described in section 2105(b) with respect to medical 
        assistance in the form of community-based attendant services 
        and supports provided to individuals described in section 
        1902(a)(10)(D)(ii) in accordance with this section on or after 
        the date of the approval of such plan amendment.
    ``(b) Development and Implementation of Benefit.--In order for a 
State plan amendment to be approved under this section, a State shall 
provide the Secretary with the following assurances:
            ``(1) Assurance of development and implementation 
        collaboration.--
                    ``(A) In general.--That State plan amendment--
                            ``(i) has been developed in collaboration 
                        with, and with the approval of, a Development 
                        and Implementation Council established by the 
                        State that satisfies the requirements of 
                        subparagraph (B); and
                            ``(ii) will be implemented in collaboration 
                        with such Council and on the basis of public 
                        input solicited by the State and the Council.
                    ``(B) Development and implementation council 
                requirements.--For purposes of subparagraph (A), the 
                requirements of this subparagraph are that--
                            ``(i) the majority of the members of the 
                        Development and Implementation Council are 
                        individuals with disabilities, elderly 
                        individuals, and their representatives; and
                            ``(ii) in carrying out its 
                        responsibilities, the Council actively 
                        collaborates with--
                                    ``(I) individuals with 
                                disabilities;
                                    ``(II) elderly individuals;
                                    ``(III) representatives of such 
                                individuals; and
                                    ``(IV) providers of, and advocates 
                                for, services and supports for such 
                                individuals.
            ``(2) Assurance of provision on a statewide basis and in 
        most integrated setting.--That consumer controlled community-
        based attendant services and supports will be provided under 
        the State plan to individuals described in section 
        1902(a)(10)(D)(ii) on a statewide basis and in a manner that 
        provides such services and supports in the most integrated 
        setting appropriate to the individual's needs.
            ``(3) Assurance of nondiscrimination.--That the State will 
        provide community-based attendant services and supports to an 
        individual described in section 1902(a)(10)(D)(ii) without 
        regard to the individual's age, type or nature of disability, 
        severity of disability, or the form of community-based 
        attendant services and supports that the individual requires in 
        order to lead an independent life.
            ``(4) Assurance of maintenance of effort.--That the level 
        of State expenditures for medical assistance that is provided 
        under section 1905(a), section 1915, section 1115, or otherwise 
        to individuals with disabilities or elderly individuals for a 
        fiscal year shall not be less than the level of such 
        expenditures for the fiscal year preceding the first full 
        fiscal year in which the State plan amendment to provide 
        community-based attendant services and supports in accordance 
        with this section is implemented.
    ``(c) Requirements for Enhanced FMAP for Early Coverage.--In 
addition to satisfying the other requirements for an approved plan 
amendment under this section, in order for a State to be eligible under 
subsection (a)(2) during the period described in that subsection for 
the enhanced FMAP for early coverage under subsection (a)(2), the State 
shall satisfy the following requirements:
            ``(1) Specifications.--With respect to a fiscal year, the 
        State shall provide the Secretary with the following 
        specifications regarding the provision of community-based 
        attendant services and supports under the plan for that fiscal 
        year:
                    ``(A)(i) The number of individuals who are 
                estimated to receive community-based attendant services 
                and supports under the plan during the fiscal year.
                    ``(ii) The number of individuals that received such 
                services and supports during the preceding fiscal year.
                    ``(B) The maximum number of individuals who will 
                receive such services and supports under the plan 
                during that fiscal year.
                    ``(C) The procedures the State will implement to 
                ensure that the models for delivery of such services 
                and supports are consumer controlled (as defined in 
                subsection (g)(2)(B)).
                    ``(D) The procedures the State will implement to 
                inform all potentially eligible individuals and 
                relevant other individuals of the availability of such 
                services and supports under this title, and of other 
                items and services that may be provided to the 
                individual under this title or title XVIII and other 
                Federal or State long-term service and support 
                programs.
                    ``(E) The procedures the State will implement to 
                ensure that such services and supports are provided in 
                accordance with the requirements of subsection (b)(1).
                    ``(F) The procedures the State will implement to 
                actively involve in a systematic, comprehensive, and 
                ongoing basis, the Development and Implementation 
                Council established in accordance with subsection 
                (b)(1)(A)(ii), individuals with disabilities, elderly 
                individuals, and representatives of such individuals in 
                the design, delivery, administration, implementation, 
                and evaluation of the provision of such services and 
                supports under this title.
            ``(2) Participation in evaluations.--The State shall 
        provide the Secretary with such substantive input into, and 
        participation in, the design and conduct of data collection, 
        analyses, and other qualitative or quantitative evaluations of 
        the provision of community-based attendant services and 
        supports under this section as the Secretary deems necessary in 
        order to determine the effectiveness of the provision of such 
        services and supports in allowing the individuals receiving 
        such services and supports to lead an independent life to the 
        maximum extent possible.
    ``(d) Quality Assurance.--
            ``(1) State responsibilities.--In order for a State plan 
        amendment to be approved under this section, a State shall 
        establish and maintain a comprehensive, continuous quality 
        assurance system with respect to community-based attendant 
        services and supports that provides for the following:
                    ``(A) The State shall establish requirements, as 
                appropriate, for agency-based and other delivery models 
                that include--
                            ``(i) minimum qualifications and training 
                        requirements for agency-based and other models;
                            ``(ii) financial operating standards; and
                            ``(iii) an appeals procedure for 
                        eligibility denials and a procedure for 
                        resolving disagreements over the terms of an 
                        individualized plan.
                    ``(B) The State shall modify the quality assurance 
                system, as appropriate, to maximize consumer 
                independence and consumer control in both agency-
                provided and other delivery models.
                    ``(C) The State shall provide a system that allows 
                for the external monitoring of the quality of services 
                and supports by entities consisting of consumers and 
                their representatives, disability organizations, 
                providers, families of disabled or elderly individuals, 
                members of the community, and others.
                    ``(D) The State shall provide for ongoing 
                monitoring of the health and well-being of each 
                individual who receives community-based attendant 
                services and supports.
                    ``(E) The State shall require that quality 
                assurance mechanisms pertaining to the individual be 
                included in the individual's written plan.
                    ``(F) The State shall establish a process for the 
                mandatory reporting, investigation, and resolution of 
                allegations of neglect, abuse, or exploitation in 
                connection with the provision of such services and 
                supports.
                    ``(G) The State shall obtain meaningful consumer 
                input, including consumer surveys, that measure the 
                extent to which an individual receives the services and 
                supports described in the individual's plan and the 
                individual's satisfaction with such services and 
                supports.
                    ``(H) The State shall make available to the public 
                the findings of the quality assurance system.
                    ``(I) The State shall establish an ongoing public 
                process for the development, implementation, and review 
                of the State's quality assurance system.
                    ``(J) The State shall develop and implement a 
                program of sanctions for providers of community-based 
                services and supports that violate the terms or 
                conditions for the provision of such services and 
                supports.
            ``(2) Federal responsibilities.--
                    ``(A) Periodic evaluations.--The Secretary shall 
                conduct a periodic sample review of outcomes for 
                individuals who receive community-based attendant 
                services and supports under this title.
                    ``(B) Investigations.--The Secretary may conduct 
                targeted reviews and investigations upon receipt of an 
                allegation of neglect, abuse, or exploitation of an 
                individual receiving community-based attendant services 
                and supports under this section.
                    ``(C) Development of provider sanction 
                guidelines.--The Secretary shall develop guidelines for 
                States to use in developing the sanctions required 
                under paragraph (1)(J).
    ``(e) Reports.--The Secretary shall submit to Congress periodic 
reports on the provision of community-based attendant services and 
supports under this section, particularly with respect to the impact of 
the provision of such services and supports on--
            ``(1) individuals eligible for medical assistance under 
        this title;
            ``(2) States; and
            ``(3) the Federal Government.
    ``(f) No Effect on Ability To Provide Coverage.--
            ``(1) In general.--Nothing in this section shall be 
        construed as affecting the ability of a State to provide 
        coverage under the State plan for community-based attendant 
        services and supports (or similar coverage) under section 
        1905(a), section 1915, section 1115, or otherwise.
            ``(2) Eligibility for enhanced match.--In the case of a 
        State that provides coverage for such services and supports 
        under a waiver, the State shall not be eligible under 
        subsection (a)(2) for the enhanced FMAP for the early provision 
        of such coverage unless the State submits a plan amendment to 
        the Secretary that meets the requirements of this section and 
        demonstrates that the State is able to fully comply with and 
        implement the requirements of this section.
    ``(g) Definitions.--In this title:
            ``(1) Community-based attendant services and supports.--
                    ``(A) In general.--The term `community-based 
                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 tasks through hands-on assistance, 
                supervision, or cueing--
                            ``(i) under a plan of services and supports 
                        that is based on an assessment of functional 
                        need and that is agreed to in writing by the 
                        individual or, as appropriate, the individual's 
                        representative;
                            ``(ii) in a home or community setting, 
                        which shall include but not be limited to a 
                        school, workplace, or recreation or religious 
                        facility, but does not include a nursing 
                        facility, institution for mental diseases, or 
                        an intermediate care facility for the mentally 
                        retarded;
                            ``(iii) under an agency-provider model or 
                        other model (as defined in paragraph (2)(C)); 
                        or
                            ``(iv) the furnishing of which--
                                    ``(I) is selected, managed, and 
                                dismissed by the individual, or, as 
                                appropriate, with assistance from the 
                                individual's representative; and
                                    ``(II) provided by an individual 
                                who is qualified to provide such 
                                services, including family members (as 
                                defined by the Secretary).
                    ``(B) Included services and supports.--Such term 
                includes--
                            ``(i) tasks necessary to assist an 
                        individual in accomplishing activities of daily 
                        living, instrumental activities of daily 
                        living, and health-related tasks;
                            ``(ii) the acquisition, maintenance, and 
                        enhancement of skills necessary for the 
                        individual to accomplish activities of daily 
                        living, instrumental activities of daily 
                        living, and health-related tasks;
                            ``(iii) backup systems or mechanisms (such 
                        as the use of beepers) to ensure continuity of 
                        services and supports; and
                            ``(iv) voluntary training on how to select, 
                        manage, and dismiss attendants.
                    ``(C) Excluded services and supports.--Subject to 
                subparagraph (D), such term does not include--
                            ``(i) the provision of room and board for 
                        the individual;
                            ``(ii) special education and related 
                        services provided under the Individuals with 
                        Disabilities Education Act and vocational 
                        rehabilitation services provided under the 
                        Rehabilitation Act of 1973;
                            ``(iii) assistive technology devices and 
                        assistive technology services;
                            ``(iv) durable medical equipment; or
                            ``(v) home modifications.
                    ``(D) 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, and other necessities required for an 
                individual to make the transition from a nursing 
                facility, institution for mental diseases, or 
                intermediate care facility for the mentally retarded to 
                a community-based home setting where the individual 
                resides.
            ``(2) Additional definitions.--
                    ``(A) Activities of daily living.--The term 
                `activities of daily living' includes eating, 
                toileting, grooming, dressing, bathing, and 
                transferring.
                    ``(B) Consumer controlled.--The term `consumer 
                controlled' means a method of selecting and providing 
                services and supports that allow the individual, or 
                where appropriate, the individual's representative, 
                maximum control of the community-based attendant 
                services and supports, regardless of who acts as the 
                employer of record.
                    ``(C) Delivery models.--
                            ``(i) Agency-provider model.--The term 
                        `agency-provider model' means, with respect to 
                        the provision of community-based attendant 
                        services and supports for an individual, 
                        subject to clause (iii), a method of providing 
                        consumer controlled services and supports under 
                        which entities contract for the provision of 
                        such services and supports.
                            ``(ii) Other models.--The term `other 
                        models' means, subject to clause (iii), 
                        methods, other than an agency-provider model, 
                        for the provision of consumer controlled 
                        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.
                            ``(iii) Compliance with certain laws.--A 
                        State shall ensure that, regardless of whether 
                        the State uses an agency-provider model or 
                        other models to provide services and supports 
                        under a State plan amendment under this 
                        section, such services and supports are 
                        provided in accordance with the requirements of 
                        the Fair Labor Standards Act of 1938 and 
                        applicable Federal and State laws regarding--
                                    ``(I) withholding and payment of 
                                Federal and State income and payroll 
                                taxes;
                                    ``(II) the provision of 
                                unemployment and workers compensation 
                                insurance;
                                    ``(III) maintenance of general 
                                liability insurance; and
                                    ``(IV) occupational health and 
                                safety.
                    ``(D) Health-related tasks.--The term `health-
                related tasks' means specific tasks that can be 
                delegated or assigned by licensed health-care 
                professionals under State law to be performed by an 
                attendant.
                    ``(E) Instrumental activities of daily living.--The 
                term `instrumental activities of daily living' 
                includes, but is not limited to, 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 traveling around and participating in 
                the community.
                    ``(F) Individuals representative.--The term 
                `individual's representative' means a parent, a family 
                member, a guardian, an advocate, or other authorized 
                representative of an individual.''.
    (c) Conforming Amendments.--
            (1) Mandatory benefit.--Section 1902(a)(10)(A) of the 
        Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in 
        the matter preceding clause (i), by striking ``(17) and (21)'' 
        and inserting ``(17), (21), and (28)''.
            (2) Definition of medical assistance.--Section 1905(a) of 
        the Social Security Act (42 U.S.C. 1396d) is amended--
                    (A) by striking ``and'' at the end of paragraph 
                (27);
                    (B) by redesignating paragraph (28) as paragraph 
                (29); and
                    (C) by inserting after paragraph (27) the 
                following:
            ``(28) community-based attendant services and supports (to 
        the extent allowed and as defined in section 1943); and''.
            (3) IMD/ICFMR requirements.--Section 1902(a)(10)(C)(iv) of 
        the Social Security Act (42 U.S.C. 1396a(a)(10)(C)(iv)) is 
        amended by inserting ``and (28)'' after ``(24)''.
    (d) Effective Dates.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section (other than the amendment made 
        by subsection (c)(1)) take effect on October 1, 2009, and apply 
        to medical assistance provided for community-based attendant 
        services and supports described in section 1943 of the Social 
        Security Act furnished on or after that date.
            (2) Mandatory benefit.--The amendment made by subsection 
        (c)(1) takes effect on October 1, 2014.

SEC. 102. ENHANCED FMAP FOR ONGOING ACTIVITIES OF EARLY COVERAGE STATES 
              THAT ENHANCE AND PROMOTE THE USE OF COMMUNITY-BASED 
              ATTENDANT SERVICES AND SUPPORTS.

    (a) In General.--Section 1943 of the Social Security Act, as added 
by section 101(b), is amended--
            (1) by redesignating subsections (d) through (g) as 
        subsections (f) through (i), respectively;
            (2) in subsection (a)(1), by striking ``subsection (g)(1)'' 
        and inserting ``subsection (i)(1)'';
            (3) in subsection (a)(2), by inserting ``, and with respect 
        to expenditures described in subsection (d), the Secretary 
        shall pay the State the amount described in subsection (d)(1)'' 
        before the period;
            (4) in subsection (c)(1)(C), by striking ``subsection 
        (g)(2)(B)'' and inserting ``subsection (i)(2)(B)''; and
            (5) by inserting after subsection (c), the following:
    ``(d) Increased Federal Financial Participation for Early Coverage 
States That Meet Certain Benchmarks.--
            ``(1) In general.--Subject to paragraph (2), for purposes 
        of subsection (a)(2), the amount and expenditures described in 
        this subsection are an amount equal to the Federal medical 
        assistance percentage, increased by 10 percentage points, of 
        the expenditures incurred by the State for the provision or 
        conduct of the services or activities described in paragraph 
        (3).
            ``(2) Expenditure criteria.--A State shall--
                    ``(A) develop criteria for determining the 
                expenditures described in paragraph (1) in 
                collaboration with the individuals and representatives 
                described in subsection (b)(1); and
                    ``(B) submit such criteria for approval by the 
                Secretary.
            ``(3) Services, supports and activities described.--For 
        purposes of paragraph (1), the services, supports and 
        activities described in this subparagraph are the following:
                    ``(A) One-stop intake, referral, and institutional 
                diversion services.
                    ``(B) Identifying and remedying gaps and inequities 
                in the State's current provision of long-term services 
                and supports, particularly those services and supports 
                that are provided based on such factors as age, 
                severity of disability, type of disability, ethnicity, 
                income, institutional bias, or other similar factors.
                    ``(C) Establishment of consumer participation and 
                consumer governance mechanisms, such as cooperatives 
                and regional service authorities, that are managed and 
                controlled by individuals with significant disabilities 
                who use community-based services and supports or their 
                representatives.
                    ``(D) Activities designed to enhance the skills, 
                earnings, benefits, supply, career, and future 
                prospects of workers who provide community-based 
                attendant services and supports.
                    ``(E) Continuous, comprehensive quality improvement 
                activities that are designed to ensure and enhance the 
                health and well-being of individuals who rely on 
                community-based attendant services and supports, 
                particularly activities involving or initiated by 
                consumers of such services and supports or their 
                representatives.
                    ``(F) Family support services to augment the 
                efforts of families and friends to enable individuals 
                with disabilities of all ages to live in their own 
                homes and communities.
                    ``(G) Health promotion and wellness services and 
                activities.
                    ``(H) Provider recruitment and enhancement 
                activities, particularly such activities that encourage 
                the development and maintenance of consumer controlled 
                cooperatives or other small businesses or micro-
                enterprises that provide community-based attendant 
                services and supports or related services.
                    ``(I) Activities designed to ensure service and 
                systems coordination.
                    ``(J) Any other services or activities that the 
                Secretary deems appropriate.''.
    (b) Effective Date.--The amendments made by subsection (a) take 
effect on October 1, 2009.

SEC. 103. INCREASED FEDERAL FINANCIAL PARTICIPATION FOR CERTAIN 
              EXPENDITURES.

    (a) In General.--Section 1943 of the Social Security Act, as added 
by section 101(b) and amended by section 102, is amended by inserting 
after subsection (d) the following:
    ``(e) Increased Federal Financial Participation for Certain 
Expenditures.--
            ``(1) Eligibility for payment.--
                    ``(A) In general.--In the case of a State that the 
                Secretary determines satisfies the requirements of 
                subparagraph (B), the Secretary shall pay the State the 
                amounts described in paragraph (2) in addition to any 
                other payments provided for under section 1903 or this 
                section for the provision of community-based attendant 
                services and supports.
                    ``(B) Requirements.--The requirements of this 
                subparagraph are the following:
                            ``(i) The State has an approved plan 
                        amendment under this section.
                            ``(ii) The State has incurred expenditures 
                        described in paragraph (2).
                            ``(iii) The State develops and submits to 
                        the Secretary criteria to identify and select 
                        such expenditures in accordance with the 
                        requirements of paragraph (3).
                            ``(iv) The Secretary determines that 
                        payment of the applicable percentage of such 
                        expenditures (as determined under paragraph 
                        (2)(B)) would enable the State to provide a 
                        meaningful choice of receiving community-based 
                        services and supports to individuals with 
                        disabilities and elderly individuals who would 
                        otherwise only have the option of receiving 
                        institutional care.
            ``(2) Amounts and expenditures described.--
                    ``(A) Expenditures in excess of 150 percent of 
                baseline amount.--The amounts and expenditures 
                described in this paragraph are an amount equal to the 
                applicable percentage, as determined by the Secretary 
                in accordance with subparagraph (B), of the 
                expenditures incurred by the State for the provision of 
                community-based attendant services and supports to an 
                individual that exceed 150 percent of the average cost 
                of providing nursing facility services to an individual 
                who resides in the State and is eligible for such 
                services under this title, as determined in accordance 
                with criteria established by the Secretary.
                    ``(B) Applicable percentage.--The Secretary shall 
                establish a payment scale for the expenditures 
                described in subparagraph (A) so that the Federal 
                financial participation for such expenditures gradually 
                increases from 70 percent to 90 percent as such 
                expenditures increase.
            ``(3) Specification of order of selection for 
        expenditures.--In order to receive the amounts described in 
        paragraph (2), a State shall--
                    ``(A) develop, in collaboration with the 
                individuals and representatives described in subsection 
                (b)(1) and pursuant to guidelines established by the 
                Secretary, criteria to identify and select the 
                expenditures submitted under that paragraph; and
                    ``(B) submit such criteria to the Secretary.''.
    (b) Effective Date.--The amendment made by subsection (a) takes 
effect on October 1, 2009.

      TITLE II--PROMOTION OF SYSTEMS CHANGE AND CAPACITY BUILDING

SEC. 201. GRANTS TO PROMOTE SYSTEMS CHANGE AND CAPACITY BUILDING.

    (a) Authority To Award Grants.--
            (1) In general.--The Secretary of Health and Human Services 
        (in this section referred to as the ``Secretary'') shall award 
        grants to eligible States to carry out the activities described 
        in subsection (b).
            (2) Application.--In order to be eligible for a grant under 
        this section, a State shall submit to the Secretary an 
        application in such form and manner, and that contains such 
        information, as the Secretary may require.
    (b) Permissible Activities.--A State that receives a grant under 
this section may use funds provided under the grant for any of the 
following activities, focusing on areas of need identified by the State 
and the Consumer Task Force established under subsection (c):
            (1) The development and implementation of the provision of 
        community-based attendant services and supports under section 
        1943 of the Social Security Act (as added by section 101(b) and 
        amended by sections 102 and 103) through active collaboration 
        with--
                    (A) individuals with disabilities;
                    (B) elderly individuals;
                    (C) representatives of such individuals; and
                    (D) providers of, and advocates for, services and 
                supports for such individuals.
            (2) Substantially involving individuals with significant 
        disabilities and representatives of such individuals in jointly 
        developing, implementing, and continually improving a mutually 
        acceptable comprehensive, effectively working statewide plan 
        for preventing and alleviating unnecessary institutionalization 
        of such individuals.
            (3) Engaging in system change and other activities deemed 
        necessary to achieve any or all of the goals of such statewide 
        plan.
            (4) Identifying and remedying disparities and gaps in 
        services to classes of individuals with disabilities and 
        elderly individuals who are currently experiencing or who face 
        substantial risk of unnecessary institutionalization.
            (5) Building and expanding system capacity to offer quality 
        consumer controlled community-based services and supports to 
        individuals with disabilities and elderly individuals, 
        including by--
                    (A) seeding the development and effective use of 
                community-based attendant services and supports 
                cooperatives, Independent Living Centers, small 
                businesses, micro-enterprises, micro-boards, and 
                similar joint ventures owned and controlled by 
                individuals with disabilities or representatives of 
                such individuals and community-based attendant services 
                and supports workers;
                    (B) enhancing the choice and control individuals 
                with disabilities and elderly individuals exercise, 
                including through their representatives, with respect 
                to the personal assistance and supports they rely upon 
                to lead independent, self-directed lives;
                    (C) enhancing the skills, earnings, benefits, 
                supply, career, and future prospects of workers who 
                provide community-based attendant services and 
                supports;
                    (D) engaging in a variety of needs assessment and 
                data gathering;
                    (E) developing strategies for modifying policies, 
                practices, and procedures that result in unnecessary 
                institutional bias or the over-medicalization of long-
                term services and supports;
                    (F) engaging in interagency coordination and single 
                point of entry activities;
                    (G) providing training and technical assistance 
                with respect to the provision of community-based 
                attendant services and supports;
                    (H) engaging in--
                            (i) public awareness campaigns;
                            (ii) facility-to-community transitional 
                        activities; and
                            (iii) demonstrations of new approaches; and
                    (I) engaging in other systems change activities 
                necessary for developing, implementing, or evaluating a 
                comprehensive statewide system of community-based 
                attendant services and supports.
            (6) Ensuring that the activities funded by the grant are 
        coordinated with other efforts to increase personal attendant 
        services and supports, including--
                    (A) programs funded under or amended by the Ticket 
                to Work and Work Incentives Improvement Act of 1999 
                (Public Law 106-170; 113 Stat. 1860);
                    (B) grants funded under the Families of Children 
                With Disabilities Support Act of 2000 (42 U.S.C. 15091 
                et seq.); and
                    (C) other initiatives designed to enhance the 
                delivery of community-based services and supports to 
                individuals with disabilities and elderly individuals.
            (7) Engaging in transition partnership activities with 
        nursing facilities and intermediate care facilities for the 
        mentally retarded that utilize and build upon items and 
        services provided to individuals with disabilities or elderly 
        individuals under the Medicaid program under title XIX of the 
        Social Security Act, or by Federal, State, or local housing 
        agencies, Independent Living Centers, and other organizations 
        controlled by consumers or their representatives.
    (c) Consumer Task Force.--
            (1) Establishment and duties.--To be eligible to receive a 
        grant under this section, each State shall establish a Consumer 
        Task Force (referred to in this subsection as the ``Task 
        Force'') to assist the State in the development, 
        implementation, and evaluation of real choice systems change 
        initiatives.
            (2) Appointment.--Members of the Task Force shall be 
        appointed by the Chief Executive Officer of the State in 
        accordance with the requirements of paragraph (3), after the 
        solicitation of recommendations from representatives of 
        organizations representing a broad range of individuals with 
        disabilities, elderly individuals, representatives of such 
        individuals, and organizations interested in individuals with 
        disabilities and elderly individuals.
            (3) Composition.--
                    (A) In general.--The Task Force shall represent a 
                broad range of individuals with disabilities from 
                diverse backgrounds and shall include representatives 
                from Developmental Disabilities Councils, Mental Health 
                Councils, State Independent Living Centers and 
                Councils, Commissions on Aging, organizations that 
                provide services to individuals with disabilities and 
                consumers of long-term services and supports.
                    (B) Individuals with disabilities.--A majority of 
                the members of the Task Force shall be individuals with 
                disabilities or representatives of such individuals.
                    (C) Limitation.--The Task Force shall not include 
                employees of any State agency providing services to 
                individuals with disabilities other than employees of 
                entities described in the Developmental Disabilities 
                Assistance and Bill of Rights Act of 2000 (42 U.S.C. 
                15001 et seq.).
    (d) Annual Report.--
            (1) States.--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 in such form and manner 
        as the Secretary may require.
            (2) Secretary.--The Secretary shall submit to Congress an 
        annual report on the grants made under this section.
    (e) Authorization of Appropriations.--
            (1) In general.--There is authorized to be appropriated to 
        carry out this section, $50,000,000 for each of fiscal years 
        2010 through 2012.
            (2) Availability.--Amounts appropriated to carry out this 
        section shall remain available without fiscal year limitation.

SEC. 202. DEMONSTRATION PROJECT TO ENHANCE COORDINATION OF CARE UNDER 
              THE MEDICARE AND MEDICAID PROGRAMS FOR DUAL ELIGIBLE 
              INDIVIDUALS.

    (a) Definitions.--In this section:
            (1) Dually eligible individual.--The term ``dually eligible 
        individual'' means an individual who is enrolled in the 
        Medicare and Medicaid programs established under Titles XVIII 
        and XIX, respectively, of the Social Security Act (42 U.S.C. 
        1395 et seq., 1396 et seq.).
            (2) Project.--The term ``project'' means the demonstration 
        project authorized to be conducted under this section.
            (3) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
    (b) Authority To Conduct Project.--The Secretary shall conduct a 
project under this section for the purpose of evaluating service 
coordination and cost-sharing approaches with respect to the provision 
of community-based services and supports to dually eligible 
individuals.
    (c) Requirements.--
            (1) Number of participants.--Not more than 5 States may 
        participate in the project.
            (2) Application.--A State that desires to participate in 
        the project shall submit an application to the Secretary, at 
        such time and in such form and manner as the Secretary shall 
        specify.
            (3) Duration.--The project shall be conducted for at least 
        5, but not more than 10 years.
    (d) Evaluation and Report.--
            (1) Evaluation.--Not later than 1 year prior to the 
        termination date of the project, the Secretary, in consultation 
        with States participating in the project, representatives of 
        dually eligible individuals, and others, shall evaluate the 
        impact and effectiveness of the project.
            (2) Report.--The Secretary shall submit a report to 
        Congress that contains the findings of the evaluation conducted 
        under paragraph (1) along with recommendations regarding 
        whether the project should be extended or expanded, and any 
        other legislative or administrative actions that the Secretary 
        considers appropriate as a result of the project.
    (e) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as are necessary to carry out this section.
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