[Congressional Record Volume 149, Number 64 (Thursday, May 1, 2003)]
[Senate]
[Pages S5660-S5665]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. HARKIN (for himself, Mr. Specter, Mr. Kennedy, Mr. 
        Cochran, Mr. Biden, Ms. Landrieu, Mr. Kerry, Mr. Corzine, Mr. 
        Schumer, Mrs. Clinton, and Mr. Dayton):
  S. 971. 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; to the Committee on Finance.
  Mr. HARKIN. Mr. President, today Senator Specter and I and others 
introduce the Medicaid Community-Based Attendant Services and Supports 
Act of 2003, MICASSA. This legislation is needed to truly bring people 
with disabilities into the mainstream of society and provide equal 
opportunity for employment and community activities.
  In order to work or live in their own homes, Americans with 
disabilities and older Americans need access to community-based 
services and supports. Unfortunately, under current Federal Medicaid 
policy, the deck is stacked in favor of living in an institution. The 
purpose of our bill is to level the playing field and give eligible 
individuals equal access to community-based services and supports.
  The Medicaid Community Attendant Services and Supports Act 
accomplishes four goals.
  First, the bill amends Title XIX of the Social Security Act to 
provide a new Medicaid plan benefit that would give individuals who are 
currently eligible for nursing home services or an intermediate care 
facility for the mentally retarded equal access to community-based 
attendant services and supports.
  Second, for a limited time, States would have the opportunity to 
receive additional funds to support community attendant services and 
supports and for certain administrative activities. Each State 
currently gets Federal money for their Medicaid program based on a set 
percentage. This percentage is the Medicaid match rate. This bill would 
increase that percentage to provide some additional funding to States 
to help them reform their long term care systems.
  Third, the bill provides States with financial assistance to support 
``real choice systems change initiatives'' that include specific action 
steps to increase the provision of home and community based services.
  Finally, the bill establishes a demonstration project to evaluate 
service coordination and cost sharing approaches with respect to the 
provision of services and supports for individuals with disabilities 
under the age of 65 who are dually eligible for Medicaid and Medicare.
  Some States have already recognized the benefits of home and 
community based services. Every State offers certain services under 
home and community based waiver programs, which serve a capped number 
of individuals with an array of home and community based services to 
meet their needs and avoid institutionalization. Some States also are 
now providing the personal care optional benefit through their Medicaid 
program.

  However, despite this market progress, home and community based 
services are unevenly distributed within and across states and only 
reach a small percentage of eligible individuals.
  Those left behind are often needlessly institutionalize because they 
cannot access community alternatives. A person with a disability's 
civil right to be integrated into his or her community should not 
depend on his or her address. In Olmstead v. LC, the Supreme Court 
recognized that needless institutionalization is a form of 
discrimination under the Americans With Disabilities Act. We in 
Congress have a responsibility to help States meet their obligations 
under Olmstead.
  This MICASSA legislation is designed to do just that and make the 
promise of the ADA a reality. It will help rebalance the current 
Medicaid long term care system, which spends a disproportionate amount 
on institutional services. For example, in 2000, 49.5 billion dollars 
were spent on institutional care, compared to 18.2 billion on community 
based care. In the same year, only 3 States spent 50 percent or more of 
their long term care funds under the Medicaid program on home and 
community based care.
  And that means that individuals do not have equal access to community 
based care throughout this country. An individual should not be asked 
to move to another state in order to avoid needless segregation. They 
also should not be moved away from family and friends because their 
only choice is an institution.
  For example, I know a young man in Iowa, Ken Kendall, who is 
currently living in a nursing home because he cannot access home and 
community based care. Ken was injured in a serious accident at the age 
of 17 and sustained a spinal chord injury. With the help of community 
based services covered by his insurance company, Ken could live in his 
home in Iowa City. Remaining independent made a tremendous difference 
in his life.
  However, several years ago, Ken lost his health insurance and after a 
time, he went onto Medicaid. As a Medicaid recipient, Ken was only 
given the option to live in a nursing home in Waterloo, almost two 
hours from his friends and family in Iowa City. In the nursing home, 
Ken has become isolated. He is very far from his family and friends and 
does not have access to transportation. He has not been to a restaurant 
or a movie since he moved to the nursing home over two years ago. His 
life has dramatically changed from when he lived in his own apartment 
and hired his own attendants to care for him. MICASSA would give him 
that choice again--the choice to control his own life and live a full 
and meaningful life in his home community surrounded by his friends and 
family.
  Federal Medicaid policy should reflect the consensus reached in the 
ADA that Americans with Disabilities should have equal opportunity to 
contribute to our communities and participate in our society as full 
citizens. That means no one has to sacrifice their full participation 
in society because they need help getting out of the house in the 
morning or assistance with personal care or some other basic service.
  I am very pleased that the administration has included the Real 
Choice Systems Change grants in its budget this year at $40 million 
dollars. Senator Specter and I have supported these grants for several 
years now. I also applaud the administration's commitment to The 
President's New Freedom Initiative for People with Disabilities and 
believe that this legislation helps promote the goals of that 
initiative.
  Community based attendant services and supports allow people with 
disabilities to lead independent lives, have jobs, and participate in 
the community. Some will become taxpayers, some will get an education, 
and some will participate in recreational and civic activities. But all 
will experience a chance to make their own choices and govern their own 
lives.
  This bill will open the door to full participation by people with 
disabilities in our workplaces, our economy, and our American Dream, 
and I urge all my colleagues to support us on this issue. I want to 
thank Senator Specter for his leadership on this issue and his 
commitment to improving access to home and community based services for 
people with disabilities. I would also like to thank Senators Kennedy, 
Cochran, Biden, Landrieu, Kerry, Corzine, Schumer, and Clinton for 
joining me in this important initiative.
  I ask unanimous consent that the text of the bill be printed in the 
Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                 S. 971

       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 ``Medicaid 
     Community-Based Attendant Services and Supports Act of 
     2003''.
       (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.

[[Page S5661]]

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 non-elderly 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 ability 
     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) Research on the provision of long-term services and 
     supports under the medicaid program (conducted by and on 
     behalf of the Department of Health and Human Services) has 
     revealed a significant funding bias toward institutional 
     care. Only about 27 percent of long term care funds expended 
     under the medicaid program, and only about 9 percent of all 
     funds expended under that program, pay for services and 
     supports in home and community-based settings.
       (3) In the case of medicaid beneficiaries who need long 
     term care, the only long-term care service currently 
     guaranteed by Federal law in every State is nursing home 
     care. Only 27 States have adopted the benefit option of 
     providing personal care services under the medicaid program. 
     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. In fiscal year 
     2000, only 3 States spent 50 percent or more of their 
     medicaid long term care funds under the medicaid program on 
     home and community-based care.
       (4) Despite the funding bias and the uneven distribution of 
     home and community-based services, 2\1/2\ times more people 
     are served in home and community-based settings than in 
     institutional settings.
       (5) 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 their 
     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, including in the workplace.
       (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 equal access to community-based attendant services 
     and supports.
       (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.

            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 1935, 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 or an intermediate care facility for the 
     mentally retarded (whether or not coverage of such 
     intermediate care facility is provided under the State plan); 
     and
       ``(III) who 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--
       (A) by redesignating section 1935 as section 1936; and
       (B) by inserting after section 1934 the following:


           ``community-based attendant services and supports

       ``Sec. 1935. (a) Required Coverage.--
       ``(1) In general.--Not later than October 1, 2007, 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 or after October 1, 
     2003, and ends on September 30, 2007, 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.
       ``(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.--That the State has developed and shall 
     implement the provision of community-based attendant services 
     and supports under the State plan 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) Assurance of provision on a statewide basis and in 
     most integrated setting.--That 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 for 
     each individual eligible for such services and supports.
       ``(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 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 optional medical assistance that--
       ``(A) is described in a paragraph other than paragraphs (1) 
     through (5), (17) and (21) of section 1905(a) or that is 
     provided under a waiver under section 1915, section 1115, or 
     otherwise; and
       ``(B) is provided 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 fiscal year in which the State plan 
     amendment to provide community-based attendant services and 
     supports in accordance with this section is approved.
       ``(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 the this title, and of other items and services that 
     may be provided to the individual under this title or title 
     XVIII.
       ``(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 individuals with disabilities, elderly individuals, 
     and representatives of such individuals in the design, 
     delivery, administration, 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

[[Page S5662]]

     an independent life to the maximum extent possible.
       ``(d) Quality Assurance Program.--
       ``(1) State responsibilities.--In order for a State plan 
     amendment to be approved under this section, a State shall 
     establish and maintain a quality assurance program 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 program, 
     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 appropriate for 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 program.
       ``(I) The State shall establish an ongoing public process 
     for the development, implementation, and review of the 
     State's quality assurance program.
       ``(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 Under a 
     Waiver.--
       ``(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 a waiver 
     approved under 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.
       ``(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 functions 
     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 by 
     the individual or, as appropriate, the individual's 
     representative;
       ``(ii) in a home or community setting, which may include a 
     school, workplace, or recreation or religious facility, but 
     does not include a nursing facility or an intermediate care 
     facility for the mentally retarded;
       ``(iii) under an agency-provider model or other model (as 
     defined in paragraph (2)(C)); and
       ``(iv) the furnishing of which is selected, managed, and 
     dismissed by the individual, or, as appropriate, with 
     assistance from the individual's representative.
       ``(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 functions;
       ``(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 functions;
       ``(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 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 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, 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 
     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.
       ``(D) Health-related functions.--The term `health-related 
     functions' means functions 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 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) Individual's representative.--The term `individual's 
     representative' means a parent, a family member, a guardian, 
     an advocate, or an 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 (27)''.
       (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 (26);
       (B) by redesignating paragraph (27) as paragraph (28); and
       (C) by inserting after paragraph (26) the following:
       ``(27) community-based attendant services and supports (to 
     the extent allowed and as defined in section 1935); 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 (27)'' 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, 2003, 
     and apply to medical assistance provided for community-based 
     attendant services and supports described in section 1935 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, 2007.

[[Page S5663]]

     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 1935 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 and activities described.--For purposes of 
     paragraph (1), the services 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, particularly 
     those services that are provided based on such factors as 
     age, disability type, 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 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 microenterprises 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, 2003.

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

       (a) In General.--Section 1935 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, 2003.

      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 
     1935 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, 
     microenterprises 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 overmedicalization 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--

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       (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 
     2004 through 2006.
       (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 NON-ELDERLY DUAL ELIGIBLE INDIVIDUALS.

       (a) Definitions.--In this section:
       (1) Non-elderly dually eligible individual.--The term 
     ``non-elderly dually eligible individual'' means an 
     individual who--
       (A) has not attained age 65; and
       (B) 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 non-elderly 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 non-elderly 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.
  Mr. SPECTER. Mr. President, I have sought recognition to join Senator 
Tom Harkin, my colleague and distinguished ranking member of the 
Appropriations Subcommittee on Labor, Health and Human Services and 
Education, which I chair, in introducing the ``Medicaid Attendant Care 
Services and Supports Act of 2003.'' This creative proposal addresses a 
glaring gap in Federal health coverage, and assists one of our Nation's 
most vulnerable populations, persons with disabilities.
  In an effort to improve the delivery of care and the comfort of those 
with long-term disabilities, this vital legislation would allow for 
reimbursement for community-based attendant care services, in lieu of 
institutionalization, for eligible individuals who require such 
services based on functional need, without regard to the individual's 
age or the nature of the disability. The most recent data available 
tell us that 58.5 million individuals receive care for disabilities 
under the Medicaid program. The number of disabled who are not 
currently enrolled in the program who would apply for this improved 
benefit is not easily counted, but would likely be substantial given 
the preference of home and community-based care over institutional 
care.
  Under this proposal, States may apply for grants for assistance in 
implementing ``systems change'' initiatives, in order to eliminate the 
institutional bias in their current policies and for needs assessment 
activities. Further, if a state can show that the aggregate amounts of 
Federal expenditures on people living in the community exceeds what 
would have been spent on the same people had they been in nursing 
homes, the state can limit the program. No limiting mechanism is 
mandated under this bill, And finally, States would be required to 
maintain expenditures for attendant care services under other Medicaid 
community-based programs, thereby preventing the states from shifting 
patients into the new benefit proposed under this bill.

  Let me speak briefly about why such a change in Medicaid law is so 
desperately needed. In 1999 the Supreme Court held in Olmstead v. L.C., 
119 S. Ct. 2176 (1999), that the Americans with Disabilities Act, ADA, 
requires States, under some circumstances, to provide community-based 
treatment to persons with mental disabilities rather than placing them 
in institutions. This decision and several lower court decisions have 
pointed to the need for a structured Medicaid attendant-care services 
benefit in order to meet obligations under the ADA. Disability 
advocates strongly support this legislation, arguing that the lack of 
Medicaid community-based services options is discriminatory and 
unhealthful for disabled individuals. Virtually every major disability 
advocacy group supports this bill, including ADAPT, the Arc, the 
National Council on Independent Living, Paralyzed Veterans of America, 
and the National Spinal Cord Injury Association.
  Senator Harkin and I recognize that such a shift in the Medicaid 
program is a huge undertaking--but feel that it is a vitally important 
one. We are introducing this legislation today in an attempt to move 
ahead with the consideration of crucial disability legislation and to 
provide a starting point for debate. The time has come for concerted 
action in this arena.
  I urge the Congressional leadership, including the appropriate 
committee chairmen, to move forward in considering this legislation, 
and take the significant next step forward in achieving the objective 
of providing individuals with disabilities the freedom to live in their 
own communities.

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