[Congressional Record Volume 149, Number 102 (Friday, July 11, 2003)]
[Senate]
[Pages S9304-S9306]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
By Mr. HARKIN (for himself, Mr. Smith, Mr. Kennedy, Mr.
Lautenberg, and Mr. Kerry):
S. 1394. A bill to establish a demonstration project under the
medicaid program to encourage the provision of community-based services
to individuals with disabilities; to the Committee on Finance.
Mr. HARKIN. Mr. President, today, Senator Smith and I and others
introduce the Money Follows the Person Act of 2003. This legislation is
needed to truly bring people with disabilities and older Americans 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.
Under our legislation, the Medicaid money paid by States and the
Federal Government would follow the person with a disability from an
institution into the community. This legislation provides 100 percent
Federal reimbursement for the community services that an individual
needs during the first year that they move out of an institution or
nursing home. By fully reimbursing the States, it gives them some
additional resources to allow people with disabilities and older
Americans to choose to live in the community.
President Bush first proposed the Money Follows the Person
Rebalancing Initiative in his FY '04 budget and indicated that the
demonstration project would provide full Federal reimbursement for
community services for the first year that an individual moves out of
an institution or nursing home. As of this date, the administration has
not suggested legislative language to Congress or provided specific
details regarding the implementation of the proposal. Working with the
disability community, we have drafted this legislation and look forward
to working with the administration and our colleagues to enact the
Money Follows the Person concept into law.
We have a Medicaid system in this country that is spending 70 percent
of its dollars on institutional care and only 30 percent on community
services. This bill is an important step toward switching those numbers
around.
It is shameful that our Federal dollars are being spent to segregate
people, not integrate them. It has been 13 years since we passed the
Americans with Disabilities Act, which said no to segregation. But our
Medicaid program says yes and we need to change it. This is the next
civil rights battle. If we really meant what we said in the ADA in
1990, we should enact this legislation.
The civil right of a person with a disability 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. An individual should not
be asked to move to another state in order to avoid needless segration.
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 2 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 had not been to a restaurant or a
movie since he moved to the nursing home over 2 years ago. His life has
dramatically changed from when he lived in his own apartment and hired
his own attendants to care for him.
Recently Ken wrote to me that he finally went to dinner and a movie
for his 30th birthday. He said ``I was almost in tears. I felt like I
had a real life again.''
This bill would give people like Ken a real life and not just on
their birthdays. People like Ken should not have to continue waiting to
be able to live in the community and enjoy the opportunities that other
Americans take for granted.
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.
This bill will open the door to full participation by people with
disabilities and older Americans in our neighborhoods, our communities,
our workplaces, and our American Dream, and I urge all my colleagues to
support us on this issue. I want to thank Senator Smith for his
commitment to improving access to home and community based services for
people with disabilities. I would also like to thank Senators Kennedy,
Lautenberg and Kerry 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. 1394
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
[[Page S9305]]
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Money Follows the Person Act
of 2003''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) In his budget for fiscal year 2004, President George W.
Bush proposes a ``Money Follows the Person'' rebalancing
initiative under the medicaid program to help States
rebalance their long-term services support systems more
evenly between institutional and community-based services.
(2) The President, by proposing this initiative, and
Congress, recognize that States have not fully developed the
systems needed to create a more equitable balance between
institutional and community-based services spending under the
medicaid program.
(3) While a few States have been successful at achieving
this balance, nationally, approximately 70 percent of the
medicaid funding spent for long-term services is devoted to
nursing facilities and intermediate care facilities for the
mentally retarded. Only 30 percent of such funding is spent
for community-based services.
(4) As a result, there are often long waiting lists for
community-based services and supports.
(5) In the Americans with Disabilities Act of 1990,
Congress found that individuals with disabilities continue to
encounter various forms of discrimination, including
segregation, and that discrimination persists in such
critical areas as institutionalization.
(6) In 1999, the Supreme Court held in Olmstead v. LC (527
U.S. 581 (1999)) that needless institutionalization is
discrimination under the Americans with Disabilities Act of
1990, noting that institutional placement of people who can
be served in the community ``perpetuates unwarranted
assumptions that persons so isolated are unworthy of
participating in community life.'' (Id. at 600). The Court
further found that ``confinement in an institution severely
diminishes the everyday life activities of individuals,
including family relations, social contacts, work options,
economic independence, educational advancement, and cultural
enrichment.'' (Id. at 601).
(7) Additional resources would be helpful for assisting
States in rebalancing their long-term services support system
and complying with the Olmstead decision.
SEC. 3. AUTHORITY TO CONDUCT MEDICAID DEMONSTRATION PROJECTS.
(a) Definitions.--In this section:
(1) Community-based services and supports.--The term
``community-based services and supports'' means, with respect
to a State, any items or services that are an allowable
expenditure for medical assistance under the State medicaid
program, or under a waiver of such program and that the State
determines would allow an individual to live in the
community.
(2) Individual's representative; representative.--The terms
``individual's representative'' and ``representative'' mean a
parent, family member, guardian, advocate, or authorized
representative of an individual.
(3) Medicaid long-term care facility.--The term ``medicaid
long-term care facility'' means a hospital, nursing facility,
or intermediate care facility for the mentally retarded, as
such terms are defined for purposes of the medicaid program.
(4) Medicaid program.--The term ``medicaid program'' means
the State medical assistance program established under title
XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
(5) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(6) State.--The term ``State'' has the meaning given such
term for purposes of the medicaid program.
(b) State Application.--A State may apply to the Secretary
for approval to conduct a demonstration project under which
the State shall provide community-based services and supports
to individuals--
(1) who are eligible for medical assistance under the
medicaid program;
(2) who are residing in a medicaid long-term care facility
and who have resided in such facility for at least 90 days;
and
(3) with respect to whom there has been a determination
that but for the provision of community-based services and
supports, the individuals would continue to require the level
of care provided in a medicaid long-term care facility.
(c) Requirements.--A State is not eligible to conduct a
demonstration project under this section unless the State
certifies the following:
(1) With respect to any individual provided community-based
services and supports under the demonstration project, the
State shall continue to provide community-based services and
supports to the individual under the medicaid program (and at
the State's Federal medical assistance percentage (as defined
in section 1905(b) of the Social Security Act) reimbursement
rate), for as long as the individual remains eligible for
medical assistance under the State medicaid program and
continues to require such services and supports, beginning
with the month that begins after the 12-month period in which
the individual is provided such services and supports under
the demonstration project.
(2) The State shall allow an individual participating in
the demonstration project (or, as appropriate, the
individual's representative) to choose the setting in which
the individual desires to receives the community-based
services and supports provided under the project.
(3) The State shall identify and educate individuals
residing in a medicaid long-term care facility who are
eligible to participate in the demonstration project (and, as
appropriate the individual's representative) about the
opportunity for the individual to receive community-based
services and supports under the demonstration project.
(4) The State shall ensure that each individual identified
in accordance with paragraph (3) (and, as appropriate, the
individual's representative), has the opportunity,
information, and tools to make an informed choice regarding
whether to transition to the community through participation
in the demonstration project or to remain in the medicaid
long-term care facility.
(5) The State shall maintain an adequate quality
improvement system so that individuals participating in the
demonstration project receive adequate services and supports.
(6) The State shall conduct a process for public
participation in the design and development of the
demonstration project and such process shall include the
participation of individuals with disabilities, elderly
individuals, or individuals with chronic conditions who are
part of the target populations to be served by the
demonstration project, and the representatives of such
individuals.
(7) The Federal funds paid to a State pursuant to this
section shall only supplement, and shall not supplant, the
level of State funds expended for providing community-based
services and supports for individuals under the State
medicaid program as of the date the State application to
conduct a demonstration project under this section is
approved.
(d) Approval of Demonstration Projects.--
(1) In general.--Subject to paragraph (2), the Secretary
shall conduct a competitive application process with respect
to applications submitted under subsection (b) (taking into
consideration the preferences provided under paragraph (2))
that meet the requirements of subsection (c). In determining
whether to approve such an application, the Secretary may
waive the requirement of--
(A) section 1902(a)(1) of the Social Security Act (42
U.S.C. 1396a(a)(1)) to allow for sub-State demonstrations;
(B) section 1902(a)(10)(B) of such Act (42 U.S.C.
1396a(a)(10)(B)) with respect to comparability; and
(C) section 1902(a)(10)(C)(i)(III) of such Act (42 U.S.C.
1396a(a)(10)(C)(i)(III)) with respect to income and resource
limitations.
(2) Preference for certain applications.--In approving
applications to conduct demonstration projects under this
section, the Secretary shall give preference to approving
applications that indicate that the State shall do the
following:
(A) Design and implement enduring improvements in
community-based long-term services support systems within the
State to enable individuals with disabilities to live and
participate in community life, particularly with respect to
those practices that will ensure the successful transition of
such individuals from medicaid long-term care facilities into
the community.
(B) Design and implement a long-term services support
system in the State that prevents individuals from entering
medicaid long-term care facilities in order to gain access to
community-based services and supports.
(C) Engage in systemic reform activities within the State
to rebalance expenditures for long-term services under the
State medicaid program through administrative actions that
reduce reliance on institutional forms of service and build
up more community capacity.
(D) Address the needs of populations that have been
underserved with respect to the availability of community
services or involve individuals or entities that have not
previously participated in the efforts of the State to
increase access to community-based services.
(E) Actively engage in collaboration between public housing
agencies, the State medicaid agency, independent living
centers, and other agencies and entities in order to
coordinate strategies for obtaining community integrated
housing and supportive services for an individual who
participates in the demonstration project, both with respect
to the period during which such individual participates in
the project and after the individual's participation in the
project concludes, in order to enable the individual to
continue to reside in the community.
(F) Develop and implement policies and procedures that
allow the State medicaid agency to administratively transfer
or integrate funds from the State budget accounts that are
obligated for expenditures for medicaid long-term care
facilities to other accounts for obligation for the provision
of community-based services and supports (including accounts
related to the provision of such services under a waiver
approved under section 1915 of the Social Security Act (42
U.S.C. 1396n)) when an individual transitions from residing
in such a facility to residing in the community.
(e) Payments to States.--
(1) In general.--The Secretary shall pay to each State with
a demonstration project approved under this section an amount
for each quarter occurring during the period described in
paragraph (2) equal to 100 percent of the State's
expenditures in the quarter for providing community-based
services and
[[Page S9306]]
supports to individuals participating in the demonstration
project.
(2) Period described.--The period described in this
paragraph is the 12-month period that begins on the date on
which an individual first receives community-based services
and supports under the demonstration project in a setting
that is not a medicaid long-term care facility and is
selected by the individual.
(f) Reports.--
(1) In general.--Each State conducting a demonstration
project under this section shall submit a report to the
Secretary that, in addition to such other requirements as the
Secretary may require, includes information regarding--
(A) the types of community-based services and supports
provided under the demonstration project;
(B) the number of individuals served under the project;
(C) the expenditures for, and savings resulting from,
conducting the project; and
(D) to the extent applicable, the changes in State's long-
term services system developed in accordance with the
provisions of subsection (d)(2).
(2) Uniform data format.--In requiring information under
this subsection, the Secretary shall develop a uniform data
format to be used by States in the collection and submission
of data in the State report required under paragraph (1).
(g) Evaluations.--The Secretary shall use an amount, not to
exceed one-half of 1 percent of the amount appropriated under
subsection (h) for each fiscal year, to provide, directly or
through contract--
(1) for the evaluation of the demonstration projects
conducted under this section;
(2) technical assistance to States concerning the
development or implementation of such projects; and
(3) for the collection of the data described in subsection
(f)(1).
(h) Funding.--
(1) In general.--There is appropriated to carry out this
section $350,000,000 for each of fiscal years 2004 through
2008.
(2) Availability.--Funds appropriated under paragraph (1)
for a fiscal year shall remain available until expended, but
not later than September 30, 2008.
______