[Congressional Record Volume 155, Number 87 (Thursday, June 11, 2009)]
[Senate]
[Pages S6560-S6564]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. CANTWELL (for herself and Mr. Kohl):
  S. 1256. A bill to amend title XIX of the Social Security Act to 
establish financial incentives for States to expand the provision of 
long-term services and supports to Medicaid beneficiaries who do not 
reside in an institution, and for other purposes; to the Committee on 
Finance.
  Ms. CANTWELL. Mr. President, I rise today to introduce the Home and 
Community Balanced Incentives Act of 2009, together with my colleague 
from Wisconsin, Senator Kohl. As we in the Senate embark on reforming 
America's health care system, we cannot forget those who are dependent 
on daily care in order to survive: those in long-term care. Long-term 
care provides health care and daily living services to the elderly and 
disabled population, providing them with the ability to live happy, 
productive lives that age, illness and disability would otherwise 
prevent.
  In 2007, the U.S. spent close to $109 billion on long term 
institutional care services under the Medicaid program; in my state of 
Washington it was approximately $2 billion. This amount represents more 
than 30 percent of all Medicaid payments, and is a number we can easily 
reduce. This legislation seeks to rebalance how states handle long term 
care by providing the tools they need to shift people out of expensive 
institutional care facilities and into home and community based care, 
where they can remain vibrant, active members of their community.
  As Dorothy from the Wizard of Oz once said: There is no place like 
home. I could not agree more, which is why I believe in providing 
individuals and

[[Page S6561]]

families with the option to remain in their home, where studies have 
shown the overall quality of life is far superior to that in an 
institutional facility. Additionally, home and community based care is 
far more cost efficient than institutional care; by diverting just 5 
percent of the long term care community away from institutional care 
and into home and community based services, we would see a net savings 
of more than $10 billion dollars over five years. In a time when rising 
health care spending plays such a pivotal role in the health of the 
overall economy, these savings represent a giant step towards reining 
in unnecessary health care spending.
  The Home and Community Balanced Incentives Act would achieve the goal 
of transitioning to home and community based services by offering 
states modest increases to their federal medical assistance payment, 
FMAP, for home and community based services. States would have to use 
these increases to develop the programs needed to provide effective 
home and community based services. These services will reduce barriers 
that currently prohibit people from accessing home and community based 
services.
  This bill succeeds in not only saving the Medicaid program a 
significant amount of money, but it will empower families to make 
informed decisions about their long term care needs.
  Specifically, this bill would: improve case management to help people 
remain in their homes and communities and out of nursing homes; provide 
consumer empowerment helping to put individuals in charge of their 
care; provide a coordinated transition structure for those wishing to 
leave institutional care and return to their homes and communities; 
create a clear and well coordinated system for providing long term care 
information and support; improve methodology for determining 
eligibility and tracking provider data on services and quality 
outcomes.
  Senator Kohl and I are excited to introduce this important 
legislation and to begin working with our colleagues on improving the 
long term care system in America.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1256

       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 ``Home and 
     Community Balanced Incentives Act of 2009''.
       (b) Table of Contents.--The table of contents for this Act 
     is as follows:

Sec. 1. Short title; table of contents.

                     TITLE I--BALANCING INCENTIVES

Sec. 101. Enhanced FMAP for expanding the provision of non-
              institutionally-based long-term services and supports.

  TITLE II--STRENGTHENING THE MEDICAID HOME AND COMMUNITY-BASED STATE 
                         PLAN AMENDMENT OPTION

Sec. 201. Removal of barriers to providing home and community-based 
              services under State plan amendment option for 
              individuals in need.
Sec. 202. Mandatory application of spousal impoverishment protections 
              to recipients of home and community-based services.
Sec. 203. State authority to elect to exclude up to 6 months of average 
              cost of nursing facility services from assets or 
              resources for purposes of eligibility for home and 
              community-based services.

      TITLE III--COORDINATION OF HOME AND COMMUNITY-BASED WAIVERS

Sec. 301. Streamlined process for combined waivers under subsections 
              (b) and (c) of section 1915.

                     TITLE I--BALANCING INCENTIVES

     SEC. 101. ENHANCED FMAP FOR EXPANDING THE PROVISION OF NON-
                   INSTITUTIONALLY-BASED LONG-TERM SERVICES AND 
                   SUPPORTS.

       (a) Enhanced Fmap to Encourage Expansion.--Section 1905 of 
     the Social Security Act (42 U.S.C. 1396d) is amended--
       (1) in the first sentence of subsection (b)--
       (A) by striking ``, and (4)'' and inserting ``, (4)''; and
       (B) by inserting before the period the following: ``, and 
     (5) in the case of a balancing incentive payment State, as 
     defined in subsection (y)(1), that meets the conditions 
     described in subsection (y)(2), the Federal medical 
     assistance percentage shall be increased by the applicable 
     number of percentage points determined under subsection 
     (y)(3) for the State with respect to medical assistance 
     described in subsection (y)(4)''; and
       (2) by adding at the end the following new subsection:
       ``(y) State Balancing Incentive Payments Program.--For 
     purposes of clause (5) of the first sentence of subsection 
     (b):
       ``(1) Balancing incentive payment state.--A balancing 
     incentive payment State is a State--
       ``(A) in which less than 50 percent of the total 
     expenditures for medical assistance for fiscal year 2009 for 
     long-term services and supports (as defined by the Secretary, 
     subject to paragraph (5)) are for non-institutionally-based 
     long-term services and supports described in paragraph 
     (5)(B);
       ``(B) that submits an application and meets the conditions 
     described in paragraph (2); and
       ``(C) that is selected by the Secretary to participate in 
     the State balancing incentive payment program established 
     under this subsection.
       ``(2) Conditions.--The conditions described in this 
     paragraph are the following:
       ``(A) Application.--The State submits an application to the 
     Secretary that includes the following:
       ``(i) A description of the availability of non-
     institutionally-based long-term services and supports 
     described in paragraph (5)(B) available (for fiscal years 
     beginning with fiscal year 2009).
       ``(ii) A description of eligibility requirements for 
     receipt of such services.
       ``(iii) A projection of the number of additional 
     individuals that the State expects to provide with such 
     services to during the 5-fiscal year period that begins with 
     fiscal year 2011.
       ``(iv) An assurance of the State's commitment to a 
     consumer-directed long-term services and supports system that 
     values quality of life in addition to quality of care and in 
     which beneficiaries are empowered to choose providers and 
     direct their own care as much as possible.
       ``(v) A proposed budget that details the State's plan to 
     expand and diversify medical assistance for non-
     institutionally-based long-term services and supports 
     described in paragraph (5)(B) during such 5-fiscal year 
     period, and that includes--

       ``(I) a description of the new or expanded offerings of 
     such services that the State will provide; and
       ``(II) the projected costs of the services identified in 
     subclause (I).

       ``(vi) A description of how the State intends to achieve 
     the target spending percentage applicable to the State under 
     subparagraph (B).
       ``(vii) An assurance that the State will not use Federal 
     funds, revenues described in section 1903(w)(1), or revenues 
     obtained through the imposition of beneficiary cost-sharing 
     for medical assistance for non-institutionally-based long-
     term services and supports described in paragraph (5)(B) for 
     the non-federal share of expenditures for medical assistance 
     described in paragraph (4).
       ``(B) Target spending percentages.--
       ``(i) In the case of a balancing incentive payment State in 
     which less than 25 percent of the total expenditures for home 
     and community-based services under the State plan and the 
     various waiver authorities for fiscal year 2009 are for such 
     services, the target spending percentage for the State to 
     achieve by not later than October 1, 2015, is that 25 percent 
     of the total expenditures for home and community-based 
     services under the State plan and the various waiver 
     authorities are for such services.
       ``(ii) In the case of any other balancing incentive payment 
     State, the target spending percentage for the State to 
     achieve by not later than October 1, 2015, is that 50 percent 
     of the total expenditures for home and community-based 
     services under the State plan and the various waiver 
     authorities are for such services.
       ``(C) Maintenance of eligibility requirements.--The State 
     does not apply eligibility standards, methodologies, or 
     procedures for determining eligibility for medical assistance 
     for non-institutionally-based long-term services and supports 
     described in paragraph (5)(B)) that are more restrictive than 
     the eligibility standards, methodologies, or procedures in 
     effect for such purposes on December 31, 2010.
       ``(D) Use of additional funds.--The State agrees to use the 
     additional Federal funds paid to the State as a result of 
     this subsection only for purposes of providing new or 
     expanded offerings of non-institutionally-based long-term 
     services and supports described in paragraph (5)(B) 
     (including expansion through offering such services to 
     increased numbers of beneficiaries of medical assistance 
     under this title).
       ``(E) Structural changes.--The State agrees to make, not 
     later than the end of the 6-month period that begins on the 
     date the State submits and application under this paragraph, 
     such changes to the administration of the State plan (and, if 
     applicable, to waivers approved for the State that involve 
     the provision of long-term care services and supports) as the 
     Secretary determines, by regulation or otherwise, are 
     essential to achieving an improved balance between the 
     provision of non-institutionally-based long-term services and 
     supports described in paragraph (5)(B) and other long-term 
     services and supports, and which shall include the following:
       ``(i) `No wrong door'--single entry point system.--
     Development of a statewide system to enable consumers to 
     access all long-term

[[Page S6562]]

     services and supports through an agency, organization, 
     coordinated network, or portal, in accordance with such 
     standards as the State shall establish and that--

       ``(I) shall require such agency, organization, network, or 
     portal to provide--

       ``(aa) consumers with information regarding the 
     availability of such services, how to apply for such 
     services, and other referral services; and
       ``(bb) information regarding, and make recommendations for, 
     providers of such services; and

       ``(II) may, at State option, permit such agency, 
     organization, network, or portal to--

       ``(aa) determine financial and functional eligibility for 
     such services and supports; and
       ``(bb) provide or refer eligible individuals to services 
     and supports otherwise available in the community (under 
     programs other than the State program under this title), such 
     as housing, job training, and transportation.
       ``(ii) Presumptive eligibility.--At the option of the 
     State, provision of a 60-day period of presumptive 
     eligibility for medical assistance for non-institutionally-
     based long-term services and supports described in paragraph 
     (5)(B) for any individual whom the State has reason to 
     believe will qualify for such medical assistance (provided 
     that any expenditures for such medical assistance during such 
     period are disregarded for purposes of determining the rate 
     of erroneous excess payments for medical assistance under 
     section 1903(u)(1)(D)).
       ``(iii) Case management.--Development, in accordance with 
     guidance from the Secretary, of conflict-free case management 
     services to--

       ``(I) address transitioning from receipt of 
     institutionally-based long-term services and supports 
     described in paragraph (5)(A) to receipt of non-
     institutionally-based long-term services and supports 
     described in paragraph (5)(B); and
       ``(II) in conjunction with the beneficiary, assess the 
     beneficiary's needs and , if appropriate, the needs of family 
     caregivers for the beneficiary, and develop a service plan, 
     arrange for services and supports, support the beneficiary 
     (and, if appropriate, the caregivers) in directing the 
     provision of services and supports, for the beneficiary, and 
     conduct ongoing monitoring to assure that services and 
     supports are delivered to meet the beneficiary's needs and 
     achieve intended outcomes.

       ``(iv) Core standardized assessment instruments.--
     Development of core standardized assessment instruments for 
     determining eligibility for non-institutionally-based long-
     term services and supports described in paragraph (5)(B), 
     which shall be used in a uniform manner throughout the State, 
     to--

       ``(I) assess a beneficiary's eligibility and functional 
     level in terms of relevant areas that may include medical, 
     cognitive, and behavioral status, as well as daily living 
     skills, and vocational and communication skills;
       ``(II) based on the assessment conducted under subclause 
     (I), determine a beneficiary's needs for training, support 
     services, medical care, transportation, and other services, 
     and develop an individual service plan to address such needs;
       ``(III) conduct ongoing monitoring based on the service 
     plan; and
       ``(IV) require reporting of collect data for purposes of 
     comparison among different service models.

       ``(F) Data collection.--Collecting from providers of 
     services and through such other means as the State determines 
     appropriate the following data:
       ``(i) Services data.--Services data from providers of non-
     institutionally-based long-term services and supports 
     described in paragraph (5)(B) on a per-beneficiary basis and 
     in accordance with such standardized coding procedures as the 
     State shall establish in consultation with the Secretary.
       ``(ii) Quality data.--Quality data on a selected set of 
     core quality measures agreed upon by the Secretary and the 
     State that are linked to population-specific outcomes 
     measures and accessible to providers.
       ``(iii) Outcomes measures.--Outcomes measures data on a 
     selected set of core population-specific outcomes measures 
     agreed upon by the Secretary and the State that are 
     accessible to providers and include--

       ``(I) measures of beneficiary and family caregiver 
     experience with providers;
       ``(II) measures of beneficiary and family caregiver 
     satisfaction with services; and
       ``(III) measures for achieving desired outcomes appropriate 
     to a specific beneficiary, including employment, 
     participation in community life, health stability, and 
     prevention of loss in function.

       ``(3) Applicable number of percentage points increase in 
     fmap.--The applicable number of percentage points are--
       ``(A) in the case of a balancing incentive payment State 
     subject to the target spending percentage described in 
     paragraph (2)(B)(i), 5 percentage points; and
       ``(B) in the case of any other balancing incentive payment 
     State, 2 percentage points.
       ``(4) Eligible medical assistance expenditures.--
       ``(A) In general.--Subject to subparagraph (B), medical 
     assistance described in this paragraph is medical assistance 
     for non-institutionally-based long-term services and supports 
     described in paragraph (5)(B) that is provided during the 
     period that begins on October 1, 2011, and ends on September 
     30, 2015.
       ``(B) Limitation on payments.--In no case may the aggregate 
     amount of payments made by the Secretary to balancing 
     incentive payment States under this subsection during the 
     period described in subparagraph (A), or to a State to which 
     paragraph (6) of the first sentence of subsection (b) 
     applies, exceed $3,000,000,000.
       ``(5) Long-term services and supports defined.--In this 
     subsection, the term `long-term services and supports' has 
     the meaning given that term by Secretary and shall include 
     the following:
       ``(A) Institutionally-based long-term services and 
     supports.--Services provided in an institution, including the 
     following:
       ``(i) Nursing facility services.
       ``(ii) Services in an intermediate care facility for the 
     mentally retarded described in subsection (a)(15).
       ``(B) Non-institutionally-based long-term services and 
     supports.--Services not provided in an institution, including 
     the following:
       ``(i) Home and community-based services provided under 
     subsection (c), (d), or (i), of section 1915 or under a 
     waiver under section 1115.
       ``(ii) Home health care services.
       ``(iii) Personal care services.
       ``(iv) Services described in subsection (a)(26) (relating 
     to PACE program services).
       ``(v) Self-directed personal assistance services described 
     in section 1915(j)''.
       (b) Enhanced Fmap for Certain States to Maintain the 
     Provision of Home and Community-Based Services.--The first 
     sentence of section 1905(b) of such Act (42 U.S.C. 1396d 
     (b)), as amended by subsection (a), is amended--
       (1) by striking ``, and (5)'' and inserting ``, (5)''; and
       (2) by inserting before the period the following: ``, and 
     (6) in the case of a State in which at least 50 percent of 
     the total expenditures for medical assistance for fiscal year 
     2009 for long-term services and supports (as defined by the 
     Secretary for purposes of subsection (y)) are for non-
     institutionally-based long-term services and supports 
     described in subsection (y)(5)(B), and which satisfies the 
     requirements of subparagraphs (A) (other than clauses (iii), 
     (v), and (vi)), (C), and (F) of subsection (y)(2), and has 
     implemented the structural changes described in each clause 
     of subparagraph (E) of that subsection, the Federal medical 
     assistance percentage shall be increased by 1 percentage 
     point with respect to medical assistance described in 
     subparagraph (A) of subsection (y)(4) (but subject to the 
     limitation described in subparagraph (B) of that 
     subsection)''.
       (c) Grants to Support Structural Changes.--
       (1) In general.--The Secretary of Health and Human Services 
     shall award grants to States for the following purposes:
       (A) To support the development of common national set of 
     coding methodologies and databases related to the provision 
     of non-institutionally-based long-term services and supports 
     described in paragraph (5)(B) of section 1905(y) of the 
     Social Security Act (as added by subsection (a)).
       (B) To make structural changes described in paragraph 
     (2)(E) of section 1905(y) to the State Medicaid program.
       (2) Priority.--In awarding grants for the purpose described 
     in paragraph (1)(A), the Secretary of Health and Human 
     Services shall give priority to States in which at least 50 
     percent of the total expenditures for medical assistance 
     under the State Medicaid program for fiscal year 2009 for 
     long-term services and supports, as defined by the Secretary 
     for purposes of section 1905(y) of the Social Security Act, 
     are for non-institutionally-based long-term services and 
     supports described in paragraph (5)(B) of such section.
       (3) Collaboration.--States awarded a grant for the purpose 
     described in paragraph (1)(A) shall collaborate with other 
     States, the National Governor's Association, the National 
     Conference of State Legislatures, the National Association of 
     State Medicaid Directors, the National Association of State 
     Directors of Developmental Disabilities, and other 
     appropriate organizations in developing specifications for a 
     common national set of coding methodologies and databases.
       (4) Authorization of appropriations.--There are authorized 
     to be appropriated to carry out this subsection, such sums as 
     may be necessary for each of fiscal years 2010 through 2012.
       (d) Authority for Individualized Budgets Under Waivers to 
     Provide Home and Community-Based Services.--In the case of 
     any waiver to provide home and community-based services under 
     subsection (c) or (d) of section 1915 of the Social Security 
     Act (42 U.S.C. 1396n) or section 1115 of such Act (42 U.S.C. 
     1315), that is approved or renewed after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall permit a State to establish individualized 
     budgets that identify the dollar value of the services and 
     supports to be provided to an individual under the waiver.
       (e) Oversight and Assessment.--
       (1) Development of standardized reporting requirements.--
       (A) Standardization of data and outcome measures.--The 
     Secretary of Health and Human Services shall consult with 
     States and the National Governor's Association, the National 
     Conference of State Legislatures, the National Association of 
     State Medicaid Directors, the National Association of State 
     Directors of Developmental Disabilities, and other 
     appropriate organizations to develop specifications for 
     standardization of--
       (i) reporting of assessment data for long-term services and 
     supports (as defined by the

[[Page S6563]]

     Secretary for purposes of section 1905(y)(5) of the Social 
     Security Act) for each population served, including 
     information standardized for purposes of certified EHR 
     technology (as defined in section 1903(t)(3)(A) of the Social 
     Security Act (42 U.S.C. 1396b(t)(3)(A)) and under other 
     electronic medical records initiatives; and
       (ii) outcomes measures that track assessment processes for 
     long-term services and supports (as so defined) for each such 
     population that maintain and enhance individual function, 
     independence, and stability.
       (2) Administration of home and community services.--The 
     Secretary of Health and Human Services shall promulgate 
     regulations to ensure that all States develop service systems 
     that are designed to--
       (A) allocate resources for services in a manner that is 
     responsive to the changing needs and choices of beneficiaries 
     receiving non-institutionally-based long-term services and 
     supports described in paragraph (5)(B) of section 1905(y) of 
     the Social Security Act (as added by subsection (a)) 
     (including such services and supports that are provided under 
     programs other the State Medicaid program), and that provides 
     strategies for beneficiaries receiving such services to 
     maximize their independence;
       (B) provide the support and coordination needed for a 
     beneficiary in need of such services (and their family 
     caregivers or representative, if applicable) to design an 
     individualized, self-directed, community-supported life; and
       (C) improve coordination among all providers of such 
     services under federally and State-funded programs in order 
     to--
       (i) achieve a more consistent administration of policies 
     and procedures across programs in relation to the provision 
     of such services; and
       (ii) oversee and monitor all service system functions to 
     assure--

       (I) coordination of, and effectiveness of, eligibility 
     determinations and individual assessments; and
       (II) development and service monitoring of a complaint 
     system, a management system, a system to qualify and monitor 
     providers, and systems for role-setting and individual budget 
     determinations.

       (3) Monitoring.--The Secretary of Health and Human Services 
     shall assess on an ongoing basis and based on measures 
     specified by the Agency for Healthcare Research and Quality, 
     the safety and quality of non-institutionally-based long-term 
     services and supports described in paragraph (5)(B) of 
     section 1905(y) of that Act provided to beneficiaries of such 
     services and supports and the outcomes with regard to such 
     beneficiaries' experiences with such services. Such oversight 
     shall include examination of--
       (A) the consistency, or lack thereof, of such services in 
     care plans as compared to those services that were actually 
     delivered; and
       (B) the length of time between when a beneficiary was 
     assessed for such services, when the care plan was completed, 
     and when the beneficiary started receiving such services.
       (4) GAO study and report.--The Comptroller General of the 
     United States shall study the longitudinal costs of Medicaid 
     beneficiaries receiving long-term services and supports (as 
     defined by the Secretary for purposes of section 1905(y)(5) 
     of the Social Security Act) over 5-year periods across 
     various programs, including the non-institutionally-based 
     long-term services and supports described in paragraph (5)(B) 
     of such section, PACE program services under section 1894 of 
     the Social Security Act (42 U.S.C. 1395eee, 1396u-4), and 
     services provided under specialized MA plans for special 
     needs individuals under part C of title XVIII of the Social 
     Security Act.

  TITLE II--STRENGTHENING THE MEDICAID HOME AND COMMUNITY-BASED STATE 
                         PLAN AMENDMENT OPTION

     SEC. 201. REMOVAL OF BARRIERS TO PROVIDING HOME AND 
                   COMMUNITY-BASED SERVICES UNDER STATE PLAN 
                   AMENDMENT OPTION FOR INDIVIDUALS IN NEED.

       (a) Parity With Income Eligibility Standard for 
     Institutionalized Individuals.--Paragraph (1) of section 
     1915(i) of the Social Security Act (42 U.S.C. 1396n(i)) is 
     amended by striking ``150 percent of the poverty line (as 
     defined in section 2110(c)(5))'' and inserting ``300 percent 
     of the supplemental security income benefit rate established 
     by section 1611(b)(1)''.
       (b) Additional State Options.--Section 1915(i) of the 
     Social Security Act (42 U.S.C. 1396n(i)) is amended by adding 
     at the end the following new paragraphs:
       ``(6) State option to provide home and community-based 
     services to individuals eligible for services under a 
     waiver.--
       ``(A) In general.--A State that provides home and 
     community-based services in accordance with this subsection 
     to individuals who satisfy the needs-based criteria for the 
     receipt of such services established under paragraph (1)(A) 
     may, in addition to continuing to provide such services to 
     such individuals, elect to provide home and community-based 
     services in accordance with the requirements of this 
     paragraph to individuals who are eligible for home and 
     community-based services under a waiver approved for the 
     State under subsection (c), (d), or (e) or under section 1115 
     to provide such services, but only for those individuals 
     whose income does not exceed 300 percent of the supplemental 
     security income benefit rate established by section 
     1611(b)(1).
       ``(B) Application of same requirements for individuals 
     satisfying needs-based criteria.--Subject to subparagraph 
     (C), a State shall provide home and community-based services 
     to individuals under this paragraph in the same manner and 
     subject to the same requirements as apply under the other 
     paragraphs of this subsection to the provision of home and 
     community-based services to individuals who satisfy the 
     needs-based criteria established under paragraph (1)(A).
       ``(C) Authority to offer different type, amount, duration, 
     or scope of home and community-based services.--A State may 
     offer home and community-based services to individuals under 
     this paragraph that differ in type, amount, duration, or 
     scope from the home and community-based services offered for 
     individuals who satisfy the needs-based criteria established 
     under paragraph (1)(A), so long as such services are within 
     the scope of services described in paragraph (4)(B) of 
     subsection (c) for which the Secretary has the authority to 
     approve a waiver and do not include room or board.
       ``(7) State option to offer home and community-based 
     services to specific, targeted populations.--
       ``(A) In general.--A State may elect in a State plan 
     amendment under this subsection to target the provision of 
     home and community-based services under this subsection to 
     specific populations and to differ the type, amount, 
     duration, or scope of such services to such specific 
     populations.
       ``(B) 5-year term.--
       ``(i) In general.--An election by a State under this 
     paragraph shall be for a period of 5 years.
       ``(ii) Phase-in of services and eligibility permitted 
     during initial 5-year period.--A State making an election 
     under this paragraph may, during the first 5-year period for 
     which the election is made, phase-in the enrollment of 
     eligible individuals, or the provision of services to such 
     individuals, or both, so long as all eligible individuals in 
     the State for such services are enrolled, and all such 
     services are provided, before the end of the initial 5-year 
     period.
       ``(C) Renewal.--An election by a State under this paragraph 
     may be renewed for additional 5-year terms if the Secretary 
     determines, prior to beginning of each such renewal period, 
     that the State has--
       ``(i) adhered to the requirements of this subsection and 
     paragraph in providing services under such an election; and
       ``(ii) met the State's objectives with respect to quality 
     improvement and beneficiary outcomes.''.
       (c) Removal of Limitation on Scope of Services.--Paragraph 
     (1) of section 1915(i) of the Social Security Act (42 U.S.C. 
     1396n(i)), as amended by subsection (a), is amended by 
     striking ``or such other services requested by the State as 
     the Secretary may approve''.
       (d) Optional Eligibility Category To Provide Full Medicaid 
     Benefits to Individuals Receiving Home and Community-Based 
     Services Under a State Plan Amendment.--
       (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
       (A) in subclause (XVIII), by striking ``or'' at the end;
       (B) in subclause (XIX), by adding ``or'' at the end; and
       (C) by inserting after subclause (XIX), the following new 
     subclause:

       ``(XX) who are eligible for home and community-based 
     services under needs-based criteria established under 
     paragraph (1)(A) of section 1915(i), or who are eligible for 
     home and community-based services under paragraph (6) of such 
     section, and who will receive home and community-based 
     services pursuant to a State plan amendment under such 
     subsection;''.

       (2) Conforming amendments.--
       (A) Section 1903(f)(4) of the Social Security Act (42 
     U.S.C. 1396b(f)(4)) is amended in the matter preceding 
     subparagraph (A), by inserting ``1902(a)(10)(A)(ii)(XX),'' 
     after ``1902(a)(10)(A)(ii)(XIX),''.
       (B) Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)) is amended in the matter preceding paragraph (1)--
       (i) in clause (xii), by striking ``or'' at the end;
       (ii) in clause (xiii), by adding ``or'' at the end; and
       (iii) by inserting after clause (xiii) the following new 
     clause:
       ``(xiv) individuals who are eligible for home and 
     community-based services under needs-based criteria 
     established under paragraph (1)(A) of section 1915(i), or who 
     are eligible for home and community-based services under 
     paragraph (6) of such section, and who will receive home and 
     community-based services pursuant to a State plan amendment 
     under such subsection,''.
       (e) Elimination of Option To Limit Number of Eligible 
     Individuals or Length of Period for Grandfathered Individuals 
     if Eligibility Criteria Is Modified.--Paragraph (1) of 
     section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended--
       (1) by striking subparagraph (C) and inserting the 
     following:
       ``(C) Projection of number of individuals to be provided 
     home and community-based services.--The State submits to the 
     Secretary, in such form and manner, and upon such frequency 
     as the Secretary shall specify, the projected number of 
     individuals to be provided home and community-based 
     services.''; and
       (2) in subclause (II) of subparagraph (D)(ii), by striking 
     ``to be eligible for such services

[[Page S6564]]

     for a period of at least 12 months beginning on the date the 
     individual first received medical assistance for such 
     services'' and inserting ``to continue to be eligible for 
     such services after the effective date of the modification 
     and until such time as the individual no longer meets the 
     standard for receipt of such services under such pre-modified 
     criteria''.
       (f) Elimination of Option To Waive Statewideness; Addition 
     of Option to Waive Comparability.--Paragraph (3) of section 
     1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by 
     striking ``1902(a)(1) (relating to statewideness)'' and 
     inserting ``1902(a)(10)(B) (relating to comparability''.
       (g) Effective Date.--The amendments made by this section 
     take effect on the first day of the first fiscal year quarter 
     that begins after the date of enactment of this Act.

     SEC. 202. MANDATORY APPLICATION OF SPOUSAL IMPOVERISHMENT 
                   PROTECTIONS TO RECIPIENTS OF HOME AND 
                   COMMUNITY-BASED SERVICES.

       (a) In General.--Section 1924(h)(1)(A) of the Social 
     Security Act (42 U.S.C. 1396r-5(h)(1)(A)) is amended by 
     striking ``(at the option of the State) is described in 
     section 1902(a)(10)(A)(ii)(VI)'' and inserting ``is eligible 
     for medical assistance for home and community-based services 
     under subsection (c), (d), (e), or (i) of section 1915''.
       (b) Effective Date.--The amendment made by subsection (a) 
     takes effect on October 1, 2009.

     SEC. 203. STATE AUTHORITY TO ELECT TO EXCLUDE UP TO 6 MONTHS 
                   OF AVERAGE COST OF NURSING FACILITY SERVICES 
                   FROM ASSETS OR RESOURCES FOR PURPOSES OF 
                   ELIGIBILITY FOR HOME AND COMMUNITY-BASED 
                   SERVICES.

       (a) In General.--Section 1917 of the Social Security Act 
     (42 U.S.C. 1396p) is amended by adding at the end the 
     following new subsection:
       ``(i) State Authority To Exclude up to 6 Months of Average 
     Cost of Nursing Facility Services From Home and Community-
     Based Services Eligibility Determinations.--Nothing in this 
     section or any other provision of this title, shall be 
     construed as prohibiting a State from excluding from any 
     determination of an individual's assets or resources for 
     purposes of determining the eligibility of the individual for 
     medical assistance for home and community-based services 
     under subsection (c), (d), (e), or (i) of section 1915 (if a 
     State imposes an limitation on assets or resources for 
     purposes of eligibility for such services), an amount equal 
     to the product of the amount applicable under subsection 
     (c)(1)(E)(ii)(II) (at the time such determination is made) 
     and such number, not to exceed 6, as the State may elect.''.
       (b) Rule of Construction.--Nothing in the amendment made by 
     subsection (a) shall be construed as affecting a State's 
     option to apply less restrictive methodologies under section 
     1902(r)(2) for purposes of determining income and resource 
     eligibility for individuals specified in that section.

      TITLE III--COORDINATION OF HOME AND COMMUNITY-BASED WAIVERS

     SEC. 301. STREAMLINED PROCESS FOR COMBINED WAIVERS UNDER 
                   SUBSECTIONS (B) AND (C) OF SECTION 1915.

       Not later than 90 days after the date of enactment of this 
     Act, the Secretary of Health and Human Services shall create 
     a template to streamline the process of approving, 
     monitoring, evaluating, and renewing State proposals to 
     conduct a program that combines the waiver authority provided 
     under subsections (b) and (c) of section 1915 of the Social 
     Security Act (42 U.S.C. 1396n) into a single program under 
     which the State provides home and community-based services to 
     individuals based on individualized assessments and care 
     plans (in this section referred to as the ``combined waivers 
     program''). The template required under this section shall 
     provide for the following:
       (1) A standard 5-year term for conducting a combined 
     waivers program.
       (2) Harmonization of any requirements under subsections (b) 
     and (c) of such section that overlap.
       (3) An option for States to elect, during the first 5-year 
     term for which the combined waivers program is approved to 
     phase-in the enrollment of eligible individuals, or the 
     provision of services to such individuals, or both, so long 
     as all eligible individuals in the State for such services 
     are enrolled, and all such services are provided, before the 
     end of the initial 5-year period.
       (4) Examination by the Secretary, prior to each renewal of 
     a combined waivers program, of how well the State has--
       (A) adhered to the combined waivers program requirements; 
     and
       (B) performed in meeting the State's objectives for the 
     combined waivers program, including with respect to quality 
     improvement and beneficiary outcomes.
                                 ______