HR 1670 IH

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.

March 23, 2009

Mr. DAVIS of Illinois (for himself, Mr. PAYNE, Mrs. CHRISTENSEN, Mr. BRADY of Pennsylvania, Ms. LEE of California, Mr. MEEKS of New York, Mr. CARNEY, Mr. DOYLE, Mr. LARSON of Connecticut, Mr. MOORE of Kansas, Mr. HINCHEY, Mr. KUCINICH, Mr. LEWIS of Georgia, Ms. BALDWIN, Mr. COHEN, Mr. FATTAH, Ms. DELAURO, Mr. ISRAEL, Ms. KAPTUR, Mr. KIND, Mr. LANGEVIN, Mr. OLVER, Ms. LORETTA SANCHEZ of California, Ms. SCHWARTZ, Mr. SESTAK, and Ms. VELAZQUEZ) introduced the following bill; which was referred to the Committee on Energy and Commerce

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

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the `Community Choice Act of 2009'.

(b) Table of Contents- The table of contents for this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Findings and purposes.

TITLE I--ESTABLISHMENT OF MEDICAID PLAN BENEFIT

Sec. 101. Coverage of community-based attendant services and supports under the Medicaid program.

Sec. 102. Enhanced FMAP for ongoing activities of early coverage States that enhance and promote the use of community-based attendant services and supports.

Sec. 103. Increased Federal financial participation for certain expenditures.

TITLE II--PROMOTION OF SYSTEMS CHANGE AND CAPACITY BUILDING

Sec. 201. Grants to promote systems change and capacity building.

Sec. 202. Demonstration project to enhance coordination of care under the Medicare and Medicaid programs for dual eligible individuals.

SEC. 2. FINDINGS AND PURPOSES.

(a) Findings- Congress makes the following findings:

(1) Long-term services and supports provided under the Medicaid program established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) must meet the abilities and life choices of individuals with disabilities and older Americans, including the choice to live in one's own home or with one's own family and to become a productive member of the community.

(2) Similarly, under the United States Supreme Court's decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals with disabilities have the right to choose to receive their long-term services and supports in the community, rather than in an institutional setting.

(3) Nevertheless, research on the provision of long-term services and supports under the Medicaid program (conducted by and on behalf of the Department of Health and Human Services) continues to show a significant funding and programmatic bias toward institutional care. In 2007, only 42 percent of long-term care funds expended under the Medicaid program, and only about 13.6 percent of all funds expended under that program, pay for services and supports in home and community-based settings.

(4) While much effort has been dedicated to `rebalancing' the current system, overall about 60 percent of Medicaid long-term care dollars are still spent on institutional services, with about 40 percent going to home and community-based services. In 2007, only 11 States spent 50 percent or more of their Medicaid long-term care funds on home and community-based care.

(5) The statistics are even more disproportionate for adults with physical disabilities. In 2007, 69 percent of Medicaid long-term care spending for older people and adults with physical disabilities paid for institutional services. Only 6 States spent 50 percent or more of their Medicaid long-term care dollars on home and community-based services for older people and adults with physical disabilities while 1/2 of the States spent less than 25 percent. This disparity continues even though, on average, it is estimated that Medicaid dollars can support nearly 3 older people and adults with physical disabilities in home and community-based services for every person in a nursing home.

(6) For Medicaid beneficiaries who need long-term care, services provided in an institutional setting represent the only guaranteed benefit. Only 30 States have adopted the benefit option of providing personal care, or attendant, services under their Medicaid programs.

(7) Although every State has chosen to provide certain services under home and community-based waivers, these services are unevenly available within and across States, and reach a small percentage of eligible individuals. Individuals with the most significant disabilities are usually afforded the least amount of choice, despite advances in medical and assistive technologies and related areas.

(8) Despite the more limited funding for home and community-based services, the majority of individuals who use Medicaid long-term services and supports prefer to live in the community, rather than in institutional settings.

(9) The goals of the Nation properly include providing families of children with disabilities, working-age adults with disabilities, and older Americans with--

(A) a meaningful choice of receiving long-term services and supports in the most integrated setting appropriate to the individual's needs;

(B) the greatest possible control over the services received and, therefore, their own lives and futures; and

(C) quality services that maximize independence in the home and community.

(b) Purposes- The purposes of this Act are the following:

(1) To reform the Medicaid program established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) to provide services in the most integrated setting appropriate to the individual's needs, and to provide equal access to community-based attendant services and supports in order to assist individuals in achieving equal opportunity, full participation, independent living, and economic self-sufficiency.

(2) To provide financial assistance to States as they reform their long-term care systems to provide comprehensive statewide long-term services and supports, including community-based attendant services and supports that provide consumer choice and direction, in the most integrated setting appropriate.

(3) To assist States in meeting the growing demand for community-based attendant services and supports, as the Nation's population ages and individuals with disabilities live longer.

(4) To assist States in complying with the U.S. Supreme Court decision in Olmstead v. L.C., 527 U.S. 581 (1999), and implementing the integration mandate of the Americans with Disabilities Act.

TITLE I--ESTABLISHMENT OF MEDICAID PLAN BENEFIT

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

(a) Mandatory Coverage- Section 1902(a)(10)(D) of the Social Security Act (42 U.S.C. 1396a(a)(10)(D)) is amended--

(1) by inserting `(i)' after `(D)';

(2) by adding `and' after the semicolon; and

(3) by adding at the end the following new clause:

`(ii) subject to section 1943, for the inclusion of community-based attendant services and supports for any individual who--

`(I) is eligible for medical assistance under the State plan;

`(II) with respect to whom there has been a determination that the individual requires the level of care provided in a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded (whether or not coverage of such institution or intermediate care facility is provided under the State plan); and

`(III) chooses to receive such services and supports;'.

(b) Community-Based Attendant Services and Supports-

(1) IN GENERAL- Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended by adding at the end the following new section:

`COMMUNITY-BASED ATTENDANT SERVICES AND SUPPORTS

`Sec. 1943. (a) Required Coverage-

`(1) IN GENERAL- Not later than October 1, 2014, a State shall provide through a plan amendment for the inclusion of community-based attendant services and supports (as defined in subsection (g)(1)) for individuals described in section 1902(a)(10)(D)(ii) in accordance with this section.

`(2) ENHANCED FMAP AND ADDITIONAL FEDERAL FINANCIAL SUPPORT FOR EARLIER COVERAGE- Notwithstanding section 1905(b), during the period that begins on October 1, 2009, and ends on September 30, 2014, in the case of a State with an approved plan amendment under this section during that period that also satisfies the requirements of subsection (c) the Federal medical assistance percentage shall be equal to the enhanced FMAP described in section 2105(b) with respect to medical assistance in the form of community-based attendant services and supports provided to individuals described in section 1902(a)(10)(D)(ii) in accordance with this section on or after the date of the approval of such plan amendment.

`(b) Development and Implementation of Benefit- In order for a State plan amendment to be approved under this section, a State shall provide the Secretary with the following assurances:

`(1) ASSURANCE OF DEVELOPMENT AND IMPLEMENTATION COLLABORATION-

`(A) IN GENERAL- That State plan amendment--

`(i) has been developed in collaboration with, and with the approval of, a Development and Implementation Council established by the State that satisfies the requirements of subparagraph (B); and

`(ii) will be implemented in collaboration with such Council and on the basis of public input solicited by the State and the Council.

`(B) DEVELOPMENT AND IMPLEMENTATION COUNCIL REQUIREMENTS- For purposes of subparagraph (A), the requirements of this subparagraph are that--

`(i) the majority of the members of the Development and Implementation Council are individuals with disabilities, elderly individuals, and their representatives; and

`(ii) in carrying out its responsibilities, the Council actively collaborates with--

`(I) individuals with disabilities;

`(II) elderly individuals;

`(III) representatives of such individuals; and

`(IV) providers of, and advocates for, services and supports for such individuals.

`(2) ASSURANCE OF PROVISION ON A STATEWIDE BASIS AND IN MOST INTEGRATED SETTING- That consumer controlled community-based attendant services and supports will be provided under the State plan to individuals described in section 1902(a)(10)(D)(ii) on a statewide basis and in a manner that provides such services and supports in the most integrated setting appropriate to the individual's needs.

`(3) ASSURANCE OF NONDISCRIMINATION- That the State will provide community-based attendant services and supports to an individual described in section 1902(a)(10)(D)(ii) without regard to the individual's age, type or nature of disability, severity of disability, or the form of community-based attendant services and supports that the individual requires in order to lead an independent life.

`(4) ASSURANCE OF MAINTENANCE OF EFFORT- That the level of State expenditures for medical assistance that is provided under section 1905(a), section 1915, section 1115, or otherwise to individuals with disabilities or elderly individuals for a fiscal year shall not be less than the level of such expenditures for the fiscal year preceding the first full fiscal year in which the State plan amendment to provide community-based attendant services and supports in accordance with this section is implemented.

`(c) Requirements for Enhanced FMAP for Early Coverage- In addition to satisfying the other requirements for an approved plan amendment under this section, in order for a State to be eligible under subsection (a)(2) during the period described in that subsection for the enhanced FMAP for early coverage under subsection (a)(2), the State shall satisfy the following requirements:

`(1) SPECIFICATIONS- With respect to a fiscal year, the State shall provide the Secretary with the following specifications regarding the provision of community-based attendant services and supports under the plan for that fiscal year:

`(A)(i) The number of individuals who are estimated to receive community-based attendant services and supports under the plan during the fiscal year.

`(ii) The number of individuals that received such services and supports during the preceding fiscal year.

`(B) The maximum number of individuals who will receive such services and supports under the plan during that fiscal year.

`(C) The procedures the State will implement to ensure that the models for delivery of such services and supports are consumer controlled (as defined in subsection (g)(2)(B)).

`(D) The procedures the State will implement to inform all potentially eligible individuals and relevant other individuals of the availability of such services and supports under this title, and of other items and services that may be provided to the individual under this title or title XVIII and other Federal or State long-term service and support programs.

`(E) The procedures the State will implement to ensure that such services and supports are provided in accordance with the requirements of subsection (b)(1).

`(F) The procedures the State will implement to actively involve in a systematic, comprehensive, and ongoing basis, the Development and Implementation Council established in accordance with subsection (b)(1)(A)(ii), individuals with disabilities, elderly individuals, and representatives of such individuals in the design, delivery, administration, implementation, and evaluation of the provision of such services and supports under this title.

`(2) PARTICIPATION IN EVALUATIONS- The State shall provide the Secretary with such substantive input into, and participation in, the design and conduct of data collection, analyses, and other qualitative or quantitative evaluations of the provision of community-based attendant services and supports under this section as the Secretary deems necessary in order to determine the effectiveness of the provision of such services and supports in allowing the individuals receiving such services and supports to lead an independent life to the maximum extent possible.

`(d) Quality Assurance-

`(1) STATE RESPONSIBILITIES- In order for a State plan amendment to be approved under this section, a State shall establish and maintain a comprehensive, continuous quality assurance system with respect to community-based attendant services and supports that provides for the following:

`(A) The State shall establish requirements, as appropriate, for agency-based and other delivery models that include--

`(i) minimum qualifications and training requirements for agency-based and other models;

`(ii) financial operating standards; and

`(iii) an appeals procedure for eligibility denials and a procedure for resolving disagreements over the terms of an individualized plan.

`(B) The State shall modify the quality assurance system, as appropriate, to maximize consumer independence and consumer control in both agency-provided and other delivery models.

`(C) The State shall provide a system that allows for the external monitoring of the quality of services and supports by entities consisting of consumers and their representatives, disability organizations, providers, families of disabled or elderly individuals, members of the community, and others.

`(D) The State shall provide for ongoing monitoring of the health and well-being of each individual who receives community-based attendant services and supports.

`(E) The State shall require that quality assurance mechanisms pertaining to the individual be included in the individual's written plan.

`(F) The State shall establish a process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports.

`(G) The State shall obtain meaningful consumer input, including consumer surveys, that measure the extent to which an individual receives the services and supports described in the individual's plan and the individual's satisfaction with such services and supports.

`(H) The State shall make available to the public the findings of the quality assurance system.

`(I) The State shall establish an ongoing public process for the development, implementation, and review of the State's quality assurance system.

`(J) The State shall develop and implement a program of sanctions for providers of community-based services and supports that violate the terms or conditions for the provision of such services and supports.

`(2) FEDERAL RESPONSIBILITIES-

`(A) PERIODIC EVALUATIONS- The Secretary shall conduct a periodic sample review of outcomes for individuals who receive community-based attendant services and supports under this title.

`(B) INVESTIGATIONS- The Secretary may conduct targeted reviews and investigations upon receipt of an allegation of neglect, abuse, or exploitation of an individual receiving community-based attendant services and supports under this section.

`(C) DEVELOPMENT OF PROVIDER SANCTION GUIDELINES- The Secretary shall develop guidelines for States to use in developing the sanctions required under paragraph (1)(J).

`(e) Reports- The Secretary shall submit to Congress periodic reports on the provision of community-based attendant services and supports under this section, particularly with respect to the impact of the provision of such services and supports on--

`(1) individuals eligible for medical assistance under this title;

`(2) States; and

`(3) the Federal Government.

`(f) No Effect on Ability To Provide Coverage-

`(1) IN GENERAL- Nothing in this section shall be construed as affecting the ability of a State to provide coverage under the State plan for community-based attendant services and supports (or similar coverage) under section 1905(a), section 1915, section 1115, or otherwise.

`(2) ELIGIBILITY FOR ENHANCED MATCH- In the case of a State that provides coverage for such services and supports under a waiver, the State shall not be eligible under subsection (a)(2) for the enhanced FMAP for the early provision of such coverage unless the State submits a plan amendment to the Secretary that meets the requirements of this section and demonstrates that the State is able to fully comply with and implement the requirements of this section.

`(g) Definitions- In this title:

`(1) COMMUNITY-BASED ATTENDANT SERVICES AND SUPPORTS-

`(A) IN GENERAL- The term `community-based attendant services and supports' means attendant services and supports furnished to an individual, as needed, to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, or cueing--

`(i) under a plan of services and supports that is based on an assessment of functional need and that is agreed to in writing by the individual or, as appropriate, the individual's representative;

`(ii) in a home or community setting, which shall include but not be limited to a school, workplace, or recreation or religious facility, but does not include a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded;

`(iii) under an agency-provider model or other model (as defined in paragraph (2)(C));

`(iv) the furnishing of which--

`(I) is selected, managed, and dismissed by the individual, or, as appropriate, with assistance from the individual's representative; and

`(II) provided by an individual who is qualified to provide such services, including family members (as defined by the Secretary).

`(B) INCLUDED SERVICES AND SUPPORTS- Such term includes--

`(i) tasks necessary to assist an individual in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks;

`(ii) the acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living, instrumental activities of daily living, and health-related tasks;

`(iii) backup systems or mechanisms (such as the use of beepers) to ensure continuity of services and supports; and

`(iv) voluntary training on how to select, manage, and dismiss attendants.

`(C) EXCLUDED SERVICES AND SUPPORTS- Subject to subparagraph (D), such term does not include--

`(i) the provision of room and board for the individual;

`(ii) special education and related services provided under the Individuals with Disabilities Education Act and vocational rehabilitation services provided under the Rehabilitation Act of 1973;

`(iii) assistive technology devices and assistive technology services;

`(iv) durable medical equipment; or

`(v) home modifications.

`(D) FLEXIBILITY IN TRANSITION TO COMMUNITY-BASED HOME SETTING- Such term may include expenditures for transitional costs, such as rent and utility deposits, first month's rent and utilities, bedding, basic kitchen supplies, and other necessities required for an individual to make the transition from a nursing facility, institution for mental diseases, or intermediate care facility for the mentally retarded to a community-based home setting where the individual resides.

`(2) ADDITIONAL DEFINITIONS-

`(A) ACTIVITIES OF DAILY LIVING- The term `activities of daily living' includes eating, toileting, grooming, dressing, bathing, and transferring.

`(B) CONSUMER CONTROLLED- The term `consumer controlled' means a method of selecting and providing services and supports that allow the individual, or where appropriate, the individual's representative, maximum control of the community-based attendant services and supports, regardless of who acts as the employer of record.

`(C) DELIVERY MODELS-

`(i) AGENCY-PROVIDER MODEL- The term `agency-provider model' means, with respect to the provision of community-based attendant services and supports for an individual, subject to clause (iii), a method of providing consumer controlled services and supports under which entities contract for the provision of such services and supports.

`(ii) OTHER MODELS- The term `other models' means, subject to clause (iii), methods, other than an agency-provider model, for the provision of consumer controlled services and supports. Such models may include the provision of vouchers, direct cash payments, or use of a fiscal agent to assist in obtaining services.

`(iii) COMPLIANCE WITH CERTAIN LAWS- A State shall ensure that, regardless of whether the State uses an agency-provider model or other models to provide services and supports under a State plan amendment under this section, such services and supports are provided in accordance with the requirements of the Fair Labor Standards Act of 1938 and applicable Federal and State laws regarding--

`(I) withholding and payment of Federal and State income and payroll taxes;

`(II) the provision of unemployment and workers compensation insurance;

`(III) maintenance of general liability insurance; and

`(IV) occupational health and safety.

`(D) HEALTH-RELATED TASKS- The term `health-related tasks' means specific tasks that can be delegated or assigned by licensed health-care professionals under State law to be performed by an attendant.

`(E) INSTRUMENTAL ACTIVITIES OF DAILY LIVING- The term `instrumental activities of daily living' includes, but is not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone and other media, and traveling around and participating in the community.

`(F) INDIVIDUALS REPRESENTATIVE- The term `individual's representative' means a parent, a family member, a guardian, an advocate, or other authorized representative of an individual.'.

(c) Conforming Amendments-

(1) MANDATORY BENEFIT- Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the matter preceding clause (i), by striking `(17) and (21)' and inserting `(17), (21), and (28)'.

(2) DEFINITION OF MEDICAL ASSISTANCE- Section 1905(a) of the Social Security Act (42 U.S.C. 1396d) is amended--

(A) by striking `and' at the end of paragraph (27);

(B) by redesignating paragraph (28) as paragraph (29); and

(C) by inserting after paragraph (27) the following:

`(28) community-based attendant services and supports (to the extent allowed and as defined in section 1943); and'.

(3) IMD/ICFMR REQUIREMENTS- Section 1902(a)(10)(C)(iv) of the Social Security Act (42 U.S.C. 1396a(a)(10)(C)(iv)) is amended by inserting `and (28)' after `(24)'.

(d) Effective Dates-

(1) IN GENERAL- Except as provided in paragraph (2), the amendments made by this section (other than the amendment made by subsection (c)(1)) take effect on October 1, 2009, and apply to medical assistance provided for community-based attendant services and supports described in section 1943 of the Social Security Act furnished on or after that date.

(2) MANDATORY BENEFIT- The amendment made by subsection (c)(1) takes effect on October 1, 2014.

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

(a) In General- Section 1943 of the Social Security Act, as added by section 101(b), is amended--

(1) by redesignating subsections (d) through (g) as subsections (f) through (i), respectively;

(2) in subsection (a)(1), by striking `subsection (g)(1)' and inserting `subsection (i)(1)';

(3) in subsection (a)(2), by inserting `, and with respect to expenditures described in subsection (d), the Secretary shall pay the State the amount described in subsection (d)(1)' before the period;

(4) in subsection (c)(1)(C), by striking `subsection (g)(2)(B)' and inserting `subsection (i)(2)(B)'; and

(5) by inserting after subsection (c), the following:

`(d) Increased Federal Financial Participation for Early Coverage States That Meet Certain Benchmarks-

`(1) IN GENERAL- Subject to paragraph (2), for purposes of subsection (a)(2), the amount and expenditures described in this subsection are an amount equal to the Federal medical assistance percentage, increased by 10 percentage points, of the expenditures incurred by the State for the provision or conduct of the services or activities described in paragraph (3).

`(2) EXPENDITURE CRITERIA- A State shall--

`(A) develop criteria for determining the expenditures described in paragraph (1) in collaboration with the individuals and representatives described in subsection (b)(1); and

`(B) submit such criteria for approval by the Secretary.

`(3) SERVICES, SUPPORTS AND ACTIVITIES DESCRIBED- For purposes of paragraph (1), the services, supports and activities described in this subparagraph are the following:

`(A) 1-stop intake, referral, and institutional diversion services.

`(B) Identifying and remedying gaps and inequities in the State's current provision of long-term services and supports, particularly those services and supports that are provided based on such factors as age, severity of disability, type of disability, ethnicity, income, institutional bias, or other similar factors.

`(C) Establishment of consumer participation and consumer governance mechanisms, such as cooperatives and regional service authorities, that are managed and controlled by individuals with significant disabilities who use community-based services and supports or their representatives.

`(D) Activities designed to enhance the skills, earnings, benefits, supply, career, and future prospects of workers who provide community-based attendant services and supports.

`(E) Continuous, comprehensive quality improvement activities that are designed to ensure and enhance the health and well-being of individuals who rely on community-based attendant services and supports, particularly activities involving or initiated by consumers of such services and supports or their representatives.

`(F) Family support services to augment the efforts of families and friends to enable individuals with disabilities of all ages to live in their own homes and communities.

`(G) Health promotion and wellness services and activities.

`(H) Provider recruitment and enhancement activities, particularly such activities that encourage the development and maintenance of consumer controlled cooperatives or other small businesses or micro-enterprises that provide community-based attendant services and supports or related services.

`(I) Activities designed to ensure service and systems coordination.

`(J) Any other services or activities that the Secretary deems appropriate.'.

(b) Effective Date- The amendments made by subsection (a) take effect on October 1, 2009.

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

(a) In General- Section 1943 of the Social Security Act, as added by section 101(b) and amended by section 102, is amended by inserting after subsection (d) the following:

`(e) Increased Federal Financial Participation for Certain Expenditures-

`(1) ELIGIBILITY FOR PAYMENT-

`(A) IN GENERAL- In the case of a State that the Secretary determines satisfies the requirements of subparagraph (B), the Secretary shall pay the State the amounts described in paragraph (2) in addition to any other payments provided for under section 1903 or this section for the provision of community-based attendant services and supports.

`(B) REQUIREMENTS- The requirements of this subparagraph are the following:

`(i) The State has an approved plan amendment under this section.

`(ii) The State has incurred expenditures described in paragraph (2).

`(iii) The State develops and submits to the Secretary criteria to identify and select such expenditures in accordance with the requirements of paragraph (3).

`(iv) The Secretary determines that payment of the applicable percentage of such expenditures (as determined under paragraph (2)(B)) would enable the State to provide a meaningful choice of receiving community-based services and supports to individuals with disabilities and elderly individuals who would otherwise only have the option of receiving institutional care.

`(2) AMOUNTS AND EXPENDITURES DESCRIBED-

`(A) EXPENDITURES IN EXCESS OF 150 PERCENT OF BASELINE AMOUNT- The amounts and expenditures described in this paragraph are an amount equal to the applicable percentage, as determined by the Secretary in accordance with subparagraph (B), of the expenditures incurred by the State for the provision of community-based attendant services and supports to an individual that exceed 150 percent of the average cost of providing nursing facility services to an individual who resides in the State and is eligible for such services under this title, as determined in accordance with criteria established by the Secretary.

`(B) APPLICABLE PERCENTAGE- The Secretary shall establish a payment scale for the expenditures described in subparagraph (A) so that the Federal financial participation for such expenditures gradually increases from 70 percent to 90 percent as such expenditures increase.

`(3) SPECIFICATION OF ORDER OF SELECTION FOR EXPENDITURES- In order to receive the amounts described in paragraph (2), a State shall--

`(A) develop, in collaboration with the individuals and representatives described in subsection (b)(1) and pursuant to guidelines established by the Secretary, criteria to identify and select the expenditures submitted under that paragraph; and

`(B) submit such criteria to the Secretary.'.

(b) Effective Date- The amendment made by subsection (a) takes effect on October 1, 2009.

TITLE II--PROMOTION OF SYSTEMS CHANGE AND CAPACITY BUILDING

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

(a) Authority To Award Grants-

(1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the `Secretary') shall award grants to eligible States to carry out the activities described in subsection (b).

(2) APPLICATION- In order to be eligible for a grant under this section, a State shall submit to the Secretary an application in such form and manner, and that contains such information, as the Secretary may require.

(b) Permissible Activities- A State that receives a grant under this section may use funds provided under the grant for any of the following activities, focusing on areas of need identified by the State and the Consumer Task Force established under subsection (c):

(1) The development and implementation of the provision of community-based attendant services and supports under section 1943 of the Social Security Act (as added by section 101(b) and amended by sections 102 and 103) through active collaboration with--

(A) individuals with disabilities;

(B) elderly individuals;

(C) representatives of such individuals; and

(D) providers of, and advocates for, services and supports for such individuals.

(2) Substantially involving individuals with significant disabilities and representatives of such individuals in jointly developing, implementing, and continually improving a mutually acceptable comprehensive, effectively working statewide plan for preventing and alleviating unnecessary institutionalization of such individuals.

(3) Engaging in system change and other activities deemed necessary to achieve any or all of the goals of such statewide plan.

(4) Identifying and remedying disparities and gaps in services to classes of individuals with disabilities and elderly individuals who are currently experiencing or who face substantial risk of unnecessary institutionalization.

(5) Building and expanding system capacity to offer quality consumer controlled community-based services and supports to individuals with disabilities and elderly individuals, including by--

(A) seeding the development and effective use of community-based attendant services and supports cooperatives, Independent Living Centers, small businesses, micro-enterprises, micro-boards, and similar joint ventures owned and controlled by individuals with disabilities or representatives of such individuals and community-based attendant services and supports workers;

(B) enhancing the choice and control individuals with disabilities and elderly individuals exercise, including through their representatives, with respect to the personal assistance and supports they rely upon to lead independent, self-directed lives;

(C) enhancing the skills, earnings, benefits, supply, career, and future prospects of workers who provide community-based attendant services and supports;

(D) engaging in a variety of needs assessment and data gathering;

(E) developing strategies for modifying policies, practices, and procedures that result in unnecessary institutional bias or the over-medicalization of long-term services and supports;

(F) engaging in interagency coordination and single point of entry activities;

(G) providing training and technical assistance with respect to the provision of community-based attendant services and supports;

(H) engaging in--

(i) public awareness campaigns;

(ii) facility-to-community transitional activities; and

(iii) demonstrations of new approaches; and

(I) engaging in other systems change activities necessary for developing, implementing, or evaluating a comprehensive statewide system of community-based attendant services and supports.

(6) Ensuring that the activities funded by the grant are coordinated with other efforts to increase personal attendant services and supports, including--

(A) programs funded under or amended by the Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170; 113 Stat. 1860);

(B) grants funded under the Families of Children With Disabilities Support Act of 2000 (42 U.S.C. 15091 et seq.); and

(C) other initiatives designed to enhance the delivery of community-based services and supports to individuals with disabilities and elderly individuals.

(7) Engaging in transition partnership activities with nursing facilities and intermediate care facilities for the mentally retarded that utilize and build upon items and services provided to individuals with disabilities or elderly individuals under the Medicaid program under title XIX of the Social Security Act, or by Federal, State, or local housing agencies, Independent Living Centers, and other organizations controlled by consumers or their representatives.

(c) Consumer Task Force-

(1) ESTABLISHMENT AND DUTIES- To be eligible to receive a grant under this section, each State shall establish a Consumer Task Force (referred to in this subsection as the `Task Force') to assist the State in the development, implementation, and evaluation of real choice systems change initiatives.

(2) APPOINTMENT- Members of the Task Force shall be appointed by the Chief Executive Officer of the State in accordance with the requirements of paragraph (3), after the solicitation of recommendations from representatives of organizations representing a broad range of individuals with disabilities, elderly individuals, representatives of such individuals, and organizations interested in individuals with disabilities and elderly individuals.

(3) COMPOSITION-

(A) IN GENERAL- The Task Force shall represent a broad range of individuals with disabilities from diverse backgrounds and shall include representatives from Developmental Disabilities Councils, Mental Health Councils, State Independent Living Centers and Councils, Commissions on Aging, organizations that provide services to individuals with disabilities and consumers of long-term services and supports.

(B) INDIVIDUALS WITH DISABILITIES- A majority of the members of the Task Force shall be individuals with disabilities or representatives of such individuals.

(C) LIMITATION- The Task Force shall not include employees of any State agency providing services to individuals with disabilities other than employees of entities described in the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.).

(d) Annual Report-

(1) STATES- A State that receives a grant under this section shall submit an annual report to the Secretary on the use of funds provided under the grant in such form and manner as the Secretary may require.

(2) SECRETARY- The Secretary shall submit to Congress an annual report on the grants made under this section.

(e) Authorization of Appropriations-

(1) IN GENERAL- There is authorized to be appropriated to carry out this section, $50,000,000 for each of fiscal years 2010 through 2012.

(2) AVAILABILITY- Amounts appropriated to carry out this section shall remain available without fiscal year limitation.

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

(a) Definitions- In this section:

(1) DUALLY ELIGIBLE INDIVIDUAL- The term `dually eligible individual' means an individual who is enrolled in the Medicare and Medicaid programs established under Titles XVIII and XIX, respectively, of the Social Security Act (42 U.S.C. 1395 et seq., 1396 et seq.).

(2) PROJECT- The term `project' means the demonstration project authorized to be conducted under this section.

(3) SECRETARY- The term `Secretary' means the Secretary of Health and Human Services.

(b) Authority To Conduct Project- The Secretary shall conduct a project under this section for the purpose of evaluating service coordination and cost-sharing approaches with respect to the provision of community-based services and supports to dually eligible individuals.

(c) Requirements-

(1) NUMBER OF PARTICIPANTS- Not more than 5 States may participate in the project.

(2) APPLICATION- A State that desires to participate in the project shall submit an application to the Secretary, at such time and in such form and manner as the Secretary shall specify.

(3) DURATION- The project shall be conducted for at least 5, but not more than 10 years.

(d) Evaluation and Report-

(1) EVALUATION- Not later than 1 year prior to the termination date of the project, the Secretary, in consultation with States participating in the project, representatives of dually eligible individuals, and others, shall evaluate the impact and effectiveness of the project.

(2) REPORT- The Secretary shall submit a report to Congress that contains the findings of the evaluation conducted under paragraph (1) along with recommendations regarding whether the project should be extended or expanded, and any other legislative or administrative actions that the Secretary considers appropriate as a result of the project.

(e) Authorization of Appropriations- There are authorized to be appropriated such sums as are necessary to carry out this section.

END