Sec. 204. Coverage of long-term care services
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Subject to the other provisions of this Act, individuals enrolled for benefits under this Act are entitled to the following long-term services and supports and to have payment made by the Secretary to an eligible provider for such services and supports if medically necessary and appropriate and in accordance with the standards established in this Act, for maintenance of health or for care, services, diagnosis, treatment, or rehabilitation that is related to a medically determinable condition, whether physical or mental, of health, injury, or age that— causes a functional limitation in performing one or more activities of daily living; or requires a similar need of assistance in performing instrumental activities of daily living due to cognitive or other impairments.
The Secretary shall promulgate rules that provide for the following: The determination of individual eligibility for long-term services and supports under this section. The assessment of the long-term services and supports needed for eligible individuals. Long-term services and supports under this section shall be tailored to an individual’s needs, as determined through assessment, and shall be defined by the Secretary to— include any long-term nursing services for the enrollee, whether provided in an institution or in a home and community-based setting; provide coverage for a broad spectrum of long-term services and supports, including for home and community-based services and other care provided through non-institutional settings; provide coverage that meets the physical, mental, and social needs of recipients while allowing recipients their maximum possible autonomy and their maximum possible civic, social, and economic participation; prioritize delivery of long-term services and supports through home and community-based services over institutionalization; unless an individual elects otherwise, ensure that recipients will receive home and community based long-term services and supports (as defined in subsection (f)(4)), regardless of the individuals’s type or level of disability, service need, or age; be provided with the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the individual’s needs; be provided in such a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity; provide long-term services and supports that are of equal quality and equally accessible across geographic regions; and ensure that long-term services and supports provide recipient’s the option of self-direction of services from either the recipient or care coordinators of the recipient’s choosing.
In developing regulations to implement this section, the Secretary shall consult with an advisory commission on long-term services and supports that includes— people with disabilities who use long-term services and supports and older adults who use long-term services and supports; representatives of people with disabilities and representatives of older adults; groups that represent the diversity of the population of people living with disabilities, including gender, racial, and economic diversity; providers of long-term services and supports, including family attendants and family caregivers, and members of organized labor; disability rights organizations; and relevant academic institutions and researchers.
Budgeting and payments for long-term services and supports provided under this section shall be made in accordance with the provisions under title VI. In this section: The term long-term services and supports means long-term care, treatment, maintenance, or services needed to support the activities of daily living and instrumental activities of daily living, including all long-term services and supports available under section 1915 of the Social Security Act ( 42 U.S.C. 1396n ), home and community-based services, and any additional services and supports identified by the Secretary to support people with disabilities to live, work, and participate in their communities.
The term activities of daily living means basic personal everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring. The term instrumental activities of daily living means activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
The term home and community-based services means the home and community-based services that are coverable under subsections (c), (d), (i), and
(k)of section 1915 of the Social Security Act ( 42 U.S.C. 1396n ), and as defined by the Secretary, including as defined in the home and community-based services settings rule in sections 441.530 and 441.710 of title 42, Code of Federal Regulations (or a successor regulation).
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Sec. 204
Coverage of long-term care services
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